Every finding on record at Oakwood Care and Rehabilitation

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety.Specifically, the quality assurance and performance improvement (QAPI) committee failed to identify and address concerns related to abuse, neglect and dementia care.Findings include:I. Facility policy and procedureThe QAPI Facility Program policy was provided by the nursing home administrator (NHA) 2/25/26 at 12:05 p.m. It read in pertinent part, The facility will establish and implement a Quality Assessment and Assurance Committee and develop a written Quality Assurance and Performance Improvement Plan, which will be reviewed and updated annually, and implement Performance Improvement Projects (PIP) through a data driven and proactive approach. II. Cross reference citationsA. Cross reference F600: The facility failed to ensure residents were free from abuse. The facility failed to protect residents from abuse on several occasions when residents were able to wander from room to room in the secure memory unit, resulting in resident-to-resident physical abuse. B. Cross-reference F744: The facility failed to ensure residents who displayed or were diagnosed with dementia received the appropriate treatment to attain or maintain their highest level of care. III. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 2/25/26 at 10:25 a.m The DON and the NHA said the facility did not have a QAPI PIP plan in place for the secure memory care unit at this time, but did talk about plans for the unit such as the ability cares programming. The NHA and the DON were interviewed together again on 2/26/26 at 4:46 p.m. The NHA and the DON said the facility was working hard to prevent residents' abusive behaviors and to train the staff on crisis prevention intervention (CPI) and dementia care procedures. The DON said that staff needed education related to abuse and dementia and they had not had that.The DON said the facility was working on several PIPs at that time, including falls and dementia training but could not provide specific details about the specific PIPS.

Based on observations, record review and interviews, the facility failed to keep residents free from abuse for six (#15, #14, #9, #8, #19 and #20) of 11 residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to:-Protect Resident #15 from physical abuse by Resident #13 on 11/29/25; -Protect Resident #15 from physical abuse by Resident #16 on 1/6/26; -Protect Resident #15 from physical abuse by Resident #17 on 1/17/26; -Protect Resident #14 from physical abuse by Resident #13 on 11/20/25;-Protect Resident #14 from physical abuse by Resident #8 on 1/2/26;-Protect Resident #9 from physical abuse by Resident #10 on 2/5/26; -Protect Resident #9 from physical abuse by Resident #18 on 2/19/26;-Protect Resident #8 from physical abuse by Resident #9 on 2/15/26; and,-Protect Resident #19 and Resident #20 from verbal and physical abuse towards each other on 2/18/26.Findings include: I. Facility policy and procedure The Abuse policy, reviewed 11/1/17, was provided by the nursing home administrator (NHA) on 2/23/26. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's medical symptoms. II. Incident of physical abuse of Resident #15 by Resident #13 on 11/29/25 A. Facility investigation The facility investigation, dated 11/29/25, documented staff heard a commotion coming from Resident #15's room and responded to see what was going on. Staff heard Resident #13 say Get the (expletive) out, this is my room. Resident #13 was at Resident #15's bedside grabbing at Resident #15's feet to try and get him out of the bed and room. The responding nurse documented on 11/29/25 at 6:43 p.m. staff responded to an interaction between two roommates in which Resident #15 was waiting for assistance to get up and out of bed. At that time, Resident #13 approached Resident #15's bedside and displayed an episode of physical aggression in an effort to get Resident #15 out of the room, saying this is my room. The CNA intervened immediately and gently separated both residents to ensure safety, as well as reported to this nurse immediately. A nursing assessment found Resident #15 to be calm and cooperative, with no pain, no discomfort, no injury, and no signs of fear noted. Resident #15 was calm following the event. He displayed no visible signs of fear, distress, or injury, and during the interview he denied recalling the incident. The investigation documented Resident #15 was moved to a new room. Resident #13 remained in the room without a new roommate. The investigation documented Resident #13's care plan was updated to reflect increased behavioral monitoring and environmental adjustments. The facility substantiated that abuse occurred. B. Resident #15 (victim) 1. Resident status Resident #15, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included severe dementia with other behavioral disturbance and adult failure to thrive. According to the 11/30/25 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The assessment indicated the resident had wandering and aggressive behaviors that affected other residents. 2. Record review Resident #15's behavior care plan, initiated 11/30/25, revealed the resident had wandering behaviors. Interventions included anticipating wandering patterns and providing early, staff-led redirection when the resident approached other resident's rooms. 3. Observation During a continuous observation on 2/23/26, beginning at 11:45 a.m. and ending at 12:45 p.m., Resident #15 was observed continuously wandering between the halls and the common area in the secure memory care unit. During a second continuous observation on 2/23/26, beginning at 6:00 p.m. and ending at 7:05 p.m., Resident #15 was observed continuously wandering between the halls and the common area in the secure memory care unit. During a continuous observation on 2/24/26, beginning at 5:31 p.m. and ending at 7:51 p.m. Resident #15 was observed continuously wandering between the halls and the common area in the secure memory care unit. Cross-reference F744 for failure to provide treatment/services for residents with dementia. C. Resident #13 (assailant) 1. Resident status Resident #13, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included Alzheimer's disease and severe dementia with other behavioral disturbance. According to the 12/5/25 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The MDS assessment indicated the resident had wandering and aggressive behaviors that affected other residents. 2. Record review Resident #13's behavior care plan, initiated 12/15/25, revealed the resident had the potential to display physical aggression and had a history of several resident-to-resident altercations. Pertinent interventions included removing other residents from the resident's room, doorway, or personal space, intervening when the resident became agitated and engaging the resident in calm conversation. III. Incident of physical abuse of Resident #15 by Resident #16 on 1/6/26 A. Facility investigation The facility investigation, dated 1/6/26, documented Resident #15 wandered and entered Resident #16's room without invitation. The staff heard yelling and loud noises and went to the Resident #16's room to investigate. Resident #16 physically redirected Resident #15 out of her room. Resident #15 lost his balance, tripped and fell to the floor. The investigation documented the residents were separated and immediate safety measures were put into place. There were no physical or psychosocial injuries noted for either resident. The investigation documented Resident #15's care plan was reviewed and no changes were made. The facility did not substantiate that abuse occurred. B. Resident #16 (assailant) 1. Resident status Resident #16, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included severe dementia with other behavioral disturbance and insomnia. According to the 11/29/25 MDS assessment, the resident had severe cognitive impairment with a BIMS score of nine out of 15. The MDS assessment indicated the resident had wandering and aggressive behaviors that affected other residents. 2. Record review Resident #16's behavior care plan, initiated 3/12/24, revealed the resident could become physically aggressive towards others when they invaded her personal space. IV. Incident of physical abuse of Resident #15 by Resident #17 on 1/17/26. A. Facility investigation The facility investigation, dated 1/17/26, documented Resident #15 wandered and entered Resident #17's room without invitation. Resident #17 pushed Resident #15 and yelled at him to get out of his room. The investigation documented the residents were separated, and each resident was assessed by nursing staff and no physical or psychosocial injuries were identified. The investigation documented Resident #17's care plan was reviewed, door modifications were added to deter unauthorized room entry, and increased staff monitoring. The facility substantiated that the abuse occurred. B. Resident #17 (assailant) 1. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included major depressive disorder, traumatic brain injury, cognitive communication deficit and a need for assistance with personal care. According to the 12/18/25 MDS assessment, the resident had severe cognitive impairment with a BIMS score of two out of 15. The MDS assessment indicated the resident had wandering and aggressive behaviors that affected other residents. 2. Record review Resident #17's behavior care plan, revised 1/22/26, revealed Resident #17 had cognitive deficits and a history of inappropriate boundaries with a potential to demonstrate physical behaviors when another resident wandered into his room and touched his belongings. Interventions included applying retractable straps placed in front of his door that both he and his roommate could remove in the hopes of deterring other residents who may attempt to wander into the room. V. Incident of physical abuse of Resident #14 by Resident #13 on 11/30/25 A. Facility investigation The facility investigation, dated 11/30/25, documented Resident #14 suffered physical abuse when Resident #13 hit Resident #14 with his wheelchair, knocking her to the floor, and then hit Resident #14 again while she was on the floor. Resident #13 became highly agitated during this encounter. The investigation documented Resident #14 sustained no physical injuries or psychosocial harm and denied any injuries, pain or fear. The investigation documented Resident #13's care plan was updated to reflect increased monitoring and supervision during mobility. The investigation documented: Based on staff statements, documentation review, resident assessments, and EMS findings, the investigation concluded that physical contact was made. The contact appeared to be the result of dementia-related agitation and impulsive wheelchair propulsion, not an intentional attempt to harm. The investigator concluded that staff followed procedures for responding to resident-to-resident altercations. B. Observations During a continuous observation on 2/23/26 from 2:40 p.m. to 3:30 p.m Resident #14 was holding Resident #13's hand and leaning on his shoulder. Resident #14 was sleeping in his wheelchair in the common area. Staffed intervened and said Resident #14 thought Resident #13 was her boyfriend and that he was good with her until he recognized he did not know her and looked at Resident #14 and told her I don't know you and wanted her to leave him alone. Cross-reference F744 for failure to provide treatment/services for residents with dementia. C. Resident #14 (victim) 1. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included severe dementia, psychotic disturbances, anxiety, depression, and adult failure to thrive. According to the 12/23/25 MDS assessment the resident had severe cognitive impairment with a BIMS score of four out of 15. The MDS assessment indicated the resident had delusional beliefs towards others and displayed physical and verbal aggressive behavioral symptoms directed toward others. 2. Record review Resident #14's behavior care plan, revised 12/26/25, documented the resident had a potential to be on the receiving end of physical aggression. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalated the resident's behavior and documenting. VI. Incident of physical abuse of Resident #14 by Resident #8 on 12/20/25 A. Facility investigation The facility investigation, dated 12/20/25, documented Resident #8 placed her hands on Resident #14 shoulders and pushed Resident #14 as she was walking down the hall and told her You need to walk faster. Resident #14 responded I'm going. The investigation documented the residents were separated, immediate safety measures were put into place and there were no physical or psychosocial injuries noted. The investigation documented Resident #8's care plan was reviewed and no changes to treatment were made. -The facility unsubstantiated that abuse occurred; however, abuse occurred because Resident #8 pushed Resident #14 in order to make her walk faster. B. Resident #8 (assailant) 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included bipolar schizoaffective disorder, severe dementia with other behavioral disturbance and insomnia. According to the 1/13/26 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The MDS assessment indicated the resident had physical behaviors directed toward others. 2. Record review Resident #8's behavior care plan, initiated 10/9/24, revealed the resident had behavioral problems with the potential to initiate physical aggression. -However, the care plan failed to document any interventions to prevent Resident #8 from becoming physically aggressive toward other residents. VII. Incident of physical abuse of Resident #9 by Resident #10 on 2/5/26 A. Facility investigation The facility investigation, dated 2/5/26, documented Resident #10 took Resident #9's face in her hands and pushed her face away from her. The investigation documented the residents were separated, immediate safety measures were put into place and there were no physical or psychosocial injuries noted. The investigation documented Resident #10's care plan was reviewed and updated, and systemic interventions were implemented to reduce the risk of recurrence. No changes to treatment were made. The two residents were roommates and remained living in the same room with no additional interventions implemented. The investigation indicated the facility did not substantiate the abuse, however, abuse occurred as Resident #10 took Resident #9's face and pushed it away from her. B. Resident #9 (victim) 1. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia and major depressive disorder. According to the 12/23/25 MDS assessment, the resident had severe cognitive impairment with a BIMS score of zero out of 15. 2. Record review Resident #9's behavior care plan, initiated, 7/12/22, revealed the resident had no other documented instances of physical aggression in the past year. C. Resident #10 (assailant) 1. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included severe dementia with other behavioral disturbances and insomnia. According to the 12/29/25 MDS assessment, the resident had severe cognitive impairment with a BIMS score of zero out of 15. 2. Record review Resident #10's behavior care plan, initiated, 3/6/24, revealed the resident could become physically and verbally aggressive towards others when they invaded her personal space. VIII. Incident of physical abuse of Resident #9 by Resident #18 on 2/19/26 A. Facility investigation The facility investigation, dated 2/19/26, documented several scenarios of the incident and did not give clear descriptions of what occurred in the course of the incident. In the conclusion of the investigation, the document revealed that Resident #18 became upset in the common area when Resident #9 was seated in her preferred location and chair in the common area near her walker and Resident #18 wanted Resident #9 to move. The investigator documented due to cognitive impairment and decreased ability to interpret social situations, Resident #18 became verbally distressed and raised her voice yelling at Resident #9. Resident #18 reached toward Resident #9 during the altercation. In the alteration Resident #9 was moving from the chair and fell to the floor. Resident #9 received a cut to her forehead and required first aid care with steri strips applied to the wound. The investigator unsubstantiated the allegation of resident-to-resident abuse because there was no evidence of intentional harm, malicious intent, or staff neglect. -However, the facility failed to take into account the regulatory definition of abuse and the importance of considering willful and abusing actions towards another resident. B. Resident #18 (assailant) 1. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included Alzheimer's disease, dementia and bipolar schizophrenia. According to the 12/22/25 MDS assessment, the resident had severely impaired cognition with a BIMS score of one out of 15. The MDS assessment indicated the resident experienced hallucinations and delusions. The MDS assessment did not indicate the resident had physically aggressive behaviors towards other residents. 2. Record review Resident #18's behavior care plan, initiated, 9/10/25, revealed the resident had impaired coping skills, poor impulse control, and fluctuating mood. She was at risk for emotional dysregulation, verbal outbursts, and occasional physical aggression, particularly when overstimulated, questioned repeatedly, or when personal boundaries were perceived to be violated. Interventions included focusing on redirection and environmental modification, offering and encouraging activities, such as music listening and other structured engagement, such as bingo. When the resident was overstimulated, staff was to offer a quieter setting and approach the resident with clear communication in a calm and respectful manner. IX. Incident of physical abuse of Resident #8 by Resident #9 on 2/15/26 A. Facility investigation The facility investigation, dated 2/15/26, documented Resident #9 wandered into Resident #8's room and grabbed and scratched Resident #8 on the hand. The investigation documented the residents were separated and relocated to different quiet areas with staff supervision to maintain safety. Resident #8 received first aid care medical attention, however did not display pain, or fear. The investigation documented Resident #9's care plan was reviewed and the existing care plan was reinforced with staff education. X. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/23/26 at 3:51 p.m. LPN #1 said the younger residents in the secure memory care unit had more mental health issues compared to the older residents who typically had dementia. LPN #1 said the younger residents tended to irritate the older residents that had dementia. LPN #1 said all the residents wandered and many would wander into other residents' rooms. LPN #1 said that staff did not do anything to prevent the unauthorized entry of residents into other residents' rooms. LPN #1 said if a resident wandered into another resident's room, the staff would redirect the resident after they entered another resident's room. LPN #1 said she did not remember the last time she had to report an abuse incident between residents, because resident-to-resident altercations mostly happened at night or on the weekends. LPN #1 attributed less altercations occurring on the day shift to the residents being more familiar with the long-term staff who worked the day shift on a regular basis. LPN #1 said nights and weekends were often staffed with temporary agencies who did not know the residents well and the residents did not know the staff very well. Certified nurse aide (CNA) #1 was interviewed on 2/25/26 at 1:30 p.m. CNA #1 said most of the residents, if not all of the residents, wandered and would wander into other residents' rooms on a frequent basis. CNA #1 said he would recommend that each resident's room have a red barrier strip applied across the threshold of the residents' room doors to prevent wandering residents from entering another resident's room that was not theirs. CNA #1 said that would prevent most resident-to-resident altercations. CNA #1 said having more activities and activities staff on the secure memory care unit would also be helpful in preventing resident-to-resident altercations. LPN #3 was interviewed on 2/24/26 at 9:51 a.m. LPN #3 said it was hard to anticipate the residents' behaviors as the residents had a lot of frontal lobe issues and had many memory issues. LPN #3 said this impairs their ability to regulate their emotions and things could change in an instant. LPN #3 said increased activities helped the residents' behavior. LPN #3 said overall, staff were doing a good job interacting with residents in the secure memory care unit. CNA #10 was interviewed on 2/26/26 at 1:20 p.m. CNA #10 said if residents were fighting, staff were to separate and distance the residents from each other. CNA #10 said if a resident walked into another resident's room, staff were to tell that resident not to go into other residents' rooms. The NHA was interviewed on 2/26/26 at 5:00 p.m. The NHA said the facility was working hard to prevent resident-to-resident abusive behaviors from occurring and were in the process of hiring a consultant to help reorganize the facility's approach to dementia-managed care. XI. Failed to protect Resident #19 and Resident #20 from verbal and physical abuse towards each other on 2/18/26 A. Facility investigation The 2/18/26 facility investigation revealed the following: Resident #19 and Resident #20 got into a physical altercation on 2/18/26. The residents were roommates and reported increasing tension over the days prior to the incident, particularly due to disagreements regarding television (TV) noise in their shared resident room area. The physical altercation resulted in Resident #19 falling on the floor. Following the incident, Resident #19 had a small abrasion on his left knee, but no other injuries were found on either resident. Both residents were interviewed by the facility following the altercation. Resident #19 said tension was building between the he and Resident #20, and that day it boiled over. Resident #19 said the incident began with verbal taunting and then escalated to pushing, finally resulting in him falling over. Resident #20 said he did not recall the incident clearly but remembered there was some pushing. The facility substantiated the incident of physical abuse and determined the root cause of the incident was Resident #19 and #20 living together. The root cause was rectified and Resident #20 was moved to another room. B. Resident #19 (victim and assailant) 1. Resident status Resident #19, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnoses included memory deficits following stroke, history of falling and history of transient ischemic attacks (mini strokes). The 11/27/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. The assessment indicated the resident did not have any aggressive behavior towards others. 2. Resident interview Resident #19 was interviewed on 2/25/26 at 2:43 p.m. Resident #19 said he had a recent altercation with his roommate (Resident #20) over the TV noise in their room. He said it started when he flipped off his roommate because the TV was too loud. He said they both exchanged verbally hostile remarks until he asked Resident #20 if he wanted to fight. He said Resident #20 came over and hit his leg, which resulted in a shoving match between them and eventually leading to him (Resident #19) falling down. Resident #19 said he felt better now that he and Resident #20 resided in different rooms. 3. Record review Resident #19's behavior care plan, initiated 9/9/24, revealed the resident had the potential to display physical aggression and had poor impulse control. Pertinent interventions included attempting to find triggers for behaviors and de-escalating and discussing the resident's aggressive behavior in a private area. C. Resident #20 (victim and assailant) 1. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnoses included cancer and hip fracture. The 11/27/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The assessment indicated the resident did not have any aggressive behavior towards others. 2. Resident interview Resident #20 was interviewed on 2/24/26 at 2:10 p.m. Resident #20 said he did not know exactly what happened the day of the incident with Resident #19 (2/18/26) and he was unsure how things escalated. He said he was not fearful or nervous of Resident #19 and was not injured during the incident. 3. Record review Resident #20's behavior care plan, initiated 2/18/26, revealed the resident had the potential to display physical aggression. Pertinent interventions included administering medications as ordered, approaching the resident in a calm manner and de-escalating and discussing the resident's aggressive behavior when appropriate. D. Staff interviews LPN #4 was interviewed on 2/26/26 at 3:48 p.m. LPN #4 said abuse could be considered anything from bullying to stealing. She said when resident-to-resident abuse was witnessed, she would separate the residents and figure out what happened. She said there had been no other issues between Resident #19 and Resident #20 after Resident #20 was moved to a different room. CNA #9 was interviewed on 2/26/26 at 3:34 p.m. CNA #9 said anything could be considered abuse, from hitting to sexual abuse. She said Resident #19 was very independent and sometimes did not get along well with others. She said Resident #19 was pretty easy to redirect when he got frustrated. She said there had been no further issues between Resident #19 and Resident #20 since Resident #20 was moved to a different room.

Based on observations, record review and interviews, the facility failed to ensure residents who were diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practical physical, mental, and psychological well-being for nine (#15, #14, #9, #8, #13, #17, #10, #24 and #25) of 11 residents reviewed for dementia care out of 25 sample residents.Specifically, the facility failed to develop and implement effective person-centered dementia management interventions to prevent Residents #15, #14, #9, #8, #13, #17, #10, #24 and #25 from wandering into other residents' rooms and/or engaging in resident-to-resident altercations.Findings include: I. Facility policy and procedure The Care of Dementia policy and procedure, revised April 2022, was provided by the regional nurse consultant on 2/25/26 at 12:00 p.m It read in pertinent part, It is the policy of this facility that all residents will have an individualized plan of care and have the least restrictive approaches to care. Staff are offered training in the care of the dementia population, appropriate approaches to care and managing behaviors. The interdisciplinary staff will initiate a thorough clinical assessment. Monitoring of mood, behavior and/or any psychosocial related issues will be used to identify possible underlying medical problems which may be causing the behavior problems. Social services will also meet with residents and attempt to identify possible psychosocial issues that may be causing behaviors and to develop a baseline social history. The interdisciplinary team (IDT) will review findings of evaluations and develop a plan of care addressing the resident's needs. The physician will be involved in plan of care and make any changes to medical regimen as necessary The facility will offer staff training regarding the dementia disease process, utilizing nationally recognized dementia care guidelines as the basis of the education, including what to expect with progression of the disease, care of this specialized population, approaches to intervening in a crisis situation and managing/monitoring behaviors.II. ObservationsDuring a continuous observation of the secure memory care unit on 2/23/26, beginning at 2:40 p.m. and ending at 3:30 p.m., the following was observed:Resident #25 was observed going into other residents' rooms The activities director (AD) was running a group activity with nine residents in attendance. The AD was applying temporary tattoos, reminiscing and refreshments then moving to a balloon toss activity. While the activity occurred, six residents were observed wandering the halls, pacing back and forth, with no particular purpose but walking and looking down the hall. Resident #14 was observed at the back patio door trying to get outside but the door was locked. The resident was becoming frustrated and continually pushing on the door. After approximately 10 minutes at the door, staff approached the resident and gave her a walker and assisted her to the main common area of the unit. Resident #14 began to wander the unit on her own, heading to the front door of the unit that led to the other community areas. The resident proceeded to try to exit the front door of the unit, for approximately two minutes, before heading back to the common space on the other end of the unit. No staff members had Resident #14 in their line of sight and were not watching her wandering. Resident #24 walked up the hall, stopping several times to look over the hall environment, and then he wandered into several rooms, shutting the door after entering each room. One room belonged to a female resident and the other room belonged to a male resident. No staff members were monitoring or redirecting Resident #24 as he was wandering in and out of other residents' rooms. The female resident's room Resident #24 entered was empty, however the male resident's room he wandered into was occupied by the male resident. Resident #24 remained in each room for a couple of minutes before moving to the next room. He eventually found his own room and went inside.Resident #9 was wandering up and down the halls. She roamed, standing in the middle of the hall for several minutes between walking. She entered another resident's room but then exited when she noted she was being observed. Neither Resident #24 or Resident #9 were being monitored by staff as they entered other residents' rooms.At 3:30 p.m. Resident #15 was observed wandering the hallway without staff assistance or direction. He was going into other residents' rooms. No staff were monitoring his activity or providing redirection to the resident. On 2/23/26 at 3:40 p.m. Resident # 14 was observed touching Resident #13 on his head and holding his hand. Resident #14 was resting her head on Resident #13. No staff monitored or redirected the behavior. -However, Resident #13 had been identified as having a tendency to become aggressive when others got into his personal space (see record review below).During a continuous observation of the secure memory unit on 2/24/26, beginning at 10:20 a.m. and ending at at 11:34 a.m., the following observations were made:Resident #24 was observed pacing the hallways and entering and leaving several other residents' rooms. He was observed wandering around without purpose. Resident #24 wandered into Resident #17's room. Resident #17's room did not have the barrier strap (a wide red cloth strap velcroed to each side of the room's doors) in place that was meant to keep wandering residents out of his room.-However, Resident #17 had been identified to not like others in his room and often became physically aggressive towards other residents who wandered into his room (see record review below). During a continuous observation of the secure memory care unit on 2/25/26, beginning at 10:25 a.m. and ending at 11:53 a.m., the following was observed: At 11:08 a.m. Resident #24 was observed wandering the hallways and going into several residents' rooms. Resident #24 entered Resident #17's room at approximately 11:40 a.m. No staff members monitored his activity or redirected him. Resident #24 continued to wander until 11:50 a.m. when CNA #4 redirected Resident #24 to the dining room.III. Resident #15 A. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included adult failure to thrive, dementia and repeated falls. The 11/30/25 minimum data set (MDS) assessment revealed the resident had severely impaired cognition. The resident was not able to complete the brief interview for mental status (BIMS) assessment. Staff assessment of the resident's cognition revealed the resident had severe cognitive impairment and he never or rarely made decisions of daily life. The MDS assessment revealed that the residents behaviors included wandering and physically aggressive behaviors that could put others at risk for injury. B. Record reviewAccording to the behavior care plan, initiated, 2/23/26, Resident #15 had aggressive behavior. The resident would become combative towards staff during hands-on care and often refused care assistance. Interventions included approaching the resident face-to-face and slowly explaining what care would be provided and why. Staff were to document and observe the behavior and what attempted interventions were used. According to the cognitive decline/dementia care plan, initiated 11/30/25, the resident was at risk for impaired cognitive function, and impaired thought processes due to symptoms of dementia. The resident was at risk for falls; and unintended privacy breaches related to cognitive impairment and wandering behaviors. Interventions included communication and making eye contact, using simple directive sentences, keeping routines consistent and staff anticipating wandering patterns, providing early staff-led redirection when the resident approached other residents' rooms and reinforcing expectations that staff, not other residents, would perform redirection. If the resident entered another resident's room, staff were to intervene immediately, escort the resident back to the common area or hallway, and restore privacy. Review of Resident #15's elopement risk/wandering care plan, initiated 11/28/25, the resident was an elopement risk due to wandering and exit-seeking behavior. Interventions included identifying pattern and purpose of wandering, intervening as appropriate and documenting wandering behaviors and the attempted diversional interventions.-However, staff were not observed to be following the care plan interventions to prevent Resident #15 from wandering into other residents' rooms (see observations above). Review of Resident #15's daily activity tracking documentation revealed the resident wandered almost daily, (22 out of 31 days in December 2025 and 28 out of 31 days in January 2026) exploring the environment, observing surroundings and visiting other residents. IV. Resident #14 A. Resident statusResident #14, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnosis included dementia, adult failure to thrive, anxiety disorder and difficulty walking. The 12/23/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. The MDS assessment indicated the resident had verbal and physical behavioral symptoms that were directed towards others.The MDS assessment did not indicate the resident wandered. B. Record reviewReview of Resident #14's elopement risk/wandering care plan, initiated, 3/28/25, revealed the resident was at risk for elopement and wandering. Interventions included identifying if the resident's wandering was purposeful or if it was aimless and if the resident was looking for something. Review of Resident #14's daily activity tracking documentation revealed the resident wandered almost daily, (30 out of 31 days in December 2025, 24 out of 31 days in January 2026 and 18 out of 28 days in February 2026).V. Resident #9 A. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnosis included heart disease, major depressive disorder and dementia. The 12/23/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. The MDS assessment indicated the resident did not have any physical or verbal behaviors, but did wander daily. B. Record reviewReview of Resident #9's wandering care plan, initiated 3/14/24, revealed the resident frequently wandered throughout the secured unit looking for her room. The resident had a decreased ability to interpret social interactions, increasing misunderstanding for resident-to-resident contact. Interventions included providing structured activities, toileting assistance, walking inside and outside and utilizing reorientation strategies, including signs, pictures and memory boxes.-However staff were not observed monitoring or redirecting Resident #11 while she was wandering (see observations above). Review of Resident #9's daily activity tracking documentation revealed the resident wandered frequently, (24 out of 31 days in December 2025, 15 out of 31 days in January 2026 and six out of 28 days in February 2026).VI. Resident #8 A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnosis included schizoaffective disorder and dementia. The 1/13/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS) score of zero out of 15. The MDS assessment indicated the resident did not have physical or verbal behaviors and did not wander. B. Record reviewReview of Resident #8's elopement care plan initiated 10/9/24, revealed the resident was at risk for elopement and wandering. The resident preferred to spend the majority of her days in her room either resting or rummaging through her items. The resident had a history of becoming upset if other residents entered her room or stood too long outside of her door. Interventions included identifying if the resident's wandering was purposeful.Review of Resident #8's daily activity tracking documentation revealed the resident wandered into other residents' rooms occasionally.VII. Resident #13 A. Resident statusResident #13, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia, Alzheimer's disease and depression. The 12/5/25 MDS assessment revealed the resident had severely impaired cognition with a BIMS score of four out of 15. The MDS assessment indicated that the resident did not have physical or verbal behaviors but did wander. B. Record reviewReview of Resident #13's elopement care plan revealed the resident was an elopement risk and wandered. The resident had a potential for physical aggression and was territorial. Interventions included diverting the resident's attention and removing the resident to an alternate location if wandering was unsafe. The residents' triggers for behavioral aggression included the resident feeling like others were going into his room uninvited and other residents entering into his personal space.-However, observations of Resident #13 in the secure memory care unit's common spaces and staff interactions revealed the unit staff did not provide Resident #13 with supervision or redirection when other residents were heading towards his room or when other residents were in close proximity to him and in his personal space (see observations above.Review of Resident #13's daily activity tracking documentation revealed the resident wandered frequently (22 out of 31 days in December 2025 20 out of 31 days in January 2026 and six out of nine days in February 2026).VIII. Resident #17 A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnoses included major depressive disorder, insomnia, personal history of traumatic brain injury and cognitive communication deficit. The 12/5/25 MDS assessment revealed the resident was severely impaired with a BIMS score of four out of 15. The MDS assessment indicated that the resident did not have physical or verbal behaviors, and did not wander. B. Record reviewReview of Resident #17's elopement risk wandering care plan, initiated 10/8/25, revealed the resident was an elopement risk and wandering risk with a potential to demonstrate physical behaviors when others wandered into his room and touched his belongings. Interventions included identifying patterns of wandering and intervening as appropriate to provide structured activities. Retractable straps would be placed in front of his door that both he and his roommate could remove in hopes of deterring other residents who may attempt to wander into his room.-However, the retractable straps intervention was not observed to be in place consistently (see observations above). Review of Resident #17's daily activity tracking documentation revealed the resident wandered frequently (28 out of 31 days in December 2025 21 out of 31 days in January 2026 and nine out of 28 days in February 2026).IX. Resident # 10 A. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnosis included anxiety disorder, dementia and muscle weakness. The 12/29/25 MDS assessment revealed the resident was severely impaired with a BIMS score of zero out of 15. The MDS assessment indicated the resident did not have physical or verbal behaviors and did not wander. B. Record reviewReview of Resident #10's behavior care plan initiated 3/6/24, revealed the resident could become physically aggressive towards others. Interventions included providing food, distraction, offering country music to listen to or to write in a book. The resident persevered with other residents going into her room. Review of Resident #10's elopement care plan initiated 3/11/24, revealed the resident was at risk for elopement and could be disoriented to place. Interventions included staff were to redirect the resident as needed.Review of Resident #10's daily activity tracking documentation revealed the resident wandered frequently (27 out of 31 days in December 2025 14 out of 31 days in January 2026 and six out of six days in February 2026).X. Resident #24 A. Resident statusResident #24, age less than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnosis included Alzheimer's disease and degenerative disease of the nervous system. The 12/22/25 MDS assessment revealed the resident was moderately impaired, per the staff assessment for mental status. The MDS assessment indicated the resident did not have physical or verbal behaviors, but did wander daily, which significantly intruded on the privacy of others. B. Record reviewReview of Resident #24's wandering care plan revealed the resident wandered frequently. Interventions included identifying if the wandering was purposeful, aimless, or escapist and providing redirection interventions as appropriate. XI. Resident #25 A. Resident statusResident #25 age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnosis include dementia, type 2 diabetes and depression. The 1/13/26 MDS assessment revealed the resident was severely impaired with a BIMS score of zero out of 15. The MDS assessment indicated the resident did not have physical behaviors and did not wander, but did have verbal behaviors and behaviors that could include hitting or scratching self B. Record reviewReview of Resident #25's wandering care plan, initiated 7/16/25, revealed the resident wandered frequently. Interventions included using redirection and diversional interventions, and identifying a pattern of wandering.XII. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 2/25/26 at 11:50 a.m. CNA #5 said she was not aware of Resident #10 displaying aggressive behaviors towards Resident #9 on 2/5/26. She said this was the first time that she had heard there may be problems with their interactions with each other. CNA #5 said Resident #9 was friends with Resident #10 and that was why Resident # 9 and Resident #10 were roommates. Cross-reference F600 for failure to keep residents free from abuse.CNA #5 said there were a few residents that wandered, including Resident #24, Resident #15, Resident #9 and a few others. CNA #5 said she did de-escalate residents when they got involved in resident-to-resident altercations. She said staff were trying to do restraints without actually restraining residents, but she was unable to explain what she meant by that. CNA #5 said when a resident complained about other residents wandering into their rooms, the staff would put up a red barrier strap across the door to prevent the other residents from entering.-However, the retractable straps intervention was not observed to be consistently in place on Resident #17's door (see observations above).Licensed practical nurse (LPN) #1 was interviewed on 2/25/26 at 11:30 a.m. LPN #1 said he had worked at the facility on the secured memory care unit for several years. He said the biggest problem in the dementia unit was the younger residents bothering the older residents. He said that all of the residents wandered and this was especially true for Resident #24. LPN #1 said the staff did not prevent the residents from wandering unless they saw a resident go into another resident's room that was not theirs and then staff would redirect the resident out of the other residents' rooms as a preventative manner.-However, staff were not observed to be consistently redirecting residents out of other residents' rooms (see observations above).LPN #1 said that activities were good for the residents and the programs were improving as well.CNA #4 was interviewed on 2/25/26 at 1:30 p.m. CNA #4 said a lot of residents, if not all residents, had wandering behaviors and wandered into other residents' rooms. Cross -reference F600 for failure to keep residents free from abuse.CNA #4 said that he had made the recommendation of having a red stripe barrier placed on all the residents' rooms to prevent wandering. He said the activities programming in the secure memory care unit was getting better. He said when a resident did not participate in activities, he would try and get them reengaged with that activity.LPN #2 was interviewed at 10:35 a.m on 2/26/26. LPN #2 said Resident #24 wandered the most out of all the residents. He said unfortunately they could not stop residents from going into other residents' rooms. He said they could try to redirect the residents from wandering into other residents' rooms but it was difficult LPN #2 said the energy in the secure memory care unit changed quickly and it was difficult to manage sometimes. He said activities programming was important to keep the residents occupied and engaged. He said he would like to see more one-to-one activities with residents but he said he knew that this was difficult, based on staffing and the need for the staff to attend to the residents' care needs. LPN #2 said training on resident care plans and interventions was provided and when provided for the residents, the care planned interventions made the day-to-day activities in the unit run more smoothly.CNA #10 was interviewed on 2/26/26 at 1:20 p.m. CNA #10 said when resident-to-resident altercations occurred, he would separate the residents and redirect the residents away from each other. CNA #10 said it was most beneficial to prevent residents from going into another resident's room initially. He said he did this by telling the resident not to go into another person's room. He said he did not know where the residents' care plans were, but knew that they were somewhere in the office. The nursing home administrator (NHA) was interviewed on 2/26/26 at 4:46 p.m. The NHA said the facility was working hard to prevent resident-to-resident altercations and abusive behaviors between residents. She said the facility's leadership team had implemented training for staff to learn redirection techniques for residents. She said leadership was working on contracting with a specialist in dementia-managed care to assist staff with providing improved care and services for residents diagnosed with dementia.

Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident abuse prevention.Specifically, the facility failed to ensure contracted and agency staff met training requirements, including timely reporting of suspected abuse. Findings include:I. Facility policy and procedureThe Abuse policy, revised April 2025, was provided by the regional nurse consultant on 2/23/26 at 12:00 p.m. The policy read in pertinent part, The facility will provide oversight and monitoring to ensure its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy. This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the facility. II. Record review and staff interview An allegation of neglect incident report, dated 11/25/25, documented the allegation was initiated by a hospice certified nurse aide (CNA) who believed a resident being provided care by himself and his contracted hospice provider was being neglected by the facility when the resident was left wet for an extended period of time. The incident report and facility investigation revealed the contracted hospice CNA failed to report suspected neglect in a timely manner. The incident report documented that although the hospice CNA witnessed suspected neglect on 11/9/25, the allegation was not reported to the facility until 11/19/25, ten days later. A request was made to the regional nurse consultant on 2/24/26 at 12:00 p.m. for documentation of training provided to contracted and agency staff working with the facility's residents, in relation to the facility's policies and procedures and expectations for reporting abuse. The regional nurse consultant provided training records of abuse identification, prevention and reporting for facility staff, however, she was unable to provide any facility-specific abuse training that had been provided to contracted or agency staff. The regional nurse said the contracted and agency staff members were trained on abuse by their agency, prior to coming to work at the facility.III. Staff interviewsCNA #6 was interviewed on 2/24/26 at 4:25 p.m. CNA #6 said she was an agency employee. She said the facility had not provided any supplementary training regarding facility policies and facility expectations related to abuse and neglect prior to her starting her shifts at the facility. The regional nurse consultant was interviewed on 2/25/26 at 4:23 p.m The regional nurse consultant said she thought the agency's and other contracted staff were educated on abuse by their agency and the facility did not need to provide additional training to the contracted and agency staff related to abuse and abuse reporting. The regional nurse consultant agreed it would be beneficial for the facility to provide a read and sign binder for agency and contracted staff so they were aware of relevant facility policies and expectations for reporting abuse. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 2/4/26 at 4:46 p.m. The DON said she thought the facility needed to work better with their hospice agency so the hospice agency had certain points of contact to keep in touch with facility leadership when concerns occurred. The DON said the facility had not provided training to agency staff in relation to reporting abuse, but they were planning to develop educational binders that could be used for agency staff training.

Based on observations, interviews and record reviews, the facility failed to conduct a thorough investigation into an allegation of physical abuse of a resident by staff for one (#23) of three residents reviewed out of 25 sample residents.Specifically, the facility failed to conduct a thorough investigation in order to assess all facts of Resident #23's allegation of abuse by certified nurse aide (CNA).Findings include:I. Facility policy and procedureThe Abuse: Prevention of and Prohibition Against policy and procedure dated November 2017 was provided by the regional nurse consultant on 2/23/26 at 2:45 p.m. It read in pertinent part: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. The facility will act to protect and prevent abuse and neglect from occurring within the facility by: supervising staff to identify and correct any inappropriate or unprofessional behaviors. The investigation will include an interview with staff members (on all shifts) who may have information regarding the alleged incident; and an interview with staff members (on all shifts) having contact with the accused employee. At the conclusion of the investigation, the facility will take action, as necessary, in light of the information gathered, which may include but is not limited to defining how care provision will be changed and/or improved to protect residents receiving services, if appropriate.II. Allegation of physical abuse of Resident #23 by CNA #3A. Facility investigationThe facility investigation, dated 1/9/26, documented Resident #23 reported CNA #3 provided rough and unnecessary care while assisting her in the shower on the evening of 1/8/26. Resident #23 filed a grievance on 1/9/26 at 10:30 a.m., revealing she felt she was physically abused by CNA #3. Resident #23 said CNA #3 pushed her onto the bath chair and then threw a towel at her and told her to wash herself. The facility's interview with Resident #23, dated 1/9/26 at 7:54 p.m., documented Resident #23 said CNA #3 pushed her onto the bath chair, a towel was thrown at her and then CNA #3 told the resident to wash herself. The interview documented Resident #23 was unable, during the interview, to provide the date that the incident occurred. The investigation revealed the social services director (SSD) interviewed Resident #3 about the incident. The investigation documented Resident #23 initially appeared emotionally distressed and tearful, with a flat affect and guarded posture. However, as the conversation progressed and reassurance and emotional support were provided, the resident's affect improved.The facility's investigation documented the SSD assessed Resident #23's ability to recall the timing of the allegation and concluded the resident was a poor historian, with difficulty recalling long-term details. When asked, the resident said she had no concerns about CNA #3 continuing to work in the facility but Resident #23 did not want CNA #3 taking care of her again. CNA #3 was suspended during the investigation. CNA #3 was interviewed on 1/14/26 by the SSD. CNA #3 denied the allegation made by Resident #23 and said she had not provided care assistance to the resident in a long time. -However, the investigation report did not document the last date that CNA #3 was assigned to the resident's care or assisted another staff member to care for Resident #23.The facility's investigation documented the allegation of abuse was unsubstantiated based on a lack of corroborating evidence, inability to identify a specific timeframe for the incident, and findings consistent with the resident's care being routine and appropriate to the resident's functional limitations.However, the facility's investigation failed to reveal documentation of the following: -The facility's investigation failed to document interviews with other CNAs or nursing staff who worked with Resident #23 to determine if the resident had reported rough care or problems with showering assistance with other staff members during the time of the incident or the initial investigation.-The facility's investigation failed to document interviews with other residents to determine if other residents had concerns related to the care provided by CNA #3.-The facility's investigation failed to thoroughly assess the condition of the shower area to determine if there were any environmental factors that may have contributed to the resident feeling like she was abused. -The facility's investigation failed to include documentation to indicate attempts were made to observe and assess CNA #3's performance while the CNA was assisting residents with showering and transfer assistance to ensure her understanding of safe transfers in the shower area. B. Resident #231. Resident status Resident #23 age [AGE], was admitted to the facility on [DATE]. According to the February 2026 CPO, diagnoses included a previous knee injury, generalized weakness and a history of falling. The 1/9/26 MDS assessment revealed the resident had moderately impaired cognition with a BIMS score of 10 out of 15. The resident required assistance from one to two staff members for transfers and bathing.2. Resident interview Resident #23 was interviewed on 2/25/26 at 2:40 p.m. Resident #23 said she had a bad experience in the facility when CNA #3 provided her with rough care on more than one occasion, so she filed a complaint. Resident #23 said CNA #3 was assisting her to take a shower but CNA #3 pushed her onto the bath chair, threw the wash cloth on her and told her to wash herself. Resident #23 said CNA #3 was mean to her another time and told her to put herself to bed. Resident #23 was near tears and became upset, speaking loudly with a reddened face, when recalling these events and repeating that she did not want to work with CNA #3 again.Resident #23 said no other staff members were around to observe the incidents with CNA #3 and so she stood up for herself and filed complaints about CNA #3's treatment towards her. Resident #23 said reiterated that never wanted CNA #3 to help her again.3. Record review Resident #23's behavior care plan, initiated 9/11/25, revealed Resident #23 had a potential for a behavior problem related to persistent depression disorder, anxiety and insomnia.Interventions included encouraging the resident to verbalize feelings related to her emotional state, monitoring behavior episodes and attempting to determine underlying cause, considering location, time of day, persons involved, and situations and documenting behavior and potential causes.-The behavior care plan revealed the resident required two staff members with bathing. III. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 1/26/26 at 4:45 p.m. The DON said CNA #3 denied the allegations made by Resident #23. The DON said Resident #23 was now being provided with care in pairs (more than one staff member) since the resident made the allegation of abuse against CNA #3, in order to protect the resident and the staff. The DON and the NHA said facility staff were provided training on how to work with residents with limited cognitive and physical functioning. The DON said Resident #23 had a history of depression and stroke and it was difficult to get detailed information from her during the investigation of the allegation. The DON said they did not do any additional investigating of the allegation, other than what was documented in the facility investigation provided during the survey. The DON said only one other resident complained about CNA #3 as a care giver ( on 2/12/26). She said the facility changed that resident's caregiver assignment so CNA #3 no longer worked with her and that was the end of the resident's concerns.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL), received the necessary services to maintain good personal hygiene for one (#4) of five residents out of 25 sample residents. Specifically, the facility failed to ensure Resident #4 received timely incontinence care.Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADL) policy and procedure, revised December 2025, was provided by the regional nurse consultant on 2/24/26 at 12:00 p.m. It read in pertinent part, Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff.II. Resident #4A. Resident statusResident #4, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included schizophrenia, an unspecified mood and behavior disorder and epilepsy.The 9/30/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident was dependent on staff assistance for toileting hygiene.B. Observations and staff interviewsDuring a continuous observation on 2/24/26, beginning at 9:20 a.m. and ending at 11:45 a.m., and again, beginning at 11:46 a.m. and ending at 12:18 p.m., the following was observed:At 9:20 a.m. Resident #4 was in his room lying in bed. At 9:50 a.m. an unidentified activities staff member knocked on the resident's door, observed that the resident was sleeping and walked away without fully entering the room.At 10:49 a.m. the hospice social worker entered Resident #4's room to talk with the resident.At 12:07 certified nurse aide (CNA) #7 entered Resident #4's room to check on the resident. CNA #7 proceeded to provide the resident with incontinence care. After checking the resident's brief, CNA #7 changed both the resident's brief and the resident's bed linens which had been soiled. CNA #7 showed Resident #4's brief which was soiled with urine.CNA #7 was interviewed on 2/24/26 at 12:18 p.m. CNA #7 said she did not know exactly when Resident #4 was last changed, but she thought it must have been before her shift started at about 6:00 a.m., when the resident would have been getting showered by hospice staff. She said she had not checked him for incontinence since her shift started at 6:00 a.m. CNA #7 did not say why she had not checked Resident #4 for incontinence since the beginning of her shift. -Resident #4 had not been provided with incontinence care in over six hours. C. Resident's representative interviewResident #4's representative was interviewed on 2/24/26 at 2:37 p.m. The resident's representative said she did not think the facility provided Resident #4 with incontinence care often enough.D. Record reviewThe ADL care plan, revised 11/27/25, revealed Resident #4 had an ADL self-care performance deficit due to his schizophrenia and weakness. Pertinent interventions included substantial supervision, and encouragement due to frequent refusal of care.The nursing progress note, dated 3/29/25 at 5:48 p.m., documented Resident #4 urinated on the floor.The nursing progress note, dated 3/16/25 at 5:33 p.m., documented Resident #4 was found in bed with stool on the floor and urine soaked bed linens and clothing.III. Staff interviewsCNA #7 was interviewed a second time on 2/24/26 at 3:59 p.m. CNA #7 said Resident #4 often refused care and often removed his own briefs when he was wet. CNA#7 said Resident #4 would often just urinate in his bed and she thought he also urinated on the floor. She said he would often lay in urine soaked sheets and she was responsible for changing these urine soaked sheets. She said she had changed them during the previous interview and thought that was likely why his briefs were not particularly saturated. She said dependent residents needed to be checked on and/or changed every two hours.Registered nurse (RN) #4 was interviewed on 2/25/26 at 10:10 a.m. RN #4 said the expectation for checking and changing residents was once every two hours. She said Resident #4 refused care often and needed to be coaxed or bribed with things, such as candy, to agree to care assistance from staff. -However, no direct care staff were observed entering Resident #4's room to offer incontinence care during continuous observations of the resident (see observations above).CNA #5 was interviewed on 2/25/26 at 9:51 a.m. CNA #5 said she checked and changed the residents on her assignment as often as possible and every two hours at a minimum.CNA #8 was interviewed on 2/25/26 at 9:55 a.m. CNA #8 said dependent residents needed to be checked on and changed every two hours. She said Resident #4 needed to be checked on every two hours at minimum. Licensed practical nurse (LPN) #3 was interviewed on 2/25/26 at 10:00 a.m. LPN #3 said dependent residents needed to be checked on for incontinence and changed at least every two hours.The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 2/26/26 at 4:46 p.m. The NHA and the DON said the expectation was that staff would check on dependent residents for incontinence and change them, if needed, every two hours.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in three of five units.Specifically, the facility failed to:-Ensure common hallways were free from odors and clutter;-Maintain clean floors in the residents' rooms, hallways and secure unit dining room; and, -Ensure resident rooms and common hallways were in good repair.Findings include:I. Facility policy and procedure The Safe and Homelike Environment policy and procedure, revised January 2025, was provided by the nursing home administrator (NHA) on 12/18/25 at 7:01 p.m. It revealed in pertinent part, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The facility will provide and maintain bed linens that are in good condition. The facility will provide and maintain adequate and comfortable light levels in all areas, minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the housekeeping department.II. Resident group interviewFour residents (#16, #17, #18 and #19), who were cognitively intact and deemed interviewable by the facility and assessment were interviewed on 12/17/25 at 2:00 p.m. The residents said the facility often had odors of urine and feces.Resident #17 said the facility frequently smelled like feces when he walked through the 400 and 700 units.Resident #18 said the facility often had odors, which made her cover her mouth and nose with the palm of her hand.III. Resident representative interviewsResident #10's representative was interviewed on 12/17/25 at 1:39 p.m. The representative said she visited Resident #10 at least weekly and she said when she entered the 500 unit, it always smelled like feces and food. She said she did not like that the blinds were not in working order and the light above Resident #10's sink in his room was missing. She said she noticed that there were areas on the floor in the 500 unit that were sticky. The representative said social services handled the broken blinds but Resident #10 still did not have a light above his sink. Resident #14's representative was interviewed on 12/16/25 at 2:33 p.m. The representative said she had visited Resident #14 three times since she was admitted on [DATE]. The representative said she noticed the smell of urine and feces in the 500 unit and in Resident #14's room. The representative said she bought body spray for Resident #14 so her room would not smell. IV. Observations The following was observed throughout the facility on 12/16/25:At 10:08 a.m. room [ROOM NUMBER] was observed to have multiple stained footprints at the foot of the bed for bed A. At 10:09 a.m. the entrance to the secure unit had a strong smell of urine.At 10:14 a.m. the 700 unit had a strong smell of feces.At 10:17 a.m. the 700 unit's handrails were observed to have multiple paint chips on the right and left side of the hallway. The carpet throughout the unit was observed to have multiple stains. At 11:57 a.m. the entrance of the 500 unit was observed to have the smell of urine. At 11:59 a.m. the hallway next to room [ROOM NUMBER] was observed to have the smell of urine. At 12:09 p.m. prior to lunch being served, two of the four dining tables in the common area had multiple crumbs underneath the table. One of the four tables had dry stains underneath the table. In the adjacent common area with one dining table, there was a dry stain. At 12:25 p.m. there was a used water pitcher that had been filled with a thick, brown liquid on the round table in the sitting area at the end of the 200 unit. There were also used, crumpled linens found on the striped sofa and the green chair in the sitting area.At 12:30 p.m. certified nurse aide (CNA) #8 went into room [ROOM NUMBER] and walked out at 12:31 p.m. CNA #8 left the room's door open and the floor was observed to be wet. At 12:38 p.m. room [ROOM NUMBER] was observed to be sticky in the middle of the room and there was a crack below the sink. At 12:41 p.m. room [ROOM NUMBER] was observed to have dried feces next to the bed and the resident's walker. The bed sheet was stained with feces and the resident who resided in room [ROOM NUMBER] was lying in bed. The floor had a spill near the dried feces on the floor that was running towards the entrance of the room. The floor was sticky throughout the room. At 12:43 p.m. room [ROOM NUMBER] was observed to have a hairline crack on the right side of the bed. At 12:46 p.m. room [ROOM NUMBER] was observed to have a hairline crack on the wall behind the bed. At 12:50 p.m. the hallway next to room [ROOM NUMBER] was observed to have the smell of feces. At 1:43 p.m. the used water pitcher and linens were still found in the sitting area at the end of the 200 unit. At 3:32 p.m. room [ROOM NUMBER] was observed to still have dried feces and a spill next to the resident's bed. On 12/17/25 during a continuous observation from 11:13 a.m. to 12:30 p.m., the following was observed. At 11:13 a.m. the entrance of the 500 unit was observed to have the smell of urine. At 11:20 a.m. two of the four dining tables in the common area had multiple crumbs underneath the table. At 11:27 a.m. room [ROOM NUMBER] was observed. The spill on the floor that was observed on 12/16/25 had been cleaned. However, the floor was sticky next to the bathroom. At 12:00 p.m. the resident who resided in room [ROOM NUMBER] walked out of her room with both socks soaked with clear liquid. CNA #8 escorted the resident to her room and licensed practical nurse (LPN) #3 came with a mop and mop bucket. LPN #3 cleaned the area in the hallway. The water in the bucket was brown and murky. The following was observed throughout the facility on 12/17/25:At 11:15 a.m. there was a dried spill in the middle of the hallway at the entrance to the 200 unit. The handrails throughout the 200 unit had deep scratches and black scuff marks on them. There was an old medicine cup shoved between the handrail and the wall between room [ROOM NUMBER] and room [ROOM NUMBER]. At 11:41 a.m. the entrance to the 200 unit had a strong smell of urine. The floor was sticky outside of room [ROOM NUMBER] by the nurses' station.At 12:01 p.m. the baseboards throughout the 200 unit were observed to be scuffed and scratched.At 12:37 p.m. there were black scuff marks on the wall between room [ROOM NUMBER] and room [ROOM NUMBER].At 2:45 p.m. the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] smelled of urine. At 3:07 p.m. the hallway at the entrance of the 500 unit smelled of urine. At 4:25 p.m. the hallway next to room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] smelled of urine.At 4:34 p.m. the 200 unit had a strong smell of urine. The following was observed throughout the facility on 12/18/25:At 8:50 a.m. there was a used coffee mug and napkin found on the round table in the sitting area at the end of the 200 unit. There was a used linen crumpled up on the green sofa chair.At 8:55 a.m. the floor between room [ROOM NUMBER] and #515 had a hairline crack covering the length of half of the walkway space. On the other side of the hairline crack there was a discolored piece of laminate that was approximately five inches by 12 inches that was lifted and looked like a temporary fix to the crack along the hallway.At 8:57 a.m. room [ROOM NUMBER] was observed to not have a light bulb on the light above the sink in the room. From 8:59 a.m. to 9:12 a.m. an unknown housekeeper was observed cleaning the common areas in the 500 unit. The housekeeper did not sweep under one of the four tables and did not mop the common area. The dining table was observed with multiple food crumbs. One of the four dining tables had stains on the table. The 500 unit smelled of urine continuously from 8:55 a.m. to 10:29 a.m. At 1:31 p.m. the 400 hallway had a strong smell of urine.At 2:30 p.m. the entrance of the 500 unit was observed with the smell of urine.At 2:32 p.m. the hallways between room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were observed with the smell of urine and feces. V. Staff interviewsLPN #3 was interviewed on 12/17/25 at 4:30 p.m. LPN #3 said housekeeping was responsible for cleaning the units. LPN #3 said housekeeping should clean the facility's floors, including mopping the floors, on a daily basis. LPN #3 said he did not know what the frequency was for deep cleaning. LPN #3 said if there was a spill in the unit and housekeeping was in the unit, they were responsible for cleaning the spill. LPN #3 said the common area was cleaned after breakfast and he was unsure if it was cleaned more than that. LPN #3 said if he noticed a light was out, he used a maintenance application so maintenance was notified of the issue. LPN #3 said the maintenance department recently had turnover. LPN #3 said maintenance usually fixed issues submitted to them immediately, if not within a couple of days. LPN #3 said he did not work in the 500 unit until this week and he was not familiar with why Resident #10's light bulb was missing over his sink. The maintenance director (MTD) was interviewed on 12/18/25 at 3:50 p.m. during a facility walkthrough. The MTD said he was responsible for the facility's maintenance and housekeeping. He said the housekeeping team was responsible for cleaning spills and disinfection; however, the housekeepers would not make contact with bodily fluids. The MTD said the nursing staff were responsible for cleaning bodily fluid spills, then the area would be disinfected by housekeeping. The MTD said if the housekeeping team was not available, then nursing staff would be expected to clean the spills. The MTD said there were housekeeping rooms with cleaning supplies available, and the nursing staff could access the housekeeping room to grab the mop and a bucket of water. He said the nursing staff would leave the mop and bucket until the end of the day when housekeeping or maintenance would replace the water.The MTD said he was not aware the floors were sticky throughout the building. The MTD said he did not know what cleaning solution nursing used when they cleaned the floor and if the mop bucket water was brown and murky, it should be replaced and not be used. The MTD said if the floor was sticky, it was because thickener or juice spilled and the floor was not cleaned thoroughly. The MTD said if there were bodily fluids, such as feces and urine, the spill should be cleaned immediately. The MTD said he was not aware of room [ROOM NUMBER] needing to be cleaned on 12/16/25. He said it was not acceptable to leave the spill in the resident's room for several hours. The MTD said the industrial floor scrubber would be run twice per day - once before breakfast and again before lunch around 10:30 a.m. He said if there were residents in the dining area at the time the housekeepers arrived to clean the dining area, the housekeeping staff would not move the residents to clean the floor around the residents. The MTD said the housekeeper could have worked with the nursing staff to move the residents safely and get the area cleaned. The MTD said he did not know why the industrial floor scrubber was not used in the common area of the secured unit. He said he would talk to his housekeeping team. The MTD said he knew about the cracks in the floor of the secure unit. He said it was a foundational problem, and the foundation needed to be leveled out. He said he was waiting for a contractor to assess the situation to provide a quote for the cost of fixing the foundation. The MTD said the paint on the flooring near the housekeeping closet in the secure unit was caused by a bad paint job. He said he was working on repainting the entire facility unit by unit. He said he already had the supplies and the paint, and he planned to start repainting next week. The MTD said he was going to repaint the scratched handrails, and the facility planned to have the carpet changed next month.The NHA was interviewed on 12/18/25 at 5:52 p.m. The NHA said maintenance was responsible for housekeeping and for the day-to-day upkeep of the building. The NHA said she had one maintenance director. The NHA said she knew what maintenance was working on through a maintenance application. The NHA said the staff used to tell maintenance verbally what needed to be repaired and that it was hard to track what needed to be done. The NHA said she was working with staff to use the maintenance application so she could prioritize and track maintenance issues with the MTD. She said she was aware of the floor in the 500 unit being cracked. She said it was based on the foundation. She said if the floor was buckling, the facility should fix it. The NHA said she found out this week (the week of the survey) about the miscommunication between housekeeping and nursing regarding who was responsible for spills and where supplies were available. She said she hired a central supply person to ensure the facility had the right supplies and where the supplies should be stored. The NHA said there was a disconnect on where supplies were stored and they were not organized. The NHA said housekeeping needed education to ensure when they cleaned common areas that they cleaned all areas, including sweeping and mopping.

Based on record review and interviews, the facility failed to ensure residents and their representatives had a right to participate in the development and implementation of their person-centered plan of care for two (#10 and #15) of 12 residents out of 19 sample residents.Specifically, the facility failed to ensure residents' representatives had the opportunity to attend quarterly care conferences for Resident #10 and Resident #15. I. Resident #10 A. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia with behavioral disturbance, transient ischemic attack (TIA - a temporary blockage of blood to the brain), cerebral infarction (blood clot blocks blood to the artery), chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus with hyperglycemia (high blood sugar), anxiety disorder and depression. The 7/21/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of zero out of 15. The resident required maximal assistance with oral hygiene, toileting, dressing and personal hygiene. B. Resident's representative interviewResident #10's representative was interviewed on 12/17/25 at 1:39 p.m. The representative said she was invited to and participated in one care conference when Resident #10 was first admitted to the facility. The representative said she had not been invited to a care conference since July 2025. The representative said she recently had a voicemail from someone in social services to schedule a care conference and she called social services back but had not scheduled a care conference. The representative said it was frustrating not being able to have a care conference since July 2025 because there was a lot of miscommunication between nursing and social services. C. Record review The 7/25/25 interdisciplinary team (IDT) care planning review and conference assessment revealed Resident #10's representative attended the care conference. -A review of Resident #10's electronic medical record (EMR) revealed there was no documentation to indicate another care conference had taken place between 7/25/25 to 12/18/25. The 12/11/25 social services note revealed a call was placed (during the survey) to Resident #10's representative and a voicemail was left. II. Resident #15A. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included epileptic syndromes with seizures, catatonic schizophrenia (schizophrenia with extreme motor disturbances) and personality and behavioral disorder. According to the 9/30/25 MDS assessment, the resident was cognitively impaired with a BIMS score of zero out of 15. The resident required maximal assistance with dressing and personal hygiene. The resident required moderate assistance with oral hygiene and was dependent on toileting and showering. B. Resident's representative interviewResident #15's representative was interviewed on 12/16/25 at 2:55 p.m. The representative said the facility made it difficult to schedule a care conference and she did not remember the last time there was a care conference for Resident #15. The representative said it was frustrating because Resident #15 had a lot going on with his healthcare and she wanted a care conference so everyone could be on the same page. C. Record review The 8/12/25 care planning review and care conference assessment revealed Resident #15's representative did not attend the care conference. The reason documented for the representative not attending was that the facility had been unable to contact the representative. -A review of Resident #15's EMR revealed there was no documentation to indicate a care conference had taken place between 8/12/25 to 12/18/25. III. Staff interviews The nursing home administrator (NHA) was interviewed on 12/18/25 at 5:52 p.m. The NHA said the social services director (SSD) and the designated social services assistant for the unit was responsible for coordinating care conferences. She said the first care conference should be completed within 72 hours from the date of admission. The NHA said everyone from the IDT participated in the care conference. The NHA said sometimes the ombudsman and hospice staff attended the care conferences. The NHA said the residents and their representatives attended the care conferences. The NHA said the residents' representatives were contacted by their preferred contact method including phone, email and text. The NHA said social services should document their attempts to contact the residents' representatives as a progress note. The NHA said she knew social services was behind in care conferences by about a quarter for all residents including Resident #10 and Resident #15. She said both the residents' initial care conference and quarterly conferences were behind schedule.

Based on record review and interviews, the facility failed to notify the resident's representative when there was a significant change in the resident's condition for one (#10) of four residents out of 19 sample residents. Specifically, the facility failed to notify the designated representative for Resident #10 when he had swelling on his face, was seen by a dentist emergently, had edema in his legs, loose stools and bruising on his knee.Findings include: I. Facility policy and procedureThe Change of Condition Reporting policy and procedure, revised October 2020, was provided by the nursing home administrator (NHA) on 12/18/25 at 7:01 p.m. It revealed in pertinent part, The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. Symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life-threatening. All attempts to reach the physician and the responsible party will be documented in the nursing progress notes. Documentation will include time and response.II. Resident #10 A. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, transient ischemic attack (TIA - a temporary blockage of blood to the brain), cerebral infarction (blood clot blocks blood to the artery), chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus with hyperglycemia (high blood sugar), anxiety disorder and depression. The 7/21/25 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. The resident required maximal assistance with oral hygiene, toileting, dressing and personal hygiene. B. Resident representative interview Resident #10's representative was interviewed on 12/17/25 at 1:39 p.m. The representative said the facility did not notify her when Resident #10's legs were swollen. She said she thought a physician would see it and come up with a plan. She said there was a time Resident #10 had another visitor who asked the representative when Resident #10 got a black eye and what caused it. Resident #10's representative said the facility did not tell her about the black eye until she asked about it. Resident #10's representative was interviewed again on 12/18/25 at 2:32 p.m. The representative said Resident #10 did not see the dentist. She said she knew his lip was swollen but she was not told about him seeing a dentist. Resident #10 representative said she never heard anything about either of Resident #10's knees. Resident #10's representative said Resident #10 had loose stools when he was first admitted to the facility and she had not heard of any loose stools since then. She said it was important for her to know what was going on with Resident #10 because he could not speak for himself and he could not tell her how he was feeling. She said since Resident #10 could not communicate his needs and his wants, it was her place to be his eyes and ears to advocate for him. C. Record review The 10/28/25 weekly skin assessment revealed there were no skin issues to note. The 10/29/25 nurse progress note revealed a physician assessed Resident #10's left knee regarding resident antalgic gait (a painful limp). There were no signs or symptoms of swelling to the left knee. There was no bruising noted. There was slight discoloration to the left knee. The resident denied pain at the time. There was a new order for two view Xray. The director of nursing (DON) called the physician to place the order for the routine Xray. The facility would continue with the current plan of care. -A review of Resident #10's electronic medical record (EMR) revealed there was no documentation to indicate the resident's representative was notified of the swelling to the resident's left knee or that an order for an Xray of the left knee was obtained. The 10/29/25 physician note revealed Resident #10 was seen walking down the hall with a physical therapist who noticed the resident was limping on the left leg with mild bruising on the left knee and complained of pain in the knee joint. There were no recent falls. Nursing reported the resident had increased agitation over the last several days but was calm and cooperative in the morning. On exam, the resident's lower lip was slightly edematous and his bottom left teeth had purulent drainage. An urgent dental referral was sent. The 10/30/25 dental note revealed the nurses reported the resident was in severe pain the day before and had facial swelling. The nurse reported antibiotics were given the day before. There was no pain during the appointment. The clinical exam revealed no facial swelling. The 11/6/25 physician note revealed Resident #10 was seen by the dentist on 10/29/25. According to the dentist, the resident did not have an oral infection but had diffuse gingivitis. The resident had right periorbital ecchymosis (discoloration) and mild visible facial trauma. -A review of Resident #10's EMR revealed there was no documentation to indicate the resident's representative was notified that Resident #10 was seen by the dentist and had bruising on his left leg and face. The 11/11/25 physician note revealed the resident had right eye ecchymosis but it appeared to be fading. The assessment and plan revealed periorbital ecchymosis was likely unwitnessed self-induced trauma given he recently broke furniture in his room. Staff were unaware of any recent traumatic incidents. - A review of Resident #10's EMR revealed there was no documentation to indicate the resident's representative was notified of the right eye ecchymosis. The 12/2/25 weekly skin assessment revealed there were no skin issues to note. The 12/4/25 physician note revealed the resident's legs had trace edema without erythema (redness), increase in warmth or calf tenderness. The plan was to encourage elevating the legs periodically, compression socks and follow up in one week or sooner if needed. -There was no documentation to indicate the resident's representative was notified of the resident's leg edema.The 12/9/25 weekly skin assessment revealed there were no skin issues to note. The 12/17/25 weekly skin assessment revealed there were no skin issues to note. The 12/18/25 nurse progress note revealed Resident #10 had two episodes of very loose stools during the shift which was very offensive. The physician was notified and requested a stool examination to rule out any serious infection. The resident was encouraged to drink more fluids and the staff was notified to offer fluids to the resident for hydration. -There was no documentation to indicate the resident's representative was notified of the loose stools. The 12/18/25 physician note revealed there was a trace of bilateral lower extremity edema without erythema or calf tenderness. The plan was to elevate the legs periodically and use compression stocks. -A review of Resident #10's EMR revealed there was no documentation to indicate the resident's representative was notified of the edema and the interventions the physician suggested. III. Staff interviewsRegistered nurse (RN) #4 was interviewed on 12/18/25 at 2:33 p.m. RN #4 said if a resident had bruising, a black eye, edema or loose stools, they would all be considered a change of condition. She said when a resident had a change of condition, she notified the physician, the DON and the resident's responsible party. She said she documented the change in condition in risk management, which included a progress note. RN #4 said it was important to notify the resident's responsible party because the resident was their loved one and they deserved to know the changes their loved one went through while in the facility. RN #4 said she was not familiar with Resident #10. She said she was given verbal report that Resident #10 had loose stools overnight and a physician's order was obtained for a stool sample to rule out infection. RN #4 said she was not aware of Resident #10's edema, bruising on his knee or his black eye because she worked part time and she did not always work in Resident #10's unit. Regional clinical resource #1 was interviewed on 12/18/25 at 5:01 p.m. Regional clinical resource #1 said if a resident had bruising, a black eye, edema or loose stools she considered all of them a change of condition. She said if a resident had a change of condition, the nurse should notify the physician, the resident's representative and the DON. Regional clinical resource #1 said a risk incident was completed if there was something associated with an accident, such as a bruise or skin tear from the resident running into something. Regional clinical resource #1 said if the resident had edema or loose stools, a change of condition eInteract assessment would be completed. Regional clinical resource #1 said she identified the nurses had a gap in where to document when there was a change of condition and who was notified when there was a change of condition. Regional clinical resource #1 had the assistant director of nursing (ADON) join the interview on 12/18/25 at 5:21 p.m. The ADON said she had worked at the facility for one week. The ADON said bruising, a black eye, edema or loose stools were considered a change of condition. The ADON said if there was a change of condition, the physician, the resident's representative and the DON should be notified. The ADON agreed with Regional clinical resource #1 that a risk assessment was completed when the change of condition was associated with an accident and a change of condition eInteract assessment was completed if the resident had edema or loose stools. The ADON said she was not familiar with Resident #10. Regional clinical resource #1 said she was familiar with Resident #10 after she spoke with Resident #10's representative in the last 24 hours. She said the representative should have been notified about the loose stools. Regional clinical resource #1 said the representative should have been notified and there might have been a miscommunication between the representative and the other family members. Regional clinical resource #1 said she had a plan to ensure Resident #10's representative was communicated with when there was a change of condition.

Based on interviews and record review the facility failed to ensure two (#1 and #8) of five residents out of 19 sample residents received treatment and care in accordance with professional standards of practice.Specifically, the facility failed to administer medications in a timely manner per the physician orders for Resident #1 and Resident #8.Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E. [NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment.Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.II. Resident #1A. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included fibromyalgia (a long-term condition that causes pain and tenderness throughout the body), hereditary and idiopathic neuropathy, diaphragmatic hernia without obstruction or gangrene and personal history of healed traumatic fracture.The 11/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set up assistance with eating and oral hygiene. She was dependent on toileting, dressing and transfers. She refused bathing. The resident did not demonstrate delusions or hallucinations. The assessment indicated the resident reported acute left shoulder pain and chronic generalized pain which limited her activities. She received scheduled medication for the pain, and had also received non-pharmacological interventions.B. Resident interviewResident #1 was interviewed on 12/16/25 at 2:25 p.m. Resident #1 said she was in pain all the time. She said her legs, ankles, wrists and hands hurt the most. She said the pain was usually as intense as a 8, 9 or 10 on a scale of zero to 10. She said the pain was due to neuropathy and fibromyalgia. She said she was taking Oxycontin for pain and it did help to decrease her pain. She said she received Oxycontin around 9:00 a.m and 9:00 p.m. She said she had received her pain medications later than the medications were scheduled several times in the last 30 days but she did not remember the dates. C. Record reviewResident #1`s pain care plan, initiated 6/7/25 and revised 6/10/25 revealed that interventions included non-pharmaceutical pain management, administering opioids as prescribed and the expected benefit of opioid use was to reduce acute/chronic pain conditions.Review of Resident #1's December 2025 CPO revealed the following physician's orders: Lyrica Oral Capsule 25 milligrams (mg) three times a day, ordered 12/3/25Oxycontin 10 mg every twelve hours, ordered 10/9/25. Acetaminophen oral tablet 325 mg, two tablets four times a day for chronic pain, ordered 7/11/25. The progress note, dated 12/18/25, revealed that Resident #1 had multiple comorbidities requiring medication management that necessitated frequent clinical evaluations. Without regular monitoring and management, the patient was at moderate to high risk of symptom exacerbation and complications resulting in hospitalization or death. Resident #1 required multiple medications which required close monitoring to avoid any drug related adverse events. She had significant pain. Review of Resident #1`s December 2025 medication administration records (MAR), from 12/1/25 to 12/18/25, revealed that Oxycontin 10 mg was scheduled at 9:00 a.m. and 9:00 p.m. daily. The December 2025 MAR revealed the following:Resident #1's Oxycontin 10 mg 9:00 a.m. dose was not administered timely on the following days:-12/10/25, the medication was administered at 10:52 a.m., which was 52 minutes after the allowed administration time; and,-12/14/25, the medication was administered at 10:02 a.m., which was two minutes after the allowed administration time.Resident #1's Oxycontin 10 mg 9:00 p.m. dose was not administered timely on the following days:-12/6/25, the medication was administered at 10:44 p.m., which was 44 minutes after the allowed administration time;-12/7/25, the medication was administered at 11:27 p.m., which was one hour and 27 minutes after the allowed administration time;-12/8/25, the medication was administered at 10:01 p.m., which was one minute after the allowed administration time; and,-12/10/25, the medication was administered at 10:52 a.m., which was 52 minutes after the allowed administration time-12/10/25, the medication was administered at 10:09 p.m., which was nine minutes after the allowed administration time.-12/14/25, the medication was administered at 10:02 a.m., which was two minutes after the allowed administration time. III. Resident #8A. Resident statusResident #8, age [AGE], was admitted to the facility on [DATE] and re-admitted on [DATE]. According to the December 2025 CPO, diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease and personal history of healed traumatic fracture. The 12/17/25 MDS assessment revealed the resident was severely cognitively impacted with a BIMS score of four out of 15. She was independent with all activities of daily living (ADL). The MDS assessment indicated the resident reported acute left shoulder pain and denied pain impacting her activities. She received scheduled medication for the pain, and had also received non-pharmacological interventions. B. Resident interviewResident #8 was interviewed on 12/17/25 at 12:05 p.m. Resident #8 said she was receiving oxycodone, a lidocaine patch, Aspercreme, and Tylenol for pain. She said her shoulder and back were what caused her the most pain. She said she received her medications at 4:00 a.m, 10:00 a.m, 4:00 p.m, and 10:00 p.m. Resident #8 was interviewed a second time on 12/17/25 at 3:51 p.m. Resident #8 said she did not want to tolerate any pain and she said she experienced pain all the time. She said she would currently rate her pain level at a 5 or 6 out of 10. She said oxycodone was the most effective medication for reducing her pain. She said if she did not get her oxycodone on time, she would experience pain. She said there were several times in the last 30 days that her oxycodone was not administered on time but she did not remember the dates. C. Record reviewResident #8`s pain care plan, initiated 3/5/24, revealed that interventions included non-pharmaceutical pain management and monitoring and documenting side effects of pain medications. Review of Resident #8's December 2025 CPO revealed the following physician`s orders: Lidocaine External Patch. Apply to left shoulder topically one time a day for pain off in the morning, ordered 12/4/25. Oxycodone HCl 5mg. Give 1 tablet by mouth four times a day for chronic pain, ordered 6/2/25.Acetaminophen 325 mg. Give 2 tablets by mouth four times a day for chronic pain, ordered 6/2/25.The pain assessment completed on 12/4/25 revealed Resident #8 would not want to experience any level of pain. Review of Resident #8`s November 2025 and December 2025 MARs, from 11/1/25 to 12/18/25, revealed that oxycodone 5 mg was scheduled at 4:00 a.m., 10:00 a.m., 4:00 p.m. and 10:00 p.m. daily. The December 2025 MAR revealed the following: Resident #8's oxycodone 5 mg 4:00 a.m. dose was not administered on 12/8/25.Resident #8's oxycodone 5 mg 4:00 a.m. dose was not administered timely on the following dates:-12/6/25, the medication was administered at 5:04 a.m., which was four minutes after the allowed administration time;-12/10/25, the medication was administered at 5:32 a.m., which was 32 minutes after the allowed administration time;-12/11/25, the medication was administered at 5:26 a.m., which was 26 minutes after the allowed administration time;-12/12/25, the medication was administered at 5:11 a.m., which was 11 minutes after the allowed administration time;-12/13/25, the medication was administered at 5:12 a.m., which was 12 minutes after the allowed administration time; and,-12/14/25, the medication was administered at 5:30 a.m., which was 30 minutes after the allowed administration time.Resident #8's oxycodone 5 mg 10:00 a.m. dose was not administered timely on the following dates:-11/18/25, the medication was administered at 11:23 a.m., which was 23 minutes after the allowed administration time; and,-12/12/25, the medication was administered at 11:02 a.m., which was two minutes after the allowed administration time.Resident #8's oxycodone 5 mg 4:00 p.m. dose was not administered timely on the following date:-12/10/25, the medication was administered at 5:39 p.m., which was 39 minutes after the allowed administration time.Resident #8's oxycodone 5 mg 10:00 p.m. dose was not administered timely on the following dates:-12/7/25, the medication was administered at 11:07 p.m., which was seven minutes after the allowed administration time; and,-12/1/25, the medication was administered at 11:55 p.m., which was 55 minutes after the allowed administration time.IV. Staff interviews Registered nurse (RN) #3 was interviewed on 12/18/25 at 10:45 a.m. RN #3 said Resident #8 was scheduled to take her oxycodone at 4:00 a.m, 10:00 a.m., 4:00 p.m. and 11:00 p.m. She said it was important to administer pain medications on time because it could reduce the potential for addiction and control pain more effectively. She said the physician's order specified administration time and staff must follow the orders. Regional clinical resource #1 was interviewed on 12/18/25 at 4:30 p.m. Regional clinical resource #1 said that the administration times documented in the MARS for both Resident #1 and Resident #8's pain medications were the correct administration times and that the medications were administered outside of the scheduled administration times. She said the nurses were responsible for administering medications timely.Regional clinical resource #2 was interviewed on 12/18/25 at 4:43 p.m. Regional clinical resource #2 said even though the facility missed the scheduled medication administration windows for Resident #1 and Resident #8 , the residents were administered their pain medications and their pain regimens worked. The assistant director of nursing (ADON) was interviewed on 12/18/25 at 5:40 p.m. The ADON said the medication administration time window was one hour on either side of the scheduled medication administration time. She said if a medication was scheduled for 4:00 a.m. then the earliest administration time was 3:00 a.m. and the latest administration time was 5:00 a.m.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 9/15/25. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (3-301.11)II. ObservationsDuring a continuous observation of the lunch meal service on 9/10/25, beginning at 10:35 a.m. and ending at 12:22 p.m. the following was observed:At 11:40 a.m. cook (CK) #2 began preparing a cheeseburger. CK #2 removed the lids for each cold container of hamburger toppings and set them aside. CK #2 donned a glove on one hand, grabbed a piece of lettuce and placed it on a plate. CK #2 then removed the glove and placed the glove in a metal bin which held clean tongs. CK #2 repeated this process to add tomato slices, onion, pickles, and cheese to the plate, and continued putting the used gloves in the metal bin. CK #2 did not perform hand hygiene before and after glove usage each time. CK #2 picked up the tongs from the metal bin and used them to apply the top bun to the cheeseburger before sending it out on the tray line. CK #2 placed the tongs back into the metal bin with the used gloves.At 11:47 a.m. CK #1 was plating a resident meal. CK #1 scooped a spoonful of carrots onto a plate. Some of the carrot slices started to fall off of the side of the plate, so CK #1 used her bare thumb to scoot them back onto the plate.At 11:54 a.m. the registered dietitian (RD) began preparing a sliced banana for a resident on a mechanically altered texture diet. The RD peeled the banana and began chopping it on a cutting board. The RD used her bare hand to stabilize the banana as she cut it into slices, and used her bare hand to brush the banana slices off of the knife and into a bowl. The RD asked a staff member if the bananas were the correct size for the resident's diet texture and proceeded to use her bare hand to scoop the banana slices out of the bowl and back onto the cutting board. After slicing the banana finer, the RD used her bare hand to slide the banana slices off of the knife and into the bowl. The RD covered the bowl with plastic wrap and gave it to an unidentified dietary aide to put onto a room tray cart.At 11:55 a.m. CK #2 began preparing two more hamburgers. CK #2 grabbed the hamburger buns and pulled them open using the same tongs from the metal bin. At 12:03 p.m. CK #2 finished preparing the hamburgers by using the same tongs from the metal bin to place the top buns on the hamburgers before sending them out on the tray line.III. Staff interviewThe dietary manager (DM) and the regional dietary consultant were interviewed together on 9/11/25 at 9:30 a.m. The DM and the regional dietary consultant both said ready to eat foods should be handled with gloved hands or utensils. The DM and the regional dietary consultant both said tongs should be stored somewhere clean between uses, such as a plate, a metal bin, or any clean surface. The DM and the regional dietary consultant both said bare hands should not come into contact with ready-to-eat foods.

Based on observations, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#53) of nine residents reviewed for services to maintain highest practicable quality of life out of 46 sample residents.Specifically, the facility failed to ensure Resident #53 received timely incontinence care and repositioning. Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADLs) policy and procedure, revised 4/3/25, was received from the nursing home administrator (NHA) on 9/11/25 at 11:51 a.m. It read in pertinent part, Care and services will be provided for the following activities of daily living: transfer and ambulation and toileting. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.II. Resident #53A. Resident statusResident #53, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with agitation and acute respiratory failure.The 6/13/25 minimum data set (MDS) assessment documented the resident was severely cognitively impaired per staff assessment. The resident was dependent on staff for all ADLs. The resident was dependent on staff for rolling left to right in bed and for transfers.The assessment documented the resident was always incontinent of bowel and bladder.B. ObservationsDuring a continuous observation on 9/9/25, beginning at 9:40 a.m. and ending at 1:44 p.m., the following was observed:At 9:40 a.m. Resident #53 was asleep in her Broda chair (a specialized type of wheelchair) at the nurses' station. Resident #53 was reclined to a 40-degree angle in her wheelchair.At 10:05 a.m. certified nurse aide (CNA) #7 pulled Resident #53 up toward the head of her wheelchair as she had slid down in her seat.At 10:35 a.m. Resident #53 was lying in her Broda chair, groaning and kicking her legs intermittently. Resident #53 stopped and fell asleep again.At 10:50 a.m. Resident #53 was lying in her wheelchair groaning, kicking her legs and grimacing.At 11:10 a.m. Resident #53 was groaning and kicking her legs. Resident #53 was also holding her forehead in her hand and grimacing.At 11:31 a.m. Resident #53 was scratching her head and groaning.At 11:44 a.m. Resident #53 was asleep in her chair and occasionally groaning.At 11:50 a.m. CNA #7 unlocked the wheels of Resident #53's Broda chair, adjusted the blanket over her legs and escorted her to the dining room.At 12:02 p.m. Resident #53 was lying in her Broda chair perpendicular to the dining table, kicking her feet and grimacing with her eyes closed.At 12:17 p.m. an unidentified CNA placed a clothing protector onto Resident #53.At 12:31 p.m. the unidentified CNA sanitized her hands, pulled Resident #53 closer to her and adjusted her Broda chair so she was sitting up a few degrees more and began assisting her with eating. At 1:04 p.m. the unidentified CNA wiped Resident #53's mouth with a paper napkin, folded and replaced the blanket on the resident's lap,and assisted her back to a spot in front of the nurses' station.At 1:18 p.m. Resident #53 was crying out and saying no and please, and groaning.At 1:30 p.m. CNA #7 told one of the facility's physicians he was going to put Resident #53 to bed and the physician requested to assess the resident before he did so. CNA #7 assisted Resident #53 to her room and the physician came in shortly thereafter.At 1:42 p.m. CNA #7 closed the door to Resident #53's room to provide incontinence care and put the resident to bed (see interviews below).-The facility failed to provide incontinence care for Resident #53 for four hours during the observation period.-The facility did not turn or offload weight for Resident #53 in her Broda chair for four hours during the observation period.C. Record reviewThe ADL care plan, revised 3/11/24, revealed Resident #53 had an ADL self-care performance deficit due to her dementia and Alzheimer's disease. Pertinent interventions revealed Resident #53 required one to two staff members to reposition and turn in bed and for toileting hygiene.The incontinence care plan, revised 3/5/24, revealed Resident #53 was incontinent of both bowel and bladder due to her Alzheimer's. Pertinent interventions included checking Resident #53 as required for incontinence.The pressure ulcer care plan, revised 3/11/24, revealed Resident #53 was at risk of pressure ulcer development due to her disease process and immobility. Pertinent interventions included following the facility's policies and protocols for the prevention and treatment of skin breakdown.A hospice nursing note, dated 8/6/25, revealed Resident #53 had developed blanchable redness to her coccyx. The hospice nurse encouraged the facility nursing staff to turn and reposition Resident #53 every two hours and keep her skin clean and dry to prevent skin breakdown.A nursing summary, dated 8/27/25, revealed Resident #53 was dependent on staff for transferring, bed mobility and toileting. The summary documented Resident #53 was incontinent and needed toileting every two hours. Resident #53's skin was free of any open areas at that time.D. Staff interviewsCNA #7 was interviewed on 9/9/25 at 1:48 p.m. CNA #7 said he had transferred Resident #53 from her chair to her bed and changed her incontinence brief (see observations above). CNA #7 said Resident #53's incontinence brief had urine in it. CNA #7 said he usually checked Resident #53 every two hours to make sure she was dry and not soiled. CNA #53 said Resident #53 previously used to go over two hours and would remain dry when he checked her brief, but since she had some cognitive decline that happened less frequently.CNA #8 and CNA #9 were interviewed together on 9/10/25 at 4:26 p.m. Both CNAs said they checked Resident #53 for incontinence care every two hours and adjusted her position in her chair. CNA #9 said Resident #53 was incontinent and had bowel movements throughout the day.The medical director (MD) was interviewed on 9/11/25 at 10:46 a.m. The MD said he would have expected the staff to reposition Resident #53 and check her for incontinence care at least every two hours, especially if she was only a few feet away from the nurse's station. The MD said these cares should have been in Resident #53's care plan. The MD said incontinence cares and repositioning were done by the staff to help the residents avoid developing any skin breakdown or pressure ulcers. The MD said sometimes when residents cried out often it became like background noise to the nursing staff and led to Resident #53 getting forgotten about.Licensed practical nurse (LPN) #2 was interviewed on 9/11/25 at 11:31 a.m. LPN #2 said incontinent residents were checked at least every two hours for toileting, but he tried to check them more frequently. LPN #2 said repositioning was done every two hours, as some residents were more susceptible to developing bed sores. LPN #2 said Resident #53 was incontinent of bowel and bladder. LPN #2 said Resident #53 was on two hour checks for toileting and adjusted her in her Broda chair. LPN #2 said Resident #53 needed repositioning. LPN #2 said Resident #53 was in her Broda chair a lot, so the nursing staff tried to move her around often. LPN #2 said Resident #53 did not have any skin breakdown at the time. LPN #2 said Resident #53 was not able to make her needs known at all. LPN #2 said Resident #53 was not able to turn independently and stayed in the same position.The director of nursing (DON) was interviewed on 9/11/25 at 12:40 p.m. The DON said residents who were dependent on staff should be offered repositioning every two hours. The DON said staff should check and change incontinent residents every two hours. The DON said she would follow up with the nursing staff and provide them with education on toileting and repositioning.

Based on observations, record review and interviews, the facility failed to implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for one (#53) of one resident out of 46 sample residents.Specifically, the facility failed to: Provide a meaningful activities program for Resident #53; and, -Ensure Resident #53's activity participation was accurately documented.Findings include:I. Facility policy and procedureThe Delivery of Activity Services policy and procedure, revised March 2025, was received from the nursing home administrator (NHA) on 9/11/25 at 11:16 a.m. It read in pertinent part, Should a resident be considered medically or mentally incompetent, or physically unable to participate in such programs, an entry will be made in the resident's medical record (chart) stating fully the reason(s) for the restriction(s). Such an entry will be signed and dated by the person recording such data. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations: Cognitive impairment (task segmentation, settings that recreate past experiences, smaller groups without interruption, one-to-one); Terminally ill (life review, spiritual support, touch, massage, music, reading to the resident)II. Resident #53A. Resident statusResident #53, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with agitation and acute respiratory failure.The 6/13/25 minimum data set (MDS) assessment documented the resident was severely cognitively impaired per staff assessment. The resident was dependent on staff for all ADLs. B. Resident representative interviewResident #53's representative was interviewed on 9/11/25 at 10:33 a.m. The representative said Resident #53 had end-stage Alzheimer's disease and was receiving hospice care. The representative said Resident #53 used to be a people person and liked to talk with people. The representative said Resident #53 never really liked to read books or watch television, but always liked to talk.C. ObservationsOn 9/8/25 at 9:43 a.m., Resident #53 was lying in her wheelchair in her room alone, facing the wall. Resident #53 was saying no repeatedly, groaning and kicking her legs. There was no music playing in the resident's room and no meaningful activity was occurring. At 12:52 p.m. Resident #53 was lying in her wheelchair near the nurses' station. Resident #53 was kicking her legs and groaning. Three nursing staff members were sitting at the nurses' station talking about their personal lives. The nursing staff members did not attempt to engage Resident #53 in a meaningful activity.During a continuous observation on 9/9/25, beginning at 9:40 a.m. and ending at 1:44 p.m., the following was observed:At 9:40 a.m. Resident #53 was lying in her wheelchair at the nurses' station. At 9:51 a.m. activity assistant (AA) #1 walked through the hallway and interacted with another resident. At 9:53 a.m. AA #1 walked back through the hallway and continued interacting with another resident. AA #1 invited a resident to the daily devotional activity at 10:00 a.m. that morning.-AA #1 did not interact with Resident #53 or invite her to the activity.At 1:13 p.m. an unidentified activity assistant invited several residents near the nurses' station to go to bingo that afternoon.-The activity assistant did not talk to or acknowledge Resident #53.On 9/10/25 at 9:43 a.m. Resident #53 was in her room alone, lying in her wheelchair and talking to herself. An unidentified activity assistant was walking down the hallway looking for residents to invite to the morning activity. The activity assistant peered into Resident #53's room from the hallway but did not enter the room or speak with Resident #53.At 10:02 a.m. Resident #53 was lying in her wheelchair in her room alone, facing a wall. Resident #53 was crying out, kicking her legs and saying unintelligible words. There was no music playing in the resident's room and no meaningful activity was occurring.D. Record reviewThe activity care plan, revised 12/24/24, revealed Resident #53 enjoyed passively participating in independent, structured and one-to-one leisure activities. Resident #53 enjoyed listening to music and spending time in the common areas watching and socializing with peers and staff members. Resident #53 practiced the Christian faith. Resident #53 became overstimulated when in large groups and had a history of yelling out. Pertinent interventions included staff assisting Resident #53 to potential groups of interest, monitoring her activity participation for any change or decline and providing therapeutic one-to-one visits three times per week.A quarterly activity assessment for Resident #53 was conducted on 8/25/25 at 10:58 a.m. The assessment documented Resident #53 preferred to be independent in her leisure activities and preferred small groups or one-to-one settings. Resident #53 engaged in structured leisure activities four to six times per week, mostly passively. Resident #53 enjoyed spending time in her room resting or in the television room on the unit watching television programs. Resident #53 enjoyed programs with bright colors and animation. Resident #53 had been observed to enjoy listening to music and spiritual visits, such as reading the daily devotions and daily chronicles. Review of Resident #53's religious activity task log, from 8/12/25 through 9/10/25, revealed Resident #53 refused to participate in activities each day, including on 9/9/25 at 10:06 a.m. and 9/10/25 at 10:00 a.m.-However, observations revealed Resident #53 was not invited to or encouraged to participate in the activities on 9/9/25 and 9/10/25 (see observations above).Review of Resident #53's creative activity task log, from 8/12/25 through 9/10/25, revealed on 8/21/25 at 3:32 p.m. Resident #53 refused to participate.-No other activities were documented during this time period for the creative activity task log.Review of Resident #53's independent activity task log, from 8/12/25 through 9/10/25,revealed the following:-Active participation was marked once per day for each day of the time period; -Activities, including television/radio/movies, walking or wheeling, exploring the environment and observing surroundings were marked almost every day for the time period; and,-Visiting with other residents was marked fifteen times, including on 9/9/25 at 12:49 p.m.-However, Resident #53 was unable to speak to or interact with other residents due to her disease progression, and the resident was not observed interacting with staff or any other residents on 9/9/25 (see observations above).Review of Resident #53's social activity task log, from 8/12/25 through 9/10/25, revealed Resident #53 refused to participate each day, including on 9/9/25 at 1:33 p.m. -However, observations revealed Resident #53 was not invited to or encouraged to participate in activities on 9/9/25 (see observations above).Review of Resident #53's mental activity task log, from 8/12/25 through 9/10/25, revealed the following:-Passive participation was documented 20 times;-Resident not available was marked two times;-Resident refused was marked 20 times; and,-Active participation was marked once.Specifically, reading and word/card games were documented almost each day over the review period, resident council was documented once, and a self-esteem workshop was documented once.Review of Resident #53's entertainment activity task log, from 8/12/25 through 9/10/25, revealed the following:-Resident not available was marked once; and,-Resident refused was marked three times.-No other activities of this kind were documented during the review period.Review of Resident #53's one-to-one activity task log, from 8/12/25 through 9/10/25, revealed the resident had actively participated in one-to-one activities 13 times over the review period for 15 minutes each time.III. Staff interviewsCertified nurse aide (CNA) #9 was interviewed on 9/10/25 at 4:18 p.m. CNA #9 said the nursing staff took Resident #53 to group activities because she liked to attend them. CNA #9 said Resident #53 enjoyed going to the daily devotions activity in the mornings.-However, observations throughout the survey period did not reveal Resident #53 attending or being invited to the daily devotions activity (see observations above).Licensed practical nurse (LPN) #2 was interviewed on 9/11/25 at 11:31 a.m. LPN #2 said he did not know if Resident #53 could read but knew she could see. LPN #2 said the facility's activity assistants invited all of the residents to each activity, and the nursing staff assisted the residents in getting to the activities.-However, the activity assistants were not observed inviting Resident #53 to the activities (see observations above). LPN #2 said Resident #53 did not really do much during the day. LPN #2 said Resident #53 mostly stayed at the nurses' station or went to group activities to listen but not actively participate in the activities. AA #1 was interviewed on 9/11/25 at 11:41 a.m. AA #1 said all of the activity assistants invited residents to activities. AA #1 said the activities staff did not always invite every resident to every activity, but they tried to do so. AA #1 said if a resident was not religious, the activities staff did not invite them to the daily devotions activity. AA #1 said she was instructed by the previous activity director to mark refused in the activity task if a resident was sleeping. AA #1 said if a resident was sitting in a common area of the facility, she documented it as visiting with other residents in the independent leisure activity task, as the resident was likely talking with others. AA #1 said in the mental activity task, receiving the daily chronicle was documented as reading and word games. AA #1 said if the resident could not read, the activity assistants would document refused. AA #1 said sometimes the activity assistants would read the daily chronicle to the residents, which was considered passive participation.AA #1 said Resident #53 mostly just sat around the facility. AA #1 said the activities staff tried to bring her to group activities but the resident would get overstimulated and start yelling out. AA #1 said Resident #53 was on a one-to-one activity visit program three times per week. AA #1 said the activities staff really struggled with Resident #53 to know what activities they could do more of for her. AA #1 said Resident #53 could not read and did not talk much, but did enjoy physical touch. AA #1 said Resident #53 did better in small groups and with one-to-one, and she thought the resident might enjoy aromatherapy.The NHA was interviewed on 9/11/25 at 12:54 a.m. The NHA said the activity director left the facility that Monday (9/8/25), so a regional consultant was helping to fill in. The NHA said all residents were to be invited to all activities. The NHA said he thought the activity assistants woke residents up to invite them to activities if they were sleeping, but he was not sure what the facility's policy was. The NHA said the activities program should be resident-centered and residents should be offered one-to-one activities and be encouraged to come to group activities.The NHA said he had not seen any issues with activity documentation.The social services consultant was interviewed on 9/11/25 at 1:22 a.m. The social services consultant said Resident #53 was on a one-to-one activity visit program, which was her main source of activity engagement. The social services consultant said the activities staff had been documenting that the resident had been receiving and using the daily chronicle, but the staff should really have been documenting that the resident was not available, as she could not interact with the daily chronicle on her own and the staff were not reading it to her. The social services consultant said the activities documentation had been divided amongst the activities staff in a way where all of the staff members were doing some segmented bits of documentation. The social services consultant thought this documentation method was possibly where some of the inaccuracies in the documentation had originated.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of three certified nurse aides (CNA).Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #7 and CNA #11. Findings include:I. Record reviewAnnual performance reviews for CNA #7 and CNA #11 were requested on 9/9/25 at 1:34 p.m. The facility was unable to provide annual performance evaluations for CNA #7 (hired on 3/1/24) and CNA #11 (hired on 3/1/24).-The CNAs did not have an annual performance review completed and the CNAs did not have an in-service education plan based on the outcome of the review.The facility provided a document on 9/9/25 at 3:03 p.m. which identified that a performance improvement plan (PIP) had been initiated on 8/22/25 regarding outstanding annual performance reviews. The PIP stated an audit had been completed and identified staff members who had not received an annual review timely. The audit revealed 36 staff members had outstanding annual performance reviews with a goal to complete the performance reviews by 10/31/25.-However, only one CNA annual performance evaluation had been completed since the PIP was initiated on 8/22/25.II. Staff interviewsThe director of nursing (DON) was interviewed on 9/11/25 at 9:02 a.m. The DON said the CNA performance reviews needed to be done annually and the facility had initiated a PIP because she was behind on the reviews. The DON said she was behind because human resources (HR) went on maternity leave and she helped with managing those. The DON said she did all of the reviews and did not utilize the assistance director of nursing (ADON) because she liked to meet face to face with the staff. The DON said the reviews were important so that the staff knew how they were doing in their roles. The DON said she did a CNA review 5/2/25 for CNA #12 but the review did not reveal any concerns so there was no in-service education based on the outcome of that review. The DON said she had completed one CNA review since the PIP was put in place.

Based on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease.Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene assisting residents with eating; and,-Ensure staff handled residents' drinkware in a sanitary manner.Findings include:I. Failed to ensure staff performed hand hygiene while assisting residents with eatingA. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 9/15/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings.B. Facility policy and procedureThe Dining and Infection Control policy, revised March 2021, was received from the NHA on 9/11/25 at 11:15 a.m. It read in pertinent part, Staff will perform appropriate hand hygiene. If hands are soiled, have touched their face/hair, have touched a resident or wheelchair, they will wash their hands before passing additional trays.C. ObservationsDuring a continuous observation of the breakfast meal in the main dining room on 9/8/25, beginning at 7:10 a.m. and ending at 8:26 a.m., the following was observed:At 8:05 a.m. licensed practical nurse (LPN) #1 was assisting two unidentified dependent residents with eating. LPN #1 alternated offering each resident a bite of food before offering a bite of food to the other resident. LPN #1 scratched her face and adjusted her face mask several times while alternating between offering bites of food to each resident.-LPN #1 did not perform hand hygiene after touching her face or mask and between offering bites of food to each resident.At 8:07 a.m. the regional dietary consultant delivered a bottle of hand sanitizer to the table where LPN #1 was sitting and told her to perform hand hygiene after adjusting her mask.At 8:08 a.m. LPN #1 finished assisting one of the unidentified residents with eating and began assisting another unidentified resident. -LPN #1 did not perform hand hygiene before assisting the other resident with eating.On 9/10/25 at 12:39 p.m. certified nurse aide (CNA) #9 was sitting in the dining room at a table assisting two unidentified dependent residents with eating. CNA #9 was alternating offering each resident a bite of food.-CNA #9 did not perform hand hygiene between assisting the two residents. -Additionally, there was no hand sanitizer visibly available at the dining room table.D. Staff interviewThe director of nursing (DON), who was also the facility's infection preventionist (IP), was interviewed on 9/11/25 at 12:40 p.m. The DON said the staff should perform hand hygiene in between feeding different residents.II. Failed to handle residents' drinkware in a sanitary mannerA. ObservationsDuring a continuous observation of the breakfast meal in the main dining room on 9/8/25, beginning at 7:10 a.m. and ending at 8:26 a.m., the following was observed:At 7:42 a.m. CNA #10 carried four glasses of orange juice through the dining room to deliver to residents. CNA #10 had the glasses stacked one on top of the other so the rims of two of the glasses were touching the bottom of the other two glasses. CNA #10 was holding the stacked glasses in the middle of the stack and her hand was touching two of the glasses by the rim of the glass. At 7:45 a.m. CNA #10 delivered two more glasses of orange juice to residents in the dining room. CNA #10 held one of the glasses by the rim of the glass. At 7:46 a.m. CNA #10 delivered a mug of coffee to a resident in the dining room. CNA #10 held the coffee mug by the rim of the mug.B. Staff interviewThe DON was interviewed on 9/11/25 at 12:40 p.m. The DON said the staff should hold residents' drinking glasses by the bottom of the glass. The DON said the staff should not hold the rim of the glass when serving drinks to residents.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of training per year for two out of three CNAs reviewed.Specifically, the facility failed to:-Ensure a system was in place to track the CNAs training to ensure they met the annual training requirements; and,-Ensure CNA #7 and CNA #11 received the required 12 hours of training per year. Findings include:I. Facility policy and procedureThe Nurse Aide Training policy and procedure, revised March 2025, was provided by the nursing home administrator (NHA) on 9/11/25 at 11:50 a.m. It read in pertinent part, This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides. The staff development coordinator (or designee), with oversight from the director of nursing, shall be responsible for the coordination and/or provision of nurse aide education. Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. The staff development coordinator shall maintain documentation of training in his/her office during the current training year, and shall forward to the HR (human resource) director at the completion of the training year to be maintained in the employee's personnel file. It is the responsibility of the employee to attend/complete mandatory in-service trainings to maintain employment status with the facility. A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review.II. Record reviewA review of the CNA training records was completed on 9/10/25 at 10:03 a.m. CNA #7 was hired on 3/1/24. The training records revealed .75 hours of training in the previous year.CNA #11 was hired on 3/1/24. The training records revealed 1.00 hours of training in the previous year. III. Staff interviewThe director of nursing (DON) was interviewed on 9/11/25 at 9:02 a.m. The DON said they did not have a staff development coordinator (SDC). She said they had one for a while but could not find someone appropriate for the job and the job was no longer posted that she was aware of. The DON said the facility staff completed online training and HR was keeping track to ensure they met the annual training requirements. The DON said they had a temporary HR staff member since the regular HR staff member was on maternity leave. The DON said it was important to ensure that the CNAs completed the annual training requirements to ensure that they were doing their job duties adequately.

Based on observations and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to maintain residents' dignity and ensure residents were provided equal access to incontinence care supplies. Findings include: I. Resident interviews Resident #1 was interviewed on 6/11/25 at 3:15 p.m. Resident #1 said he did not have briefs for four days because the facility ran out of briefs. Resident #1 said he asked a nurse manager what to use for briefs if the facility ran out and the nurse manager told him to use a towel instead. Resident #1 said he was not sure what the facility meant by using a towel but there were no briefs available. Resident #1 said the issue started on a Friday and the new briefs were delivered on a Tuesday. Resident #9 was interviewed on 6/12/25 at 9:45 a.m. Resident #9 said a certified nurse aide (CNA) told him the facility did not order briefs. Resident #9 said he only had one pair of briefs left and the facility finally got more briefs in. Resident #9 said the facility was out of briefs at the end of May 2025. Resident #1 was interviewed a second time on 6/12/25 at 10:15 a.m. Resident #1 said the staff told him they were out of briefs and the staff told him the director of nursing (DON) told the facility not to order facility supplies because it was the end of the month. Resident #10 was interviewed on 6/12/ 25 at 10:25 a.m. Resident #10 said he decided to wait to have his brief changed one night because he thought he would run out of briefs in the beginning of June 2025 because he had one brief remaining and he thought the facility was going to run out of briefs again later in the month. Resident #10 said his briefs were wet when he waited to have his briefs changed but it was only for six to seven hours. Resident #10 said when he did not have his briefs changed he did not feel discomfort because he was paraplegic. Resident #10 said he did not like to sit in his briefs too long because he did not want any open sores. Resident #10 said he could not remember who told him the facility was out of briefs but thought it was a CNA. Resident #10 said he was told by a staff member running low on briefs was a money issue and that the facility wanted to order the briefs after the first of the following month. Resident #11 was interviewed on 6/12/25 at 10:37 a.m. Resident #11 said the facility ran out of briefs at the beginning of June 2025 and staff had to use a pull-up garment for him instead. Resident #11 said the pull-up garment leaked into his bed but he did get his wet sheets changed by staff. Resident #11 said he used briefs and needed staff assistance to change his briefs. Resident #12 was interviewed on 6/12/25 at 2:13 p.m. Resident #12 said the facility was constantly running out of necessary supplies the residents needed. Resident #12 said a staff member brought him a package of incorrectly sized incontinence briefs earlier in the day (see observation below). Resident #12 said he normally wore size three extra large (3XL) briefs and the staff member brought him size two extra large (2XL). Resident #12 said the staff member performed incontinence care on him and changed him into the 2XL briefs. Resident #12 said the staff member returned to his room a short while after, with a package of 3XL briefs, and told the resident that the central supply area was full of supplies on 6/11/25 and most of them were gone by 6/12/25. An open package of 2XL briefs and a closed package of 3XL briefs were observed next to Resident #12's bed during the interview. II. Observation On 6/12/25 at 10:28 a.m. an unidentified staff member walked into Resident #12's room. The staff member was holding a package of incontinence briefs. The staff member was heard telling Resident #12 she could not find his size of briefs. The unidentified staff member asked Resident #12 if the smaller size would work and the resident replied that he guessed so. III. Grievance forms Facility grievances were provided by the DON on 6/12/25 at 9:00 a.m. A grievance, dated 6/2/25, documented Resident #1 was concerned he ran out of supplies and only had one brief left and that a night shift CNA told him he was out (of briefs). IV. Staff interviews A staff member, who wished to remain anonymous, was interviewed on 6/12/25 at 3:10 p.m. The staff member said the facility ran out of briefs at the end of May 2025/beginning of June 2025 and there were pull-up garments available, but the supply of pull-up garments was limited. The staff member said some residents were unable to wear a pull-up garment and briefs were not an option for them based on their build. The staff member said the staff took briefs from residents' rooms to use for other residents.The staff member said a nurse manager instructed the staff to put towels under the residents if the facility ran out of briefs. The staff member said a resident expressed his concerns about the limited supply of briefs to the nurse manager and the nurse manager told the resident to just use towels. A second staff member, who wished to remain anonymous was interviewed on 6/12/25 at 3:13 p.m. The second staff member said the facility ran out of briefs. The second staff member said most of the residents who were offered pull-up garments instead of briefs did not want pull-up garments and some residents did not fit in the pull-up garments. The second staff member said one resident declined to take his medicine and to have his briefs changed because he did not want to go to the bathroom in his briefs. The second staff member said a central supply staff member told the staff that the DON instructed the central supply staff member not to order supplies because the facility was over budget and the facility would probably run out of briefs. A third staff member, who wished to remain anonymous, was interviewed on 6/12/25 at 3:18 p.m. The third staff member said each unit had its own storage closet for supplies and staff would go to the central supply area or other units in the facility if the storage closet on a particular unit was out. The third staff member said they were told by another staff member that on 5/31/25, a member of management told staff to use towels as incontinence briefs for the residents. The third staff member said the staff all had an understanding that there was a lack of resident care supplies in the facility. The third staff member said they felt frustrated and hurt by not having adequate resources necessary for resident care. The nursing home administrator (NHA) and the DON were interviewed together on 6/12/25 at 4:00 p.m. The DON and the NHA said they were not aware of a member of the management telling staff to use towels underneath residents for briefs. The DON said it was not appropriate for staff to be told to use towels instead of incontinence briefs. The NHA said the facility did not run out of briefs for the residents. The DON said she did not instruct the central supply staff not to order supplies, but to order the supplies if needed.

Based on record review and interviews, the facility failed to ensure that the transfer or discharge was documented accurately in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for one (#2) of three residents reviewed for discharge out of 12 sample residents. Specifically, for Resident #2, the facility failed to: -Ensure the resident's discharge summary included the resident's need for two transfer poles; -Ensure the resident's discharge care plan included the resident's medical equipment needs, specifically the two transfer poles -Document communication and responses from the referral sources to confirm the resident's discharge needs; and, -Ensure the resident's discharge date documented in the physician's orders was accurate and the physician's order was obtained timely. Findings include: I. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE] and discharged to home on 5/21/25. According to the June 2025 computerized physician orders (CPO), diagnoses included cervical spinal stenosis (narrowing of the spinal canal in the neck), paroxysmal atrial fibrillation (irregular heart beat), need for assistance with personal care, mixed incontinence, unilateral primary osteoarthritis of unspecified hip (one-sided hip joint condition) and unsteadiness on feet. The 5/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial assistance with toileting hygiene, bed mobility and transfers. He was dependent on staff for shower/tub transfers. He independently used a motorized wheelchair for locomotion. The MDS assessment documented Resident #2 was discharged from the facility, as planned, on 5/21/25 through a local contact agency. B. Resident interview Resident #2 was interviewed via phone on 6/11/25 at 1:16 p.m. Resident #2 said his apartment was incorrectly set up and his medical equipment was just beginning to be set up. Resident #2 said he was supposed to have two transfer poles in his apartment; one in his bedroom and one in his bathroom. Resident #2 said the transfer pole in his bedroom was not set up in the correct spot and a transfer pole had yet to be installed in his bathroom. During the interview with Resident #2, the resident handed the phone to the transition services agent to answer questions (see interview below). C. Record review A review of the 4/24/25 occupational therapy (OT) and physical therapy (PT) notes documented Resident #2 was waiting for approval for a home visit to install vertical transfer poles for a safe discharge to his community apartment. The nursing Discharge summary, dated [DATE] at 7:55 a.m., documented Resident #2 had completed therapy services and obtained the highest practical level in a long-term care setting. It documented Resident #2 would require assistance with toileting, bathing and functional transfers upon discharge to the community. It documented Resident #2 was independent with mobility once he was transferred to his power wheelchair. It documented home health nursing and therapy services were arranged to assist Resident #2's transition back to the community. It documented Resident #2 had physician's orders for a specialty bed and mattress and a shower chair with wheels for use at home. -Review of Resident #2's discharge summary revealed there was no documentation regarding the resident's need to have two transfer poles set up in his apartment. The discharge care plan, initiated 2/29/24 and revised 2/10/25, documented Resident #2 intended to be discharged back to the community through a local contact agency. Interventions included reviewing the resident's discharge care plan quarterly and as needed, preparing and providing Resident #2 with contact numbers for all community referrals and staff providing the resident with any needed support. -Review of the discharge care plan revealed there was no documentation addressing Resident #2's specific durable medical equipment needs for a safe discharge, including his need for two transfer poles. Review of Resident #2's May 2025 CPO revealed the following physician's order: Resident to discharge from [facility] to [apartment] on 5/22/25. Resident to discharge with all medications needed, ordered 5/23/25. -The physician's order incorrectly listed Resident #2's date of discharge as 5/22/25, instead of 5/21/25. -Additionally, the physician's order was not obtained until two days after Resident #2 was discharged home from the facility (on 5/21/25). On 6/11/25 at approximately 3:00 p.m., a purchase order for two transfer poles was provided by the SSD. The purchase order indicated the order was placed on 4/8/25 and had not yet shipped. The purchase order was signed by Resident #2, but was not dated as to when the resident signed it. II. Staff interviews The social services director (SSD) was interviewed on 6/10/25 at 3:30 p.m. The SSD said the social services assistant (SSA) confirmed with the home health agency over the phone, on 5/20/25, that they had approved home health services for Resident #2. The SSD said the home health agency confirmed Resident #2 would be seen the day following his discharge from the facility on 5/21/25. The SSD said his understanding was that the resident's equipment in his apartment had been set up and the resident's care was successfully transitioned to the home health agency after his discharge from the facility. The director of rehabilitation (DOR) was interviewed on 6/11/25 at 11:27 a.m. The DOR said Resident #2 was assessed prior to his discharge from the facility for a bed to chair transfer with a transfer pole because that was the equipment the resident was going to use at home. The DOR said the transitions services team said Resident #2 would have a transfer pole in his bathroom at his new apartment. The SSA was interviewed on 6/11/25 at 12:07 p.m. The SSA said she spoke to the home health agency contact on 5/20/25 and she said the home health agency confirmed services for Resident #2 that would start on 5/22/25. The SSA said she did not document the conversation in which the home health agency confirmed they would be assuming care for the resident. The SSA said she verbally confirmed with the transition services team on 5/20/25 that Resident #2's two transfer poles were installed at his apartment. -However, only one transfer pole was installed at Resident #2's apartment (see interview below). The transition services agent was interviewed via phone on 6/11/25 at 1:16 p.m. The transition services agent said Resident #2 needed assistance transferring from his bed to his motorized wheelchair. The transition services agent said Resident #2 had one transfer pole installed in his bedroom. The transition services agent said the second transfer pole for Resident #2's bathroom had not been installed yet, but he said he would install the transfer pole in Resident #2's bathroom while he was there (on 6/11/25). The transition services supervisor was interviewed on 6/11/25 at 1:50 p.m. The transition services supervisor said the facility ordered the equipment based on the medical needs of the resident. The transition services supervisor said he knew there was one transfer pole for Resident #2 provided by the facility. The transition services supervisor said the facility did not give the transition team an inventory of the resident's equipment, but during the discharge meeting, via the phone on 5/20/25, the equipment Resident #2 required at discharge had been reviewed. The transition services supervisor was interviewed again on 6/11/25 at 5:45 p.m. The transition services supervisor said a second transfer pole was found in a box at Resident #2's apartment (on 6/11/25) and was going to be installed. The SSD was interviewed a second time on 6/12/25 at 3:37 p.m. The SSD said Resident #2's discharge date was verbalized over the phone to the home health agency but it was not documented in the resident's record.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#9) of five residents reviewed for medications errors out of 12 sample residents. Specifically the facility failed to ensure Resident #9 was administered Farxiga (for chronic kidney disease and diabetes mellitus type 2) per physician's orders. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: -The right medication; -The right dose; -The right patient; -The right route; -The right time; -The right documentation; and, -The right indication. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, congestive heart failure, ischemic cardiomyopathy (narrowed arteries reducing blood flow) and chronic kidney disease. The 5/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required set up or clean up assistance with his activities of daily living (ADL) and supervision while bathing. B. Resident interview Resident #9 was interviewed on 6/12/25 at 9:45 a.m. Resident #9 said the facility ran out of his medications frequently. He said the facility ran out of two of his medications in May 2025 and he was told a nurse forgot to order the medications. C. Record review A review of Resident #9's June 2025 CPO revealed the resident had physician's orders for the following medication: Farxiga oral tablet (dapagliflozin propanediol) 5 milligrams (mg), give two tablets by mouth one time a day for chronic kidney disease and diabetes mellitus type 2, ordered 5/13/25. Resident #9's May 2025 medication administration record (MAR) revealed the resident did not receive the Farxiga as ordered on 5/17/25, 5/18/25 and 5/19/25. A 5/17/2025 at 7:27 a.m. medication administration note documented Resident #9's Farxiga was not administered and the facility was awaiting delivery of the medication from the pharmacy. A 5/18/25 at 9:27 a.m. medication administration note documented to administer Farxiga 5 mg; give two tablets by mouth one time a day for chronic kidney disease and diabetes mellitus type 2. -The note did not indicate why the resident's Farxiga medication was not administered. A 5/19/25 at 11:40 a.m. medication administration note documented to administer Farxiga 5 mg; give two tablets by mouth one time a day for chronic kidney disease and diabetes mellitus type 2 and the medication was on order. -However, there were no progress notes documented to indicate the pharmacy or the physician had been contacted or notified that Resident #9's Farxiga medication was not available and had not been administered to the resident on 5/17/25, 5/18/25 and 5/19/25. III. Staff interviews The consultant pharmacist was interviewed on 6/12/25 at 1:48 p.m. The consultant pharmacist said Farxiga was approved for coronary heart failure and studies had shown that it reduced mortality in residents with heart failure. She said the medication was also approved for use with chronic kidney disease. The consultant pharmacist said if the facility were out of a medication, the facility would not contact the pharmacist but should instead contact the pharmacy and could also contact the resident's physician. Licensed practical nurse (LPN) #1 was interviewed on 6/12/25 at 2:58 p.m. LPN #1 said she had had to call the pharmacy after the facility had ordered a medication and sometimes the facility had to order the medication a second time. LPN #1 said she usually documented when she called the pharmacy. LPN #1 said the facility could order medications electronically, and if a medication had to be ordered a second time, she would call the pharmacy for follow up. LPN #1 said if a medication was not available to administer, staff had to notify the physician. The clinical nurse consultant (CNC) was interviewed on 6/12/25 at 4:30 p.m. The CNC said she checked Resident #9's Farxiga medication order and the physician had ordered the medication on 5/13/25. She said the medication showed on the resident's profile but the medication was not filled by the pharmacy. She said the facility reordered the medication on 5/18/25 and it was delivered to the facility on 5/18/25. She said she was not sure why the medication was not administered on 5/19/25. IV. Facility follow-up A provider education document, dated 6/13/25, was provided by the NHA on 6/13/25 at 3:20 p.m., after the survey exit The provider education documented the physician sent an electronic prescription for Resident #9's Farxiga medication to the pharmacy on 5/13/25 and indicated the prescription was for the resident's profile only. Therefore, the pharmacy added the medication to the resident's medication list but did not fill the prescription. The physician was counseled on ensuring that the profile only was not marked on the electronic prescription submission.

Based on observations, record review and interviews, the facility failed to ensure four (#1, #8, #7 and #27) of 11 residents reviewed for abuse out of 28 sample residents were kept free from abuse. Resident #2 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (disease that affects movement and muscle tone), acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. Resident #2's care plan documented he had potential to demonstrate physically and verbally aggressive behaviors due to his diagnosis of dementia. The resident had exhibited aggression toward staff and other residents. On 11/3/24, Resident #8 reported to staff that his roommate, Resident #2, had hit him. Resident #8 was assessed and found to have a bruise under his right eye. Resident #2 told staff that he swung at Resident #8. Resident #8 was sent to the emergency department (ED) where he was treated for bruising and swelling to his face and returned to the facility the same day. On 1/19/25, screaming was heard in Resident #2's room. Resident #2 and Resident #1 were found lying on the floor, both on their right side. Resident #1 was behind Resident #2. Resident #1 had a large bruise and swelling to her left eye, bleeding from her mouth and facial redness and discoloration. Resident #2 stated that he beat up Resident #1. Resident #1 was transported to the hospital and admitted with trauma to the head and neck where she was monitored for agitation and tachycardia (high heart rate). Resident #1 was readmitted to the facility on [DATE] with bruising to the face, chest and neck. Additionally, the facility failed to protect Resident #7 and Resident #27 from verbal abuse by Resident #4. Findings include: I. Facility policy and procedure The Abuse Prevention and Reporting-Guideline policy, revised August 2021, was provided by the nursing home administrator (NHA) on 1/27/25 at 11:49 a.m. It read in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff or other agencies serving the residents family members or legal guardians, friends, or other individuals. All allegations of abuse are investigated. Verbal abuse is any use of oral, written or gestured language that includes knowingly threatening a resident causing fear or imminent, serious bodily injury within hearing distance, to described residents, regardless of their age, ability or disability to comprehend. Physical abuse is the intentional action of inflicting bodily injury including, but not limited to hitting, slapping, pinching or kicking. It also includes unreasonable confinement, restraint, and bruises of unknown origin. The administrator or designee will complete the investigation and will notify the suspected assailant and victim or responsible party of the conclusions and any corrective actions implemented based on investigative findings. II. Incidents of physical abuse of Resident #1 and Resident #8 by Resident #2 A. Facility incident reports of physical abuse of Resident #8 and Resident #1 The NHA provided investigations for the incidents of abuse of Resident #8 and Resident #1 on 1/28/25 at 3:00 p.m. The investigations documented the following: On 11/3/24, Resident #8 reported to staff that his roommate, Resident #2, had hit him. Resident #8 was assessed by facility staff and found to have a bruise under his right eye. Resident #2 told staff that he swung at Resident #8 because Resident #8 did not want to go to sleep. Resident #8 was permanently moved to a different room and Resident #2 was placed on one-on-one facility staff supervision and no longer had a roommate. After an 11/4/24 physician evaluation, it was determined Resident #8 should be sent to the emergency department where he was treated for bruising and swelling to his face and returned to the facility the same day. On 11/9/24 Resident #2 was documented as having been on 15-minute checks after one-on-one facility staff supervision was discontinued. On 1/19/25, screaming was heard in Resident #2's room. Resident #2 and Resident #1 were found lying on the floor, both on their right side and Resident #1 was behind Resident #2. Resident #1 had a large bruise and swelling to her left eye, bleeding from her mouth and facial redness and discoloration. When questioned, Resident #2 stated that he beat up Resident #1 because she wandered into his room. Resident #1 and Resident #2 were immediately separated and Resident #1 was sent to the hospital for further evaluation and treatment. Resident #1 was transported to the hospital and admitted with trauma to the head and neck and was readmitted to the facility on [DATE] with bruising to the face, chest and neck. Resident #2 was placed on one-on-one facility staff monitoring and discharged to the hospital on 1/19/25 with right hand discoloration to his knuckles and fourth and fifth digits. B. Resident #2 (assailant) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on 1/19/25. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral palsy, acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. The 1/24/25 minimum data set (MDS) assessment revealed the resident was moderately impaired regarding tasks of daily life and cues and supervision were required per staff assessment. A review of the residents electronic medical record (EMR) documented, on 10/22/24, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of six out of 15. The 1/24/25 assessment documented Resident #2 needed substantial to maximum assistance with oral hygiene, bathing, dressing and bed mobility. He needed set up assistance with eating. The MDS assessment documented the resident had physical and verbal behaviors directed at others. 2. Record review Resident #2's comprehensive care plan, initiated 7/16/24, documented the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to his dementia diagnosis. Pertinent interventions, initiated 7/16/24, included to monitor, document and report to the physician or a nurse any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing himself, difficulty understanding others, level of consciousness and mental status. Resident #2's focused care plan for verbally aggressive behaviors related to dementia, initiated 9/5/24 and revised 11/9/24, documented Resident #2 acted in a playful way toward other residents which could be misconstrued. Pertinent interventions included to document the resident's behavior and attempted interventions (initiated 9/6/24 and revised 11/9/24), and analyzing key times, places, circumstances, triggers and what de-escalated the resident's behavior and document; the resident responded to verbal interventions from staff, was placed in a private room (with no roommate) and had potential for unprovoked aggression towards others. -The playful behaviors which could be misconstrued however, were not specified or documented. Resident #2's focused care plan for physical behaviors, initiated 11/4/24, documented he had the potential to demonstrate physical behaviors related to dementia, had exhibited aggression toward staff and other residents and was placed in a private room (with no roommate). Pertinent interventions, initiated 11/4/24, included to document observed behavior and attempted interventions, monitor, document and report to the physician if the resident was a danger to himself and others, and analyze key times, places, circumstances, triggers and what de-escalated the behaviors and document the findings. A review of Resident #2's EMR documented the following: On 7/17/24 provider documentation revealed Resident #2 was previously admitted to a hospital in April 2024 after assaulting an individual at a previous facility and being verbally abusive to the staff prior to admission to the current facility on 7/16/24. -However, the facility failed to implement a care plan that addressed Resident #2's behavior history upon his admission to the facility. Cross reference F744 for failure to provide a person centered dementia services. On 7/18/24 a nursing progress note, written at 3:55 p.m., documented Resident #2 approached multiple residents screaming and cursing at them for no reason. The staff directed Resident #2 away from the other residents and offered Resident #2 food and conversation. The assistant director of nursing (ADON) and on-call provider were notified. Cross reference F609 for failure to report abuse to the State Agency. On 7/19/24 a nursing progress note, written at 5:01 a.m,. documented Resident #2 was extremely aggressive and agitated throughout the shift and was calling residents names using explicit language and overall disrupting the normal nightly routines. Other residents were fearful of Resident #2 during this shift. Resident #2 began stalking residents and trying to physically trip other residents with his feet. Multiple interventions were attempted without effectiveness and a non-emergent message was left with the director of nursing (DON). -However, the incidents on 7/17/24, 7/18/24 and 7/19/24 were not reported to the NHA, who was the facility's abuse coordinator. On 7/19/24 a nursing progress note, written at 6:01 p.m., documented Resident #2 was extremely agitated throughout the shift and was using profanity. Resident #2 began following other residents and trying to trip them with his feet but did not make contact and was more than ten feet away from the other residents. -The facility failed to document attempted interventions to redirect the resident or if the physician was notified. On 8/13/24 a nursing progress note, written at 2:27 a.m., documented Resident #2 continued to wander on the secure memory care unit needing one-on-one facility staff care due to increased aggressive behavior and attempting to go in and out of other residents' rooms. After Resident #2 was redirected away from other residents' rooms, the resident held a closed fist up to staff while swinging and yelling profanities. Several residents got up and returned to their room, as they appeared afraid. Reassurance was given to residents redirected by staff back to their rooms. Resident #2 continued on one-on-one facility staff monitoring for resident safety. The facility placed a call to the provider to send the resident to the ED for evaluation and the ADON was notified. On 8/13/24 at 6:31 p.m. the DON documented a clarification note that indicated the DON followed up and Resident #2 was not yelling at any specific residents but residents were redirected into their rooms related to loud noise from Resident #2. On 8/16/24 a nursing progress note, written at 12:42 p.m., documented Resident #2 was observed in his wheelchair propelling in the hallway and yelling profane names at the female residents as they walked by. Resident #2 was then observed kicking and banging on a resident's door, while yelling and cursing at the female resident on the other side of the door. The resident was redirected to a quiet area, and listened to the staff member, appeared disinterested, verbalized understanding then laughed. On 10/9/24 a provider note documented the staff reported ongoing behaviors of Resident #2 attempting to interact with other residents in a playful manner, which could be irritating to other residents, and providing verbal redirection was usually sufficient. On 10/10/24 a nursing progress note, written at 11:47 a.m., documented Resident #2 was screaming at another resident in the hallway. Staff intervened and separated both residents safely. The resident was redirectable and went to participate in activities. -The facility failed to document the interventions used to redirect the resident or if the physician was notified. On 10/11/24 at 5:53 a.m. a nursing progress note documented Resident #2 continued to scream at a resident and staff and needed to be redirected multiple times. The nurse continued to monitor the resident's behaviors. -The facility failed to document attempted interventions to redirect the resident or if the physician was notified. The 11/4/24 physician note, documented at 7:26 a.m., revealed the physician followed up with Resident #2 regarding the resident assaulting and punching his roommate, and the resident had not had this type of behavior before and had intermittent verbal altercations with staff. -However, previous documentation revealed Resident #2 had previously used profane and derogatory language directed at other residents as well as kicking and banging another resident's door and cursing at her while she was in her room. On 12/8/24 a nursing progress note, written at 5:31 p.m., documented Resident #2 had multiple outbursts, yelling obscenities at staff and other residents. Resident #2 was at times able to be redirected, and this was reported to the DON. -The facility failed to document attempted interventions to redirect the resident or if the physician was notified. On 1/19/25 at 5:20 p.m. a certified nurse aide (CNA) heard screaming from resident Resident #2's room and notified a registered nurse (RN). Upon entering the room, Resident #2 was found on his right side on the floor and Resident #1 was lying on her right side behind him. Resident #1 had a large bruise and swelling to her left eye as well as bleeding from her mouth and facial redness/discoloration. Resident #2 said that he beat up Resident #1 because she wandered into his room. C. Resident #8 (victim) 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, chronic respiratory failure, emphysema, depressive episodes, cognitive communication deficit and the need for assistance with personal care. The 1/1/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of two out of 15. Resident #8 required substantial to maximal assistance with toileting hygiene, bathing and lower body dressing, moderate assistance with personal hygiene and transfers, and supervision with eating. The MDS assessment documented Resident #8 had physical and behavioral symptoms directed toward others. 2. Record review Resident #8's behavior care plan, revised 4/3/24, documented the resident had potential to become verbally and physically aggressive toward others related to dementia and Alzheimer's disease. The care plan indicated his triggers were not understanding his surroundings and others approaching him from behind or not in his line of vision. Pertinent interventions, initiated 3/14/24, included if the resident could not be redirected or calmed, and if safe to do so, staff were to attempt to perform cares at a later time after the resident was calm, offering a deck of cards and staff to approach the resident within his line of vision. Interventions added on 11/11/24 included to approach the resident from the front or make it known you were approaching, redirect the resident and/or offering the resident a deck of cards. D. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included early onset Alzheimer's disease, severe dementia, bipolar disorder, anxiety disorders, and psychotic disorder with hallucinations. The 1/1/25 MDS assessment revealed the resident had a memory problem and was severely impaired, never or rarely making decisions per staff assessment. Resident #1 was dependent on care or needed substantial to maximal assistance for all activities of daily living (ADL), used a wheelchair, was independent with eating and transferring self and required set up assistance with showering. The MDS assessment documented the resident had behaviors that were not directed at others. 2. Record review Resident #1's behavior care plan, revised 10/15/24, documented she had potential for a behavior problem related to her Alzheimer's diagnosis, schizoaffective disorder, bipolar type, psychotic disorder with hallucinations, and behavioral exacerbations as evidenced by wandering tendencies through the unit and into others' rooms. Resident #1 presented with periods of affection towards others. Pertinent interventions, initiated 3/1/24, included to document the resident's behaviors and resident response to interventions. Additional interventions, initiated 1/24/25, included to offer Resident #1 a safe wandering area and provide a quiet environment. The facility added a personalized shadow box outside her room so she could easily identify her room. Upon return from the hospital (on 1/24/25) Resident #1 was monitored for 72 hours to determine a pattern of behaviors and wandering. E. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/28/25 at 11:25 a.m. LPN #3 said when Resident #2 was asleep alone in his room, he would at times wake up screaming, yelling and throw his wheelchair and other belongings around the room. LPN #3 said Resident #2 was easily redirectable and if he said Resident #2's name, the resident would immediately change his behavior. LPN #3 said Resident #2 sometimes wandered and he reported the resident's behaviors to the physician. LPN #3 said Resident #2 verbally lashed out at other residents. LPN #3 said he was able to redirect the resident's behavior by saying his name and asking the resident to be a gentleman. LPN #3 said he never witnessed Resident #2 have physical contact with another resident. LPN #3 said when Resident #2 had behaviors, it usually happened very quickly and nothing specific triggered the resident's behaviors. LPN #3 said the facility conducted abuse education and he knew to contact the NHA to report abuse. LPN #3 said if he was unable to reach the NHA, he would contact the DON and the ADON to report abuse. The DON and the NHA were interviewed together on 1/29/25 at 11:00 a.m. The DON said the 24-hour nursing report was reviewed daily in the morning meeting. The DON said a note in a resident's EMR could be marked, by the writer, to enable the note to be viewed in the 24 hour report. The DON said when an agency staff member worked at the facility, the facility staffing coordinator provided the agency staff member information that included the DON's and the NHA's phone numbers. The DON said the facility was working on assembling an information and orientation packet for agency staff that included what incidents to report and whom to report to. The DON said the facility identified agency staff were working when Resident #2's behaviors were not accurately documented or reported. The NHA said after interviewing staff after the 1/19/25 incident between Resident #2 and Resident #1, the staff reported they heard the residents in Resident #2's room, and the residents (Resident #2 and Resident #1) were both lying on the floor. The NHA said the staff reported Resident #1 was behind Resident #2, holding him. The DON said both Resident #2 and Resident #1's behaviors were not observed to be out of the ordinary on 1/19/25. The DON said the regional clinical resource (RCR) interviewed the staff about the incident on 1/19/25 and staff reported both residents were baseline. The DON said a stop sign was placed on Resident #2's door in November 2024 to discourage other people from going in his room. The DON said Resident #2 did not like other people in his room. The DON said Resident #1 wandered into Resident #2's room but she was unsure if Resident #1 was able to understand the stop sign. The DON said it took time to become familiar with a resident's baseline behavior, which was why Resident #2 did not have a behavior care plan upon admission to the facility. The DON said if a new resident was admitted to the facility, the facility reviewed the resident's referral packet and resident's PASRR (pre admission screening and resident review) documentation and if behaviors were listed the facility put them into the care plan. The DON said the facility tried to establish a baseline for a residents' behavior and then determine if there were specific resident behaviors that needed to be added to a care plan. The NHA said he was the abuse coordinator for the facility and the staff were to call him to report allegations or suspicions of abuse. The NHA said if staff were not able to reach him, the next person to call was the DON, and if staff were unable to call the DON they could call the ADON. The NHA said he expected staff to call him to report abuse and not text him. The RCR and the DON were interviewed together on 1/29/25 at 3:00 p.m. The RCR said the facility's documentation of Resident #2's behaviors could have been more specific when describing if the behaviors were directed to a specific resident or not. The RCR said Resident #2 would be in his room and fine by himself and then could escalate quickly with no warning. The DON said Resident #2 had his medications adjusted in the latter part of 2024 which seemed to be more beneficial to the resident and his behaviors decreased. The DON said Resident #2 was triggered by people wandering into this room. The RCR said after reviewing the documentation in Resident #2's record, the facility recognized the documentation errors in the resident's EMR primarily originated from agency staff. She said after the incident on 1/19/25, the facility implemented a plan to only schedule facility staff in the secured unit (where Resident #1, Resident #2 and Resident #8 resided) instead of agency staff. The RCR said facility staff knew the residents better, could better anticipate a resident's needs and recognize if a resident's behavior began to change and intervene before the behavior escalated. The RCR said part of the plan of correction implemented after 1/19/25 was to create cards for the staff in memory care so staff could access, on the card, immediate and specific interventions for each resident. She said the cards were made for staff to carry on their person. The RCR said the staff found the cards helpful. The RCR said the plan of correction included ongoing monitoring of the memory care unit for at least a three-month period, which would be reviewed monthly in the facility's quality and performance improvement (QAPI) meetings. F. Facility plans of correction and follow up The NHA provided plans of correction (POC) on 1/30/25 at 3:20 p.m. for the incidents on 11/3/24 and 1/19/25. 1. POC for incident between Resident #2 and Resident #8 The POC for the 11/3/24 incident between Resident #2 and Resident #8 included: -A chart review for Resident #2 completed on 11/6/24 by the medical director with medication recommendations; -Resident #1 returned to the facility with bruising that was monitored and resolved with no complications and offered psychosocial support; -Resident #2 was started on immediate one-to-one staff to resident monitoring; -A chart review and identification of residents on the secure unit on 11/11/24 to ensure residents had appropriate care plans with identified triggers; -A chart review for roommate evaluation to ensure all roommate situations were working; -Monitoring initiated 11/13/24 to 1/24/25 that included observation of the secure unit to identify if any resident behaviors were happening and if staff responded appropriately; -Staff interviews three times a week to determine if they knew residents' triggers and interventions; and, -The DON or designees educated all staff who worked on the secured unit regarding resident's specific triggers. (However, the education was not dated). 2. POC for the incident between Resident #2 and Resident #1 The POC for the 1/19/25 incident between Resident #2 and Resident #1 included: -Resident #2 was put on one-to-one staff to resident monitoring until emergency responders transported the resident to the emergency department; -A review of all residents on the secure unit and five residents were identified who wandered and IDT reviewed their care plans; -The DON provided education to staff who provided direct care of potential triggers and interventions for each resident in the secure unit on 1/21/25; -An audit of the secure unit, initiated 1/25/25, that included five residents three times a week, that included review of resident behaviors, interventions and staff observations of appropriate staff response to resident behaviors; -Resident #1 was monitored for 72 hours upon return to the facility; -A consultation with an abuse preventionist coordinator about triggers and interventions; and, -Results of the audit would be presented in QAPI until substantial compliance was met. -However, the POC was complete as the facility had additional allegations of physical and verbal abuse that were not addressed (see below). 50219 III. Incident of verbal abuse by Resident #4 toward Resident #27 on 7/24/24 The facility incident report, dated 7/25/24 at 9:05 p.m., was provided by the NHA on 1/28/25 at 3:00 p.m. The report revealed Resident #4 arrived at the 400 unit seeming upset on 7/24/24 at 9:15 p.m. Resident #4 began yelling at staff members who attempted to de-escalate the resident and direct him away from the common area and other residents. During these attempts, Resident #4 said things about Resident #27 and the nurse present was not sure if Resident #27 heard what Resident #4 was saying about her. Resident #4 was eventually able to be redirected to his room. Resident #27 was assessed and interviewed and did not recall hearing anything or that an incident occurred. Resident #4 was placed on cares in pairs and one-to-one supervision until his behaviors improved. Both residents received psychosocial monitoring. Resident #4 was also placed on a success plan. A. Resident #4 (assailant) 1. Resident status Resident #4, age 66, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the December 2024 CPO, diagnoses included multiple sclerosis, depressive episodes, muscle weakness, and thyrotoxicosis (a disorder in which the thyroid gland produces too much thyroid hormone). The 12/23/24 MDS assessment revealed the resident was cognitively intact and was independent with making decisions regarding tasks of daily life. The resident was dependent for most activities of daily living. The assessment indicated that the resident exhibited verbal behavioral symptoms directed towards others one to three days out of the assessment period. 2. Record review The trauma care plan, initiated 3/30/24 and resolved 5/23/24, revealed Resident #4 was at risk for retraumatization due to a history of trauma. Pertinent interventions included engaging with mental and behavioral health support and medication management, approaching in a calm manner, administering medications as ordered, discussing behavior and attempting to de-escalate and implement coping strategies and praising any indication of progress/improvement in behavior. The personality disorder care plan, initiated 3/30/24, revealed Resident #4 had a potential for mood problems due to his personality disorder which included anger and emotional outbursts, slamming objects down and using profanity. Pertinent interventions initiated 3/30/24 included administering medications as ordered, behavioral health consults as needed, encouraging the resident to express his feelings, de-escalating the resident, assisting him to a quieter or less stimulating environment, assisting him to an outdoor space for fresh air and medication. Interventions initiated on 5/6/24 included a success plan and encouraging the resident to ask for assistance when unable to perform ADLs independently. Interventions initiated on 7/25/24 included having the resident on one-to-one supervision. The behavior problem care plan, initiated 3/6/24, revealed Resident #4 had the potential for a behavior problem resulting from his personality disorder and depression. Pertinent interventions initiated on 3/7/24 included having caregivers provide an opportunity for positive interaction and attention, encouraging the resident to use his call light, intervening as necessary to protect the rights and safety of others, praising any indication of progress or improvement in behavior and a success plan. The verbal behavior care plan, initiated 3/7/24, revealed Resident #4 had the potential to demonstrate verbally aggressive behaviors due to anger and his personality disorder, which included swearing and using racially-insensitive language. Pertinent interventions initiated on 3/7/24 included a success plan analyzing key times, places, circumstances, triggers, and what de-escalated the behavior and documenting that information, giving the resident choices for care and activities, encouraging the resident to sit outside or watch funny videos online when upset or angry. Interventions initiated on 5/6/24 included a success plan in which the resident would ask for assistance from staff when he was having problems with his peers or removing himself from interactions with peers by going outside or to his room. Interventions initiated on 7/24/24 included a one-to-one companion and success plan. The behavior problem care plan, initiated 3/30/24, revealed Resident #4 had a potential for behavior problems due to his depression and personality disorder. A Level II PASSAR was conducted and found no significant mental illnesses. Pertinent interventions included the following PASRR recommendations: assisting with transitional housing, providing psychiatric case consultation, providing rehabilitation services and providing management. A practitioner note, dated 4/17/24 at 3:13 p.m., revealed Resident #4 was initially admitted from a previous facility where he had been hospitalized for three months due to psychiatric issues involving aggressive behavior. A progress note, dated 7/24/24 at 6:03 p.m., revealed Resident #4 was roaming up and down the hallways screaming about the food at the facility, using profanity, and disrupting other residents. The facility staff tried to redirect Resident #4 but he began targeting the staff with verbal aggression. The staff stopped engaging with Resident #4 except to politely ask him to discontinue his verbal aggression but were ineffective. The DON, the NHA, and the social services director (SSD) were notified of Resident #4's behaviors. A progress note, dated 7/25/24 at 12:29 a.m., revealed Resident #4 continued to use obscene and racially-insensitive language toward staff members. Resident #4 requested to be transferred to the emergency room , but when paramedics arrived, Resident #4 refused to go with them. Resident #4 then called emergency services throughout the night until he fell asleep. The DON, the NHA, and the SSD were notified of his behavior. B. Resident #27 (victim) 1. Resident status Resident #27, age 70, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, dementia and cognitive communication deficits. The 10/25/24 MDS assessment revealed the resident was significantly cognitively impaired with a BIMS score of three out of 15. The resident was independent for most activities of daily living. 2. Record review The behavior care plan, revised 4/24/24, revealed Resident #27 had[TRUNCATED]

Based on interviews and record review, the facility failed to ensure four (#79, #60, #31, #13) of four residents reviewed for abuse out of 48 sample residents were kept from mental and verbal abuse, contributing to residents experiencing, among other emotions, anxiety, fear, and humiliation. I. Staff to resident mental and verbal abuse A. In interviews with Resident #79, she stated the activities director (AD) was mean to her, spoke to her rudely, raised her voice at her, and made her feel belittled and like a scolded child on 4/3/24. Resident #79 was upset and was tearful as she recalled the incident. Although three staff who witnessed the incident promptly reported it to the nursing home administrator (NHA), the facility failed for several hours to initiate an investigation or implement corrective actions to protect Resident #79 from further abuse. B. In interviews with Resident #60, he said he was in severe pain from being reclined in his wheelchair for a long time. When he asked certified nurse aide (CNA) #2 to get him out of the wheelchair and into bed, the CNA raised his voice and, in a scolding tone, told him other residents had more important needs and that he would just have to wait. Resident #60 said the CNA made him feel that he was not as important as the other residents. II. Resident to Resident Mental and Verbal Abuse In separate interviews with Resident #13 and Resident #60, the residents said that Resident #31 verbally abused them by using racial slurs and offensive language and making derogatory comments about them. Both residents said they avoided common areas of the facility out of fear and worry that they would be subject to Resident #31's verbal attacks when they were in the same space as Resident #31. Resident #13 said he had to stay in his room more than usual to keep from crossing paths with Resident #31. Resident #13 said this treatment caused him distress and triggered feelings of worry. Resident #60 said he tried to avoid passing by Resident #60 as much as possible because the verbal attacks about his person made him feel bad. Record review and interview revealed the facility failed to take corrective action to prevent further verbal abuse of Resident #13 and #60 by Resident #31. Cross-reference F610; failure to initialize a timely investigation of reports of allegations of abuse. Findings include: I. Facility policy and procedure A. The Abuse policy, revised in October 2022, was provided by the nursing home administrator (NHA) on 4/3/24 at 3:13 p.m. It read in pertinent part: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. B. NHA and the social services director (SSD) were interviewed on 4/9/24 at 6:18 p.m. about the facility's response to allegations of abuse. The NHA said reports of potential abuse should be fully investigated. The NHA said when abuse was alleged, the process was to suspend the staff in question, protect the residents from further harm, make notifications to the power of attorney, and start a report to the State Agency. The NHA said if a resident's safety was in question, he would also notify adult protection services. He said he would start the investigation by interviewing the resident, then he would interview witnesses and find out if anything similar had happened before, and after completion of the investigation, he would perform a post-incident review. The SSD said he would interview the residents to find out what happened, whether or not they had fear, and if they felt safe. The NHA said the SSD took the lead in investigating allegations of abuse and reported findings to the NHA. II. Staff to Resident mental and verbal abuse - Incident involving the activities director (AD) and Resident #79 A. Resident #79 1. Resident status Resident #79, age over 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, bipolar disorder, post-traumatic stress disorder (PTSD), anxiety, and depression. The 3/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with hygiene, dressing, and transferring herself and did not exhibit any behavioral symptoms or refusal of care. The resident's comprehensive care plan, revised on 3/24/24, documented Resident #79 had a history of trauma involving an adverse childhood experience and had the potential to demonstrate physical behaviors related to dementia. The interventions included approach in a calm manner, attempt to de-escalate, and implement coping strategies. When agitated, guide away from the source of distress and staff to walk away if the resident becomes aggressive. 2. Resident interview Resident #79 was interviewed on 4/3/24 at 1:35 p.m. Resident #79 was sniffing and wiping tears from her eyes. She grabbed a tissue, sat down on her bed, and apologized for being so upset. Resident #79 then reported she was very upset over a recent interaction with the AD during and after the resident council meeting that morning. Resident #79 explained the library book program meant so much to her and said many of the other residents had been asking her when they could get books again. She said she felt bad for the people who could not get out to do things and especially bad for those who were deaf and really enjoyed reading. She began to tear up again and wiped her eyes with a tissue. She said the library books meant a lot to her because she felt the book program really helped others and she enjoyed helping people. She said she felt the AD did not understand how important the books were to her and other residents. Resident #79 said the AD was very mean to her, raised her voice at her, was very rude, and told her the facility's library book program was not a priority and would not be a priority. Resident #79 said she was so upset by the way the AD spoke to her that she began crying. She said two therapy staff witnessed the interaction and helped to console her. Resident #79 said the AD's tone was snotty and very belittling. She said it made her feel like a scolded child. Resident #79 began to cry again and said she did not understand why the AD was so mean to her. She said she was so upset by the interaction that she just wanted to lie down and sleep. Resident #79 said she did not think she would even be able to do her therapy session that afternoon because she was so upset. 3. Report and response of staff witnesses to the incident a. Speech therapist (ST) #1 ST #1 was interviewed on 4/3/24 at 1:50 p.m. ST #1 said she witnessed an incident/inappropriate interaction between the AD and Resident #79 that occurred around 11:15 a.m. that morning. She said the AD was speaking to the resident in a manner that was not appropriate and was belittling the resident. She said she did not feel it was appropriate to communicate with residents with dementia in that manner. ST #1 said Resident #79 was crying after the encounter so she and occupational therapist (OT) #1 tried to console the resident. ST #1 said that she observed most of the interaction and OT #1 also heard the end of the interaction between the AD and Resident #79. ST #1 said physical therapist (PT) #1 saw the resident crying after the incident and also tried to console the resident. ST #1 said after the resident calmed down, she went with OT #1 and PT #1 to report the incident to the NHA. ST #1 said they felt more comfortable reporting the incident together because they believed their observations would be better received and not ignored if all three of them reported what they observed as a group since the allegation was against a member of the leadership team. ST #1 was interviewed a second time on 4/9/24 at 2:26 p.m. ST #1 said the AD sounded stressed and very busy. ST #1 said the tone of the AD was not appropriate since the resident had dementia. She said she did not feel it was her job to define abuse but it was her responsibility to report any incident that was concerning and she felt this incident fell into that category. b. PT #1 was interviewed on 4/3/24 at 1:53 p.m. PT #1 said he did not witness the incident but he did see Resident #79 crying after it was over. He said he helped to console her and went with ST #1 and OT #1 to report the incident to the NHA. c. OT #1 OT #1 was interviewed on 4/3/24 at 1:55 p.m. OT #1 said she heard the end of the interaction between the AD and Resident #79. The OT said the AD used an inappropriate tone of voice with Resident #79. OT #1 said the resident was very upset and was seen crying by the end of the resident and AD's encounter. OT #1 said she, ST #1, and PT #1 consoled the resident because she was so upset and tearful. OT #1 said the interaction was very concerning and they felt it needed to be reported to the NHA so that is what they did. OT #1 was interviewed again on 4/9/24 at 2:05 p.m. OT #1 said the AD's tone of voice during the incident with Resident #79 was very stern, direct, and inappropriate. OT #1 said the comment made by the AD that stuck out most to her was when the AD told Resident #79 that the library book program was not a priority. OT #1 said she defined verbal abuse as any type of talk that made a person feel bad or upset. d. The activities assistant (AA) #1 AA #1 was interviewed on 4/9/24 at 2:45 p.m. AA #1 said he only observed the end of the incident between Resident #79 and the AD. When he saw them they were standing in the hall in front of the activities room. AA #1 said Resident #79 started to walk away from the AD and then started talking again but could not remember what the resident said. AA #1 said the AD apologized to Resident #79 for losing her cool in her office. B. Facility response - failure to initiate an investigation or implement corrective actions for several hours to protect Resident #79 from further abuse. The NHA was interviewed on 4/3/24 at 2:00 p.m. The NHA said the staff that reported the incident between the AD and Resident #79 did not tell him that they thought the incident was verbal abuse so he did not start an investigation or take any action to suspend the AD. The NHA said he would look into it further and, depending on his findings, the AD might be sent home. An interview with the NHA on 4/3/24 at 4:30 p.m. revealed he had suspended the AD pending investigation. However, the AD continued to work in the facility without restricted access to interact with Resident #79 or other residents in the facility for five hours after the incident that morning and for two hours after he received reports of the incident from staff who witnessed it. C. The AD was interviewed on 4/10/24 at 3:15 p.m. The AD said the incident began after the resident council meeting when Resident #79 came to her office to talk about the library book program. The AD said she told Resident #79 that it would take time to get it set up as other items had to be relocated first. She said she told Resident #79 that she did not have an immediate solution and the resident became very upset and told the AD that the AD did not care about the library book program. The AD said she did not handle the situation very well and ended the conversation with Resident #79 by saying, If you don't like any of my solutions then we have nothing else to talk about. The AD said she tried to apologize to Resident #79 but the resident did not want to hear it. The AD said she had reflected on the interaction with Resident #79 and said she did not do a good job of de-escalating the resident. The AD said she needed more training and should remember that the facility was home for the residents and she had to respect that. She said if she were in that situation again, she would ask the resident for a break to regroup and settle herself down. The AD said Resident #79 kept talking over her and interrupting her so she raised her voice toward the resident because she did not like being interrupted. D. Facility investigation - failures in the facility investigation (Cross-reference F610) 1. The facility investigation was provided by the NHA on 4/10/24 at 2:10 p.m. The investigation, dated 4/3/24, documented Resident #79 reported the AD was snotty and she did not like her tone of voice. Resident #79 reported she had tried to talk to the AD about supplies needed for the library book program. The resident was placed on increased monitoring. Resident #79 was interviewed by the SSD as a part of the investigation. The investigation interview read: There was a Lengthy meeting with Resident #79 this afternoon to discuss resident council and interactions after resident council. The resident was noted to be calmly resting in her room when I knocked and entered her room. She reported to me that the day hadn't gone very well. Residents expressed frustration regarding the library books that she had previously managed and how many of the residents attended Bingo at the same time she used to set up the library. She reported that she has been waiting for space/supplies to continue with the library books but it hadn't happened yet. She also expressed frustration that everything is changing. She stated that the new activities lady was snotty and that she didn't like her tone of voice. I asked her if she was afraid of anyone here and she stated, Absolutely not. Throughout our meeting her mood varied, however frequently throughout our conversation the resident was joking and laughing. The meeting concluded when physical therapy (PT) came to work with her and she reported to PT that she's having a much better day. The investigation documented that Resident #79 was noted by staff who observed the incident to be tearful at the time of the incident. The facility investigation did not document that an allegation of verbal abuse was substantiated. It concluded that the resident raised her voice during the incident and the AD was attempting to diffuse the interaction. A staff witness said the AD's tone was stern and aggravated. Other staff thought the AD was professional. 2. Failures in facility investigation (Cross-reference F610) The corporate social worker (CSW) was interviewed on 4/10/24 at 2:45 p.m. She said she interviewed the AD but did not document the interview, she only took notes in her personal notebook which she did not share. She said she did not interview AA #1 regarding his statement that he overheard the AD apologizing to Resident #79 for losing her cool. A review of the facility's investigation did not explain which staff thought the AD was professional in her response to the resident and if those staff had witnessed the incident or part of the incident, or had only heard about the incident from other staff witnesses. 47422 III. Staff to resident mental and verbal abuse - Incident involving CNA #2 and Resident #60 A. Resident #60 1. Resident status Resident #60, under age 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included schizoaffective disorder, chronic pain, cognitive-communication deficit, and a history of traumatic brain injury. The 2/28/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident had functional limitations in both lower extremities (hips, knees, ankles, and feet) and was fully dependent on staff to complete all activities of daily living (ADL), was not able to walk and used a wheelchair. A review of the resident's record revealed a self-care performance care plan, revised on 3/1/24, related to weakness, impaired cognition, hypertension, psychosis, and osteoarthritis. Interventions included Resident #60 required physical assistance from two staff members with any transfers. 2. Resident interview and observations Resident #60 was interviewed on 4/9/24 at 10:42 a.m. Upon entering the room, Resident #60 was observed in a reclined position in his mechanical wheelchair in his room. The resident had been crying and said he was in severe pain from being reclined for a long time and he could not adjust the position of the wheelchair because it was broken. Resident #60 said he needed to get up out of his wheelchair. Resident #60 said he had asked certified nurse aide (CNA) #2 to get him out of the wheelchair and into bed but CNA #2 just yelled at him. During the interview, CNA #2 appeared in the resident's doorway and entered the room. Resident #60 asked CNA #2 again if he could get him into bed. CNA #2 raised his voice and, in a scolding tone, said to Resident #60 that there were other residents who had more important needs who were wet and needed to be taken care of first because it was a priority to take care of wet residents first. CNA #2 told Resident #60 that he would just have to wait until he had time to come back and help him. After CNA #2 left the room, Resident #60 said the way CNA #2 treated him had made him feel as if he was not as important as the other residents. Resident #60 said he was so uncomfortable and in pain from sitting so long that he just wanted to be repositioned for some relief. B. Facility Response The NHA was interviewed on 4/9/24 at 11:00. The NHA said when residents required assistance they should have been cared for, especially residents who had visible discomfort and distress. He said any staff member who was unable to assist residents in a timely manner was to notify the charge nurse and reach out to other staff for assistance. He said CNA #2 was having a difficult time assisting all his assigned residents in a timely manner but should have reached out for help. The NHA suspended CNA #2 pending an investigation. IV. Resident-to-resident mental and verbal abuse - Incidents involving Residents #60, #13, and #31 A. Residents #60, #13, and #31 1. Resident #60 status - see above 2. Resident #13 status Resident #13, age under 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included paraplegia related to a gunshot wound, cognitive-communication deficit, and schizoaffective disorder. The 2/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident had not exhibited any behavioral symptoms. A review of the resident's record revealed Resident #13 had a mental health care plan initiated on 3/7/24, revised 4/4/24, which documented that the resident was at risk for re-traumatization related to a history of trauma involving a shooting and losing his brother at a young age. Additionally, the resident was at risk for ineffective coping related to psychiatric diagnosis. Interventions included: Adjust the environment to be more individually preferred and homelike, document behaviors, and response to interventions. The care plan listed two triggers for his post-traumatic stress disorder (PTSD) related to violence, including talking about violence and violent movies. An ineffective coping care plan initiated on 3/23/24, revealed the resident had ineffective coping skills related to schizoaffective disorder, hallucinations, and a history of trauma. Interventions included an adjusted environment to be more individualized and homelike and encouraged contact with a support system. 3. Resident #31 status Resident #31, under the age of 65, was admitted on [DATE] with an initial admitted [DATE]. According to the April 2024 CPO, diagnoses included multiple sclerosis, hyperlipidemia, lymphocytopenia, and personality disorder. The 2/28/24 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for a mental status score of 15 out of 15. The behavior section indicated verbal behavioral symptoms directed toward others with a frequency of every one to three days. B. Incidents of mental and verbal abuse by Resident #31 toward Resident #13 and #60 on 3/5/24 and 3/10/24 1. Investigative report of resident-to-resident mental and verbal abuse on 3/5/24 a. Facility investigation The facility investigation of an allegation of verbal/mental abuse occurring on 3/5/24, documented that Resident #31 was observed to be verbally aggressive with Resident #13 and Resident #60. Resident #31 was heard by a staff witness calling Resident #13 racial slurs and telling him to go back to [NAME]. Resident #31 then called Resident #60 offensive names and made negative comments about his weight. Staff responded and separated the residents from each other. The director of nursing (DON) and the SSD tried to de-escalate the situation and calm Resident #31. Resident #31 remained agitated and started throwing his food and plate. The facility called the police to ensure the safety of facility residents. The police arrived and were able to calm Resident #31. Resident #31 went to his room and remained there for the rest of the night. Resident #13 and #60 were offered psychosocial support and Resident #31 was placed on frequent checks and referred for a psychiatric evaluation and behavioral health services. The SSD interviewed the assailant, Resident #31. The SSD described Resident #31's demeanor as agitated and frustrated. Resident #31 said he had been frustrated because his housing transition application was being delayed. Resident #31 told the SSD, I can say what I want, I have First Amendment rights to do whatever I want. The SSD interviewed Resident #13 who said Resident #31 used racial slurs to call him names and told him to go back to [NAME]. Resident #60 told the SSD that Resident #31 used foul language and made negative comments about his weight. The investigator said neither victim was fearful. The investigator concluded that the allegation was substantiated based on staff witness statements. b. Failure of the facility to take corrective action to prevent further mental and verbal abuse of Resident #13 and #60 by Resident #31. -The facility did not make any changes to Resident #13 and #60's care plans related to the potential for repeated incidents of verbal abuse and emotional distress by Resident #31. -The facility investigation did not pursue questioning of Resident #13 or Resident #60, both of whom were at risk for re-traumatization, to identify other emotional responses characteristic of being a victim of mental and verbal abuse and identify any behavioral changes in Resident #13 and Resident #60. -The facility investigation failed to contain any staff witness statements about the details of the incident, what each resident said and did, or how staff responded to de-escalate the incident and protect the residents from further abuse. However, a progress note in Resident #13's electronic medical record (EMR) dated 3/5/24 that was not a part of the investigation packet (see above) read: Incident note. Late entry: Clarification note on 3/11: Nurse (working) on[the] floor (the unit) was standing at nurses' station when Resident #31 said to Resident #13 (explicit language), go back to [NAME] you (derogatory term) the Resident #31 said he would hit him (Resident #13) with his wheelchair if he didn't get the (explicit language) out of the way. This nurse stood in between the residents and asked them to separate. Resident #13 told Resident #31[that] he doesn't need to be talking to anyone like that. Resident #31 was yelling out at the nurses' station (explicit language) and was moving closer with his [m]otorized chair (to Resident #13) Resident #13 was able to get around Resident #31 and return to his room on his unit. Facility leadership and the police were notified of the incident. Psychosocial assessment [was] performed on [Resident #13] and [the] resident denies feeling fearful or afraid. Will continue with the current plan of care. -The note did not document who conducted the psychosocial assessment, when the assessment was completed, or if the assessor explored emotions other than fear of the assailant related to [Resident #13's] emotional status and existing psychiatric conditions that might be an outcome or side effect of the incident. 2. Investigative report of resident-to-resident mental and verbal abuse on 3/10/24 a. The facility investigation, for an allegation of verbal/mental abuse occurring on 3/10/24, documented Resident #31 was observed by nursing staff to be blocking the hallway path and was verbally harassing and cursing at residents that happened to walk by. When Resident #13 attempted to pass, Resident #31 was observed to say I'm not moving for him and then used racial slurs against Resident #13. The nursing staff asked Resident #31 to move several times but he refused and he would not move. A few minutes later Resident #31 turned his aggression against Resident #60, making derogatory comments about his weight. Resident #31 became increasingly angrier and started yelling profanities and cuss words at staff and despite many efforts, staff was not able to calm him down or determine the cause of his behavior. Resident #31's physician gave an order for the resident to be sent to the hospital for a full evaluation but the paramedics and police refused to take the resident to the hospital. The facility placed the resident on one-to-one monitoring to ensure the safety of all residents until the interdisciplinary (IDT) could determine the root cause for the change in the resident's behavior. The investigation determined that the resident's behavior may have been related to a similar change in behavior that was observed on 3/9/24 when Resident #31 was rude to another resident. The SSD interviewed Resident #31. Resident #31 said he did say stuff to Resident #13 and #60 but said he could not remember exactly what he had said. He then expressed frustration about wanting to leave the facility to move to his own apartment. A review of hallway security footage confirmed staff witness and resident accounts of what happened. Follow-up actions included: A plan to consult with the facility's medical director to meet resident's needs and to develop a plan to keep all residents safe. The SSD was to continue psychosocial monitoring to address Resident #31's behaviors. -Resident #13 and Resident #60 were offered counseling to manage their feelings around the incident of verbal abuse. -The IDT met and discussed a possible discharge plan for Resident #31 if his behavior continued but discharge plans were not initiated at that time. b. Failure of the facility to take corrective action to prevent further mental and verbal abuse of Resident #13 and #60 by Resident #31. -No changes were made to Resident #31's care plan following the incident and the facility gave no documentation of their findings. -The facility investigation did not pursue questioning of Resident #13 or Resident #60, both of whom were at risk for re-traumatization, to identify other emotional responses characteristic of being a victim of verbal abuse and identify any behavioral changes in Resident #13 and Resident #60. -The facility investigation failed to contain any staff witness statements about the details of the incident, what each resident said and did, or how staff responded to de-escalate the incident and protect the residents from further abuse. A progress note in resident #31's EMR that was not a part of the investigative packet read: Incident note. Late entry: Clarification note on 3/10/24. At approximately 1:10 p.m. on 3/10/24, Resident #31 was sitting in the hallway near the nurses station. He began verbally harassing and cursing at other residents [who] happened to walk by. Resident #13 attempted to propel himself in his motorized wheelchair past Resident #31 who was blocking the hallway and refused to move. [The] nurse witnessed Resident #31 refusing to move and verbalizing I am not moving for him. And then said to Resident #13, Hey aren't you from Nigeria? Oh wait, that's because you are a (racial slur). [The] nurse calmly asked Resident #31 to move several times to which he refused. Resident #13 sat quietly during Resident #31's episode and did not respond to his (Resident #31's) comments. [The] nurse was able to redirect Resident #31 but a few minutes later he (Resident #31) called Resident #60 fat. Leadership and police were notified. Resident #31's behavior required police intervention. The resident's physician wrote an order to send the resident to the hospital for further evaluation and treatment but the resident refused care [to go]. Paramedics were unable to take [the] resident due to refusal. Police were then called and spoke to the Resident but unable to do anything further. Resident [#31] was then placed on one to one monitoring. C. Resident interviews 1. Resident #60 was interviewed on 4/9/24 at 9:13 p.m. Resident #60 said Resident #31 had called him names and cursed him out and the facility would not do anything about it. He said the things Resident #31 said were hurtful and offensive, such as comments about his weight and disability. He said Resident #31 had done this more than once and Resident #60 just wanted it to stop. Resident #60 said he did not provoke Resident #31 in any way and took extra precautions going out of his way to avoid passing by Resident #31 because he did not want to be verbally attacked again. He said Resident #31's comments affected him negatively and made him feel bad about himself. Resident #60 said he was scared of Resident #31 and was still fearful that the resident would be verbally aggressive to him if they were to be in the same area. He said he knew it would happen again. He said he avoided parts of the facility to stay away from Resident #31. He said the facility had not put any protective measures in place to keep the situation from happening again. 2. Resident #13 was interviewed on 4/4/24 at 3:10 p.m. Resident #13 said Resident #31 made rude and racist remarks to him on several occasions. He said he did not ever provoke Resident #31 and tried every way possible, including staying in his room when possible, to avoid Resident #31 so Resident #31 would not say anything to attack him again. Resident #13 said that the incidents on 3/5/24 and 3/10/24 were not the first times he was yelled at and call[TRUNCATED]

Based on interviews, record review, and observations, the facility failed to protect six of nine residents reviewed out of 22 sample residents (#14, #20, #21, #15, #16, and #17) from incidents of resident-to-resident abuse and neglect. A. Record review revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care (secure) unit that protected residents from repeated incidents of resident-to-resident abuse. Residents #14, #20, #16, #17, and #21 resided in the facility's secure unit, along with 20 other residents. Residents #14, 21, #16, #17, and #21 were cognitively impaired and all had the potential for aggressive behavior toward other residents and/or staff. Residents #14 and #20 were known to wander into other residents' rooms. On [DATE], staff observed Resident #17, identified ten days earlier as beginning to display aggressive/combative behavior toward others, push Resident #16 out of her dining room chair. Resident #16 sustained a pelvic fracture and was admitted to hospice care after her return from the hospital. Record review revealed an interdisciplinary team (IDT) event review of the incident; however, the only intervention was to keep the residents separated and Resident #17 to call for help and not be physical. There was no indication the facility considered systemic factors that could have prevented the incident. Thereafter, record review revealed a series of resident-to-resident alterations involving Resident #14, #7, #20, and #21, pushing, punching, and throwing items that resulted in Resident #14 and #20 sustaining facial injuries. On [DATE], Resident #7 threw a cowbell at Resident #14, hitting the resident in the face when Resident #14 wandered into his room. On [DATE], Resident #14 shoved Resident #20's shoulder, and Resident #20 punched Resident #14 in the face. On [DATE], Resident #21 yelled at Resident #14 and when Resident #14 responded in a foreign language, Resident #21 punched Resident #14 in the face. Finally, on [DATE], Resident #14 was found standing over Resident #20, punching him in the face. Notwithstanding the series of escalating resident-to-resident alterations, a review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the secure unit that protected residents from resident-to-resident abuse. The facility's failure created a situation of immediate jeopardy with the potential for serious harm. Cross-reference F744; treatment and services for dementia. B. Record review revealed the facility failed to take steps to protect Resident #15 from potential staff-to-resident abuse and from incidents of alleged neglect in the non-secure unit. Resident #15 reported to the assistant director of nursing (ADON) on [DATE] that she felt certified nurse aide (CNA) #8 verbally threatened her in retaliation for reporting that the CNA had been on her cell phone in the resident's room. The CNA continued to work on the resident's hallway without an investigation of the allegation. The resident experienced fear of physical harm, loss of sleep, and anxiety. Resident #15 also alleged she was not provided incontinence care for seven hours. Although the facility confirmed this allegation of neglect, the facility failed to protect the resident from further neglect, regarding lack of incontinence care and assistance with eating, which were reported prior to the substantiated allegation. The resident experienced shame, humiliation, and increased anxiety regarding whether care would be provided or not. Cross-reference F609 and F610 Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Record review revealed the facility failed to take steps to prevent repeated incidents of resident-to-resident abuse in the secure unit. Residents #14, #20, #16, #17, and #21 resided in the facility's secure unit, along with 20 other residents. Residents #14, 21, #16, #17, and #21 were cognitively impaired and all had the potential for aggressive behaviors toward other residents and/or staff. Residents #14 and #20 were known to wander into other residents' rooms. On [DATE], staff observed Resident #17, identified ten days earlier as beginning to display aggressive/combative behavior toward others, push Resident #16 out of her dining room chair. Resident #16 sustained a pelvic fracture and was admitted to hospice care after her return from the hospital. Record review revealed an interdisciplinary team (IDT) event review of the incident; however, the only intervention was to keep the residents separated and Resident #17 to call for help and not be physical. There was no indication the facility considered systemic factors that could have prevented the incident. Thereafter, record review revealed a series of resident-to-resident alterations involving Resident #14, #7, #20, and #21, pushing, punching, and throwing items that resulted in Resident #14 and #20 sustaining facial injuries. On [DATE], Resident #7 threw a cowbell at Resident #14, hitting the resident in the face when Resident #14 wandered into his room. On [DATE], Resident #14 shoved Resident #20's shoulder, and Resident #20 punched Resident #14 in the face. On [DATE], Resident #21 yelled at Resident #14 and when Resident #14 responded in a foreign language, Resident #21 punched Resident #14 in the face. Finally, on [DATE], Resident #14 was found standing over Resident #20, punching him in the face. Notwithstanding the series of escalating resident-to-resident altercations, a review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the secure unit that protected residents from resident-to-resident abuse. The facility's failure created a situation of immediate jeopardy with the potential for serious harm. B. Facility notice of immediate jeopardy On [DATE] at 5:30 p.m. the nursing home administrator (NHA), director of nursing (DON), and the director of clinical services (DOCS) were notified that the failure to ensure the safety of residents from resident-to-resident physical abuse, and in particular, Resident #14 escalating incidents of resident-to-resident abuse, created a situation of immediate jeopardy for serious harm. C. Temporary plan to abate the immediate jeopardy situation On [DATE] at 6:30 p.m., the nursing home administrator (NHA) and the director of nursing (DON) presented the following intermediate plan to abate the immediate jeopardy situation. It read in pertinent part: The facility initiated one-to-one oversight 24 hours a day 7 days a week for resident #14 on [DATE] at 5:45 p.m. with dementia trained facility staff members only. When the sitter has their scheduled break the sitter will notify the nurse, who will then pull a qualified staff member to sit with Resident #14 until the scheduled sitter has returned. The facility will continue one-to-one care until IDT (Interdisciplinary team) reviews and deems resident behaviors have stabilized. Stabilization will be defined as (the) Resident will not be agitated and will not strike out at staff or other residents. IDT will review for removal of (the) sitter every 72 hours and complete an IDT review note. The Corporate Director of Clinical Services educated the Director of Nursing, Social Service Director, and Unit Coordinator, [DATE], on de-escalation tactics to help manage Resident #14 when he was escalated. Resident enjoys Ukrainian or Russian music, Resident 14 enjoys dancing, he also enjoys different snacks, redirection to his private room to watch tv, offer to walk with Resident outside, work a puzzle, or painting. The Director of Nursing/ Designee will provide education to all staff regarding Dementia training and specific intervention for resident #14 beginning [DATE] and ongoing until all staff are educated prior to working (the) next scheduled shift. On [DATE] at 6:10 p.m., the NHA and the DON were notified that the intermediate plan to abate the immediate jeopardy was accepted, contingent on evidence of the facility's implementation of the plan. On [DATE] at approximately 7:10 a.m., the facility was observed to be implementing what was in their immediate jeopardy removal plan; the facility staff working at that time had received dementia training. However, on [DATE] at approximately 10:30 a.m., seven staff members, including one agency staff working in the facility that day, reported they had not been trained in dementia care before they began their shift. On [DATE] at approximately 12:20 p.m. the NHA and DON were notified that the immediate jeopardy was not lifted. On [DATE] at 12:30 p.m., the NHA acknowledged the facility had not implemented the temporary abatement plan. He said he did not realize he had agreed in writing to have the staff trained before they began their shift. He said the memory care coordinator (MCC), who was a certified nurse aide, was the one responsible for teaching dementia training and said he had told the MCC to teach the staff dementia training. He said the MCC came in early each day and he came in later, so it was up to her to teach the staff. However, he said he had not had the MCC read the plan for the immediate jeopardy removal. E. Removal of the Immediate Jeopardy On [DATE] at 2:50 p.m., the facility presented a revised plan to abate the immediate jeopardy situation. The revised plan included the following additions: 1. As of [DATE] the Director of Clinical Services educated the Administrator, Director of Nursing, Social Services and the Memory Care Coordinator that ALL staff regardless of [the] Unit they are assigned to, will be educated regarding Dementia training, the behavior binder for unit 5, and the communication binder and interventions for Resident #14. 2. The Administrator/ Director of Nursing has completed education with all staff in the building on [DATE] by 12:00 p.m. regarding dementia training and specific interventions and a communication book for Resident #14, and the behavior binder for unit 5. 3. Moving forward the Administrator/Director of Nursing will cross-reference an employee roster with signature sheets to ensure all staff have been educated. 4. For staff that have not been educated the Administrator/Director of Nursing will contact them via phone/text message advising them that this training must be completed prior to the start of their next shift. If an employee does not complete the training, they will not be permitted to work. 5. The Administrator/Director of Nursing will have all staff employed by the facility educated by [DATE] either in person or via phone by 6:00 p.m. 6. Agency staff, if utilized, will be educated prior to the start of their shift. The above plan was accepted on [DATE] at 2:50 p.m. However, deficient practice remained G level, actual harm that is isolated. II. Facility policy and procedure The Abuse Policy, revised [DATE], was provided by the DON on [DATE] at 2:05 p.m. It read in pertinent part, Residents have the right to be free from abuse and neglect. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect, and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: facility staff, other residents, staff from other agencies, or any other individual. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents, neglect of residents. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, and handling verbally or physically aggressive resident behavior. Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities, instruct staff regarding appropriate ways to address interpersonal conflicts, and help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. Identify and investigate all possible incidents of abuse and neglect. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations. Establish and implement a QAPI review and analysis of reports, allegations and findings of abuse and neglect. III. Record review revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the secure unit that protected residents from resident-to-resident altercations. A. Record review revealed the facility failed to take steps to prevent Resident #17's physically aggressive behavior toward Resident #16. 1. Resident #17 Resident #17, over age 65, was readmitted to the facility on [DATE]. Diagnoses included anoxic brain injury (lack of oxygen to the brain), alcohol-induced persisting dementia, major depressive disorder, bipolar disorder, and Alzheimer's disease. According to the [DATE] minimum data set (MDS) assessment, the resident had a moderate cognitive deficit with a brief interview mental status (BIMS) score of eight out of 15. The resident required one-person physical assistance with bed mobility, transfers, and walking in his room and corridors. The care plan for behaviors, revised on [DATE], documented the resident had begun to display aggressive/combative behavior toward others. Interventions included to attempt to identify triggers for behavior, to attempt to redirect the resident to a quiet area during episodes of combative/aggressive behavior, and staff to check resident's room including the closet and bathroom to ensure residents are not still in the room when other residents wander in and redirect others from wandering into residents' rooms. 1. Resident #16 Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident entered hospice on [DATE] and expired on [DATE]. According to the August computerized physician orders (CPO), diagnoses included fracture of the neck of the left femur, dementia with agitation, depressive episodes, urinary tract infection, muscle weakness, and cognitive communication deficit. According to the [DATE] MDS assessment, the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident's behavior care plan, initiated on [DATE], documented the resident had behavior problems, could become verbally and physically aggressive toward others, and could be physical with staff often striking out. Interventions included one-on-one activities, anticipating and meeting the resident's needs, assisting the resident to develop more appropriate methods of coping and interacting, and intervening as necessary to protect the rights and safety of others. The cognition care plan, (undated), documented the resident had cognitive impairment as evidenced by impaired orientation and distressing hallucinations and delusions. Interventions included keeping the daily routine as consistent as possible, reassuring the resident as needed if confused, and keeping the resident separated from certain residents during meal times. 3. Resident-to-resident altercation [DATE] Summary for providers note in Resident #16's record, dated [DATE] at 6:47 p.m., documented a change of condition. Nursing observations, evaluation, and recommendations read a resident-to-resident altercation resulting in a fall. A physician progress note, history and physical, dated [DATE] at 7:13 a.m. documented the resident was pushed by another resident. The resident had an acute fracture of the pelvis with displacement. A nursing progress note dated [DATE] at 1:12 p.m. documented the resident's return from the hospital and a physician progress note dated [DATE] at 6:25 p.m., documented the resident was admitted to hospice care. A medication administration note dated [DATE] at 4:33 a.m. documented the resident crying in pain and another note at 1:53 a.m. documented the resident moaning. A note on [DATE] at 5:16 p.m. documented the resident crying out in pain. A nursing progress note dated [DATE] at 11:37 a.m. documented the resident passed away. 4. Facility failures following the incident on [DATE]. Record review revealed an interdisciplinary team (IDT) event review of the incident; however, the only intervention was to keep the residents separated and to educate Resident #17 to call for help instead of being physical. Resident #17's care plan was not revised with new interventions to address his aggressive/combative behavior. Moreover, there was no evidence the facility considered how to create an environment to prevent further incidents of resident-to-resident abuse; there was no indication the facility considered systemic factors that could have prevented the incident. B. Record review revealed the facility failed to take steps following the incident on [DATE] to prevent additional incidents of resident-to-resident abuse involving Resident #14. Documentation revealed Resident #14 was involved in a series of incidents with Residents #7, #20, and #21. 1. Resident #14, over age 65, was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses included Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes, and cognitive communication deficit. a. Resident status The admission and baseline care plan summary dated [DATE] at 7:38 p.m. documented communication and difficulty understanding others due to language barrier, wandering, anxiousness, and restlessness concerns. The [DATE] minimum data set (MDS) assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of three out of 15. Further record review revealed the resident spoke a foreign language and was ambulatory. The resident was care planned for aggressive behavior ([DATE] and revised on [DATE]), secure unit placement ([DATE] and revised [DATE]), and impaired communication (revised [DATE]). -The plan for aggressive behavior read the resident had a history of experiencing physical and verbal aggression toward others. He experienced distressing delusions such as thinking the whole unit is his house and thinking his peers are intruders. Interventions included: administering medications as ordered, attempting interventions before the resident's behaviors begin, not seating the resident around others who disturb this resident, helping the resident to maintain his favorite place to sit, helping the resident avoid situations or people that are upsetting to him, making sure the resident was not in pain, offering to take him outside and offering lower stimulating environment and things he likes as a diversion. -The care plan for the secured unit ([DATE] and revised on [DATE]) documented the resident resided in the secure unit related to wandering. Interventions included staff to redirect the resident to a safe wandering area as needed. -The care plan for communication, no initiation date, revised on [DATE]) documented the resident had impaired communication due to a diagnosis of Alzheimer's and was Russian-speaking. It read the resident can communicate effectively via a translating machine. Interventions include communication through identified communication method. Staff use a translator [machine] to communicate. b. Documentation of abusive behaviors toward staff and the presence of behaviors that could lead to abusive situations with other residents. The facility's interventions were ineffective in preventing the resident's aggressive behaviors and/or not implemented. -A nursing progress note dated [DATE] at 6:01 a.m. documented the resident was difficult to redirect, was confused, and was going to another resident's room. -A nursing progress note dated [DATE] at 10:10 p.m. documented the resident continued to wander into other residents' rooms. -A nursing progress note dated [DATE] at 10:26 p.m. documented the resident was angry and was using the walker to strike out at staff and residents. The resident was rummaging through the roommate's belongings. The staff removed the roommate for their safety and placed Resident #14 on a one-to-one observation. -An administrator progress note dated [DATE] at 9:37 a.m. documented the resident kicked a nurse in the groin, punched the unit manager in the face, and grabbed a certified nurse aide (CNA). He was unable to be redirected and was placed on a one-to-one observation. -A nursing progress note dated [DATE] at 12:15 a.m., documented the resident had increased agitation and intruded into all residents' rooms one by one, taking their belongings and attempting to hit other residents with wheelchairs, walkers, and other items, believing the other residents were in his room. The resident attempted to break the windows on the double doors, attempted to crawl over the nurses' station half door, and attempted to hit staff with a chair. After being redirected to his room he attempted to break the window. Staff called 911. -An administrator progress note dated [DATE] at 8:52 a.m. documented the resident was sent to the hospital on a mental health hold. He returned the same evening at 8:32 p.m., displaying aggressive behaviors toward staff by grabbing, pinching, hitting, and taking a CNA's jacket and wallet. -A physician progress note dated [DATE] at 8:00 a.m. documented a psychiatric consultation was sent but had not been received and therefore the consultant was not able to see the resident. -A physician progress note dated [DATE] at 5:54 a.m. documented the psychiatric consultation was pending. -A nursing progress note dated [DATE] at 4:24 p.m., documented the resident going in and out of other residents' rooms and attempted to push other residents out of their rooms. The registered nurse (RN) and CNA had to physically remove the resident from other residents' rooms. -A nursing progress note dated [DATE] at 1:17 p.m. documented the resident appeared upset and was pacing and wandering in and out of other residents' rooms and throwing a wet floor sign down the hall. The resident then started punching, kicking, and attempting to bite a CNA. The resident pulled a full can of soda out of his pocket and threw it at CNA #2. -A physician progress note dated [DATE] at 1:57 a.m. documented the psychiatric consultation was still pending. -A nursing progress note dated [DATE] at 3:01 a.m. documented the resident was going in and out of other residents' rooms and was unable to be redirected. The resident was picking up chairs, walker, and wet floor signs and attempting to hit staff and other residents. The resident said, This is my house, and they all need to leave. He attempted to hit residents who were walking in the hallway. The resident spit at the nurse. Staff called 911, and officers calmed the resident but when the officers departed the resident became aggressive again. The staff placed other residents who were ambulating in the halls in the nurses' station for their safety while the resident banged on the door with his fists and other objects. -An IDT follow-up progress note dated [DATE] at 10:31 a.m. documented a review of the resident's targeted behaviors. Interventions included offering lower stimulating activities, utilizing the translator machine, and offering to take the resident outside. -A nursing progress note dated [DATE] at 1:16 p.m. documented the resident was very agitated and physically aggressive, spitting and hitting staff. The resident was going into other residents' rooms, telling them to leave his house. The resident attempted to hit another resident with a chair and then hit the nurses' station door attempting to knock it down. The resident was put on a one-to-one observation. The note stated all interventions to redirect the resident failed and the resident could not be reasoned with. -A progress note, dated [DATE] at 9:46 a.m. documented that on [DATE] at 4:20 p.m., Resident #14 wandered into Resident #7's room, and Resident #7 threw a 2-inch cowbell, hitting Resident #14 in the face and causing a reddened area to his left cheek. -An IDT follow-up progress note dated [DATE] at 10:16 a.m. documented the review of the resident-to-resident altercation interventions included the resident being redirected into a safe wandering area. c. Facility failure to respond to Resident #14's increasingly aggressive and abuse-triggering behaviors, such as wandering into other residents' rooms (see above notes on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE],[DATE], and ,d+[DATE]) and attempting to push them out (see above note on [DATE]). While the facility initiated one-to-one supervision on ,d+[DATE], ,d+[DATE], and [DATE], an interview with NHA on [DATE] at 12:20 p.m. revealed this intervention was not documented and invoked only as long as needed or until the end of the shift. There was no evidence the IDT met after [DATE] and until [DATE], to discuss Resident #14's increasingly aggressive and abuse-triggering behaviors and no evidence the IDT considered how they might address his behaviors by working with his repeated belief that the facility was his home and other residents were intruders in his house. Moreover, there was no plan to address his repeated behavior of wandering into other residents' rooms, which led to an incident with Resident #7 on [DATE] (see above). Further, there was no evidence the facility reached out to the resident's family for assistance in addressing the resident's needs in order to minimize his behaviors or that the facility actively pursued the psychiatric consult, first considered on [DATE]. Finally, there was no evidence the facility sought the assistance of others knowledgeable in dementia care to develop new and effective interventions to meet the resident's needs as well as the safety needs of other residents and staff on the unit. 2. Series of incidents of resident-to-resident abuse involving Resident #14 and Resident #20 and #21 and failure of the facility to initiate new and effective interventions to prevent recurrent incidents. a. Resident #20, over age 65, was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses included dementia, muscle weakness, cognitive-communication deficit, anxiety disorder, depressive episodes, and chronic obstructive pulmonary disease. The [DATE] MDS assessment documented the resident had a severe cognitive deficit with a BIMS score of zero out of 15. The resident required supervision with one person's physical assistance with bed mobility, transfers, walking in the room, and walking in corridors. A nursing progress note dated [DATE] at 3:32 a.m. documented the resident continued to pace and be intrusive into other residents' rooms. b. Resident #21 Resident #21, was over the age of 65 and was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses included Alzheimer's disease, depressive episodes, dementia, and delirium due to known physiological condition. The [DATE] MDS assessment documented the resident had a severe cognitive deficit with a BIMS score of three out of 15. c. Review of Resident #14, #20, and #21's records revealed physically aggressive resident-to-resident altercations and repeated aggression between Resident #14 and #20. -A progress note in Resident #14 and Resident #20's records dated [DATE] at 3:15 p.m. and 3:40 p.m. respectively, documented a resident-to-resident altercation on [DATE] at 3:00 p.m. between Resident #14 and Resident #20. Resident #14 walked toward Resident #20 with a closed fist and shoved him in the shoulder. Resident #20 then hit Resident #14 in the face, causing a small swelling on Resident #14's left cheek. -A physician progress note in Resident #20's record dated [DATE] at 3:43 p.m. documented Resident #20 punched another resident on [DATE] and grasped other residents and staff. -An IDT event review progress note in Resident #14's record dated [DATE] at 8:40 a.m. documented no new interventions suggested at the time. - A nursing progress note in Resident #14's record dated [DATE] at 7:30 p.m. documented a witnessed resident-to-resident altercation between Resident #14 and Resident #21. Resident #14 was walking in the hallway when Resident #21 came out of his room yelling at Resident #14, Resident #14 responded in a foreign language and Resident #21 punched Resident #14 on the left side of his face. No injury was noted at the time. -An IDT event initial progress note in Resident #14 and #20's records both dated [DATE] at 2:17 p.m. and 2:51 p.m. respectively, documented a resident-to-resident altercation between Resident #14 and Resident #20. The RN heard a plate break on the floor in the dining room and found Resident #14 standing over Resident #20, who was seated, hitting him in the face. Resident #20 suffered a cut on the left eyelid. -A nursing progress note in Resident #14's record dated [DATE] at 11:35 p.m. documented the resident continued to wander in and out of other residents' rooms and was difficult to redirect. -A nursing progress note in Resident #20's record dated [DATE] at 12:02 a.m. documented the resident had bruising to the left eye. -An IDT event review progress note in Resident #14's record dated [DATE] at 9:45 a.m. and in Resident #20's record at 9:47 a.m. documented an IDT review that read no new interventions suggested at this time. -An IDT follow-up progress note in Resident #20's record documented it was determined the resident altercations were happening in the late afternoon and to have activities after the schedule and offer activities during the late afternoon. -A nursing progress note in Resident #14's record dated [DATE] at 8:36 p.m. documented the resident continues to wander in and out of other resident's rooms and was difficult to redirect. -A social services progress note dated [DATE] at 11:30 a.m. read the social services director (SSD) reached out to the psychiatric services provider for a female provider; the provider stated they do not have female providers. -An IDT follow-up progress note dated [DATE] at 1:25 p.m. documented that staff were to ensure Resident #14 and Resident #20 were separated during meal times. -A nursing progress note dated [DATE] at 2:48 p.m. documented the IDT met to review the resident-to-resident incident on [DATE]. Interventions included for staff to utilize the translator [machine] for Resident #14 to be able to communicate with other residents due to a language barrier. d. Record review, observations, and staff interviews confirmed the facility failed to take steps to develop and implement effective interventions to create an environment in the secure unit that protected residents from resident-to-resident abuse. Planned interventions were not implemented and new interventions were not developed to prevent additional resident-to-resident interventions among residents known to have physically aggressive behaviors. Record Review: A review of the IDT notes revealed a delay in recommending that Resident #14 and Resident #20 be separated during mealtime. Record review revealed the resident-to-resident altercation

Based on observation, interview, and record review the facility failed to ensure three (#14, #20 and #22) of three residents reviewed for dementia care of 22 sample residents, received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident #14 was admitted to the facility for long term care on 5/25/23 with diagnoses of Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes, and cognitive communication deficit. The resident required supervision with one person physical assistance with walking in the room and corridors. The resident required extensive one person assistance with dressing. Since admission on 5/25/23 the resident had increasing wandering, agitation and physically aggressive behaviors. Due to the facility failures, Resident #14 wandered into other residents' rooms. The facility failed to determine and prevent triggers that caused agitation and physical aggression toward other residents. The facility failed to maintain the ability for the resident to communicate with staff with the translator machine that required the internet to operate. These failures resulted in Resident #14 was involved in four resident to resident altercations with three other residents, one resident twice over an eight day period. Additionally, the facility failed to implement personalized interventions for Resident #20 and Resident #22, who wandered into other resident rooms. Cross-reference F600 the facility failed to prevent resident to resident altercations by implementing appropriate safety measures for Residents #14 and #20. Findings include I. Census and conditions demographic The 9/26/23 Census and Condition form documented 111 residents resided at the facility. There were 62 residents with dementia or Alzheimer's disease and 28 with behavioral health needs. The facility had one long-term secured memory care unit open with 25 residents in the unit. II. Facility policy and procedures The Dementia - Clinical protocol, revised April 2021, was delivered by the director of nursing (DON) on 9/27/23 at 2:05 p.m. It read in pertinent part, As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes. As needed the physician will help verify or reconsider the diagnosis of dementia and identify other possible causes and coexisting psychiatric conditions. Individuals with dementia can also have personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions (ADRs), or other conditions causing or contributing to impaired cognition and problematic behavior. As needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. The staff and physician will determine any relationship between the resident's level of pain and cognitive loss. For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. If a psychiatric consultation is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT team will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress. III. Resident #14 A. Resident status Resident #14, over age 65, was admitted to the facility on [DATE] and lived in the secured memory care unit. According to the September 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes and cognitive communication deficit. The 8/17/23 minimum data set (MDS) assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of three out of 15. The resident required supervision with one person physical assistance with bed mobility, personal hygiene, and toileting, and supervision with set up assistance with transfers between surfaces, walking in the room and corridors, locomotion on and off the unit, and eating. The resident required extensive one person assistance with dressing. -The facility failed to assess the resident's behaviors. B. Record review The care plan for the secured unit, initiated on 5/25/23 and revised on 8/29/23, documented the resident resides on the secured unit related to wandering. Interventions included staff to redirect the resident to safe wandering area as needed. The care plan for communication, no initiation date and revised on 8/29/23, documented the resident had impaired communication due to a diagnosis of Alzheimer's and was Russian speaking. The resident can communicate effectively via a translating machine. Interventions include communicate through identified communication method; staff used a translator to communicate. The care plan for mood, revised on 8/31/23, documented the resident got nervous and anxious at times. Interventions included to approach the resident from the front and address him or her by name, touch/hold his or her hand, avoid things that make the resident more anxious, and if the resident was upset to redirect the conversation or task. The care plan for activities, revised on 9/1/23 documented the resident had a language barrier and the staff was able to use a translator when needed, he enjoyed watching the news, going outside in warm weather, gardening, and listening to Russian music. Interventions included to provide an activity calendar, provide independent leisure as requested and speak to the resident with the translator machine. -The care plan did not have personalized interventions for dementia care. The admission and baseline care plan summary dated 5/25/23 at 7:38 p.m. documented communication and difficulty understanding others due to language barrier, wandering, anxiousness and restlessness concerns. Social services progress note dated 6/22/23 at 1:50 p.m. documented the IDT team met to discuss resident wandering and secure unit placement. The social services director (SSD) and assistant director of nursing (ADON) found a wander guard bracelet in the resident's bedside drawer. -The facility documented moving the resident to the secure memory care unit on 6/22/23, the facility failed to initiate safety measures to prevent the resident from wandering into other residents rooms to prevent physical abuse (cross-reference F600). Administrator progress note dated 6/22/23 at 1:51 p.m. documented the resident was admitted to the secure unit due to wandering and going into other residents rooms. Nursing progress note dated 7/3/23 at 12:15 a.m, documented the resident had increased agitation and intruded into all residents rooms one-by-one, taking their belongings and attempting to hit other residents with wheelchairs, walkers and other items believing the other residents were in his room. The resident attempted to break the windows on the double doors, attempted to crawl over the nurses station half door and attempted to hit staff with a chair. After being redirected to his room he attempted to break the window. Staff called 911. Administrator progress note dated 7/3/23 at 8:52 a.m. documented the resident was sent to the hospital on an M1 (mental health) hold. Nursing progress note dated 7/3/23 at 8:32 p.m. documented the resident returned to the facility from the hospital. The resident displayed aggressive behaviors toward staff by grabbing, pinching, and hitting and taking a CNA's (certified nurse aide) jacket and wallet. Physician progress note dated 7/5/23 at 8:00 a.m. documented a psychiatric consultation was sent but had not been received and were not able to see the resident. Physician progress note dated 7/12/23 at 5:54 a.m. documented the psychiatric consultation was pending. Nursing progress note dated 7/16/23 at 11:09 a.m. documented the resident was digging in the trash and found bread and put it in his pocket. Physician progress note dated 7/31/23 at 1:57 a.m. documented the psychiatric consultation was still pending. Nursing progress note dated 8/14/23 at 3:01 a.m. documented the resident was going in and out of other resident's rooms and was unable to be redirected. The resident was picking up chairs, walker and wet floor signs and attempting to hit staff and other residents. The resident said this is my house, and they all need to leave. He attempted to hit residents who were walking in the hallway. The resident spit at the nurse. Staff called 911, officers calmed the resident but when the officers departed the resident became aggressive again. The staff placed other residents who were ambulating in the halls in the nurses station for their safety while the resident banged on the door with his fists and other objects. IDT follow up progress note dated 8/31/23 at 10:31 a.m. documented a review of resident targeted behaviors. Interventions included offer lower stimulating behavior, utilize translator machine and offer to go outside. IDT follow up progress note dated 9/25/23 at 10:16 a.m. documented the review of the resident to resident altercation interventions included resident to be redirected into a safe wandering area. Nursing progress note dated 10/1/23 at 11:35 p.m. documented the resident continued to wander in and out of other resident's rooms and was difficult to redirect. IDT event review progress noted dated 10/2/23 at 9:45 a.m. documented following the current IDT review no new interventions suggested at this time. Social services progress note dated 10/6/23 at 11:30 a.m. social services director (SSD) reached out to the psychiatric services provider for a female provider, the provider stated they do not have female providers. Nursing progress note dated 10/6/23 at 2:48 p.m. documented the IDT met to review the resident to resident incident. Interventions included for staff to utilize translator for resident to be able to communicate with other residents due to language barrier. C.Altercations Event initial progress note dated 9/25/23 at 9:46 a.m. documented on 9/24/23 at 4:20 p.m. Resident #14 was arguing with Resident #7 and Resident #7 threw a two inch cowbell and hit Resident #14 in the face causing a reddened area to the left cheek. Event initial progress note dated 9/26/23 at 3:15 p.m. documented a resident to resident altercation on 9/26/23 at 3:00 p.m. between Resident #14 and Resident #20. Resident #14 was walking toward Resident #20 with a closed fist and shoved him in the shoulder. Resident #20 then hit Resident #14 in the face causing a small swelling on the left cheek. Nursing progress note dated 9/30/23 at 7:30 p.m. documented a witnessed resident to resident altercation between Resident #14 and Resident #21. Resident #14 was walking in the hallway when Resident #21 came out of his room yelling at Resident #14, #14 responded in a foreign language and Resident #21 punched #14 on the left side of his face. No injury noted at the time. IDT event initial progress note dated 10/1/23 at 2:17 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate break in the dining room and found Resident #14 standing over Resident #20, who was seated, hitting him in the face. Resident #20 suffered a cut on the left eyelid. -The facility failed to provide person-centered approaches to Resident #14's dementia care services to address triggered physical aggressive behavior in order to prevent physical altercations (cross-reference F600). D. Observation During a brief tour of the memory care unit on 9/26/23 at approximately 3:00 p.m. it was observed two male residents coming face-to-face and their tempers started to rise. The memory care coordinator (MCC) and two CNAs were present and intervened. The MCC redirected Resident #14 away from the dining area since he was agitated. Many of the resident rooms did not have personal appearing items such as pictures, to make the room homelike. Resident #14's room had bare walls and an empty, stripped second bed. The rooms had shadow boxes outside each door that were empty. Some of the doors had stop signs taped to the door, not fabric/velcro across the entry way to prevent wandering into resident rooms. During a brief tour of the memory care unit on 10/1/23 at approximately 4:30 p.m. it was observed the Activities Director (AD) was in the dining area with activities and speaking with Resident #14 in Russian. The AD said the resident is calm when the staff can communicate with him. IV. Resident #20 A. Resident status Resident #20 who lived in the secured memory care unit, over age 65, was admitted to the facility on [DATE]. According to the September 2023 CPO, diagnoses included dementia, muscle weakness, cognitive communication deficit, anxiety disorder, depressive episodes and chronic obstructive pulmonary disease. The 8/10/23 MDS assessment documented the resident had severe cognitive deficit with a BIMS score of zero out of 15. The resident required supervision with one person physical assistance with bed mobility, transfers, walking in the room, walking in corridors, and dressing. He required supervision with set up assistance for eating, and limited one person physical assistance with toileting and personal hygiene. The resident did not exhibit any behavior symptoms. B. Record review The mood care plan, revised on 8/22/23, documented the resident exhibited signs and symptoms of depression related to life circumstances. Interventions included utilizing antidepressant (medication) for depression, encourage resident to participate in activities outside of room, including meal and other social activities, involve resident it IDT and care planning and one-to-one validation of feelings and concerns as needed. The care plan for cognition, revised on 8/22/23, documented the resident had cognitive impairments as evidenced by impaired decision making and orientation. Interventions included encouraging resident to make daily decisions, reassure resident as needed if confused, and reorient resident to situations as needed. The care plan for activities revised on 9/8/23 documented the resident enjoyed listening to music, watching tv, and going outside in warm weather. Interventions included to provide an activity calendar and independent leisure materials as requested. -The care plan did not indicate personalized interventions for dementia care. Nursing progress note dated 9/14/23 at 3:32 a.m. documented the resident continued to pace and be intrusive into other resident's rooms. Physician progress note dated 9/27/23 at 3:43 a.m. documented the resident punched another resident on 9/26/23 and grasped other residents and staff. IDT event review progress note dated 10/2/23 at 9:47 a.m. documented a review of the resident to resident altercation; no new interventions were suggested at that time. C. Altercations Event initial note progress dated 9/26/23 at 3:40 p.m. documented a resident to resident altercation between Resident #20 and Resident #14. Resident #14 was walking toward Resident #20 in the hallway, Resident #14 had a closed fist and shoved Resident #20 in the shoulder, Resident #20 hit Resident #14 in the face. Resident #14 had swelling to the left cheek. Event initial progress note dated 10/1/23 at 2:51 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate fall on the floor, she went to investigate and found Resident #14 standing over Resident #20, who was sitting, punching him in the face. -The facility failed to provide person-centered approaches to Resident #20's dementia care services to address his behaviors, to include wandering, in order to prevent physical altercations (cross-reference F600). V. Staff interview Certified nurse aide (CNA) #2 was interviewed on 9/27/23 at 11:44 a.m. The CNA said Resident #14 had a language barrier, the staff used the translator phone to talk to him. The CNA said the resident thought he was security for the building and he did not want these people in it. He is under the impression this was his building and they were trespassing. The MCC was interviewed on 9/27/23 at 11:52 a.m. The MCC said interventions in the memory care unit include stop signs on doors. She said the main intervention that was used by staff to prevent resident altercations was redirection. She said Resident #14 had been having behaviors for the past several days. The DON was interviewed on 10/3/23 at 11:45 a.m. She said Resident #14 was on the secure unit and he had a few resident to resident altercations that involved someone hitting him or him hitting someone else. She said his behaviors include getting agitated. She said he had gotten better. She said he was often non-redirectable. She said Resident #14 had four altercations since 9/24/23 and these were more geared toward other residents rather than the staff. She said when he was not redirectable then the staff put him on a one-to-one observation, mainly when he was agitated and not redirectable. She said the facility tried to send him out on the M1 hold due to behaviors but he was sent back. She said to keep other residents safe the staff directed him to his room. The nursing home administrator (NHA) and the social services director (SSD) were interviewed on 10/3/23 at 12:20 p.m. The NHA said there were two instances where Resident #14 was the aggressor. He said the staff put him on a one-to-one observation. He said one-to-one staff was assigned to him as long as needed or the end of the shift. He said the NHA or the DON could initiate the one-to-one observation if needed. He said the facility did not have documentation for one-to-one observations. The NHA said nurses, CNAs or the staff who saw Resident #14 with behaviors should be monitoring him. The NHA said Resident #14 liked to use the translator machine. Registered nurse (RN) #1 was interviewed on 10/3/23 at 12:45 p.m. The RN said the internet was not working and the translator machine was not working. Licensed practical nurse (LPN) #1 was interviewed on 10/5/23 at 12:00 p.m. The LPN said the facility had not had internet service for a while, it had been down. The LPN said the internet had not worked the previous week, yesterday or today. The LPN said the translator machine did not work if the internet was down so the staff has not been able to use it. -The facility failed to ensure the translator machine, which required internet access, was working. The staff was unable to communicate with the resident which caused agitation to the resident. 41172 VI. Resident #22 A. Resident #15's interview and record review about Resident #22's wandering Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said Resident #22 was confused and wandered into her room and rummaged through things in her room, including the trash. She said the nursing staff said the resident had a history of wandering, rummaging and aggression. Resident #15 said Resident #22 had recently come into her room and taken a blanket. She said she did not say anything to Resident #22 when she came in her room because she was afraid Resident #22 would get upset and physically hurt her. Resident #15 said she had no way to defend herself due to the inability to move her legs and arms. She said she felt helpless, with increased feelings of anxiety and fear of physical harm from Resident #22 if she said anything to her. Resident #15 said she had spoken to the assistant director of nursing (ADON) #1 about her fear and concern with Resident #22 coming into her room, but nothing had changed and the resident continued to come into her room. Additionally, Resident #15 said she was concerned when she had seen Resident #22 in the lobby area, eating out of the trash can. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted . The notes documented in pertinent part that Resident #15 has said she was scared because a resident with known to be violent wheels herself into her room and Resident #15 had no way to defend herself. Additionally, the notes documented that Resident #22 had been observed by the resident representative eating out of the trash can in the lobby on 9/22/23. B. Resident status Resident #22, age 83, was admitted on [DATE]. According to the October 2023 CPO diagnoses included dementia and major depression. The 7/14/23 MDS assessment indicated the resident had severe cognitive impairment and could not complete a BIMS evaluation. She had short and long term memory loss and did not recognize faces, names, rooms, seasons, or the facility. She required two persons extensive assistance with transfers, dressing, toileting and personal hygiene. She required extensive one person assistance with personal hygiene and eating. The assessment documented the resident had wandered daily and had no behaviors. The assessment documented the resident was on antipsychotic medication. C. Record review The care plan related to behavior, revised 9/12/23 did not indicate when it was initiated. It documented, Resident #22 was confused and forgetful and took others belongings. She became physically aggressive towards others. She was observed by staff eating non edible items like paper and flowers. The goal was that the resident would be able to be redirected when she became physically and verbally aggressive. Interventions were to offer her a snack if she was seen eating non edible items. If the resident could not be redirected or calmed, staff should attempt to do care at a later time. Staff to explain was to the resident prior to and during the process of cares. Staff to redirect the resident to other activities. Staff to reorient the resident to place and situation as appropriate to their cognitive level. The care plan for wandering, revised 9/16/23 did not indicate when it was initiated. It documented Resident #22 was at risk for injury due to wandering throughout the building and attempting to go toward the front door. The care plan documented the resident had a wanderguard and to redirect her when wandering. Ensure all basic needs are met such as if the resident has gone to the bathroom, is hungry or thirsty. Invite the resident to activities. The progress notes documented in pertinent part, On 2/27/23 at 4:16 p.m. the nursing note document the resident was moved off the secure unit to a room two doors down from Resident #15. On 4/11/23 at 4:38 p.m. the progress notes documented that on 4/10/23 between 7:00 p.m. and 7:30 p.m. Resident #22 had gotten into an argument with her roommate when Resident #22 tried to take her roommate's pillow. The roommate resisted and Resident #22 slapped her roommate in the face. On 6/21/23 at 4:35 p.m. and 6/20/23 at 10:03 p.m. the progress notes documented Resident #22 was on monitoring for wandering and invading others privacy. -The progress notes did not document when or why the resident had been placed on this monitoring. On 7/11/23 at 3:59 p.m. assistant director of nursing (ADON) #1 documented that Resident #22 was in Resident #15's room again and Resident #15's spouse wheeled Resident #22 out of Resident #15's room. On 8/18/23 at 11:31 a.m. the director of nursing (DON) documented an IDT (interdisciplinary team) note. The note documented the resident was impulsive. The resident grabbed and rummaged through things like furniture. On 9/19/23 at 2:10 p.m. the provider documented the resident was on seroquel due to delusions and aggression. The provider documented the resident had been eating paint chips. The provider documented it was unclear how long this behavior had been occurring. D. Staff interviews ADON #1 was interviewed via telephone on 9/28/23 at 2:10 p.m. He said Resident #22 propelled around in her wheelchair and wandered into other resident rooms and rummaged. He said she had dementia and recently stole a blanket from a room. He said she was confused and recently stole a blanket from a room. The ADON said Resident #22 was usually looking for something to eat, and he tried to give her snacks. He said Resident #15 had reported to him that Resident #22 had been in her room. He said the plan to prevent Resident #22 from going into other rooms was to continue to try to give Resident #22 snacks. The DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not aware of Resident #22 wandering into Resident #15's room and rummaging. She said she knew Resident #22 had wandered into other resident's rooms. She said Resident #22 was very confused and had done this since she admitted . The DON said she only heard Resident #22 wandered into other resident rooms, not that she rummaged in other resident rooms. The DON said she felt that someone would have said something if Resident #22 was really going into Resident rooms and rummaging. However, Resident #22's care plan documented she wandered throughout the building and took others belongings.(see above). Additionally, ADON #1 said Resident #15 had reported to him Resident #22 had been in her room. The DON acknowledged that this behavior could cause Resident #15 to be fearful due to her inability to move, or defend herself. She said a plan to prevent this would be to maybe put a stop sign on Resident #15's door. Certified nurse aide (CNA) #12 was interviewed on 10/9/23 at 1:00 p.m. She said Resident #22 wandered into other resident's rooms. She said she was usually looking for food and digging in the trash cans of other resident rooms or the lobby trash can. She said the resident ate inappropriate things such as recently trying to eat a blanket. CNA #10 said Resident #22 was frequently physically and verbally aggressive, at least two to three times per shift. CNA #10 said Resident #22 would scream, pinch, grab and kick the staff when they attempted to redirect her.

Based on record review and interviews, the facility failed to provide medically related social services to two (#12 and #15) of two residents reviewed out of 22 sample residents. Specifically, the facility failed to assist Resident #12 in making a dental extraction appointment timely after she reported pain and the dentist recommended extractions resulting in infection. Resident #12 was seen by the mobile dentist at the facility on 3/2/23. The mobile dentist recommended sending a referral to a dentist in the community for five tooth extractions. At this time the resident was in pain. The facility did not obtain consent from the resident until 4/4/23 to send the referral. The facility failed to schedule an appointment for Resident #12's teeth extractions for four and a half months. On 7/19/23 Resident #12 had her teeth extracted and was put on an antibiotic because she had developed an oral infection. Resident #15, who required assistance from staff, had five medical appointments that still had not been scheduled. Due to the lack of following up with scheduling her appointments, the resident felt anxious and frustrated due to her ongoing pain, unexplained muscle weakness and voice issues. Findings include: I. Facility policy and procedure The Dental Services policy, revised December 2016, was provided by the director of nursing (DON) on 10/3/23 at 10:28 a.m. It read in pertinent part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Social services representatives/designee will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. II. Resident #12 A. Resident status Resident #12, age 67, admitted on [DATE], readmitted on [DATE] and passed away on 8/30/23. According to the August 2023 computerized physician orders the diagnoses included: neurocognitive disorder with Lewy bodies (dementia), dysphagia (difficulty swallowing), dementia, Parkinson's disease (deterioration of the brain), anxiety and depression. The 8/22/23 minimum data set (MDS) assessment revealed she had severe cognitive impairments with short-term and long-term memory deficits according to staff interview. She required extensive assistance of two people for bed mobility, transfers, personal hygiene, walking in her room and in the corridor, locomotion on and off the unit and dressing. She required extensive assistance of one person for eating. The MDS documented the resident had no mouth problems. The MDS documented the resident was on a scheduled pain medication regimen, received as needed pain medications and did not receive non-medication pain interventions. B. Record review 1. Comprehensive care plan-dental A review of Resident #12's electronic medical record, revealed Resident #12's comprehensive care plan did not address her oral/dental needs. 2. Dental progress notes The 11/10/22 dental examination note documented the resident's mouth tissue was inflamed and red. The dentist recommended having all remaining lower teeth extracted and then get upper and lower dentures. The dentist documented to send a referral to another dentist for full lower extractions. The 1/24/23 dental examination note documented the resident refused to see the mobile dentist. The 3/2/23 dental examination note documented the resident was having pain on her lower right side of her mouth. The resident needed to have teeth extracted. The dentist requested a referral to be sent to another dentist for lower teeth extractions. The 6/2/23 dental examination note documented the resident had not gone to the local dentist for teeth extraction. The note documented the resident wanted the work done and was in pain. The dentist requested a referral to be sent to another dentist. The 7/19/23 dental progress note documented the resident had eight teeth extracted. The dentist ordered an antibiotic as the resident had a dental infection. -The facility failed to send a referral to the dentist to get the resident's teeth extracted till July 2023, although the resident started reporting pain in March 2023. 3. Progress notes The 3/6/23 care conference note documented the social services director (SSD), assistant director of nursing (ADON) #2, the activities director (AD) and the resident met. The power of attorney (POA) was invited and said she would be there, but did not arrive. The SSD called the POA and left a voicemail. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 3/27/23 care conference note documented the resident, nursing home administrator (NHA), SSD, speech therapist, activities assistant, DON, ADON #2, the ombudsman and the doctor were present. The daughter was invited to come, but did not attend. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 4/4/23 social services progress note documented the dentist made recommendations to follow-up for extractions. The resident gave consent and an appointment request was sent to transportation. -The dentist recommended a referral to be sent on 11/10/22 and 3/2/23. The facility did not obtain consent to send a referral until 4/4/23. The 7/20/23 nursing progress note documented the resident was on an antibiotic for eight teeth extractions. The resident was on a soft diet until her mouth was healed. The licensed nurse documented she would continue to monitor. C. Staff interviews The SSD was interviewed on 9/27/23 at 2:54 p.m. The SSD said the mobile dentist saw Resident #12 in November 2022 and recommended for the resident to be seen by a community dentist for teeth extractions. The SSD said the mobile dentist attempted to see the resident in January 2023 and February 2023 and the resident refused to be seen. The SSD said Resident #12 was seen by the mobile dentist again on 3/2/23 and recommended to have the teeth removed. The SSD said the resident then had her teeth extracted in June 2023. -Resident #12 did not have her teeth extracted until 7/19/23. The SSD was interviewed again on 9/27/23 at 2:54 p.m. The SSD said she did not obtain consent from the resident to send a referral to the community dentist until 4/4/23. The van driver (VD) was interviewed on 9/28/23 at 4:03 p.m. The VD said he was responsible for scheduling appointments for all residents and transporting them to their appointments. The VD said typically dentist referrals were emailed to him from the SSD and he would make the appointment. The VD said sometimes referrals were not communicated to him. The VD said he called the doctor's office within a day or two from receiving a referral to calling the physician offices to make appointments. The VD said he was unsure the exact date he sent a referral for Resident #12 to have her teeth extracted. The VD said he did not document or keep record of when he received or sent referrals to doctors. The VD said he was unsure why it took several months to get Resident #12 an appointment to have her teeth extracted. The VD was interviewed again on 9/28/23 at 4:03 p.m. The VD said he spoke with the DON regarding documenting in resident medical records regarding sending referrals for medical records. The DON was interviewed on 9/28/23 at approximately 3:15 p.m. The DON said the nursing staff were responsible for placing referral orders into the electronic medical record and notifying the VD that an appointment needed to be scheduled The DON said the VD was responsible for calling the doctor's office, making an appointment and transporting the resident to the appointment. The DON said at times it took awhile to get certain appointments related to doctors availability. The SSD was interviewed again on 9/28/23 at 9:40 a.m. The SSD said she attempted to reach out to Resident #12's daughter who was the residents proxy (decision maker) and get consent to send a referral to an outside dentist for Resident #12's teeth extractions. The SSD said the VD was responsible for making appointments and transporting the residents to the appointments. The SSD said she was not involved in scheduling Resident #12's dental extraction appointment. The SSD was interviewed again on 9/28/23 at 9:53 a.m. The SSD provided two care conference notes from March 2023. The SSD said she attempted to reach out to the resident's daughter to obtain consent to send a referral to the community dentist. The SSD said the daughter did not call her back. The SSD said a month after the mobile dentist saw Resident #12 and recommended to have teeth extracted she asked the resident for consent to send the referral. The SSD said Resident #12 was able to make her own choices. The SSD said she was unsure why she did not ask the resident for consent sooner than 4/4/23. The NHA was interviewed on 10/3/23 at 11:35 a.m. The NHA said the VD was responsible for scheduling appointments and transporting residents to their appointments. The NHA said the facility had attempted to get her into the dentist that accepted her insurance. The NHA said pain is very subjective and if the facility felt it was an emergency then they would have had Resident #12 seen immediately. The NHA said the resident was not in that much pain. -However, the mobile dentist documentation revealed Resident #12 was in pain and wanted her teeth extracted. The NHA was interviewed again on 10/3/23 at 1:25 p.m. The NHA said the facility had referred the resident to the dentist, but the 7/19/23 date was the soonest available appointment. The NHA said the SSD tried to confirm the appointment with Resident #12's family, but she did not call her back. -However, the care conference notes do not indicate that the SSD attempted to speak to the daughter or the resident regarding consent to send a referral to a community dentist. The NHA said the VD was unable to document in the resident's medical records when he sent referrals. The NHA said the VD was given permission to document in medical records when he sends referrals and schedules appointments for the residents. 41172 III. Resident #15 A. Resident status Resident #15, under age 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. The assessment documented the Resident#15 had pain frequently which affected her day to day activities. She was on scheduled and PRN (as needed) pain medication and had no non pharmacological pain interventions. B. Resident interview Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said she was still waiting on five appointments to be scheduled by the facility. She said she was suppose to see an ENT (ear, nose and throat) doctor related to changes in her voice, a gynecologist related to pelvic pain which during a urinary tract infection on 9/8/23, a neurology appointment related to ongoing pain from neuropathy (weakness, numbness, pain due to nerve damage), a sleep study for concerns for sleep apnea (sleep disorder where breathing stops and starts during sleep) and a pain clinic related to her chronic pain. Resident #15 said she had not received any follow up from the nursing staff as to when the appointments were scheduled for. Resident #15 said she was frustrated and anxious regarding the lack of follow up on appointments for her pain, her unexplained muscle weakness and voice issues. C. Record review The September 2023 CPO was reviewed on 9/26/23 at 1:25 p.m. The orders documented the following. 7/27/23, Referral to ENT for voice change, needs vocal cords visualized. 8/11/23, Consult pain management and rehab for chronic pain syndrome. 8/15/23, Referral to neurology to establish care and get EMG (muscle response to electrical activity) done. 8/24/23, Schedule outpatient EMG for generalized weakness and concern for myopathy. 8/24/23, Please schedule sleep study for concern for OSA (obstructive sleep apnea). 9/15/23, Referral to pain management for diagnosis of chronic pain. 9/15/23, Referral to OB-GYN (obstetric gynecologist) for vaginal burning. Twice the provider wrote orders for an EMG and a referral for pain management (see above) and no appointments were scheduled. The provider notes revealed the following: On 7/25/23 at 12:53 p.m. the provider documented in the progress notes the resident had not gotten an EMG as previously discussed. Refer to neurology. The resident would like a referral to ENT. She has had a permanent voice change since intubation. On 7/27/23 at 9:23 a.m. the provider documented in the progress notes confirmed that orders for referrals have been placed to ENT, and neurology for EMG. On 8/3/23 at 12:51 p.m. the provider documented in the progress notes, follow up on neurology referral, if not for some time, plan neuropathy labs, see if EMG can be done elsewhere without neurology appointment. On 8/29/2023 at 1:17 p.m. the provider documented in the progress notes, the resident has still not yet had an EMG. On 9/14/23 at 9:15 a.m. the provider documented in the progress notes, EMG and sleep study pending. On 9/15/23 at 11:11 a.m. the provider documented in the progress notes the referral to gynecology pain management clinic for chronic pain syndrome were still pending. On 9/22/23 at 2:26 p.m. the provider documented in the progress notes the referral to gynecology and pain management clinic were still pending. -However, once the survey began on 9/25/23, appointments began to get scheduled (see below). D. Staff interviews The director of nursing (DON) was interviewed on 9/28/23 at 9:30 a.m. She said if there was a referral in the physician orders the DON or nurse manager sent the referral to the van driver (VD) to schedule the appointment.The DON said the VD schedules and provided transportation to appointments for residents. The assistant director of nursing (ADON) #1 was interviewed on 9/28/23 at 2:10 p.m. He said he was in charge of nursing oversight on the hall Resident #15 resided on. ADON #1 said he did not know if an OB-GYN, neurology, pain, sleep study or ENT appointments had been scheduled. He said he was new at this, being the ADON, and it had been a struggle for him to keep everything straight. He said the VD was responsible for appointments. The nursing home administrator (NHA) was interviewed on 10/3/23 at 11:35 a.m. He said the VD scheduled appointments and transported the residents to the appointments. He said if it was a bariatric resident, the facility would use an outside agency to transport because they would not fit in the facility van. The NHA said he was not sure how the VD was notified of a referral and appointment that needed to be scheduled. The VD was interviewed on 10/5/23 at 10:28 a.m. He said he scheduled appointments, found specialty physicians for referral orders and drove the facility van for appointments. The VD said providers will text him if a resident needs an appointment. He said appointment needs were usually word of mouth. The provider will test him that they put in a referral for a resident and the diagnosis. He said he would then go into the electronic medical record (EMR) and print off the order. The VD said he was just learning how to use the EMR system. He said once he printed the order he would call the physician office to see if they accepted the residents insurance and faxed them the referral order. He said once the appointment was made he gave a copy of the appointment to the resident and the resident's nurse. The VD said he did not go through the medical record to look for new orders for referrals. He said someone had to notify him if there was a new referral order. He said it could take three to seven days to get the appointment once he sent the specialist the fax with resident information and insurance. The VD said he had been working on scheduling appointments for Resident #15. He said she had all her appointments scheduled. -However, this was not completed until after the survey began on 9/25/23 (see below). He said the neurology appointment was scheduled when the referral was made by the provider. The VD said the sleep study had been hard to schedule because the resident needed to fill out a questionnaire for the referral. He said he was not medical so he could not do the questionnaire with the resident. He said the director of nursing (DON) would need to do the phone call and questionnaire together. The VD said he did not keep records of when a specialist office was contacted with a referral or appointment attempts he had made. The VD said he did not want to say why there was a delay. He said there was a delay in getting referrals in the residents chart as orders. E. Facility follow-up On 10/5/23 at 11:00 a.m. the VD provided copies of appointments scheduled for Resident #15. All the appointments were scheduled after the survey began on 9/25/23. The documentation provided by the VD revealed: A pain management clinic referral was dated as ordered 9/28/23, due to chronic pain. There was still no documentation about when this appointment was scheduled for. The original orders for a pain clinic were written on 8/11/23 and 9/15/23 (see above). A neurology referral was dated as ordered 9/28/23 for an EMG. The appointment was scheduled for 12/6/23. The original orders for a neurology referral were written on 8/15/23 and 8/24/23 (see above). An ENT referral was dated as ordered 9/28/23, no diagnosis was listed. The appointment was scheduled for 10/5/23. The original orders for an ENT referral were written on 7/27/23. The VD was interviewed again on 10/9/23 at 11:11 a.m. The VD said the resident did not go to her ENT appointment on 10/5/23 because her wheelchair did not fit in the van from the transport agency. He said the appointment would need to be rescheduled when the transport agency had their larger transport van available. The OB-GYN appointment documented it was ordered on 10/3/23, and was scheduled for 10/24/23 at 1:15 p.m. However, the order for the OB-GYN was written on 9/15/23. -There was no documentation provided regarding an appointment for a sleep study.

Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#15 and #10) of three residents reviewed out of 18 sample residents. Resident #15 admitted on [DATE] with chronic pain and neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection). According to record review and interviews, the facility failed to ensure the Resident #15's Oxycodone pain medication was available on three separate occasions resulting in increased pain. Additionally, the facility failed to administer Resident #10 the correct pain medication per physician order after a surgical procedure. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, revised October 2022, was received from the director of nursing (DON) on 9/28/23 at 2:00 p.m. The policy documented in pertinent part, Contact the prescriber immediately if the residents pain or medication side effects are not adequately controlled, report the following information to the physician or practitioner, significant changes in the level of residents pain, prolonged unrelieved pain. II. Resident #15 A. Resident status Resident #15, under age 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity and myopathy (disease affects muscles causing muscle weakness), neuritis (nerve pain) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated Resident #15 was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. The assessment documented the resident reported her worst pain level on a 0 to 10 scale (with 10 being the worst pain on the scale) was 8 out of 10. The assessment documented Resident#15 had pain frequently which affected her day -to-day activities. She was on scheduled and PRN (as needed) pain medication and had no non-pharmacological pain interventions. B. Resident interview Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said the nursing staff did not have her Oxycodone pain medication at least three times since she was admitted in July 2023. Resident #15 said there was no Oxycodone pain medication available for her on admission for the first two days, and then twice in July 2023. She said on admission she only received Tylenol for pain. She said the staff would have it for two weeks and then run out on the weekend. The resident said this happened twice. She said she had chronic nerve pain all over and new pelvic pain. Resident #15 said the pain was tolerable at level 3 out of 10 if she did not move. She said when the nursing staff ran out of Oxycodone she had pain all over from 9 to 10 out of 10. Resident #15 said her pain was usually around a f5, but often could get up to an 8 before she received her pain medication. She said when the facility ran out of the Oxycodone pain medication she experienced anxiety and her mind began racing. She said she worried all the time about the staff running out of her pain medication now. Resident #15 said the lack of pain medication affected her ability to get out of bed and sleep. Resident #15 described the pain as throbbing to her back, knees and arms. Resident #15 said she had new pelvic pain since she had a urinary tract infection in the beginning of September 2023. The resident said the facility was supposed to have scheduled a follow up appointment with a gynecological physician related to the pelvic pain, and a neurologist for her nerve pain but she had not heard from the facility regarding either appointment (cross-reference F745 provision of social services). Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. C. Record review On Saturday 7/1/23 at 7:03 p.m. the nursing notes documented the resident was out of Oxycodone. The nurse spoke to the pharmacy this morning about it and the pharmacy said they would deliver it. The note documented no oxycodone had been delivered. The nurse attempted to get it from the facility's emergency kit, but there was no second nurse at the facility available with username access to the kit to get the medication. The nurse documented she called the provider, but the provider was unreachable and she left a message. -There was no further documentation. On 7/16/23 at 6:00 p.m. the nurse's notes document the resident was having pain 10 out of 10 and the resident's Oxycodone had not arrived from the pharmacy. The nurses note documented the medication had been ordered on 7/15/23 from the pharmacy. The pharmacy said they were waiting on information from the physician. The progress notes documented the resident requested the nurse call the provider to get a one time order for Oxycodone 10 mg, twice the amount the resident normally took for pain. The nurse obtained a one time order for Oxycodone 10 mg and administered the medication from the emergency kit. On 7/17/23 at 1:21 p.m. the progress notes documented a one time order was received for Oxycodone 5 mg times two. This was twice the amount Resident #15 normally took again. On 7/18/23 at 4:03 p.m. the nursing progress notes documented the resident wanted her Oxycodone at 5:00 p.m. She said she had previously been in pain for a long time. She said it was fine now but it had taken her a long time to recover. On 7/25/23 at 12:53 p.m. the provider documented the resident had chronic pain. She complained the facility had run out of her Oxycodone the weekend before the fourth of July holiday. The note documented the resident was back on her routine dosing. The provider note further documented that the nursing staff had asked to discontinue the nighttime Oxycodone because they have to wake up the resident. The provider documented the resident did not want to discontinue the Oxycodone at that time because that was when she received incontinence care and she did not want to have any decrease in care. On 7/27/23 at 2:00 p.m. the nursing progress notes documented Resident #15 was concerned about her medication and wanted to make sure she had enough Oxycodone for the weekend. The June 2023 medication administration record (MAR) was reviewed. The MAR documented after the resident was admitted on [DATE], the Resident #15 received Acetaminophen (Tylenol) 325mg two tablets via PEG tube (percutaneous endoscopic gastrostomy) twice on 6/15/23 for pain levels of 5 and 6. She received Tylenol at the end of the month for pain levels of 4 to 6. -There were no parameters for what pain level the tylenol was to be given. The June 2023 MAR was blank for Oxycodone 5 mg tablet one tablet via PEG every four hours as needed for pain for the day of admission 6/14/23 and 6/15/23. After 6/15/23 the Oxycodone was given three to four times per day for pain ranging from 4 to 8. -There were no parameters for when to give the Oxycodone The July 2023 MAR was reviewed. The July MAR revealed the resident received Oxycodone on 7/1/23 at 4:30 a.m. for pain level of 4 and then not again until 7/3/21 at 2;17 p.m. for pain level of 8. -The resident did not have any Oxycodone available (see above). After 7/3/21 the July MAR revealed the resident received Oxycodone between two and four times daily for pain levels between 4 and 10. -However, another gap in the MAR indicated the resident had no Oxycodone 5mg after Saturday 7/15/23 at 5:00 p.m. for pain level of 7 until Monday 7/17/23 at 10:00 p.m for pain level of 7. The resident again had ran out of Oxycodone on the weekend again from 7/15/23 until Monday 7/17/23 (see above). The resident continued to receive Oxycodone as needed up to five times per day for pain levels up to 8 after 7/17/23. The resident was administered a one time dose of Oxycodone 10mg on 7/16/23 at 2:47 p.m. and one time on 7/17/23 at 1:26 p.m. (see above). On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes the resident's representative had typed for her regarding the events since the resident admitted . The notes documented in pertinent part that on a number of occasions the facility had run out of the residents pain medication on the weekends. The resident had to go the weekend and most of Monday without her pain medication. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 9/28/23 at 9:12 a.m. She said medication reordering was done through a computer program with the pharmacy. She said when medications are reordered or ordered for a new admission the medication was usually delivered the same day or the next day. LPN #2 said there was no formal process for reordering medications. She said the nurses reordered medications when they noticed they were getting low. She said if the nurses ran out of medication they would call the pharmacy or get the medication out of the emergency medication kit. Assistant director of nursing (ADON) #1 was interviewed on 9/28/23 at 2:10 p.m. He said Resident #15's pain was manageable with pain medication. He said the facility had an order for a pain clinic and the facility was going to get her an appointment. ADON #1 said the resident took Oxycodone as needed for pain. He said Resident #15 had new pelvic pain and the facility was going to get the resident an appointment with a specialist. ADON #1 said if the nurse did not have a prescribed pain medication they should call the pharmacy and notify the physician of the missed dose or request new orders for something else for pain. ADON #1 said regarding the missed Oxycocodne medication for Resident #15, he was not in charge of ensuring narcotics were ordered. The DON was interviewed on 10/3/23 at 9:30 a.m. She said when a new resident admitted to the facility, orders were faxed over to the pharmacy. She said medications arrive that night or the next day. The DON said if the resident needed medication on the day of admission the nurse could get the medication from the facility's emergency supply machine. She said Oxycodone was in the machine. She said the nurse would have had to call the pharmacy for a code to open the machine and have a second nurse present. She said barriers to this have been the pharmacy not answering the phone. The DON said the nurse could have called the physician and received an order for a different pain medication. The DON said the nurse could call the on-call nurse for help or the medical director when they did not get a hold of the physician. She said the on call number the nurse called on 7/1/23 was the number for the medical director. She said the number for the medical director did not answer when called. She said the nurses did not have access to any other number for the medical director. The nursing home administrator (NHA) was interviewed on 10/9/23 at 3:17 p.m. The NHA said the unavailability of pain medication was brought up during the facility's clinical meetings in the morning but the facility had no process improvement plan for the concern. 46022 III. Resident #10 A. Facility policy and procedure The Medications Brought to the Facility by the Resident/Family, revised April 2007, was provided by the DON on 10/9/23 at 12:44 p.m. It revealed in pertinent part, The facility shall ordinarily not permit residents and families to bring medications into the facility. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that: state law and regulations allow such use; the medications have been ordered by the resident's Attending Physician, and documented on the physician's ordered sheet; the contents of each container are labeled in accordance with established policies; the contents of each container have been verified by a licensed pharmacist; and signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP (representative) and receiving staff member is completed. B. Resident status Resident #10, age 76, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the April 2023 CPO the diagnoses included type two diabetes mellitus, dementia, dysphagia (swallowing difficulty) and gastro-esophageal reflux disease (GERD). The 1/25/23 MDS assessment revealed Resident #10 was cognitively intact with a brief interview for mental status with a score of 13 out of 15. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting and personal hygiene. She required extensive assistance of two people for transfers. She required supervision of one person assistance for walking in her room and in the corridor, eating. The MDS assessment indicated the resident was on a scheduled pain medication regimen and had not received non-medication interventions for pain during the review period. According to staff assessment, Resident #10 displayed non-verbal sounds of pain and showed evidence of pain daily. C. Record review 1. Comprehensive care plan-pain The pain management care plan, initiated on 1/18/23, revealed Resident #10 needed pain management and monitoring related to limited mobility. The interventions included: administering pain medication as ordered, coordinating with the patient and family to identify patient's favorite items and activities that could serve to distract from pain, evaluating and establishing a level of pain on a numeric scale, evaluating characteristics and frequently of pain, evaluating need to provide medications prior to treatment, implementing the patient's preferred non-pharmacological pain relief strategies, observing for potential medication side effects, repositioning as needed and utilizing a pain monitoring tool to evaluating effectiveness of interventions. 2. Physician orders related to pain The March 2023 CPO revealed Resident #10 had the following physician orders for pain management: -Acetaminophen Tablet 325 MG (milligrams), give two tablets by mouth three times a day for chronic pain syndrome, ordered 10/6/22. -Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 3/30/23 and discontinued on 4/5/23. According to the March 2023 medication administration record (MAR), Resident #10 received the Norco Oral Tablet 5-325 MG on 3/31/23 at 9:11 a.m. when she reported her pain level as a 5 and on 3/31/23 at 4:35 p.m. when she reported her pain level as a 7. -However, Resident #10 was prescribed Percocet for pain. The April 2023 CPO revealed Resident #10 had the following physician orders for pain management and skin treatments: -Acetaminophen Tablet 325 MG, give two tablets by mouth three times a day for chronic pain syndrome, ordered 10/6/23. -Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 3/30/23, discontinued on 4/5/23. -Left upper arm: apply bacitracin ointment twice a day and cover with a bandage every shift for incision site for 14 days, ordered on 4/3/23. -Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 4/5/23 and discontinued on 4/6/23. According to the April 2023 MAR, Resident #10 received the Norco Oral Tablet 5/325 MG on 4/1/23 at 8:18 a.m. when she reported her pain level as a 5, on 4/2/23 at 8:45 a.m. when she reported her pain level as a 4, on 4/3/23 when she reported her pain level as a 5, on 4/5/23 at 5:36 a.m. when she reported her pain level as a 9 and on 4/5/23 at 9:59 a.m. when she reported her pain level as a 5. -However, Resident #10 was prescribed Percocet for pain. 3. Controlled drug records The health information manager (HIM) provided a copy of two controlled drug records on 10/5/23 at 4:30 p.m. The controlled drug record documented Resident #10 received Norco 5/325 MG 1 tablet every 4 to 6 hours as needed for pain on 3/3/23, 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23 and 4/5/23. The second controlled drug record documented Resident #10 received Hydrocodone/APAP 5 (Norco) on 4/5/23. -According the the April 2023 MAR, Resident #10 did not receive the Norco 5/325 MG on 4/4/23. However, the nurse signed the controlled drug record on 4/4/23 at 10:00 a.m. Norco 5/325 MG was administered. 4. Progress notes The 3/30/23 operative report documented by the dermatologist (DERM) revealed in pertinent part, Resident #10 had surgery to remove a soft tissue mass on her left upper arm. The 3/31/23 nurse practitioner progress note documented in pertinent part, Resident #10 saw the dermatologist yesterday (3/30/23) and had a left arm lesion removed. Resident #10 was placed on as needed Norco for pain management. Resident #10 reported she had pain to her left arm. The 4/4/23 nurse practitioner progress note documented in pertinent part, Resident #10 was seen lying in bed. Resident #10 reported ongoing pain to her left arm and has relief from the prescribed as needed Norco. The 4/4/23 nursing progress note documented at 11:38 p.m. revealed the resident was on an antibiotic after a surgery to her left upper arm. Resident #10 refused to have her dressing changed to her arm due to pain. The progress note documented the nurse administered the scheduled pain medication. The nurse attempted to change the dressing to the resident's arm later that shift and the resident declined the dressing change and said she did not want the dressing touched. -The licensed nurse administered the scheduled Acetaminophen Tablet 325 MG when the resident reported pain to her dressing site. Resident #10 did not receive the as needed Norco Oral Tablet 5-325 MG as needed pain medication when she refused to have her dressing changed related to pain. The 4/5/23 nursing progress note documented by the DON revealed Resident #10 had a dermatology appointment last week. The dermatologist prescribed Percocet for pain. The note documented Resident #10 had been receiving Percocet. The order was incorrect in the MAR. The progress note documented the order was under Norco instead of Percocet. The note documented the resident had been receiving the correct medication. The note documented the facility would continue to monitor. -However, according to the March 2023 and April 2023 MAR and the controlled substance records Resident #10 received Norco on 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23 and 4/5/23 (see interviews below). The 4/5/23 dermatology note documented the resident had an excision of a left upper arm lesion on 3/30/23. The dermatologist documented the area was grossly infected, painful and the nursing home was not taking care of the site. The note documented the resident had severe cellulitis and 40 cubic centimeters (CC) of purulence (puss) was drained from the site. Cultures were taken, the wound was irrigated and cleaned and a clean dressing was placed. Resident #10 was transferred to the hospital for intravenous (IV) antibiotics related to the gross cellulitis and infection. D. Interviews The dermatologist was interviewed on 9/28/23 at 2:10 p.m. The dermatologist said Resident #10 had surgery to remove a cancer lesion on 3/30/23. The dermatologist said Resident #10 had cognitive impairment and was not able to always accurately voice her pain. The dermatologist said he would have expected Resident #10 to have pain, as the surgery covered a big area. The dermatologist assistant (DA) was interviewed on 9/28/23 at 2:10 p.m. The DA said the dermatologist prescribed Percocet for pain management following the surgical procedure on 3/30/23. The DA said the doctor called the facility and gave the order to the nurse on duty. The DON was interviewed on 10/9/23 at 11:48 a.m. The DON said Resident #10 was prescribed Percocet for pain management following a surgical procedure on 3/30/23. The DON said the dermatologist called the facility and verbally gave the order to the nurse on duty. The DON said Resident #10's granddaughter provided the medication from an outside pharmacy. The DON said the facility relied on the outside pharmacy to verify the medication was correct and accurate. The DON said the physician's order was entered incorrectly into the resident's electronic medical record. The DON said the physician's order read to give the resident Norco instead of Percocet for pain management. The DON said the controlled substance sheets and MAR documented the resident had received Norco. The DON said the resident's physician notified the DON that the order in the electronic medical record was not accurate. The DON said Resident #10 received Percocet. The DON said multiple licensed nurses signed off on the MAR and the controlled substance record sheets that they administered Norco. -However, according to Resident #10's MAR and the controlled substance record sheets, Resident #10 received Norco.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#10) of three residents reviewed for professional standard out of 22 sample residents. Specifically, the facility failed to ensure Resident #10 received the care and services to treat a surgical wound and prevent the development of severe cellulitis (skin infection). Resident #10 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. Resident #10 had a diagnosis of chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, dementia, need for assistance with personal care and gastro-esophageal reflux disease (GERD). Resident #10 had a dermatological surgical procedure on 3/30/23 to remove a cancer lesion from her left upper arm. The dermatologist prescribed oral antibiotics, topical antibiotics, dressing changes and pain medications. The facility failed to complete all physician ordered dressing changes and accurately assess Resident #10's surgical incision to her left upper arm for infection. According to the follow-up appointment note on 4/5/23 from the dermatologist, the wound was grossly infected and had severe cellulitis. The dermatologist drained 30 cubic centimeters (CC) of drainage, cleaned the wound and sent the resident to the hospital to receive intravenous (IV) antibiotics. Findings include: I. Resident #10 A. Resident status Resident #10, age 76, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the April 2023 computerized physician orders (CPO) the diagnoses included type two diabetes mellitus, dementia, dysphagia (swallowing difficulty) and gastro-esophageal reflux disease (GERD). The 1/25/23 minimum data set (MDS) assessment revealed Resident #10 was cognitively intact with a brief interview for mental status (BIMS) with a score of 13 out of 15. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting and personal hygiene. She required extensive assistance of two people for transfers. She required supervision of one person assistance for walking in her room and in the corridor, eating. B. Record review The pain management care plan, initiated on 1/18/23, revealed Resident #10 needed pain management and monitoring related to limited mobility. The interventions included: administering pain medication as ordered, coordinating with the patient and family to identify patient's favorite items and activities that could serve to distract from pain, evaluating and establishing a level of pain on a numeric scale, evaluating characteristics and frequently of pain, evaluating need to provide medications prior to treatment, implementing the patient's preferred non-pharmacological pain relief strategies, observing for potential medication side effects, repositioning as needed and utilizing a pain monitoring tool to evaluating effectiveness of interventions. The March and April 2023 CPO revealed Resident #10 had the following physician orders for post operative skin care: -Post-surgery instructions left upper arm: light activity, keep dressing on for 72 hours, then remove and apply bacitracin ointment twice a day, do not get incision wet until follow-up, every shift for incision for 14 days, ordered 3/30/23. -Cleanse wound area to left upper arm with wound cleanser and cover with xeroform and dry dressing once a day and as needed, one time a day for wound care, ordered 3/18/23 and discontinued on 4/3/23. -Left upper arm: apply bacitracin ointment twice a day and cover with a bandage every shift for incision site for 14 days, ordered 4/3/23. -According to the April 2023 treatment administration record (TAR), the licensed nurses completed cleansing the wound area to left upper arm with wound cleanser and cover with xeroform and dry dressing on 4/1/23 and 4/2/23. -However, the dermatologist had ordered a new treatment to the wound after the surgery on 3/30/23. The physician's order was to leave the dressing on the surgical incision for 72 hours. The dressing should have remained intact to the surgical site until 4/2/23. -According to the April 2023 TAR, the facility failed to provide treatment as ordered to the residents left upper extremity on the night shift on 4/3/23. The resident refused treatment on 4/4/23 due to pain. The facility did not notify the physician of the increased pain to the area, resulting in the resident refusing treatment. Cross-reference: F697 the facility failed to provide pain medications as ordered by the physician for post operative pain management. The 3/30/23 nursing progress note documented Resident #10 returned to the facility after having a surgery to her left upper arm at 5:26 p.m. The resident's vital signs were within normal limits, she denied pain and had not acute distress. The post-surgery orders were entered. Resident #10 was eating dinner and the licensed nurse documented she would continue to monitor the resident. The 3/30/23 weekly wound assessment documented the resident had a surgical incision to her left arm that was 3.6 centimeters (cm) in length by 3.6 cm in width and 0.1 cm in depth. The wound had 30% epithelial, 45% granulation, 5% sloth and 20% dermis. The wound had scant serous drainage. -The physician ordered the dressing to stay intact for 72 hours after surgery. The dressing should have remained intact from 3/30/23 until 4/2/23. The licensed nurse removed the dressing to assess the wound (see wound assessment above). The licensed nurse did not follow the physician's post operative instructions. The 3/30/23 operative report documented by the dermatologist (DERM) revealed in pertinent part, Resident #10 had surgery to remove a soft tissue mass on her left upper arm. The 3/31/23 nurse practitioner progress note documented in pertinent part, Resident #10 saw the dermatologist yesterday (3/30/23) and had a left arm lesion removed. Resident #10 was placed on as needed Norco for pain management. Resident #10 reported she had pain to her left arm. The 3/31/23 nursing progress note documented Resident #10 had surgery on 3/30/23 to remove a lesion from her left upper arm. A dressing was placed to the surgical area and was not to be removed for 72 hours. The nursing progress note documented the resident had two new orders for medications, which were entered. The family provided the medications from an outside pharmacy and the medications were in the medication cart. The 3/31/23 nursing progress note documented Resident #10 continued on monitoring for antibiotic use related to her recent surgery to her left upper extremity. The resident's vital signs were within normal limits. Resident #10 complained of pain and as needed pain medications were administered. The progress note documented the pain medications were effective. The resident was at her baseline. The 3/31/23 nursing progress note documented the resident was alert and oriented at baseline. The resident ate all of her meals and was taking her medications as ordered. The resident's vital signs were within normal limits. The resident complained of pain and as needed pain medication was administered. The pain medication was effective. The dressing to the residents left upper arm was clean, dry and intact. According to the April 2023 MAR the licensed nurse completed a weekly head to toe skin assessment on 4/3/23. -However, a review of Resident #10's electronic medical record revealed there was no documented head to toe skin assessment on 4/3/23 (see interview below). The 4/2/23 nursing progress note documented the resident's surgical dressing was clean, dry and intact. There were no signs or symptoms of infection. The resident had no allergic reactions to the antibiotic. The licensed nurse documented she would continue to monitor. The 4/2/23 nursing progress note documented the resident remained on antibiotics post surgery. The resident's dressing remained in place per physician orders. The dressing was clean, dry and intact. The resident complained of pain and there were no further concerns. The 4/3/23 nursing progress note documented the resident remained on increased observation due to her recent surgery to remove a cancer legion from her left upper arm. The resident was on an oral and topical antibiotic for infection prevention. The skin was warm and dry to touch. The nursing progress note documented there was trace edema to the resident's left upper arm. The resident denied pain or discomfort. The licensed nursing encouraged fluid. The note documented facility staff would continue to monitor the resident. The 4/4/23 nurse practitioner progress note documented in pertinent part, Resident #10 was seen lying in bed. Resident #10 reported ongoing pain to her left arm and has relief from the prescribed as needed Norco. The 4/4/23 nursing progress note documented at 11:38 p.m. revealed the resident was on an antibiotic after a surgery to her left upper arm. Resident #10 refused to have her dressing changed to her arm due to pain. The progress note documented the nurse administered the scheduled pain medication. The nurse attempted to change the dressing to the resident's arm later that shift and the resident declined the dressing change and said she did not want the dressing touched. The 4/5/23 head to toe skin assessment documented the resident had skin issues. The assessment documented the licensed nurse was unable to assess the resident as she was at the hospital. The 4/5/23 nursing progress note documented the resident remained on an antibiotic after a surgical procedure to remove a mass from her left upper arm. The dressing remained clean, dry and intact. There was no draining or warmth. The resident's upper arm was slightly red and swollen. The resident complained of pain and as needed pain medication was administered. The 4/5/23 dermatology note documented the resident had an excision of a left upper arm lesion on 3/30/23. The dermatologist documented the area was grossly infected, painful and the nursing home was not taking care of the site. The note documented the resident had severe cellulitis and 40 cubic centimeters (CC) of purulence (puss) was drained from the site. Cultures were taken, the wound was irrigated and cleaned and a clean dressing was placed. Resident #10 was transferred to the hospital for intravenous (IV) antibiotics related to the gross cellulitis and infection. The 4/5/23 incident report documented Resident #10's granddaughter alleged the facility did not treat Resident #10's arm and identify infection. Resident #10 was sent to the hospital from the dermatologist appointment. Resident #10 received intravenous (IV) antibiotics when she arrived at the hospital. The incident report documented the facility reviewed resident notes, care plan diagnosis and medications. Through staff interviews the facility concluded that the redness on Resident #10's arm was at baseline and there were no signs or symptoms of infection. The facility determined the 4/5/23 allegation was not substantiated due to staff providing dressing changes consistently. -However, according to the April 2023 MAR and skin assessments, the licensed nurses did not follow the physician orders and removed the dressing prior to the 72 hour order. According to the April 2023 TAR the facility did not provide the physician prescribed topical antibiotic or a dressing change on the night shift of 4/3/23. A review of the 4/5/23 hospitalist note documented the resident had increased pain, erythema (redness), heat, pain and edema. The resident was admitted to the hospital and started on IV Vancomycin (antibiotic) and IV Ceftriaxone (antibiotic) to treat the infection. II. Interviews The dermatologist was interviewed on 9/28/23 at 2:10 p.m. The dermatologist said Resident #10 had a follow-up appointment on 4/5/23. The dermatologist said upon assessing the surgical incision to the resident's left upper arm he knew it was infected. The dermatologist said the surgical incision was dried out, crusted over, extremely swollen, warm to the touch, tender and fluid filled, which were all signs of infection. The dermatologist said he cleaned the wound and drained fluid from the wound. The dermatologist said it was clear the infection had been developing for several days and not just a few hours. The dermatologist said the wound was in very bad shape and needed immediate attention. The dermatologist said he cleaned the wound and packed it. The dermatologist said the best course of action was to send the resident to the hospital to get IV antibiotics. The dermatologist said he had to clean the wound out two or three more times to help with the infection. The dermatologist said he had ordered the licensed nurses at the nursing home to leave the dressing on for 72 hours after the surgery. He said after 72 hours the licensed nurses were supposed to clean the wound, place an antibiotic ointment on the wound and place a clean dry dressing over the wound. The dermatologist said the licensed nurses should have noticed the infection and called him for further orders. The dermatologist said he ordered an oral and topical antibiotic prior to the surgery prophylactically. The dermatologist said the resident was at a high risk for infection related to her comorbidities. Registered nurse (RN) #2 was interviewed on 10/3/23 at 10:29 a.m. RN #2 said signs of infection include red, oozing and painful. The director of nursing (DON) was interviewed 10/9/23 at 11:48 a.m. The DON said Resident #10 had a surgical procedure to remove a cancer lesion from her left upper arm on 3/30/23. The DON said the resident attended a follow-up appointment on 4/5/23 as was sent to the hospital. The DON said the granddaughter alleged the facility did not care for the resident's surgical incision The DON said the facility completed an investigation by interviewing staff members and determined the resident did not have signs of infection. The DON said she did not review the dermatologist notes that indicated the facility was not caring for the resident's surgical incision. The DON said she briefly spoke to the dermatologist assistant on 4/5/23 when they notified the DON that the resident was being transferred to the hospital. The DON said the licensed nurse signed off on the MAR that she completed a head to toe skin assessment, but there was not a skin assessment documented in the resident's medical record. The DON said she would have expected the resident's arm to be a little swollen and red, since the resident recently had surgery. The DON said she was not aware that Resident #10 had not received her dressing change on 4/3/23. The DON said the facility typically notified the resident's primary care physician if the resident was refusing medications or treatments. -However, a review of the resident's medical record revealed the facility had not notified the physician of the resident's dressing change refusal related to pain on 4/3/23.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#15) of one resident reviewed for dignity out of 22 sample residents. Specifically, the facility failed to ensure staff were not using their personal cell phones while providing incontinence care, assisting a resident with eating and while in resident care areas. The use of employee cell phones during care resulted in Resident #15 reporting anxiety, humiliation, embarrassment and frustration. Findings include: I. Facility policy and procedure The Resident Rights policy, revised February 2021, as received from the nursing home administrator (NHA) on 10/9/23 at 9:53 a.m. The policy documented in pertinent part, the resident has the right to a dignified existence, to be treated with respect, kindness and dignity, to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and have the facility respond to his or her grievance. A policy on employee cell phone use while providing resident care was requested from the NHA on 10/9/23 at 3:17 p.m. and not received by the end of the survey 10/9/23. II. Resident #15 A. Resident status Resident #15, under age 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. B. Resident interview Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said CNA #8 had been in her room on her cell phone on 8/3/23 while changing the resident and providing incontinence care. The resident said the CNA had her earphones in and was talking. Resident #15 said she was humiliated, frustrated and embarrassed the CNA would be on the phone while providing personal care. The resident said she had no use of her arms or legs and felt helpless. The resident said she reported it to the other CNA on duty. Resident #15 said CNA #8 came back to her room a short time later and got within an inch of the resident's face. The resident said the CNA gritted her teeth and said sarcastically we're gonna be friends. The CNA said she was not on her cellphone and accused the resident of lying. (Cross-reference F600). Resident #15 said she reported it to the nursing staff on duty at the time. She said she reported it again to assistant director of nursing (ADON) #1 on 8/7/23. The resident said the CNA continued to work on the resident's hall until her employment was ended on 9/22/23. Additionally, Resident #15 reported CNA #9 was texting on her phone while assisting the resident to eat on the first week of September 2023 and two days in a row at the end of August 2023. She said the CNA denied it and spoke to the resident as if the resident were confused. Resident #15 said she reported this to ADON #1. Resident #15 stated she continued to have anxiety and frustration over the staff use of cellphones while providing care. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. III. Record review The resident council notes were received from the director of nursing (DON) on 9/26/23 at 10:55 a.m. On 7/11/23 (for June 2023), the resident council notes documented in pertinent part, old business, CNAs were on their phones at the nurse's station while call lights were going off. The resident council notes document the NHA and DON were present at the meeting. Resident #15 was not at the resident council meeting and did not report the concern. There was no documentation as to which resident reported the concern. The resident council form documented the staff was educated. All grievance reports related to staff cell phone use were requested from the DON on 9/26/23 at 4:00 p.m. There were no grievance reports for June or July 2023 related to staff cell phone use, despite the concern in resident council. A grievance report dated 8/4/23 for Resident #15 documented the resident complained that CNA #8 was on her cell phone in her room. The DON documented verbal education was provided to the CNA and the resident did not want the CNA in her room again. The grievance form documented the CNA said she was using the flashlight on her phone in the resident's room. -There was no further information as to why the resident did not want the CNA in her room again. It did not address the use of a personal cell phone while providing incontinence care. A grievance report dated 9/10/23 documented Resident #15 complained a staff member was on her phone in her room. The grievance form documented the staff said they were just texting about the schedule. The form documented the DON provided verbal education. The name of the CNA was not documented. The grievance was signed by the NHA on 9/11/23. -There were no grievance forms regarding the staff the cellphone use for the end of August 2023 despite the concern reported by Resident #15. On 9/12/23 the resident council notes documented new business, residents were concerned the CNA's were on their cell phones. The resident council notes documented the NHA and DON were present at the meeting. -It did not document when or where the staff were on their cell phones. A Resident Council Concern Follow Up note dated 9/12/23 documented CNA's on their phones at nurses station. The grievance form documented that signs were posted at nurse stations and bathrooms that phones were not allowed at nurses stations or care areas. -The form was blank under was action sufficient and was action effective. However no signs were posted (see below). The personnel file for CNA #8 was reviewed on 10/3/23 at 10:00 a.m. There was no counseling regarding personal cell phone use while providing incontinence care. The file documented CNA #8 was terminated on 9/22/23 for sleeping on the job as seen on video. She had been previously given a final written warning for sleeping on the job 7/18/23 and racial misconduct having to do with pictures taken. The personnel file for CNA #9 was reviewed on 10/3/23 at 10:00 a.m. The file contained verbal counseling for cell phone use in a resident room on 9/11/23. There was no education or counseling in August 2023 for the concern reported by Resident #15. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted . The notes documented in pertinent part on a number of occasions the resident's representative had walked by the nurses' station and the CNA staff were sitting at the nurses' station on their cell phones. It further documented that a number of times, CNA #9 was on her cell phone while assisting the resident with eating. The notes further documented there were a number of incidents of the CNAs taking personal calls while assisting the resident with eating and changing her, violating her confidentiality. The representative documented he felt the resident was beginning to withdraw and shut down due to the concerns above. Education regarding cell phone use with resident care for September 2023 was requested from the DON on 10/3/23. No documentation was received by the end of the survey on 10/9/23 or within 24 hours after the survey. IV. Staff interviews The DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not aware of CNA #8 getting in Resident #15's face after Resident #15 had reported the CNA for being on her cellphone during care. The DON said she was aware of the concerns with staff use of cellphones at the nurses station and while providing care for Resident #15. She said had written a grievance on it. She could not explain why the grievance on 8/4/23 documented Resident #15 no longer wanted CNA #8 in her room. -The DON provided no further information. The NHA was interviewed on 10/9/23 at 3:17 p.m. He said he was not aware of the concern with staff use of cellphones while providing care. -However, the resident council minutes documented the NHA was present, and some of the grievance forms related to staff cell phone use were signed by the NHA (see above). He said if the concern had been brought up at resident council then he would have looked into it. V. Observations On 10/9/23 at 10:08 a.m., the nurse station and staff bathroom on the hall where Resident #15 resided was observed with ADON #1. The ADON confirmed there were no postings regarding staff cellphone use. ADON #1 said he had not seen any postings. At 2:00 p.m. two CNAs were observed at the nurses' station viewing something on a cellphone together.

Based on observations, interviews, and record review, the facility failed to ensure three residents (#1, #2 and #3) of three residents out of 13 residents at moderate/high risk for elopement, received adequate supervision and assistive devices to prevent accidents. The facility failed to provide Residents #1, #2 and #3 the supervision necessary to prevent elopements. These facility failures created a situation with serious harm and the likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions) and mood disorder, eloped from the facility on 4/2/23 at 2:00 p.m. when he signed out. It was discovered the facility was not monitoring the sign-out book and it was not perceived that the resident was missing from the facility until 4/3/23 at 9:00 a.m. (over 18 hours later). Resident #1's whereabouts were unknown until 4/4/23 at 11:00 a.m. (over 45 hours later) when the facility was informed that he was at a distant hospital. According to 4/2/23 hospital records, Resident #1 was admitted to the hospital on 4/2/23 on a M1 (emergency mental health hold) hold due to suicidal ideation. The resident had tried to jump in front of traffic during the elopement and attempted suicide, which was unsuccessful. The facility responded by educating nursing staff about missing person protocol. The education proved to be ineffective as additional resident elopements occurred 13 and 16 days later. Staff were unaware of these elopements until notified by community members. Resident #2, diagnosed with paranoid schizophrenia, dementia with behavioral disturbance and cognitive communication deficit, eloped on 4/18/23 out the front door and was not discovered to be missing until the facility received a call from a convenience store at 1:45 a.m. The facility door was alarmed at night but either it did not alert or the staff did not respond to Resident #2's exit. Resident #2, assessed by the facility to be cognitively intact, reported leaving the facility at 12:20 a.m. An employee from the convenience store reported that Resident #2 attempted to get into a stranger's car. Resident #2 said she intended to walk or get a ride to the city of Parker (about 36 minutes away from the facility) and was resistant to return to the facility when the facility staff came to retrieve her. According to the 4/18/23 facility's investigation, staff said they noticed she was gone at 1:45 a.m (at the same time they were notified by the convenience store). Record review revealed the last staff interaction with Resident #2 was at 9:45 p.m. after staff conducted a pain assessment (it was four hours before the facility noticed the resident was gone). The facility responded by conducting an updated wandering assessment, completed upon Resident #2's return and revealed the resident was at high risk for wandering and the use of a wander prevention device was recommended. However, there was no evidence this recommendation was implemented and a wander prevention device was currently not in use for Resident #2. The care plan was not updated with interventions related to elopement. Resident #3, diagnosed with unspecified dementia and cognitive communication deficit, had eloped on 4/21/23 at approximately 9:00 a.m. He had eloped from the back patio gate which was unlocked. Resident #3 was found by a neighbor from the apartments next door, he was lying on the ground by the fence outside of his apartment. Resident #3 had a fall that resulted in skin tears to the left side of torso, left inner wrist and small scratches under his chin. Resident #3 denied hitting his head but was unable to recall how he fell . Resident #3 had packed a bag and said he intended to leave the facility with no intention to return. The facility responded by placing a wander prevention device on Resident #3. The facility's failure to implement an immediate and comprehensive review of the facility's system and response to Resident #1's elopement on 4/2/23, as well as Residents #2 and #3 elopements, placed residents at risk for serious harm if immediate corrections were not implemented. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Review of the elopement investigation from 4/2/23 for Resident #1, observations conducted from 5/1/23 through 5/2/23 and staff interviews revealed the facility failed to provide Resident #1, #2, and #3 with a safe environment and adequate supervision to avoid preventable accidents. Specifically, the facility failed to take immediate and comprehensive steps following Resident #1's elopement on 4/2/23, to review, revise and sufficiently educate staff, evaluating the effectiveness of the education, on how to protect Resident #1, as well as Residents #2 and #3. There was no evidence the facility thoroughly investigated the incident to uncover and address why the staff did not appropriately report a missing person for Resident #1, why no alarm was heard or responded to for Resident #2 at the front door and why the back door was unsecured where Resident #3 eloped. B. Facility notice of immediate jeopardy On 5/2/23 at 2:00 p.m. the nursing home administrator (NHA) was notified that the facility's failure to provide residents with a safe environment and adequate supervision to avoid preventable accidents created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 5/3/23 at 3:45 p.m. the facility submitted a final plan for the immediate jeopardy. The plan read: On 5/2/23 at 3:00 pm the following actions were taken: -Resident #1 has been discharged . -Director of nursing/designee completed updated wander risk assessment on Resident #2 and Resident #3. IDT(interdisciplinary team) reviewed and interventions initiated and care plan updated related to elopement risk. -Director of nursing/designee provided immediate training/education to staff responsible for monitoring the front door and responding to alarms at the door. -Administrator/designee validated gate on patio, which is not considered an exit, was securely locked to prevent exit via this route. -Administrator/designee validated all doors are functioning as appropriate, locking appropriately and alarming as expected with exits. -Administrator/designee initiated staff monitoring of the front exit door at all hours on 5/2/23 to assure the door was under constant monitoring as an ongoing intervention. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. -Director of nursing/designee completed assessment of all residents wander risk in point click care (facility electronic medical record) on 5/2/23. -Director of nursing/designee validated all residents at high risk of elopement/show signs of wandering, have appropriate interventions and plan of care in place per risk assessment on 5/2/23. -Director of nursing/designee has been validated that all residents with order/intervention for wander guard, have one in place and functioning as started on 5/2/23. -Director of nursing/designee will complete wandering assessments within 72 hours on every admission ongoing starting on 5/3/23. SYSTEMIC CHANGES AND/OR MEASURES: -The corporate RN (registered nurse) consultant provided training and material to the director of nursing and administrator of wandering/unsafe resident and elopement risk policy started on 5/2/23. -The corporate RN consultant educated administrator on requirement to validate doors are functioning properly and facility doors/gates are secured as per facility plan. Reception to validate that the front door are functioning properly. Maintenance to validate all other doors in the building are working properly. Completed on 5/2/23. -The director of nursing/designee completed education with all staff on missing resident protocol and proper response to alarms in the facility. -All education and training were started on 5/2/23 and will continue until all staff have received training prior to the start of their work shift. -Administrator/designee initiated inquiries on 5/2/23 for a camera system to assist in remote monitoring of doors for potential elopement risks. -Administrator/designee will provide education to the receptionist/door monitor on the process of checking the sign out log to validate that resident has logged an anticipated return time and the expectation that frequent monitoring to validate that the resident has returned as indicated on log. Education will be initiated on 5/2/23 and ongoing will all new staff attending to doors prior to shift. -Ad hoc QAPI (quality assurance and performance improvement) meeting held with the IDT team and MD (medical doctor) to review policy on missing persons, elopement risks and plan of removal/response to immediate jeopardy citation on 5/2/23 at 3:45 p.m. Tracking and Monitoring -Director of nursing/designee will review residents with high wander risk identified by doing wandering assessments upon admission for every resident, to assure appropriate interventions and plan of care are in place daily for seven days beginning 5/3/23, then five times per week. -Administrator/designee will monitor exits for appropriate functioning and alarms as installed five times per week beginning 5/3/23. -Administrator/designee will complete audit of resident sign out log daily for seven days, then five times a week to assure residents are completing anticipated time of return and receptionist is monitoring return each day, beginning 5/3/23. -Director of nursing/designee will monitor new orders for wander guard, and validate that placement of the wander guard device has occurred and appropriate care planning for device has been implemented five times per week, beginning 5/3/23. -Administrator/designee will complete a random audit every shift for seven days, beginning 5/3/23, for appropriate staff response to alarms, immediate education will be provided if necessary, then will monitor random shifts, five times a week. -Administrator/designee will monitor all residents on pass to ensure timely return and proper notification will be provided to administrator/director of nursing if resident does not return upon expected time. If a resident does not return at expected return time, administrator/ director of nursing will contact family and follow elopement policy. If a family is contacted and the resident is running late, the provider will be notified and order will be added for pass extended. D. Removal of immediate jeopardy The above plan was accepted and based on the facility plans above, the immediate jeopardy was removed on 5/3/23 at 3:45 p.m. However, deficient practice remained at an G scope and severity. II. The facility failed to identify risk for elopement and ensure the safety of three residents (#1, #2 and #3). A. Facility policy and procedure The Wandering, Unsafe Resident policy and procedure, revised 2022, was provided by the director of nursing (DON) on 5/3/23 at 11:33 a.m. It read in pertinent part, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement/missing resident emergency procedure will be initiated: determine if the resident is out on an authorized leave or pass; if the resident was not authorized to to leave, initiate a search of the building(s) and premises; if the resident is not located, notify the administrator and the DON services, the resident's legal representative (sponsor), the attending physician, law enforcement officials, and (as necessary) volunteer agencies (emergency management, rescue squads); provide search teams with resident identification information; and initiate an extensive search of the surrounding area. When the resident returns to the facility, the DON shall complete and file an incident report; and document relevant information in the resident's medical record. B. Resident #1 1. Resident status Resident #1, age under 65, was admitted initially on 3/22/23, readmitted [DATE] from acute care hospital and discharged [DATE] due to elopement. According to the April 2023 computerized physician orders (CPO), diagnoses included hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease (kidneys have stopped doing their job to filter waste from your blood causing high blood pressure and heart disease), type 2 diabetes mellitus and schizoaffective disorder. He attended dialysis three days per week. The incomplete 3/22/23 entry, 3/26/23 discharge return anticipated, 3/27/23 entry and 4/2/23 discharge return not anticipated minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required limited assistance with transfers and showers; supervision with bed mobility, walking in room/corridor, dressing, eating, toilet use, and personal hygiene. The activities of daily living (ADL) support provided were not recorded. The MDS revealed no behaviors, no rejection of care and no wandering behavior exhibited. He received seven days of antipsychotic medication, six days of antidepressant medication, one day of antibiotic and seven days of diuretic medication. 2. Review of 4/2/23 incident On 5/1/23 at 2:30 p.m. the DON provided the investigation of the resident's elopement on 4/2/23. The final report revealed the following: Resident #1 signed out to go out on pass at approximately 2:00 p.m. and did not return. Stated to the nurse that he was going to the convenience store across the street. Consumer location at the time of elopement-unsecured unit, with general population oversight. The resident was last observed by staff on 4/2/23 at 2:00 p.m. The occurrence was not witnessed. Risk level at the time of elopement was at risk to self, with risk factors of mental health and homelessness. Investigation started 4/3/23 with staff interviews and checking the cameras. Other residents were kept safe during the investigation by calling the police and the resident's brother to ask about his whereabouts. A grounds search was conducted and the residents whereabouts were unknown. The resident was missing for approximately 40 hours. The resident was not assessed because he did not return to the facility. The resident was transferred to a higher level of care and ended up at the hospital. The resident did not return to the previous level of care because the resident was still in the hospital. Results of documentation review and interviews revealed the resident signed out to go on pass on 4/2/23 and did not return. On 4/4/23 the facility was informed that he was at the hospital. Policy and procedures were not followed. The DON/NHA (nursing home administrator) were not informed about the resident signing out and not returning. Conclusion was the facility determined that this met elements for a missing person due to the resident signing out but did not return and his whereabouts were unknown. No changes were made to the residents treatment regimen and/or care plan as a result of the occurrence because the resident did not return to the facility. Interventions that were put into place to help prevent a recurrence included education to certified nurse aides (CNAs) and nursing about missing person protocol. Police, family/guardian, ombudsman, and physician were notified. Elopement incident report: dated 4/3/23 at 8:50 am. DON was notified of the resident missing by the assistant director of nursing (ADON). DON investigated the incident and interviewed staff. Resident had signed himself out at 2:00 p.m. on 4/2/23 and he did not return to the facility. Resident #1 had no behaviors and did not verbalize wanting to leave the facility prior to signing out of the facility for pass. DON spoke to Resident #1's representative regarding the resident and the family member had not heard from him. The physician and police were notified. Reportable was completed. Admissions/DON received a call from the hospital on 4/4/23 around 11:00 a.m. to notify us that the resident was at their facility. Unable to get Resident #1's description of the incident or perform a head to toe skin check due to the resident not returning to the facility. Police notification was 4/3/23 at 9:00 a.m., physician 4/3/23 at 9:10 a.m., family member on 4/3/23 at 9:00 a.m. Statement by the DON, dated 4/3/23, Resident signed out in book on 4/2 at 1400 (2:00 p.m.) and has not returned to the facility. Spoke to the resident's brother and he has not heard from the resident. Resident was reported missing to police and reportable was completed. MD (medical doctor) notified. AMA(against medical advice) paperwork completed as discharge was not safe. Will continue to monitor changes. Interviews conducted by DON: Interviewee: Licensed practical nurse (LPN) #1 When was the last time that you saw the resident? I saw the resident right before 2 p.m. and he said he was headed across the street to (convenience store). Did you see him prior to your shift ending? No, I gave a report to the nurse that he had signed himself out on a pass. Did you report him missing? No he was out on pass and usually gone for a bit. Interviewee: CNA #2 When was the last time that you saw the resident? I did not see him during my shift. Did you see him prior to your shift ending? No, I was not taking care of him at that time. Did you report him missing? No. Interviewee: CNA #3 When was the last time you saw the resident? I saw the resident briefly around 6 pm. Did you see him prior to your shift changing? The last time I saw him was around 6 pm. Did you report him missing? No. -The conclusion of the report indicated it was substantiated that the resident left the facility unattended and was later located by a hospital. 3. Record review- steps taken after the resident's elopement on 4/2/23 Progress notes The 4/2/23 at 5:38 a.m. nurses note revealed, Resident remains on antibiotic ointment to right eye with no adverse effects noted tonight. He is complaining of not being able to sleep with the trazodone 100mg he is on now. Will call MD on Monday morning to request an increase in his Trazodone order. Vital signs are within normal limits this shift. The 4/3/23 at 8:56 a.m. nurses note revealed, Nurse was told in report that resident left yesterday day shift and has not returned since. Nurse reported it to the ADON. The 4/3/23 at 9:58 a.m. nurses note, late entry revealed, Resident signed out in book on 4/2 at 1400 (2:00 p.m.) and has not returned to facility. Spoke to the resident's brother and he has not heard from the resident. Resident was reported missing to police and reportable was completed. MD notified. AMA (against medical advice) paperwork completed as discharge was not safe. Will continue to monitor for changes. The evening 4/2/23 and morning 4/3/23 medication administration record (MAR) was marked as out of facility. -The facility staff recognized that Resident #1 was gone but did not act and his whereabouts were unknown. The in-service attendance form, provided by the DON on 5/1/23 at 4:10 p.m , read in pertinent part, In-service title: Frequent checks. Topics discussed: Resident's must be checked on frequently. If a resident appears missing, the administrator or DON must be notified immediately. Staff must immediately search the premises for the resident and the nurse must complete a risk management. Instructor's name: DON. Required departments: nursing. Date of in-service: 4/3/23, mandatory in-service. Signed by 28 staff members. Hospital medical records for Resident #1 were received from the hospital on 5/1/23 at 2:20 p.m. The hospital records revealed Resident #1 was admitted on [DATE] and discharged on [DATE]. The emergency department (ED) records, dated 4/2/23 revealed in pertinent part, (age)year old male with a history of schizoaffective disorder, depression here with suicidal ideations. Patient states he is living in a nursing home in Lakewood, he got on a bus trying to get back to California. He was feeling suicidal today and felt that he needed to jump in front of traffic. It is unclear though it seems the patient eloped from his nursing home down in Denver. States that he attempted to do this earlier however he was brought here instead. Medical decision making: Assessment: He is complaining of suicidal ideations and concern for possibly running into traffic. It is of note that he may have eloped from his nursing home in Lakewood, Colorado. ED course/reevaluation: Patient admitted /observed overnight pending social work evaluation. The Psychiatry consult, dated 4/3/23 at 9:30 a.m. revealed in pertinent part, Patient is a (age) year old male with a history of schizophrenia, depression, anxiety, hypertension, CKD (chronic kidney disease) analysis presented to the ER (emergency room ) reporting suicidal ideation. Patient stated that he was living in a nursing home in Denver for awhile and he reportedly left because he was feeling suicidal. The patient reports trying to go to Grand Junction however he missed his bus at Vail and started feeling suicidal. Patient said he tried to jump in front of the traffic which reportedly did not work out. Patient said he had been out of his medications for more than a month and had anxiety and depression symptoms. Today he continued depression symptoms, feelings of hopelessness and worthlessness. He reported stress due to his underlying medical issues and expressed hopelessness. Past Psychiatric history: Inpatient treatment: last hospitalization was over three years ago. Suicide attempts: Previous history of two suicide attempts. Mental status exam: mood: depressed. Affect: Flat. Thought content: Suicidal ideation. Insight: Limited. Judgment: Impaired. Assessment: Patient reports feeling depressed in the context of his medical issues and physical disability. He continued to endorse hopelessness and does not contract for safety. Patient is judged to be at imminent risk and meets criteria for acute inpatient psychiatric hospitalization . DSM 5 (standard classification of mental disorders) diagnoses: Major depressive disorder; recurrent and moderate schizophrenia. Plan: Restart Risperdal (antipsychotic medication) for schizophrenia; start Zoloft (depression medication) for anxiety and depression; continue trazodone (depression medication); transfer to acute inpatient psychiatric unit once medically cleared; recommend involuntary psychiatric placement due to safety concerns. 4. Staff interviews Registered nurse (RN) #1 was interviewed on 5/2/23 at 4:20 p.m. She said residents should be checked by nurses every two hours. RN #1 said if a resident misses medication administration the nurse staff did a search, checked the book if signed out and searched for the resident especially if they were an elopement risk. RN #1 said if the resident was still missing, the nurse would call the family, doctor, the DON and the NHA. CNA #4 was interviewed on 5/2/23 at 4:21 p.m. She said she tried to check on residents every two hours but sometimes it was hard with so many residents to care for. CNA #4 said her residents tell her if they were going to go out on a pass. CNA #4 said if they were gone for more than 45 minutes she knew something was wrong because usually the residents were not gone very long. CNA #4 said if the resident was gone for an hour she would report that to her nurse and it would go up through the chain of command (up to administration). The DON was interviewed on 5/3/23 at 11:00 a.m. She said she thought the wandering assessment screenings were being done for everyone on admission and were in the resident admission packets. She said the wandering assessments were not being done, she would now implement them from now forward. The DON said with Resident #1's elopement, the nurse staff were aware he was missing but did not act because it was a communication error. The DON said the CNAs should be checking on the residents every two hours for any needs. The DON was interviewed again on 5/3/23 at 12:15 p.m. She said she was not sure if there was a system for regular checks on residents but would encourage it. The DON said she would usually provide education to the residents on the front desk sign in/sign out process at admission. The DON said it was important to emphasize to the residents to know when they were going out and when they would be returning. The DON said she would now educate the residents to notify the facility if they would be late and to call the receptionist who checked the sign in/sign out book. The DON acknowledged that prior to the survey no staff had been assigned to check the sign in/sign out book. The DON said if a CNA noticed that a resident missed a meal, the CNA should see if they had a pass to go out, look for the resident and contact the family. The DON said triggers for the staff to look for a resident were if the resident had not been seen in the past two hours, missed a meal or missed medication administration. The DON acknowledged that prior to the survey there was no staff at the front desk at night. The DON said every resident now had a wandering assessment. The DON said for Resident #1, the nurses on duty failed to communicate with the administration that the resident was missing and those nurses had corrective action and additional education. The DON said the preferred process was for the CNA to tell the nurse and to search for the resident. The nurse would check if the resident signed out on pass, and to notify the DON and the NHA. The DON said the receptionist would now check the sign-in book to make sure the residents arrived. The DON said the facility's policy and procedures were not followed with Resident #1 because the nursing staff did not inform her or the NHA about the resident not returning. The DON said the 4/3/23 staff education plan had documented to frequently check on residents but it was not specific enough so she would be re-visiting the education. The DON said the education to staff was not effective due to other residents eloping after Resident #1. The DON said it was important for the staff to follow the missing person protocol so the facility could locate the resident and make sure they were free from injury. The front desk receptionist (REC) #2 was interviewed on 5/3/23 at 5:50 p.m. He said his shift was from 5:30 p.m. to 4:00 a.m. He said he received education on the new resident sign in/sign out procedure from the NHA. He said he received his education over the phone yesterday (5/2/23) and in person today. He said the resident sign in/sign out book was now located at the receptionist desk where the book and residents could be seen when leaving. He said if the resident did not return at the designated time he was to tell the nurse on the unit where the resident lived and to call the DON. The NHA was interviewed on 5/3/23 at 4:55 p.m. He said the facility would develop a sign in/sign out policy if they did not have one. The NHA said they had just completed resident education on the new facility sign in/sign out process. C. Resident #2 1. Resident status Resident #2, age 77, was admitted on [DATE]. According to the May 2023 CPO, diagnoses included paranoid schizophrenia, dementia with behavioral disturbance and cognitive communication deficit. The 4/22/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. It indicated the resident had delusions but no wandering behavior. The resident was independent for locomotion on and off the unit and independent for bed mobility, dressing, toileting and personal hygiene. 2. Wandering assessments The 12/13/22 wandering assessment showed Resident #2 had a moderate risk of wandering and was a known wanderer and had a history of wandering. The 3/13/23 wandering assessment showed she was a low risk of wandering and did not indicate she was a wanderer or had a history of wandering. On 5/2/23 at 3:43 p.m. the director of nursing (DON) provided a treatment record of Resident #2 last known documented observation before she was reported missing on 4/18/23 at 1:45 a.m. The documentation revealed a pain evaluation was completed for the resident by LPN # 3 on 4/17/23 at 9:45 p.m. 3. Review of 4/18/23 incident The 4/18/23 investigation included the final report, an interview of the resident and interventions completed. -The investigation did not include witness statements. The final report revealed the following: -At approximately 1:45 am on 4/18/23 the nurse on shift noticed Resident #2 was not in the facility. The facility received a phone call from the convenience store across the street at approximately 1:45 a.m., stating Resident #2 was there. The resident was then returned back to the facility. -The report documented the level of oversight which was provided at the time of the incident was identified as general population (a resident not in the secured unit). The report indicated the facility was not aware the resident had left the facility unaccompanied until they were notified by the convenience store at 1:45 a.m. on 4/18/23. It revealed the last time the resident was observed was at 1:00 a.m.; the resident was missing for 45 minutes. -The facility actions revealed the resident left the facility because she had been experiencing delusions. The facility report revealed Resident #2 received her psychotropic meditation injection on 4/16/23 two days late on 4/18/23 due to it not arriving from the pharmacy timely. The facility interventions included ensuring the resident's psychotropic medication was ordered a week before it was to be administered. -The conclusion of the internal investigation determined the incident met the criteria of a missing person. 4. Resident observation and interview On 5/2/23 at 9:43 a.m. Resident #2 was observed leaving her room with her walker and walking down the corridor to the main dining area. The resident was observed moving around the facility independently. Resident #2 was interviewed on 5/2/23 at 10:50 a.m. The resident said she left the faciity on [DATE] at 12:20 a.m. Resident #2 said she wanted to go home to Parker, CO and decided she would walk there. Resident #2 said she left by the front and did not see any staff members in the halls on her way out nor did she hear an alarm. She said she decided she should try to get a ride to Parker from the convenience store across the street. She said she offered a hundred dollars to a man who agreed to give her a ride. Resident #2 said she did not get into the car because the nursing staff arrived before the man returned to his car from the store. 5. Record review-steps taken after the resident's elopement on 4/18/23 A wandering assessment was completed on 4/18/23 following the elopement incident. It indicated she was a high risk of wandering, was a known wanderer and had a history of wandering. It revealed that a wander/elopement alarm was indicated. Resident #2 had a wandering care plan that was initiated on 4/18/23 which revealed the resident was at risk for injury due to moderate risk of wandering. -The goals initiated on 3/ [TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure supervision and assistive devices to prevent accidents for three (#34, #62 and #4) four residents reviewed for accidents/hazards out of 49 sample residents. Specifically, the facility failed to prevent residents at risk for falls from having repeated falls, falls with injury, and major injury. Resident #34 experienced multiple falls while a resident of the facility. Resident #34 was assessed to have had poor balance, unsteady gait and poor safety awareness. The resident was blind and had severely impaired cognitive impairments, however, the resident's fall prevention care plan lacked any specific person centered interventions which would be appropriate for the blindness and the cognitive impairments. The facility failed to implement effective fall precautions. As a result, the resident had multiple falls causing pain and injuries. On 2/12/22 the resident fell and hit her head on the floor. The fall caused the resident pain and required pain relief medication. On 5/28/22 the resident fell and hit her head on the floor. The physician determined x-rays of her skull were necessary. On 6/14/22 the resident fell to the floor and had hip pain. The resident had pain and x-rays were ordered for evaluation. On 9/6/22 the resident fell to the floor and had severe hip pain. She was transferred to the hospital for evaluation and it was determined she had a fractured right hip that required hip replacement surgery and hospitalization . On 9/21/22 the resident fell and had pain in her wrist and required narcotic pain relief medication. She was transferred and evaluated at the hospital where it was determined she had a non operable wrist fracture that required use of a soft cast for healing. On 9/28/22 the resident fell and hit her head. She required x-rays of her previously fractured wrist and pain relief medication. On 10/22/22 the resident fell to the floor and had pain in her hip. She was transferred to the hospital emergency department for evaluation and it was determined she had a chronic non operable thoracic spine fracture and returned to the facility. In addition, the facility failed to: -To assess risk and maintain safety for Resident #62, who verbalized a desire to go home and then left the facility; and, -To assess Resident #4 for community awareness and ensure adequate supervision to prevent an accident/hazard. Findings include: I. Resident #34 A. Professional reference According to Potter, P.A., Perry, A.G. , et.al. Fundamentals of Nursing, ninth ed., 2017, pp. 375: Falls are a major public health problem. Among adults [AGE] years and older, falls are the leading cause of both fatal and nonfatal injuries. Numerous factors increase the risk of falls, including a history of falling being age 65 or over, reduced vision, orthostatic hypotension, lower-extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, diuretics, hypnotics, sedatives, certain analgesics). Common physical hazards that lead to falls in the home include inadequate lighting, barriers along normal walking paths and stairways, loose rugs and carpeting, and a lack of safety devices in the home. Falls are also a common problem in health care settings. Hospitals throughout the country carefully monitor the incidence of falls and fall-related injuries as part of their ongoing performance improvement work. Falls are often a combination of individual and transient risk factors, the physical environment (e.g., poor lighting, high bed position, improper equipment), and the riskiness of a person's behavior (unwilling to call for assistance when getting up). Falls often lead to serious injuries such as fractures or internal bleeding. Patients most at risk for injury are those with bleeding tendencies resulting from disease or medical treatments and osteoporosis. B. Facility policy and procedure On 11/17/22, a request was made to the nursing home administrator (NHA) for the facility's fall prevention policy; the policy was not provided during the survey. C. Resident status Resident #34, age 87, was admitted on [DATE], discharged to the hospital on 9/5/22 and readmitted on [DATE]. According to the September 2020 computerized physician orders (CPO) diagnoses included fracture of the right femur (hip), dementia, cognitive communication deficit, abnormalities of gait and mobility. On 10/1/22 she was admitted to hospice care. The 10/7/22 minimum data set (MDS) assessment showed the resident had severely impaired cognitive status with a score of four out of 15 on the brief interview for mental status (BIMS). The resident required one person extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene and limited assistance for walking in her room and in the corridor. D. Observations On 11/14/22 at approximately 10:30 a.m., the resident was observed in her wheelchair near the nurses' station. Facility staff walked in the hallways, entered and exited other resident rooms. The resident was frequently without line of sight supervision. On 11/16/22 at 9:30 a.m., the resident sat in her wheelchair next to the nurses' station. There were no staff members present at the nurses' desk or in the hallways. The staff were observed as they entered and exited other resident rooms. The resident was frequently without line of sight supervision. At 9:50 a.m., the resident was observed sitting in her wheelchair in the middle of her room. The resident's room was near the nurses' station; however, she was not in the line of sight of staff members. The resident did not have her call light pull cord within her reach. C. Record review The progress notes indicated the resident had suffered eleven or more falls since admission on 9/17/20, and seven of those falls occurred in 2022. The falls were as follows: Fall #1 Nursing progress note dated 2/12/22 at 11:30 a.m., documented the resident stated she was standing and talking to her roommate for a long time, then slipped in her socks, tripped and fell . The nurse assessment revealed the resident hit her head and hip and she had pain requiring pain medication. It was determined that no injury occurred. The resident was educated she should sit in her chair while talking for long periods or use her walker for support. The note stated the resident was legally blind and the trip hazard was moved to the corner of the room. Interdisciplinary team (IDT) post fall review note dated 2/14/22 at 9:41 a.m., read: (Resident) was diagnoses dementia with behavioral disturbance, malnutrition, homicidal ideations. The resident's medications were reviewed, the care plan reviewed and updated. The IDT determined the root cause was the resident tripped over roommate's possessions. Intervention: Therapy to evaluate and treat. Therapy progress note dated 2/14/22 revealed the resident fell in her room, tripping over roommate's possessions. Resident #34 was to be evaluated by physical therapy to facilitate safety and functional mobility. The comprehensive care plan dated 1/18/22 documented the resident was at risk for falls. Pertinent interventions included, offer non-skid footwear, encourage resident to call for assistance with items not immediately in reach, encourage resident to use a wheelchair and monitor for resident impulsivity to decrease fall. -The care plan was updated on 2/25/22 to include therapy evaluation. The physician's assistant (PA) note dated 3/15/22 documented, the resident was observed standing in her room without an assistive device. She had good balance and gait (manner of walking). The PA recommended continue to monitor closely with frequent check-ins by staff for fall prevention. Fall #2 A nurse's progress note dated 5/28/22 at 7:53 a.m., documented the resident was observed as she fell backward and hit her head on the floor. The nurse assessment was completed and skull series x-rays were ordered. The 5/31/22 IDT post fall review note documented, the root cause was she slipped and fell backward. The care plan was updated to ensure she was wearing proper footwear at all times. Fall #3 A nurses's progress note dated 6/15/22 at 10:53 a.m., documented the resident was observed on 6/14/22 lying on the floor on her right side in her room. The resident complained of pain when the nurse touched her right hip. An x-ray film of the right hip was ordered and had no evidence of fracture. TheIDT post fall review note dated 6/16/22, revealed the root cause of the resident's fall was the resident slipped and fell to the floor, she was not wearing socks. The care plan was updated to include, frequent checks by staff to meet resident's needs. Therapy progress note dated 6/16/22 documented the resident fell ambulating in the room while completing her morning routine. Resident #34 was currently receiving therapy services and would continue safety awareness education and training. A physician note dated 6/19/22 at 23:00 p.m., documented the resident requested to be evaluated but the staff had not been responding to her needs and wished to be transferred to the hospital. The physician documented he evaluated the resident in follow up to residents complaints and follow up for dementia, hypertension, and depression. It was noted by the physician the resident had confusion, was angry, agitated, and had a decreased mood. Fall #4 A nurse's progress note dated 9/6/22 at 4:46 p.m., documented the resident was found lying supine between her bed and bedside table. The resident screamed during the nurse assessment when her right hip was touched. The physician was contacted and ordered the resident be transferred to the hospital for evaluation. The resident sustained a right hip fracture and required hip replacement surgery. An IDT post fall review note dated 9/7/22 at 9:53 a.m., indicated: medications were reviewed. Root cause: resident tripped and fell in her room. The care plan was updated. Intervention: educate staff to ensure all articles are off floor room free of clutter. A therapy note 9/9/22 at 3:23 p.m., documented the resident's fall incident was discussed with the IDT. Resident fell in her room, was sent to ED (emergency department) for evaluation, will complete therapy evaluation upon return. The PA note dated 9/13/22 documented the resident had a mechanical fall with injury and the resident should continue with physical and occupational therapy. The PA noted the resident had a history of falling, had diagnoses of dementia and poor vision, and the facility should continue fall precautions per facility protocol. The care plan updated 9/17/22 indicated fall prevention interventions included: encourage resident to call for assistance with items not immediately in reach, frequent checks by staff to meet resident's needs, re-educate staff on use of non skid shoes and socks, resident to be in wheelchair near nurses station within sight while awake, staff to provide textured tennis ball attached to call light so resident can find it due to her low vision, staff to rearrange room for safety, therapy to evaluate and treat as indicated, therapy to evaluate for safety with transfers. Fall #5 A nurse's progress note dated 9/21/22 at 6:53 p.m., documented the resident was heard yelling for help. The resident was found sitting on her buttocks in front of her bed holding her right hand and stated she thought she hurt her right wrist. The nurse assessment indicated the resident required narcotic pain medication after the fall. The resident was transferred to the hospital for evaluation of her painful and swollen wrist. The resident sustained a right wrist fracture from the fall that required wrapping with a soft cast. The IDT post fall review note dated 9/23/22 documented the root cause was self-transferring. Pertinent interventions were to: place a tennis ball on her call light so the resident can find easily secondary to poor eyesight. A nurse practitioner (NP) note dated # 9/22/22 documented the resident had a history of falling, had diagnoses of dementia and poor vision, and the facility should continue fall precautions per facility protocol for fall prevention. Fall #6 A nurse progress note dated 9/28/22 at 8:56 p.m., documented the resident was found lying on her right side on the floor in the hallway. Resident reported that she hit her head. The nurse determined that no injury was sustained. Resident complained of pain that required pain medication. An order was obtained to x-ray the previously fractured wrist. A NP note dated 9/28/22 documented the NP evaluated the resident for a recent fall with wrist fracture and did not indicate a plan for fall prevention. A PA note dated 9/29/22 documented the PA evaluated the resident for a recent fall and recommended the facility continue to follow facility protocol for fall prevention. A social services note dated 9/30/22 at 12:00 p.m., revealed the resident was referred to hospice services. An IDT post fall review note dated 10/3/22 9:20 a.m., indicated: the team reviewed and discussed resident's usual self-care and functional mobility performance as reflected in above evaluation. The note indicated the score was derived from an IDT review and discussion of activities of daily living (ADL) documentation, nursing progress notes, staff observations, nursing assessment/evaluation, and skilled therapy evaluation/notes. The following goals have been identified by the IDT: Resident did not reach her goals. discharged to Hospice services. The Hospice diagnosis: senile degeneration of brain. An IDT post fall review note dated 10/3/22 documented the root cause of the fall was ambulating without assistance and fell . Interventions put into place were to keep the resident in line of sight to prevent falls. Although the IDT note documented the care plan would be updated, it was not. Fall #7 A nurse progress note dated 10/22/22 at 6:30 p.m., documented the nurse responded to a loud noise and resident screaming for help. The resident was found sitting on her floor. Resident complained of excruciating pain to her right hip and tailbone area. The physician ordered to the transfer the resident to the hospital for evaluation. On 10/25/22 at 4:34 p.m., the PA evaluated the resident for a post-fall follow up. It was determined at the emergency department the resident sustained a thoracic spine fracture at the T12 level and it was thought to be chronic because the examination at the emergency department was benign. The IDT post fall review note dated 10/24/22 documented, the resident had a diagnosis of dementia, and was blind. The root cause was self- transferring. -The care plan was not updated after fall #7. A physician noted dated 10/24/22 documented the resident had a fall with injury and the plan was to continue to follow facility protocol. The physician noted the resident was unlikely to rebound from her injuries in sequence and discussed the plan to pursue hospice services. Fall risk assessment A falls assessment was completed following each of the resident's fall's. The assessment evaluated the resident status pertaining to falls within the last six months, medications used, memory and recall ability, vision, continence in the last 14 days, agitation in the last seven days, confinement to a chair, blood pressure, and gait analysis. The post fall assessments revealed the resident was: -On 2/12/22 at moderate risk for falls; -On 5/28/22 at moderate risk for falls; -On 6/15/22 at moderate risk for falls; -On 9/6/22 at moderate risk for falls; -On 9/21/22 at high risk for falls; -On 9/28/22 at high risk for falls; and, -On 10/22/22 at moderate risk for falls. E. Interviews Certified nurse aide (CNA) #13 was interviewed 11/17/22 at 10:50 a.m. The CNA stated the resident had several falls and because of staffing it was not always possible to keep the resident in line of sight due to staffing assignment. The CNA stated the resident would sometimes sit in her wheelchair next to the nurses' desk where the staff could watch the resident. The CNA was not aware of specific interventions for fall prevention except to keep a close watch on the resident so that she did try to stand up without assistance. Licensed practical nurse (LPN) #2 was interviewed 11/17/22 at 12:45 p.m. LPN #2 said that the resident was identified as a fall risk based on her fall history. The LPN said a fall assessment was completed after a fall. When the doctor was notified after a fall the doctor would indicate what action was necessary for the resident. The LPN stated the staff could add what was needed like a fall mat and make sure the call light is in place within residents' reach. The LPN stated that Resident #34 was independent and mobilized throughout the facility when she was admitted to the facility and now she was wheelchair bound. The director of nursing (DON) was interviewed 11/17/22 at 5:30 p.m. The DON said Resident #34 was blind and impulsive, that she was not compliant and had gone downhill in her health. She stated Resident#34 had a right to fall. The facility staff recognized that she was impulsive and relocated the resident to a new room to be close to the nurses' desk where staff could watch her closely by keeping the resident in sight. The DON stated the resident received physical and occupational therapy and the facility staff tried the best they could to prevent the resident falls. 44949 II. Resident #62 A. Facility policy and procedure The Elopements policy and procedure, initiated 2018, was provided by the director of nursing (DON) on 11/17/22 at 6:05 p.m. It read in pertinent part, Staff shall investigate and report all cases of missing residents. When the resident returns to the facility, the director of nursing services or charge nurse shall: complete and file an incident report and document relevant information in the resident's medical record. B. Resident status Resident #62, age 77, was admitted on [DATE]. According to the November 2022 computerized physician orders, diagnoses included paranoid schizophrenia, dementia, and symptoms and signs of cognitive functions and awareness. The 8/4/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. It indicated the resident was independent with activities of daily living. It indicated the resident did not have signs of psychosis, no physical or verbal behaviors, and did not wander. C. Record review The 9/8/22 progress note indicated a nurse found the resident attempting to leave the facility through the front entrance. It indicated the resident said I'm going home and was reluctant to come back inside. The 10/31/22 progress note indicated staff found the resident sitting in the parking lot. It indicated the resident asked for a ride home. The resident was agreeable to come into the facility and the nurse was notified to check on the resident frequently. The nursing home administrator (NHA) provided psychiatrist notes for Resident #62 on 11/17/22 at 1:30 p.m. On 11/8/22 the resident was seen by the psychiatrist and the notes indicated the resident was having delusions that she was going home and people were outside waiting for her. The behavior care plan, revised 5/17/22, indicated Resident #62 experienced delusions where they made her vomit and a history of suicidal ideations. Interventions included performing care when resident was calm, explaining care prior to and during the process of care, involving family as necessary in behavior management, redirection, and reorientation. -There was not a care plan related to wandering or elopement behaviors. -There was no wandering or elopement assessment. The treatment administration record indicated behavior tracking for antipsychotic use as evidenced by distressing delusions. No delusions were indicated for September, October and November 2022. D. Interviews Registered nurse (RN) #2 was interviewed on 11/16/22 at 4:02 p.m. She said Resident #62 did not have behaviors and had no history of elopement. Certified nurse assistant (CNA) #6 was interviewed on 11/17/22 at 10:05 a.m. She said she was not sure if Resident #62 had a history of elopement. RN #3 was interviewed on 11/17/22 at 11:49 a.m. She said Resident #62 stayed in her room a lot and was not an elopement risk. The director of nursing (DON) was interviewed on 11/17/22 at 1:38 p.m. She said Resident #62 had a diagnosis of paranoid schizophrenia and had frequent paranoia. She said the resident preferred to stay in her room but would work with physical therapy. She said the resident had been found outside of the facility a few times and she was confused. She said the events appeared to be isolated and the resident had not attempted to elope again. She said any attempt to leave the facility would require an assessment related to wandering. She said she was unsure if the resident had an assessment completed for wandering or elopement and she was unsure if a WanderGuard was an option for the resident. The social services director (SSD) was interviewed on 11/17/22 at 2:56 p.m. She said Resident #62 experienced distressing delusions. She said there were a few times the resident had left the facility but was easily redirected inside by staff. She said the resident was experiencing a delusion when she left the facility and said she wanted to go home. She said the care plan should be updated to include wandering or elopement behaviors. She said the resident enjoyed sitting outside and was allowed to sit outside if she wanted but should notify the nurse first. 31821 III. Resident #4 A. Resident status Resident #4, age 61, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, diabetes Mellitus, and cerebral palsy. According to the 9/9/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had verbal and physical behaviors directed toward other symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. B. Record review The care plan, initiated 4/11/22 and revised 9/15/22, identified the resident exhibits and reports mood problems related to life circumstances, verbal outbursts towards staff. The resident makes false allegations against staff members. Residents would delay times of shower times and get out of bed. Interventions include offering grievance forms as needed. Monitor for increase in depression, anxiety, and address accordingly. Encourage residents to participate in activities outside of the room, including meals and other social activities. Validate residents' feelings and concerns, as needed. The care plan, initiated 4/11/22 and revised 9/15/22, identified the resident has a physical functioning deficit related to multiple sclerosis (MS). Resident has a left hand splint that is managed by therapy. Interventions include assistive devices for motorized wheelchairs. Inform the resident of risk of refusal of care. Resident required two person assistance for all ADL and transfers. Log note dated 11/7/22 at 3:02 p.m., revealed in pertinent part: Report received that the resident left the building at 9:30 a.m. this morning and did not give a description of where he was going. Resident is currently still not in the building and his cell phone is not going through. Director of nursing (DON), assistant director of nursing (ADON), and nursing home administrator (NHA) notified. Resident was self-responsible. Lakewood police department notified. Log note dated 11/2/22 at 7:03 p.m., revealed in pertinent part: Resident left the building this morning at 9:30 a.m. Medications were administered per physician's order. Resident stated I would be back by 3:00 p.m., it is currently 7:05 p.m., and he is not back yet. DON, and NHA were notified. NHA stated to tell the night nurse to call him if the resident is not back by 8:00 p.m. Written request for missing person investigation for Resident #4 was given to the nursing home administrator on 11/16/22 at 2:07 p.m., and again on 11/16/22 at 4:26 p.m. In addition, a request for Resident #4 sign out sheet, facility off ground assessment, and education for Resident #4's safety of campus. C. Interviews The social services director (SSD) and nursing home administrator (NHA) were interviewed on 11/16/22 at 10:46 a.m. The NHA said Resident #4 was his own person and he could leave the facility as long as he signed out and gave a description of where he was going and when he would return. The SSD said there was no assessment completed for Resident #4, which identified if Resident #4 was safe to go out into the community. The NHA said there was an assessment which assessed the resident's ability to use his power chair indoors but there was not an assessment for residents community use. The SSD said the facility had not received a report on condition of Resident #4 or if Resident #4 would return to the facility. At time of facility exit facility on 11/17/22, documentation was not provided including the resident's sign out sheet, facility off ground assessment and safety education for Resident #4.

Based on observations, record review and interviews, the facility failed to prevent development of pressure ulcers for two (#14 and #101) of four residents reviewed for pressure ulcers of 49 sample residents. Specifically, the facility failed to prevent avoidable pressure ulcers and to provide necessary services to promote healing and prevent new ulcers from developing. The facility failed to obtain physician orders for pressure ulcer prevention, to update the resident's care plan, to implement interventions, and to monitor the effectiveness of interventions for Residents #14 and #101. Due to the facility's failures, Residents #14 developed an unstageable pressure ulcer to her right ischium (the area of skin covering the lower hip bone) that worsened to a Stage 4. Resident #101 developed a deep tissue injury pressure ulcer to his right heel and unstageable pressure ulcer to his coccyx. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 11/21/22, pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (retrieved 11/22/22): Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. Individuals with a medical device are at a high risk of pressure ulcers related to the device. These pressure ulcers often conform to the pattern or shape of the device and develop due to prolonged, unrelieved pressure on the skin, often contributed to by associated moisture around the device, impaired sensation or perfusion and/or local edema, as well as systemic factors. Assessment of skin that is placed at risk due to a medical device is highlighted. II. Facility policy and procedure The facility policy and procedure regarding prevention and care of pressure ulcers was requested on 11/17/22 and was not received. III. Resident #14 A. Resident status Resident #14, age 70, was admitted on [DATE], discharged to the hospital on 10/14/22 and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO) diagnoses included dementia, major depression, lack of coordination, need for assistance with personal care, and muscle wasting. The 10/21/22 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 11 out of 15. The resident was totally dependent on staff to complete activities of daily living including assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for developing pressure injuries; had one unstageable pressure ulcer; and used a pressure reducing device in her wheelchair and was on a turning/repositioning program. B. Observations On 11/14/22 at 10:45 a.m. Resident #14 was asleep in a semi-reclining position in her bed and her legs were folded slightly to her left side. The resident was lying on an alternating air mattress, had a pillow beneath her head, and was covered with bed linens. Resident #14 was interviewed on 11/16/22 at 9:55 a.m. The resident said repositioning was difficult for her because her pressure ulcer was painful. The resident described the ulcer pain as constant and burning and not having relief. The resident said she expected to have some pain because she had a pressure wound. The resident reported she received narcotic pain medication prior to dressing changes which helps reduce her pain during wound care to a tolerable level. On 11/16/22 a continuous observation was made from 9:55 a.m. through 12:20 p.m. During the observation period the resident was awake in her bed and was served her lunch. At 12:20 p.m. the resident was observed in the same position as she was observed at 9:55 a.m., lying in her bed in a semi-reclining position, on her left side. The resident was not offered any repositioning over the two hour period. On 11/17/22 at 9:30 a.m., Resident #14 was observed during a wound care procedure performed by the resident's wound physician. The resident's right ischium pressure wound was covered by whitish yellow slough and necrotic (both dead tissue). The skin surrounding the wound was a purplish color. The wound physician performed surgical debridement to remove some of the dead tissue from the wound. The wound physician said the wound was starting to spread underneath the top layer and edge of the wound and said the skin surrounding the wound appeared to have a fungal rash. The wound physician recommended changes to the resident's wound care, suggesting the skin surrounding the wound be treated with an antifungal barrier cream. The wound care physician said the wound was improved because there was less slough and the size of the wound was decreasing. Resident #14 was interviewed just after wound care and the dressing change Resident #14 said the staff had talked with her in the past and told her how important repositioning was to help heal her wound; the resident said she understood why the staff encouraged her to accept regular repositioning assistance. The resident said she depended on staff for repositioning due to her paralysis, contractures, and multiple sclerosis; and accepted the assistance whether or not she was in pain. C. Record review Resident #14's comprehensive care plan, revised 9/15/22, revealed the resident had a potential for altered skin integrity related to her decreased mobility, multiple sclerosis, paraplegia, dementia and chronic pain. Interventions included: alternating air mattress on bed; assisting the resident to reposition frequently; document any beginning stages of breakdown; notify wound consultant/nurse and MD (medical doctor); follow skin breakdown protocol and take above measures to prevent further breakdown and promote healing. Perform labs and administer medications,as ordered. Observe and report any changes to skin integrity such as discoloration, blisters, open areas, injuries, provide diet as ordered, provide treatments as ordered, and reinforce the importance of mobility, turning, repositioning of pressure ulcers. The Weekly Head to Toe Skin Check Assessments dated 7/20/22, 8/17/22, and 8/25/22 revealed the resident's skin was clean, dry, and intact. A skin check assessment dated [DATE] revealed the resident had a new skin tear to the right buttock that measured 0.3 cm x 0.2 cm. The assessment gave no other details. A skin check assessment document dated 9/13/22 revealed the resident had a small post surgical wound on the right iliac crest (the upper bone of the pelvic region). -There were no skin assessment notes in the resident's chart until 10/6/22. Wound physician assessment dated [DATE], revealed the resident had developed an unstageable pressure wound on her right ischium (the area of skin covering the lower hip bone) due to necrosis (dead tissue). The pressure injury was facility acquired and had been present for at one day. The wound measured 3.2 centimeters (cm) by 4.0 cm by a non measurable depth. The wound was unstable or due to being covered with 100% slough (whitish yellow stringy dead tissue). The wound was cleansed with normal saline and cleaned by surgical technique. The physician removed a depth of 0.2 cm of dead tissue to reveal healthy bleeding tissue was observed. A weekly skin assessment dated [DATE], documented that the resident had developed a wound on the right bottock; there was no description or measurement of the wound. Wound physician note dated 10/13/22, revealed the resident's right ischium pressure wound remained unstageable due to necrotic dead tissue. The wound present seven days measured 3.2 cm by 4.0 cm and was covered with 80% slough and 20 % granulated tissue inflamed tissue with new capillaries. The skin surrounding the wound was macerated (wrinkly, soft and soggy). The resident was admitted to the hospital 10/14/22-10/17/22 for an medical reason unrelated to the resident pressure wounds. A readmission skin assessment completed on 10/17/22 indicated the resident had a right ischium wound that was unstageable and measured 3.2 by 4.0 cm. A description of the wound was not documented. The resident had a surgical incision present on her back where a nephrostomy tube was placed while she was at the hospital. Wound physician note dated 10/20/22, revealed the resident's right ischium pressure wound had deteriorated. The wound remained unstageable and now measured 5.5 cm by 4.5 cm with an unmeasurable depth due to thick adherent necrotic tissue. The wound was present for more than 13 days. The resident had a new unstageable deep tissue injury to the right sacral area (the coccyx - the skin covering the area between the end of the lumbar spine and the tailbone) measuring 3.2 cm by 2.0 cm. The injury was present for one day. Wound physician note dated 10/27/22, revealed the resident's right ischium pressure wound was improving and measured 5.0 cm by 4.0 cm the depth was unmeasurable. The wound remained unstageable with 80% slough and 20 % dermis viable skin. The wound was present for 19 days. The resident's unstageable deep tissue injury to the right sacral area measured 2.0 cm by 1.0 cm. The injury was present for seven days. A weekly skin assessment, dated 11/2/22 documented the resident's right buttock wound had slough and purulent (foul smelling) drainage. The assessment did not document measurements. Wound physician note dated 11/3/22, revealed the resident's right ischium pressure wound stage 4 pressure wound measured 4.0 cm by 3.5 cm the depth was unmeasurable with 80% slough and 20% dermis viable skin. The resident's unstageable deep tissue pressure injury to the right sacral area measured 1.9 cm by 0.8 cm. The injury was present for 13 days. Wound physician note dated 11/10/22, revealed the resident's right ischium pressure wound stage 4 pressure wound measured 3.5 cm by 3.0 cm the depth was unmeasurable with 70% necrotic tissue, 10% granulation and 20% dermis viable skin. The wound was present for 31 days. The resident's unstageable deep tissue pressure injury to the right sacral area measured 1.0 cm by 1.0 cm. The injury was present for 19 days. Wound physician note dated 11/17/22, revealed the resident's right ischium pressure wound stage 4 pressure wound measured 3.2 cm by 2.8 cm the depth was unmeasurable with 60% necrotic, 10% slough, 10% granulation and 20% dermis viable skin. The wound was present for 37 days. The resident's unstageable deep tissue pressure injury to the right sacral area measured 0.5 cm by 0.5 cm. The injury was present for 25 days. The November 2022 CPO revealed the following orders related to wound care: -Cleanse wound on right buttock with wound cleanser apply skin prep to periwound, cover the wound with medi-honey, apply a silver alginate wound dressing (used to prevent or reduce infection), cover with foam dressing one time a day every other day. -Limit the resident's time in her wheelchair to one hour as the resident will allow, start date 10/7/22. -Turn resident frequently throughout the shifts, when in bed, start date 10/7/22. Review of the resident October and November 2022 treatment administration record (TAR) revealed the staff repositioned the resident 21 of 22 opportunities until 10/6/22. On 10/7/22 the order was changed to reposition the resident frequently during each shift. From 10/7/22 to 10/31/22 the TAR indicated the resident was repositioned each shift 42 of 43 opportunities and 11/1/22 to 11/17/22 the TAR indicated the resident was repositioned 27 of 29 opportunities. D. Staff interview Licensed practical nurse (LPN) #2 was interviewed 11/17/22 at 2:55 p.m. LPN #2 said the resident was dependent on staff for repositioning and preferred to be on her left side due to her contractures. The resident was alert and oriented and would sometimes refuse repositioning. The LPN said the resident had not been repositioned that afternoon because she was sleeping and appeared comfortable. The LPN did not want to disturb the residents. The LPN said when caring for a resident with pressure ulcers staff was expected to provide care assistance to provide repositioning and help the resident offload to relieve pressure on vulnerable areas of the body. III. Resident #101 A. Resident status Resident #101, age 89, admitted on [DATE]; discharged to the hospital on 11/6/22; readmitted on [DATE]; discharged to the hospital on 11/14/22; and readmitted on [DATE]. According to the November 2022 CPO diagnoses included type 2 diabetes mellitus, atrial fibrillation, neuropathy, need for assistance with personal care, and dislocation of lumbar vertebra. The 9/28/22 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident required limited assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at low risk for pressure ulcers. B. Observations On 11/14/22, the resident was observed from 9:00 a.m to 11:30 a.m. The resident was laying in bed with the head of the bed up at 30 degrees propped up with a pillow to the left side. The resident had not been repositioned during the observation. On 11/16/22 a continuous observation was made from 10:00 a.m. to 12:20 p.m. The resident was sleeping, lying on his back. His head was on a pillow and he had one heel protector in place on his right foot. The resident had not been repositioned during this continuous observation. C. Record review The Braden Scale assessment dated [DATE], (a tool used to determine a resident's risk for pressure ulcer development), documented Resident #101 was a low risk for developing pressure ulcers. The Weekly Head to Toe skin check on 10/15/22, 10/29/22 and documented the resident had no skin issues. -There were no weekly skin checks for the other weeks since admission on 9/22/22 that were present in the resident chart. The 11/11/22 hospital discharge note revealed the resident had a facility acquired pressure injury related to tissue damage on his right heel and sacrum that were present when the resident was admitted to the hospital on 11/6/22. On 11/11/22 the readmission nurse documented a pressure wound on the residents coccyx and a deep tissue injury on the residents right heel. There were no descriptions or measurements of either wound. Review of resident #101's November 2022 CPO revealed the following physician order: -Coccyx wound care cleanse with wound cleanser, pat dry, apply medi honey and alginate and cover with foam dressing, one time a day, every other day for wound care. The order started on 11/12/22. The comprehensive care plan updated on 11/15/22 identified the resident had a pressure injury. Interventions included to complete the Braden Scale, preform weekly skin inspection, do not massage over bony prominence, float heels, heel boots, nutritional and hydration support, preventative foot care shoes, inserts, pads, provide pressure reducing wheelchair cushion, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream, administer treatments as ordered. Wound physician note dated 11/17/22, revealed the resident was seen for an initial consultation by a wound specialist. The note documented the resident had: -An unstageable deep tissue pressure injury to the right heel. The wound was present for less than two days. The wound measured 4.2 cm by 4.2 cm, the depth was not measurable. -An unstageable pressure injury to the sacrum/coccyx, present for less than two days. The wound measured 11.5 cm by 3.0 cm the depth was not measurable due to the presence of necrotic dead tissue. The skin surrounding the wound was purplish maroon in color. -Recommendations included: wound care and offloading and repositioning for pressure relief. D. Staff interviews The director of nursing (DON) was interviewed on 11/17/22 at 5:30 p.m. The DON said staff were expected to follow facility protocol and physician orders and offload pressure points and assist dependent residents with repositioning in order to promote healing and prevent pressure wounds. The DON stated when a resident refused positioning the nurse should make notes in the record and the physician needs to be notified.

Based on observations, interviews, and record review the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for three (#218, #99 and #73) of three sample residents. Specifically the facility failed to: -Thoroughly assess, timely consult the physician, obtain orders, develop interventions and render treatments for pressure ulcers developed at the facility for Resident #218. The facility's failure contributed to the resident developing an unstageable pressure ulcer to her and one stage four pressure ulcer. Resident #218 was admitted to the facility without pressure injuries. The resident developed a stage III pressure injury to the coccyx while at the facility. The pressure injury was discovered on 7/16/21. The documentation and interviews showed the resident did not have any other skin issues. However, when she was admitted to the hospital on 7/20/21 the hospital diagnosed a right heel unstageable pressure injury. The documentation showed, the resident was seen at the hospital by the emergency room physician within six minutes of arrival. -Furthermore the DON confirmed the nursing staff had not had any training on how to identify and report pressure injuries which was consistent with not identifying pressure injuries as evidenced by Resident #218, # 99 and #73 pressure injuries to the heels; and -Identify a pressure injury for Resident #73 stage II pressure injury to the right heel; and -Identify Resident #99's stage II pressure injury to right heel and stage I to left heel. Findings include: I. Professional reference The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (undated) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Pressure injury prevention points, updated 2016, revealed in part Consider bedfast and chairfast individuals to be at risk for development of pressure injury; Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within eight hours after admission); Use heel offloading devices .on individuals at high risk for heel ulcers. II. Policy The facility policy Skin Assessment Monitoring Guidelines were requested and delivered by the DON on 8/31/21 at 4:36 p.m. The policy states, all residents will be assessed upon admission, quarterly and with a significant change in condition to identify risk factors that may lead to impaired skin integrity. Designated assessment tools will be utilized by the nursing stall to identify residents at risk to ensure consistency and accuracy of collected data. All residents identified at risk will be reviewed by the Interdisciplinary Team to ensure that all efforts to implement preventive measures have been addressed. Purpose: to prevent skin impairment by assessing risk factors in a timely manner; to gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the residents needs; to ensure consistency in implementation of prevention measures to assist with maintaining skin integrity; to evaluate outcomes. III. Facility matrix The facility matrix was received on 8/30/21 from the director of nurses (DON). The facility matrix indicated there was no pressure injuries in the building. The DON was interviewed on 9/2/21 at 3:25 p.m. The DON said that to her knowledge there were no other residents in the building that had pressure injuries. IV. Avoidable pressure injury for Resident #218 1. Resident #218 A. Resident Status Resident #218, age 78, was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with moderately cognitive impairment with a brief interview for mental status score of seven out of 15. She required extensive assistance with one to two persons for ADLs. The care plan revised on 4/9/21 identified that the resident had impaired skin integrity and required turning and positioning every two hours to three hours to prevent skin breakdown. Pertinent interventions included an air mattress, weekly skin checks and reminders to the resident to turn and reposition. B. Development of a pressure injury coccyx The 7/5/21 skin assessment documented the resident did not have any wounds or skin issues, heels- no identifiable skin issues noted. The 7/12/21 skin assessment documented that the resident had no skin issues, heels-no identifiable skin issues noted. The 7/16/21 nurse progress note documented, the resident was seen by the wound clinic. The documentation showed, the resident had a stage III coccyx pressure injury and measured at 3.4 x 6.7 x 0.1 with 60% granulation and 40% epithelial; minimal serosanguinous drainage; periwound [CONDITION(S)], bruised, red. The new order was for the coccyx to be cleaned with wound cleaner, pat dry, skin prep periwound, apply [MEDICATION(S)] to wound bed, cover with foam dressing. Change every day. Power of attorney and primary physician were involved in the plan of care. The 7/16/21 documentation from the wound physician did not identify any other skin issues. The wound nurse was interviewed on 9/3/21 at approximately 12:00 p.m. The wound nurse said Resident #218 was being treated by the wound physician for the coccyx pressure injury stage III. The wound nurse said the resident did not have any wounds on her heels. C. Change of condition The 7/20/21 progress note showed the resident had an increased lethargy and vital signs that had changed slightly from the previous assessment resident was [CONDITION(S)]. The resident was transferred to the emergency room for evaluation. The facility did not have a skin assessment completed prior to the resident leaving for the hospital. The resident arrived at the hospital on 7/20/21 at 5:33 p.m. The registered nurse triaged her at 5:35 p.m., and the emergency room physician exam was at 5:39 p.m. The hospital record progress note dated 7/20/21 documented the resident was admitted to the intensive care unit. The hospital records showed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -septic shock from E. coli urinary tract infection; -obstructing [CONDITION(S)] stones, -acute kidney injury, -acute respiratory failure secondary to sepsis; and -multiple decubitus ulcers on the coccyx, and right posterior shoulder. The ICU notes dated 7/20/21 documented she arrived to the ICU at 8:24 p.m., and it showed she had a stage III coccyx pressure injury, and right heel was unstagable pressure injury. The wound care physician at the hospital was consulted on 7/21/21at 6:41 a.m. for the sacral (coccyx) wound which was staged as a state IV pressure injury with measurements 4 x 5 cm with tunneling that required surgical debridement by plastic surgeon. The right heel was an unstageable pressure injury. D. History of Resident #218 Resident#218 was having increased complications related to [CONDITION(S)] and renal [MEDICATION(S)] which required surgical placement of nephrostomy tubes on 3/19/21. There was resolution of the renal [MEDICATION(S)] however more renal [MEDICATION(S)] developed in April 2021 which required surgery on 4/7/21. Resident#218 returned to the facility and was placed on the interdisciplinary team (IDT) for weekly review for nutritional status tracking due to weight loss. The RD had placed Resident#218 on multiple nutritional supplements for weight loss. Resident#218 had been successfully treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD was interviewed on 9/2/21 at 2:20 p.m., stated that the resident demonstrated the ability to recover from the MASD and they were supplementing her nutritional needs to promote wound healing. E. Failure to identify right heel pressure injury The hospital record progress note dated 7/20/21, showed the resident had an unstageable right heel pressure injury. The facilities records failed to identify the right heel pressure injury. The skin assessments showed that on 3/20/21 the resident was readmitted from an overnight hospital stay for surgical procedure. The nurse skin assessment documentation noted that the resident had very dry heels. There was no further mention or documentation of continued care for the dry heels from 3/20/21 through 7/20/21 when the resident was admitted to the emergency room for a change in condition-lethargy. The electronic medical records do show that skin assessments were being conducted and documented however not on a weekly basis until 4/2/21 when the wound nurse practitioner identified a moisture associated skin damage (MASD) to the left buttock but there was no indication of right heel pressure injury. The care plan revised on 4/9/21 identified the resident was at risk for skin integrity problems and to be turned and positioned every two to three hours. F. Skin assessments The electronic records show that weekly skin assessments were being documented with no changes in skin condition to include the right and left heels. The nurse progress notes document that the resident refused to be turned and positioned multiple times however the interview with LPN #4 stated that the resident would not refuse but would become anxious with the turning and repositioning. On 7/16/21 when the facility wound care physician identified the sacral (coccyx) wound there is no documentation of a right heel injury. G. Nutrition interventions The electronic record shows that the resident was on a care plan related to increasing nutritional needs due to weight loss. The RD had added [MEDICATION(S)] cereal three times a day (TID); Boost pudding twice a day (BID); Breeze nutritional supplement TID; fluids were encouraged in addition to house made shakes (supplemental nutrition) 240 ml TID between meals for hydration. Staff were monitoring the percentage of meal that was eaten by Resident t#218 consumed. H. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 8/31/21 at 2:09 p.m. LPN #4 said Resident #218 used to reside on the hall he worked. He said she was beginning to have a change in condition and she was not as verbal as prior. He said they would reposition her, and she would moan. He said she did not refuse, however, she was more anxious about it. He said she did sit up in her chair and attend meals in the dining room. He said he could not remember if she had any pressure ulcers. She was discharged to the hospital on 7/16/21. Registered dietician (RD) was interviewed on 9/2/21 at 2:20 p.m. The RD said the resident ' s nutritional status intakes were variable 50-75% and sometimes 0-26%. The RD reviewed the medical record and said Resident #218 was hospitalized on [DATE]. She said she did have a weight loss from 139.5 to 134 pounds. At this point she was on weekly weights then started trending down so she was placed on weekly weights. She said she added 750 calories per day the breeze and then house made shake. The RD said the resident was also offered a substantial snack multiple times per day (half a sandwich, cookie with yogurt). The RD said that prior to hospitalization she was treating the resident for a pressure ulcer on her coccyx. She said the resident was consuming the health shakes and she increased protein calories and carbohydrates to promote wound healing. The RD said she was notified of new pressure wounds through weekly rounds, interdisciplinary team (IDT) conferences. In general nutritional supplements were reserved for residents with venous wounds and diabetic ulcers. The amount of pain and pain medications could have led to her early satiety and decreased PO intake but her nutritional needs would remain the same. States that this resident also had chronic constipation. Feels like she gets updates on resident changes in condition both from nurses and her own investigation of the residents records in PCC. If meals are missed and the resident can make their needs known they are able to get a replacement meal or supplement but if they cannot make their needs known then she relies on nursing and ancillary staff to catch this and then provide a meal alternative. The director of nursing (DON) was interviewed on 9/2/21 at 3:25 p.m. The DON said she was aware of Resident #218 coccyx pressure wound and that the wound was discovered on the day that the wound care doctor was rounding on residents. She stated that a new care plan was put into place by the wound care doctor. She was not aware the resident had also an unstageable right heel pressure injury. The DON further stated, that the licensed nurses had not had any training on pressure injuries, since October 2020. She said the staff lacked knowledge on how identify, and report the pressure injuries. 2. Resident #73 A. Resident status Resident #73, age 50, was admitted on [DATE]. According to the August 2021/September 2021 computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/28/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance with one person physical assistance for bed mobility, transfers, and dressing. Limited assistance with one person for walking in the room, locomotion on unit with an electric wheelchair, eating, toilet use, and personal hygiene. Bathing/showering requires physical help limited to transfer only. No behavioral symptoms or rejection of care. The MDS further documented that the resident was at risk of developing pressure ulcers/injuries. No pressure ulcers/injuries at time of admission. B. Resident observation and interview On 9/1/21 at 10:02 a.m., Resident #73 reported he had a right heel blood blister that had popped. He said he got the blister three to four days ago. The resident's right heel had a white bandage at the right heel. Theresident had slippers on both of his feet. The resident said his right heel hurt, and the nurses usually changed the bandage once per day. He said he was mad because he asked them to change the bandage that morning and they said they would do it later. The resident said the blister had developed on 8/28/21 or 8/29/21. On 9/1/21 at 4:26 p.m., the resident ' s right heel was observed with a registered nurse (RN #1). The RN #1 said she was the charge nurse and worked regularly with the resident. She said the resident was not currently seen by the wound clinic. The resident told RN #1 that the pressure injury happened four days ago. The RN #1 did not respond to the answer. After observing the wound RN #1 said there was no drainage as it was intact and they were permitted to use a dry bandage. She said the resident would see the wound physician when it opened up. Resident #73 said it was open, and it drained on his bed last night. He said it was a big blister and it had been draining. RN #1 said the wound physician would be here Friday. RN #1 said she did not know if the wound was reported to the physician. Resident #73 said I told you this morning and you changed my bandage. RN #1 said she should have reported to the physician and wound nurse right away. RN #1 said she had not done an assessment beyond looking at it. On 9/3/21 at 7:28 a.m., the resident ' s heel was observed with the wound care nurse practitioner specialist (WCN). The resident ' s heel was laying directly on the bed. The WCN removed the dressing from his right heel. The dressing was wet, and the heel wound was macerated. The WCN measured the wound and said it was 8 X 10 X 0. She said the pressure injury was a stage II. The WCN painted it with [MEDICATION(S)]. The WCN gave the order to keep a dry dressing on the pressure wound. She also said to order [NAME] boots (pressure relieving boots). While the WCN was cleaning the wound, the resident said it hurt and grimaced his face. The WCN asked the resident if he moved his foot in bed a lot, the Resident #73 said yes, and the WCN said that was probably how he got the pressure wound. On 9/5/21 at 10:43 a.m., the resident was sitting in his electric wheelchair in the common area. The resident ' s right heel was sitting directly on the foot rest on an incontinence pad. The resident said they had not received the pressure relief boots as of yet. On 9/6/21 at 9:58 a.m., the resident was observed to have his right heel directly on the foot rest. The resident said he was only offered to offload his heel while in bed. He said they continue to not have the pressure relief boots as of yet. On 9/7/21 at 9:30 a.m., the resident was observed sitting in his eclectic wheelchair. Observed the resident ' s right foot bandage, it was marked 9/7/21. There was a drainage pad on the foot rest under his foot, but no pressure relief boot or heel offloading was observed. C. Record review Review of the August/September 2021 computerized physician orders revealed there were no physician orders for wound care to the resident ' s right heel. The August and September 2021medication administration records (MAR) and treatment administration records (TAR) revealed no wound care orders. The care plan dated 8/15/2021 failed to identify that the resident was at risk for a pressure injury, therefore there was no plan in place. The weekly head-to-toe skin assessment dated [DATE] at 8:10 p.m., revealed there was no documentation of a heel blister. It specifically documented that the heel was intact with no blister. Resident #73 said the heel blister had developed on 8/28/21 or 8/29/21. Review of progress notes dated from 8/27/21 to 9/1/21 revealed no documentation of a heel blister in the progress notes. After the pressure injury was brought to the nurse's attention, progress notes revealed the first documentation on the wound/blister was on 9/1/21 at 4:42 p.m. It read, Nurses note: Right heel blister: dressing changed twice this shift, second time, colorless fluids dripping on the floor with no noted odor upon opening old dressing, skin still there. Right heel was cleaned with a wound cleanser, pat dry then dry dressing was applied. No sign of facial grimacing noted. Resident appeared comfortable with the procedure. D. Staff interviews RN #2 was interviewed on 9/1/21 at 4:46 p.m. She said she could not recall Resident #73 being added to the wound care list, she looked up on the computer record and confirmed that he had not been. She said she had not received any report of a skin issue or wound on his heel. She said if he had a big blister on his heel that the nurse staff should notify her and his physician right away. The RD was interviewed on 9/2/21 at 2:20 p.m. She said she was informed about wounds at morning meetings, looking at the wound log, 24 hour report, and from the wound physician/nurse rounding once per week. She said the pressure injuries were staged by the wound care physician. She said she was not currently addressing Resident #73 ' s skin issue because it was a blister, and she had not been made aware of prior to yesterday. She said they use protein for wound healing, and nutritional supplements are mainly used for pressure wounds. The DON was interviewed on 9/2/21 at 3:09 p.m. The DON said she first heard about Resident #73 ' s right heel wound/blister yesterday. She said she trained her staff to do a skin assessment, document in the risk management system and notify the physician. She said the risk management system included measuring the wound, alert charting to check for redness/infection, and follow up with the wound. She said we would notify RN #2 (wound nurse) through texting her, or writing on a paper wound log. She said she had not seen Resident #73 ' s wound/blister yet. She said they did an interdisciplinary team (IDT) meeting today and Resident #73 was observed rubbing his right foot on the power chair. She said he either wears socks or slippers. The DON said at this point he was not putting on a lot of pressure because of how he was reclined in his electric wheelchair, so they were not off-loading his heel. The DON said she wished she knew where the system failed when it was not reported when it first occurred. She said her staff had been educated ad nauseam. She said she gave the staff an example of how notes should look. She said at this point it was going to have to be a weekly education. She said the nurses should be documenting each shift about wounds/blisters. The DON acknowledged that Resident #73 had a wound/blister for four days and the nurses were treating it with a dry dressing but it had not been assessed or documented. The DON acknowledged the failure to identify wounds, or pressure injuries, whether stage one or worse. She said it was concerning to her also. 3. Resident #99 A. Resident status Resident #99, age 70, was admitted on [DATE]. According to the September 2021 computerized physician orders (CPOs), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/30/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. The resident required extensive, two person assist, for activities of daily living. It indicated the resident was at risk of developing pressure injuries. B. Resident interview Resident #99 was interviewed on 8/30/21 at 2:59 p.m. She said she had a broken back and preferred to stay in bed. She said her back itched frequently and the staff applied cream to it regularly. She said she was supposed to wear boots on her feet but that staff did not put them on her. She was not wearing the boots at the time. C. Observations On 9/1/21 at 9:35 a.m., care for Resident #99 was observed. Certified nurse aide (CNA) #1 and CNA #12 brought in a hoyer lift, sling, and a shower chair to initiate a transfer. The CNAs rolled Resident #99 onto her side and her back was observed with a white tint due to barrier cream previously applied. A dark purple circular spot, approximately two centimeters in diameter was observed on her right heel. The right heel was not being floated nor had a pressure relieving boot on either foot. D. Staff interviews Licenced practical nurse (LPN) #2 was interviewed on 8/31/21 at 1:48 p.m. She said there were no pressure injuries on the hallway. She said skin checks were completed at admission and then weekly. She said a risk management assessment was completed should any skin issues be observed. Staff development coordinator (SDC) was interviewed on 8/31/21 at 3:45 p.m. She said she had not provided any recent training on pressure injuries. She said she went over all the different types of assessments with the nurses upon hire LPN #2 was interviewed on 9/1/21 at 4:17 p.m. She said Resident #99 had a pressure-like injury on her heel that was healing and the wound nurse was notified when the wound was first identified. She said it was a blister and it had now popped. She said the resident should have boots on in bed to prevent an injury. She said the resident refuses care frequently and has her own preference for positioning in bed. Registered nurse (RN) #2 (facility wound nurse) was interviewed on 9/1/21 at 4:46 p.m. RN #2 said she was the facility ' s wound care nurse. She said when a skin issue was observed, she was notified or the director of nursing (DON) was notified. She said the nurse would write a note as well. She said if a wound or skin issue was not brought to her attention, she would not know about the wound. She said she was not aware of a wound for Resident #99. The DON was interviewed on 9/2/21 at 3:09 p.m. She said she was not aware of Resident #99 having a wound on heel. She said according to documentation, an interdisciplinary team meeting was conducted on 8/3/21 regarding a new skin issue for Resident #99 on the right heel. She said risk management was done and a palliative consult was offered but the resident declined the consult. She said a border gauze was applied on 8/3/21 to the right heel, but that it was not an order. She said the nurse should have obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Although the facility had identified the right heel pressure injury on 8/3/21, the facility failed to obtain physician order, and failed to continue to treat the pressure injury. The resident was not referred to the wound clinic for further treatment. D. Record review The skin care plan was last updated on 5/14/2020, identified Resident #99 had the potential for altered skin integrity related to decreased mobility, pain, and incontinence. It indicated the therapy department had offered different pressure relieving equipment with resident refusing. A weekly skin assessment was completed on 8/3/2. It indicated redness on the right heel. A nursing progress note was completed on 8/3/21. It indicated a foam border gauze applied to the right heel. It noted the DON and the physician were notified. An interdisciplinary team progress note was completed on 8/4/21. It indicated Resident #99 had a blister on right heel. It noted a palliative consult would be offered. A nursing progress note was completed on 8/4/21. It indicated a possible pressure wound on the right heel. No treatments noted. A nursing progress note was completed on 8/5/21. It noted redness was observed on heels. It indicated resident refused to float heels. A nursing progress note was completed on 8/6/21. It noted redness was observed on heels. It indicated the resident refused to float heels and was uncooperative with repositioning. A nursing progress note was completed on 8/7/21. It noted the resident was cooperative with skin treatment and allowed heels to be floated. The weekly skin assessment from 8/10/21 indicated a blister-like area on the right heel. The note indicated the wound nurse was notified. The weekly skin assessment from 8/17/21 indicated the blister on the right heel popped. The note indicated the skin was not torn and there were no signs of infection. The weekly skin assessment from 8/24/21 indicated blister on the right heel. The weekly skin assessment from 8/31/21 indicated a blister on the right heel and that it was healing progressively. The resident had no physician orders for wound care to the heel. E. Wound care observation Wound care rounds were observed on 9/3/21 at 7:40 a.m. Wound care was completed by RN #2 and the wound care nurse practitioner (WCN). Resident #99 was observed in bed with a boot on her right foot. WCN removed the boot. WCN said she observed a two inch by one and a half inch deep tissue injury on right foot and she staged it as a stage II pressure injury. She treated the wound and ordered daily wound care. She then lifted the resident ' s left foot. Resident #99 cried out in pain. WCN said she observed a red spot on the left malleolus. She said it was a stage I pressure injury. She asked RN #2 to order an air mattress and have an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on staff interviews, observation and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVD-19) and other communicable diseases and infections. The facility failed to ensure they had a trained infection preventionist to effectively implement an adequate infection control program for the facility. This failure to have an effective infection control program contributed to the facility failing to identify their outbreak status based on county positivity rates and did not test staff accordingly. Furthermore, the facility failed to ensure staff were educated on policies and procedures of infection control. Moreover, the facility failed to have a thorough screening process in place to identify employees with symptoms or around those with COVID-19 symptoms. The failure to provide training and the lack of a through screening process when entering the facility, allowed an employee and her minor child entry into the facility on [DATE] while the minor child had been instructed by her local county health department to quarantine at home due to her exposure to a fell ow student who had tested positive for COVID-19. The facility did not prevent the employee and her minor child from being in resident care areas while in the facility to be tested for COVID-19 and the test results were pending for the employee who had a COVID-19 test on 12/30/2020. The employee was identified as being COVID-19 positive on 1/7/21 on 12/30/2020 test but had tested negative on 1/4/21. Due to the facility's failures, it created the likelihood of immediate and serious adverse outcomes for all of the residents in the facility, who were identified as high risk, from contracting COVID-19. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 1/7/21 at approximately 2:00 p.m., it was identified that six of the 14 certified nurse aides working in the facility that day had failed to complete their required COVID-19 testing prior to working with residents. Additionally, on 1/4/21, the human resource director (HR) and her minor child (nine years old) were allowed entrance to the facility after being screened for signs and symptoms and potential exposure to COVID-19. The minor child parent had been instructed by the local health department to quarantine at home due to exposure at school to a fell ow student, who had tested positive for COVID-19. Due to the minor child and HR's exposure to COVID-19, the facility should have been thoroughly screened by a staff member, to determine if they posed a health risk to the residents in the facility. On 1/7/2021 at 6:55 p.m. the nursing home administrator (NHA) and the interim director of nursing (DON) #2 were notified that the failures above created an immediate jeopardy situation that placed all of the residents in the facility at risk for serious harm (COVID-19). B. Facility plan to remove immediate jeopardy On 1/11/21 at 7:36 p.m. the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Immediate corrections implemented for removal of immediate jeopardy. -Director of Nursing/designee conducted COVID-19 rapid [MEDICATION NAME] testing and (will follow up with PCR (polymerase chain reaction test) to all staff currently working to validate current COVID-19 active status. All employees tested negative. -Director of Nursing/designee validated availability of testings supplies required to test all staff and all employees. -Director of Nursing/designee completed testing for all residents. Results pending. -Director of Nursing/designee completed all employees who meet testing criteria prior to next work shift. -Director of Nursing/designee reviewed and replaced the current screening tool with a screening tool that captured all required elements including applicable COVID-19 signs and symptoms. -Director of Nursing/designee provided training to everyone who is responsible for screening and validated comprehension as evidence by return demonstration. Identification of other affected: All resident(s) and staff have the potential to be affected. -Corporate RN (registered nurse) consultants conducted a review of all resident's routine monitoring for signs and symptoms of COVID-19 for the last 72 hours to validate residents are free of COVID-19 symptoms and if symptoms were present other etiologies were noted, being treated ie; sinus infection, etc. -Corporate RN consultant and Director of Nursing/designee implemented and trained on new screening tool, added question have you been tested twice this week to validate all employees are free of symptoms and are being tested per County positivity rate and CDC guidelines. Systemic changes and/or measures: -The facility will develop and implement an effective Infection Control Plan by 1/11(2021). -The Corporate RN Consultant/designee will provide training to all staff on s/s (signs and symptoms) of COVID and what to do. -The Corporate RN Consultant created education plans and educated Director of Nursing/designee to provide training with staff responsible for coordinating testing, documenting, and tracking testing understands the process that includes the use of an employee roster to assist with tracking staff who are illegible (sic) to work or may need follow up testing. Education also included rounding the facility on the day of testing to remind staff that they need to test. Training completed 1/8 (2021). -The Corporate RN Consultant provided training and material to Director of Nursing/designed to complete training to staff responsible for screening on new screening tool. Completed 1/8 (2021) -The Corporate RN Consultant educated Administrator on requirement to keep an accurate and updated, staff/vendor/provider roster/list. Completed 1/11 (2021). -The facility has designated Infection Preventionist, the Interim DON, that will participate in the Quality Assurance Process by 1/11 (2021). -All education and training was started on 1/7 (2021) and will continue until all staff have received training prior to the start of their work shift. Tracking and monitoring: -The Corporate RN Consultant/Designee will review COVID-19 Employee Roster after scheduled testing dates to validate that testing has occurred and if employees have missed testing they will have a rapid testing prior to their next shift. -The Corporate RN Consultant/designee will validate testing schedule, times etc. ls posted through-out the facility 3 times a week. -The Corporate RN Consultant/designee will conduct observation and screening document review daily. -The Corporate RN Consultant/designee will identify infections at time of test results are reported and results will be documented on the facility line listing report. -Any trends or concerns were/will be addressed with Quality Assurance Performance Committee. C. Removal of immediate jeopardy On 1/11/21 at 7:36 p.m. the NHA and the senior corporate consultant (SCC) were informed the immediate jeopardy had been abated, based on the facility's implementation of the above plan. However, deficient practice remained at F level that was widespread with the potential for more than minimal harm. II. Failure to thoroughly screen employees A. Professional reference According to the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, last revised 12/14/2020, retrieved on 1/14/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part: Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection and ensure they are [MEDICATION NAME] source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature =100.0°F or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with [DIAGNOSES REDACTED]-CoV-2 infection. B. Facility policy and procedure The COVID Pandemic Plan, undated, was provided by the NHA on 1/7/2021 at 4:00 p.m., and documented the following: Certain phases of a pandemic alert should include specific precautions: -When a [MEDICAL CONDITION] such as COVID-19 is increasing and sustaining human to human spread in the United States and cases are occurring in the facilities state: -All prospective residents and employees will be screened to identify exposure to COVID-19. Monitoring for common COVID-19 symptoms (fever, respiratory symptoms, sore throat, body aches etc.) will be implemented. -Residents, employees, contract employees, vendors and visitors will be screened and evaluated prior to entry for symptoms and exposure risk. C. Observations and interviews On 1/6/21 at 9:30 a.m. three surveyors answered yes to being in a COVID-19 building within the last 24 hours.The receptionists, who were the screeners of the facility, allowed the three surveyors in the building with no follow-up on the yes answer indicated on the questionnaire. The receptionist, who was the screener, was interviewed on 1/7/21 at 10:30 a.m. She said she did call the DON or the NHA when someone answered yes to a question on the screening form. She wrote a note on the back of the form to explain why someone answered yes to the questions. She said after hours, the staff screened themselves at the nurses station. The staff development coordinator/infection preventionist (SDC/IP) #1 was interviewed on 1/6/21 at 5:05 p.m. She said she had not looked at the screening forms of any employees or visitors after they were screened. She was not aware of any staff answering yes to the screening questions. D. Administrative interviews The interim director of nursing (IDON) #2 was interviewed on 1/8/2021 at 11:00 a.m. She said she had trained the front desk staff/receptionist who were responsible for screening staff and visitors. She said she had updated the screening form, as well as the process for screening, and anytime there is a yes response or concern on the screening form, the front desk was to notify the clinical manager on duty, so they could complete the screening and determine if the staff member or visitor should be allowed into the facility. The human resource director (HR) was interviewed on 1/12/2021 at 1:27 p.m. She said she had been informed by her minor child's school of her child's exposure to COVID-19. The HR director said her child was told she needed to quarantine at home and said she was working remotely so she could care for her. The HR director said she called the nursing home administrator on 1/4/21 to see if she and her child could come into the facility for the weekly COVID-19 testing. The HR director said if her daughter had a negative test result she would have been allowed to return to school, and the HR director would be able to return to work in the facility. The HR director said she and her daughter entered the facility on 1/4/21 and were both screened by the receptionist prior to entering the facility. The HR director said she wore a KN95 mask and her daughter wore a cloth mask. She said they walked through the facility to the staff development coordinators/infection preventionists (SDC/IP) #1 and #2's office for testing. The HR director said her daughter watched her get the nasal swab COVID-19 test, and the daughter was uncomfortable getting the test done with the SDC/IP. The HR director said she and her daughter walked back through the facility to the front of the building, where her office was located, and the HR director completed the test for her daughter. They both walked through the facility again to return the test tubes to the IP, walked back through the facility and exited the building. The HR director stated when she had spoken with the NHA she had asked if she and her daughter needed to stay outside for testing, the NHA told her since they had no signs or symptoms of COVID-19, they were fine to come into the facility for testing. The HR director said on 1/7/21 she had received a text notification from the lab, who ran the COVID-19 test, that she had tested positive on her 12/30/2020 test and negative on her 1/4/21 COVID-19 test. She said she was in contact with her local health department, who advised her, she needed to isolate at home until 1/9/21. The NHA, interim director of nursing (IDON) #3, and senior corporate consultant (SCC) were interviewed on 1/12/21 at approximately 4:30 p.m. The NHA said he did advise the HR director and her child to come to the facility for testing on 1/4/21. He said he was unaware of the HR director testing her daughter in her office, but he was aware they had both been in the facility including in resident care areas. The SCC said she was unaware the daughter had been screened and allowed access into the facility. She said she was unsure if the child should have been allowed to be tested for COVID-19 by the facility. The IDON #3 said she would not want a child, who was on quarantine, walking through the building for a COVID-19 test. E. Record review Record review of the Screening Checklist forms dated 1/1/21 to 1/7/21, provided by the nursing home administrator (NHA), revealed the screening checklist read in pertinent part: If answered yes to any of the above questions the employee or visitor will need to talk to the director of nurse (DON)/nursing home administrator (NHA) or Designee before proceeding to work. The screening forms reviewed from 1/1/21 to 1/7/21 had the facility staff or visitors' first name on the back of the form with a check mark that allowed entry into the building. The front of the form had one check mark for fever with the temperature listed. There were no other questions marked with a yes or no on the screening forms which were to be answered as part of the facility's screening process. III. Failure to test according to county positivity rates A. Professional reference The Centers for Disease Control and Prevention, (updated 12/14/2020) Interim Guidance on Testing Healthcare Personnel for [DIAGNOSES REDACTED]-CoV-2, retrieved on 1/20/21 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-healthcare-personnel.html, This document provides a summary of considerations and current Centers for Disease Control and Prevention (CDC) recommendations regarding testing healthcare personnel (HCP) for [DIAGNOSES REDACTED]-CoV-2 . The CDC recommendations for [DIAGNOSES REDACTED]-CoV-2 testing have been developed based on what is currently known about COVID-19 and are subject to change as additional information becomes available. Testing of HCP can be considered in four situations: -Testing HCP with signs or symptoms consistent with COVID-19; -Testing asymptomatic HCP with known or suspected exposure to [DIAGNOSES REDACTED]-CoV-2; -Testing asymptomatic HCP without known or suspected exposure to [DIAGNOSES REDACTED]-CoV-2 for early identification in special settings (e.g., nursing homes); and, -Testing HCP who have been diagnosed with [REDACTED]. B. Facility policy and procedure The Pandemic-COVID-19 Testing-Employees policy and procedure, dated quarter three 2020, was provided by the NHA on 1/7/21 at 4:00 p.m. and documented the following: Routine testing: testing all staff based on the extent of [MEDICAL CONDITION] in the community, using CMS ' (Centers for Medicare and Medicaid Services) published county positivity rate in the prior week as the trigger for staff testing. If outbreak testing has been triggered and a staff member refuses testing, the staff member will be restricted from the building until the procedures for outbreak testing have been completed. C. Staff interviews The SDC/IP #1 and #2 were interviewed on 1/7/21 at 11:30 a.m. They both said the current county positivity rate required the facility to conduct testing twice weekly. They said the facility currently tested employees on Monday and Thursday. They said when it was a testing day for the facility, they did not have a system in place to ensure all staff, including agency staff were tested the required twice weekly prior to working their shifts. -Cross-reference F886 the facility failed to ensure all staff were tested for COVID-19 using their county positivity rates. SDC/IP #2 said she had worked with the HR director on getting an updated and correct staff list, but to date she did not have a current staff list. The SDC said she was unsure if all of the staff work. SDC/IP #2 said she would need to review the schedule with test results from the lab to determine who had been tested as required (twice weekly). The SDC/IP said she did not track other departments employees to determine if they were following the testing schedule. She said she knew not all the staff were being tested accordingly because on 1/4/21, 72 staff members were tested and on 1/7/21 approximately 65 staff had been tested , and according to her employee roster there were over 100 employees. The SDC/IP #2 was interviewed a second time on 1/7/21 at 2:43 p.m., after she had reviewed the schedule to determine if all the staff working had been tested twice weekly as required. The SDC/IP said six of the 14 certified nurse aides (CNAs) working on 1/7/21 had not been tested accordingly. She said: -One CNA last tested on [DATE], missing nine COVID-19 tests; and -Two CNAs had last tested on [DATE], missing four COVID-19 tests; and, -Three CNAs had last tested on [DATE], missing two COVID-19 tests. The SDC/IP said there was one nurse working who had no documentation of ever being tested for COVID-19. The SDC/IP said she was new to the facility and did not know many staff members were in the kitchen, laundry, housekeeping, maintenance, or therapy departments. She said she did not have any of those department schedules and was unsure if those staff members were being tested twice weekly. Licensed practical nurse (LPN) #3 was interviewed on 1/7/21 at 11:42 a.m She said she was tested for COVID-19 one time a week instead of two times a week as mandated because she was not able to get to the facility. The dietary manager (DM) was interviewed on 1/7/21 at 2:50 p.m. He said he thought all of the dietary staff had been getting tested twice weekly for COVID-19, but he was not given any type of notification if staff had or had not been tested . He said he verbally reminded all of the dietary staff to get tested if they were working on a testing day. The NHA was interviewed on 1/7/21 at approximately 4:00 p.m. He said the SDC/IP #2 had spoken with him regarding the concerns with not all staff getting tested as required. He said he was not sure if it had been resolved, and was unsure what the facility policy was if staff were not getting tested as required. The interim director of nursing (IDON) #2 was interviewed on 1/8/21 at 11:00 a.m. She said all of the staff who were working in the facility had been rapid COVID-19 tested prior to working their shift. She said the testing that was completed on 1/7/21 had come back and a night nurse had tested positive for COVID-19, so the facility currently had two positive staff members. She said the facility was in the process of testing all of the residents for COVID-19. The HR director was interviewed on 1/12/21 at 3:55 p.m. She said that there had been some issues with staff clocking in and out of work. She said she had asked for backup information to ensure time clocks were accurate, or if corrections had been made. She said that the facility needed to have a daily account of who was at the facility each day, and who was not. She said that in order to find out if some staff had worked or not, she often had to look at resident records to see if the staff member had charted that day. She said that they had recently identified that there was a need to add additional information about COVID-19 testing and signs and symptoms to the new employee orientation. C. Record review On 1/7/21 the nursing schedule was reviewed at 11:45 a.m. It revealed six CNA staff members and one nurse on the schedule were listed as not being tested on [DATE] for COVID-19. On 1/7/21 at 3:00 p.m. the weekly (1/4/21 through 1/10/21) dietary schedule was reviewed. It revealed six of the 15 kitchen staff employees had not been tested , as required, on 1/4/21 for COVID-19. On 1/7/2021 at 3:40 p.m. the maintenance/kitchen and laundry schedule was reviewed. Only first names were listed on schedule. The schedule was reviewed with the SDC/IP #2, she said she did not know any of the staff on the schedule, and was unsure if or when the last time they had been tested for COVID-19. -The environmental services director (ESD) was not available to review the schedule to determine when her staff had last been tested for COVID-19. IV. Failure to have a trained infection preventionist who failed to implement the facility infection control policy and procedure related to COVID-19 A. Professional reference The Centers for Disease Control and Prevention (updated 11/20/2020, Preparing for COVID-19 in Nursing Homes, retrieved on 1/25/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. It read in pertinent part, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens, including [MEDICAL CONDITION]. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Facilities should assign at least one individual with training in IPC to provide on-site management of their COVID-19 prevention and response activities because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of HCP, and auditing adherence to recommended IPC practices. B. Facility policies and procedures The Infection Preventionist policy and procedure, last revised April 2007, was provided by the SCC on 1/12/21 at 12:56 p.m. and documented the following: The infection preventionist is responsible for coordinating the implementation and updating our established infection prevention and control policies and procedures. The Infection Prevention and Control Program policy and and procedure, undated, was provided by the SCC on 1/12/21 at 12:56 p.m. and documented the following: -The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. -The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. C. Staff interviews SDC/IP #1 and #2 were interviewed on 1/5/21 at 11:45 a.m. They both said they had worked in the facility for a short time, less than six months, and had very little training regarding the facilities policies and procedures for infection prevention. -Cross-reference F882 the facility failed to have a trained infection preventionist who attended the quality assurance meetings on a regular basis. SDC/IP #1 said she had completed the CDC (Center of Disease Control) infection preventionist program, but it was prior to COVID-19. She said the facility offered little to no guidance, and she was doing several roles in the facility including scheduling and staffing. She said she did not have the time to complete all of the SDC and IP duties, so she asked SDC/IP #2 to assist her. SDC/IP #2 said she had not completed any infection preventionist training, and had only received minimal training from the facility mostly about keeping the infection log books. SDC/IP #2 said she and SDC/IP #1 were frequently required to work as floor nurses during the overnight shift (6:00 p.m. to 6:00 a.m.), because they were both registered nurses (RN) and there were not enough nurses in the building (cross-reference F725 for sufficient nursing staff). SDC/IP #1 said she was in charge of the scheduling, and staffing in addition to her role as the SDC/IP. She said she would work as floor nurse several times a week, and that she had very little time to do her job as the SDC/IP. SDC/IP #2 said the facility had been without a director of nursing (DON) since 12/14/2020 , and there was very little clinical oversight in the facility. She said she had brought the concerns to the NHA, but there was no follow up to any of her concerns. SDC/IP #2 was interviewed a second time 1/7/21 at 11:30 a.m. She said she notified the NHA, in December 2020, of her concern about not having an accurate employee roster, and her concern that not all staff were following the testing schedule of two times per week. She said at the end of December she and the HR director went over the most recent employee roster, but it was still incorrect, and had employees who were no longer working on the list. The SDC/IP#2 said she and SDC/IP had done some training with staff regarding donning (putting on) and doffing (removing) PPE (personal protective equipment), but they had not completed any additional training with staff. The SDC/IP said she thought the facility had COVID-19 policies and procedures in a binder, but those were located in the NHA's office and she had not reviewed them. D. Facility plan moving forward The NHA, IDON #3, SCC were interviewed on 1/12/21 at approximately 4:30 p.m. The NHA said the facility was in the process of ensuring they had an accurate staff list for all of the departments. The NHA said they were coming up with a procedure to notify all of the managers of any of their staff who had not completed the required COVID-19 testing, to ensure they were removed from the schedule. The SCC said the new screening process was in place, and anytime a screener had a concern or question regarding screening, they were to call a nurse manager or licensed nurse to assess the staff or visitor. The SCC said the facility had access to the corporate infection control policy and procedures, and those were going to be used moving forward. The SCC said IDON #3, would be responsible for the SDC/IP role until the position was filled, but they had an offer in place, and planned to fill the position within the next week. V. Staff wore and stored contaminated PPE appropriately On 1/10/21 at 2:15 p.m. the NHA entered from the administrative hallway, into the facility front lobby wearing an N95 mask and regular eyeglasses. An employee entered the facility lobby from the outside, wearing only a surgical mask, at the same time. The employee doffed the surgical mask, placed a new one on, and then stored the previous mask. After screening, the employee passed by the NHA, and headed towards the resident areas. The NHA said that staff were educated to come into the facility with a surgical mask (car mask), then switch it out to one of the masks in the lobby donning area. He said staff would wear an N95 mask if they were working on the isolation unit, and surgical masks for the rest of the facility. He said that all staff would be required to wear eye protection. From 3:10 p.m. to 4:30 p.m. observations revealed: -A third party vendor was observed walking down the administrative hallway, towards the facility exit. He was pulling his phlebotomy equipment behind him, and was wearing a face shield, an N95 mask, and a disposable gown. The interim director of nursing (IDON) #3, stopped the individual and asked where in the facility he had been working in. He said he had been working on the secured unit. He said his education on how to wear his personal protective equipment (PPE) was provided by his employer. He said he had not doffed his gown prior to leaving the secured unit, and stated he did not understand why he should not be wearing his gown throughout the facility. The IDON #3 told him that he needed to doff his gown prior to entering a common area. -An uncovered PPE doffing bin was observed by the front door to the facility. Inside the doffing bin was a loose discarded KN95 mask. The NHA and IDON #3 observed this, and stated it should not have been there. On 1/11/21 at 10:20 a.m. an uncovered and unidentified box was observed in the front lobby. Inside it was a face shield. The NHA said that it should not have been placed there, and the box was going to be removed from the lobby. The staff development coordinator/infection preventionist (SDC/IP) #2 was interviewed on 1/11/21 at 12:30 p.m. She said that she had not been included in the infection control process in the facility before, during, or after the COVID-19 outbreak. She said she had not been included in any discussions to place isolation carts throughout the facility, or to set up donning and doffing stations at the front entrance to the facility. She was not included in the staff education of PPE donning or doffing, or isolation cart placement. VI. Facility COVID-19 status As of 1/12/21 at 10:58 am the facility had completed 161 COVID-19 tests for residents (who had previously tested negative for COVID-19) and staff. Ninety-three had been returned and were negative and 68 tests were still pending. Two staff members were currently COVID-19 positive from previous COVID-19 tests, and no residents were identified as COVID-19 positive.

Based on observations, record review and staff interviews, the facility failed to ensure the facility was as free of accident hazards as possible, affecting the safety of 29 (#31 - #59) residents in the secured unit (wing 5) as well as two (#21 and #25) residents in the nonsecured unit and including residents residing on the 200 hall/Longs Peak. Specifically: Observations on 6/26/18 revealed the secured unit courtyard gate, identified on the facility map as an emergency exit for residents residing in the secured unit (wing 5), was locked with a combination padlock. Interviews revealed staff did not know the combination to unlock the padlock. Review of the facility's Emergency Preparedness Manual revealed the combination was not recorded there and further review of the manual revealed it lacked detailed, written plan and procedures directing staff in the secured unit how to respond in emergencies involving evacuation, fire and other disasters. Staff's lack of knowledge on how to unlock the courtyard gate in the event of an emergency, as well as the lack of detailed, written plans and procedures on emergency procedures created a situation of immediate jeopardy with potential for serious harm at a pattern to the residents residing on the secured unit. Additional observations revealed other accident hazards. Resident #21 and Resident #25 were at risk for injury from smoking and untemped microwaved food, respectively. And, residents' access to an emergency exit on the 200 hall/Longs Peak was obstructed by equipment. Findings include: I. Lack of knowledge to egress the secured unit courtyard and lack of of plans on emergency procedures creating a situation of immediate jeopardy A. Imposition of immediate jeopardy On 6/26/18 at 1:08 p.m., the nursing home administrator (NHA) was informed the locked courtyard gate and staff's lack of knowledge of the codes to unlock the gate, as well as the facility's failure to have detailed written emergency and disaster plans directing staff how to respond in emergencies, created a situation of immediate jeopardy with widespread potential for serious harm to the residents residing on the secured unit. B. Facility response to immediate jeopardy On 6/26/18 at 5:05 p.m., the following abatement plan (draft #3) was submitted by the NHA to the Colorado Department of Public Health and Environment (CDPHE) to remove the immediate jeopardy situation. The abatement plan read: On (MONTH) 26, (YEAR) at 1:26 PM a staff member was assigned to the gate to ensure that in the event of an emergency on wing 5 everyone can get out of the gated area away from the building. The staff member will remain in place until the IDT (interdisciplinary) team determines that the staff on unit 5 have been educated and can operate the lock in the event of an emergency. Plan is to educate all staff on unit for evening and night shift so the staff member will be able to leave. On (MONTH) 26, (YEAR) at approximately 2:00 PM we updated all disaster manuals to include codes for each entrance/exit in building. On (MONTH) 26, (YEAR) approximately 5:00 PM all maps and directions for exits were updated in disaster manuals. On (MONTH) 26, (YEAR) at 2:00 PM we purchased a new lock for the gait (sic) that is easier to use. On (MONTH) 26, (YEAR) at 2:00 PM we posted a sticker on the lock so that code is available to all staff in the event of an emergency. On (MONTH) 26, (YEAR) at 2:00 PM we created laminated signs with the code to be placed next to the wing 5 door so that it is available to staff in the event of an emergency and placed another sign on the fence outside of wing 5. Maintenance Director or designee will complete daily checks of all exit doors/gates to ensure they are up to code and sticker and laminated sheets are in place. Education: On 6/26/18 at approximately 1:37 PM an all staff education was started to in-service all staff about the emergency exit on wing 5 and proper exit code on gate out of the facility. All staff not scheduled was contacted via phone to provide verbal education about the code to exit the wing 5 gated area in the event of an emergency. Staff that receive verbal education will be given in-person training when they come back into the building. The training was completed by Admin Assistant, DON (director of nurses), ADON (assistant director of nurses), SDC (staff development coordinator), and plant operations director. Training was given at the site of the gate on wing 5 and return demonstration was done to confirm staff education at approximately 3:45 PM. Ongoing education for staff will continue to be completed prior to them working their next shift until all current employees are educated. Plan is to have everyone verbally educated by (MONTH) 27, (YEAR). No staff will be able to work until (they) have been in-serviced about wing 5 gait (sic) and lock. The facility provided CDPHE the following updated policies and procedures, all of which were approved by CDPHE: --Updated floor plan with egress exits --Updated contact list --Updated list of all codes to the locked doors; and --Updated combination padlock to the outside gate on wing 5 C. Removal of the immediate jeopardy: On 6/26/18 at 5:51 p.m. the NHA was notified the immediate jeopardy had been removed based on staff interview and review of the facility's abatement plan. However, deficient practice remained at E level (potential for more than minimal harm at a pattern) based on facility's systemic failures in emergency preparedness identified during survey 6/25/18 - 6/28/18, including the lack of floor plans that mapped residents' evacuation and the lack of staff training on staff response to emergency situations. II. Lack of information on how to egress the secured unit courtyard and on procedures to respond in an emergency A. Description of the secured unit and adjacent courtyard 1. The secured unit, observed on 6/26/18 beginning at 10:00 a.m., was located on the 500 hallway. The unit was for residents with [MEDICAL CONDITION] and dementia. As of the 6/24/18 daily census, 29 residents resided on the unit. The unit contained a TV room which was adjacent to the hallway, a dining room which was down the hallway, and a secured courtyard. There was a glass door in the TV room with a keyed door knob which opened into the secured courtyard. According to the maintenance director (MTD) on 6/26/18 at approximately 10:15 a.m., only activity staff and maintenance had a key for this door. 2. Further down the 500 hallway and adjacent to the dining room was a door identified as an exit door. This door opened with a keypad and provided egress into a secured unit courtyard, approximately 15 feet by 30 feet, which was surrounded by a wrought iron fence, approximately five feet tall. The fence had a gate which was locked with three-digit combination padlock. The combination padlock had three dials on the body of the lock which dialed the combination. When dialed, the selected combination was displayed on the base rather than the body of the combination lock. 3. Down the hallway from the secured unit dining room, a facility floor plan was posted on the wall. The floor plan revealed the emergency evacuation route and exit from the secured unit was into the courtyard. The courtyard gate was identified as an emergency exit. B. Emergency Preparedness Manual 1. On 6/26/18 at 10:00 a.m., a red notebook labeled Emergency Preparedness Manual was observed at the nurses' station on the secured unit. The notebook lacked a current updated contact list, lacked an emergency floor plan with a marked egress exit to the courtyard, and lacked the code to the exit door and the combination to the padlock on the courtyard gate. Further review of the facility's Emergency Preparedness Manual revealed no information instructing staff how to evacuate residents and in what order and no information on how to transport residents to an off-site evacuation location. The manual was dated as reviewed 1/25/17 with signatures from the interdisciplinary team (IDT). 2. The maintenance director (MTD) was interviewed on 6/26/18 at approximately 10:15 a.m. The MTD said she was in charge of the facility's Emergency Preparedness Manuals. She confirmed the manual in the secured unit was last updated on 1/25/17, and agreed it did not have an updated contact list, code to the secure unit exit door to the courtyard, or the combination to the padlock on the courtyard gate. She indicated the other Emergency Preparedness Manuals in the facility were also last updated 1/25/17 and they, too, lacked this information. She said she was currently attending meetings with others in the community to discuss emergency preparedness, and said the facility was continuing to work on improving its Emergency Preparedness Manuals. C. Staff interview Interviews with staff that worked on the secured unit confirmed they were unfamiliar with the combination to unlock the padlock on the courtyard exit gate and lacked training in emergency procedures. Licensed practical nurse (LPN) #7 who had worked in the secured unit for about a month, was interviewed on 6/26/18 at approximately 10:00 a.m. She said she was not aware of the combination to the padlock on the secured unit courtyard gate or that the combination to the lock when entered would appear on the base rather the the face of the lock. The LPN said the TV area also had a door which exited into the courtyard and which had a lock; however, she was unsure if she had a key to that door. She then called the assistant director of nurses (ADON). After the phone call, she said the ADON told her she, too, did not know the combination to the padlock on the gate. Certified nurse aide (CNA) #11 who said she had been working in the secured unit for the past few weeks, was interviewed on 6/26/18 at approximately 10:00 a.m. The CNA said she did not know the combination to the padlock on the courtyard gate. She said in the event of fire, she would evacuate the residents to the courtyard. CNA #19 was interviewed on 6/26/18 at approximately 10:30 a.m. She said that she had only been working in the secured unit for one day and she did not know the combination to the padlock on the courtyard gate. She said in the event of fire, she would evacuate residents to the courtyard. The physical therapist assistant (PTA) who had worked at the facility for two weeks and at times worked in the secured unit, was interviewed on 6/26/18 at approximately 10:30 a.m. and again on 6/26/18 at 12:40 p.m. The PTA said she did not know the combination to the padlock on the courtyard gate. She said she had a brief training on emergency preparedness when she began work. She said that in the event of the fire, she would evacuate residents to the courtyard. The physical therapist (PT) was interviewed on 6/26/18 at 11:00 a.m. The PT said that she did not regularly work on the unit; however, today she was providing treatment to one of the residents on the secured unit. She said she did not know the combination to the padlock on the courtyard gate. LPN #7, CNA #11, and CNA #19 were interviewed a second time on 6/26/18 at 12:43 p.m. They all said they had not been provided any training on the code to the secured unit exit door or to the combination for padlock on the courtyard gate. Housekeeper (HK) #1 was interviewed on 6/26/18 at 12:45 p.m. He said he cleaned the secured unit on a regular basis. He said that in the event of an emergency, he would have the residents from the secured unit exit out into the courtyard where the sign in the hallway directed one to go. He said he had not received training on emergency preparedness, including resident evacuation, and did not know the combination to the padlock on the courtyard gate. The laundry aide was interviewed on 6/26/18 at approximately 12:45 p.m. She said she was on the secured unit frequently. She said she had not been provided any training on emergency preparedness, including resident evacuation. She said she did not know the combination to the padlock on the courtyard gate. D. Administration interview The NHA and the assistant NHA were interviewed on 6/26/18 at 11:45 a.m. Both the NHA and ANHA agreed that egress from the facility's secured unit was to exit the unit into the courtyard and then through the courtyard gate. Although the ANHA said she knew the combination to the padlock on the gate, the NHA said he did not but had it stored in his phone. The NHA said that they do annual trainings on the emergency preparedness. When informed of staff interviews that revealed not all staff in the secured unit knew the combination to the padlock, he said he did not know this and said he would send out an email now to department heads to inform them staff needed to be educated on the code to the exit door to the secured courtyard and to the combination to the padlock on the courtyard gate. E. Facility follow-up during survey Review of the Emergency Preparedness Manual in the secured unit and those located elsewhere in the facility on 6/26/18 at approximately 5:00 p.m. revealed all of the manuals had been updated to include a floor plan with evacuation routes and exits, the codes to unlock all the doors and the combination for padlock on the courtyard gate. The manuals also had been updated with a current list of emergency contacts. III. Other Accident Hazards A. Smoking 1. Facility expectations The Smoking Policy (last revised 3/18) was provided by the clinical consultant (CC) on 6/28/18 at 6:33 p.m. According to a list provided by the facility at approximately 5:00 p.m. on 6/28/18, 11 facility residents smoked. The purpose of the smoking policy was for the facility to establish and maintain safe smoking practices. The policy, which only allowed supervised smoking at designated times, read in part: -Residents will be permitted to smoke if the Interdisciplinary Team (IDT) completes an assessment and determines that they are safe to smoke. -IDT will review the smoking privilege of each resident on an ongoing basis: quarterly, (when) a safety concern is identified, or (the) smoking policy violated. -Smoking Evaluation(s) may include, but is not limited to: physical ability to handle smoking materials, the need for protective smoking gear, and loss of sensation of feeling/pain. -Upon completion of Smoking Evaluation a Care Plan will be developed and reflect the following: Identifies the assistance the resident needs (if any), type of protective clothing needed if applicable, and other specific concerns/plans. -Supervised smoking times: 9:00 a.m.,11:00 a.m.,1:00 p.m., 3:45 p.m., 6:00 p.m., and 7:40 p.m. As each resident has to be supervised to smoke at (facility) these will be the only times available to smoke unless a resident has a visitor with them to observe them while smoking. -All smoking materials will be kept in the smoking cart. Residents shall NOT be permitted to keep cigarettes, pipes, tobacco, disposable safety lighters, matches, or other smoking articles in their possession. -Smoking shall not be permitted without direct supervision. 2. Systemic failures in implementation of facility smoking policy a. Failure to assess and supervise residents who smoke for safety, as expected per policy. The social services director (SSD) was interviewed 6/27/18 at 5:00 p.m. about smoking assessments. -She said she started completing the smoking assessments 3/7/18 when the supervised smoking policy was implemented (see above). The smoking policy was executed 3/7/18 because residents who smoked would go off site to smoke and the facility was concerned about the residents' safety. -She said a smoking assessment was completed for each resident who desired to smoke after admission, existing smokers previous to admission, and residents with a history of smoking. -She stated the smoking assessment should be completed by the nurse moving forward after 3/7/18 since she was not able to accurately assess the questions asked. The minimum data set coordinator (MDSC) was interviewed on 6/27/18 at 5:13 p.m. about smoking assessments. She stated the SSD helped with assessments initially but the assessment should be completed by the nurse on admission and added to the resident's care plan within 48 hours. She said she reviews the baseline care plan completed by the nurse on admission and incorporates smoking into a comprehensive care plan. Review of the assessments of the residents on the smoking list, revealed seven of the 11 residents' last smoking evaluations were completed 3/7/18. The SSD and the nursing home administrator (NHA) #1, interviewed 6/27/18 at 6:34 p.m., indicated these assessments were not current. They said the residents' assessments needed to be redone. The activity assistants (AA #1, AA #3, AA #4), who provided oversight at the posted smoking times per the NHA #1, were interviewed on 6/27/18 at 4:47 p.m. about supervised smoking. -They stated first, they confirm that any resident who wished to smoke was on the resident smoking list and capable of smoking on his or her own. This list was located in the smoking cart outside which also contained the smoking paraphernalia in the locked, top drawer. Second, they ensure the smoking residents did not have oxygen. -They said if a resident tried to smoke outside of the designated, supervised smoking times, a door alarm would sound and the AAs would redirect residents away from smoking area and back to their room. If a resident expressed interest in smoking, then the resident would be directed to social services. Licensed practical nurse (LPN) #5 was interviewed on 6/27/18 at 4:55 p.m. about the smoking policy and stated the designated supervised smoking times were posted outside of the door that exited into the smoking area. She confirmed the activities department supervised the smokers at the times posted. However, if a resident desired to smoke after the last time posted around 7:00 p.m., the resident was directed by staff to smoke off the facility property. NHA #1, NHA #2, the director of nursing (DON), and the SSD were interviewed together on 6/27/18 at 6:34 p.m. -They stated that all residents need supervision while smoking; if a resident desired to smoke at the facility, they needed to be supervised. They said they review the smoking policy and designated smoking times weekly with the residents who smoke. The SSD said the residents have never complained about the smoking times offered and were thankful that they were able to have supervised smoking times. -They said the facility was aware some residents went off site to smoke. To address this, the facility has implemented a sign out book for the residents that is kept at the front desk. NHA #1 said he had noticed the residents smoking off site in the street and the facility staff have provided these residents education for safety. He said part of that education was to have the residents smoke at the church adjacent to the facility property, not in the street. He said the safety education provided to the residents that smoked off site was verbal and not documented. b. Failure to adequately store smoking paraphernalia according the facility policy AA#4, during the AA interview on 6/27/18 at 4:47 p.m., provided a tour of the supervised smoking area and unlocked the smoking cart. When the smoking cart was checked, the top drawer was empty. Contrary to facility policy (above) and AA statements (above), AA #4 stated that residents do not want to keep their smoking paraphernalia in the cart, so it was kept in their rooms. Resident #15, who was cognitively intact with a brief interview for mental status (BIMS) score of 15/15 per the minimum data set (MDS) assessment on 6/12/18, was interviewed on 6/27/18 at 5:33 p.m. He stated he smokes off site at a church located next to the facility. He said he keeps his smoking paraphernalia in a plastic container hidden off site. The resident stated he would not keep his smoking paraphernalia in the locked cart because he does not attend the supervised smoking times offered by the facility. Resident #21, moderately cognitively impaired per his BIMS, was interviewed at 5:40 p.m. regarding smoking paraphernalia. He said he keeps his lighter and cigarettes in his room. NHA #1, interviewed 6/27/18 at 6:34 p.m., stated residents may not have smoking paraphernalia in their rooms according to the smoking policy. The facility should keep the resident's smoking paraphernalia locked in the cart in the supervised smoking area. He said there was a problem with families bringing items in and he said the facility cannot search the residents' belongings in their room or search areas when the residents keep the smoking items off site. 3. Individual failures - Resident #21 - failures related to smoking and wandering risks Resident #21, age 73, was admitted on [DATE]. According to (MONTH) (YEAR) computerized physician orders [REDACTED]. a. Resident status Record review, observations, and interview revealed the resident had a number of safety risk factors. Record review: -A wandering assessment completed 1/13/18, documented a score of 12, which indicated Resident #21 was at high risk for wandering. And, a physician's history and physical progress note on 1/15/18 at 9:22 a.m. documented that Nurse feels he might need a wander guard but no elopement attempts. He (Resident #21) did have wander guard previously. (No other wandering assessments were documented in the medical record since the initial assessment.) -According to the quarterly MDS assessment dated [DATE], the resident's BIMS score was 10 out of 15, which indicated moderate cognitive impairment. The MDS assessment read the resident was not steady during transitions and walking, but able to stabilize without assistance. -A care plan for mobility, revised 5/31/18, indicated resident was at risk for mobility because of poor safety awareness, confusion, and visual deficit. Approaches included therapy services to assess for transfer and mobility safety, strengthening, balance, and endurance. b. Observations On 6/26/18 at 6:12 p.m., Resident #21 exited the front doors of the facility unaccompanied and in a wheelchair. He wheeled himself down the steep grade of the facility's driveway toward the street and stopped himself abruptly at the edge of driveway. The resident propelled himself over a curb on the sidewalk to enter the street. The resident wheeled himself over the white lines designating a bicycle lane and onto the main street. The resident then went around a parked car in the bicycle lane, crossed back over the white line, and met the other residents smoking along the street off of the facility property. c. Resident interview The resident was interviewed at 4:11 p.m. on 6/27/18 in his room. -He stated he was at a facility out of state prior to his admission here. He said that at the previous facility, he wore a wander guard, but had never worn one here. He stated that, sometimes, he smokes out back during the supervised smoking times but often he goes out of the front of the facility and off site to smoke every two to three hours. He said when he smokes off site, he goes to the edge of the street. No staff have checked up on him or warned him not to go off site. He said therapy had not assessed him for safety; however, he said when he goes off site he prefers to travel by wheelchair so he does not fall. -He said staff had told him he had to be off site when he wanted to smoke outside of the facility's designated smoking times. He said the last smoking time was around 7:00 p.m. and that was not late enough for him. 2. Failure to take steps to address Resident #21's safety risks. a. Failure to reassess Resident #21's smoking risks Although an IDT-QA (Quality Assurance) progress note on 3/12/18 at 9:42 a.m. documented the resident attended a meeting where the smoking policy was reviewed, attended resident council where the policy was reviewed, met with the social services to review the smoking policy and acknowledged understanding and signed the policy agreeing to it, the resident was not following the smoking policy (see above). Although he was not following the facility smoking policy, Resident #21 had not been reassessed. His last smoking assessment (evaluation) was completed 3/7/18 by the SSD. The assessment documented the IDT has reviewed the resident and have determined the resident was safe to smoke in the designated smoking area during supervised smoke times. b. Failure to develop a resident-centered care plan addressing the resident's smoking behavior and risks. The resident's care plan revealed a care plan for smoking, revised on 5/31/18, which documented Resident #21 would only smoke in designated areas. The care plan read the facility determined the resident was safe to smoke independently per the smoking assessment and he had been educated to appropriate smoking areas. It further read when safety became a concern, IDT team and resident would reevaluate the resident's smoking needs. -The care plan failed to address the resident's risk for wandering and how that related to his safety while smoking. -The care plan failed to address that the resident went off site, unaccompanied, to smoke. c. Failure to develop a resident-centered care plan addressing the resident's wander risk, compounding his risk with smoking. Although assessed at high risk to wander, the resident had no care plan related to wandering. Certified nurse aide (CNA) #9 was interviewed at 10:15 a.m. on 6/28/18 regarding Resident #21. He said the resident often would leave the unit to smoke and staff were not aware when the resident left or where he was located. CNA #9 stated the resident does not check in with the nurses or nurse aides when he leaves to go smoke. The MDSC was interviewed at 5:10 p.m. on 6/28/18. She stated that when a resident was assessed to be a high wandering risk, this risk would be included in the resident's care plan. She could not locate a current care plan for Resident #21 on wandering or elopement. She said the wandering risk assessments should be completed on admission; if high risk, ongoing quarterly or if there was a significant change. The MDSC said the resident's baseline care plan would be in the paper chart. The baseline care plan was requested, but the MDSC was unable to locate it at as of 6:11 p.m. The DON was interviewed at 7:52 p.m. on 6/28/18. She stated a resident should have a wandering assessment completed with 48 hours upon admission. If determined a resident was high risk, it should be indicated on the baseline care plan. Since the admission nurse completed the wandering assessment on Resident #21, she should have implemented a wander guard initially until the management team reviewed the resident's risks in the IDT meeting. She said the wandering risk assessment should be completed quarterly on those residents considered at risk. NHA #1, NHA #2 and CC were interviewed together at 9:38 p.m. NHA #1 stated that the facility does have a wander guard system. He stated IDT would make the determination on those residents that would need a wander guard. NHA #1 stated that Resident #21 does not have a wander guard and did not have any episodes of elopement. However, they confirmed the concern for the resident's safety since the resident was admitted as a high wander risk. B. Failure to check the temperature of microwaved food 1. Observations On 6/25/18 at 5:05 p.m., dietary aide (DA) #1 was observed placing a sealed soup can in a soup bowl onto Resident #25's meal tray. Resident #25's meal ticket indicated she was to be served soup with her dinner meal. A CNA brought the meal tray to Resident #25's room. At 5:07 p.m., the CNA was observed opening the can of soup, pouring it into the bowl and heating the soup in the activity room microwave. The temperature of the soup was not checked after it was heated. The CNA brought the soup immediately back to Resident #25's for her to consume. On 6/26/18 at 5:19 p.m., Resident #25 again was served a sealed soup can in a soup bowl in the dining room. LPN #8 was observed opening the can of soup, pouring it into the bowl and heating the soup in the activity room microwave. The temperature of the soup was not checked after it was heated. LPN #8 then immediately brought the soup back to Resident #25's for her to consume. He was observed pouring the soup from the soup bowl into a mug for the resident and steam was coming out of it. 2. Interviews and facility follow up LPN #8 was interviewed on 6/26/18 at 5:24 p.m. He stated he had not received training on how to heat up food. When asked the temperature of the soup, he stated he did not know and did not have a thermometer. He said he did not know what temperature the soup should be served at. The temperature of the soup was checked and it was 162 degrees Fahrenheit. The clinical nurse consultant (CNC) was notified on 6/26/18 at 5:36 p.m. She stated she would provide education on reheating foods and proper food temperature. At approximately 5:40 p.m., the CNC was observed removing the microwave from the activity room. The CNC was interviewed on 6/28/18 at 5:46 p.m. She stated that she removed the microwaves from all patient areas on 6/26/18. She stated the microwaves will be replaced once all staff have been inserviced on how to properly heat food in the microwave. She stated a thermometer, a chart with safe food temperatures, and instructions will be provided next to each microwave. The CNC stated they were working on developing a facility policy regarding reheating foods in the microwave. At 5:55 p.m., the CNC provided documentation of the microwave inservice dated 6/26/18 and the safe food temperature chart. The inservice read dietary staff to heat/reheat all foods. All foods temped before given to patient. Do not use breakroom microwave for patient food. C. Obstructed exits 1. Observations A Hoyer lift was positioned in front of the emergency exit door on the 200 hall/Longs Peak at 2:58 p.m., 4:03 p.m. and 5:42 p.m. on 6/26/18. A Hoyer lift as well as a chair were positioned directly in front of the emergency exit door on the 200 hall/Longs Peak at 10:50 a.m. on 6/27/18. 2. Interviews On 6/27/18 at 11:00 a.m. the MTD was shown the Hoyer lift and chair in front of the emergency exit door on the 200 hall/Longs Peak. She was informed of the observations made on 6/26/18. The MTD moved the chair and stated that she had seen the lift and removed it earlier from the emergency door during her morning rounds around 6:00 a.m. When asked where the lift and chair should be stored, she it depended on whether the lift needed to be charged or brought to different wing. She confirmed it should not be in the path of egress. She stated staff just leave it here. On 6/28 at 8:45 a.m. CNA #9 stated the facility did not have anyone that used a lift on the 200 hall/Longs Peak. He said if they did, the lift would be stored in the resident's room. The CNA stated that they were told on 6/27/18 not store lifts in front of exit doors. The CNA stated the maintenance assistant (MA) might be putting the lift in front of the emergency exit as the MA is the one who brings it over to the 200 hall/Longs Peak. On 6/28/18 at 11:40 a.m. the MA was interviewed. He stated maintenance puts a Hoyer on the 200 hall, the 400 hall and the manual lift on the 700 hall. For the 200 hall, he said they put the lift in the shower room to charge or where there is an empty space but never in front of a emergency exit door. On 6/28/18 at 8:48 p.m. the director of nursing (DON) was interviewed. She stated Hoyer lifts should be stored in an alcove so they are not a tripping haza (TRUNCATED)

Based on record review, family and staff interviews the facility failed to have evidence that all allegations of staff to resident abuse, resident to resident abuse, and misappropriation of property were thoroughly investigated, affecting residents in secure unit, including residents #157, #186, #181, #151. The facility's failure to thoroughly investigate allegations contributed to additional resident to resident allegations involving resident #186 and #151 which created fear, stress, and sleep disturbance of resident #186, who feared for her safety and life inside the secure unit. Cross reference F223; failure to protect residents from abuse. The findings include: An abuse policy was provided on 7/12/17 at 9:10 a.m. by the Nursing Home Administrator (NHA). The policy had no initiation date and read in pertinent part, It is the policy of this facility to prohibit any abuse of its residents regardless of source. This facility seeks to promote the well-being of its residents by providing a safe and supportive environment .The administration will initiate the investigation process by interviewing all staff and residents having knowledge of the allegation immediately upon notification. 1. Allegations of resident to resident abuse (sexual harassment) - Cross reference F223 Record review and interviews revealed allegations of resident to resident sexual harassment by resident #181 of residents #186 and #151 were reported to the facility on [DATE], 5/19/17 and 6/23/17 by resident #186's family member. Interview and record review revealed evidence the repeat allegations were not thoroughly investigated. Interview and record review revealed the facility video tapes were reviewed and interviews were conducted with secure unit residents. However, record review and staff interviews revealed family members were not interviewed and there was no documentation of staff interviews. Furthermore, the allegations were not reported to the state agency or law enforcement. Resident #186's family member, interviewed on 7/11/17 at 2:51 p.m. stated the continued harassment created fear, stress and sleep disturbance for resident #186, and the resident feared for her safety and life inside of the secured unit. See F223 for further details. 2. Allegation of staff to resident physical abuse a. Interview A frequent visitor to the facility was interviewed on 7/13/17 at 11:48 a.m. She said her mother resided in the secure unit and that she visited often. She said she was concerned about a certified nurse aide (CNA #9) who worked with residents on the secure unit. She said when she was visiting her mother around 5/18/17, she overheard CNA #9 say to her mother's roommate, resident #157, no I'm not in response to resident #157 saying you're hurting me honey. She said she went out into the hallway and asked CNA #9 why resident #157 was distressed and the CNA said the resident would not stay in the dining room to eat and that she (the CNA) did not hurt the resident. She said she reported this concern to the administrator, never heard anything back about it and the CNA was still working on the unit. b. Record review Record review revealed resident #157, age 93 admitted to the facility on [DATE]. According to the July 2017 computerized physicians order (CPO), [DIAGNOSES REDACTED]. According to the 5/3/17 minimum data set (MDS) assessment, the resident had severe cognitive impairment and scored a five out of 15 on the brief interview of mental status (BIMS). She required supervision with daily decision-making. She had no moods or behaviors assessed during the review period. She was assessed to wander daily. CNA #9's time sheet from 5/1/17 through 7/13/17 revealed she worked exclusively on the secure unit on the evening shift. c. Facility response to allegation On 7/13/17 at 12:53 p.m., the NHA was asked to provide the facility's investigation of the allegation reported by the frequent visitor. He said he did not recall hearing or seeing anything about the allegation but would provide follow up. At 1:00 p.m., the NHA said he was not in the building during the time of the concern; the interim NHA received the complaint and documented it on a concern log. Review of a concern log dated 5/22/17 revealed in part a family member of a resident residing in the secure unit was concerned about (CNA #9) who man-handles residents. -The family member said she heard CNA #9 through a closed door of her mother's room say No, I'm not. She said she heard a resident (her mother's roommate) say, You're hurting me honey. The family member said the incident occurred the night before (5/21/17) sometime between 6:30 p.m. and 10:00 p.m. -The resolution section of the concern log revealed TV cameras were reviewed for the claimed time frame that showed CNA #9 assisting other residents in the hallway. CNA #9 was not seen assisting the referenced resident. The facility concluded there was no evidence CNA #9 hurt the resident. On 7/13/17 at 1:15 p.m., the NHA and interim NHA were interviewed. -The interim NHA said the family member called to speak to her about her concern and she filled out a concern form. She said at that time she reviewed the video on the alleged day of the concern and the videos did not show CNA #9 anywhere near resident #157's room. She said based on that, she did not conduct an investigation. The NHA was asked if they had a copy of the video footage from that day and he said the videos only save back two weeks. . d. Facility follow up On 7/13/17 at 1:45 p.m., the NHA said he would begin an investigation right away. At 3:48 p.m., the NHA provided additional follow up to the investigation and said CNA #9 had been suspended pending the outcome of the investigation, and that additional interviews were still being conducted. On 7/17/17 at 9:00 a.m., the completed investigation was provided by the NHA. The investigation revealed in part that the interim NHA had reviewed videos after the initial concern was filed on 5/22/17 before CNA #9 returned back to work and ruled out abuse. The current investigation completed 7/13/17 revealed the allegation was unsubstantiated. 3. Allegation of misappropriation of property. a. Allegation Interview with resident #186's family member on 7/11/17 at 2:51 p.m. revealed resident #181 wandered into and out of residents' rooms. She said family members had observed resident #181 entering resident #186's room, stealing personal items and running away. The personal items that were observed to be taken out of the resident #186's room included a water bottle and television remote. The family member said the allegations were reported to several staff members, including the NHA, Director of Nurses (DON), Assistant DON, and social worker #1. b. Record review Review of a concern form dated 5/17/17 revealed resident #186's family member reported missing personal property. The items documented were: two porcelain mugs with specific designs, a plastic water bottle, a white wash basin and many clothes. -In the resolution section, the writer documented the family member understood that residents will pick up other residents belongings and that she has seen other residents with her mother's cups and she was okay with it. She further said that she felt that no one was intentionally stealing her mother's things. She said she was concerned because the stop sign on her mother's door was not always in place. The facility further documented that the family member was invited to express any missing items to any staff member and they would search for them and return to the resident. It read the family member was pleased with proposed solution. An email sent by the family member after the 5/17/17 concern form (above) revealed the facility had not followed up with the family member or provided a resolution to the lost items. The email read in part, My mom saw her lost items and tried to communicate requesting others to return her belongings but those seniors refused to return them due to language barrier . There was no evidence found in the clinical record of any investigation or any follow up regarding the missing items. Observations on 7/11/17 at 8:35 a.m. revealed the stop sign, implemented as an intervention on a concern form dated 5/5/17 but not added to her care plan was not in place. (A stop sign was placed at 11:15 a.m.) c. Interviews The social worker assistant was interviewed on 7/11/17 at 3:45 p.m. She confirmed resident #186's family member had alleged a male resident (resident #181) was taking resident #186's personal belongings out of her room. The social services director (SSD) and the Assistant DON were interviewed on 7/11/17 at 4:28 p.m. Both said they were aware of resident #186's family member's allegation of misappropriation of the resident #186's property. The social worker (SW #1) was interviewed on 7/18/17 at approximately 4:30 p.m. She said if a resident reported missing items, a concern form would be filled out and they would try to locate the property right away depending on what the item was. She said if it was a clothing item they would check with the laundry department. She said if the missing item was unique, she would bring it to the NHA's attention. She said she remembered the email from the daughter and following the email she found the wash basin and the plastic water cup. She said she did not know what happened to the porcelain cups. The social service director (SSD) was interviewed again on 7/18/17 at 5:00 p.m. She said she was not aware of the missing porcelain mugs or the clothes. She said an investigation should be done and the police called if it was a matter of missing money. She said she would look into the matter further. The NHA was interviewed on 7/18/17 at approximately 5:15 p.m. he said their policy was not followed and there should have been an investigation regarding the missing property for resident #186.

Based on observations, record review, and staff and resident interviews the facility failed to provide one resident (#92) out of 40 sampled residents the right to make choices about aspects of his or her life in the facility that was significant to the resident. Specifically, the facility failed to: -Allow Resident #92 the right to refuse medications without the denial of activity participation; and -Allow Resident #92 the right to make decisions regarding what, when and where he preferred to eat his meals, resulting in significant weight loss and feeling like a prisoner within the facility. The findings included: A. Resident Status Resident #92, age 72, was admitted on [DATE]. According to face-sheet, [DIAGNOSES REDACTED]. According to the 3/3/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment and minimum depressive symptoms. He required extensive assistance with toileting and dressing and limited assistance with bed mobility, transferring, and walking. He required supervision only for eating. The resident moved to a secure memory care unit on 8/25/15. He was oriented to person and place. He was able to hold a conversation and remembered staff and visitors' names and faces. He displayed delusional thoughts related to the structure of the building (i.e. having multiple levels and two entrance doors to his room). B. Food Choices 1.Record Review The weights and vitals summary for Resident #92 revealed the following weights: -1/4/16, 194 pounds -1/18/16, 188 pounds -2/2/16, 188 pounds -3/7/16, 184.5 pounds -4/5/16, 176.5 pounds -4/11/16, 174.5 ponds -5/2/16, 182.5 pounds According to the weights summary, the resident lost 19 pounds and experienced a 9.7% weight loss within three months between January 2016 and April 2016. The 4/13/16 dietitian weight note revealed the resident had a nineteen pound weight loss, 9.7%, within three months. The note documented the resident had dementia with behaviors and decided whether or not to eat meals. Chocolate high protein milk was added with meals and [MEDICATION NAME] cereal for breakfast. The note further indicated the efforts to prevent weight loss were hampered by the resident's meal refusals and [DIAGNOSES REDACTED]. The 2/15/16 nurses note documented the resident was late to dinner and was provided the food available on the unit. 2. Observations On 4/27/16 at 4:45 p.m. the resident was observed in his room with his wife during dinner service. No staff were observed encouraging the resident to eat or offering alternatives. At 4:47 p.m. RN #6 was observed speaking to the resident's wife. The RN notified her that the resident would not be served the main hot entrée because he chose not to come to the dining room and participate in the meal. On 4/27/16 at 5:05 p.m. the RN was observed telling the resident's wife she would call down to the kitchen to obtain a room tray. The RN offered this after the wife was interviewed by the surveyor. The RN said she could not promise the kitchen would deliver one. The resident received the main meal from the dining room. RN #6 was overheard telling the wife that a room tray would be provided this one time only because the resident knew and understood the rules. On 5/4/16 at 8:54 a.m. certified nurse aide (CNA) #7 went into the resident's room after being notified that he was hungry. She came back out of his room a minute later and said he had just eaten pancakes and cereal but asked for more pancakes and mini-wheat cereal. She said she showed him the juice that was on the table in front of him and encouraged him to drink that. She did not provide him with additional food. 3. Interviews The resident's wife was interviewed on 4/27/16 at 4:49 p.m. She said she was unable to get to the dining room in time to request a room tray for her husband. She said the steam table had already left by the time she spoke to the nurse. She said she understood since the resident declined to go to the dining room often and the staff had a lot of residents for whom to provide care. She said when this occurred in the past her husband was able to get a sandwich from the nurse. RN #6 was interviewed on 4/27/16 at 5:25 p.m. She said she provided the resident with a room tray because the assistant director of nursing (ADON) informed her to do so. She said she notified the ADON that they had food in the refrigerator and the resident could have a sandwich. She said the resident was often stubborn and had behaviors and did not want to come to the dining room. At 5:32 p.m. the RN said the resident was asked twice to come to the dining room. Today, she said, he was too late and the steam table was gone by the time he was ready. She said he was aware of the rules and he could have a sandwich because they were in the refrigerator on the unit. She said sometimes his wife enabled him and his behaviors were worse around her. She said today the staff had offered him to come to the dining room for dinner twice but he refused. She said he wanted a room tray but the staff did not provide room trays unless a resident was sick or something was wrong. She said the residents needed to come to the dining room to eat, and the resident was aware of that. He did not receive a room tray, she said, because he was able to come to the dining room for meals and if he had a room tray he would have caused a mess that would have been hard to clean up. The resident was interviewed on 4/28/16 at 10:39 a.m. He said that morning he had gone to the dining room after 9:00 a.m., which was a no, no. He said residents did not get breakfast if they went to the dining room after 9:00 a.m. That was the rule; he said if a resident got to the dining room and the steam table had already left the unit there was no food left. He said if he asked for a hot meal the staff told him no, because they informed him everyone had a schedule and he needed to meet the staff's schedule. He said he got to the dining room around 9:20 a.m., and there was no food left so he received cold cereal. He said the staff expected the residents to do as they were told. He said it was all about the staff wanting control, and he did not like it because it made him feel like a prisoner. He said a couple of times he was too late to the dining room for dinner so he was provided with sandwiches from the refrigerator on the unit. He said the sandwiches were less than filling. He said he did not eat snacks because all they had were sandwiches. He said he might eat a snack if he had other options. On 4/28/16 at 2:32 p.m. the resident said when he did not eat with his medications he felt sick to his stomach, which was why he declined his medications sometimes. He said he had been unable to get breakfast this morning when he was late to the dining room. He said he was late because he was unable to get himself dressed. Sometimes, he said, he missed breakfast because he was waiting for toileting or dressing assistance. Today the staff offered him a sandwich or a cookie, but he said he did not want those items for breakfast. He said the same rules applied for lunch and dinner; if you were not in the dining room on time you did not receive a hot meal. Once, he stated, he wanted to bring a sandwich to his room, however, the staff told him he had to sit in the dining hall. On 4/29/16 at 5:28 p.m. the resident said he did not care for chocolate milk. The dietary supervisor (DS) was interviewed on 5/2/16 at 1:15 p.m. He said the kitchen honored residents' food preferences, including when they wanted to eat. He said residents were able to come to the kitchen to request food. On the secure unit, he said the CNAs and nurses were able to call down to the kitchen to request a meal for a resident and then come pick up the food. He said if the nursing staff was too busy to pick up the food, the dietary staff would deliver it to the resident. CNA #5 was interviewed on 5/3/16 at 8:10 a.m. She said she had never witnessed a resident on the secure memory care neighborhood receive a room tray. She said the staff tried not to have residents eat in their rooms because it could attract ants. She said if residents wanted to eat the staff brought them back to the dining room. The nursing home administrator (NHA) and NHA consultant were interviewed on 5/3/16 at 1:22 p.m. The NHA consultant said residents were given their preferences in regard to what meals they ate and where they ate their meals. The NHA said residents should be able to eat at any time. When informed of the observations, the NHA consultant said staff training would be initiated. C. Denial of Participation 1. Record Review The 2/17/16 nurses note revealed Resident #92 was not able to go on an activity outing due to his behavior the evening before and for refusing medications. 2. Resident Interview Resident # 92 was interviewed on 4/28/16 at 2:32 p.m. He said if he did not take his medications the staff would not let him go on outings; however, he had been unable to get breakfast this morning because he was too late to the dining room. He said if he took his medications without food it made him sick to his stomach. 3. Staff Interview Registered nurse (RN) #6 was interviewed on 4/27/16 at 5:25 p.m. She explained earlier that day the resident declined to eat breakfast or take his medications, so she informed him that he could not go on the activity outing if he did not eat and take his medications. She said he had wanted a hot meal; however, it was too late so he received cereal instead. She said he was then able to go on the outing since he ate cereal. She said when he returned he had been playing again because he was not following her directions. The NHA was interviewed on 5/4/16 at 11:52 a.m. He said there were no rules as to when, where, and what residents could eat. He said the facility did the best they could to allow residents to eat what and when they preferred. He said the facility did not punish residents for refusing food or medications because this was their right. D. Facility Follow-up On 5/3/16 the ADON provided a copy of the in-service conducted that day with the staff. The in-service documented, in pertinent part, .Teach employees the importance of accommodating our residents' needs. Specific examples include the following: If residents request food/snacks at any time we must provide them regardless of time of day . if residents ask for anything we need to do our best to accommodate them . Twenty-one staff signed the in-service document.

Based on record review, observtion and interview the facility failed to provide supervision or implement or assess the effectiveness of interventions for one (#1) of 12 sampled residents. Specifically the facility did not provide additional interventions, assess the current interventions or provide additional supervision for the resident who sustained four falls in a nine day period. The last fall resulted in a cervical fracture, hospitalization and death. Cross Reference F309: Failure to maintain highest practicable well being. Resident #1 was not treated in a timely manner after sustaining a fall with injury, resulting in a delay of care and potential interventions. I. Facility Policies Fall Risk Assessment Policy (dated 12/07) in pertinent part: The nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls. Falls and Fall Risk, Managing Policy (dated 12/07) in pertinent part: The staff with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If systematic evaluation of a resident ' s fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., try one or a few at a time, rather than many at once). If falling recurs despite initial interventions, staff will implement additional or different intervention, or indicate why the current approach remains relevant. The staff will monitor and document each resident ' s response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. Falls - Clinical Protocol Policy (dated 4/13) in pertinent part: The nurse shall assess and document/report the following: Precipitating factors, details on how the fall occurred; II. Hospital record: The Emergency Department report dated 4/19/15 noted fall yesterday at 2200 (10:00 p.m.) unwitnessed, c/o (complaints of) ha (headache) today with hematoma to head .On upper extremities the patient does not withdraw from painful stimulus of either upper extremity .There is a contusion on the left skull. The CT (Computerized Tomography) Scan of the cervical spine on 4/19/15 revealed: Current study shows an acute displaced fracture .There is associated prevertebral soft tissue swelling. The MRI (Magnetic Resonance Imaging) on 4/19/15 revealed: Additionally there is secondary spinal cord edema .There is also trace susceptibility artifact within the spinal cord suggestive of the cord contusion. III. Coroner ' s Report On 4/22/15 the Coroner documented the cause of death as: Cardiopulmonary arrest due to or as a consequence of Type II Odontoid (Cervical C-2) fracture due to or a consequence of mechanical fall. IV. Resident Status Resident # 1 was an [AGE] year old who according to the face sheet was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident was receiving palliative care prior to discharge to the hospital. The resident was discharged to the hospital on [DATE] to rule out a subdural hematoma, headache, increased lethargy and decreased appetite. The minimum data set (MDS) assessment dated [DATE] revealed the resident scored a six on the brief interview for mental status (BIMS) which indicated sever cognitive impairment. The MDS further revealed the resident sometimes understood others, and required extensive assistance of one person for bed mobility, transfers and locomotion off of the unit. The resident was identified as requiring limited assistance of one person for locomotion on the unit, used a wheelchair for mobility and had not walked on or off of the unit during the assessment period. Additionally the MDS identified the resident had no rejection of cares. Care Plan-Falls: A care plan for an actual fall was initiated on 12/12/14 and revised on 1/5/15. This was the most updated care plan for an actual fall (see record review and interview below). A care plan for falls was initiated on 1/28/15 and identified the resident was at risk for falls related to: Unaware of safety needs, confusion, poor communication/comprehension, vision/hearing problems, gait/balance problems, incontinence, malaise and fatigue. Interventions included: Administer medications as ordered; anticipate and meet the resident ' s needs; be sure the resident ' s call light is within reach and encourage the resident to use it for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair); ensure the resident ' s environment is safe: floors free from spills and or clutter, adequate glare free light, working and reachable call light, the bed in the low position at night, handrails on wall and personal items within reach; follow facility fall protocol; monitor labs as ordered; notify physician of any change in condition. The interventions for administering medications, monitoring labs and notifying the physician were last revised on 2/3/15; no other interventions had been revised since initiation on 1/28/15. A care plan for falls related to medications was initiated on 10/11/13 and last revised on 2/3/15. Interventions included: call light within reach while in room; clutter free environment; DME (durable medical equipment) as ordered; encourage call light use for assistance; low bed for safety while in bed, resident needs frequent reminders not to play with bed remote control; medication as ordered; notify MD (Medical Doctor) of changes; quarterly and PRN (as needed) fall assessments. There was not an updated care plan or acute care plans in the medical record and staff confirmed (see interview below) the above care plan was the most current. IV. Record Review (hard copy and electronic medical record (EMR) reviewed) a. Progress notes On 3/4/15 the facility documented the initiation of the discontinuing of the resident ' s Wanderguard (an elopement alerting system). The Facility initially identified the resident as a wandering/elopement risk on 3/22/14. -An event of an unwitnessed fall, on 4/10/15 at 11:30 a.m. noted the resident had an unwitnessed fall in their room. The resident ' s room was located close to, but out of line of sight from the nurses ' station. The note revealed the staff nurse had observed the resident sitting up in the hall, minutes before being notified of the fall. There was no apparent injury or change in mental status. The note identified the fall appeared unrelated to poor safety awareness and was related to the resident attempting to go to the restroom without assistance. The note identified the resident as frequently confused and noncompliant. The section for interventions in place and discuss risks and benefits with resident/family were blank. New interventions included vital signs for 72 hours, monitor for increased injury, signs and symptoms of bleeding, monitor for increased pain and monitor for further injury. There was no additional documentation that identified the effectiveness of the current interventions or recommendation for additional interventions beyond monitoring. An interdisciplinary team (IDT) event review note for the 4/10/15 fall dated 4/12/15 at 8:20 p.m. identified a fall from the wheelchair next to bathroom. The identified preventative measures in place included resident continues with fall mat. New interventions included to monitor vital signs for 72 hours, orthostatic blood pressure and neurological checks, monitor for increased injury, increased pain and discomfort. The discuss risks and benefits with resident/family section noted will continue to educated (sic) family as possible. There was no additional documentation that identified the effectiveness of the current interventions. -An event of an unwitnessed fall, on 4/12/15 at 4:00 a.m. noted the resident had an unwitnessed fall. The note identified the resident was on the mat next to the bed. The resident stated they just rolled out of bed and were not attempting to get out of bed. The resident was noted to have a hematoma on the left front aspect of their forehead and a hematoma on the left hip. The resident denied pain or headache. The note identified the resident frequently transferred without staff assistance and was non-compliant as evidenced by refusal of assistance or refusal to call for assistance (see MDS above). New interventions included Resident encouraged to use call light. There was no additional documentation that identified the effectiveness of the current interventions. - An IDT event review note for the 4/12/12 fall dated 4/12/15 at 8:24 p.m. identified the resident was found on the floor next to bed and identified preventative measures in place as, high low bed with fall matt, frequent safety checks and close observation. The note identified the resident was confused, noncompliant and continued with poor decision making per baseline. New interventions included the request for a palliative assessment and if the resident did not meet the criteria, laboratory follow up would be requested. The discuss risks and benefits with resident/family section noted will continue to educated (sic) family as possible. There was no additional documentation that identified the effectiveness of the current interventions. -An event of an unwitnessed fall, on 4/13/15 (time of fall unidentified) included a nursing note written at 1:03 p.m. which indicated the resident had an unwitnessed fall. The resident was in the television room of the unit where they resided. The room was approximately 125 feet from and out of line of sight from the nurses ' station. The note indicated the resident stated I fell . The nurse determined the resident had attempted a self transfer. There was no apparent injury and the resident did not report pain. The note identified the resident was confused and refused assistance often. The note did not identify what if any interventions were in place at the time of the fall and there was no additional documentation that identified the effectiveness of the current interventions or recommendation for additional interventions -An IDT event note for the 4/13/15 fall dated 4/13/15 at 5:21 p.m. identified the facility found the resident on the floor in the television room on the hall where the resident resided. The note identified the resident was alert with confusion and capable of asking for assistance, however is frequently confused and refuses assistance often. Interventions in place were not identified and there was no additional documentation that identified the effectiveness of the current interventions or recommendation for additional interventions. -An event for an unwitnessed fall, on 4/18/15 dated 4/19/15 at 3:11 a.m. identified the resident had an unwitnessed fall on 4/18/15 and identified the resident was found on the floor in the hall (not the hall where the resident resided) at 10:15 p.m. beside their wheelchair. The note revealed the resident was unresponsive and clammy and had a skin tear to the left hand (see 4/19/15 note below which indicated a head injury). The note indicated the resident later complained of a headache and was given Tylenol. Interventions listed in place were low bed with floor mat. The new interventions included, put into bed, O2 (oxygen) on, given Tylenol, 72 hour charting c (with) ortho and neuros started. Lt (left) hand cleansed and covered with (named) dressing. The note (signed by registered nurse (RN) #1) further revealed the resident was unresponsive when found but did come around sev (several) min (minutes) later (and) started moaning. The note identified the resident had a left forehead abrasion and the MD was notified (see interview below) at 10:30 p.m. On 4/19/15 at 10:23 a.m. the nurse ' s note identified Resident stated this AM (morning) that he feels pretty crappy. On 4/19/15 at 2:49 p.m. the resident reported pain to his head and Tylenol was administered. At 4:30 p.m. the resident reported pain to his head and all over his body. At 5:20 p.m. a call was made to the resident ' s physician. At 6:32 p.m. the physician returned the call and advised the facility to send the resident to ER (emergency room ). The resident left the facility at 7:05 p.m. via ambulance. -The IDT note for the 4/18/15 fall was completed on 4/20/15 (after discharge) and identified the resident had been found unresponsive with a front left forehead abrasion and skin tear to the left hand. The note identified the interventions in place as a low bed with floor mat (see fall location in record review above and interview below). b. Accident Investigations and Assessments -On 4/10/15 the Accident/Incident report revealed the resident was found lying on the floor of their room by occupational therapy assistant (OTA) #1. The resident was still in the wheelchair which was on its side. An environmental assessment indicated no causation and the investigation determined the resident was non-compliant, attempted to self transfer frequently, refused care often (see MDS above) and required encouragement to use the call light. Neurological checks were initiated and were unremarkable. There was no additional documentation to indicate the facility had assessed the care planned interventions for appropriateness or effectiveness or assessed for additional interventions. -On 4/12/15 the Accident/Incident report revealed the resident was found on the floor next to their bed and was attempting to get back into bed when found. The resident was noted to have a hematoma to the left forehead and the left hip. An environmental assessment indicated no causation to the fall and there was no additional documentation to indicate factors contributing to the fall. Neurological checks were initiated and were unremarkable. There was no additional documentation to indicate the facility had assessed the care planned interventions for appropriateness or effectiveness or assessed for additional interventions. -On 4/13/15 the Accident/Incident report revealed the resident was found by a member of the housekeeping staff, in a television room (common area) on the floor. The resident was noted to be free of injury. Licensed practical nurse (LPN) #3 noted they had been charting at the nurses ' station when they were notified by the housekeeper. The report identified the resident frequently attempted to self transfer and did not request assistance (see MDS above). An environmental assessment indicated no causation to the fall and there was no additional documentation to indicate factors contributing to the fall. Neurological checks were initiated and were unremarkable. There was no additional documentation to indicate the facility had assessed the care planned interventions for appropriateness or effectiveness or assessed for additional interventions. -On 4/18/15 the Accident/Incident report revealed the resident was found at 10:15 p.m. on the floor in the carpeted main hallway (a hall other than where the resident resided) that led into and out of the facility and the resident was unresponsive. The report identified injuries to the left forehead abrasion and left hand skin tear (RN #1 interview below). An environmental assessment indicated no causation to the fall and there was no additional documentation to indicate factors contributing to the fall. c. Neurological Checks The resident ' s baseline Glasgow Coma Scale (GCS) score from the 4/10/15, 4/12/15 and 4/13/15 falls was 14. -On 4/18/15 at 10:45 p.m. (30 minutes after the fall was documented to have occurred) the first documented neurological check was performed. The resident was noted to not open eyes, have no verbal response and have no motor response. The resident ' s GCS score was documented as a three, which correlated with severe brain injury according to the instructions on the back of the Neurological Evaluation Flow Sheet, which the nurse had filled out and signed. The resident was absent of a gag reflex. Additionally the resident was noted to have equal pupil size of 2 mm (millimeters), and movement with command was listed as weak (the form had earlier indicated no movement). -On 4/18/15 at 11:00 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open eyes to speech, had inappropriate speech, would withdraw from pain and had no gag reflex. The resident ' s GCS score was ten which correlated with moderate brain injury according to the instructions on the back of the document. -On 4/18/15 at 11:15 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes to speech, was confused, would withdraw from pain and had no gag reflex. The resident ' s GCS score was 11 which correlated with moderate brain injury according to the instructions on the back of the document. -On 4/18/15 at 11:30 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes to speech, was confused, would obey commands and had no gag reflex. The resident ' s GCS score was 13 which correlated with mild brain injury according to the instructions on the back of the document. -On 4/18/15 at 12:00 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes spontaneously, was confused, would obey commands and had no gag reflex. The resident ' s GCS score was 14 which correlated with mild brain injury according to the instructions on the back of the document. -On 4/19/15 at 12:30 a.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes to speech, was confused, would obey commands and had no gag reflex. The resident ' s GCS score was 13 which correlated with mild brain injury according to the instructions on the back of the document. -On 4/19/15 at 1:00 a.m. the Neurological Evaluation Flow Sheet indicated the resident would open eyes spontaneously, was confused, would obey commands and for the first time since the neurological checks were initiated had gag reflex. The resident ' s GCS score was 14 and this GCS score and condition remained until the resident ' s discharge from the facility. -An orthostatic blood pressure tracking for was provided with the investigation. The form notes the first blood pressure was taken at 10:45 p.m. and matched the reading recorded on the neurological check form; however, there was no resident identifier on the form (no name, room number, medical record number or physician). d. Medications According to the medication administration record (MAR) the resident was prescribed and administered Trazadone (an anti-depressant and off label medication for insomnia) 25 mg (milligrams) for insomnia at bedtime on 4/18/15. (See fall investigation above, resident propelled in wheelchair to other hall prior being found at 10:15 p.m.). The time of medication administration was not recorded. On 4/19/15 at 1:54 a.m. according to the MAR the resident complained their head was hurting and was administered 650mg of Tylenol. e. Resident Transfer Form Dated 4/19/15, the transfer form from the facility to the hospital indicated the resident had a skin tear to the left hand, an abrasion/hematoma to the left forehead, increased lethargy and a decreased appetite. V. Interviews -On 6/22/15 at licensed practical nurse (LPN) #2 was interviewed. The LPN stated if a resident fell the expectation was to ensure the resident was comfortable and not in acute distress and to stay with the resident until an RN could be summoned to assess the resident. The LPN stated that after an unwitnessed fall or a witnessed fall where a resident had hit their head, neurological (neuro) checks would be conducted every 15 minutes for the first hour, then every 30 minutes for two hours, then every hour for two hours and then once per shift for 72 hours. The LPN stated there were instructions on the form that assisted nursing staff in interpreting the recorded scores. The LPN stated a medical doctor (MD) would need to be notified of any neurological change after a fall. -On 6/23/15 at 10:22 p.m. RN #1 was interviewed. The RN stated she had been the resident ' s nurse on the night of 4/18/15. She stated the resident ' s medications for insomnia had been administered on the previous shift and she did not know why the resident would still have been up in the wheelchair after being given bedtime medications. The RN stated the resident wandered at times and used a wheelchair for mobility. The RN stated the resident had often tried to self transfer and had recently had multiple falls. The RN stated the resident was not capable of transferring without assistance and often did not use the call light. The RN stated the resident ' s room was close to the nurses ' station due to the resident ' s fall risk and that the resident ' s room was not in line of sight of the nurses ' station but was in a high traffic area. The RN stated the resident had been in the same room for at least the past seven months. The RN stated that on 4/18/15 at approximately 10:15 she was notified that resident #1 was found on the floor in another hall. The RN identified the location where the resident was found to be approximately 50 feet from the resident ' s room. From the resident ' s room going approximately 25 feet then a 45 degree turn into another hall then 25 feet down this hall leading toward the entrance and exit of the facility. This hallway where the resident was found did not have resident rooms or a nurses ' station and was not in line of sight of any nurses ' stations in the facility. The RN stated the resident was unconscious when she arrived and she was unable to determine how long the resident had been on the ground or unconscious. She reported that the resident had a skin tear on the left hand and an abrasion to the left forehead. The RN stated the resident had a black eye from a previous fall and the new abrasion looked like a good sized carpet burn. The RN stated due to the location of the new injury on the front of the head she was not concerned. The RN stated the resident did regain consciousness after five to seven minutes and began moaning. The RN stated the House Manager (RN #3 see interview below) was notified and she assumed that if the resident required hospitalization , RN # 3 would have made that decision. The RN stated the resident was helped to the wheelchair, taken to the room, placed into bed, the MD and responsible party were notified and neuro checks were initiated. -On 7/15/15 at 12:55 p.m. the palliative care nurse (PN) stated they had been informed by the facility that resident #1 had sustained a fall on 4/18/15. The PN stated they had been informed the resident had been found on the floor and was unresponsive (not unconscious) and limp. The NP further stated they were informed the resident was helped to bed and that vitals and neuro checks were normal. -On 7/15/15 at 11:41 a.m. RN #3 was interviewed. The RN stated they had been working the night resident #1 fell . RN #3 stated that RN#1 had performed the post fall assessment on the resident prior to his arrival and the resident was being helped into the wheelchair when he first observed the resident post fall. RN #3 stated they had not been informed that the resident had been unconscious/unresponsive or had injury to the forehead when found. RN #3 stated he offered assistance and that RN #1 declined the need for additional assistance or assessment. RN # 3 stated had he been informed that the resident the resident had been found unconscious/unresponsive or that the resident had remained in that condition for five to seven minutes after being discovered on the floor, he would have called 911 (emergency response). -On 7/15/15 at 1:31 p.m. the nursing clinical supervisor (NCS) stated it was their responsibility to update care plans, review investigations and assess for effectiveness of interventions to prevent falls. The NCS stated that after any fall an acute care plan would be created and interventions that were effective would become part of the permanent care plan after 14 days. The NCS stated that it was determined that the resident did not consistently use the call light and encouraging the resident to do so remained an effective intervention as care planned. The NCS stated that the resident ' s room was not in line of sight of the nursing station but was an effective intervention due to the high volume of staff traffic by the room. The NCS stated that all four falls were unwitnessed and that two of the four falls in the nine day period (including the fall that eventually led to the resident ' s hospitalization ) occurred somewhere other than the resident ' s room. The NCS stated each intervention would have been assessed for effectiveness after each fall and this would appear in the acute care plan or IDT (interdisciplinary team) notes. The NCS stated that encouraging the resident to use the call light (see MDS and record review above) and the use of the floor mat (see record review above, identified as in use for falls not from bed) continued to be appropriate interventions. The NCS additionally confirmed that in the nine day period two of the four falls occurred someplace other than the resident ' s room, out of sight of the nurses ' station and the resident had been discovered in those two falls by staff that were not assigned to primary care for the resident. -On 7/15/15 at 2:19 p.m. the NCS stated they were not able to locate an acute care plan for any of the four falls. The NCS stated the care plan last updated, initiated 1/8/15 and revised 2/3/15, was the most current. The NCS stated there was no additional documentation that would have identified the facility ' s assessment of the effectiveness of the interventions at the time of or after the four falls. -On 7/15/15 between 1:17 p.m. and 3:15 p.m. the director of nursing (DON) and assistant director of nursing (ADON) were interviewed. The ADON stated that after a fall the expectation would be for the facility to review all falls the next day and assess the appropriateness of the current interventions, determine if new interventions would be appropriate, and the findings would be expected to be documented. The ADON stated that new interventions would be documented in the care plan after an event. The ADON stated the MAR indicated the resident had been given a medication for insomnia on 4/18/15 and that the order indicated the medication was to be given at bed time. The ADON stated while the facility did not record the exact time of the medication administration, any mediation that was ordered to be given at bedtime to aide in sleep, should have been administered just prior to helping the resident to bed. The DON stated the facility had identified the resident had been at a high risk for falls and was care planned accordingly. The DON stated some of these risks included a history of falls, impulsiveness, confusion and urinary urgency. The DON stated she would have expected the care plan to have been updated and interventions assessed and documented for effectiveness and appropriateness with the resident ' s recent falls. The DON stated she had not previously reviewed the Accident Investigations and Assessment reports for the resident ' s falls on 4/10, 412, 4/13 and 4/18/15. Upon review on 7/15/15 the DON stated it appeared the facility had not implemented new interventions or assessed the existing interventions for appropriateness or effectiveness at preventing falls for the resident.

Based on record review and interview the facility failed to ensure the highest practicable well being for one (#1) of 12 residents reviewed, who sustained a fall. Specifically the facility staff did not take appropriate actions based on the resident ' s condition after a fall with injury or provide accurate details of the resident ' s condition to the physician (after the fourth fall) resulting in a delay in hospitalization . The injury was determined to have contributed to the resident ' s death. I. Coroner ' s Report On 4/22/15 the Coroner documented the cause of death as: Cardiopulmonary arrest due to or as a consequence of Type II Odontoid (Cervical C-2) fracture due to or a consequence of mechanical fall. II. Facility Policy, Falls -Assessing Fall and Their Causes (dated 10/10) in pertinent part: After a Fall: a. If a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. d. Nursing staff will notify the resident ' s Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or change in condition, nursing staff will notify the practitioner by phone immediately. - Clinical Protocol Policy (dated 4/13) in pertinent part: The nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how the fall occurred; i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. II. Hospital record: The Emergency Department report dated 4/19/15 noted, fall yesterday at 2200 (10:00 p.m.) unwitnessed, c/o (complaints of) ha (headache) today with hematoma to head .On upper extremities the patient does not withdraw from painful stimulus of either upper extremity .There is a contusion on the left skull. The CT (Computerized Tomography) Scan of the cervical spine on 4/19/15 revealed: Current study shows an acute displaced fracture .There is associated prevertebral soft tissue swelling. The MRI (Magnetic Resonance Imaging) on 4/19/15 revealed: Additionally there is secondary spinal cord [MEDICAL CONDITION] .There is also trace susceptibility artifact within the spinal cord suggestive of the cord contusion. III. Resident Status Resident # 1 was an [AGE] year old, who according to the face sheet, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident was receiving palliative care prior to discharge to the hospital. The resident was discharged to the hospital on [DATE] to rule out a subdural hematoma, headache, increased lethargy, and decreased appetite. The minimum data set (MDS) assessment dated [DATE] revealed the resident scored a six on the brief interview for mental status (BIMS) which indicated severe cognitive impairment. The MDS further revealed the resident sometimes understood others, and required extensive assistance of one person for bed mobility, transfers and locomotion off of the unit. The resident was identified as requiring limited assistance of one person for locomotion on the unit, used a wheelchair for mobility and had not walked on or off of the unit during the assessment period. Additionally the MDS identified the resident had no rejection of cares. Care Plan-Falls: A care plan for an actual fall was initiated on 12/12/14 and revised on 1/5/15. This was the most updated care plan for an actual fall (see record review and interview below). A care plan for risk for falls was initiated on 1/28/15 and identified the resident was at risk for falls related to: Unaware of safety needs, confusion, poor communication/comprehension, vision/hearing problems, gait/balance problems, incontinence, malaise and fatigue. Interventions included: Administer medications as ordered; anticipate and meet the resident ' s needs; be sure the resident ' s call light is within reach and encourage the resident to use it for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair); ensure the resident ' s environment is safe: floors free from spills and or clutter, adequate glare free light, working and reachable call light, the bed in the low position at night, handrails on wall and personal items within reach; follow facility fall protocol; monitor labs as ordered; notify physician of any change in condition. The interventions for administering medications, monitoring labs and notifying the physician were last revised on 2/3/15: no other interventions had been revised since initiation on 1/28/15. IV. Record Review (hard copy and electronic medical record (EMR) reviewed) a. Progress notes -On 4/18/15 at 10:15 p.m. the resident had an unwitnessed fall. The resident was found on the floor in the hall (not the hall where the resident resided) beside their wheelchair. The note revealed the resident was unresponsive and clammy and had a skin tear to the left hand (see 4/19/15 note below which also indicated a head injury). The note indicated the resident later complained of a headache and was given Tylenol. The intervention listed in place was a low bed with a floor mat (the fall had not occurred in the resident ' s room). The new interventions included, put into bed, 72 hour charting. According to the note the physician was notified at 10:30 p.m. -On 4/19/15 at 3:11 a.m. a note signed by registered nurse (RN) #1 for the 4/18/15 fall revealed, the resident was unresponsive when found but did come around sev (several) min (minutes) later (and) started moaning. The note further revealed the resident had a left forehead abrasion and the physician (MD) was notified (see interview below). On 4/19/15 at 10:23 a.m. the nurse ' s note read, Resident stated this AM (morning) that he feels pretty crappy. --On 4/19/15 at 2:49 p.m. the resident reported pain to his head and Tylenol was administered. At 4:30 p.m. the resident reported pain to his head and all over his body. At 5:20 p.m. a call was made to the resident ' s physician. At 6:32 p.m. the physician returned the call and advised the facility to send the resident to ER (emergency room ). The resident left the facility at 7:05 p.m. via ambulance. b. Accident Investigations and Assessments -Investigations and fall assessments revealed the resident had falls on 4/10/15, 4/12/15 and 4/13/15. On 4/18/15 the Accident/Incident report revealed the resident was found at 10:15 p.m. on the floor in the carpeted main hallway (a hall other than where the resident resided) that led into and out of the facility and the resident was unresponsive. The report identified injuries to the left forehead abrasion and left hand skin tear (RN #1 interview below). An environmental assessment indicated no causation to the fall and there was no additional documentation to indicate factors contributing to the fall. c. Neurological Checks --The resident ' s baseline Glasgow Coma Scale (GCS) score from falls on 4/10/15, 4/12/15 and 4/13/15 was 14. --On 4/18/15 at 10:45 p.m. (30 minutes after the fall was documented to have occurred) the first documented neurological check was performed. The resident was noted to not open his eyes, have no verbal response and have no motor response. The resident ' s GCS score was documented as a three, which correlated with severe [MEDICAL CONDITION] according to the instructions on the back of the Neurological Evaluation Flow Sheet. The resident was absent of a gag reflex. Additionally the resident was noted to have equal pupil size of 2 mm (millimeters), and movement with command listed as weak. The form was signed by RN #1. --On 4/18/15 at 11:00 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes to speech, had inappropriate speech, would withdraw from pain and had no gag reflex. The resident ' s GCS score was ten which correlated with moderate [MEDICAL CONDITION] according to the instructions on the back of the document. --On 4/18/15 at 11:15 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes to speech, was confused, would withdraw from pain and had no gag reflex. The resident ' s GCS score was 11 which correlated with moderate [MEDICAL CONDITION] according to the instructions on the back of the document. --On 4/18/15 at 11:30 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes to speech, was confused, would obey commands and had no gag reflex. The resident ' s GCS score was 13 which correlated with mild [MEDICAL CONDITION] according to the instructions on the back of the document. --On 4/18/15 at 12:00 p.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes spontaneously, was confused, would obey commands and had no gag reflex. The resident ' s GCS score was 14 which correlated with mild [MEDICAL CONDITION] according to the instructions on the back of the document. --On 4/19/15 at 12:30 a.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes to speech, was confused, would obey commands and had no gag reflex. The resident ' s GCS score was 13 which correlated with mild [MEDICAL CONDITION] according to the instructions on the back of the document. --On 4/19/15 at 1:00 a.m. the Neurological Evaluation Flow Sheet indicated the resident would open his eyes spontaneously, was confused, would obey commands, and for the first time since the neurological checks were initiated, had a gag reflex. The resident ' s GCS score was 14 and this GCS score and condition remained until the resident ' s discharge from the facility. --An orthostatic blood pressure tracking form was provided with the investigation. The form noted the first blood pressure was taken at 10:45 p.m. and matched the reading recorded on the neurological check form; however, there was no resident identifier on the form (no name, room number, medical record number or physician). c. Medications and Medication Administration Record [REDACTED] On 4/19/15 at 1:54 a.m. according to the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In the previous 19 day period the resident had only received one other administration of Tylenol PRN for general pain. d. Resident Transfer Form Dated 4/19/15 the transfer form from the facility to the hospital indicated the resident had a skin tear to the left hand, an abrasion/hematoma to the left forehead, increased lethargy, and a decreased appetite. V. Interviews -On 6/22/15 at licensed practical nurse (LPN) #2 was interviewed. The LPN stated if a resident fell , the expectation was to ensure the resident was comfortable and not in acute distress and to stay with the resident until an RN could be summoned to assess the resident. The LPN stated that after an unwitnessed fall or a witnessed fall where a resident had hit their head, neurological (neuro) checks would be conducted every 15 minutes for the first hour, then every 30 minutes for two hours, then every hour for two hours and then once per shift for 72 hours. The LPN stated there were instructions on the form that assisted nursing staff in interpreting the recorded scores. The LPN stated a medical doctor (MD) would need to be notified of any neurological change after a fall. -On 6/23/15 at 10:22 p.m. RN #1 was interviewed. The RN stated she had been the resident ' s nurse on the night of 4/18/15. The RN stated the resident wandered at times and used a wheelchair for mobility, often tried to self transfer and had recently had multiple falls. The RN stated the resident was not capable of transferring without assistance and often did not use the call light. The RN stated that on 4/18/15 at approximately 10:15 p.m. she was notified that resident #1 was found on the floor in another hall. This hallway where the resident was found as identified by the RN, did not have a nurses ' station and was not in line of sight of any nurses ' stations in the facility. The RN stated the resident was unconscious when she arrived and she was unable to determine how long the resident had been on the ground or unconscious. She reported that the resident had a skin tear on the left hand and an abrasion to the left forehead. The RN stated the resident had a black eye from a previous fall and the new abrasion looked like a good sized carpet burn. The RN stated due to the location of the new injury on the front of the head she was not concerned and that if it would have been on the back of the resident ' s head that would have been more concerning. The RN stated the resident did regain consciousness after five to seven minutes and began moaning. The RN stated the House Manager (RN #3 see interview below) was notified and would have made the decision whether to send the resident to the hospital or not. The RN stated the resident was helped to the wheelchair (once able to move), taken to the room, placed into bed, the MD and responsible party were notified, and neuro checks were initiated. The RN stated that the initial neurological checks appeared abnormal but with the resident ' s confusion it did not seem concerning. The RN stated the resident later complained of a headache and was given a PRN medication. The RN stated she had not contacted the physician in regards to the resident ' s complaint of six out of ten head pain (approximately three hours after the fall). -On 7/15/15 at 11:41 a.m. RN #3 was interviewed. The RN stated they had been working the night resident #1 fell . RN #3 stated that RN #1 had performed the post fall assessment on the resident prior to his arrival and the resident was being helped into the wheelchair when he first observed the resident post fall. RN #3 stated they had not been informed that the resident had been unconscious/unresponsive or had an injury to the forehead when found. RN #3 stated he offered assistance and that RN #1 declined the need for additional assistance or assessment. RN #3 stated that had he been informed the resident had been found unconscious/unresponsive or that the resident had remained in that condition for five to seven minutes after being discovered on the floor, he would have called 911 (emergency response). The RN stated (after review of the neurological checks) that based on the recorded information on 4/18/15 at 10:45 p.m. the facility should have called 911 at that time and or notified the physician of the results. The RN further stated the neurological information recorded on 4/18/15 at 11:00 p.m. and 11:15 p.m. while improving were still below the resident ' s baseline and the physician should have been notified. RN #3 stated that when the resident complained of, and was medicated for, the new onset of a headache on 4/19/15 at 1:54 a.m. the physician should have been notified. -On 7/15/15 at 12:55 p.m. the palliative care nurse (PN) stated they had been informed by the facility that resident #1 had sustained a fall on 4/18/15. The PN stated they had been informed the resident had been found on the floor and was unresponsive (not unconscious) and limp. The NP further stated they were informed the resident was helped to bed and that vitals and neuro checks were normal (see record above). -On 7/15/15 between 1:17 p.m. and 3:15 p.m. the director of nursing (DON) and assistant director of nursing (ADON) were interviewed. The ADON stated that after a fall the expectation would be for the facility to review all falls, the next day and, assess the appropriateness of the current interventions, and determine if new interventions would be appropriate. The ADON stated that new interventions would be reflected in the care plan after an event. The ADON stated the resident ' s care plan had last been updated on 2/3/15. The ADON stated the absences of a gag (protective) reflex should have indicated potential neurologic involvement with the fall. The ADON stated that the resident should have been sent to the hospital after being found on the floor unresponsive. The DON stated the first neurological check should have been conducted 15 minutes after the initial assessment and it appeared (see record review) to have occurred 30 minutes later. The DON stated 911 should have been called after the unwitnessed fall when the resident was found unresponsive with a new head injury. The DON further stated that based on the neuro sheets the RN (#1) should have contacted the physician or sent the resident out emergently. The DON stated once the resident began to complain of head pain after the fall the physician should have been notified. The DON stated the facility had missed many opportunities to either send the resident to the hospital or notify the physician for further directives. -On 7/17/15 at 12:24 p.m. the MD who was on call for the resident ' s physician was interviewed. The MD stated they were notified that the resident had fallen in his room on 4/18/15 and with the information provided by the facility advised the facility to monitor vital signs, continue neurological checks and notify the MD if a change of condition occurred. The MD stated the facility did not inform them that the resident was found in a hallway (not his room) after an undetermined amount of time nor did the facility inform then that the resident had remained unresponsive for five to seven minutes after being found. The MD further stated they had not been made aware of the abrasion (later identified as a hematoma) to the resident ' s forehead and had not been informed of the irregular neurological checks. The MD stated had the above information (as recorded by the facility) been communicated with them the medical directive would have been different; specifically they would have advised for emergent hospitalization .

Based on observations, record review and staff interviews the facility failed to ensure a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one (#70) of two residents reviewed for pressures ulcers out of 45 sample residents. Specifically, the facility failed to ensure timely and adequate interventions, monitoring and collaboration of care and services for a facility acquired pressure ulcer. The Findings include: Professional Reference: 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 (2/2015 http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories(2/2015), read in part: NPUAP Pressure Ulcer Stages/Categories: "The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. 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. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones and may indicate "at risk" persons. 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-sanguinous 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. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA 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. Evolution may be rapid exposing additional layers of tissue even with optimal treatment." Cross reference F309, Care and Services, failure to provide proper positioning. Cross reference F325, Maintain nutritional status, failure to ensure resident maintained acceptable parameters of nutritional status. Resident Status Sample resident #70, [AGE] years of age was originally admitted to the facility on [DATE]. According to the most recent face sheet the resident had [DIAGNOSES REDACTED]. According to the most recent quarterly minimum data set (MDS) assessment dated [DATE] the resident was assessed to have moderate cognitive impairment with a six out of 15 score on the brief interview of mental status (BIMS). The resident was totally dependent on all activities of daily living, required the assistance of one staff person. The resident was incontinent of bowel and bladder and wore adult incontinent products. The resident was assessed at high risk for pressure ulcer development. The resident was assessed to have no current or healed pressure ulcers with preventative measures to include pressure reducing device for chair and bed, applications of nonsurgical dressings (with or without topical medications) other than to feet. A turning and repositioning program was not included as a preventative measure. A review of an 8/3/14 significant change MDS revealed the resident was assessed at high risk for pressure ulcer development and had no current or healed pressure ulcers. The resident was now on Hospice care. The preventative measures were unchanged, and, did not include a turning and repositioning program. Review of the care area assessment (CAA), related to pressure ulcers, revealed in the analysis of findings that the resident had a potential for pressure ulcers, but did not have any pressure ulcers at the time of the assessment. The resident was at risk due to dementia, incontinence and due to being wheelchair and bedbound. Another area of the CAA revealed the following: "will the pressure ulcer be addressed in the care plan? This was marked "yes." "If care planning for this problem, what is the overall objective? Slow or minimize decline; minimize risks." A review of a 7/13/14 quarterly MDS revealed the resident was assessed at high risk for pressure ulcer development and had no current or healed pressure ulcers. The preventative measures were unchanged, and, did not include a turning and repositioning program. Observations: On 4/8/15 at approximately 9:00 a.m. the resident was observed sitting in a blue geri-chair type wheelchair parked against the wall in the hallway. The chair had a "cushion like" feel to it. The resident appeared small framed and thin. The resident's position in the chair showed her in a "cradled" typed position. Upon greeting the resident she repeated twice "I want to go home." On 4/9/15 at 1:00 p.m., the resident was observed resting in her bed and lying on her back with her eyes closed. Her air mattress pump made a low humming sound and the control panel had the green lights lit across all of the settings. On 4/13/15 at 9:09 a.m. the resident was observed in her bed asleep and lying slightly on her left side. The pump to the air mattress did not appear to be on as evidenced by no sound and no lights lit on the control panel. The air mattress appeared to still be fully inflated. The resident's geri-chair was observed in the room and it had a scooped center with no cushion. On 4/13/15 at 9:20 a.m., the licensed practical nurse (LPN #3) was asked to check the resident's mattress pump. LPN #3 acknowledged the panel on the pump was not lit up. The LPN continued to check the bed and then pulled the bed away from the wall to check the plug and the plug was bent and coming out of the wall. The LPN then plugged it in fully and the panel on the pump lit up green. LPN #3 stated the machine was supposed to sound an alarm if it was not functioning correctly. The LPN stated the nurses and CNA's do not touch the machine only the restorative department and hospice did that. On 4/13/15 at 2:41 p.m. observations were made with the hospice wound nurse practioner (HWNP) and LPN #3 providing wound care to the resident's coccyx wound. After the resident was positioned on her left side to expose the coccyx wound, the right hip was observed to have a large round area of dark red, non-blanchable discoloration/breakdown. The skin was not broken, but appeared excoriated in the center. There was no dressing over the area. LPN #3 confirmed it was a pressure area due to her overall decline and the resident favored lying on that side. LPN #3 stated the hip wound had been there for awhile, but did not recall when it developed and the only treatment being done to the area was skin prep (as she proceeded to apply this to the area). The right inner toe area was also observed to have a small white gauze dressing. LPN #3 stated the resident had another smaller wound that showed up over a bunion. At approximately 2:45 p.m. after obtaining additional supplies the HWNP proceeded to assess the coccyx wound. A disposable pad was placed under the resident's hips. The old bandage was removed revealing a very large open and deep wound exposing the bone. The wound had a foul odor. The HWNP cleansed the inside of the wound with ampoules containing normal saline. The HWNP worked quickly to treat the wound. The HWNP then proceeded to remove some of the necrotic tissue from around the outer right edges and along the bottom of the wound, proximal to the gluteal fold using sterile tweezers and scissors. The resident moaned softly and briefly during the debridement and LPN #3 assured the resident in a soft tone that they would be done quickly. The HWNP did not apply a local anesthetic prior to the debridement and asked the resident if she was doing ok, while LPN #3 attempted to comfort and distract the resident. The wound measured 7.0cmx5.5cmx2.0cm and undermining of 6.0 cm at 11 o'clock. The HWNP then quickly applied the [MEDICATION NAME] into the wound bed with a gauze packing. The procedure was completed at 2:50 p.m. Record review: physician's orders [REDACTED]. Review of the 4/15 computerized physicians order (CPO) revealed the most recent skin/wound orders: -"skin assessment every Thursday on day shift; -barrier cream, apply to coccyx q (every) shift and as needed; -Coccyx wound: cleanse with wound cleaner (dry) or NS (normal saline), apply generous amount of [MEDICATION NAME] pack with 4x4's or 2x2's, cover with border adhesive foam as needed during the day for excessive drainage. Leave [MEDICATION NAME] 2x2 or 4x4 packing and only change daily and as needed if dressing comes off." Start date: 2/5/15. Review of the physician's telephone orders (T.O.'s) copies, provided from 9/14 through present 4/15, revealed evidence the facility was making wound order changes for the coccyx wound. The treatment (above) with the [MEDICATION NAME] had not been changed since 2/5/15. Review of a pressure ulcer risk evaluation dated 11/12/14 revealed the resident was at moderate risk for developing pressure ulcers. Coccyx/sacral wound: Review of the residents clinical record revealed a nurse note dated 6/27/14, which read in part, the resident had a new order for barrier cream to buttocks near coccyx area for an abrasion with every incontinent episode. Review of an incident investigation dated 6/27/14 at 12:00 p.m. read in part, the resident had an abrasion on the left buttocks and the incident was unobserved. The physician and family were notified. The report further revealed a certified nurse aide (CNA) called the nurse into the room to show a small abrasion on the resident's coccyx area just to the left. The steps taken to prevent re-occurrence were to monitor the area for increase in pain, injury, bruising, bleeding and signs of infection. The contributing factors were listed as dementia and [MEDICAL CONDITION]. Medications were listed as another contributing factor as well as incontinence and need for extensive assistance for transfers. In the section titled "possible cause for incident" it was documented that the injury was likely due to shearing. Immediate interventions initiated included barrier cream after each incontinent episode and the resident was to be seen by the wound doctor. There were no environmental hazards found to contribute to the resident's injury. There was no written statement from the CNA, who discovered the wound, to describe what the resident was doing at the time of the discovery to provide additional information to show how the shearing injury may have occurred. Evidence was provided on 4/15/15 (during the survey) at approximately 5:30 p.m. of an order invoice for a low air loss mattress for the resident and ordered by Hospice on 7/28/14 (30 days after the shearing injury occurred). Further review of the resident's physical clinical record revealed beginning on 7/1/14 through 2/3/15 an outside provider (wound doctor) began treating the residents wound at the facility. Review of the wound doctor's visit notes revealed in part, the resident was seen on a weekly basis, except on the following dates: 10/14/14, 10/21/14, 10/28/14, 11/4/14, 11/25/14, 12/9/14, and 12/16/14. On 7/1/14, first visit by the wound doctor, the wound was described as a shearing wound on the coccyx/sacrum and, beginning with his first visit through 2/3/15, included measurements of the wound. Measurements from the facility wound nurse are also included below: -7/1/14: 3.3cmx1.5cm with no measureable depth (wound doctor measurements). The wound was debrided on this date and the post-debridement depth was 0.3cm. -7/8/14: 3.0cmx2.0cm with no measureable depth (wound doctor measurements); -7/15/14: 3.0cmx0.9cm with no measureable depth (wound doctor measurements); -7/22/14: 1.6cmx0.7cmx0.3cm (wound doctor measurements; wound improved); -7/29/14: 4.1cmx1.7cmx0.3cm (wound doctor; deteriorated, generalized decline of patient, nutritional compromise and infection); -8/5/14: 3.6cmx2.7cm with no measurable depth (wound doctor measurements). Chemical cauterization was done to the wound due to hypergranulation of tissue; -8/12/14: 3.9cmx0.8cm with no measurable depth (wound doctor measurements). Chemical cauterization done; -8/19/14: 3.3cmx0.8cm.0.4cm (wound doctor measurements). The wound was debrided on this date and the post-debridement depth was 0.5cm. -8/26/14: 4.2cmx1.5cm with no measurable depth (wound doctor measurements); -9/2/14: 1.7cmx0.6cm with no measurable depth (wound doctor). Wound improved; -9/9/14: 1.8cmx0.6cm.0.4cm (wound doctor); From 9/16/14 through 12/31/14 the wound, as documented in the wound doctor notes was stable and not measuring above 1.9cm width and 1.2cm length. -12/30/14: 3.3cmx2.0cm (as documented by the facility wound nurse); -12/31/14: 1.9cmx1.2cm with no measurable depth (wound doctor). There was no explanation why the measurements by the wound nurse were different from the wound doctor just one day apart. -1/6/15: 2.9cmx2.2cmx0.6cm (wound doctor), wound deteriorating, Dakins solution (a strong antiseptic used to treat odorous wounds) added as part of the treatment. -1/13/15: 4.2cmx1.4cmx1.4cm (wound doctor). The wound was debrided on this date and the post-debridement depth was 1.5cm. The wound doctor noted he was doubtful the resident's previously stable wound would heal due to poor nutrition and overall deterioration requiring palliative care. -1/20/15: wound measurements unchanged from the previous week; -1/27/15: 4.5cmx2.2cmx1.9cm (wound doctor). The wound was derided on this date and the post-debridement depth was 2.0cm. -2/3/15 the wound doctor signed off care of the resident due to hospice taking over wound care. -2/26/15 per ECR nurse note the resident was identified with a new unstageable wound to the right bunion. The facility provided a notebook of handwritten measurements that were being logged by the facility wound nurse. The notebook was not part of the resident's clinical record and included information for other residents in the facility with skin/wound issues. The first page of the notebook log began on 8/19/14 through approximately the first week of 3/15. The notebook log did not provide any additional documentation by the facility wound nurse other than the measurements and location of the wound. Review of a log entitled "Monthly other skin issues report log" for 1/15 revealed evidence the resident had a shear to her coccyx and measurements were documented from 1/6 through 1/27/15 as follows: -1/6/15: 2.9cmx2.xcmx0.6cm; -1/13/15: 4.2cmx1.4cmx1.4cm; -1/20/15: 4.2cmx1.4cmx1.4cm; -1/27/15: 4.5cmx2.2cmx1.9cm. There was no measurements or description (i.e., exudates, slough, ecshar) of the wound by the facility wound nurse found for the weeks of 2/9/15, 2/16/15, 2/23/15, 3/2/15, 3/9/15, 3/16/15, 3/23/15. Review of a hospice progress note dated 2/5/15 revealed the HWNP had assessed the wound, provided debridement and measurements. The note documented in part the wound was a Stage IV coccyx wound with 100% black necrotic tissue measuring 4.5cmx3.0cmx3.0cm with bone present and a foul smell. The HWNP was only able to remove a small amount of necrotic tissue due to pain control. The wound was treated with the [MEDICATION NAME] and packed with gauze and a border foam dressing. The HWNP then instructed LPN #3 to check the dressing every 30 minutes times two hours for any bleeding. There was no further documentation found the HWNP had communicated the condition of the wound to the director of nursing (DON). Review of the hospice progress notes revealed the HWNP saw the resident again on 2/12/15 and performed another sharp debridement to the sacral wound. The wound was described to have 100% black eschar, moderate to large amount of foul smelling drainage. The note further documented the HWNP was unable to remove necrotic tissue from the wall secondary to the resident request to stop related to pain. The wound measured 5.0cm.3.0cmx4.0cm. The HWNP documented the measurements vary with position and the wound was unlikely to heal secondary to poor nutrition and continual decline. There was no further documentation found that the HWNP had communicated the condition of the wound to the DON. Review of a 2/19/15 hospice progress note revealed the HWNP provided wound care and debridement of a large amount of necrotic tissue from the sacral wound. The wound measured 6.0cmx3.0cmx4.0cm with undermining 3.0cm from 10 to 2 o'clock. There was no further documentation the HWNP had communicated the condition of the wound to the DON. Review of a 2/25/15 hospice progress note revealed the HWNP provided wound care to the sacral wound with partial debridement secondary to the resident having pain. The staff reported the sacral wound was worsening with increase in necrotic tissue. The wound measured 7.5cmx5.0cmx4.0cm with undermining 4.0cm from 6 to 12 o'clock with the sacral bone visible. The resident was identified with a new wound to the right first toe bunion, deep tissue injury and dark purple. There was no further documentation found in the hospice progress notes from the HWNP from 2/25/15 until 4/13/15 (during the survey) when the HWNP was in to see the wound and provide treatment as per the observation above. The regular hospice nurse manager continued to visit the resident during the above time frame and documented collaboration occurred with facility staff regarding the coccyx and bunion wounds. There was no evidence the hospice nurse actually visualized the coccyx wound during her visits. Review of a pressure ulcer log for 2/15 revealed the wound was measured on 2/3/15 and 2/10/15. There were no measurements for 2/18/15 or 2/24/15. Beginning in 3/15 through present there was a change in facility wound nurses. Wound measurements were no longer being kept by the previous notebook method, but were now being generated through the computer system and now the wound assessments including measurements were being placed in the resident's electronic record. Review of pressure ulcer log for 3/3/15 revealed the resident's sacral wound was not measured. On 3/12/15 the wound log revealed the resident's sacral wound was described as a Stage 4 pressure ulcer. The log documented that on 2/10/15 the wound (on the sacrum) measured 5.0cmx3.0cmx4.0cm. The wound was not measured or assessed by the physician on 3/12/15 related to the resident being on hospice. On 3/17/15 the wound log revealed the resident's sacral wound was described as a Stage IV pressure ulcer. The resident's wound was not measured or assessed by the physician on this date related to the resident being on hospice. On 3/19/15 the sacral wound measured 7.1cmx4.9cmx3.3cm. The wound was not assessed by the physician related to the resident being on hospice. On the 3/26/15 wound log revealed that on 3/24/15 the sacral wound measured 7.0cmx4.8cmx4.0cm. The wound was deteriorating further at this point and there was no evidence the wound was assessed by the physician related to the resident being on hospice. Review of a hospice nurse manager visit note dated 3/31/15 revealed the resident's right hip was red and to reposition with pillows. There was no further documentation the hospice nurse had measured the area of redness or that she collaborated with the facility nurse regarding treatment. On 4/1/15 the wound log revealed the sacral wound measured 5.5cmx5.5cmx3.1cm with undermining at 11:00 o'clock measuring 4.9cm. On 4/8/15 the sacral wound measured 6.3cmx5.2cmx2.4cm with undermining at 12:00 o'clock measuring 3.7cm. Review of a physicians progress note by the NP documented the sacral wound with the following measurements: 7.0cmx5.5cmx2.0cm with undermining of 6.0cm at 11 o'clock. Further review of the record revealed the wound treatment in place for the sacral wound had not been changed since it was first started on 2/5/15, when the hospice wound nurse began treating the wound. The wound continued to worsen. Review of the hospice nurse visit notes, found in a separate hospice binder, mentioned the resident had a coccyx wound and that the hospice nurse consulted with facility staff regarding the status of the wound. There was no evidence found that the hospice nurse was looking at the wound when she made her weekly visits. Furthermore, there was no documentation found of hospice nurse visits prior to 3/10/15 in the hospice binder of the resident's physical clinical record. Weekly Skin Assessments: Review of weekly skin assessments by the medication nurse from 7/3/14 through 12/25/14 revealed the wound to the resident's coccyx was mentioned twice. There was no evidence of weekly skin assessments conducted in 1/15 until 2/5/15. From 2/5/15 through 2/26 the wound to the coccyx was mentioned once. Beginning 3/5/15 through 4/16/15 the weekly skin assessments were being completed in the resident's electronic clinical record (ECR) and documented the resident with a pressure ulcer. ECR documentation from 3/5 to 4/16/15 (the last day of the survey) revealed the coccyx wound was mentioned twice and to see the hospice nurse orders and measurements. Review of the physicians/nurse practitioner progress notes from 7/14 through 4/13/15 revealed the providers identified the resident as having a coccyx/sacral wound. The visit notes by the primary physician described the wound as either a coccyx wound or a Stage IV sacral wound. -6/27/14 visit did not document the resident had any wounds; -7/3014 visit documented "coccyx wound, new orders;" -8/22/14 visit documented"coccyx wound per wound team;" -9/14 no physician visit note found; -10/9/14 visit did not mention wound; -11/14 no physician visit note found; -12/14 no physician visit note found; -1/2/15 visit, read in part, wound doctor was following the wound and the wound was worse per report due to the resident's trip home with power of attorney (POA). The physician documented the wound as a "coccyx decub;" -2/2/15 visit documented in part the coccyx wound per staff report was worse, deeper, wider and malodorous; -3/30/15 follow up visit note by the NP (wound specialist for hospice) documented in part the resident with a Stage IV sacral wound that was painful and improving per staff report with multiple sharp debridements. The note also mentioned an unstageable wound to the resident's right bunion; -4/3/15 follow up visit note by the NP (wound specialist for hospice), read in part, the resident was being seen, per hospice request, for the Stage IV sacral wound. The wound was debrided and measured and described as having foul smelling black eschar tissue. The recommendation was to continue the [MEDICATION NAME] treatment; -4/13/15 follow up visit (see observation above) by the NP (wound specialist for hospice) documented in part the resident was being seen for the sacral wound. The note documented the resident with a Stage I to the right trochanter. The note mentioned the resident tolerated well but did not document the NP had performed a dressing change with partial debridment. The note did not recommend any treatment for [REDACTED]. The note further documented the resident was in the final stages of death in the near future and to continue current regimen; Hospice. -4/15/15 the physician progress notes [REDACTED]." On 4/15/15 a letter by the resident's primary care physician (PCP) was provided by the facility and documented in part the resident was identified to have an abrasion wound on her coccyx and a wound specialist was immediately involved . The PCP documented the wound had deteriorated since first observed and he recognized the wound as a Kennedy ulcer (associated with end of life), unavoidable and not healable from the time it was first discovered. The letter documented after a month of aggressive wound treatment the resident was placed on Hospice care. Per record review the resident began Hospice on 7/25/14. Wound notes from electronic clinical record (ECR): Review of the current wound nurses' wound notes found in the ECR revealed wound note entries began the last part of 3/15. Prior to this, the wound was being tracked on the skin issues report logs (see above). Care Plan: Review of a skin integrity care plan initiated on 7/17/14 last revised on 11/13/14 and with a target date of 2/13/15, read in part, the resident had an actual skin integrity impairment; specifically, a wound to the sacrum. The care plan revealed the wound was related to expected continual deterioration to include poor nutrition status and end stage disease process and incontinence. The goal was the resident would have no complications related to the sacral wound through the review date. Interventions included in part preventing skin from excessive moisture, coordinate care with the hospice wound nurse (added 10/3/14), promote good nutrition and hydration, keep skin clean and dry, monitor labs, use a draw sheet or lifting device to move resident, weekly skin assessments per protocol and monitor/document location, size and treatment of [REDACTED]. The care plan did not include the resident's specialty mattress to include monitoring of the device settings, any specialty cushions in place as per the MDS or any type of turning schedule to reflect the resident's care needs for promoting healing of the wound. The care plan had not been updated since 10/3/14 to reflect the current status of the wound. Although evidence was found in the ECR the current wound nurse was doing weekly wound rounds beginning approximately the third week in March and other documentation occurring (above), there was no evidence of consistent skin monitoring as evidence by missing skin assessments and wound monitoring with measurements from the time the shearing injury occurred and turning into a Stage IV pressure ulcer. In addition, there was a failure to identify a large pressure area to the right hip. Prior to 3/15 wound measurements were kept in a "hand-written" notebook. Moreover, the resident's physician had never seen the wound (see below). Additionally, although the resident was being followed by the WD from 7/1/14 through 2/3/15, this did not excuse the facility from assuring the resident's skin and wound was being monitored in a consistent manner to include continuity of care and evidence of effective communication amongst all involved parties. Interviews: On 4/13/15 at 9:14 a.m. a certified nurse aide (CNA #11) entered the resident's room to provide cares. CNA #11 stated the resident had not been getting up out of bed in the past week and was declining. The CNA acknowledged the resident had a wound on her coccyx. The CNA stated she had seen her wound and it was pretty big and deep. The CNA confirmed the resident was incontinent of bowel and bladder. The CNA stated the residents "comfy chair" did not have a cushion in it and sometimes she would place a pillow on the bottom of the chair for the resident to sit on. The CNA was asked if she knew anything about the pump for the air mattress. CNA #11 stated she thought it had a green light and if it was not working it would make a beeping sound. She stated she did not and they didn't have anything to do with the pump and that hospice took care of that. On 4/13/14 at 9:20 a.m. LPN #3 stated the facility had a wound nurse that did rounds every Tuesday. LPN #3 stated there had been a recent change in wound nurses in the last month. The LPN stated the resident was being seen by the Hospice wound nurse and the facility wound nurse still did the weekly measurements. The LPN stated the nurses did the resident's wound treatment daily and weekly skin assessments. LPN #3 stated the regular Hospice nurse came in to see the resident twice a week and the hospice wound nurse at least weekly. The LPN stated the resident's wound had become worse because she was declining and not eating well. LPN #3 stated the resident's wound treatment had not been changed in awhile and the hospice wound nurse was [MEDICATION NAME] the wound. LPN #3 stated she believed the wound may have been caused by the wheelchair she was in before, prior to the comfy chair. On 4/13/15 at 2:26p.m. the HWNP was interviewed. The HWNP stated she saw the resident for wound treatment through the Hospice provider as well as doing alternate visits with the residents PCP. The HWNP stated she began seeing the resident for the wound around 2/5/15 wrote all the treatments and collaborated with the nurses. The HWNP described the wound as a sacral wound and because of the resident's immobility, decreased oral intake and overall declining condition the wound became unpreventable and non-healing. The HWNP stated she spoke with the director of nursing (DON) about the wound whenever she saw her, but mostly communicated with the floor nurse on the unit and was under the impression the floor nurse was the wound nurse. The HWNP stated she would be looking at the wound today (see above observation). The HWNP stated that depending on how you held the resident's skin and how she was lying, the measurements could vary significantly from one measurement to the other. The HWNP stated she was not able to see the resident for a few weeks

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible. Specifically, the facility failed to develop and implement a smoking policy and smoking practices that ensured the safety of residents, including five of 15 sample residents (#1, #6, #7, #2 and #4) who smoked and were known to be non-compliant with safe smoking practices. The findings include: Record review revealed that on [DATE], resident #1, known to be at risk for injury related to smoking, sustained second and third degree burns to his face, nose, and left chest area while smoking outside unsupervised with his oxygen on. Further record review revealed that approximately a month earlier, on [DATE], resident #1 was found under similar circumstances, smoking without supervision with his oxygen on. Staff interviews revealed that after the incident involving resident #1 on [DATE], residents #4 and #6 with smoking materials (lighter and pack of cigarettes) in their possession and two packs of cigarettes were found unsecured in resident #1's room. The facility's interim smoking policy implemented on [DATE], and revised [DATE], directed that all smoking materials be kept at the nurse's station. The facility's failure to adequately supervise residents who smoked and failure to enforce the facility smoking policy and smoking practices for safeguarding smoking materials, created a situation of immediate jeopardy for serious harm. I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY On [DATE], at 3:30 p.m., the nursing home administrator (NHA), the Director of Nursing (DON) and the owner of the facility, were informed by the Health Facilities and Emergency Medical Services Division (HFEMSD) of the State Health Department that the facility's failure to adequately supervise residents who smoked and failure to enforce the facility smoking policy for safeguarding smoking materials, created situation of immediate jeopardy for serious harm. The facility began implementing safety measures at this time with current smokers and smoking materials. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY The following allegation to remove Immediate Jeopardy was submitted by the facility on [DATE], at 9:55 a.m. Section 1: This section included a timeline of actions taken immediately after the incident involving resident #1 on [DATE], and included alarming the door to the outside courtyard to the designated smoking area and resident smoking assessments. Section 2: (1) " ... [DATE] Course of additional interventions: -Verbal checks q 15 min (every 15 minutes) checks continued (of all smokers). -Q shift (every shift) room checks (of all smokers). -New smoking material box with aprons (special smoking aprons that prevented burns/fires) and sign out sheet implemented on Unit 7. -Wing 7 door alarm connected to Wing 4 alarm panel unit; Unit 6 courtyard door secured. Staff was in-serviced on proper procedure min regarding alarm panel use. -Activities door alarm connected to Wing 4 panel. -In service of verbal q 15 min checks, room checks, smoking apron list and smoking times. Nurses instructed to place the names of smokers on the CNA (certified nurse aide) assignment sheets. -Ongoing resident and staff counseling available and as needed in the future (to deal with the traumatic death of resident #1). (2) [DATE] Course of additional interventions: -Verbal q 15 min checks continue. -Verbal room checks continue. -QA (Quality Assurance Meeting): -Q 15 min checks and q shift room checks (to search rooms of smokers for unauthorized smoking materials) formalized by committee. -Wing 4 Door Alarm log formalized by committee. -In service for staff r/t (related to) smoking policy, q 15 min checks, room checks, smoking apron list, smoking times, CNA notification of smokers on unit via assignment sheet formalized -Management follow-up procedure of formalized q 15 min checks and room checks for completion daily -Fire Safety in service with (name of) Fire Department (scheduled) on [DATE] at 1430 (2:30 p.m.) formalized (3) [DATE] Course of additional interventions: -Fire blankets obtained and available for immediate use. -Container for portable O2 (Oxygen) tanks while smokers smoke, obtained and placed in Unit 7 dining room. -Removal of ashtrays (open ones where butts could be reused by residents) from smoking area. -Install Aladdin smoker stations (tall containers with a base and a long tube-like opening that prevents butts being removed once dropped inside) for cigarette butt removal. (4) [DATE] Course of additional interventions: -Develop a smoking monitor schedule. -Implement a smoking monitor checklist. -Inform the smokers that the facility will be smoke and tobacco free (but all current smokers will be grandfathered in). -Offer assistance to smokers who want to quit, i.e. offer of assist with Nicorette gum, etc. -Initiate activities for smokers to assist with keeping them busy. (5) [DATE] Course of additional interventions: -Letter to family members to not bring smoking materials directly to the residents, they must be checked in at the nurse's station. -Inform residents/family members of process for non compliance. -Change Visitor sign in to include Time In, Who visiting, Time out. (6) [DATE] Course of additional interventions: -Hold Safety committee meeting. (7) [DATE] Course of additional interventions: -In-service staff on what to do if someone is on fire. -In-service on proper use of Aladdin smoker stations. (8) [DATE] Course of additional interventions: -Place signs that the facility is tobacco and smoke free. (9) [DATE] Course of additional interventions: -Monitor daily and per shift, all room search checklists and smoking resident checks. (10) [DATE] Course of additional interventions: -Update all CNA assignments sheets with pre-printed name of smokers and their special needs-smoking Aprons, etc. (11) [DATE] Course of additional interventions: -Make facility smoke free. -Grandfather in the current smokers. (12) [DATE] Course of additional interventions: -Install a camera in the smoking areas. Section 3: The leaves have been raked (in reference to the smoking area outside of Wing 7 dining room, which was a large covered patio surrounded by grassy areas) and the grass will be mowed in an effort to collect any cigarette butts that were missed with visual clean up. We will in-service the staff by [DATE], on how to properly dispose of cigarette butts. Housekeeping will empty the Aladdin smoker station cigarette butt containers weekly. The Aladdin smoker station containers are non-retrievable containers." The allegation to remove Immediate Jeopardy was signed by the NHA. C. REMOVAL OF IMMEDIATE JEOPARDY On [DATE], at 1:15 p.m., the NHA and owner were notified that the immediate jeopardy had been removed; however, deficient practice remained at a scope and severity of a G (actual harm). II. FAILURES IN SMOKING SAFETY PRIOR TO [DATE] A. PROFESSIONAL REFERENCES -According to the U.S. Food and Drug Administration FDA Consumer magazine November-[DATE], "Although oxygen doesn't burn, it does fuel the combustion process...Smoking anywhere near oxygen, even in the same room, can be extremely dangerous." -According to the FDA website, www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/UCM 6, "Section Contents Menu:" -"Safe Practices for Handling and Operating Oxygen Equipment, "Oxygen used in the medical profession can be very hazardous. Although oxygen does not burn, it does support combustion...Some general guidelines for minimizing the chance of fire are provided below: -Storage, Maintenance and Handling: *Do not allow smoking around oxygen." B. FACILITY POLICIES, PROCEDURES AND TOOLS IN EFFECT [DATE] 1. Smoking Safety Data Collection and Assessment Tool The facility did not formerly assess residents that smoked prior to the incident on [DATE]. The NHA, DON and owner confirmed during interviews on [DATE], that they did not do smoking safety assessments because it was their policy that all smokers were to be supervised. 2. Smoking Policy Review of the [DATE] (revised [DATE]) Smoking Policy, provided on [DATE], revealed it read in pertinent part: -"We provide our residents and employees as near a smoke-free environment as possible. While we recognize the need for many of our residents and employees to live and work in a smoke-free environment, we must also respect the rights of those residents and employees that choose to smoke. It is not our intent to establish a smoking policy based on moral judgments, or to deny one group of residents and employees rights over another. The intent of this policy is to establish a fair and equitable smoking policy that is in the best interests of the residents, employees and the company alike. Policy Guidelines ......Residents and Visitors -While this policy refers primarily to our staff, certain smoking restrictions apply to our residents and visitors. -Residents and visitors shall not be permitted to smoke in any area that is not designated as a smoking area. -The facility will establish a smoking schedule for residents. -A facility employee or adult visitor will supervise the residents when smoking. -For the safety of the residents and others, smoking is not permitted in resident rooms or corridors, but is permitted in certain designated areas. The facility will inform you of these areas during the resident's orientation to the facility. -Combustible items are prohibited in the resident's possession. Combustible items, such as butane, lighters, lighter fluid, and matches as well as smoking materials including, but not limited to, cigarettes, loose tobacco, papers, flints, cigars and pipes are prohibited in the resident's possession. Matches and lighters are available from staff. -No one is permitted to smoke in resident rooms. Reporting Violations -It is the responsibility of all personnel to report smoking violations. Violations should be reported to the employee's supervisor as soon as is practical. The various supervisors are responsible for enforcing these rules. -Visitors should be politely informed of our smoking regulations. If the visitor continues to violate our smoking policies, report such actions to the department head or the person in charge. -Inquiries concerning smoking regulation should be directed to the Administrator." The policy was signed, but not dated by the owner of the facility. C. RESIDENT FAILURES 1. Resident #1 Resident #1 sustained second and third degree burns on [DATE], after he caught on fire outside the building in the smoking area (outside of the main dining room on Unit 7), smoking while wearing his oxygen. Resident #1 expired approximately ten hours later in the hospital. Per Nurses' Notes, approximately a month earlier, the resident was found under similar circumstances, smoking unsupervised with his oxygen on. The facility had taken no measures between [DATE] and [DATE], to prevent the resident from engaging in unsafe smoking practices. a. Resident Status Sample resident #1, a [AGE] year-old male, was admitted to the facility on [DATE]. According to the face sheet and computerized physician orders [REDACTED]. According to the [DATE] quarterly Minimum Data Set (MDS), the resident had short-term memory impairments; was oriented to person, place and occasionally time. The resident demonstrated the ability to be understood and to understand others. Resident #1 had no behaviors or moods documented. The resident required limited supervision with activities of daily living and moved throughout the facility with the use of a walker. According to review of the resident's Medication Administration Records (MARs), resident #1 had a Wanderguard (device that triggers an alarm if the individual attempts to leave through an alarmed door), which was attached to his walker. According to the MAR, the nursing staff was to "check function of Wanderguard." It was initialed as being checked every shift and as being in proper working order. However, per a telephone conversation with the NHA and a facility Registered Nurse (RN) on [DATE] at 1:00 p.m., the door to the outdoor courtyard used for smoking was not alarmed on [DATE]; only the main entrance was set up to alarm if a resident with a Wanderguard went outside. Record review revealed the resident was dependent on continuous oxygen (O2). Interview with the NHA and a facility RN on [DATE] at 1:00 p.m., confirmed the rate of O2 flow was determined by the amount required to keep his O2 saturation level above 90%. The facility RN stated the resident was usually on 2 liters of O2 per minute, but occasionally received up to 4 liters of O2 per minute (LPM). The resident had a portable O2 tank attached to his walker. Review of resident's MAR, further revealed resident #1 took an antidepressant (Cymbalta 30 mg each morning) and an antipsychotic (Zyprexa 5 mg every evening) for schizo affective disorder, bipolar type. He had an order for [REDACTED]. Record review revealed the resident was his own responsible party. Review of the advance directive paperwork, revealed the resident had signed Do Not Resuscitate paperwork, indicating he did not want cardiopulmonary resuscitation (CPR) if his heart stopped or in case of respiratory arrest/malfunction on [DATE]. The physician co-signed the form on [DATE]. b. Known risks for unsafe smoking Record review revealed (see MDS above) that the resident had moderately impaired decision-making with poor short-term memory. He was noted to have dementia secondary to a traumatic brain injury sustained in an automobile accident. Record review revealed multiple references to resident #1's unsafe smoking practices. (1) Social Service (SS) Progress Notes -On [DATE] (no time listed), a SS entry in the resident's record, revealed the following (in pertinent part): "Annual care conference held this date, (neither) resident nor family in attendance. (Resident #1) is A&O (alert & oriented) X ,[DATE] (meaning he knew who he was, sometimes where he was and did not know date), able to voice needs, simple daily choices. He is a smoker and has difficulty adhering to smoking policy. He prefers to be in his room, reading or watching TV rather than being out among others ... " -On [DATE], "1420 (2:20 p.m.) Met with (resident #1) following reports from last two nights in which he was observed smoking unsupervised. He said "Another resident told him to go with him and they wouldn't get caught." (Resident #1) stated he did not have any cigarettes or a lighter with him and he gave writer permission to search his room. Writer along with social services assistant searched room with (resident #1) and no items were found. Writer informed him he had already received his last letter for non-compliance with facility smoking policy and that the next step was a 30 day notice. He was tearful and said, "I won't ever do it again. I don't want to leave." Writer informed him he needed to comply with facility policy and just say no when the other resident asks him to go (smoke) unsupervised. He said he would." -On [DATE], 1440 (2:40 p.m.) "...complying with facility smoking policy..." (SS did not document any knowledge of the rehearsal event that occurred on [DATE]. See above.) (2) Nurse's Notes (NN) -On [DATE] - "Resident transferred back to room #414A per his request (He had been in the 200 hall and was actually transferred to room #423A)." (This transfer put resident 156 feet from the door, from the main dining room, to the outside smoking area.) -On [DATE] - "Resident was continued on Chianti for smoking cessation though resident continues to smoke... " (NNs from [DATE] to [DATE], confirmed the resident continued to smoke the entire time he was on the Chantix, although Physician's Progress Notes documented the resident was not smoking.) -On [DATE], 1850 (6:50 p.m.) Resident found in smoking area unsupervised smoking with oxygen on. When asked to put out cigarette, (resident) did so on to nasal cannula tubing. Resident moved from smoking area and cigarettes confiscated. Informed he was to smoke supervised only. c. Facility Response to Resident's Smoking Risks (1) There were no specific orders from the physician with regard to the resident's smoking. (2) Smoking assessments and Smoking policy/Acknowledgments See above; according to the DON, the facility did not use smoking assessments prior to the incident on [DATE], because facility policy was for all smokers to smoke only while supervised. The DON stated there was no reason to assess their safety for that reason. The DON on [DATE], at approximately 3:30 p.m., provided an acknowledgment signed by resident #1 and dated [DATE], to show that the resident was made aware of the facility's smoking policy and agreed to it. The DON stated they did not update the acknowledgement once it was signed. The acknowledgement read in pertinent part: "...I am a smoker, and I have received the Smoking Policy. I agree to the conditions and understand that I must follow the facility policy for my safety, the safety of others, and the safety of property..." (3) Care Plan Review of the resident's comprehensive care plan, revealed problems identified [DATE] (and last reviewed [DATE]) included: "(resident #1) is a smoker ...Short Term Goal: (resident#1) will remain safe while smoking supervised at the facility through the next 90 days ...Approach: 1. All cigarettes and combustibles will be locked in nursing station. 2. Smoking in designated smoking areas and at supervised smoking times only, unless; 3. May smoke outside the designated smoking times only if accompanied/supervised by family, or friends outside of the facility. 4. Provide reminders of designated smoking times. 5. Has been provided facility smoking policy & signed stating understanding. 6. Non-compliance with policy will/may lead to further action by the facility. 7. Observe for unsafe bx (behavior) r/t (related to) smoking. Notify M.D., DON, Administrator, SS (social services) and family. The care plan was dated as being updated/reviewed on eight different dates (ranging from [DATE] until [DATE]). d. Facility Failures (1) Failure to investigate incident [DATE] See above; review of the SS notes, revealed no SS follow-up following the incident on [DATE], when the resident was discovered smoking unsupervised with his O2 on. There was no documentation that the [DATE] incident was investigated to determine how the resident obtained smoking materials. There was no documentation that safety interventions were reviewed or that the resident's care plan was revised to prevent a reoccurrence. Specifically, there was no plan to re-evaluate the resident's ability to smoke safely, no plan to increase resident supervision, and no plan to ensure the resident lacked access to smoking materials. (2) Failure to follow through, after [DATE] incident, on planned response to continued unsafe smoking practices. There was no documentation after the [DATE] incident, that the facility considered proceeding with a 30 day notice for discharge, even though SS notes [DATE] (referring to the previous two nights - ,[DATE] and [DATE] - when resident #1 was observed smoking unsupervised with another resident) stated, "Writer informed him he had already received his last letter for non-compliance with facility smoking policy and that the next step was a 30 day notice." e. Actual Harm Review of the hospital emergency department report ([DATE] at 5:56 a.m.), revealed documentation under "Physical Exam," which read in pertinent part: -General appearance: Unconscious, unresponsive. -Skin: Patient does have second and third degree burns to the face, neck, right shoulder, bilateral hands. Approximately 10% total burn. The resident was transferred to a hospital burn center where he expired. On departure to the burn center, the resident's primary [DIAGNOSES REDACTED]." His condition was "Critical." On [DATE], at approximately 3:00 p.m., a telephone interview was conducted with the County Deputy Coroner (he was also a physician) who investigated the death of resident #1. He reviewed the case with the surveyor and stated that due to the recent time frame (it had been 17 days since the death of resident #1) the final death certificate would be completed and issued within the week. He stated the preliminary cause(s) of death were: 1. Acute Coronary Failure 2. Due to and as a consequence of pulmonary compromise 3. Due to and as a cause of flash flame burn with inhalation (see definition below). The coroner indicated that he did not believe pain medications given to resident #1 for his injuries had contributed to his death. According to National Fire Protection Association <http://www.nfpa.org/categoryList.asp?categoryID=143&URL=About%20NFPA>. Per website review on [DATE]: -The NFPA is the world's leading advocate of fire prevention and an authoritative source on public safety, NFPA develops, publishes, and disseminates more than 300 consensus codes and standards intended to minimize the possibility and effects of fire and other risks. A flash fire is defined by the National Fire Protection Association 2113 as: "A rapidly moving flame front which can be a combustion explosion. Flash fire may occur in an environment where fuel and air become mixed in adequate concentrations to combust...flash fire has a heat flux of approximately 84 kW/m2 for relatively short periods of time, typically less than 3 seconds." 2. RESIDENT #6 Resident #6 had 12 episodes of noncompliance with facility smoking policy in the last nine months - smoking unsupervised, smoking in undesignated areas, and having combustibles in his room and on his person. a. Resident Status Sample resident #6, a [AGE] year-old male, was admitted [DATE], with diagnoses, per his face sheet, that included rehabilitation, history of a stroke with right sided weakness, seizures, dementia, depression and personality disorder. Although his native language was other than English, he was most often able to understand others and be understood. According to his Minimum Data Set (MDS) an annual assessment completed [DATE], the resident was oriented to person, place and date (within a few days). He was not documented to have any behaviors or significant mood changes. He required only supervision with all (activities of daily living), which included bed mobility, transfers, self propelled in wheel chair, dressing, eating, bathing, toileting and personal hygiene. b. Known risks for unsafe smoking See Physician Note [DATE] below; documentation that resident "forgets" he can not smoke unsupervised. "... Old CVA (cerebral vascular accident) with memory deficit." Record review revealed multiple references to unsafe resident #6's smoking practices. (1) Social Service Progress Notes -On [DATE] - Outside smoking unsupervised with another resident, warned it was the 2nd time he had been caught smoking unsupervised. -On [DATE] - Met with NHA warned if it happened again he would be given a 30 day discharge notice. -On [DATE] - Smoking unsupervised (Unless otherwise stated, "smoking unsupervised" referred to smoking in the smoking area, but without supervision and at unauthorized smoking time). -On [DATE] - Given 30 day discharge notice (However, facility unable to provide evidence of discharge notice given until [DATE]). -On [DATE] - Smoking unsupervised. -On [DATE] - Smoking unsupervised. -On [DATE] - Smoking unsupervised. -On [DATE] - Facility met with resident #6. He was warned of 30 day notice. -On [DATE] - 30 day discharge notice given. (Facility provided a copy.) -On [DATE] - Reported that resident #6 was smoking unsupervised over weekend. Was put on 15 minute checks. -On [DATE] - While still on every 15 minute checks, he was discovered smoking unsupervised. Refused to give cigarettes and/or lighter to nurse. -On [DATE] - Smoking unsupervised. -On [DATE] - Smoking unsupervised between lounge and patio. Refused to surrender cigarettes or lighter. Sat down on floor (from wheelchair) refused to get up, sat screaming to be left alone. -On [DATE] - 30 day discharge notice given. -On [DATE] - Smoking unsupervised, surrendered five packs of cigarettes and a lighter. Room search yielded a half a pack of cigarettes, butts inside a drawer, and four full packs in a carton in his room. -On [DATE] - Room search (after incident with resident #1- see above) yielded two cigarettes and a lighter. -On [DATE] - SS Note referred to resident #6 having been given a 30 day discharge "received last week", but no details. Also noted that SS reminded resident he was to wear a smoking apron (first reference to an apron). Spoke about the non-compliance with one friend on [DATE]. -On [DATE] - Called two (different than one noted [DATE] above) friends of resident #6 to speak to them about not bringing resident smoking materials, but instead to give them to nurse. (2) Nurse's Notes Review of NN from ,[DATE] through ,[DATE], revealed that not all of the episodes of non-compliance noted by SS were documented in the NN, but no additional incidents were recorded. (3) Physician Orders/Notes Review of the MD Progress Notes, revealed the following two entries: -[DATE] Special Visit - Request of Pt (patient). Smoking privileges - He is supervised. He feels he can smoke unsupervised. Supervision drives him crazy with anxiety... -[DATE] FU (follow up) to [DATE] visit - Discuss with Soc. Serv. - Everyone here smokes supervised. No one is unsupervised. Pt. Knows this, but forgets. I remind him...Old CVA (cardiovascular accident) with memory deficit - Reminded he must smoke supervised like everyone else..." c. Facility response to resident's risks (1) Smoking assessments and Smoking policy/agreements See above; the facility did not use smoking assessments prior to the incident on [DATE]. The facility policy was for all smokers to only smoke while supervised. The DON stated there was no reason to assess their safety for that reason. As evidence that the resident was made aware of the above policy and agreed to it, the SW provided an acknowledgment on [DATE], at approximately 1:10 p.m., signed by resident #6, dated [DATE], which was the date the facility initiated an investigation into the [DATE] incident involving resident #1. The acknowledgement read in pertinent part: "...I am a smoker, and I have received the Smoking Policy. I agree to the conditions and understand that I must follow the facility policy for my safety, the safety of others, and the safety of property..." (2) Care Plan Review of the resident's comprehensive care plan, revealed problems identified [DATE] (and last reviewed [DATE]) that included: "(resident #6) is a smoker ...Short Term Goal: (resident #6) will remain safe and compliant while smoking supervised throughout the next 90 days ...Approach: 1. Smoking in designated smoking areas during designated times. 2. Provide printout of rules and facility policy. 3. Provide reminders of designated smoking times. 4. Should non compliance with smoking policy occur notify DON, Administrator and S.S. 5. All cigarettes and lighters to be kept in secured area at all times. 6. Offer smoking apron d/t (due to) hx (history) of cigarette burns on clothing (that entry was dated [DATE]). 7. May smoke with friends/family during visits if supervised. 8. Notify M.D. if non compliant with policy." The care plan was dated as being updated/reviewed seven different dates (ranging from [DATE] until [DATE]). Under Comments/Outcomes, there were four incidents of non compliance noted. It read: -"[DATE] - (resident #6) has displayed non compliance with smoking policy AEB (as exhibited by) smoking unsupervised, having cigarettes/lighter on person. -[DATE] - (resident #6) has been issued 30 day notice of discharge d/t (due to) continued non compliance with smoking policy. -[DATE] - found smoking unsupervised with lighter in possession. Process of 30 day notice to proceed. -[DATE] - found today a.m. smoking unsupervised. Refused to turn in cigs & lighter." (3) Discharge Notice(s) The facility provided copies of two discharge notices. One was dated [DATE], and the other [DATE]. Both read, in pertinent part: "This letter serves as a 30 day Eviction notice and you must now find alternative placement at another facility. The reason for this eviction is due to non-compliance with the facility smoking policy. A copy of the policy was reviewed upon admission and has since been reviewed with you..." d. Facility Failures (1) Failure to prevent repeated incidents of unsafe smoking Review of the resident's care plan (see above), revealed there were no safety interventions added to the care plan, even though the resident remained noncompliant, except on [DATE], when it was noted to offer smoking apron due to history of burned clothing. There was no indication staff considered increasing resident supervision to prevent unsupervised smoking. There was no documentation that staff considered additional measures to prevent the resident from access to smoking materials. (2) Failure to follow through on planned response to continued unsafe smoking practices. There was no explanation why the facility had no follow-up on the 30 notices of discharge given to the resident for noncompliance with the facility's smoking policy over the past year when documentation revealed the resident's unsafe smoking practices continued. (Staff interviews (see below) revealed that discharges had been pursued, but no other facility wanted to admit residents with a history on non-compliance with smoking.) (3) The facility could not provide evidence that staff had ever reviewed the smoking policy with the resident (prior to the one dated [DATE]) to ensure he understood and agreed to the policy. The NHA stated on [DATE], at approximately 1:45 p.m., that the expectation was that all residents signed appropriate acknowledgments. 3. RESIDENT #7 Resident #7 had four episodes of noncompliance with facility smoking policy in the previous nine months - smoking unsupervised, smoking in undesignated areas, and having combustibles in his room and on his person. a. Resident Status Sample resident #7, a [AGE] year-old male, was admitted to the facility on [DATE]. According to the face sheet and computerized physician orders [REDACTED]. According to the [DATE] annual MDS, the resident was moderately impaired in his decision making ability; he was not oriented to person, place or time. He also had short-term memory problems. The resident rarely demonstrated the ability to be understood and to understand others. Resident #7 had no behaviors or moods noted. The resident required limited supervision with activities of daily living and moved throughout the facility with the use of a wheelchair. Review of resident's February/[DATE] Medication Administration Records (MARs), revealed resident #7 had a PRN (as needed) order for Valium for seizures. He had acetaminophen ordered for pain and had not used it during the months of February or [DATE]. According to review of his MARs, resident #7 had a Wanderguard (attached to his wheelchair per interview with the NHA on [DATE], at 1:00 p.m.). However, see above; the door to the outdoor smoking area was not alarmed. According to the MAR, the nursing staff was to "check function of Wanderguard every night." It was circled every day of the m

Based on record review, observations, resident interviews, and staff interviews, the facility failed to ensure three (#18, #103, and #196) of 34 sample residents received necessary treatment and services to prevent new sores from developing and to promote healing. Specifically: - Adequate interventions to prevent skin breakdown were not implemented for resident #18. Subsequently, her reddened coccyx worsened into two stage II pressure sores; and - Planned pressure sore prevention measures were not implemented for resident #103, and resident #196 was not regularly repositioned. The findings include: A. Professional References According to Pressure Ulcers in Adults: Prediction and Prevention (Bergstrom, Allman, Carlson, et al., 1992, page 15), "Any individual assessed to be at risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattress...For chair-bound individuals, the use of a pressure-reducing device such as those made of foam, gel, air, or a combination is indicated. Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every two hours if consistent with overall patient goals." B. Resident Failures 1. Resident #18, age 69, was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the face sheet, of adult failure to thrive, vascular insufficiency, [MEDICAL CONDITION], personality disorder, [MEDICAL CONDITION], coronary [MEDICAL CONDITION], and urinary tract infection. The 9/2/10 significant change MDS assessment documented the resident had a short-term memory problem and required modified independence with daily decision-making. She was usually able to make herself understood and usually able to understand others. The resident did not exhibit any mood or behavioral symptoms. The resident required extensive assistance with bed mobility, transfers, locomotion, and toilet use. The resident had no pressure sores but had a history of [REDACTED]. a. Record Review - Pressure Ulcer Risk and Stage I Pressure Ulcer The 7/28/10 pressure ulcer risk assessment documented the resident was at high risk for pressure sores due to her lethargy, chairfast status, incontinence, poor nutrition and fluid intake, predisposing diagnoses, and use of predisposing medications. A 7/8/10 care plan documented the resident was at risk for skin breakdown related to refusal to get out of bed and and poor food and fluid intake. The approaches included: encourage intake, encourage exercise, and remind and encourage repositioning. The 9/10 treatment administration record (TAR) documented, "At risk for skin breakdown FYI (for your information)." A 9/18/10 hospice skin assessment documented the resident had a stage one pressure sore to her coccyx and the surrounding tissue was fragile. The recommendations were: "air mattress (and protective barrier cream)." A 9/19/10 nurse's note documented hospice ordered a hospital bed with an air mattress and protective barrier cream to be applied twice daily and as needed for the reddened area to the coccyx. A 9/24/10 nurse's note documented the resident's coccyx was red and "brokendown." Protective barrier cream was applied several times. On the 9/10 TAR, the order to apply protective barrier cream twice daily was documented as completed from 9/22/10 to to 9/30/10. The 9/10 TAR documented, "Weekly Skin Assessment (every) Sat(urday)." On 9/13/10 and 9/25/10, skin assessments were completed. Though the TAR documented weekly skin assessments were to be done, there were no initials on the TAR on 9/4/10 and 9/18/10, documenting the weekly skin assessment was completed. - The 9/13/10 skin assessment documented the resident's coccyx was red. - The 9/25/10 skin assessment documented the resident had protective barrier cream applied to her coccyx. There was no evidence in the resident's medical record the resident's physician was informed of the reddened area to her coccyx. There was no documentation of a wound assessment when a stage I pressure ulcer was identified by hospice on 9/18/10. Also, there was no evidence the wound treatment nurse and interdisciplinary team were notified of the resident's stage I pressure ulcer to the coccyx. Likewise, there was no evidence the care plan was updated to address the new interventions put in place to prevent further breakdown (Cross-reference F281: Professional Standards and F280: Care Plan Revision). b. Observations On 9/27/10 from 3:21 p.m. to 4:30 p.m., the resident was intermittently observed lying on her back in bed. There was an air mattress overlay, which was turned on, lying on the floor at the foot of the bed. The resident was not lying on the air mattress overlay. On 9/28/10 from 10:40 a.m. to 4:00 p.m., the resident again was intermittently observed lying in bed with the air mattress overlay on the floor at the foot of the bed, turned on. She was not lying on the air mattress overlay. On 9/29/10 at 1:55 p.m., 2:40 p.m., 3:20 p.m., and 4:15 p.m., the resident was observed lying in bed. The air mattress overlay was lying on the floor at the foot of the bed; it was not on the bed. On 9/30/10 at 11:00 a.m., 1:20 p.m., and 2:20 p.m., the resident was observed lying in bed with the air mattress overlay lying on the floor at the foot of the bed. The resident was not lying on the air mattress overlay. c. Record Review - Development of Stage II Pressure Ulcers Two 10/2/10 wound assessments were completed. - One assessment documented that a stage II wound on the resident's right medial coccyx, measuring 0.9 centimeters (cm) by 0.3 cm was noted on 10/2/10. The wound was a new pressure ulcer. - The second assessment documented that another (second) stage II wound to the resident's coccyx, measuring 2.7 cm by 0.5 cm was noted on 10/2/10. The wound was a new pressure ulcer. A 10/2/10 physician's telephone order documented an order, written by the wound treatment nurse, to apply a dressing every other day to the resident's coccyx. The order was not signed by the resident's physician. A 10/2/10 nurse's note documented that an order for [REDACTED]. A 10/4/10 hospice nursing note documented the resident had a stage II wound on her coccyx that measured 8 cm by 3 cm. There was no evidence in the resident's medical record her physician had been informed of the new open wounds. d. Wound observations On 10/4/10 at 10:23 a.m., a dressing change completed by licensed practical nurse (LPN) #13 with the wound treatment nurse present was observed. The resident's coccyx had open areas with a moist wound bed and a scant amount of serous drainage. The skin surrounding the wounds was pink. LPN #13 applied gloves, then touched the resident's bed side table and assisted the resident to roll over. He then prepped the skin surrounding the wounds and applied the dressing with the same gloved hands. LPN #13 assisted the resident back to her original position and adjusted the nasal cannula, then removed his gloves and washed his hands. The LPN failed to don clean gloves prior to prepping the resident's skin and applying a clean dressing to the wound (Cross-reference F441: Infection Control). e. Staff Interviews On 9/28/10 at 10:55 a.m., LPN #15 stated the resident had a reddened area on her coccyx, but did not have any pressure sores. On 10/4/10 at 9:45 a.m., LPN #13 stated the resident's coccyx area opened over the weekend and the resident now had stage II pressure ulcers separated by a crease on the coccyx. He stated the previous order to apply protective barrier cream was discontinued and a dressing was now ordered to be applied every other day. On 10/4/10 at 11:32 a.m., the assistant director of nursing (ADON), who was the wound treatment nurse, stated the resident had two stage II open areas side by side on the coccyx. - The ADON stated she did not know how long the area was red before it opened. She stated the first time the area was reported to her was the morning of 10/2/10. She stated she was unaware of the reddened area to the resident's coccyx before 10/2/10. - The ADON stated she would immediately complete a wound assessment of a stage I wound if she was notified, but she was not alerted to the stage I wound until it had opened and worsened to a stage II. The ADON stated the resident was using an air mattress overlay for pressure sore prevention. On 10/4/10 at 11:37 a.m., unit manager (UM) #4 stated the resident now had a stage II wound to her coccyx. He stated he was unsure how long the skin was red and had not heard of any problems to her coccyx area until the morning of 10/2/10. The UM stated the air mattress overlay should have been on the bed after it was recommended by hospice on 9/18/10, and he was unsure why it was not. He stated there were no mechanical problems with the overlay. He stated the lack of the air mattress overlay could have contributed to the opening of the wound. On 10/4/10 at 11:45 a.m., the UM stated he asked the resident, but she did not state that she had ever removed the air mattress during the last week. The resident did not know why the air mattress overlay was not on her bed from 9/27/10 to 9/30/10 (see observations above). On 10/5/10 at 8:00 a.m., the on-call physician working with the resident's primary physician stated he was not familiar with the resident's care and whether the physician was involved in the treatment of [REDACTED]. He stated he would have the resident's primary physician follow-up. On 10/5/10 at 5:20 p.m., the primary physician stated he was unsure whether he was notified of the resident's red coccyx or the development of the pressure ulcer. He stated he would review the resident's record and follow up. The primary physician did not contact the surveyor by the deadline to provide additional information (10/8/10). f. Facility Follow-Up On 10/4/10, the ADON provided in-service training to nursing staff regarding skin assessments, documentation and notification of changes in skin condition, and checking resident equipment. 2. Resident #103, age 81, was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses, according to the physician order [REDACTED]. The 6/7/10 annual MDS assessment documented the resident had a short-term and long-term memory problem and was coded as severely impaired with daily decision-making. She was not able to make herself understood and sometimes understood others. The resident did not exhibit any mood or behavioral symptoms. - The resident required total assistance with all activities of daily living. - The resident had no pressure sores and a history of one resolved pressure ulcer. She received nutrition/hydration interventions, pressure reducing devices for the bed and chair, applications of ointments/medications and other preventative or protective skin care to prevent pressure sores. A 6/28/10 significant change MDS assessment documented the resident had a short-term and long-term memory problem and was coded as severely impaired with daily decision-making. She was not able to make herself understood and sometimes understood others. The resident did not exhibit any mood or behavioral symptoms. - The resident required total assistance with all activities of daily living. - The resident had two stage II pressure sores and a history of one resolved pressure ulcer. She received nutrition/hydration interventions, pressure reducing devices for the bed and chair, ulcer care, applications of ointments/medications and other preventative or protective skin care to prevent pressure sores. a. Record Review The resident's care plan documented the resident was at risk for pressure ulcer development related to dementia diagnosis, incontinence, decreased mobility and history of pressure wounds. - The care plan also identified the resident had bilateral heel wounds and a slit on her coccyx. - The approaches included: medications as ordered, labs as ordered, diet as ordered, offer fluids with and between meals, pressure ulcer risk assessment quarterly and PRN, showers as ordered, turn and change positions frequently as tolerated, wound dressings as ordered, wound rounds once a week, skin assessment weekly, Trinova mattress, pillow between knees at all times and involve hospice nurse when available. Review of the resident's 9/10 and 10/10 Computerized Physician order [REDACTED]. The 10/10 Treatment Administration Record (TAR) documented the following interventions/preventions occurred: on 10/1, 10/2, 10/3, 10/4 and 10/5, the resident was turned twice a shift, she was in her reclining foam comfort chair on wheels when she was out of bed, santyl was applied to both heels and covered with poly-mem, poly-mem was applied to her coccyx once a day, resident was up 30 minutes prior to meals, and 30 minutes after meals, a pillow was placed between her knees at all times, and the resident used the Trinova mattress. b. Observations On 9/30/10 at 9:35 a.m. the resident was observed in her room sitting in her comfort chair. The resident's heels were resting on a pillow and the resident stated she was wet. The Unit Manager #1 and CNA #10 were observed transferring the resident from the chair to the bed when it was noticed that the resident did not have a wound dressing on either heel. The resident's nurse performed wound care and applied new heel dressings. The resident did not complain of pain during the treatment. During several observations on 10/3/10 at 9:00 a.m., 10:15 a.m. and 11:45 a.m., the resident was observed in her room sitting in her oversized chair, rather than in her bed as ordered. The resident did not have a pillow between her knees. During an interview on 10/3/10 at 12:00 p.m. CNA #10 stated the resident had been up in her chair since breakfast and he was going to lie her down after lunch. During an observation on 10/4/10 at 3:45 p.m., the resident was observed lying in bed. CNA #12 was asked to pull the covers down so that the resident's feet could be observed, as well as bed positioning and this was done with the resident's permission. The resident was observed to not have a pillow between her knees and when the CNA lifted the resident's feet, the right wound covering fell off. The CNA quickly re-applied the dressing to the right heel. The left heel dressing was intact. The CNA repositioned the resident in bed and when she pulled the resident up she yelled, "that hurts" and began to cry. The CNA calmed the resident, floated the resident's heels on the bed, and placed a pillow between her knees. On 10/4/10 at 4:00 p.m., change of the dressings on the resident's bilateral heels and coccyx by floor nurse was observed. - The nurse washed hands, applied gloves, and assessed the wounds to bilateral heels. The dressings to heels at that time were not attached to heels; the heels were resting on the dressings. The right heel had loose eschar, skin surrounding the wound was pink. The left heel had firmly attached eschar, skin surrounding the wound was pink. - The nurse removed the dressings from under the heels, removed his gloves, washed his hands and applied new gloves. He applied new dressings to the heels and then removed his gloves and washed his hands. After the surveyor asked about the dressing on resident's coccyx, the nurse applied gloves, assisted resident to a side lying position to assess this dressing. The coccyx dressing was coming off; the nurse removed the dressing, applied new dressing, removed gloves and washed his hands. c. Staff Interviews During an interview on 9/27/10 at 4:28 p.m. Unit Manager #1 identified that the resident had bilateral heel wounds, she was not sure what stage the wounds were, and that the resident had a doctor's order from Friday which identified an open area on coccyx. The Unit Manager was not sure if the coccyx wound was caused from sheering or pressure. Further discussion revealed the resident was followed by the wound team, she had a Trinova mattress and was turned 2x/shift. Finally, the manager said the wound team met every Thursday and did rounds. During an interview on 9/30/10 at 9:38 a.m., the Assistant Director of Nursing (ADON) stated that the resident's wounds should have been covered and staff was not aware how long the dressing had been off. The ADON indicated the resident had a wound infection. She said the wound team did rounds every Thursday, wound measurements were taken at that time, as well as discussion regarding treatment effectiveness and changes to the plan of care. The dietary manager was also a part of the wound team. During an interview on 9/30/10 at 9:40 a.m. the Unit Manager #1 agreed that the resident's heels should have been floated, not resting on the pillow. (See observations above) The Unit Manager said the Trinova mattress distributes pressure on pressure points and, because of this, the resident's heels were not to be floated when the resident was in bed. During an interview on 9/30/10 at 9:10 a.m., nurse #5 and the resident's hospice nurse discussed that the resident had the heel dressings on at 3:00 p.m. the day before, and the resident had not received a bath. The hospice nurses stated that the resident's heels were always dressed during her visit and this was the first time she had seen the dressings off. During an interview with CNA #12 on 10/4/10 at 4:40 p.m. she said she was not aware the resident's heels should not be floated while in bed, and she was not aware of the purpose and protocol for the Trinova mattress. The CNA reported that the resident should be turned and changed every two hours. During an interview on 10/4/10 at 4:45 p.m., Unit Manager#1 stated that CNA #12 may not have known the resident's current treatments as she just returned from a leave of absence. During an interview on 10/5/10 at 9:17 a.m. the staff development coordinator (SDC) discussed that staff re-orientation depended on how long the staff member had worked for the facility, how long they had been gone, and whether they were able to return to their previous unit. She stated that staff is always oriented to new residents, nursing gives the CNA's report and an assignment sheet, but all staff should be trained/oriented prior to or at the time of care. The SDC stated she had spoken with CNA #12 and she was re-oriented to the unit and special equipment today. Information was also provided which showed that CNA #12 had received staff education regarding the use and benefit of the Tri-nova mattress. 3. Resident #196 was admitted t the facility on 6/21/10. Her [DIAGNOSES REDACTED]. a. Resident status According to the MDS dated [DATE], the resident had short-term and long-term memory problems. Her cognitive skills for daily decision-making were severely impaired. She was incontinent of bowel and bladder. According to the facility weight records on 9/22/10 the resident's weight was 95 pounds. A pressure ulcer risk assessment, dated 6/21 (no year available), scored the resident at 8, indicating that the resident was at high risk for skin breakdown. There was no care plan addressing resident's risk for skin breakdown. However, an acute care plan, dated 8/19/10, indicated the resident had a reddened area on her coccyx. Interventions included lie resident down, pain assessment, wound team to assess and treat/orders. Computerized Physician order [REDACTED]. b. Observations On 9/29/10 at 1:16 p.m. resident #196 was observed in her room in Broda chair with lap tray on. She was restless, fidgeting, and calling out. At 1:22 p.m. the resident was moved to nurses' station to sit with nurses. At 2:00 p.m. the activity assistant sat with resident for 15 minutes. At 2:30 p.m. the CNA and Licensed Practical Nurse (LPN) assisted the resident to bathroom. At 2:34 p.m. the resident assisted back into the Broda chair and the lap tray applied. They Broda chair was placed in a reclining position. Resident was restless, fidgeting, and calling out. At 4:00 p.m. the resident remained in same position, continued to be restless, fidget, and called out. On 9/30/10 at 9:04 a.m., resident #196 sat in doorway of her room in Broda chair with lap tray on, restless and crying out. At 10:00 a.m. the resident appeared calmer and was not calling out. At 10:30 a.m. the resident was in her room sleeping in Broda chair with the lap tray on. At 11:15 a.m. the resident continued to sleep in Broda chair in the same position. At 11:30 a.m. the resident assisted to dining room by the CNA, seated against wall in the Broda chair with the lap tray on. The resident's meal was placed on the lap tray. At 1:00 p.m. the resident assisted back to her room where she remained in the Broda chair. c. Staff interview Interview with floor nurses on the 200 hall on 9/30/10 at 3:00 p.m., the nurses stated the resident stays in the (Broda) chair with the lap tray on all day because she rolls out of bed and is restless. Interview with Certified Nurse Aide (CNA) on the 200 hall on 9/30/10 at 3:30 p.m., the CNA, too, stated that the resident stays in the (Broda) chair with the lap tray all day because she moves around a lot and rolls out of bed all the time.