Every finding on record at Parker Post Acute

Based on record review and interviews, the facility failed to provide emergency basic life support and cardiopulmonary resuscitation (CPR) when needed for one (#1) of three residents reviewed for advance directives out of seven sample residents.Resident #1 was admitted to the facility on [DATE] with a history of acute and chronic respiratory failure and aspiration pneumonia.On [DATE], the power of attorney for Resident #1 completed and signed a Colorado Medical Orders for Scope of Treatment (MOST). The MOST form documented Resident #1 desired to receive CPR with full treatment in the event it was required. On [DATE], a physician's order was entered into Resident #1's electronic medical record (EMR) that identified Resident #1 was a full code and should receive CPR. Additionally, the profile screen in Resident #1's EMR record revealed Resident #1 had an advance directive for full code/CPR. On [DATE] at 2:30 a.m. registered nurse (RN) #1 heard a scream from Resident #1's room. When RN #1 entered the room, he heard and observed Resident #1 and his spouse discussing the continued use of an arm sling. While in the room, Resident #1 complained of shortness of breath. RN #1 assessed Resident #1 and initiated a nebulizer breathing treatment. RN #1 remained with Resident #1 during the breathing treatment and, after the treatment, determined Resident #1 had oxygen saturation (measure of oxygen in the blood) readings over 90% and the resident was stable. On [DATE] at 2:57 a.m. RN #1 returned to Resident #1 and found Resident #1 was unresponsive in his bed. RN #1 exited the room and instructed certified nurse aide (CNA) #1 to call 911 and to call the nurse from another floor to respond for assistance. RN #1 retrieved a portable oxygen cylinder and returned to Resident #1 and began CPR. RN #1 provided CPR for approximately three minutes. RN #1 stopped CPR, exited the room and went to the nurses' desk to verify the code status on Resident #1's MOST form.At 3:02 a.m. RN #2 and CNA #2 arrived at Resident #1's room with the emergency response (crash) cart. At the same time, a law enforcement officer arrived at Resident #1's room carrying an automatic external defibrillator. RN #1 entered Resident #1's room after the law enforcement officer and informed the officer and other staff members present that Resident #1's had a MOST form that identified that Resident #1 had a do-not-resuscitate advance directive, and CPR was not resumed. Resident #1 was pronounced deceased at 3:07 a.m.-However, Resident #1's code status indicated the resident wanted CPR.Specifically, the facility failed to:-Provide CPR for Resident #1 until relieved by emergency medical services personnel; and,-Ensure staff received education and training to accurately verify advance directives during an emergency.Findings include:I. Findings of Immediate Jeopardy A. Situation of immediate jeopardyThe facility failed to provide CPR for Resident #1 until relieved by emergency medical services personnel. Additionally, the facility failed to ensure staff had education and training to accurately verify advance directives during an emergency.B. Facility notice of immediate jeopardyOn [DATE] at 2:25 p.m., the nursing home administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #1 received basic life support and CPR according to his advance directives.C. Facility plan to remove immediate jeopardyOn [DATE] at 6:21 p.m. the NHA provided a plan to remove the immediate jeopardy situation. The plan read: 1. Immediate action On [DATE] the facility completed an investigation regarding the initiation of basic life support and CPR for Resident #1. The root cause analysis of the CPR event revealed areas of concern related to staff education and emergency response for Resident #1.2. Identification of others An audit was completed on [DATE] by the director of nursing (DON) and/or a designee. The audit included a review of direct care staff for current competencies for CPR, code status verification, accurate MOST form review, and communication of correct code status to emergency medical services personnel.Additionally, on [DATE], audits were completed to ensure all residents had current MOST forms with code status documentation, physician orders in the EMR, CPR, and code status competency.3. Systemic changesBeginning [DATE], all newly hired and agency staff would receive education before providing direct care regarding code status verification, initiation of CPR, emergency response expectations, and CPR protocols to transfer care or discontinue CPR. The DON educated all nursing staff on following the physician's orders for emergency resuscitation, and if they had questions or concerns about any order, they must notify the provider and document the reasons for the concern. 4. MonitoringOn [DATE], the facility would conduct weekly audits of 10 residents to verify code status accuracy, MOST form accuracy, accessibility to direct care staff, and to ensure code status was correctly documented consistently across documentation systems. The audit results would be reviewed weekly by the interdisciplinary team (IDT) for effectiveness. D. Removal of immediate jeopardyBased on the facility's plan above, the immediate jeopardy was removed on [DATE] at 6:21 p.m. However, deficient practice remained at a G level, actual harm that was isolated.II. Facility policy and procedureThe CPR policy, revised [DATE], was provided by the NHA on [DATE] at 11:10 a.m. The policy read in pertinent part,It is the policy of this facility to provide basic life support, including CPR, to any resident requiring such care before the arrival of emergency medical personnel.The facility will have staff certified in CPR available 24 hours a day to provide basic life support and CPR before the arrival of emergency medical services personnel.If a resident experiences a cardiac or respiratory arrest and the resident does not show clinical signs of irreversible death, the facility staff must provide basic life support, including CPR, before the arrival of emergency medical services for all residents who have requested CPR in their advance directives or as designated in related physician orders.III. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included right arm fracture, acute and chronic respiratory failure, aspiration pneumonia, dysphagia (difficulty swallowing), atrial fibrillation (abnormal heart rate) and pulmonary high blood pressure.The [DATE] minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. C. Record review1. Care planThe oxygen therapy care plan, initiated [DATE], revealed Resident #1 required oxygen therapy due to ineffective respiratory function. Pertinent interventions included giving medications as ordered, monitoring and documenting side effects and effectiveness of oxygen therapy, monitoring for symptoms of respiratory distress and reporting the symptoms to the physician as needed and administering oxygen as ordered.2. Progress notes and assessmentsThe [DATE] nurse progress note, documented at 7:52 a.m., revealed that at 2:30 a.m. RN #1 heard a scream from Resident #1's room. When RN #1 arrived, Resident #1 said he was uncomfortable and wanted his right arm sling removed. The progress note revealed Resident #1 then complained of feeling short of breath. RN #1 administered a nebulizer treatment that was ineffective, and Resident #1's oxygen saturations remained below 90%. The resident declined being transferred to the emergency department. The progress note revealed that after the nebulizer treatment, RN #1 applied oxygen at a flow rate of 5 liters per minute (LPM) via a non-rebreather mask. RN #1 documented the oxygen saturation was 93% to 94% and noted Resident #1 was stable. The progress note revealed that after 20 to 25 minutes, RN #1 returned to Resident #1 and found Resident #1 not breathing and with no pulse. The progress note revealed Resident #1 was confirmed to have an advance directive with full code status and full treatment. Paramedics arrived and confirmed Resident #1 was not breathing and had no pulse.-Review of the EMR did not reveal any further documentation regarding the CPR event on [DATE].Review of the [DATE] CPO revealed a physician's order that identified Resident #1 was a full code and should receive CPR, ordered on [DATE]. Additionally, the profile screen in Resident #1's EMR record revealed Resident #1 had an advance directive for full code/CPR. D. Video surveillance review and timelineThe [DATE] facility's video surveillance review was received from the NHA on [DATE] at p.m. The surveillance review revealed the following timeline of events:-At 2:57 a.m. RN #1 entered Resident #1's room.-At 2:58 a.m. RN #1 exited the room, retrieved a portable oxygen cylinder, and returned to Resident #1's room. CNA #1 used the telephone and called 911 and the upstairs floor staff. -At 3:01 a.m. emergency medical services (EMS) arrived at the entrance to the facility.-At 3:02 a.m. RN #1 exited Resident #1's room, and RN #2 and CNA #2 entered Resident #1's room with the crash cart.-At 3:03 a.m. EMS entered Resident #1's room.The [DATE] facility's event timeline was received from the NHA on [DATE] at 2:31 p.m.The timeline revealed that on [DATE] at 2:30 a.m., Resident #1 yelled out and RN #1 responded. Resident #1 complained of discomfort from the right arm sling, and then shortness of breath. RN #1 administered a nebulizer treatment that was ineffective, and Resident #1's oxygen saturations remained below 90%. Resident #1 declined being transferred to the emergency department.The timeline documented that after the nebulizer treatment, RN #1 applied oxygen at a flow rate of 5 LPM via a non-rebreather mask. RN #1 documented the oxygen saturation was 93% to 94% and noted Resident #1 was stable.Twenty to 25 later, RN #1 returned to Resident #1's room to reassess Resident #1 and found Resident #1 not breathing and without a pulse. RN #1 initiated CPR and directed CNA #1 to notify EMS and retrieve the crash cart.-EMS arrived and confirmed Resident #1 had no pulse and no respiration, and death procedures were initiated. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on [DATE] at 8:24 a.m. LPN #1 said she had worked in the facility for over 18 months and was involved in admitting residents. LPN #1 said the admission packet included paperwork with a blank MOST form that was completed with the resident and/or responsible party. LPN #1 said that after the MOST form was completed, the admitting nurse entered the resident's desired advance directives into the EMR. LPN #1 said the MOST form was then placed in a binder at the nurses' station for the provider to review and sign. LPN #1 said the MOST form was used to clearly identify if a resident wanted to be a full code or do not resuscitate, and what level of care was desired, such as full treatment or comfort care. LPN #1 said she was not aware of any CPR outcomes in the previous week where code status was mistaken and led to staff withholding CPR. LPN #1 said education about CPR and emergency response had been provided in approximately [DATE], and was from computer-based education. LPN #1 said that if she found an unresponsive resident, she was able to verify code status using her shift report sheet, using the EMR, or referencing the MOST form binder at the nurses' desk. LPN #1 said in nursing school, she was taught that once CPR was initiated, CPR was not stopped until emergency services personnel arrived or if the rescuer was physically unable to continue CPR. CNA #3 was interviewed on [DATE] at 8:41 a.m. CNA #3 said she had worked at the facility for over three years and had a current CPR certification. CNA #3 said she maintained a current CPR certification, but was unsure if she was required to have the certification for her position. CNA #3 said she was aware of the resident's code status by referring to her report sheet. CNA #3 said she was unsure who verified each code status and who updated the report sheet. CNA #3 said that if she were unsure of a resident's code status, she would verify with the nurse. CNA #3 said that if she found a resident unresponsive, she would call out for help from coworkers and initiate CPR. CNA #3 said she had not had recent education or training on verification of advance directives or CPR protocol regarding the initiation and stopping of CPR. The DON was interviewed on [DATE] at 9:50 a.m. The DON said she reviewed the [DATE] CPR event in the morning of [DATE]. The DON said she spoke to RN #1 on [DATE] (the day after Resident #1 passed away). The DON said after RN #1 determined Resident #1 was unresponsive, he left the room to ask CNA #1 to call 911. The DON said RN #1 grabbed an additional oxygen cylinder and returned to Resident #1 and initiated CPR. The DON said RN #1 was rushing from the heat of the moment, and while providing CPR, RN #1 thought that he had tried to wake up the sleeping spouse to talk about CPR. The DON said RN #1 was unable to wake the spouse and left the room to verify advance directives and code status on the MOST form. The DON said RN #1 should not have stopped CPR until he was relieved, but had just wanted to make sure he was doing what Resident #1 desired. The DON said on [DATE], during the quality assurance meeting, the committee discussed reviewing the process for direct care staff to quickly and accurately identify advance directive/code status for residents so that future CPR events would not be delayed. RN #1 was interviewed by telephone on [DATE] at 4:49 p.m. RN #1 said he was assigned to care for Resident #1 on [DATE]. RN #1 said that at 2:30 a.m., he heard a scream from Resident #1's room, and when he entered the room, he observed Resident #1 and his spouse arguing about whether or not to remove his arm sling. RN #1 said Resident #1 then complained of shortness of breath. RN #1 said he completed an assessment and offered to transfer Resident #1 to the emergency department, but Resident #1 declined. RN #1 said he offered and administered a nebulizer treatment with a medication used to open up respiratory airways. RN #1 said the nebulizer treatment was ineffective, and Resident #1's oxygen saturations remained below 90%. RN #1 said he then placed a non-rebreather mask on Resident #1 with an oxygen flow rate of 5 LPM and that was effective to raise the oxygen saturation to 90% to 93%. RN #1 said Resident #1 was then stable, and he left the room to care for other residents assigned to him. RN #1 said he returned to reassess Resident #1 at 2:57 a.m. and found Resident #1 was not breathing and did not have a pulse. RN #1 said he went quickly to call out for CNA #1 to call 911, and he obtained another oxygen cylinder and returned to initiate CPR for Resident #1. RN #1 said that he thought Resident #1 was not revivable but that he should initiate CPR anyway. RN #1 said he provided CPR for a few minutes and then left the room to verify the advance directive/code status for Resident #1. RN #1 said that as he left the room, RN #2 and CNA #2, who was working upstairs, were heading to Resident #1's room with the crash cart. RN #1 said he went to the nurses' station and used the MOST form binder to locate Resident #1's MOST form. RN #1 said that he noted on the MOST form that it indicated an advance directive was do not resuscitate and returned to Resident #1's room to update caregivers. RN #1 said when he entered the room, RN #2, law enforcement, and paramedics were present. RN #1 said that he informed EMS providers that Resident #1 had a do-not-resuscitate advance directive. RN #1 said that it was then discovered he had referenced a MOST form from another resident. RN #1 said that when the error was discovered, the spouse declined further CPR. RN #1 said the event happened in a very quick sequence, and he thought to himself that while doing CPR, he should confirm code status and needed to leave the room to confirm advance directives. RN #2 was interviewed on [DATE] at 5:29 p.m. RN #2 said he and CNA #2 responded to the CPR event on [DATE] from an upstairs floor. RN #2 said they arrived at Resident #1's room with the crash cart at the same time the law enforcement officer arrived with an automatic external defibrillator. RN #2 said RN #1 informed EMS personnel that Resident #1 had a do-not-resuscitate order, and when it was discovered the incorrect information was provided, EMS and the spouse determined Resident #1 had expired, and CPR was not resumed. The NHA was interviewed on [DATE] at 2:53 p.m. The NHA said that on [DATE] (during the survey), the facility completed an ad-hoc (impromptu) quality improvement meeting and initiated a plan of correction for CPR/code response. The NHA said on [DATE], he initiated policy education with direct care staff regarding CPR initiation, the continuation of CPR until relieved, and correctly verifying code status.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#64) of three residents out of 62 sample residents. Resident #64, was admitted on [DATE] with a diagnosis including sepsis, acute respiratory failure, congestive heart failure, pneumonia and pressure-induced deep tissue damage of the left ankle. Resident #64 said he experienced pain when the staff were repositioning him. Observations revealed while the staff were repositioning Resident #64, he cried out in pain and asked the staff to stop. The staff continued care despite the resident crying out in pain and did not stop to reassess the resident to ensure he did not suffer from additional pain. Specifically, the facility failed to stop providing care and reassess Resident #64 when he cried out in acute pain. Findings include: I. Facility policy and procedureThe Pain Management policy, revised January 2026, was provided by the nursing home administrator (NHA) on 3/12/26 at 8:39 p.m. It read in pertinent part, The facility will assess each resident for pain to maintain or achieve the highest predictable level of well-being and functioning by screening to determine if the resident has been or is experiencing pain. Provide a comprehensive evaluation of pain by licensed nursing staff and using pharmacological and non-pharmacological interventions to manage the pain and try to prevent the pain, while staying consistent with the residence goals. Residents will be assessed for pain on admission, and if pain is indicated throughout the nursing home admission assessment using verbal and non- verbal assessment. The facility will continue to monitor and assess a resident's pain on a regular basis.II. Resident #64 A. Resident statusResident #64, age greater than 65, was admitted on [DATE], sent to the hospital via 911 emergency transport for shortness of breath on 2/3/26, readmitted from the hospital for pneumonia on 2/22/26 and discharged to home with family on hospice on 3/11/26. According to the March 2026 computerized physician orders (CPO), diagnoses included sepsis, acute respiratory failure, congestive heart failure, pneumonia and pressure-induced deep tissue damage of the left ankle. The 3/1/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of eight out of 15. He required partial to moderate assistance with rolling from his back to his left and right side. The resident required substantial to maximal assistance with toileting hygiene and bathing and showers. The assessment revealed Resident #64 did not have a pain management regimen. He took pain medication as needed and received non-medication interventions for pain. The assessment said he had no pain in the past five days of the look back assessment period. B. Resident interview Resident #64 was interviewed on 3/11/26 at 1:30 p.m Resident #64 said he had pain when the nursing staff repositioned him. He said he was always in pain when he moved or repositioned in bed and he was always tired. He said he did not have pain when he was lying still. He said he did not currently have pain because he was not moving. He said when the nursing staff repositioned him, his pain increased to 8 out of 10 all over his body. He said did not know if he received medication for his pain. He said the nursing staff never asked him if he had pain. He said he would like pain medication before the nursing staff repositioned him. He said he often needed help from nursing staff for changing positions because he was unable to reposition in bed independently. C. ObservationsOn 3/11/26 at 1:38 p.m., certified nurse aid (CNA) #5 and registered nurse (RN) #5 repositioned and provided incontinent care to Resident #64. The resident had contractors in the bilateral lower extremities and bilateral upper extremities. The resident said to the nursing staff oh that hurts and that hurts repeatedly as the staff repositioned the resident. The staff assisted Resident #64 with rolling from his left side to his right side. CNA #5 said to Resident #64 I know it hurts but we are trying to be fast ok. Resident #64 was moaning loudly. Resident #64 said please help me to the nursing staff very loudly. CNA #5 said to the resident I know, I know. Resident #64 said to CNA #5 You don't know how bad it hurts. CNA #5 and RN #5 continued with resident care. RN #5 said to Resident #64 said to the resident I will see if you have any pain medication when we are done. RN # 5 return with Tylenol 650 mg and administered to the resident. -The staff did not assess the residents pain level and location. The facility nursing staff continued with care, despite the resident reporting pain. D. Record review Review of Resident #64's comprehensive care plan did not reveal documentation regarding interventions to include non-pharmacological interventions, monitoring for pain medication effectiveness, and monitoring for side effects of opioid (a class of natural, man-made, or semi-synthetic chemical compounds that interact with opioid receptors on nerve cells in the body and brain to reduce the intensity of pain signals) use. Resident #64's March 2026 CPO revealed the following physician's orders: Oxycodone 5 milligram (mg). Give one tablet by mouth four times a day for pain, ordered 3/5/26.Acetaminophen. Take 325 mg two tablets by mouth every six hours as needed for pain, ordered 2/22/26.Review of the March 2026 medication administration record (MAR) revealed Resident #64 was administered the oxycodone at 12:00 p.m. -However, Resident #64 cried out in acute pain during care and the staff did not stop care to reassess the resident to alter the care being provided to ensure the resident no longer experienced acute pain (see observations above). D. Staff interviews RN #5 was interviewed on 3/11/26 at 4:00 p.m. RN #5 said her responsibilities at the facility included medication administration, assessment of the resident's skin, assessment and monitoring a resident's pain and comfort level and documenting any change of condition in the resident chart. She said Resident #64 was always in pain when he needed to be repositioned. She said she should have stopped providing care when the resident started moaning and telling the staff that he was in pain. She said she would always treat a resident pain level prior to providing care. She said she continued providing care to the resident because she wanted to complete care first. She said Resident #64 had scheduled pain medication in the morning. She said she did not assess the resident pain level when she gave him his scheduled pain medication. She said she only assessed the resident's pain level and location if she was giving a PRN (as needed) pain medication. She said she would then document the pain assessment in the resident's medical record, and do a pain reassessment 30 minutes after the PRN medication was administered. She said if a resident was taking pain medication she monitored for side effects such as drowsiness, change and level of consciousness, breathing difficulties and vital sign changes. CNA #5 was interviewed on 3/11/26 at 4:20 p.m. CNA #5 said she provided care for the residents including assisting with, providing showers, repositioning and toileting hygiene. She said Resident #64 was always in pain whenever he was touched or repositioned. She said she tried to complete the repositioning for Resident #64 quickly and provided verbal reassurance to him when he started to complain of pain. She said she would not stop providing care assistance to the resident if he complained of pain. She said when Resident #64 complained of pain, she would complete the care being provided first, and then report the pain to the nurse when she was finished providing care. CNA #7 was interviewed on 3/12/26 at 9:57 a.m. She said she was familiar with Resident #64. She said the resident would require staff assistance with bed mobility. She said the resident would require repositioning every two hours because he had wounds on his feet. She said the resident required two staff to be repositioned. She said the resident would moan in pain when being repositioned. She said when the resident would moan during repositioning, she would tell the nurse the resident was in pain after the repositioning was finished. She said she wanted to complete the care first before notifying the nurse of the reported pain symptoms. The nursing home administrator (NHA), the director of nursing (DON) and the clinical nurse resource were interviewed together on 3/12/26 at 4:28 p.m. The DON said Resident #64 was readmitted to the facility for sepsis after he acquired pneumonia. The DON said he was in a lot of pain most of the time since being readmitted to the facility. She said the resident recently had a referral to hospice because he was not doing so well. She said the resident had a medication order for stronger pain medication. She said the nursing staff would assess Resident #64 for pain using a verbal one to 10 pain scale in addition to non verbal pain indicators. The DON said a brief pain assessment was completed every shift as a part of the daily nursing documentation. The DON said the CNA's are expected to report any symptoms of pain to the nursing staff immediately. The DON said the nursing staff chart by exemption means a separate detailed pain assessment is not required. The DON said the nurses relied on the residents to report any current pain to the nurses. The clinical consultant said sometimes the family members of Resident #64 would decline repositioning of the resident because of the discomfort and pain it caused the resident. The clinical consultant said the nursing staff were trained upon hire of pain reporting and assessments. He said the CNAs should be reporting any symptom of pain to the nurses, so that a determination of the cause of pain can be established.The NHA said it was important to assess a resident when there were pain indicators to rule out things like broken bones because of the resident's terminal diagnosis. The NHA said he would start reeducation of the nursing staff immediately. The NHA said the reeducation was needed to ensure the staff are following the training they received when they were hired for pain assessments. The NHA said a complaint of pain should be treated as a new symptom every time.

Based on observations and interviews, the facility failed to ensure infection prevention and control programs were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on three out of three floors. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene while performing wound care and don correct PPE (gown) while perform transfers for Resident #6; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when providing care to residents who were on enhanced barrier precautions (EBP); -Ensure staff wore the appropriate PPE when providing care to residents who were on contact precautions;-Ensure contaminated laundry was handled appropriately; and,-Ensure oxygen tubing was handled in a sanitary manner.Findings include: I. EBP failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 3/19/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. B. Observations On 3/10/26 at 8:22 a.m. registered nurse (RN) #1 was administering intravenous (IV) medication to Resident #135's chest port. -RN #1 failed to don (put on) a gown. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 3/10/26 at 9:40 a.m. Resident #6 was being assisted with a transfer from his bed to his electric wheelchair via mechanical lift by two unidentified certified nurse aides (CNAs). The two unidentified CNAs were wearing gloves. -The CNAs failed to wear a gown. On 3/11/26 at 1:38 p.m. CNA #5 and RN #5 were repositioning Resident #64. There was a sign on Resident #64's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. Resident #64 was on EBP due to his wound on his left lateral ankle. C. Staff interviews RN #1 was interviewed on 3/10/26 at 8:30 a.m. She said Resident #135 did not have any current precautionary measures in place for giving medication through his intravenous line. -However, Resident #135 was on EBP. RN #5 was interviewed on 3/11/26 at 4:00 p.m. She said if a resident were on contact precautions or EBP, she would wear a gown and gloves when entering the resident's room. She said the facility staff would look for signage on a resident's door to let them know if a resident was on precautions. She said this was important because we want to prevent infection to residents who were at a higher risk for infection due to skin injury. She said she did not see the sign on Resident # 64's door indicating that he was on EBP. She said if she would have seen the sign on Resident number 64's door, she would have worn a gown and gloves when repositioning and providing pier care for the resident. CNA #5 was interviewed on 3/11/26 at 4:20 p.m. CNA #5 said if a resident was on precautions, she would wear gloves with a gown. CNA #5 said she did not know the difference between contact precautions and EBP. She said she received training on precautions every year on the facility on-line learning platform. She said no one told her Resident #64 was on EBP. She said normally the nurses would tell her if a resident was on precautions, in which she would wear a glove and gown when providing care. She said the glove and gowns were important to prevent the resident from getting an infection. II. Hand hygiene failures A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 3/21/26 from https://www/cdc.gov/cleanhands/hcp/clinical-safety/index.html, 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 procedure The Infection Control policy, undated, was received from the nursing home administrator (NHA) on 3/9/26 at 1:20 p.m. The policy read in pertinent part, The objective of the infection prevention and control program was to establish written standards, policies and procedures for a system in preventing, identifying, reporting, investigating and controlling infections following accepted national standards for all residents. Prevention of the spread of infections are accomplished by use of standard precautions and or other transmission based precautions, handwashing, appropriate treatment and follow-up, and employee work restriction for illness. Hand hygiene procedures will be followed by staff involved in direct resident contact. C. Observations On 3/10/26 at 9:57 a.m. licensed practical nurse (LPN) #1 was performing wound care for Resident #6. The resident had a wound on his left heel. LPN #1 removed the old wound dressing from the left heel on Resident #6. LPN #1 changed her gloves without performing hand hygiene. LPN #1 donned new gloves, touched her clipboard located outside the resident's room, and went back into the residents room to apply the new wound dressing. Upon prompting LPN #1 removed her gloves, performed hand hygiene and donned a new pair of gloves. LPN #1 proceeded to reach into her pocket of her scrubs to grab an ink pen to write her initials and date on the new clean wound dressing. LPN #1 proceeded to apply the new clean wound dressing on to the resident's left heel. -LPN #1 failed to change your gloves or perform hand hygiene after reaching into her scrub pants pocket for the ink pen. D. Staff interviews LPN #1 was interviewed on 3/10/26 at 10:10 a.m. LPN #1 said she did not realize she contaminated her gloves when going to check the wound order on her clipboard outside of the resident's room. LPN #1 said she assumed her gloves were still clean as she reached in her pocket to retrieve the ink pen. LPN #1 said it was important to perform hand hygiene and change gloves in between possible contamination to prevent the spread of bacteria causing infection. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 3/12/26 at 1:47 p.m. The IP said if a resident was on EBP, the nursing staff did not need to wear a gown if they were assisting the resident with bed to chair transfers or linen change. The IP said gloves and gowns were only needed during wound care activities. -However, a gown and glove should be worn when completing wound care (see professional reference above). The DON said nursing staff were expected to wear a gown and gloves while performing any high-contact direct resident care activity. The DON said high-contact resident care activity would include wound care, administering intravenous medications, assisting with resident transfers, linen change, or peri care. The DON said any resident that had a wound, in-dwelling device such as a percutaneous endoscopic gastrostomy (PEG) tube, an IV, wound vacuum, foley catheter would be required to be on EBP. The DON said EBP was utilized to prevent residents from acquiring an infection because they were at higher risk. The DON said EBP precautions would be added to the residents chart as a physician's order and in the care plan for the nurses to reference. The DON said EBP would also be indicated on the resident's Kardex (staff directive tool) for the CNA's to reference. III. Contact precaution failures A. Facility policy and procedure The Infection Prevention and Control Program, revised April 2024, was provided by the NHA on 3/9/26 at approximately 1:45 p.m. It read that when a resident was on contract precautions a gown, gloves and mask must be worn. B. Observations On 3/10/26 at approximately 9:15 a.m. Resident #94`s room had a sign that indicated the resident was on contact precautions. On 3/10/26 at 9:22 a.m. the scheduler entered Resident #94`s without putting on PPE. On 3/10/26 at 9:22 a.m. an unidentified CNA entered Resident #94`s room without donning PPE. On 3/11/26 at 9:57 a.m. the speech therapist was sitting on Resident #94`s footboard. The speech therapist was not wearing PPE. An unidentified CNA was observed on 3/12/26 at 8:06 a.m. entred Resident #94`s room with her breakfast tray. She had gloves on when she walked down the hallway. -The unidentified CNA failed to don a gown. On 3/12/26 at 8:10 a.m. an unidentified CNA entered Resident #94`s room. She wore gloves when she walked down the hallway with the breakfast tray in hand. She placed the breakfast tray by Resident #94`s roommate and left. -She did not wear a gown or mask. C. Staff interviews LPN #2 was interviewed on 3/10/26 at 9:22 a.m. LPN #2 said she did not have to wear PPE if she did not provide direct care to Resident #94. CNA #3 was interviewed on 3/12/26 at 8:12 a.m. CNA #3 said Resident #94 was not on precautions according to her list CNA #3 said the nurse would inform her at the beginning of her shift if there were any residents on isolation precautions. She said there were also signs on the residents' doors to indicate if they were on isolation precautions. She said she would don into PPE before entering the room if a resident was on contact precautions. She said PPE was mandatory whether staff provided direct or indirect care. She said the PPE must be discarded inside the room before exiting. RN #3 was interviewed on 3/12/26 at 8:30 a.m. RN #3 said Resident #94 was on contact precautions because she had shingles. RN #3 said staff must don PPE before entering a room when a resident was being monitored for shingles. She said PPE must be worn whether the staff were providing direct or indirect care. RN #3 said Resident #94 was not cleared of shingles. The assistant director of nursing (ADON) was interviewed on 3/12/26 at 8:48 a.m. She said Resident #94 was on the highest level of precaution due to shingles. She said if staff provided direct or indirect care for Resident #94 they needed to wear a mask and a gown. She said Resident #94 was highly infectious. She said the room itself must be taken as infectious. IV. Laundry room failures A. Professional reference The CDC, Environment Cleaning Procedures, (revised 1/28/24) was retrieved on 3/15/26 from https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html/. It read in pertinent part, Laundry workers should wear appropriate personal protective equipment (gloves and protective garments) while sorting soiled fabrics and textiles. B. Facility policy and procedure The Infection Prevention and Control Program policy, revised April 2024, was received from the NHA on 3/9/26 at 1:45 p.m. It read in pertinent part, Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (gowns if soiling of clothing is likely). B. Observations and interview An observation was conducted on 3/11/26 at 4:35 p.m. of the facility laundry room. Housekeeper (HK) #1 provided a tour of the laundry room including the soiled area (where all items needing to be laundered were handled) and the clean area (all laundered items needing folding). HK #1 said the soiled laundry was sent down a laundry chute and landed into a rolling container. HK #1 said the soiled laundry was sorted into the appropriate cart and rolled to the washing machines. HK #1 said PPE was only worn when sorting sugar bags or biohazard bags. HK #1 said when the laundry was done being washed, it was placed into appropriate rolling carts and rolled to the dryer. HK #1 said when the drying was complete, the clean laundry was brought to the clean area where it was folded or hung and then distributed back to the facility. HK #1 said all of the facility staff had access to the laundry chute and would bag the soiled laundry accordingly. She said clear bags were used for non contaminated items including bed sheets, linens, and towels. She said these bags were sorted and washed accordingly. HK #1 said gloves were used for the sorting process. She said the sugar bags (bags that disintegrate in the wash) and yellow bio hazard bags were carried down and laundered separately. HK #1 said full PPE was used for this process which included gloves, mask, and a gown. HK #1 said when sorting the laundry the staff checked for items including hearing aids as sometimes they were thrown in with the residents' bedding. She said sometimes the staff found contaminated laundry had come down in the clear bag. HK #1 said she would get frustrated because staff had access to a hopper unit (rinsing station) and sometimes bedsheets would come down with fecal matter or be drenched in urine. When this happened, the laundry staff would have to rinse off the debris before laundering it. HK #1 said she was caught off guard when contaminated laundry came down and she was not wearing PPE. HK #1 further said the process of the clean area where she and another staff member would fold and put away the laundry into carts for distribution back to the facility. She said this included towels, washcloths, linens, pillows and personal clothing. HK #1 said this was a shared responsibility between her and her co-worker (HK #2). HK #1 said when a resident was placed on transmission based precautions, their laundry was generally placed in a sugar bag or the bio hazard bag. She said she was not aware of any other indication of contaminated laundry. HK #1 said she had confidence in the floor staff that laundry would be bagged accordingly. HK #1 said there were times when personal items or contaminated items came down the chute. HK #1 said she informed her manager when that happened. D. Staff interviews The housekeeping supervisor (HKS) and the NHA were interviewed on 3/11/26 at 4:59 p.m. The HKS said the process that HK #1 described was the correct process. She said she was not aware staff needed to don PPE when sorting through the laundry that was not in a biohazard bag. She said she understood the importance of preventing the spread of pathogens in the laundry room and would educate staff about donning the appropriate PPE moving forward. The DON and the IP were interviewed on 3/12/26 at 2:45 p.m. The IP said she was not aware the laundry staff were not donning the appropriate PPE. The IP said it was important to wear a gown when sorting clothes as a measure to ensure infection control was being practiced and no cross contamination was occurring. The IP said she would talk to management to determine which areas in the facility needed re education on infection control. The IP said training would be provided to the laundry department. The DON agreed additional immediate training was needed. V. Failed to replace a contaminated nasal cannula A. Observations On 3/12/26 at 9:52 a.m. in the second floor dining area the activities assistant (AA) was untangling a resident's nasal cannula from underneath the resident's wheelchair. The resident was assisted away from the dining area and was positioned in front of the nurses' station. The AA was weaving the cannula around the wheel and frame of the wheelchair. The cannula was on the floor several times during the untangling process. The AA untangled the cannula and tried to place the cannula back on the resident. The AA placed the cannula around both of the residents ears but then hesitated to place the nasal prongs of the cannula into the residents nose. She tried two times and then put the cannula on the resident's blanket. The AA then walked to the nurses' station and spoke with CNA #2. The AA then walked back to the dining room to assist another resident leaving the dining room. At 9:54 a.m. CNA #2 walked over and greeted the resident with the cannula. She quickly placed the cannula back on the resident and was observed checking both sides of the cannula around the ears and the nose of the resident for placement. CNA #2 then went back to the nurses' station. B. Staff interviews CNA #2 was interviewed on 3/12/26 at 9:55 a.m. CNA #2 said the AA asked her for assistance as she was not sure how to place a cannula on someone. CNA #2 said she quickly finished up her note and then came over to the resident to assist. CNA #2 said she was not aware the cannula had been on the floor. CNA #2 said staff would replace the cannula if it touched a contaminated surface. CNA #2 said this practice was to maintain good infection control. The AA was interviewed on 3/12/26 10:12 a.m. The AA said she tried her best to assist the resident, but did not know how. The AA went to the first person at the nurses' station for assistance. The AA did not know the process for replacing or cleaning cannulas and said that was another reason why she asked for assistance. The AA said she did not receive infection control or infection prevention training regarding cannulas. The AA said she did not recall if she told the CNA the cannula was on the floor. The IP and the DON were interviewed together on 3/12/26 at 2:45 p.m. The IP and the DON said it was best practice to replace a contaminated cannula to prevent cross contamination which was crucial for infection control and also to prevent respiratory concerns for the residents'. The IP said she would talk to management to determine which areas in the facility needed re education on infection control. The IP said training would be provided to the staff. The DON said additional immediate training was needed.

Based on observations, record review and interviews, the facility failed to honor residents' choices for two (#58 and #42) of three residents out of 62 sample residents.Specifically, the facility failed to:-Facilitate and honor a wheelchair preference for Resident #58; and,-Ensure Resident #42's call light was within reach.Findings include:I. Facility policy and procedureThe Resident Rights policy and procedure, revised February 2026, was received from the nursing home administrator (NHA) on 3/12/26 at 9:03 p.m. It read in pertinent part, It is the policy of the facility that all resident rights be followed according to state and federal guidelines as well as other regulatory agencies. The resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. The right to self-determination through support of choice.II. Resident #58A. Resident statusResident #58, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle weakness, depression, chronic pain syndrome, and muscle contracture.The 12/30/25 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 was dependent on staff assistance with toileting, bathing, personal hygiene, transfers, and moderate assistance with dressing. She used a wheelchair for mobility.The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period.B. Resident interviewResident #58 was interviewed on 3/10/26 at 4:15 p.m. Resident #58 said she had a power wheelchair that had been taken away from her by the facility due to an incident that happened a couple of years ago. Resident #58 said she ran into a wall with her power wheelchair and fractured her foot. Resident #58 said that, due to that incident, she was provided with a manual wheelchair and had not been permitted to use her electric power wheelchair since then. Resident #58 said she informed the facility during her care conference in December 2025 of her interest in resuming use of her electric power wheelchair. She said she had not received any update concerning her request. Resident #58 said she felt no one cared about her feelings, and that was very upsetting.C. Record reviewThe mobility care plan, revised 5/3/24, revealed Resident #58 had limited physical mobility related to contracture of the right hand. Interventions included providing supportive care and mobility assistance as needed. The quarterly interdisciplinary team (IDT) conference summary, dated 2/17/25, revealed Resident #58 inquired again about the use of her electric wheelchair. The care conference summary documented that the director of rehabilitation (DOR) and the resident's sister reminded Resident #58 of past conversations regarding poor safety choices while using the electric wheelchair and the injury that resulted from that incident.-However, review of the electronic medical record (EMR) did not reveal the facility re-assessed the resident to determine if it was safe to use the power wheelchair after the request was made.The social services summary note, dated 12/23/25, did not document the resident's request to use her electric wheelchair (see resident interview above).A review of psychiatric evaluation note, dated 2/9/26, documented Resident #58 was using a manual wheelchair but requesting access to her electric wheelchair for improved mobility and independence. The note documented the request was relayed to the social services department. -However, the facility did not make any attempts to assess Resident #58's safety when using her power wheelchair as requested.III. Resident #42A. Resident statusResident #42, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included chronic kidney disease, dementia, pain in the right shoulder, muscle weakness, overactive bladder, and unspecified hearing loss.The 1/13/26 MDS assessment revealed Resident #42 was cognitively impaired with a BIMS score of eight out of 15. She required partial/moderate assistance with toileting, showers, and transfers, and did not reject care.B. ObservationsOn 3/9/26 at 4:03 p.m. Resident #42 was observed lying in bed in her room with her call light device on the floor under her bed out of the resident's reach.On 3/10/26 at 2:28 p.m. Resident #42 was lying in bed in her room. The resident's call light device was on the floor under her bed, out of the resident's reach. A certified nursing assistant (CNA) #8 walked into Resident #42's room, briefly checked on the resident and walked out without ensuring the resident's call light was within her reach.On 3/11/26 at 11:00 a.m. Resident #42 was observed lying in her bed in her room. Resident #42's call light device was on the floor under her bed in the same position that it was the last two days during the observations.At 11:03 a.m. Resident #42 yelled out several times for help. CNA #3 arrived and walked into the resident's room. The CNA assisted Resident #42 in opening a bottle of Coke. CNA #3 noticed the call light on the floor out of the resident's reach and placed it within reach.C. Resident interviewResident #42 was interviewed on 3/11/26 at 11:03 a.m. Resident #42 said she stayed in her room most of the day, except for a few preferred activities. She said she did not know where her call light was and usually yelled out for help. The resident said she preferred not to yell when she needed help.D. Record reviewThe fall care plan, initiated 4/17/24 and revised 9/11/24, revealed Resident #42 was at risk for falls related to dementia and decreased mobility. Interventions included ensuring the call light was within reach, encouraging the resident to use it for assistance as needed, and ensuring needed items were within the resident's reach.-However, the resident's call light was not consistently in place (see observations above).IV. Staff interviewsCNA #3 was interviewed on 3/11/26 at 11:15 a.m. CNA #3 said Resident #42 had a hearing deficit making it difficult to communicate with her. CNA #3 said Resident #42 was yelling for assistance to open a bottle of Coke. CNA #3 said the resident's call light was under her bed. CNA #3 said the resident was at risk for falls and required assistance with her daily care.The social services director (SSD) and social services assistant (SSA) were interviewed on 3/12/26 at 9:56 a.m. The SSA said the resident resides on her floor and was familiar with her care. The SSA said she was not aware of Resident #58's desire to use her electric wheelchair. The SSA said the resident had always used a manual wheelchair since she became the SSA.The SSD said Resident #58 was cognitively intact and was her own power of attorney (POA).The SSD said she was present at the last care conference on 12/23/25 for Resident #58 and recalled that the resident expressed a desire to use her electric wheelchair for better mobility and independence. The SSD said the DOR had a conversation with the resident's sister and the resident regarding the use of the electric wheelchair. The SSD said she had not followed up with DOR and the resident sister concerning Resident #42's request.The DOR was interviewed on 3/12/26 at 10:10 a.m. The DOR said she was present at the last care conference held on 12/23/25 for Resident #58. The DOR said she remembered the resident's desire to use her electric wheelchair; however was waiting for the resident's sister to purchase a smaller electric wheelchair. She said Resident #58's current electric wheelchair was stored in the facility's basement. The DOR said she did not complete a safety assessment when the resident expressed a desire to use her electric wheelchair. The DOR said she had no documentation of any safety concerns discussions held with Resident #42's sister.The assistant director of nursing (ADON) was interviewed on 3/12/26 at 3:50 p.m. The ADON said Resident #42 had hearing loss and required staff to speak louder in order for her to understand conversations. She said the resident was a fall risk and required staff to ensure her call light was within her reach at all times. The ADON said she did not know why Resident #42's call light was out of her reach for three consecutive days. The ADON said she would immediately provide education to all nursing staff to ensure that residents' call lights were within reach, so residents would not have to yell for assistance.

Based on record review and interviews, the facility failed to investigate and report an alleged violation of potential abuse to the State Survey and Certification Agency in accordance with state law for two (#56 and #102) of five residents reviewed for abuse out of 62 sample residents.Specifically, the facility failed to timely report an incident of potential sexual abuse involving Resident #56 and Resident #102 to the State Agency.Findings include:I. Facility policy and procedureThe Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment policy, revised October 2022, was provided by the nursing home administrator (NHA) on 3/12/26 at 8:39 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. Residents must not be subjected to abuse by anyone, including, but not limited to: facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that all alleged violations are reported immediately but not later than two hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury, and not later than twenty-four hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator of the facility, the state survey agency, and adult protective services, and will conduct a prompt, thorough, and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property.II. Resident #56A. Resident statusResident #56, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit.The 12/22/25 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. She required one person's assistance as needed for transfers, bathing, and toileting.B. Resident #56's representatives interviewResident #56's representative was interviewed on 3/11/26 at 2:48 p.m. The representative said he was aware of Resident #56's close relationship with Resident #102. The representative said he was not aware of the incident on 11/18/25. He said nobody reported it to him. C. Record reviewThe behavioral care plan, revised on 3/24/25, documented Resident #56 had potential for behavior problems related to her dementia. Interventions included anticipating and meeting needs, approaching the resident in a calm manner, assisting to develop more appropriate methods of coping and interacting, encouraging to express feelings appropriately, providing opportunity for positive interaction, stopping and talking with her as passing by, explaining all procedures before starting and allowing her to adjust to changes, reasonably discussing behavior, explaining to her why the behavior was inappropriate or unacceptable, praising any indication of progress or improvement in behavior, and providing a program of activities of interest to the resident.The 11/18/25 nursing progress note documented in Resident #56 electronic medical record (EMR) revealed Resident #56 was found naked in Resident #102's bedroom, right after dinner. A staff member spoke to her, she got dressed and came out of the room. Resident #56 spent the rest of the evening watching television in the living room. The director of nursing (DON) was aware of the incident.III. Resident #102A. Resident statusResident #102, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2026 CPO, diagnoses included Parkinson's disease with dyskinesia (involuntary, erratic muscle movements), auditory hallucinations and visual hallucinations. The 12/26/25 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. He required one to two staff members assistance for transfers, bathing, and personal hygiene. B. Record reviewThe behavioral care plan, revised on 12/18/25, documented Resident #102 had the potential for behavior problems that included yelling at staff members and attempting to enter others' rooms related to wanting to spend time with another female resident. Interventions included anticipating and meeting needs, approaching in a calm manner, assisting to develop more appropriate methods of coping and interacting, encouraging to express feelings appropriately, documenting behaviors and resident response to interventions, discussing behaviors, explaining why behavior was inappropriate or unacceptable and praising any indication of progress in behavior.-The facility was unable to provide documentation that the incident of potential sexual abuse was reported to the State Agency.VI. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 3/11/26 at 4:27 p.m. CNA #6 said Resident #56 and Resident #102 were boyfriend and girlfriend. She said she heard from other staff members that they had the right to have relationships. CNA #6 said she was aware of the incident on 11/18/25 and that it was reported to the nursing department. CNA #6 said she was not sure if it happened only once.Licensed practical nurse (LPN) #3 was interviewed on 3/11/26 at 4:55 p.m. LPN #3 said she was aware of a romantic relationship between Resident #56 and Resident #102. LPN #3 said she was not aware of the incident on 11/18/25.The NHA, the DON, the clinical consultant, the social services director (SSD) and the social services consultant were interviewed together on 3/12/26 at 5:23 p.m. The NHA said the facility staff were aware of the relationship between Resident #56 and Resident #102. He said Resident #56 and Resident #102 had been involved in a relationship for a while now and said they were in love. He said the relationship was complicated as Resident #102 was still married and his wife visited the facility. He said Resident #56 had cognitive impairment and was diagnosed with dementia. The NHA said Resident #102 also had cognitive impairment, but not as much. The NHA said Resident #102 was diagnosed with Parkinson's disease. The NHA said he was not aware of the incident in November 2025 when Resident #56 was found naked in Resident #102's room (see progress notes above).The DON said the incident was reported to her by the nurse. She said it was her understanding Resident #56 went into Resident #102's room and was taking off her clothes when the nursing staff walked by. She said she did not think Resident #56 was fully naked. The DON said the facility did not have documentation of an investigation following the incident to determine what happened. She said the facility did not have documentation of an evaluation of consent for either Resident #56 or Resident #102. The DON said she did not think Resident #56 could consent to a sexual relationship with Resident #102 due to her cognitive status.Cross-reference F744 failure to effectively identify person-centered approaches for dementia care.The SSD said she was aware of the incident between Resident #56 and Resident #102. She said she spoke to both residents and said Resident #56 was in the process of undressing but not completely undressed. She said Resident #102 had his clothes on.The SSD said she spoke with Resident #56's representative regarding the incident.-However, according to an interview conducted with Resident #56's representative, he said he was never made aware of the incident in November 2025 when Resident #56 was found naked in Resident #102's room (see resident representative interview above).The SSD said she did not document the conversation with either resident or with Resident #56's representative. She said prior to the incident in November 2025, both residents were friends and would sit together and talk. She said they were together constantly and it was not long after the relationship started that it had escalated into holding hands and then with the encounter in November 2025. The SSD said the facility did not document the relationship between Resident #56 and Resident #102 in either resident's EMR. She confirmed the facility did not include the relationship in either resident's comprehensive care plan.The SSD said she felt Resident #102 was able to consent, however the concern would be if Resident #56 could consent. The SSD said there was no written documentation that consent had been evaluated for either resident.The NHA said the facility did not report the incident in November 2025 between Resident #56 and Resident #102 to the State Agency. The clinical consultant said this incident did not represent abuse since the residents were in a relationship. The clinical consultant confirmed the federal regulation read to report an allegation of potential abuse, not actual. He said the determination of abuse should be through the investigation into the incident. The NHA said the facility did not conduct a formal investigation into the incident between Resident #56 and Resident #102. The NHA, the DON and the SSD confirmed each resident had the right to change their consent even though they were in a relationship.

Based on observations, record review, and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#36) of three residents reviewed for hearing problems of 62 sample residents. Specifically, the facility failed to ensure Resident #36`s pocket audio device was regularly charged for the resident`s use. Findings include:I. Facility policy and procedureThe Hearing and Vision Services policy, revised 2026, was provided by the nursing home administrator (NHA) on 3/12/26 at 8:39 p.m. It revealed in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The facility will utilize the comprehensive assessment process for identifying and assessing a resident`s vision and hearing abilities in order to provide person-centered care. This process includes: ongoing monitoring of sensory problems. Employees should refer any identified need for hearing or vision services/appliances to the social worker/social service designee. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision or hearing.II. Resident #36A. Resident statusResident #36, age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE]. According to the March 2026 computerized physician orders (CPO) diagnoses included chronic obstructive pulmonary disease with exacerbation, type 1 diabetes mellitus without complications, bipolar disorder, personal history of transient ischemic attack and cerebral infarction without residual deficit, and cognitive communication deficit.The 1/7/26 minimum data set (MDS) assessment document the resident had no cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 14 out of 15. According to the MDS assessment she required moderate assistance with toileting and showering and supervision with dressing. The resident had impaired communication due to impaired hearing according to the care plan. B. Resident observations and interviewOn 3/10/26 Resident #36 was seated in her wheelchair, facing away from the door. She did not wear a hearing aid nor did she have the pocket audio device with her. She did not respond to initial greetings. Resident #36 said she said she could not hear.On 3/10/26 at approximately 2:30 p.m. licensed practical nurse (LPN) #2 entered Resident #36`s room. Resident #36 was facing away from the door. She was not wearing her hearing aide nor did she have the pocket audio device with her. After LPN #2 called Resident #36`s name several times without response, LPN #2 stepped in front of Resident #36. Resident #36 lifted her head and looked up. LPN #2 asked the resident about the pocket audio device whereabouts several times before Resident #36 finally replied the question. Resident #36 said she was not sure. LPN #2 pointed at Resident #36`s bedside table drawer. The pocket audio device and the hearing aid were in the drawer.Resident #36 was interviewed on 3/10/26 at approximately 2:30 p.m. Resident #36 said the hearing aid stopped working months ago. She said the pocket audio device did not work appropriately because it only held one hour charge and the staff often forgot to charge it. Resident #36 was interviewed again 3/11/26 at 10:06 a.m. Resident #36 said she felt helpless for not hearing and being cut off from the world without hearing. She said she was not able to hear the staff at all. She said her pocket audio device was given by her power of attorney after being left without a working hearing aid for several weeks. She said she kept forgetting to charge the pocket hearing aid and the certified nurse aides (CNA) did not stay on top of the charging either. She said she asked the staff to keep it charged. She said she stopped using the pocket hearing device because every time she tried it was not charged. Resident #36 was interviewed again on 3/11/26 at 2:30 p.m. She said there was no point in having the pocket audio device on her neck during the day because it only held charge for an hour. She said she only used the audio device for appointments. C. Record reviewThe communication care plan, initiated on 6/26/24, revealed the resident had impaired communication due to impaired hearing. The care plan documented Resident #36 was hard of hearing and declined the use of hearing aids. The care plan documented she used a pocket talker for most communications and was able to adjust the volume to her preference. Interventions included offering audiology visits as needed, talking to the resident face-to-face per her preference, using the pocket talker and using cue cards to communicate with the resident. The 2/17/23 ancillary services note documented Resident #36 had bilateral hearing loss ranging from moderately-severe to profound. Rechargeable devices were recommended to alleviate the need for frequent battery changes in her hearing aid. -Review of Resident #36's electronic medical record (EMR) did not reveal any documentation regarding the resident's hearing impairments, broken hearing aids or the charging issues with the pocket talker. D. Staff interviewsCNA #1 was interviewed on 3/11/26 at 12:40 p.m. CNA #1 said Resident # 36 was not able to hear without the pocket audio device. CNA #1 said the staff had to talk loud and get very close to Resident #36 to make sure Resident #36 could hear them if she did not have the device. She said Resident #36 did not wear the device most times. CNA #1 said she was not sure why Resident #36 did not wear the device more often. LPN #2 was interviewed on 3/11/26 at 1:18 p.m. She said Resident #36 could not hear without the pocket audio device. She said it depended on Resident #36`s mood whether she wore the device or not. She said Resident #36 wore the device on most days. She said the device did not hold charge, but Resident #36 did not allow staff to charge it for her. The social services director (SSD) was interviewed on 3/11/26 at 1:31 p.m. She said the pocket audio device had been the most effective communication method with Resident #36. She said she did not know about the pocket audio device charging problems. She said these problems should be tracked in nursing reports or in the grievance form. She said Resident #36 had not been seen by the audiologist in 2025. The SSD said the resident was scheduled to see the audiologist on 3/26/26.

Based on record review, observations and interviews, the facility failed to ensure an environment free of accident hazards for one (#46) of two of five residents reviewed for accident hazards out of sample residents reviewed for accident hazards.Specifically the facility failed to ensure fall interventions were implemented for Resident #46 as written in the care plan. Findings include:I. Resident #46A. Resident statusResident #46, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included history of falling, unspecified abnormalities of gait and mobility, and palliative care.The 3/2/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment identified the resident required substantial and maximal assistance with functional abilities. B. Record reviewResident #46's care plan, initiated 5/27/25, revealed Resident #46 was at risk for falls due to deconditioning. Pertinent interventions included keeping the call light within reach, keeping the bed in the lowest position and keeping needed items within reach. The progress note, dated 6/3/25, revealed Resident #46 had a fall while the hospice certified nurses aid (CNA) was assisting him with a shower. The CNA was unable to catch his fall and he hit the back of his head in the shower. Additional interventions were implemented on 6/5/26 including neurological checks, range of motion checks and vital signs. C. ObservationsOn 3/9/26 at 11:56 a.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/9/26 at 2:26 p.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/10/26 at 8:20 a.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/10/26 at 11:03 a.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/10/26 at 3:34 p.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/11/26 at 8:07 a.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/11/26 at 10:12 a.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/12/26 at 11:35 a.m. Resident #46 was in his room resting in his bed. The bed was approximately three feet in the air.On 3/12/26 at 11:50 a.m. registered nurse (RN) #6 lowered Resident #46's bed to the lowest position.D. Staff interviewsRN #6 was interviewed on 3/11/26 at 11:50 a.m. RN #6 said fall interventions the facility implemented included keeping the bed in the lowest position, frequent checking and sometimes fall mats. RN #6 said Resident #46 was at risk for falls and had fall interventions. During the interview, RN #6 observed resident #46s bed in the highest position and immediately went into the residents room and to lower the bed. RN #6 said the CNA did not leave the bed in the lowest position as Resident #46 care plan reads (see above)The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 3/12/26 at 4:00 p.m. The ADON said residents with fall interventions had specific interventions in their care plans. The ADON said Resident #46 was a fall risk and had specific interventions implemented. The ADON said she was not aware Resident #46 had his bed the highest position (see observations above). The DON said specific floor training would be provided as a reminder to staff of which residents were at risk for falls.

Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for one (#21) of one resident reviewed for respiratory care out of 62 sample residents.Specifically, the facility failed to ensure that Resident #21 received oxygen therapy in accordance with their physician's orders. Findings include:I. Facility policy and procedureThe Oxygen Administration, Storage, and Handling policy, revised January 2026, was provided by the nursing home administrator (NHA) on 3/12/26 at 9:03 p.m. It read in pertinent part, It is the policy of this facility to promote resident safety with oxygen administration.Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain medical gases shall be trained on the risks associated with their handling and use.II. Resident #21A. Resident statusResident #21, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), moderate, persistent asthma, chronic respiratory failure with hypoxia, major depressive disorder, and obstructive sleep apnea.The 3/10/26 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. She was independent with eating, dependent with toileting, moderate assistance with personal hygiene and transfers. The assessment revealed the resident was receiving oxygen therapy.B. ObservationsOn 3/10/26 at 10:45 a.m., certified nursing assistant (CNA) #3 walked into Resident #21's room with a portable oxygen tank and hung it behind the resident's wheelchair. Resident #21's nasal cannula (tubing device that delivers oxygen through the nose) was in her nose, connected to a room oxygen concentrator with a setting of 4 liters per minute (LPM) of oxygen. CNA #3 transferred the cannula from the room concentrator to the portable tank and set it to 4 LPM of oxygen. Resident #21 asked the CNA how many liters of oxygen she was on and CNA #3 replied 4 LPM. Resident #21 told the CNA to reduce the amount of oxygen from 4 LPM to 2 LPM and CNA #3 complied without verifying with the nurse to ensure the resident received the required amount according to Resident #21's physician's order.On 3/11/26 at 9:04 a.m. Resident #21 was sitting in her wheelchair in her room. The nasal cannula was in the resident's nose and the portable oxygen tank was on and set at 2.5 LPM of oxygen.On 3/12/26 at 10:14 a.m. Resident #21 was lying in bed in her room. The resident was connected to the oxygen concentrator via a nasal cannula in her nose, and the concentrator was set at 4 LPM of oxygen. Registered nurse (RN) #4 and CNA #4 confirmed the concentrator was set at 4 LPM.C. Resident interviewResident #21 was interviewed on 3/10/26 at 3:16 p.m. Resident #21 said she used oxygen continuously at all times. She said she was not sure how many liters of oxygen her physician's order wa,s but knows that 4 LPM was probably too much. She said she did not know what oxygen setting her oxygen concentrator was currently set on. She said CNA #3 set her portable tank to 4 LPM earlier in the morning and she thought that was a little too much due to her condition of COPD.D. Record reviewThe respiratory care plan, initiated 8/28/25, revealed Resident #21 had an altered respiratory status related to COPD, chronic respiratory failure, and asthma. Interventions included administering medication and metered-dose inhalers as ordered, monitoring for effectiveness and side effects, monitoring for signs and symptoms of respiratory distress and reporting to the medical director (MD) as needed.-A review of Resident #21's electronic medical record (EMR) revealed she was on room air on 12/12/25 with an oxygen saturation level of 93%. On 12/14/25 she received 22 LPM with an oxygen saturation level of 95%. On 12/15/25 she received 2 LPM with a saturation level of 93%. On 3/6/26 she received 2 LPM with a saturation level of 98%.-Review of the EMR revealed Resident #21 was consistently receiving 2 LPM of oxygen.Review of Resident #21's March 2026 CPO revealed a physician's order for continuous 1 LPM oxygen via nasal cannula to maintain the resident's oxygen saturation at or above 90%, dated 8/28/25.-However, observations on 3/10/26, 3/11/26 and 3/12/26 revealed Resident #21 was receiving 2.5 and 4 LPM of oxygen, not 1 LPM as ordered by the physician (see observation above).III. Staff interviewsCNA #4 was interviewed on 3/12/26 at 10:50 a.m. CNA #4 said Resident #21's room concentrator was set at 4 LPM since the beginning of her shift at 6:00 a.m. CNA #4 said she did not know how many liters of oxygen the resident was supposed to be receiving. She said CNA's were not permitted to change the liter flow of residents' oxygen concentrators. She said she did not inform the nurse when she noticed the resident was receiving 4 LPM of oxygen.RN #4 was interviewed on 3/12/26 at 11:00 a.m. RN #4 said Resident #21 had a diagnosis of COPD, asthma and was recovering from pneumonia. RN #4 said Resident #21's physician's order indicated the resident was to receive 1 LPM of oxygen. RN #4 confirmed that Resident #21 was on an incorrect LPM of oxygen. She said she did not verify the concentrator setting at the beginning of her shift at 6 a.m. RN #4 said she should have verified the concentrator's LPM during her morning rounds.The director of nursing (DON) was interviewed on 3/12/26 at 11:10 a.m. The DON said it was necessary to follow the physician's oxygen orders because oxygen was considered a form of medication. She said CNA's were not allowed to change the liter flow of an oxygen concentrator. The DON said nurses were able to change the liter flow of oxygen orders when necessary, document the changes and inform the physician. The DON said that insufficient or excessive oxygenation could result in medical complications for a resident. She said she would immediately provide education to all nursing staff to ensure all oxygen orders were followed.

Based on observations, record review and interviews, the facility failed to ensure one (#56) of three residents reviewed for dementia care received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being out of 62 sample residents Specifically, the facility failed to assess Resident #56 to determine if she was able to consent to a romantic relationship with a diagnosis of dementia. Findings include:I. Facility policy and procedureThe Care of Dementia policy, revised April 2025, was provided by the nursing home administrator (NHA) on 3/12/26 at 8:39 p.m. It revealed 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 specialized training in the care of the dementia population, appropriate approaches to care, and managing behaviors. The interdisciplinary staff will initiate a thorough clinical assessment. The monitoring of mood, behavior, or any psychosocial-related issues to identify possible underlying medical problems that may be causing the behavioral problems. The interdisciplinary team will review findings of evaluations and develop a plan of care addressing the resident's needs. The physician will be involved in the plan of care and make any changes to the medical regimen as necessary. The facility will offer to staff specialized 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. Resident #56A. Resident statusResident #56, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit.The 12/22/25 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. She required one person's assistance as needed for transfers, bathing, and toileting. B. ObservationsOn 3/10/26, at 4:10 p.m. Resident #56 was in a common area. She talked to Resident #102 for a few minutes, then she spent time alone. On 3/12/26 at 10:20 a.m. Resident #102 knocked on Resident #56's bedroom door, but she did not open it. At 11:10 a.m. Resident #102 knocked on Resident #56's bedroom door again, but a staff member redirected Resident #102 and took him to a different area. At 11:25 a.m. Resident #56 looked for Resident #102, then they spent time together in the living room. C. Record reviewThe dementia care plan, revised on 3/21/24, documented Resident #56 was at risk for impaired cognitive function and impaired thought processes related to dementia. Interventions included administering medications as ordered, engaging in simple activities that avoid overly demanding tasks, giving step by step instructions as needed to support cognitive function, keeping routine consistent and trying to provide consistent care givers as much as possible to decrease confusion, and documenting and report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, and level of consciousness and mental status.The behavioral care plan, revised on 3/24/25, documented Resident #56 had potential for behavior problems related to her dementia. Interventions included anticipating and meeting needs, approaching calmly, assisting to develop more appropriate methods of coping and interacting, encouraging to express feelings appropriately, providing opportunity for positive interaction, stopping and talking with her as passing by, explaining all procedures before starting and allowing her to adjust to changes, reasonably discuss behavior by explaining her why the behavior was inappropriate or unacceptable, praising any indication of progress or improvement in behavior, and providing a program of activities of interest to the resident.-Review of Resident #56's comprehensive care plan that Resident #56 and Resident #102 were involved in a romantic relationship. The 11/18/25 nursing progress note documented Resident #56 was found naked in Resident #102's bedroom, right after dinner. A staff member spoke to her, she got dressed and came out of this room. Resident #56 spent the rest of the evening watching television in the living room. The director of nursing (DON) was aware of the incident. -Cross-reference F609: failure to timely report an incident of potential sexual abuse to the State Agency.-Review of the electronic medical record (EMR) did not reveal documentation did not reveal that the facility assessed Resident #56 to determine the resident could consent to a sexual relationship. III. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 3/11/26 at 4:27 p.m. CNA #6 said Resident #56 was able to make her own decisions, even though she was sometimes confused. CNA #6 said she believed Resident #56 was able to give her consent to have a relationship with Resident #102. Licensed practical nurse (LPN) #3 was interviewed on 3/11/26 at 4:55 p.m. LPN #3 said Resident #56 was able to make decisions and give her consent to have a relationship. LPN #3 said sometimes Resident #56 was confused, and a week ago, the resident was unable to follow instructions.The nursing home administrator (NHA), the director of nursing (DON), and the social services director (SSD) were interviewed on 3/12/26 at 5:23 p.m. The NHA said the facility staff were aware of the relationship between Resident #56 and Resident #102. He said Resident #56 had cognitive impairment and was diagnosed with dementia and Resident #102 also had cognitive impairment, but not as much, as was diagnosed with Parkinson's disease. The DON said shE did not think Resident #56 could consent to a sexual relationship with Resident #102 due to her cognitive status.The SSD said she felt Resident #102 was able to consent, however the concern would be if Resident #56 could consent. The SSD said there was no written documentation that consent had been evaluated for either resident.

Based on observations, record review and interviews, the facility failed to assess, arrange, and document discharge services for one (#1) of one resident reviewed out of three sample residents. Specifically, for Resident #1, the facility failed to: -Assess oxygen therapy discharge needs for the resident; and, -Ensure home health services were confirmed for the resident prior to discharge. Findings include: I. Facility policy and procedure The Discharge Planning Process policy and procedure, revised May 2025, was provided by the nursing home administrator (NHA) on 6/24/25 at 5:20 p.m. The policy read in pertinent part, The discharge process should effectively transition residents to post-discharge care and minimize clinical or other factors related to the possibility of readmission. The discharge planning process shall: -Provide and document sufficient preparation and orientation to residents in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the facility; -Ensure the discharge needs of each resident are identified on admission, and a discharge plan for each resident is developed and implemented promptly; -Include re-evaluation of residents to identify changes that require a modification of the discharge plan, and update the discharge plan to reflect changes; -Involve the interdisciplinary team (IDT) in developing the discharge plan; -Involve the resident and resident representative in developing the discharge plan, and inform the resident and resident representative of the final plan. If participation of the resident of the resident representative is not practicable, an explanation shall be documented in the resident's medical record; -If the resident indicates an interest in returning to the community, the facility shall document any referrals made; and, -The facility shall update the resident's comprehensive care plan and discharge plan in response to information received from referrals to local contact agencies or other appropriate entities. The facility shall document on a timely basis the resident's needs and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The result of the evaluation must be discussed with the resident or representative. All relevant information must be incorporated into the discharge plan. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to her home on 5/16/25. According to the May 2025 computerized physician orders (CPO), diagnoses included endocarditis (infection of a heart valve), enterocolitis (colon infection), sepsis (body systemic infection), emphysema and chronic obstructive pulmonary disease (respiratory diseases), heart failure and pulmonary hypertension (high blood pressure in the lungs). The 5/2/25 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #1 required substantial to maximum assistance from staff for standing and partial to maximum assistance from staff for ambulation. The MDS assessment documented the resident had no oxygen therapy or use of oxygen at admission. B. Record review The pneumonia care plan, initiated 4/24/25, revealed Resident #1 had pneumonia. Pertinent interventions included oxygen therapy as ordered (initiated 4/24/25). The respiratory care plan, initiated 4/24/25, revealed Resident #1 had difficulty breathing related to COPD and respiratory failure. Pertinent interventions included providing oxygen as ordered (initiated 4/24/25). The care plan failed to include an oxygen use plan of care or a discharge planning needs assessment for oxygen services at home. Review of Resident #1's May 2025 CPO revealed the following physician's order: Apply oxygen via nasal cannula at 2 liters per minute (LPM) to keep oxygen saturations (level of oxygen in the blood) at or above 90% (percent). Ordered 4/25/25. Review of Resident #1's electronic medical record (EMR) revealed the resident used supplemental oxygen administered by nasal cannula for 42 of 47 assessments. The Discharge summary, dated [DATE], documented Resident #1 should use 2 LPM of oxygen via nasal cannula. -However, review of Resident #1's electronic medical record (EMR) revealed there were no physician's orders or home health referrals for oxygen equipment for the resident after discharge from the facility. The physician's discharge order, dated 5/14/25, read Ceftriaxone (antibiotic), 2 grams (gm), intravenously at bedtime until 5/23/25. -However, review of Resident #1's EMR failed to reveal documentation to indicate the facility confirmed a start date for home health services prior to discharging Resident #1. -The home health Patient Information Report, was provided by the NHA on 6/24/25 at 1:18 p.m. The report documented the home health provider received the referral on 5/16/25 and started services for Resident #1 on 5/20/25, four days after the resident was discharged from the facility. -The facility failed to ensure Resident #1 would have home health services in a timely manner, to include oxygen therapy and antibiotic therapy, per the discharge summary and physician's orders (see above), upon the resident's discharge from the facility on 5/16/25. III. Staff interviews The social services assistant (SSA), the director of nursing (DON) and the NHA were interviewed together on 6/24/25 at 2:30 p.m. The SSA said she arranged for home health services by sending a referral to Resident #1's insurance provider. She said she visually confirmed the referral facsimile (fax) transmitted, but she did not confirm receipt that the insurance company received the referral or that they had authorized the home healthcare services for antibiotic administration at home. The DON said Resident #1 used oxygen while admitted to the facility. The DON said the facility discharge process started with a review by the IDT. The DON said the IDT documented discharge needs and then the SSA was responsible for arranging services for residents when they were discharged from the facility. The DON said she was unable to locate a discharge needs assessment for oxygen for Resident #1 or documentation to indicate a referral had been made for home oxygen for the resident. The DON said if home services were unavailable at discharge, the resident's discharge should be canceled, and a physician should be contacted for review. The DON said the physician was not notified that home health services were not arranged before Resident #1's discharge. The DON said Resident #1 should have received her antibiotic medication from the home health provider on 5/16/25 after she arrived home. The NHA said Resident #1 had a history of noncompliance with oxygen use before admission to the facility. The NHA said the facility had not completed a discharge needs assessment for home oxygen because she probably had oxygen at home. -However, the Resident #1's EMR documented the resident was utilizing oxygen and was compliant with use during the resident's stay in the facility (see record review above). The NHA said Resident #1 had an insurance company that required referrals to be sent to for insurance review, and not directly to a post-discharge home health services provider. The NHA said the insurance provider process included approval and arranging of post-discharge services by the insurance company. The NHA said Resident #1 was discharged before the facility had confirmed a home health provider accepted the referral to administer antibiotics after discharge. The NHA said that he contacted Resident #1's insurance provider on 6/24/25 (during the survey) and received the home health Patient Information Report which documented the start of care date for Resident #1 as 5/20/25. The NHA said Resident #1 discharged from the facility on 5/16/25 and he was not aware that there was a four-day delay in home health services for the resident which resulted in the resident missing three doses of intravenous antibiotics.

Based on record review and interviews, the facility failed to ensure one (#5) of four residents had an effective pain management regimen in a manner consistent with professional standards of practice out of 13 sample residents. Resident #5 was admitted to the facility on [DATE] with a diagnosis of low back pain and dementia. The resident was on a scheduled pain regimen, which consisted of Tylenol 1000 milligrams (mg) three times a day and Aspercreme 1% (topical pain medication) to be applied to the resident's right shoulder twice a day. On 1/23/25 at 3:40 a.m. the resident began complaining of excruciating pain to her shoulder, back of both thighs, both knees, calves and hips. The facility failed to address Resident #5's reports of excruciating pain for three and a half hours until the nurse obtained a physician's order to administer Valium (muscle relaxer medication). Findings include: I. Facility policy and procedure The Pain Management policy, revised January 2025, was received from the nursing home administrator (NHA) on 3/6/25 at 1:56 p.m. The policy read in pertinent part, Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: screening to determine if the resident has been or is experiencing pain; comprehensive evaluation of the pain, licensed nurse will completed the LN-pain (licensed nurse pain) evaluation or PAINAD (pain assessment in advanced dementia) and use of pharmacological and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals. For the resident who is unable to communicate verbally or understand abstract concepts use PAINAD. II. Resident #5 A. Resident status Resident #5, age 67, was admitted on [DATE] and discharged on [DATE] to the hospital. According to the February 2025 computerized physician orders (CPO), diagnoses included low back pain, post-traumatic stress disorder, unspecified, dementia with other behavioral disturbance, anxiety disorder, unspecified, and unsteadiness on feet. The 12/18/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. The resident required assistance from one staff member with showering, toileting, transferring and personal hygiene. The assessment revealed the resident was on a scheduled pain management regimen, which included both medication and non-medication interventions for pain. B. Record review The pain care plan, initiated 5/29/24, identified the resident was at risk for both chronic and acute pain related to depression and disease progression. Pertinent interventions included administering pain medications as ordered, completing a pain scale every shift, repositioning the resident for comfort, providing non pharmacological interventions, anticipating the resident's need for pain relief and responding immediately to any complaint of pain. -The care plan failed to reveal the resident's pain goals, acceptable levels of pain or what type of pain assessment should be used to evaluate pain. The 12/20/24 quarterly pain management review documented the resident could not be interviewed and the PAINAD assessment was to be completed. -However, the January 2025 CPO revealed the physician's order indicated to use a numerical pain scale. Review of the January 2025 CPO revealed the following physician's orders related to pain management: Monitor pain every shift, using a 0 to 10 scale; 0 was no pain, 1 to 3 was mild pain, 4 to 5 was moderate pain, 6 to 9 was severe pain and 10 was excruciating pain. Tylenol extra strength 500 mg, give 1000 mg three times a day for chronic pain, ordered 10/8/24. Aspercreme arthritis pain external gel 1%, apply to the right shoulder topically two times a day for pain, ordered 6/9/24. Aspercreme Lidocaine external cream 4%, apply to affected area topically two times a day for pain, ordered 1/23/25. -The physician's order did not specify where the affected area was. Ibuprofen oral tablet, give 400 mg by mouth one time for pain, ordered 1/24/25. Valium oral tablet 5 mg, give 5 mg by mouth STAT (immediately) for hallucinations/anxiety, ordered 1/23/25. Review of the January 2025 medication administration record (MAR), from 1/22/25 to 1/24/25 revealed the following: Tylenol 100 mg was administered on 1/23/25 at 7:14 a.m. and 12:06 p.m. Aspercreme arthritis pain external gel 1% was administered on 1/22/25 at 11:34 a.m. and 8:05 p.m. to both shoulders, on 1/23/25 at 7:08 a.m. and 11:05 a.m. to her shoulders and on 1/24/25 at 9:09 a.m. to her right front shoulder. Aspercreme Lidocaine external cream 4% was administered on 1/23/25 at 9:08 a.m. and 4:46 p.m. and on 1/24/25 at 9:09 a.m. Ibuprofen 400 mg was administered on 1/24/25 at 7:50 a.m. Valium 5 mg was administered on 1/23/25 at 7:51 a.m. -The ibuprofen and Valium were not administered until three and a half hours after the resident was screaming out in excruciating pain (see progress notes below). The 1/23/25 nursing note revealed Resident #5 was heard screaming at 3:40 a.m. The resident was sitting on the toilet. She complained of pain to her shoulder, backs of both thighs, both knees, calves and hips. The physician was contacted. The physician instructed to apply Aspercreme (topical pain medication) to the affected areas. -Review of the January 2025 medication administration record (MAR) revealed the resident was administered Aspercreme 1% at 7:08 a.m., (three and a half hours after the resident was screaming in pain), which was applied to the resident's shoulders. Review of the MAR did not document the facility administered Aspercreme to the resident's thighs, knees, calves and hips (see MAR above). The 1/23/25 nursing note, documented at 7:14 a.m., revealed Resident #5 continued to display signs of pain and was administered 1000 mg of Tylenol. The 1/23/25 nursing note, documented at 7:36 a.m., revealed the nurse practitioner (NP) was contacted because the resident was shaking, was having hallucinations and crying that she hurt so bad but was unable to tell staff where she hurt. The NP gave a verbal order for Valium 5 mg one dose, nitrofurantoin (antibiotic) 50 mg daily prophylaxis (preventative) for chronic urinary tract infection (UTI) and ordered a CBC (complete blood count, blood test) and a CMP (comprehensive metabolic panel, blood test) STAT. The 1/23/25 NP note, documented at 11:36 a.m., documented that Resident #5 was lying in bed shivering and stating that she was in pain. The note documented the resident was unable to point out where the pain was. The note documented the resident went to an urology appointment on 1/22/25 and received a physician's order to start on antibiotics prophylactically, which she had not started yet. The resident had a temperature between 99.4 and100 degrees Fahrenheit. The note documented the resident had Tylenol 1000 mg scheduled three times a day. The resident denied congestion and a sore throat. The 1/23/25 nursing note, documented at 7:51 a.m., revealed Valium 5 mg was administered to the resident. -Review of the resident's electronic medical record (EMR) did not reveal documentation indicating the facility addressed the resident's pain for three and a half hours. The 1/24/25 physician note, documented at 6:43 a.m., revealed the resident was lying in bed, alert, appeared weak, but had no acute distress. She had some pain when her right leg was moved, but appeared comfortable when at rest and not being disturbed. She was unable to recall any specific injury and staff had no reports of an accident. The right thigh was swollen and tender. An x-ray was ordered. The physician prescribed ibuprofen 400 mg to be given one time. The note was updated to indicate the imaging confirmed a femur fracture and the resident was transferred urgently to the hospital. The 1/24/25 nursing progress note, documented at 7:09 a.m., revealed the resident was having excruciating pain to her right leg. Staff received a verbal physician's order for ibuprofen 400 mg one time, Eliquis 10 mg (blood thinning medication used to prevent blood clots) twice a day for seven days and an ultrasound for her upper right leg. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/6/25 at 11:13 a.m. LPN #1 said on the morning of 1/23/25, she checked on Resident #5 and noted the resident had a low-grade fever. She said the resident was lying on her back and was moaning in pain. She said registered nurse (RN) #1 assessed the resident and informed her that the resident's leg and her upper leg appeared swollen and questioned whether it could be a blood clot. LPN #1 said she then contacted the physician and obtained orders for an x-ray and an ultrasound. LPN #1 said the resident was found to have a fracture after the x-ray was completed. LPN #1 said prior to 1/23/25, Resident #5 did not complain of pain. She said the staff were supposed to use the PAINAD scale for pain assessment, since the resident was cognitively impaired. LPN #1 said on 1/23/25 the resident was voicing that she was in pain, so the 10 out of 10 pain scale was utilized. LPN #1 said the resident was typically very quiet and her pain medication regimen was effective. LPN #1 said prior to this incident, Resident #5 never complained of pain. The director of nursing (DON) was interviewed on 3/6/25 at 3:42 p.m. The DON said on 1/22/25 Resident #5 was at her normal baseline. The DON said Resident #5 went to an urology appointment on 1/22/25. She said the resident came back to the facility with a physician's order for a prophylactic antibiotic for UTIs. The DON said that in the early morning of 1/23/25, the resident walked herself to the bathroom. She said the CNAs heard Resident #5 screaming and rushed to her room to assess the situation. The DON said the resident was complaining of pain in her thighs, knees, calves and shoulders. The DON said the resident was assisted back to bed. The DON said Resident #5 was complaining of pain in the morning and the CNA did not want to get her up because she was saying she was hurting. The DON said she reviewed Resident #5's medical record and said the resident was on scheduled Tylenol three times a day. She said she also had Aspercreme 1% gel for her shoulder pain. The DON confirmed the Tylenol was given as scheduled on 1/23/25 at 7:14 a.m. The DON said that follow up after administering pain medication should typically occur within one to two hours, depending on the individual, as some residents had higher pain tolerance. She said since Resident #5 was crying out in excruciating pain, follow up should have occurred every 30 minutes to monitor her condition and ensure pain relief was achieved. -However, review of Resident #5's EMR did not reveal the facility regularly monitored Resident #5 after she reported pain (see record review above).

Based on observations, record review and interviews the facility failed to ensure two (#7 and #4) of four residents reviewed for accidents out of 13 sample residents received adequate supervision to prevent accidents. Resident #7, who had diagnoses of unspecified dementia, a history of falling and muscle wasting, was admitted to the facility on [DATE]. Between 6/14/24 and 7/21/24, the resident experienced six falls. The facility failed to put effective fall interventions into place after each fall. On 8/7/24, Resident #7 experienced a seventh fall and sustained a laceration on her forehead which resulted in the resident being transferred to the hospital for sutures to the laceration. Upon the resident's return from the hospital, a fall mat and instructions to keep the resident's bed in the low position were added to the resident's care plan as fall interventions. However, between 8/7/24 and 2/19/25, Resident #7 experienced eight more falls. The facility again failed to put effective fall interventions into place following each of the resident's falls. On 2/22/25 Resident #7 experienced another fall (fall #16) and sustained a laceration to her left eyebrow and a hematoma (an injury that causes blood to collect and pool under the skin) to her left cheek. The resident was again transported to the hospital for evaluation and treatment of the injuries. Upon the resident's return to the facility, Resident #7 was moved to a room closer to the nurses station in order to more closely monitor her, however, the resident sustained another fall on 3/1/25. Due to the facility's failures to determine the root cause of the resident's continued falls and put effective, person-centered interventions into place, Resident #7 experienced 17 falls between 6/14/24 and 3/1/25, two of which required transportation to the hospital for treatment of injuries. Additionally, the facility failed to ensure Resident #4 had effective person-centered interventions put into place after each of her 12 falls between 11/8/24 and 2/17/25 to prevent further falls. Findings include: I. Facility policy and procedure The Falls Monitoring and Management policy, revised January 2025, was provided by the nursing home administrator (NHA) on 3/6/25 at 5:06 p.m. It revealed in pertinent part, The licensed nurse is responsible for assessing and evaluating the resident's fall risk on admission, quarterly, and with a significant change in condition. The nurse will document fall risk on the Fall Risk Assessment form and implement a plan of care for high fall risk residents. For an individual who has fallen, the following interventions should include, but are not limited to, obtain vital signs, assess for head injury/change in level of consciousness, assess for change in normal range of motion/weight bearing, initiate neurological assessment on residents that have hit their head or un-witnessed fall (even if resident states they did not hit their head, because they may have hit their head and may not have a recollection that they hit their head), assess for pain, precipitating factors, details on how fall occurred, provide first aid (including intervention for pain if pain is identified), notify MD (physician) for further orders, notify responsible party, document details under Risk Management in electronic medical record (EMR), document neurological assessments on Neurological Assessment form, complete initial neurological assessment, update plan of care to minimize risks for injury due to falls. Examples of interventions to minimize risks for injury due to falls include, but are not limited to; vitamin D, fall mats, raised edge mattresses, night lights, non-skid socks, hip protectors, toileting schedule, therapy evaluation, restorative program evaluation, monitor/document daily for 72 hours, notify physician if signs/symptoms of complications and update plan of care. The IDT (interdisciplinary team) will meet in the morning to discuss the following: predisposing factors, injuries and interventions. The IDT will place a fall IDT note in the computer with verification of interventions or new interventions. Recommended in the morning meeting would be the director of nursing (DON)/ designee, activities, social services and therapy. II. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side, unspecified dementia, history of falling, history of transient ischemic attack (a temporary interruption of blood flow to the brain that causes sudden neurological symptoms that typically resolve within 24 hours, also known as a mini-stroke) and muscle wasting. The 2/19/25 minimum data set (MDS) assessment revealed the resident was not able to complete the brief interview for mental status (BIMS) assessment.The Care Area Assessment revealed she had dementia and delirium. She scored zero on all memory questions. She used a wheelchair, she required maximum assistance with showers, supervision with toileting and moderate assistance with transferring. The MDS assessment indicated the resident had a fall since admission. B. Observations On 3/5/25 at 11:40 a.m. Resident #7 was sitting alone in the common area. On 3/6/25 at approximately 9:00 a.m., the resident was sitting in the hallway. She had bruises to her left cheek and she had a visible laceration under her left eyebrow. On 3/6/25 at 6:45 p.m. Resident #7 was sitting in the dining room in her wheelchair. She was supervised by a staff member. She had a bruise on her left cheek and was wearing a band-aid on her cheek. She did not pay attention or react to her surroundings and did not interact with her peers or caretaker during meal time. Her gaze remained on the table and on her meal in front of her. C. Record review The 1/30/23 admission fall risk assessment identified Resident #7 as a high risk for falls. It instructed staff to lower her bed and to encourage her to be in common areas for increased supervision. Furthermore, it recommended an anti-rollback or anti-tipper device evaluation for her wheelchair. The 2/22/25 and the 3/5/25 fall risk assessments documented that Resident #7 fell more than three times in the last three months. Review of Resident #7's at risk for falls care plan, initiated 3/22/24 and revised 3/6/25, revealed the resident was at risk for falls related to CVA (stroke), weakness, and paired mobility. The goal was to prevent any fall related injuries by providing physical therapy and providing physical assistance with mobility. The interventions added to the at risk for falls care plan on 3/22/24 included anticipating and meeting the residents needs, placing the resident's call light within reach, avoiding rearranging furniture, frequent room checks, clearing pathways and lowering the bed. The interventions added to the at risk for falls care plan on 7/24/24 included offering/assisting with toileting the resident before meals and at bedtime. The interventions added to the at risk for falls care plan on 8/8/24 included placing the resident's bed in the lowest position when she was in bed. The interventions added to the at risk for falls care plan on 3/6/25 care plan included frequent rounding and anticipating the resident's needs and encouraging the resident to be in common areas to increase supervision. -The facility failed to implement new fall interventions following Resident #7's falls on 6/14/24, two falls on 6/23/24, 11/2/24, 12/19/24, three falls on 12/23/24, 12/27/24 and 2/19/25 (see fall incidents below). The actual fall care plan, initiated 12/20/24 and revised on 3/1/25, documented the resident had had an actual fall. The goal was for the resident to resume usual activities without further incident through the review date. -The facility failed to initiate an actual fall care plan until 12/20/24, after the resident had already sustained 10 falls between 6/14/24 and 12/19/24, one of which required transportation to the hospital for sutures to a laceration on her forehead (see fall incidents below). Interventions added to the actual fall care plan on 12/20/24 included directing staff to keep the bed in the lowest position and continuing interventions on the at risk for falls care plan. Interventions added to the actual fall care plan on 3/1/25 included evaluating her wheelchair for proper fitting and frequent room checks. Review of Resident #7's Kardex (a quick care plan summary reference tool to assist staff in providing efficient and consistent care of residents) on 3/6/25 revealed the resident was to have her bed in the lowest position when in bed, and staff was to conduct frequent rounding, anticipate the resident's needs and encourage the resident to be in common areas for increased supervision. Therapy was to evaluate the resident for the use of anti-rollback or anti-tipper devices to her wheelchair, if appropriate. -However, according to the DON, anti-tipper devices were placed on the resident's wheelchair, but were removed because they did not work for the resident (see DON interview below). Review of Resident #7's electronic medical record (EMR) revealed the resident had 17 falls from 6/14/24 through 3/1/25. Review of Resident #7's falls between 6/14/24 and 3/1/25 revealed the following: 1. Fall incident on 6/14/24 at 6:45 p.m. - unwitnessed The 6/14/24 progress note documented that a certified nurse aide (CNA) found Resident #7 sleeping in her chair. CNA helped her to get into bed by request. Shortly after, a CNA found Resident #7 lying on the floor mat in her room. The CNA notified the nurse. Resident #7 sustained a bruise on her left elbow but her skin remained intact. The 6/17/24 IDT review note documented that an up/down therapy assessment was scheduled as an intervention. The note documented risk factors were poor safety awareness, poor cognition, and incontinence. -However, Resident #7's fall occurred shortly after she had been put to bed by a CNA after being up in her chair. -The facility failed to identify the root cause of the fall. 2. Fall incident on 6/22/24, time not documented - unwitnessed The 6/22/24 fall investigation documented a CNA found Resident #7 lying on the floor in front of her wheelchair in the activity room. Three staff assisted Resident #7 back to her wheelchair using a gait belt. A registered nurse (RN) assessed the resident for injury and pain. She complained about high hip pain but no injury was found. The 6/24/24 IDT review documented that an x-ray was ordered. CNAs and nurses were educated on the risk of leaving residents unattended. The note documented risk factors were lack of coordination, cognitive deficits, hypertension and muscle weakness. -However, there were no additional fall interventions added to the fall care plan following the 6/22/24 fall (see care plan above). -Additionally, Resident #7 was observed alone in the common area on 3/5/25 (see observations above). -The facility failed to identify the root cause of the fall. 3. Fall incident on 6/23/24 at 2:40 a.m. - unwitnessed The 6/23/24 progress note documented that a nurse and a CNA found Resident #7 lying on the living room floor. It documented the resident attempted to walk on her own instead of using her wheelchair. The 6/24/24 IDT review note documented that the physician ordered laboratory bloodwork (labs) and a urinary analysis due to the resident's increased confusion and multiple falls. The physician's goal was to rule out a urinary tract infection (UTI) as she had a history of UTIs. 4. Fall incident on 6/23/24, time not documented - unwitnessed The 6/23/24 progress note documented that a CNA found Resident #7 sitting on the floor in front of her wheelchair in the common area. -However, according to the 6/24/24 IDT note for the resident's 6/22/24 fall, staff was educated on the risks of leaving the resident unattended (see above). -Additionally, Resident #7 was observed alone in the common area on 3/5/25 (see observations above). The 6/25/24 IDT review note documented that Resident #7 continued therapy for safety awareness. The note documented risk factors were lack of coordination, cognitive deficits, hypertension and muscle weakness. -The facility failed to identify the root cause of the fall. 5. Fall incident on 7/6/24 at 5:11 p.m. - unwitnessed The 7/6/24 fall investigation documented that Resident #7 was found sitting on the floor in the television (TV) area. She had a bruise on the back of her head. The 7/8/24 IDT review note documented that the resident needed to be reevaluated for safety awareness. Her wheelchair needed to be assessed for anti-roll back or anti-tipped back. The note documented risk factors were lack of coordination, cognitive deficits, hypertension and muscle weakness. -The facility failed to identify the root cause of the fall. 6. Fall incident on 7/21/24 at 4:15 p.m. - unwitnessed The 7/21/24 fall investigation documented that a nurse found Resident #7 sitting on the floor in her room in front of her wheelchair. The 7/22/24 IDT review note documented that Resident #7's social worker was going to set up a care conference with the family to discuss relocating the resident to a locked unit. The note documented risk factors were lack of coordination, cognitive deficits, hypertension and muscle weakness. -However, there was no follow up note to indicate whether the care conference occurred or not. 7. Fall incident on 8/7/24 at 12:16 p.m. - unwitnessed The 8/7/24 fall investigation documented that a CNA found Resident #7 on the floor in front of her bed. She suffered a laceration on her forehead and was transported to the hospital. The 8/7/24 progress note documented Resident #7 hit her forehead and suffered bruises to her left and right elbow. She received two sutures at the hospital which would be removed in five days. She had no new behaviors or pain and her vital signs were within normal limits. The 8/8/24 IDT review note documented that Resident #7`s room was assessed for safety. Staff removed her nightstand for safety. Additional interventions added were the placement of a fall mat and ensuring the resident's bed was in the low position. The note documented risk factors were lack of coordination, cognitive deficits, hypertension and muscle weakness. -However, the facility failed to update the at risk for falls care plan with the fall mat intervention following the resident's 8/7/24 fall. -The facility failed to identify the root cause of the fall. 8. Fall incident on 9/10/24 at 6:02 p.m. - unwitnessed The 9/10/24 fall progress note documented a nurse found Resident #7 lying on the floor in front of a couch. The 9/11/24 IDT review note documented that the anti-roll back device was in place, however, it was not functional. The facility requested therapy to assess for proper functioning of the anti-roll back device. There was no mention of the fall location. -The note did not document what other safety interventions would be put into place if the anti-roll back devices were not functioning properly. -The facility failed to identify the root cause of the fall. 9. Fall incident on 11/2/24 at 6:36 p.m. - witnessed The 11/2/24 fall investigation documented that staff reported Resident #7 fell to the floor in her bathroom while wiping herself after a bowel movement. She hit her head on the wall. The 11/4/24 IDT note documented staff were educated on fall prevention and would encourage Resident #7 to use the grab bars during toileting. The IDT team note documented she had a risk factor of lack of coordination, cognitive deficits and dementia. -The facility failed to update the at risk for falls care plan with a new fall intervention following the resident's 11/2/24 fall (see care plan above). 10. Fall incident on 12/19/24 at 5:48 p.m. - unwitnessed The 12/19/24 fall risk assessment revealed Resident #7 was a high risk for falls. The 12/19/24 fall investigation documented staff found Resident #7 lying on the East hallway floor. Her wheelchair was tipped over backwards. The resident had a bump to the back of her head with redness. The resident was assisted back to the wheel chair. The fall investigation documented the predisposing psychological factors were confusion, incontinence and impaired memory. The 12/19/24 IDT review note documented lab work was ordered. -The note did not document that additional fall interventions were put into place. -The facility failed to update the at risk for falls care plan with a new fall intervention following the resident's 12/19/24 fall (see care plan above). -The facility failed to identify the root cause of the fall. The 12/20/24 nursing note documented the swelling to the back of Resident #7's head was decreasing. The resident had four large bruises to her right lower arm and a urine culture was pending results. 11. Fall incident on 12/23/24 at 7:00 a.m. - unwitnessed The 12/23/24 fall investigation documented that staff found Resident #7 in another resident`s room. She was laying on her back close to the bed. Her wheelchair was near her. The resident had no injuries. The investigation revealed she was assisted back to her wheel chair and range of motion was completed. The resident had no injury. The fall investigation documented the predisposing physiological factor was confusion. The 12/24/24 IDT review note documented the physician needed to review the resident's medications. -The note did not document that additional fall interventions were put into place. -The facility failed to update the at risk for falls care plan with a new fall intervention following the resident's 12/23/24 at 7:00 a.m. fall (see care plan above). -The facility failed to identify the root cause of the fall. 12. Fall incident on 12/23/24 at 1:15 p.m. - unwitnessed The 12/23/24 fall investigation documented another resident reported to the nurse that Resident #7 was on the floor. Resident #7 was sitting on the floor by the common area next to her wheelchair. She wore non-skid socks and shoes. The floor was dry and uncluttered. She hit her head. The fall investigation documented the predisposing physiological factors were a current UTI and impaired memory. The 12/24/24 IDT review note documented the physician ordered labs which came back positive for a UTI. The resident was currently on antibiotics due to confusion and falls. -The note did not document that additional fall interventions were put into place. -The facility failed to update the at risk for falls care plan with a new fall intervention following the resident's 12/23/24 at 1:15 p.m. fall (see care plan above). -The facility failed to identify the root cause of the fall. 13. Fall incident on 12/23/24 at 3:15 p.m. - unwitnessed The 12/23/24 fall investigation documented staff found Resident #7 on the floor in the dining room. She was laying on her back under a table. The resident was assessed and she denied pain. The fall investigation documented the predisposing physiological factors were confusion and impaired memory. The 12/24/24 IDT note documented that the physician reviewed the Resident #7's medications and implemented medication changes. -The note did not document what the medication changes were or that additional fall interventions were implemented. -The facility failed to update the at risk for falls care plan with a new fall intervention following the resident's 12/23/24 fall at 3:15 p.m. fall (see care plan above). -The facility failed to identify the root cause of the fall. 14. Fall incident on 12/27/24 at 4:27 a.m - witnessed The 12/27/24 fall investigation documented that staff witnessed Resident #7 yelling and propelling her wheelchair. She attempted to transfer from her wheelchair to a sofa. She started to slide then sat on the floor. The fall investigation documented the predisposing physiological factors were confusion, weakness, gait imbalance and impaired memory. The 12/27/24 IDT review note documented the physician needed to complete a medication evaluation. -However, physician evaluation of the resident's medications was documented as an intervention for the resident's falls on 12/23/24 and the medication review was documented as having been completed in the 12/24/24 IDT review notes (see above). -The facility failed to update the at risk for falls care plan with a new fall intervention following the resident's 12/27/24 fall (see care plan above). 15. Fall incident on 2/19/25 at 7:44 a.m. - unwitnessed. The 2/19/25 fall investigation documented Resident #7 was found on the floor by her bed. She tried to ambulate without assistance. She wore non-skid socks. The resident's call light was within reach, however, she did not use her call light. The fall investigation documented the predisposing physiological factors were confusion, incontinence and impaired memory. She ambulated without assistance. The 2/19/25 IDT review note documented interventions were for frequent room checks and to meet the resident's needs. -However, the note did not specify what needs the resident needed met or how staff was to ensure those needs were met. -The facility failed to update the at risk for falls care plan with a new fall intervention following the resident's 2/19/25 fall (see care plan above). -The facility failed to identify the root cause of the fall. 16. Fall incident on 2/22/25 at 1:45 a.m. - unwitnessed The 2/22/25 fall investigation documented that staff heard Resident #7 calling for help. Staff found the resident lying on the floor on her left side. Her face was covered in blood. Her head was close to the drawer. She told staff she wanted to go to the bathroom when she fell . She sustained a cut to the left eyebrow measuring 2.5 centimeters (cm) in length by 0.5 cm wide and she had a hematoma to her left cheek. The resident said her head hurt. Pressure was applied to the cut on her left eyebrow to control bleeding. The 2/22/25 hospital records revealed the resident had a hematoma over her left cheek, but no facial fractures. The 2/24/25 IDT review note documented Resident #7 was transported to the hospital for treatment. She was moved closer to the nurses station after her return to the facility. -However, the facility failed to move Resident #7 closer to the nurses station as a fall intervention until after the resident had sustained 16 falls, two with injuries that required transportation to the hospital for treatment. -The facility failed to identify the root cause of the fall. 17. Fall incident on 3/1/25 at 6:30 p.m. - unwitnessed The 3/1/25 fall investigation documented that Resident #7 slid from her wheelchair to the floor in the dining area. The resident did not have any injuries. The RN completed a total head to toe assessment and found no apparent injury. She was assisted back to the wheelchair. The fall investigation documented the predisposing psychological factors were incontinence and impaired memory. The 3/4/25 IDT review note documented the resident needed to be re-evaluated for proper wheelchair cushion fitting and staff were to notify hospice if wheelchair replacement was needed. The 3/6/25 progress note (added during the survey) documented that occupational therapy (OT) the resident's wheelchair fit and cushion that morning (3/6/25) to reduce risk of falls. Resident #7 reported the wheelchair was comfortable and the wheelchair cushion was in good shape. Dycem (a non-slip material used to provide stability and improve gripability) was added under the cushion to reduce the risk of the wheelchair cushion slipping and the OT recommended continued use of the cushion and wheelchair. -However, the assessment of the resident's wheelchair and cushion did not occur until 3/6/25, five days after the resident's 3/1/25 fall. -The facility failed to identify the root cause of the fall. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/6/25 at 10:15 a.m. LPN #1 said Resident #7 had a fall on 2/22/25 which resulted in a transport to the hospital. LPN #1 said the resident received steri-strips to her left eye brow for the laceration. She said the resident frequently fell . She said that she got up by herself and then fell . She said the resident was recently moved to a room closer to the nurses station. She said that helped, however, she said the resident still had falls. She said Resident #7 had dementia and would continue to get up by herself. She said she had a urinary tract infection which had increased her fall risk. However, she said the resident had no infection currently. She said staff were encouraged to keep the resident in the common areas so she could be supervised. The DON was interviewed on 3/6/25 at 4:40 p.m. The DON said Resident #7 had sustained numerous falls and was at a high risk for falls. She said after each fall, the IDT discussed the falls and the reason for each fall and tried to prevent further falls with interventions. She said sometimes the interventions were effective and other times they were not effective. She said Resident #7 had close monitoring. The DON said the resident started on hospice services on 2/19/25. The DON said Resident #7's wheelchair was assessed for anti-tip bars, however, she said the bars were removed because they did not work for the resident. She said the wheelchair was not the cause of the frequent falls. She said she would review the Kardex and would remove the anti-tip device. The DON reviewed Resident #7's EMR and said she could not locate documentation that the resident's medications were reviewed by the physician, as was documented as the intervention after the resident's 12/27/24 fall. The DON said Resident #7 was working with restorative nursing on range of motion. She said the staff kept the resident busy with activities. The DON said the facility had tried different interventions to prevent Resident #7's falls, such as medication review, activities, close monitoring and removing furniture from the resident's room. However, she said the facility had not been able to identify reasons for the resident's frequent falls. She said she was not able to answer how the facility monitored and assessed fall prevention effectiveness. -However, review of the fall investigations did not indicate the facility attempted to identify the root cause of Resident #7's falls after each fall. The DON said she encouraged Resident #7's family to visit more frequently. 52309 III. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included left sided hemiplegia (paralysis affecting only one side of your body), muscle weakness, cognitive communication deficit, abnormalities of gait and mobility, and history of falling. The 2/11/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. Resident #4 was substantial/maximal assistance to sit to stand and partial/moderate assistance with chair/bed-to-chair transfer. B. Observations During a continuous observation on 3/5/25, beginning at 11:30 a.m. and ending at 12:10 p.m., the following was observed: At 11:35 a.m. Resident #4 self transferred to her wheelchair from her bed and self propelled the wheelchair to the dining room. The resident had an ankle motion walking boot on her left foot. At 11:50 a.m. Resident #4 self propelled her wheelchair to her room and self transferred to her bed. At 12:00 p.m. Resident #4 self transferred to her wheelchair from her bed and self propelled the wheelchair to the dining room. C. Resident interview Resident #4 was interviewed on 3/5/25 at 3:35 p.m. Resident #4 said she fell a lot at home and broke her foot. She said she had fallen at the facility. She said was supposed to call for help when getting up but had to wait too long for staff to respond so she got up on her own. D. Record review The admission fall risk assessment, dated 11/4/24, revealed Resident #4 had a history of falls, required assistive devices, was regularly incontinent and was identified as a high risk for falls. Review of Resident #4's activities of daily living (ADL) self care performance deficit care plan, initiated 11/5/24, indicated Resident #4 required partial assistance with chair/bed to chair and toilet transfers. Review of the risk for falls care plan, initiated 11/7/24 and revised 2/11/25, revealed Resident #4 was at risk for falls due to recent surgery (left ankle) and had gait/balance problems. Pertinent interventions included ensuring the resident's call light was within reach and her bed was in the lowest position. Review of the actual fall care plan, initiated 11/18/24 and revised 12/17/24 revealed Resident #4 had an actual fall. Pertinent interventions included frequent room checks, medical provider to evaluate and order laboratory (lab) work and offering to transfer the resident to her wheelchair when awake. The Kardex Report, dated 3/6/25, indicated Resident #4 was a high fall risk and required frequent rounding, staff were to anticipate her needs, encouraging the resident to be in common areas for increased supervision as appropriate and to monitor for falls. Review of Resident #4's EMR revealed the resident had 12 falls from 11/15/24 through 2/17/25. Review of Resident #4's falls between 11/18/24 and 2/17/25 revealed the following: 1. Fall incident on 11/15/24 - unwitnessed The 11/15/24 fall risk evaluation identified the resident was a high risk for falls. The 11/15/24 fall investigation documented Resident #4 was found on the floor in her room next to the bed. The wheelchair was not locked and the resident had one non-skid sock on her right foot. Staff were unable to put a non-skid sock over the splint on her left foot. The resident had no injuries, but had a small red mark on her back. Resident #4 complained of pain to her left lower extremity (LLE). The resident said she was trying to get back into bed. The resident was educated on call light use and keeping weight off of her LLE. Resident #4 voiced understanding and apologized for trying to walk. The fall investigation documented the predisposing physiological factors were confusion and gait imbalance. The interdisciplinary team (IDT) review of the fall, dated 11/18/24, revealed the interventions put into place were to remind the resident to use the call system when she needed assistance with transfers and the resident continued on therapy services addressing overall safety awareness for decreased risks for falls. 2. Fall incident 11/26/24 - unwitnessed The 11/26/24 fall risk evaluation identified the resident was a medium risk for falls. The 11/26/24 fall investigation documented the resident was lying on the floor. Resident #4 said she was trying to go to bed. The resident was assessed and assisted to bed with the assistance of two staff members. The fall investigation documented the predisposing physiological factors were confusion, incontinence and gait imbalance. The IDT review of the fall, dated 11/27/24, revealed the interventions put into place were to check labs for ammonia level (a nitrogen-containing waste product produced by the body's metabolism) and the resident continued on therapy services to address overall safety awareness for decreased risk for falls. 3. Fall incident on 11/27/24 - un[TRUNCATED]

Based on record review and interviews, the facility failed to develop and implement a baseline care plan which included the instructions needed to provide effective and person-centered care for two (#2 and #6) of three residents reviewed for baseline care plans out of 13 sample residents. Specifically, the facility failed to ensure pertinent medical information was included on Resident #2 and Resident #6's baseline care plans within 48 hours of admission. Findings include: I. Facility policy and procedure The Policy/Procedure-Nursing Administration, Subject: Care planning policy, revised January 2025, was received from the nursing home administrator (NHA) on 3/6/25 at 1:56 p.m. It read in pertinent part, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive, person-centered care plan for each resident. A care plan is initiated within 48 hours of admission per assessment findings. The care plan is developed by the IDT which includes, but is not limited to the following professionals: nursing, therapy (as indicated), social services, activities, and dietary. II. Resident #6 A. Resident status Resident #6, age 78, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included end stage renal disease, dependence on renal dialysis (medical procedure that filters waste out of the blood) and a pressure ulcer (skin damage when prolonged pressure disrupts the flow to the tissues) to the coccyx. The 1/6/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. B. Record review Review of Resident #6's admission orders, dated 12/24/24, revealed the resident was receiving renal dialysis for end stage renal disease, she had a stage 3 pressure ulcer on her coccyx and a wound to her right hand. She was maximum assistance of two staff members for transfers using a Hoyer lift, she was dependent on staff for toileting and hygiene care, she had bladder incontinence and required set up assistance for her meals. -Review of the baseline care plan, dated 12/27/24, revealed the care plan did not include information regarding the resident's dialysis three times a week, wound care to the right hand, interventions for activities of daily living (ADLs), including the use of a total lift for transfers, dependence on staff for toileting and hygiene and set up meal assistance and the need for incontinence care. III. Resident #2 A. Resident status Resident #2, age 74, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included cognitive communication deficit, type 2 diabetes mellitus without complications, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease and dependence on renal dialysis. The 2/18/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The MDS assessment revealed that the resident was dependent on dialysis. B. Record review -Review of Resident #4's baseline care plan, dated 1/10/25, revealed the care plan did not include information regarding interventions for the resident's chronic kidney disease and the resident's insulin use. On 2/7/25 Resident #2 was admitted to the hospital and returned to the facility on [DATE] with physician's orders for dialysis three times per week and dialysis weights could be used for facility weight monitoring. Review of Resident #2's 2/11/25 baseline care plan revealed the facility documented the resident's chronic kidney disease and insulin use on the care plan. -However, the baseline care plan did not include information related to the resident's dialysis care. IV. Staff interview The director of nursing (DON) was interviewed on 3/6/25 at 3:45 p.m. The DON said the admitting nurse was responsible for initiating the baseline care plan for each resident and the care plans were then audited by another nurse or the DON for accuracy. She said staff should personalize the residents' baseline care plans for such things as wounds, infections, fall risks or ADL needs. The DON said the nurses did not pull the baseline care plan to get information on a new resident because they went directly to the admitting orders for any needed information. The DON said when Resident #2 was initially admitted to the facility, he had a dialysis port (a medical device used to provide access to a patient's bloodstream for hemodialysis treatment) and a new fistula (a surgical procedure that creates a connection between an artery and a vein) but was not yet receiving dialysis. The DON said the facility was not required to include the dialysis port on the initial baseline care plan. 52288

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#2) of three residents reviewed out of eight sample residents. Specifically, the facility failed to ensure transportation services were provided for Resident #2 which resulted in the resident missing an appointment with her oncologist and several chemotherapy infusion appointments. Findings include: I. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included malignant bladder cancer with bilateral nephrostomy (kidney) tubes. The 7/22/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #2 required set up assistance with eating, oral hygiene, dressing, and showers. She required supervision for toileting, and transfers, and was independent with bed mobility. II. Facility policy and procedure The Arranging Transportation policy, revised May 2020, was provided by the nursing home administrator (NHA) on 10/21/24 at 3:56 p.m. It read in pertinent part, It is the policy of this facility for the facility staff to assist in arranging for transportation when such assistance is requested or needed. The cost of transportation will be covered, as dictated by insurance coverage. II. Resident interview Resident #2 was interviewed on 10/21/24 at 11:55 a.m. Resident #2 said she had missed appointments for oncology and chemotherapy infusions since being at the facility. She said there was a problem with transportation but she wanted to continue with her cancer care and be able to attend her future appointments. III. Resident care manager interview Resident #2's third-party care manager (CM), was interviewed by telephone on 10/22/24 at 10:21 a.m. The CM said Resident #2 had missed an oncologist office visit on 9/17/24 and had missed chemotherapy infusion appointments on 9/5/24, 9/19/24 and 9/26/24. The CM said on 8/16/24 she spoke with scheduler (SCH) #1 on the telephone about Resident #2's cancer care appointments. She said SCH #1 told her she had confirmed transportation for the resident's 8/15/24 to 9/26/24 appointments. However, the CM said Resident #2 did not attend those appointments on 9/5/24, 9/17/24, 9/19/24 and 9/26/24 because transportation had not been arranged by the facility. The CM said she contacted the facility on 10/15/24 to confirm Resident #2 attended her appointment on 10/14/24 and to ensure transportation for 10/17/24 had been arranged. The CM said on 10/17/24 the facility confirmed by email message Resident #2 attended her appointment on 10/14/24 and transportation was arranged for the 10/17/24 appointment. The CM said Resident #2 missed the appointments on 10/14/24 and 10/17/24. -However, there was no documentation in Resident #2's electronic medical record (EMR) to indicate the resident had actually attended the appointment on 10/14/24, despite the email message from the facility indicating she had. IV. Record review -A review of Resident #2's electronic medical record (EMR) revealed there were no physician orders documented oncologist or chemotherapy infusion appointments. -Further review of Resident #2's EMR revealed there were no progress notes documented regarding the resident's missed appointments or that the resident's primary care physician was informed when Resident #2 missed her cancer care appointments. V. Staff interviews Registered nurse (RN) #1 was interviewed on 10/21/24 at 12:20 p.m. RN #1 said the facility had a process for residents to attend appointments. She said when the nurse was notified of an appointment, the nurse entered a physician's order into the resident's EMR so the date and time of the appointment populated on the resident's treatment administration record (TAR) where it was visible to the nurses. RN #1 said the scheduler made transportation arrangements and added the appointments to an electronic calendar that was accessible to the nursing staff. RN #2 was interviewed on 10/21/24 at 12:07 p.m. RN #2 said she provided care to Resident #2 but she was unaware Resident #2 had missed several cancer care appointments. She said it was important for the provider to be notified about missed appointments to allow the provider to evaluate and intervene if needed. RN #2 said when the nurse confirmed an appointment for a resident, the nurse completed a transportation request for the appointment and forwarded the form to the scheduler to make the transportation arrangements. SCH #2 was interviewed on 10/21/24 at 12:40 p.m. SCH #2 said when she received a transportation request form from a nurse, it was her responsibility to arrange transportation for the appointment. She said after the transportation was arranged, she entered the appointment and transportation information on an electronic calendar that was accessible to the nursing staff. She said if the nursing staff did not notify her of residents' appointments, there would be no transportation arranged for the appointments. -SCH #2 was unable to locate transportation request forms or billing invoices for Resident #2's cancer care appointments on 9/5/24, 9/17/24, 9/19/24, 9/26/24, 10/14/24 and 10/17/24. SCH #1 was interviewed on 10/22/24 at 9:40 a.m. SCH #1 said she worked as an interim transportation scheduler during August 2024 throughOctober 2024. She said she recalled speaking with Resident #2's third-party CM about her cancer care appointments for 8/29/24 through 9/26/24. -SCH #1 said she scheduled transportation for Resident #2 for those dates during that time period, however,she was unable to provide copies of the scheduling calendar, transportation request forms, or billing invoices for transportation on the dates of missed appointments. The NHA was interviewed on 10/22/24 at 12:07 p.m. The NHA said it was the policy of the facility to arrange transportation for residents' appointments when needed. The NHA said he was unaware Resident #2 had missed her cancer care appointments. The NHA said during July 2024 through October 2024 the facility had a change of scheduling staff and a new scheduler was hired on 10/7/24. The NHA said the new scheduler used the transportation request form to confirm residents' needs and to communicate transportation with nursing staff. VI. Facility follow-up On 10/22/24 at 3:55 p.m., the NHA provided copies of the transportation request forms for Resident #2's future cancer care appointments scheduled on 10/25/24, 10/31/24, 11/7/24, 11/21/24, and 11/27/24. The NHA said he had educated all nursing staff and schedulers to use the transportation request forms for every request received in any manner (email, telephone, paperwork, or in person).

Based on observation and interviews, the facility failed to ensure medications and biologics were stored and labeled properly on three of five medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Ensure medications were not stored in staff pockets; -Insulin (medication for diabetes) pen injection devices, were labeled appropriately with open dates; -Ensure inhaler medications were stored and labeled appropriately with open dates; -Ensure expired medications were removed from the medication rooms; and, -Ensure food items were not stored in the medication carts. Findings include: I. Profession reference According to the Advair Diskus manufacturer recommendations retrieved on 1/24/24 from: https://www.advair.com/, Safely throw away Advair Diskus on the trash one month after you open the foil pouch or when the counter reads zero, whichever comes first. According to the Lantus glargine package insert, retrieved 1/24/24 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, When in use can be kept at room temperature for up to 28 days. According to the Humalin N kwikpen instructions for use, retrieved on 1/24/24 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf, Throw away the Humulin N pen after 14 days even if it still has insulin in it. According to the Novology package insert, retrieved on 1/24/24 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/020986s082lbl.pdf, Once the pen was punctured it should be kept at temperatures below 86 degrees Fahrenheit for up to 28 days. II. Facility policy and procedures The Storage of Medication policy and procedure, dated November 2020, was received from the nursing home administrator (NHA) on 1/23/24 at 2:40 p.m. revealed in pertinent part, The facility stores all drugs and biologics in a safe, secure and orderly manner. The nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medications were stored separately from food and were labeled accordingly. III. Observations and staff interviews On 1/18/24 at 1:12 p.m. the second floor Red Cloud pass medication cart was reviewed with licensed practical nurse (LPN) #3. It contained topical and inhaled medications stored with gait belts (belt used to help transfer residents) in a sticky medication drawer. Medication boxes were stuck to the drawer. LPN #3 had to pull them off the bottom in order to see what the medications were: -One fluticasone nasal spray with no open date. -One Ketoconazole 2% cream with no open date. -One tube of Cortisone 2.5% with no open date. -One box Albuterol 0.083% nebulizer with no open date. LPN #3 was interviewed on 1/18/24 at 1:17 p.m. He said medication should be stored according to the route it was to be administered. LPN #3 said topical medications should not be stored with inhaled medications because they could become mixed/contaminated. LPN #3 was unsure when or who cleaned the medication carts. The first floor medication room was reviewed on 1/18/24 at 1:30 p.m. with registered nurse (RN) #1. There were nine eight ounce cartons of Jevity 1.5 tube feeding formula that had expired on 9/1/23. RN # 1 said these should not be in the medication room as they had the potential to be used by a nurse. RN #1 was unsure who removed expired medications or discontinued medications from the medication room. The first floor medication cart was reviewed at 1:40 p.m. with RN #1. RN #1 unlocked the medication cart and removed a medication cup from the top drawer and placed the medication cup into his left shirt pocket. RN #1 was immediately interviewed and he said the medication in his pocket was being saved for a resident who was receiving therapy when he attempted to administer them earlier. RN #1 pulled the medication cup out of his pocket, there was no name or room to identify whom the medication belonged. RN #1 said the medication belonged to Resident #170 and identified the following medications: lactobacillus, B complex, sodium chloride, magnesium and zinc. RN #1 then destroyed the medication and said he would prepare the medications for Resident #170 as he should not administer the medications since they were in his pocket. RN #1 said medications should not have been placed into his shirt as it was not clean and not the correct place to store medications. The medication cart contained the following: -One Fluticasone inhaler 100 milligrams (mg) with no name or open date on it. -One Fluticasone nasal spray 50 mg with no name or date on it. -One vial of artificial tears with no name or open date. -One Lantus insulin pen with no open date. -One Humulin kwikpen with no open date. -One Basaglar kwikpen with no open date. RN #1 said he did not know when the insulin pens were opened and he did not know how many days after the insulin was opened it would be good for. RN #1 said the eye drops he opened them this morning and he should have dated them and placed the resident's name on them. RN #1 said he needed to speak with the director of nursing (DON) about what to do with the identified medications from the medication cart. The medications were then left on the DON desk at 1:58 p.m. The second floor Wolf Creek medication cart was reviewed at 2:06 p.m. with LPN #4. The bottom drawer of the medication cart contained bottles of lotion, an open container of Sani Cloth wipes (disinfectant wipes) and multiple food items that included: four cans of soda, a bag of chocolates, two Jello cups, two packages of Goldfish crackers, two packages of Cheez-it crackers and two packages of peanut butter. The following medications were found on the cart: -One Lispro insulin pen with no open date. -One Fluticasone nasal spray with no open date. -One Advair Diskus inhaler with no open date. LPN #4 was interviewed on 1/18/24 at 2:17 p.m. She said open dates were important to know when a medication was opened as some medications were only good for so many days. LPN #4 said insulin was only good for 28 or 30 days after opening them and should not be used after that because the medication would not be as effective. LPN #4 said food and medications should not be stored together because they could become contaminated and expose residents to medications that were not prescribed to them. LPN #4 took medications to the medication room and placed them in the medication box for discontinued or expired medications and ordered the medications from the pharmacy. IV. Administrative interviews The DON was interviewed on 1/18/24 at 4:30 p.m. She said medication like insulin, nasal sprays and inhalers should be labeled with the resident name and date it was opened. The DON said some medications were only good for so many days and then should not be used as they were not as effective. The DON said medication should be stored according to route they were to be administered and mixing medications could lead to contamination of medications. The DON said food and medications should not be stored together as it increases the risk of infection and contamination of both the food and medications. The DON said medications should not be stored in a pocket at any time since it increases the risk of medication errors and infection. The DON was interviewed again on 1/23/24 at 2:45 p.m. She said it was the night shift nurses' responsibility to clean the medication cart on Sunday nights. The DON said the night shift nurse should be pulling all medications out and wiping the cart down with Sani cloth bleach wipes. The DON said the facility currently did not have a log to determine the last time medication carts or rooms were cleaned but moving forward she would have one put in place.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units in the facility. Specifically, the facility failed to: -Ensure high touch areas were cleaned appropriately by the housekeeping staff; -Ensure the housekeeping staff used proper surface disinfectant times; -Ensure appropriate cleaning products were used in resident areas; and, -Ensure the housekeeping staff cleaned from cleaner to dirtier areas. Findings include: I. Professional reference The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 1/24/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedures The Cleaning and Disinfection of Environmental Surfaces policy, revised August 2019, was provided by the nursing home administrator (NHA) on 1/23/24 at 12:06 p.m. It read in pertinent part: Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) bloodborne pathogens standard. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors. (2) Most non-critical items can be decontaminated where they are used. A one-step process and an EPA (Environmental Protection Agency) -registered hospital disinfectant designed for housekeeping purposes will be used in resident areas. Housekeeping surfaces (floors and tabletops) will be cleaned on a regular basis. The Cleaning and Disinfecting resident rooms policy, revised August 2019, was provided by the NHA on 1/23/24 at 12:06 p.m. It read in pertinent part: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Housekeeping surfaces will be cleaned on a regular basis, when spills occur and when surfaces are visibly soiled. Environmental surfaces will be disinfected on a regular basis and when surfaces are visibly soiled. Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Clean personal use items (lights, phones, call bells, bedrails, etc.) with disinfectant solution at least twice weekly. The Housekeeping Checklist, undated, was provided by the interim maintenance director (IMNT) on 1/23/24 at 5:15 p.m. It read in pertinent part: Empty trash, wipe down and dust, tables, chairs, window sills, light fixtures, and phones. Sweep and mop floor. Wipe down, scrub, and sanitize, toilet seat, handle, bowl and base. Wipe down, scrub and sanitize shower walls, floor and handles. Sanitize and wipe sink, including base. Dust vents. Clean mirror. Restock if needed soap, paper towels, and toilet paper. III. Disinfectant used in the facility The disinfectant in the facility was identified as Oxivir Five 16 concentrate, one step disinfectant cleaner with a five minute surface disinfectant time. IV. Observation and interview During a continuous observation on 1/18/24 at approximately 12:45 p.m. in room [ROOM NUMBER], where housekeeper (HSK) #1 was cleaning the resident's room. HSK #1 sprayed the bathroom mirror, sink, shower floor, handrails and toilet then HSK immediately wiped the mirror, sink and handrails dry. HSK #1 sprayed the shower and immediately wiped it dry. HSK #1 said the surface disinfectant time was five seconds. HSK #1 said the shower chairs were not to be cleaned, only wiped dry when wet. HSK #1 used a bleach wipe to clean the outside rim, tank and seat of the toilet and immediately wiped it dry with a cloth. -The HSK failed to spray bathroom door and room door knobs, shower chair, bedside table, call button and television remote. HSK #1 said the housekeeping staff were not permitted to touch personal items of the residents including the call button and remote controls. HSK #1 said high touch areas included call buttons, handrails, door knobs, bedside tables and television remotes. During a continuous observation on 1/18/24 at approximately 2:20 p.m. in room [ROOM NUMBER]. HSK #2 utilized a magic eraser sponge to clean the sink and wiped it dry immediately. HSK #2 sprayed the toilet and inserted bowl cleaner then used the toilet brush to clean the bowl, rim and underside of the seat. The HSK immediately wiped the entire toilet dry. -HSK #2 failed to clean high touch areas, used inappropriate cleaning materials, failed to observe appropriate disinfection times, and used the toilet brush to clean outer portions of the toilet. -HSK #2 failed to spray door knobs, handrails, call button, bedside table and remote. HSK #2 was unsure of surface disinfectant times required for disinfectant chemicals. HSK #2 said the call button, handrails and remote were to be cleaned when soiled. V. Administrative interviews The director of nursing, who was the infection preventionist, was interviewed on 1/23/24 at 3:23 p.m. The DON said the resident rooms should be cleaned weekly and deep cleaned once a month. She said door knobs, call lights, light switches and bedside tables were considered high touch areas and should be cleaned daily and as needed. She said she did not know the sanitation disinfection times for the cleaning products used to clean resident rooms, however the information should be listed on the bottles. She said if the cleaning product was not left on a surface long enough it would not have time to kill any bacteria on the surface which could lead to infection and spread of infections, including viruses, bacteria and other germs. The NHA was interviewed on 1/23/24 at 4:10 p.m. She said high touch areas including bedside tables, door knobs, trash cans, television remotes and call buttons should be cleaned routinely. She said housekeeping staff should know and use the proper sanitation disinfectant times. She said she did not know why a housekeeper had used a magic eraser sponge and it was not routine practice to use sponges.

Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#46) of three sample residents for incontinence care out of 48 sample residents. Specifically, the facility failed to ensure Resident #46 was offered incontinence care timely. Findings include: I. Facility policy and procedure The Activities of Daily Living policy, revised March 2018, was provided by the nursing home administrator (NHA) on 1/23/24 at 2:33 p.m. It read in pertinent part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -Hygiene (bathing, dressing, grooming, and oral care); -Mobility (transfer and ambulation, including walking); -Elimination (toileting); -Dining (meals and snacks); and -Communication (speech, language, and any functional communication systems). The resident's response to interventions will be monitored, evaluated and revised as appropriate. II. Resident status Resident #46, age over 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO) diagnoses included, Alzheimer's, dementia, muscle weakness and periodic paralysis. According to the 12/6/23 minimum data set (MDS) assessment, the resident brief interview for mental status (BIMS) score was a zero out of 15 which indicated the resident was severely cognitively impaired. The resident required extensive assistance with activities of daily living. The resident was frequently incontinent of bladder and bowel. The resident had refusals of care between four to six days. III. Observations 1/18/24 The resident was observed continuously from 11:15 a.m. to 3:15 p.m. -At 11:15 a.m., prior to entering the resident's room a strong odor of urine was identified approximately two feet in front of the resident's room. The resident's room had a strong odor of urine upon entering the room. The odor of urine grew stronger when going towards the resident, who was in bed. The resident was observed lying in bed with the television on. The room had trash bins that were empty and did not have any soiled briefs in them. -At 11:30 a.m., the resident's room door remained closed. Two unidentified certified nurse aides (CNAs) were observed walking down the hallway. The odor of urine remained present in the hallway. -At 12:10 p.m., an unidentified male CNA entered the room. The urine odor remained present. No incontinence care was offered. The male CNA exited the room within one minute. -At 12:17 p.m., the social services director (SSD) entered the room to check in on the resident. The urine odor remained present. The SSD exited the room within one minute and did not alert the nursing care staff about the urine odor. -At 12:27 p.m., the assistant director of nursing (ADON) and an unidentified licensed practical nurse (LPN) walked by the resident's room with a urine odor present. Both staff members did not address the urine odor. -At 12:56 p.m., the ADON, the SSD, an LPN and two unidentified CNAs walked by the resident's room with urine odor present yet the urine odor and or incontinence care was not addressed. -At 1:03 p.m., CNA #2 entered the resident's room, the urine odor remained present. CNA #2 did not offer incontinence care. CNA #2 exited the room within 30 seconds. -At 1:13 p.m., the ADON entered the room adjacent to the resident's room. The urine odor remained present in the hallway, however, incontinence care was not provided. -At 1:18 p.m., CNA #2 walked by the resident's room with the urine odor present yet no intervention and or incontinence care was provided. -At 1:40 p.m., the activities director (AD) entered the resident's room and asked the resident questions. The urine odor remained present. Nursing care staff were not alerted to the urine odor and no interventions or incontinence care was provided. -At 2:00 p.m., the AD left the room and obtained juice for the resident. -At 2:12 p.m., the AD left the room. The urine odor remained present. -At 2:40 p.m., the AD entered the room and left within one minute. The urine odor remained present. -At 2:48 p.m., an unidentifed housekeeping staff entered the room to clean it. The urine odor remained present. The housekeeping staff did not alert the nursing care staff of the urine odor. -At 2:53 p.m., the housekeeping staff exited the room after cleaning it and left the resident's room door open. Urine odor remained present from approximately two feet from the resident's room. -At 2:57 p.m. the resident was in bed with a urine odor present. The resident watched television and the room door remained open. -At 3:02 p.m. an unidentified LPN staff member peaked head into the room and walked away. The urine odor remained present. Incontinence care was not offered to the resident. -At 3:15 p.m. CNA #2 walked by the room and was asked to identify the odor by the resident's room. The CNA said the odor was urine. -At 3:26 p.m. CNA #2 offered the resident to be changed and the resident refused. CNA #2 did not inform the nurse of the resident's refusal. -No other attempts were made by CNA #2 to encourage the resident to be changed after she had not been changed for over four hours from the observation, however according to CNA #2 (see interview below) she had not been changed since 10:00 a.m. that morning by her daughter. -The nursing staff did not attempt to prompt her to be changed again nor contact the resident's daughter to attempt to encourage the resident to be changed (see staff interview below). IV. Record review The care plan, revised 8/11/21, read Resident #46 had bladder and bowel incontinence related to Alzheimer's. Interventions included to ensure the resident had an unobstructed path to the bathroom, check the resident for incontinence as she allowed. If she is resistive, attempt again later. The 1/8/24 to 1/20/24 nursing progress notes were reviewed on 1/23/24 at 2:12 p.m. The nursing progress notes did not document the resident had any refusals of incontinence care. V. Staff interviews CNA #2 was interviewed on 1/18/24 at 3:15 p.m. She said residents should be checked and changed at minimum every two hours and sometimes even sooner than two hours. CNA #2 said a resident should not be left for more than two hours without being changed because leaving a resident in their brief too long could cause pain, bruising, burning to their skin and skin breakdown. CNA #2 said she changed all her residents before meals or after meals and at times between meals. CNA #2 said all residents should be offered at minimum incontinence care every two hours and if the resident refused a different staff member should enter the room within 15 minutes to try again. CNA #2 said when a resident refused any care she would let the nurse know and the nurse would document the refusal. CNA #2 said Resident #46 was not offered to be changed because she refused a lot and her daughter came in on 1/28/23 at approximately 10:00 a.m. and took care of the brief change. CNA #2 said the resident at times was combative when incontinence care was provided. CNA #2 said Resident #46 should have been offered incontinence care every two hours and documented the refusal if the resident refused. CNA #2 said the resident was not offered to be changed for over four or more hours since she was responsible for the resident's care and the resident was not changed since approximately 10:00 a.m. Registered nurse (RN) #2 was interviewed on 1/23/24 at 1:45 p.m. The RN said the resident should be checked and repositioned every two hours. The RN said to ensure resident's were changed and repositioned within two hours she would put something in the medication administration record (MAR), however, there was no schedule in the MAR to prompt the RN for the resident. The RN said nursing care staff should ask and prompt for repositioning and incontinence as the resident is cognitively impaired. The RN said if the resident refused care then the nursing care staff should alert another nursing care staff member to attempt prompting the resident to be changed for incontinence care and if the resident still refused then the RN would call and notify the resident's daughter to try to encourage the resident to let staff change her. The director of nursing (DON) was interviewed on 1/23/24 at 4:17 p.m. The DON said residents should be repositioned and checked for incontinence at least every two hours.

Based on record review and staff interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical record for two (#51 and #89) of 24 residents reviewed for advance directives out of 48 sample residents. Specifically, the facility failed to ensure the medical orders for scope of treatment forms (MOST) forms matched the physician's orders for Resident #51 and #89. Findings include: I. Facility policy and procedure The Advanced Directive policy and procedure, revised [DATE], was received from the nursing home administrator (NHA) on [DATE] at 2:39 p.m. It revealed in pertinent part, (the) resident has the right to formulate an advanced directive, including the right to accept or refuse medical surgical treatment. Advance directives were honored in accordance with state law and facility. Do not resuscitate (DNR), indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods were being used. The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives were still the wishes of the resident. II. Resident #51 A. Resident Status Resident #51, older than [AGE] years old, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included hemiplegia (decrease functional mobility) of the left side, acute respiratory failure (affected breathing) subarachnoid hemorrhage (brain bleed), dementia (impaired memory) and peripheral vascular disease (decrease circulation). The [DATE] minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. B. Record review According to the January CPO, the resident had orders for DNR and CPR. According to the resident's MOST form in the resident's record, the resident was a DNR. III. Resident #89 A. Resident status Resident #89, younger than [AGE] years old, was admitted on [DATE]. According to the [DATE] CPO diagnoses included cerebral infarction (blood flow disruption to the brain), hemiplegia affecting the left side, bipolar disorder (abnormal mood) and chronic kidney disease (abnormal kidney function). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. B. Record review According to the January CPO, the resident had orders for CPR. According to the resident's MOST form in the resident's record, the resident was a DNR. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 11:48 a.m. She said in the event of an emergency she would look for either the CPO or the MOST form whichever was the closest option. LPN #1 said it was the responsibility of the admitting nurse to ensure the MOST form and order matched and it should be reviewed at care conferences but was unsure who would change the order if the resident changed their most forms. She said the MOST form and physician order did not match for Resident #89. LPN #2 reviewed Resident #51's CPO orders she did not know why the resident had orders for CPR and DNR. The director of nursing (DON) was interviewed on [DATE] at 11:55 a.m. She said it was the responsibility of the admitting nurse to fill out the MOST form, place it in the physician's box for signature and once it was signed the order could be placed into the resident's orders. The DON said the nursing staff should view the physical MOST form at the nurses' station in the event of an emergency to verify the resident's wishes. The DON said the orders for Resident #89 did not match their resuscitation wishes and there were two orders for Resident #51's wishes. The DON said this could cause complications and confusion in the event of an emergency.

Based on observations, record review and interviews, the facility failed to ensure one (#99) of three residents who entered the facility with limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable out of 48 sample residents. Specifically, the facility failed to ensure Resident #99 received restorative services to prevent potential worsening of functional ability. Findings include: I. Facility policy and procedures The Restorative Nursing Services policy, revised July 2017, was provided by the nursing home administrator (NHA) on 1/23/24 at 2:33 p.m., it read in pertinent part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. -The resident or representative will be included in determining goals and the plan of care. -Restorative goals may include, but are not limited to supporting and assisting the resident in: -Adjusting or adapting to changing abilities; -Developing, maintaining or strengthening his/her physiological and psychological resources; -Maintaining his/her dignity, independence and self-esteem; and -Participating in the development and implementation of his/her plan of care. II. Resident status Resident #99, above age 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO) diagnoses included low back pain, severe protein-calorie malnutrition, adult failure to thrive and muscle weakness. The 12/10/23 minimum data set (MDS) assessment coded the resident with a brief interview for mental status of 11 out of 15 which indicated mild cognitive impairment. The MDS assessment showed the resident was not assessed for upper and lower extremities range of motion. The resident used an assistive device (walker) to walk. The resident required substantial assistance to walk with the assistive device according to staff interviews (see below). III. Resident observation and interviews The resident and her family member were interviewed on 1/17/24 at 1:17 p.m. Resident #99 said she wished staff would help her walk with her walker because she was worried she would lose her ability to walk. Resident #99 said when her husband brought the concern to the facility's therapy staff the only response he received was they could not continue therapy due to lack of insurance coverage and the facility did not help them find a solution to prevent her from potentially declining. The resident and her husband said they did not know what to do and they felt the facility always made it their responsibility to navigate the resident's care and they needed help to guide them. The resident said she wished someone would make a schedule with her and encourage her to walk again even if it was only nursing staff and not physical therapy. The resident's walker was behind the bed. The resident said she had not used the walker in the last few weeks unless her husband was with her. The resident said staff would help her walk to the bathroom or the dining room by holding on to them and they would rarely ever use the walker to help her walk by herself. IV. Record review The care plan updated on 9/12/23 identified the resident had a self care deficit related to cognitive impairment and impaired mobility. Interventions included provide positive reinforcement for all activities attempted; note partial achievement and use unhurried manner, allow ample time for tasks. -The resident did not have a care plan for the restorative program or range of motion to address her potential decline of functional ability. The PT progress note dated 10/10/23 revealed the resident actively participated with skilled interventions. The PT progress note dated 10/11/23 revealed the resident actively participated with skilled interventions. The PT progress note dated 10/12/23 revealed the resident agreed to therapy but required encouragement. The PT progress note dated 10/16/23 revealed the resident actively participated with skilled interventions. The physical therapy (PT) discharge summary dated 10/16/23 revealed the reason for the resident's discharge was due to exhaustion of benefits and the resident's refusal for services. The resident's prognosis indicated it would be good with staff follow through to maintain current level of functioning. -The resident did not refuse ongoing services and or a transition to restorative care according to the notes previous to the discharge of PT on 10/16/23. -The restorative program was not established and or indicated. In addition, the facility did not have a restorative program (see staff interviews below). -Review of the medical record failed to show the resident had a restorative program indicated or provided. -There were no orders for a restorative program. V. Staff interview The director of rehabilitation (DOR) was interviewed on 1/22/24 at 2:04 p.m. She said the resident was discharged from therapy due to lack of insurance coverage, however Resident #99 would benefit from continued therapy to avoid a decline in Resident #99's functional ability and the resident record should have nursing notes and recommendations on the kardex (abbreviated plan for care staff) if there were recommendations in place. -No recommendations were in place on the kardex and no nursing progress notes were observed related to the resident's functional ability exercises, participation and or functional status. Registered nurse (RN) #2 was interviewed on 1/23/24 at 11:17 a.m. She said the facility did not have a restorative program to prevent residents from potentially declining in functional ability but that the facility should have a restorative program. Assistant director of nursing (ADON) #1 was interviewed on 1/23/24 at 11:59 a.m. She said the facility did not have a restorative nursing program in place but the nursing care staff would promote the maintenance of functional status and ability through encouraging the residents to eat in the dining room and or range of motion exercises during ADL care. Certified nurse aide (CNA) #2 was interviewed on 1/23/24 at 12:10 p.m. She said the facility did not have a restorative program in place to assist the resident with walking and or maintenance of their functional ability, however, as a CNA she would help residents maintain their functional ability with range of motion during activities of daily living care and or assisting them with going to the bathroom. The director of nursing (DON) was interviewed on 1/23/24 at 1:53 p.m. She said the facility did not have a restorative program in place however she wished the facility did. The NHA was interviewed on 1/23/24 at 2:50 p.m. She said the facility did not have a restorative program in place. She said the facility would implement a restorative program soon. The NHA said having a restorative program was important in order to maintain a resident's functional abilities and encourage their highest level of functioning and independence. The NHA said the documentation for restorative therapy and or functional ability was not documented in the resident record since they did not have a restorative program in place.

Based on observations, record review and interviews, the facility failed to ensure two (#37 and #170) of seven residents who required respiratory care received the care consistent with professional standards of practice out of 48 sample residents. Specifically, for the facility failed to: -Ensure a care plan was in place to include for oxygen therapy to include oxygen route, frequency, and liters required for Resident #37; -Ensure a physician's order was in place for oxygen therapy for Resident #37; -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine for Resident #37 and Resident #170; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #170 and Resident #37's CPAP; -Ensure a care plan was in place for CPAP to include route, oxygen supplementation, storage, cleaning and settings for Resident #37 and Resident #170; and, -Accurately complete the respiratory section of the minimum data set (MDS) assessment for Resident #37 and Resident #170. Findings include: I. Facility policies and procedures The Oxygen Management policy, revised October 2010, was provided by the nursing home administrator (NHA) on 1/23/24 at 2:33 p.m. The policy revealed in pertinent part: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician. Procedures for oxygen therapy to include: -Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. -Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears. -Check the mask, tank, humidifying jar, to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. -Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated (see 'Assessment'). -Periodically re-check water level in humidifying jar. -Discard used supplies into designated containers. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: -The date and time that the procedure was performed. -The name and title of the individual who performed the procedure. -The rate of oxygen flow, route, and rationale. -The frequency and duration of the treatment. -The reason for p.r.n. (as needed) administration. -All assessment data obtained before, during, and after the procedure. -How the resident tolerated the procedure. The CPAP policy and procedure, revised March 2015, was provided by the NHA on 1/23/24 at 2:35 p.m. The policy revealed in pertinent part: Provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen, to improve arterial oxygenation in residents with respiratory insufficiency obstructive sleep apnea or restrictive obstructive lung disease. to promote resident comfort and safety. Use clean distilled water only in the humidifier chamber. -Review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory and gastrointestinal status. -Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (Positive end-expiratory pressure) for the machine. - Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery. II. Resident #37 A. Resident status Resident #37, age above 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), personal history of transient ischemic attack (similar symptoms to a stroke), cerebral infarction (stroke) without residual deficits, type 2 diabetes mellitus with hyperglycemia (increased blood sugar), other obesity due to excess calories, obstructive sleep apnea and essential (primary) hypertension. The 11/25/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She had no behaviors and did not reject care. She required substantial/maximal assistance with personal hygiene and moderate assistance with mobility, however ambulation was not attempted due to medical condition or safety concerns. -The use of the CPAP was not coded on the MDS assessment. B. Resident interview Resident #37 was interviewed on 1/17/24 at 11:00 a.m. She said she has been on oxygen since she was admitted and she was not sure how often the tubing had been changed. She said she has been on a CPAP since she was admitted and she was not sure how often it was cleaned. She said the mask was typically stored on top of the machine on her bedside stand uncovered. C. Observations Resident #37 was observed on 1/17/24, 1/18/24, 1/22/24 and 1/23/2 4 from 9:00 a.m. to 5:00 p.m. Her oxygen concentrator was set for 2 liters via a nasal cannula. Her CPAP was not in use and was on her bedside with the mask stored on top of it. D. Record review -Review of medical record on 1/17/24 revealed the resident did not have an order for the use of her oxygen. An order read CPAP ensure mask in place and functioning properly for sleep apnea. -The order did not include the route, frequency, oxygen supplementation, storage and or settings of the device. The care plan revised 8/28/23 revealed the use of oxygen therapy was listed on the care plan as an active problem area. The use of CPAP was listed on the care plan as an active problem area. -The care plan did not have goals and interventions listed for the oxygen therapy to include route, frequency, liters and frequency of tubing change. -The care plan did not have goals and interventions listed for the CPAP to include route, frequency, oxygen supplementation, storage and or settings. E. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 1/23/24 at 11:15 a.m. She said she typically sets the oxygen's liters in the morning or make sure it was set to the correct amount of liters. She said would ask the nurse how many liters of oxygen a resident should be on and or use the information sheet that told her how many liters the resident should be on. She said she did not do anything for the resident's CPAP machine. Registered nurse (RN) #1 was interviewed on 1/23/24 at 11:35 a.m. She said she would look at the resident's order to see how many liters they should be using. She looked at Resident #37's medical record and said there was no physician's order for the use of her oxygen. She said there should have been a physician's order to include the liters, the route and the frequency. She said the oxygen should have been addressed in her care plan. She said Resident #37 was on 2 liters since admission to the facility. She said she would look at the resident's order to see when the CPAP should be used, how it should be stored, how often the tubing needed to be changed and the settings for the device. She looked at Resident #37's medical record and said there was no physician's order for the use of her CPAP aside from a general order. She said there should have been a physician's order to include the route, storage, settings, tubing changes, oxygen connected or not and the frequency. She said the CPAP should have been addressed in her care plan to also include the route, storage, settings, tubing changes and whether oxygen was connected or not to the CPAP. The director of nursing (DON) was interviewed on 1/23/24 at 3:36 p.m. She said all residents using oxygen should have an order including the liters, the route and the frequency. She said it should have been addressed in his care plan. She said the care plan and physician's order were updated after being identified during the survey process for the resident's oxygen therapy use. She said all residents using a CPAP should have an order to include the route, settings, frequency, storage and cleaning. She said it should have been addressed in her care plan and the MDS assessment should have included the CPAP's use. She said the care plan and physician's order were updated after being identified during the survey process for the resident's CPAP use. 40960 III. Resident #170 A. Resident status Resident #170, age above 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included chronic obstructive obstructive pulmonary disease, acute respiratory failure with hypoxia (not enough oxygen), acute pulmonary edema (excess fluid in the lungs), morbid obesity with alveolar hypoventilation (insufficient ventilation) and unspecified atrial fibrillation (irregular heartbeat). The 1/11/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of nine out of 15. She had inattention and disorganized thinking. She required maximal assistance with assistance with toileting hygiene, bathing, lower body dressing, and putting on footwear. She used continuous oxygen. -The use of the CPAP was not triggered/coded on the MDS assessment under section O. B. Resident interview Resident #170 was interviewed on 1/22/24 at 9:33 a.m. She said her CPAP mask and machine had not been cleaned since she had admitted and the tubing had not been changed. She said staff always stored her CPAP mask on top of her nightstand. C. Observations The CPAP (continuous positive airway pressure) mask was observed on: -1/17/24 at 11:22 a.m. the mask and tubing were on the top of the CPAP machine on the nightstand. -1/18/24 at 9:27 a.m. the mask and tubing were on the top of the CPAP machine on the nightstand. -1/22/24 at 9:33 a.m. the mask and tubing were on the top of the CPAP machine on the nightstand. D. Record review -The medical record was reviewed on 1/17/24 and did not reveal an order for the CPAP, the settings, care for the CPAP mask, whether the CPAP should be initiated with or without oxygen, or a care plan addressing the CPAP. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/22/24 at 9:37 a.m. She said the nurse was responsible for cleaning the CPAP machine but was not sure how often it should have been cleaned. She said the CPAP mask should be rinsed with water and stored in a clean basin in the top drawer of the nightstand. She entered Resident #170's room and found the CPAP mask and tubing laying on top of the CPAP machine on top of the nightstand. She said she did not know why she did not store it properly. She then placed the mask in the top drawer of the nightstand on top of salt and pepper packets, a jar of used vaseline, a used tube of barrier cream, a used tube of zinc oxide, a used bottle of wash and a used bottle of lotion. Licensed practical nurse (LPN) #1 was interviewed on 1/22/24 at 9:48 a.m. She said the nurse was responsible for cleaning the CPAP machine. She said the mask should be rinsed in water and air dried. She said a physician order should be in place to include whether oxygen was needed, the settings, and cleaning/storage when not in use. She said the resident should have a care plan in place identifying the use of the CPAP. She said the CPAP mask should be stored in a clean basin in the top drawer of the nightstand. She said she did not know how often the CPAP machine should be cleaned or how often the tubing should be changed. The director of nursing (DON) was interviewed on 1/22/24 at 9:59 a.m. She said the night nurse should clean the CPAP mask daily with water and air dry. She said she was not sure how often the machine should be cleaned. She said she was not sure how the mask should be stored

Based on observations, interviews, record review, and document and policy review, the facility failed to ensure care and services were provided to prevent new pressure ulcer development for one (Resident #98) of three residents reviewed for pressure ulcers. Specifically, the facility failed to monitor the resident's skin under a knee brace and foot boot every shift as ordered, and the resident developed a stage 3 pressure ulcer to the right calf. Findings included: The facility's undated policy titled Pressure Ulcers/Injuries Overview indicated, Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. According to the policy, an avoidable pressure ulcer/injury meant that the resident developed a pressure ulcer/injury and that the [sic] one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions. A review of Resident 98's Admission Record revealed the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. Per the MDS, Resident #98 required extensive physical assistance of one staff for bed mobility and required limited physical assistance of one staff for toilet use and personal hygiene. Further review indicated the resident had one stage 3 pressure ulcer and was provided with a pressure-reducing device for a chair and received pressure ulcer care. A review of Resident #98's Care Plan, initiated on 08/09/2022, indicated the resident was admitted with a pressure ulcer to the right heel, with interventions directing staff to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing at least weekly and to report improvements and declines to the doctor, assist with turning/repositioning frequently, offload heels when in bed, offload the right lower extremity at all times, and to wear Prevalon (pressure-relieving) boots to the bilateral lower extremities. The resident's care plan did not indicate the resident was non-compliant with care. Further review indicated the resident had an activity of daily living (ADL) self-care deficit dated initiated 08/11/2022 with interventions that directed staff to monitor the knee brace for proper fit and to observe the resident's skin for redness, open areas, scratches, cuts, and bruises and to report any changes to a nurse. A review of Resident #98's Order Summary Report indicated that, on 08/03/2022, the resident had an order to offload heel at all the times, check skin under brace every shift for skin management. Further review indicated the resident was to go to a wound clinic every Wednesday related to the stage 3 right heel wound, with a start date of 07/27/2022. Additionally, the resident had an order to cleanse the right heel wound with wound cleanser, apply skin prep to the peri wound, apply [MEDICATION(S)] (collagen wound dressing) cut to fit the wound bed, and wrap with Kerlix (bandage roll) three times a week and as needed, with a start date of 07/29/2022. A review of Resident #98's progress notes indicated that, on 07/25/2022, the resident was admitted with a chronic stage 3 pressure wound to the right heel and the resident was being followed by a wound clinic. A review of Resident #98's Wound Care Center Note indicated the resident had been visiting the wound care center prior to admission to the facility. Further review of the notes revealed the resident was seen by the wound care clinic on 07/27/2022, 08/03/2022, 08/10/2022, and 08/17/2022. Review of a wound clinic note dated 08/24/2022 revealed Medical Doctor (MD) #1 (from the wound care clinic) noted the heel wound was larger, and the resident had a new posterior calf decubitus ulcer as well. Per the note, MD #1 was unsure if the skilled nursing facility had been assisting with turning the resident, and the resident's foot had been stuffed into the resident's sneaker (which the provider had previously recommended the resident not wear). The resident denied leg pain, discomfort, any drainage, fever, or chills. Review of the Assessment portion indicated the resident's wound had failed to heal and had gotten worse due to infrequent turning and non-compliance with recommendations/regimen. Per the document, the resident had been non-compliant with recommendations for footwear and offloading and had not followed up with [MEDICATION(S)] radiology as recommended. The Plan indicated MD #1 reiterated the importance of offloading and the resident had remained non-compliant. MD #1 discussed the risks of non-compliance with the resident, including the risk of infection/[CONDITION(S)], loss of limb, and loss of life. MD #1 indicated they would call the facility to discuss the worsening of the resident's wounds. A review of Resident #98's Treatment Administration Record indicated the resident was to have their skin checked underneath the brace on each shift. For the month of August of 2022, four out of 55 observations of the resident's skin were not completed. On 08/24/2022, the day the calf wound was identified by the wound clinic, RN #1 documented she checked the skin underneath the resident's brace. A review of Resident #98's progress notes revealed no mention of a pressure ulcer to the right calf on 08/24/2022. A review of a progress note dated 08/26/2022 at 7:38 AM revealed the resident had a new right calf wound. The progress note indicated the physician was aware and was fine with staff not using and ankle foot orthosis. Further review of the progress notes indicated that, on 08/26/2022, the interdisciplinary team (IDT) met and discussed the resident's new right calf wound. The IDT team had no recommendations at that time and the resident was to continue to go to the wound clinic weekly. On 08/31/2022, the resident was transferred to the hospital and did not return back to the facility. During a telephone interview on 09/27/2022 at 11:30 AM, Wound Clinic Registered Nurse (RN) #2 stated the resident came into the wound care clinic due to a wound that developed at the hospital. RN #2 stated the resident's wounds were getting bigger and deeper and included a deep tissue injury up and down the resident's leg. RN #2 stated Resident #98 initially only had one wound but then the RN noticed a new wound on the back of the resident's calf that was black/necrotic. RN #2 stated it was noted to be a pressure injury where the resident's brace had been, and the RN had attempted to contact the facility and left a message for the Assistant Director of Nursing (ADON). RN #2 stated she ultimately spoke with RN #1, who planned to pass along the message to have the ADON return the call to RN #2. RN #2 stated the resident's family member was present during the appointment on 08/24/2022 when the new pressure ulcer was identified on the back of the resident's calf. RN #2 stated the resident came to the facility weekly for debridement and they sent any new orders to the facility. During an interview on 09/27/2022 between 12:42 PM and 1:05 PM, Certified Nursing Assistants (CNA) #1, #2, #3, and #4 stated they could not remember Resident #98. During an interview on 09/27/2022 between 11:12 AM and 11:14 AM, CNA #5 and CNA #6 stated they could not remember Resident #98. During an interview on 09/27/2022 at 12:48 PM, RN #1 stated the resident had a wound to the resident's heel but could not recall which heel. RN #1 stated the resident went to the wound clinic, came back to the facility, and then was sent to the hospital on the same day, and that was when the calf wound was identified. RN #1 could not recall the date. RN #1 stated she never saw the calf wound, and the ADON and DON were notified of the new wound by the wound clinic nurse. RN #1 stated the resident went to the wound clinic every week and wore a brace all the time to the unknown leg, which was a non-weight-bearing. RN #1 stated the resident did not refuse any care, and the RN could not remember how often she assessed the resident's skin. RN #1 stated a notification would come up in the resident's electronic health record (EHR) and she would then check off on the notification to indicate that a skin assessment was completed. During a follow-up interview on 09/27/2022 at 2:52 PM, RN #1 stated she completed skin assessments on the resident and did not notice anything on the resident's calf. At that time, RN #1 was shown that she had assessed the resident's skin underneath the resident's boot on 08/24/2022, the day the calf wound was identified at the wound clinic. RN #1 stated the resident had a brace and the skin underneath the brace was covered with gauze, and she did not check the skin under the gauze. RN #1 stated she only checked to see if there were any new skin issues around the gauze, not under the gauze. During an interview on 09/27/2022 at 1:13 PM, the Assistant Director of Nursing (ADON)/Wound Treatment Nurse stated the resident was admitted with a right heel pressure ulcer. The ADON stated the resident developed a right calf pressure ulcer, and after speaking with the wound clinic, it was believed to have developed from the boot the resident had been wearing. The ADON stated she did not have the exact date of when the new pressure ulcer developed. The ADON stated the facility knew the same day the resident went over to the clinic but could not state who identified the wound and stated, It must have been the nurse that noticed it before sending [the resident] out to the wound clinic. The ADON stated the resident did refuse care and it should have been documented in the nurse's notes. The documentation related to the resident's refusal of care was requested but never received during the survey. The ADON stated she completed weekly wound rounds on the resident to assess the resident's skin. However, she noted she never measured the wounds due to the resident going to the wound care clinic weekly. During an interview on 09/27/2022 at 3:20 PM, Licensed Practical Nurse (LPN) #3, who had provided wound care to the resident, stated they could not remember the resident and had taken care of a lot of residents that wore a brace on their leg. LPN #3 stated they would open the brace and assess the resident's skin underneath the brace, unless there was an order to not open the dressing. However, LPN #3 could not recall the resident. During a telephone interview on 09/28/2022 at 9:21 AM, LPN #4, who had provided wound care to the resident, stated they could not remember working with the resident or providing care to any resident who wore a boot. During an interview on 09/28/2022 at 9:28 AM, LPN #1 stated the resident wore a brace on the right leg and also had a wound. However, LPN #1 could not recall what type of wound. LPN #1 stated there was an order to look around the skin around the brace, and the order was to assess the resident's skin once a shift and to document it on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated the resident did not develop any new skin concerns while at the facility. LPN #1 stated the resident would go to the wound clinic every Wednesday, and the LPN would get the paperwork ready on Tuesday night. LPN #1 stated the resident did not refuse care and was able to make their needs known. During an interview on 09/28/2022 at 9:55 AM, LPN #2 stated the resident was admitted with a heel wound and wore a brace, but LPN #2 was not aware of any new skin concerns for Resident #98 that had developed at the facility. LPN #2 stated the resident went to the wound clinic every Wednesday and wore a brace on the resident's right leg. LPN #2 endorsed assessing the resident's skin underneath the brace but could not provide any additional information related to the assessments. LPN #2 stated the resident did not refuse care, and the facility was to assess the resident's skin every seven days. LPN #2 stated the resident had an order to check the skin under the brace every shift and the LPN removed the brace to do so. LPN #2 stated there was Kerlix that was covering the calf, and the LPN never assessed the skin under the Kerlix. LPN #2 stated they could not remember if the resident was admitted with a calf wound. During an interview on 09/28/2022 at 11:20 AM, MD #1 from the wound care clinic stated Resident #98 developed a calf ulcer that was near the resident's knee by the knee immobilizer brace, and the MD did not believe the facility was checking the resident's skin as the facility was not aware of the new ulcer. MD #1 stated if the resident's leg wound had been assessed on a daily or every-other-day basis and if orders were followed, the calf pressure ulcer may not have developed, and the facility should have discovered the pressure ulcer that week. During a telephone interview on 09/28/2022 at 10:41 AM, LPN #5, who had provided wound care to the resident, stated they did not know if the resident had any skin concerns. During an interview on 09/28/2022 at 2:04 PM, the Director of Nursing (DON) stated the resident was admitted with a wound to the resident's foot, and when the resident was discharged , the resident had a new wound to their calf. The DON stated the pressure ulcer to the calf was acquired at the facility but did not know how it was acquired. The DON stated the calf wound was identified on 08/26/2022. At that time, the DON was advised about the wound clinic note on 08/24/2022, where the wound clinic identified the new wound to the calf. The DON then stated the wound was identified on 08/24/2022 by the ADON. The DON stated they were aware the resident wore a boot on the right foot. The DON stated the resident was noncompliant with care and the wound was unavoidable based on the resident's nutrition. The DON stated the noncompliance should be documented in the nurse progress notes. The progress notes were requested but not received during the survey. The DON stated the resident had an order to check the skin under the resident's boot every shift, and staff should have removed the gauze to check the skin under the boot. The DON stated the pressure ulcer should have been identified by the facility and not the wound clinic if the staff were completing the skin checks every shift. The Administrator was not present during the survey and was unavailable for interview.

Based on observations, record review and interviews, the facility failed to ensure the care and services provided met professional standards of practice to ensure the residents highest practicable level of well-being for one (#1) out of six sample residents reviewed. Resident #1 who was admitted on [DATE] to the facility with [DIAGNOSES REDACTED]. Resident #1 who presented with an elevated temperature the morning of [DATE] was given orders by the physician for staff to follow regarding her care. Failure of the staff to give the medication prescribed by the physician, monitor the resident's current status frequently and follow orders to treat symptoms of COVID-19 lead to the resident being found unresponsive hours later during a medication administration by a nurse. The documentation from the nurse working with the resident indicated the tylenol that was given was ineffective, and no further interventions were given. When the nurse went to administer medications hours later, the resident was documented to have an elevated blood sugar, temperature of 99.9 F, and was being administered three liters of oxygen. This was a contraindication to what the paramedics found of a blood sugar level of 550, with an oxygen saturation level of 76% on room air with a pulse of 112 and an elevated temperature of 107. The resident was transported to the hospital and treated for [REDACTED]. Findings include: I. Delay of treatment A. Resident status Resident #1, age 76, admitted [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident cognitive status was not assessed, however according to an [DATE] quarterly comprehensive clinical health status assessment, the resident was alert and her cognition was intact. The MDS indicated the resident required extensive assistance of one to two people for all of her activities of daily living (ADLs), she was incontinent of bowel and had an indwelling urinary catheter. B. Family interview A member of the resident 's family was interviewed on [DATE] at 5:37 p.m. They said they had not been able to get a hold of the resident for several days and when they called to talk to the nurse on [DATE], they were told that the resident had a fever and was not doing well. They said they requested the resident be sent out to the emergency room but the facility did not send her out until the following morning. They said the resident died within 24 hours of being hospitalized from complications of COVID-19. C. Record review The vital sign summary report revealed the resident had a temperature recorded on [DATE] at 8:44 a.m. of 100.5 degrees Fahrenheit and her pulse was 110 beats per minute. There were no progress notes in the resident 's record to indicate that the resident 's elevated temperature had been reported to the physician. On [DATE] at 1:14 p.m. an order was entered into the resident 's electronic medical record (EMR) for [MEDICATION NAME] 6 milligrams (mg) one tablet by mouth in the evening for COVID-19 symptoms for 10 days and for a complete blood count (CBC) and urinalysis (UA) with culture and sensitivity (C & S), the order did not clarify if it was to be done stat (immediately) or routine. The [DATE] Medication Administration Record [REDACTED]. A progress note revealed the medication had not been received from the pharmacy. There was no documentation the physician had been notified of the medication not being available to administer to the resident or to give an update of the residents status at this time. The [DATE] MAR indicated [REDACTED]#1 was no longer in the building) and the urine was not obtained at all (see below). The lab results report revealed the collection date of the blood for the CBC was on [DATE] at 2:25 p.m. and the UA with C & S was not performed due to no specimen being collected. Interviews with the director of nursing (DON) below confirm that the resident was not in the facility at the time the blood was collected and the sample was believed to be from the resident 's roommate instead. The laboratory requisition form for the CBC and UA with C & S was initialed as being completed by the phlebotomist on [DATE] at 2:25 p.m. According to the [DATE] MAR, the resident was given Tylenol 650 mg on [DATE] at 10:58 p.m. for a fever and it was marked as ineffective. -No documentation was found to indicate the resident was given another medication or non-pharmacological interventions for the tylenol being ineffective to ensure reduction of fever occurred. No temperature was documented to indicate it had been rechecked. Review of the record revealed no documentation of the staff monitoring or following up with the resident until [DATE] at 4:30 a.m. (see below) The [DATE] change of condition progress note revealed the nurse went to give the resident her scheduled medications at 4:30 a.m. and found the resident lying on her back in bed, unresponsive to verbal and tactile stimuli, with deep shallow breaths. It indicated her blood glucose level was 516, her oxygen saturation was 86% on 3 liters per minute of oxygen and her temperature was 99.9 degrees F. It indicated when the paramedics arrived her temperature had jumped to 106 degrees F. The resident was transported to the hospital emergency room at 5:13 p.m. -These findings are contradictory to the findings of the paramedic who documented the resident was on room air and quite a significant temperature difference from 99.9 degrees to a finding of 106.8 degrees. (see paragraph below) The [DATE] emergency medical services (EMS) run sheet revealed at 4:58 a.m. the resident 's temperature was 107 degrees F and confirmed at 106.8 degrees F. It indicated the residents blood glucose was 550, her oxygen saturation was 76% on room air and her pulse was 112. According to the [DATE] hospital discharge summary, the resident presented from the nursing home with stool around her chronic indwelling urinary catheter, low blood oxygen levels and in septic shock with multi-organ failure. It indicated the resident was transitioned to comfort measures and died in the early hours of [DATE]. The cause of death was acute [MEDICAL CONDITION] from COVID pneumonia. The care plan, last revised [DATE], revealed the resident was at risk for signs and symptoms of COVID-19 and was on continuous oxygen therapy related to [MEDICAL CONDITIONS]. Interventions included: -Observe for signs and symptoms of COVID-19, document and promptly report fever, coughing, sneezing, sore throat and respiratory issues; and, -Monitor for signs and symptoms of respiratory distress and report to the physician as needed. D. Staff interviews Registered nurse (RN) #1 was interviewed on [DATE] at 1:09 p.m. He confirmed he was the nurse working with the resident on [DATE]. He said when he saw the resident in the morning of [DATE], she was tired and lethargic but was verbal and responsive. He said she had spiked a temperature and complained of being very thirsty. He said he gave her Tylenol for her fever. (This was not signed out on the MAR indicated [REDACTED]. He said she was unable to swallow her medications so he crushed them and gave them to her in pudding. He said he spoke with the resident 's family and they told him she always acted like this when she had a urinary tract infection and he needed to call the physician to get a UA done. He said he called the physician and received orders for [MEDICATION NAME] and labs including a UA. He said he could not remember if the laboratory tests were ordered to be done that day but he thought they should have been done stat (right away) since the resident was having a change of condition. He said he worked a double that day and checked on the resident frequently but was very busy and did not have time to document everything that he did. The DON was interviewed on [DATE] at 12:45 p.m. She said the laboratory tests ordered on [DATE] were put into the computer as routine, which means they would not have been drawn until the following Sunday [DATE]. She said the facility had determined that the laboratory tests drawn on [DATE] were from the resident 's roommate and not her since she was not in the facility at the time. She said the laboratory company had been notified and an audit was to be completed. She said laboratory tests would only be done the same day if it was specifically ordered by the physician. She said it was up to the physician to determine if laboratory tests should be drawn stat. RN #2 was interviewed on [DATE] at 2:20 p.m. He said if a resident 's vital signs were out of parameter, he would retake the vitals and assess the resident. He said if they continued to be out of normal parameters, he would contact the physician and document it in a progress note. He said orders for laboratory tests and medications obtained due to vital signs being out of parameter and the resident having a change of condition should be obtained stat and not routine. The physician was interviewed on [DATE] at 3:00 p.m. He said if laboratory tests and medications were ordered based on a resident 's change of condition, he expected those orders to be carried out that same day and not on a routine basis.

Based on observation, record review and staff interview, the facility failed to ensure two (#149 and #102) of four residents to have known accidents or exposure to hazards of 68 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to provide safety oversight for resident #149, who left the building without staff supervision and fell , sustaining facial and left hand trauma; and, the facility failed to ensure resident #102 did not have access to an electric fireplace with a metal screen that attained high surface temperatures. The findings included: 1. Resident #149 Resident #149, age 80, was admitted on [DATE]. According to the 3/16 physician orders, [DIAGNOSES REDACTED]. According to the 3/16/16 minimum data set (MDS) assessment (looking from 3/16/16 back to the 3/9/16 day of admission, see below), the resident had impaired short- and long-term memory. The resident required extensive assistance of staff for bed mobility, transfers, locomotion on and off the nursing care unit, dressing, eating, toileting and personal hygiene. He required supervision only for eating. He was frequently incontinent of bowel and bladder. He sustained a fall since admission. According to the 3/9/16 interim care plan in place on admission (three days before the fall, see below), the resident had fall mats on either side of his bed, and a low bed. He had independent mobility with his wheelchair, but might also need assistance with mobility. He wore an incontinence brief at all times. He was resistive with cares, and had poor safety awareness. One word instructions were best, and task segmentation was indicated. Wandering was not checked as a behavior. According to the 3/21/16 fall care plan (nine days after the fall, see below), the resident was at a high risk for falls due to falls within 30 days and within two to six months prior to admission. He had difficulty maintaining a standing position, had impaired balance while changing from sitting to standing, and used medications known to cause lethargy or confusion. He had a stroke with one-sided paralysis, muscle weakness, was impulsive with poor safety awareness, and had cognitive impairment. Approaches included wearing appropriate footwear when ambulating on foot or in his wheelchair, and the resident required staff or family oversight when outside. a. Observations On 3/25/16 at 12:05 p.m. the resident was observed being pushed in his wheelchair to the dining room. His left arm was hanging beside the spokes of the left large wheelchair wheel. His hand was swollen, and there was a thick irregular brown scab over the dorsum of the hand. A healing cut was visible on his left cheek. The wound edges were approximated without sutures, and there were no signs of infection in either wound. Staff repositioned his left hand and arm so it rested on the left armrest of his wheelchair. He was placed at the dining room table and meal service began at that time. On 3/30/16 at 5:05 p.m. the resident sat in the dining room at a table. He sat in his wheelchair, and drank coffee. He stood up without any change in his demeanor or any attempt to get help, and the nurse assisted him to sit down in his wheelchair. On 3/30/16 at 5:12 p.m. the resident stood up again while seated at the table. He began to turn to his left side. Again, the nurse assisted him to sit down in his wheelchair. On 3/31/16 at 5:00 p.m. the resident sat in his wheelchair at a dining room table, sipping a juice drink. His left cheek and left hand were healing without signs or symptoms of infection. On 4/5/16 at 10:25 a.m., the resident sat in his wheelchair in the front lobby. The left cheek wound was healed. On the back of his swollen left hand was a thick intermittent brown scab. There was no evidence of redness or other indication of wound infection. On 4/5/16 at 10:05 a.m. the resident had a new padded device on his wheelchair to support his left arm and hand above his left leg, at the elbow level. b. Record Review According to the 3/12/16 emergency department (ED) physician note, the resident was brought to the ED by ambulance from his skilled nursing facility after a fall. The resident had exited the facility in his wheelchair and was found outside in the parking lot on the ground with obvious facial and extremity trauma. The resident had baseline aphasia (difficulty speaking) and was unable to describe what happened. He answered yes when asked if he had a headache, and otherwise said I don't think so to all other questions. After examination and multiple radiology studies, the physician determined the injuries were a left cheek facial laceration, and a large left hand skin tear and contusion. The physician sutured the 5 centimeter laceration to the left cheek, and nursing placed steri-strips to approximate the wound edges of the skin tear on the back of the left hand. The resident was returned to the skilled nursing facility after this ED care. According to the 3/9/16 (initial) fall risk evaluation (three days before the fall), his score was 17, indicating he had a high risk for falling. He had a history of [REDACTED]. He displayed a memory problem. He was unable to walk, even with assistance and/or an assistive device. He had an unsteady gait, was confined to a wheelchair and was disoriented. Fall mats were placed on each side of his bed and the bed was maintained in its lowest position. The nurse author of the document wrote he needed very frequent observation. The CNAs were notified of this, and to check on him very frequently. He was alert to his name only. The initial elopement risk evaluation was completed 3/18/16 (six days after the fall with injury). He had the physical ability to leave the facility. He was not alert, oriented or coherent with decisional capacity. The resident's representative requested he be monitored for elopement. He was confused to time and place and had the physical ability to leave the building, though he had not attempted actual elopement in the past year. Staff was aware of his wander and elopement risks. The check box in front of frequent monitoring was not checked. The resident had an electronic device in place to alert staff if he got near the front door, or the elevators. According to the 3/9/16 admission assessment, the resident was admitted from an acute hospital. He resided in the memory care unit of an assisted living facility, where he fell prior to his hospital treatment. He was alert and oriented to person only, was confused and forgetful at times. He had the ability to express his needs, whether verbal or non verbal, but he did not have the ability to understand and hear information from other persons. A note read he was very forgetful, alert to himself. He wanted to go to bed, and needed very frequent observation to prevent a fall. He had a history of [REDACTED]. According to a 3/10/16 (two days before the fall) progress note entered at 5:31 a.m., the resident was kept in the nursing station for the entire shift, sitting in his wheelchair. He was trying to get out of bed while in his room by himself. He required very close observation to prevent a fall beside his bed, maintained in the lowest position. His call light and floor mats were in place. He denied any pain or problem when asked. He did not display distress or agitation at that time. According to the 3/11/16 (one day before the fall) daily skilled nursing evaluation, the resident was alert and oriented to person only. He did not display any mood problems. According to the 3/12/16 (the day of the fall) daily skilled nursing evaluation, entered at 3:13 p.m., the resident was alert and oriented to person only. He did not display any mood problems. According to the 3/30/16 fall risk evaluation, effective 3/12/16 at 6:30 p.m., the resident did not have a memory problem. He was unable to walk, even with assistance and/or an assistive device. He had an unsteady gait, was confined to a wheelchair and was disoriented. The narrative summary indicated staff was summoned outside as someone fell outside of the building. He was able answer questions, and was awake, looking around. A facial laceration was present, as well as a large skin tear to the right (sic) hand. The resident was transported to the local emergency department for treatment. According to the 3/12/16 fall investigation, the resident fell at 4:30 p.m. The resident had a history of [REDACTED]. He had known neuromuscular alterations due to a stroke, as well as perceptual visual and hearing impairments. No medications were given close to the time of the fall. He was unrestrained in his wheelchair, and had dementia. He was on a therapy treatment program. A new intervention implemented after the fall, upon his return to the facility, was an electronic device to monitor when he got near an exit or elevator. In addition, staff or family was to accompany him outside of the building. The care plan was updated with new interventions, as repeat falls were anticipated. Interventions in place at the time of the fall included instructing the resident to ask for assistance, use of a low bed, keeping the call light in reach, education of resident and family, and review of his medications. The form was signed by the director of nursing and the nursing home administrator. According to a 3/12/16 witness statement, at 5:00 p.m. certified nurse aide (CNA) #7, heard from the front desk someone had fallen outside the building. She ran out and found resident #149 laying face down on the ground. He was alert and oriented, answering questions. Vital signs were assessed, and she remained with him until the ambulance arrived to take him to the hospital. c. Staff Interviews The director of nursing (DON) was interviewed 4/6/16 at 4:17 p.m. She said the resident had never made any attempts to go outside prior to the day he fell . The family had taken him outside the day before, as the weather was nice. He did not have an electronic device in place that would have alerted the staff he was exiting the nursing care unit prior to the fall. There were several persons sitting outside, and she thought he went outside to sit. She said he was sitting under the roofed area immediately outside the automatic sliding glass front door. The nurse heard someone holler in the front door for a nurse, as someone was hurt outside. She said visitors said the resident stood up and fell to the ground, under the roofed area of front entryway, to the left of the front door. The names of the witness(es) to the fall were not noted in the fall investigation report. The DON said RN #4 went out to check him, left him on the ground and went in to call 911. She did not know who the last staff person was to see him prior to his exit from the building, nor was there any information specific to the time of the actual fall, or alert from bystanders that someone was injured. She said he had been a resident in the facility before this admission, and had not made any attempts to go outside at that time. She said she defined frequent checks as being every 30 minutes. She said the staff checked on him more frequently than that. She said he was returning to his memory care unit at the end of the week. The certified nurse aide (CNA) #7 was interviewed via telephone on 4/6/16 at 4:35 p.m. She said she was working on the first floor (skilled nursing unit) on the day this resident fell a few days after admission. She was in another resident's room, and resident #149 knocked on the door. She answered the door, and informed him she was not able to stay with him at that time. She said the agency nurse (she did not recall who this was) on duty that day walked by and said she would take him to the dining room. The CNA said the charge nurse on duty wanted him to be out of his room, so the staff could keep an eye on him. The agency nurse assured her she would lock his wheelchair brakes when he was at the dining room table. She was unsure how long he was there, perhaps 15 to 20 minutes. She did not know who unlocked the resident's wheelchair brakes. She said she did not think the resident had the strength to unlock his own wheelchair brakes. She said she had last provided incontinence care about 1:30 or 2:00 p.m. that afternoon. She said he was wearing black shoes with rubber soles, and hook-and-loop closures on top. She said she and the registered nurse (RN) #4 on duty went out near the front door to see who had fallen. She did not know who had informed the RN that a person fell outside of the facility. She said the RN called an ambulance, and went to locate a pillow for the resident's comfort. The RN brought out towels to fold and place under the resident's head as he lay on the ground. She said the male receptionist on duty was not sitting at the front desk at the time she exited the building to provide assistance to the fallen resident. When asked if it was her practice to keep this resident in places where he was visible to the staff, she said he liked to roam up and down the hall. Outside the wheelchair had rolled down the right sidewalk, near the edge of the parking lot. She said she thought the resident had fallen about 5:00 p.m., but was not sure of the time. RN #4, who was on duty at the time of the 3/12/16 fall, was interviewed by telephone on 4/6/16 at 4:51 p.m. She was unsure exactly what time the resident fell . She said she was seated at the first floor nurse station, and an unknown person came into the front door, saying someone had fallen outside and a nurse was needed. She and CNA #7 went out the front door. She said a CNA from another floor happened to be outside the building, and was standing by. She said she exited the building to find someone laying on their stomach on the asphalt with their head turned to the right. As she got closer to him, she identified him as resident #149. She said he was lying on the asphalt of the parking lot, in front of and just to the right of the front door as she exited the building. He was near the sidewalk of the roofed entryway. His glasses were off and broken, lying on the ground and the unlocked wheelchair was near his feet. He had a skin tear on his right (sic) hand, and a skin tear on the left side of face. She said it was significant enough to know he hit his head. The front desk receptionist on duty was not sitting at the desk as she exited the building. She said a family member had taken him outside earlier that day as the weather was nice. She said he was a resident she liked to keep within her line of sight. She said an ambulance was notified and he was taken by ambulance to the hospital. She said prior to learning of the fall, another staff person (she was unsure who it was) had sat him in his wheelchair, and that staff got him something to drink. She was unsure if the wheelchair was locked, and was unsure if he could unlock his own wheelchair. She said it was seven to ten minutes after that when she learned someone had fallen outside, and a nurse was needed to evaluate that person. She said he was wearing brown shoes he wore frequently, with a hook and loop closure. The receptionist on duty at the time of the 3/12/16 fall was interviewed by telephone on 4/7/16 at 11:11 a.m. He said he did not see the resident leave the building, and did not see the resident fall. He said he remembered staff telling him the resident fell . He said the resident tried to go out the front door, and he tried to keep an eye on him. 2. Resident #102 Resident#102, age 91, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 2/10/16 MDS assessment, the resident displayed short-term and long-term memory impairment, disorganized thinking, and inattention. She experienced moderate depression, hallucinations, and delusions. She required extensive assistance with dressing, toileting, and personal hygiene. She was independent with bed mobility, transfers, walking, locomotion, and eating. The care plan, initiated 7/14/14, identified a risk for elopement due to wandering activity. Interventions included monitoring the resident's activity, providing activities, maintaining a calm environment, and providing comfort measures. The care plan, initiated 2/19/16, identified a cognitive impairment related to a [DIAGNOSES REDACTED]. Interventions included inviting her to activities and providing sensory awareness groups. a. Observations On 3/30/16 at 9:47 a.m. resident #102 was observed wandering the unit. The MDS coordinator (MDSC) approached the resident and brought her to her seat at a dining table. The resident was about one foot away from an electric fireplace plugged into the wall behind it. The resident was observed touching it. The MDSC told the resident not to touch the fireplace because it was hot. At 9:47 a.m. the resident was left sitting at the table alone, without staff within direct line of sight. She continued to place her hand on the fireplace multiple times, lifting her hand and touching different areas. At 9:53 a.m. she remained sitting at the table touching the fireplace repeatedly. At 10:06 a.m. the center of the front panel above the glass was temped at 160.3 degrees F. At 11:39 a.m. the same panel was temped at 175 degrees F. On 4/1/16 at 5:20 p.m. an electric fireplace was observed in the lobby of the first floor. The center front panel of the fireplace, above the glass, was too hot to the touch to leave your hand on for more than a few seconds. b. Staff Interview The director of nursing (DON) was interviewed on 4/5/16 at 4:40 p.m. She confirmed resident #102 had dementia and said some residents on the first floor had dementia. She said no assessments had been completed on residents or the fireplace to be sure residents were safe near them. She was unaware of any surveillance in place for the safety of residents near the fireplace. She said many residents enjoyed sitting by the fireplace but if residents were touching the fireplace, it would have been a risk. She denied any residents having unexplained burns or blisters. On 4/1/16 at 5:20 p.m. the Legacy consultant said they would purchase something to cover the front panel to avoid anyone touching it. c. Record Review An incident summary note, dated 2/14/16, revealed the resident had been found on the floor in front of the fireplace.

Based on observations, interviews, and record review, the facility failed to provide care and services to promote the highest practicable level of well-being for two (#167 and #40) out of 41 sample residents. Specifically, the facility failed to -Monitor and treat resident #167's pain, resulting in his experiencing a pain level of eight out of 10. -Monitor, assess and communicate specific to the provision of [MEDICAL TREATMENT] services for Resident #40. The findings include: Professional Reference: The National Institutes of health, "[MEDICATION NAME]", [MEDICATION NAME] Oral, 12/24/14, http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 0.html (1/28/15), read in part, [MEDICATION NAME] acts on the spinal cord nerves and decreases the number and severity of muscle spasms caused by [MEDICAL CONDITION] or spinal cord diseases. It also relieves pain and improves muscle movement. 1. Failure to Manage Resident Pain Resident #167: Resident Status Resident #167, age 60, was admitted to the facility on [DATE]. The resident's face sheet indicated that he had a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment, which was provided on paper by the Medical Records staff on 1/12/15, indicated that the resident received both scheduled pain medication, and pain medication as needed. The MDS also indicated that the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated minimal to no cognitive impairment. Care Plan: -The resident's care plan, as provided on 1/12/15 by the Medical Records team, did not include a care plan specific to his pain. -The resident's care plan for Activities of Daily Living (ADLs) and rehabilitation, dated 1/12/15, indicated that the resident was at risk for a decline in his ADLs due to his MS and [DIAGNOSES REDACTED]. The care plan indicated that the goal was for the resident to maintain a stable health status with minimal symptoms of his disease process. One action item listed under the goals of the care plan was to administer all medication as specified in the physician's orders [REDACTED]. Observations: -On 1/14/15 at 9:03 a.m., the resident was observed in his room. The resident was lying on his bed and during an interview was observed to tense up, grimace, inhale sharply and produce a gasping sound. -On 1/14/15 at 11:38 a.m., Licensed Practical Nurse (LPN) #3 was overheard telling the resident's physician (MD #1), that the resident had not received his medication for the morning. -On 1/14/15 at 12:09 p.m., the facility's electronic Medication Administration Record [REDACTED]. Resident Interviews: -On 1/14/15 at 9:03 a.m., the resident was interviewed. The resident stated he had not received his morning medications. The resident stated that one of the medications he had not received was his [MEDICATION NAME], which was prescribed for his MS, and that he was in pain. When asked to rate his pain on a one to 10 scale, with one being no pain at all and 10 being the worst pain he had ever experienced, the resident stated that his pain level was at a seven or eight out of 10. Physician's Progress Note -A physician's note, dated 1/5/15, indicated that the resident's MS caused him to have muscle [DIAGNOSES REDACTED], which caused painful spasms throughout the day, and that [MEDICATION NAME] was used to treat this condition. Computerized Physician order [REDACTED]. -The CPOs dated 1/3/15, indicated that the resident had been prescribed two 10 mg tablets of [MEDICATION NAME], which were to be given at 8:00 a.m., and again at 10:00 p.m., for MS. -The CPOs dated 1/3/15 indicated that the resident had an order for [REDACTED]. -The CPOs dated 1/5/15 indicated that the resident had been prescribed [MEDICATION NAME], with one 5-325 mg tablet to be given every four hours as needed for pain. -The CPOs dated 1/3/15 indicated that the resident was to be assessed for pain every shift. Medication Administration Record [REDACTED] -The MARs for 1/14/15 indicated that the resident's [MEDICATION NAME], which was scheduled to be administered at 8:00 a.m., was administered at 12:19 p.m, more than four hours late. The note on the MAR indicated [REDACTED]. -The MARs for 1/14/15 also indicated that there had been no pain assessment completed for that morning. The most recent pain assessment had been completed 1/13/15, but the MAR indicated [REDACTED] -The MARs for 1/14/15 indicated that the resident did not receive a dose of either [MEDICATION NAME] or [MEDICATION NAME] to manage his pain. Staff Interviews: - On 1/14/15 at 11:14 a.m., LPN #3 was interviewed. The LPN stated that she was running " late on medication pass." The LPN stated that she had not arrived to work until 10:00 a.m. - On 1/14/15 at 11:43 a.m., the resident was interviewed a second time. The resident stated that he had still not received his pain medication, and indicated that his pain was now an eight out of 10 on a scale of 1 to 10. The resident stated that the nurse had not been by to check on him that morning. - On 1/14/15 at 12:26 p.m., the resident was interviewed. The resident stated that he had just received his medication, but that it had not started working yet, and that he had pain "from shoulders to toes" at an eight out of 10. - On 1/14/15 at 5:51 p.m., the Director of Nursing (DON) was interviewed. The DON stated that any pain assessment that had been conducted for the resident would have been noted in the MARs under the order for pain assessments, and that the absence of documentation indicated that no pain assessment had been performed. The DON stated there had been a four hour delay for the resident's medications and that there was no documentation regarding the resident's pain level or that any of his "as needed" pain medications had been administered. The DON stated this was not acceptable. The DON further stated that she was aware that the resident's nurse had not gotten to the facility until 10:00 a.m. and another nurse (RN #3) was suppose to administer the medications, but apparantly did not ensure that resident's medications for pain were administered as ordered. 2. Failure to Monitor, Assess and Communicate Specific to the Provision of [MEDICAL TREATMENT] Services Long Term Care Facility [MEDICAL TREATMENT] Services Agreement Review of a 1/31/14 "Long Term Care Facility [MEDICAL TREATMENT] Services Agreement" revealed the facility agreed to furnish all appropriate medical information relating to the resident's condition, including a statement of current treatment provided to the resident (including medications), which was necessary and/or useful in connection with the provision of [MEDICAL TREATMENT] services to the resident. In turn, the agreement noted the [MEDICAL TREATMENT] center would provide the facility with all appropriate information and guidance regarding the renal condition of the resident. [MEDICAL TREATMENT] Services Procedure An undated "[MEDICAL TREATMENT] Services Procedure" provided by the facility indicated staff were expected to coordinate care of the [MEDICAL TREATMENT] resident with the [MEDICAL TREATMENT] center. The procedure included a directive to "send a current medication list with resident to [MEDICAL TREATMENT]." Resident #40: resident status -Resident #40, age 79-years-old, was admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. The resident's 12/22/14 quarterly minimum data set (MDS) assessment coded the resident, in pertinent part, with anxiety disorder, diabetes mellitus, hypertension, [MEDICAL CONDITION], and aortic valve disorder. The MDS identified the resident received an anti-anxiety medication and anticoagulant seven of seven days during the MDS look back period, as well as a diuretic six of seven days and insulin injections five of seven days during the MDS look back period. Record Review: Care Plan The resident's 10/20/14 care plan revealed the resident required [MEDICAL TREATMENT] and directed staff to monitor the resident's access site every shift, provide access site care, and to report any signs of leakage/clotting or localized or systemic infection. Staff was also directed to avoid unnecessary diagnostic/therapeutic procedures, to avoid taking blood pressure readings or starting intravenous lines/drawing blood from the shunt arm and to restrict the resident's fluids to 1500 cubic centimeters (cc) per day. Physician order [REDACTED]. Review of the resident's December 2014 and January 2015 "Physician order [REDACTED]. - 10/17/14 open-ended order: Resident to [MEDICAL TREATMENT] every Monday, Wednesday and Friday - 10/22/14 open-ended order: Hold blood pressure medications before [MEDICAL TREATMENT] - 11/1/14 open-ended order: Give 20 milligrams (mg) of [MEDICATION NAME] (a diuretic) twice a day - 11/3/14 open-ended order: No [MEDICATION NAME] on [MEDICAL TREATMENT] days - 11/8/14 open-ended order: Take two [MEDICATION NAME] 2.5mg tablets (cardiovascular agent) to [MEDICAL TREATMENT] - 11/10/14 open-ended order: Increase fluid restrictions to 1500cc/day - 12/23/14 open-ended order: Two eggs every breakfast [MEDICAL TREATMENT] Communication Record Review of the resident's "[MEDICAL TREATMENT] Communication Record" book revealed a template form was used to facilitate communication between facility staff and [MEDICAL TREATMENT] center staff regarding the resident's status pre- and post-[MEDICAL TREATMENT]. The form contained sections for completion by facility staff that included information about medications the resident received within the last six hours, prior to sending the resident to [MEDICAL TREATMENT], assessment of the resident's vascular access site, time of last meal, last weight and date of last weight and any changes to/information about the resident's condition, including information regarding the resident's compliance with fluid and diet restrictions. The form also contained sections for completion by [MEDICAL TREATMENT] center staff that included information about medication given during/after [MEDICAL TREATMENT], pre- and post-treatment weights, pre- and post vital signs and special instructions/comments and/or changes noted in the resident's condition. Review of the resident's 1/1/15 (dated 12/31/14 with an arrow pointing to the date "1/1/15") [MEDICAL TREATMENT] Communication Record revealed facility staff failed to complete any section of the form and the facility nurse failed to sign or date the form. In lieu of listing medications the resident received within the last six hours prior to [MEDICAL TREATMENT], the facility attached a copy of "Current Orders" to the communication sheet. The Current Orders sheet reflected medications ordered, but failed to reflect which medications were actually administered within the last six hours, prior to sending the resident to [MEDICAL TREATMENT]. Additionally, the [MEDICAL TREATMENT] center failed to include post-[MEDICAL TREATMENT] vital signs for the resident or a post-treatment weight, which had not been identified or addressed by the facility. Nursing Progress Notes Review of a nursing progress note documented 1/1/15 at 10:55 a.m. revealed the resident complained to facility staff of nausea as he left for [MEDICAL TREATMENT]. This information was not captured on the [MEDICAL TREATMENT] Communication Record. Additionally, the progress note indicated the [MEDICAL TREATMENT] center called the facility that morning to obtain the resident's temperature prior to leaving for [MEDICAL TREATMENT], as the resident's temperature registered 100.3 degrees Fahrenheit while at [MEDICAL TREATMENT]. The progress note identified the resident had a normal temperature prior to leaving for [MEDICAL TREATMENT]. The facility nurse noted the facility planned to monitor the resident's temperature, as the resident had a central venous catheter removed the day prior, which facility staff had not noted on the [MEDICAL TREATMENT] Communication Form. Review of the resident's 1/2/15 [MEDICAL TREATMENT] Communication Record revealed facility staff failed to complete any section of the form and the facility nurse failed to sign or date the form. In lieu of listing medications the resident received within the last six hours prior to [MEDICAL TREATMENT], the facility attached a copy of "Current Orders" to the communication sheet. The Current Orders sheet reflected medications ordered, but failed to reflect which medications were actually administered within the last six hours prior to sending the resident to [MEDICAL TREATMENT]. Additionally, the [MEDICAL TREATMENT] center failed to list a post-treatment weight or sign and date the form which had not been identified or addressed by the facility. Review of the resident's 1/5/15 (written as 1/5/14) [MEDICAL TREATMENT] Communication Record revealed facility staff failed to list medications given to the resident in the last six hours prior to sending to [MEDICAL TREATMENT], the time of the last meal, the last weight or the date of the last weight. The facility nurse failed to sign or date the form. In lieu of listing medications the resident received within the last six hours prior to [MEDICAL TREATMENT], the facility attached a copy of "Current Orders" to the communication sheet. The Current Orders sheet reflected medications ordered, but failed to reflect which medications were actually administered within the last six hours prior to sending the resident to [MEDICAL TREATMENT]. Additionally, the [MEDICAL TREATMENT] center staff failed to list a complete set of post-[MEDICAL TREATMENT] vital signs or date their signature which had not been identified or addressed by the facility Review of the resident's 1/7/15 [MEDICAL TREATMENT] Communication Record revealed facility staff failed to complete any section of the form other than writing "(no) new orders" and directing [MEDICAL TREATMENT] staff to review the resident's Medication Administration Record [REDACTED]. The form lacked nurse signatures from the facility and [MEDICAL TREATMENT] center staff which had not been identified or addressed by the facility. Review of the resident's 1/9/15 [MEDICAL TREATMENT] Communication Record revealed facility staff failed to list medications given to the resident in the last six hours prior to sending to [MEDICAL TREATMENT], the time of the last meal, the last weight or the date of the last weight. The facility nurse failed to sign or date the form. In lieu of listing medications the resident received within the last six hours prior to [MEDICAL TREATMENT], the facility nurse wrote "See MAR" and attached a copy of "Current Orders" to the communication sheet. The Current Orders sheet reflected medications ordered, but failed to reflect which medications were actually administered within the last six hours. Review of the resident's 1/12/15 [MEDICAL TREATMENT] Communication Record revealed facility staff failed to list medications given to the resident in the last six hours prior to sending to [MEDICAL TREATMENT], the time of the last meal, the last weight or the date of the last weight. The facility nurse failed to sign or date the form. In lieu of listing medications the resident received within the last six hours prior to [MEDICAL TREATMENT], the facility nurse wrote "See MAR" and attached a copy of "Current Orders" to the communication sheet. The Current Orders sheet reflected medications ordered, but failed to reflect which medications were actually administered within the last six hours. Additionally, the [MEDICAL TREATMENT] center staff failed to list a complete set of post-[MEDICAL TREATMENT] vital signs, pre- or post-treatment weights or sign and date the form which had not been identified or addressed by the facility. Dietary Progress Note Review of a 1/12/15 dietary progress note revealed the resident's weight for 1/5/15 was inaccurate and previous (but unspecified) weights obtained for the resident were recorded without subtracting the weight of the wheelchair and/or wheelchair legs. The progress note indicated weights were obtained for the resident (which had not been recorded on the [MEDICAL TREATMENT] Communication Records), and were largely inaccurate. Interviews: The Director of Nursing (DON) was interviewed on 1/14/15 at 12:45 p.m. The DON was shown the lack of information provided by facility staff to the [MEDICAL TREATMENT] center and vice versa. She stated she expected facility staff to send the resident's MAR indicated [REDACTED]. The DON also stated she expected facility nurses to pursue information from the [MEDICAL TREATMENT] center when not provided on the communication form. Additionally the DON stated all of the information on the form was important for good coordination of care for the resident, including a narrative statement regarding the resident's adherence to the ordered fluid restriction and dietary orders. She confirmed the facility currently lacked proper coordination of care based on the lack of information provided to the [MEDICAL TREATMENT] center and information missing from the [MEDICAL TREATMENT] center which her nursing staff failed to pursue.

Based on observations, record review, and interviews the facility failed to ensure one (#3) of three sampled residents received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically the facility failed to report skin integrity issues to the physician, evaluate and assess the resident's skin weekly as ordered, and obtain appropriate treatment for [REDACTED]. The findings include: Cross reference F157: notification of change. The facility failed to notify the physician of a significant change in the resident's skin integrity. A. Facility Policy: The facilities protocol for the care of a pressure ulcer or wound dated 8/2014, read in pertinent part: "The first step in identification of a pressure ulcer or wound is to know the difference in types of wounds and staging. There are pressure ulcers and non pressure related ulcers. Nursing assessment is needed to determine the type of ulcer and effective treatment and interventions for improvement and healing to occur. Pressure ulcer is a lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear may not be the underlying cause of pressure ulcers, friction and shear are contributing factors to the development of pressure ulcers. Category/stage one: non-blanchable [DIAGNOSES REDACTED]: - Intact skin with non-blanchable redness (reddened area that loses its redness when touched) 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. Stage one may be difficult to detect in individuals with dark skin tones. 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 (dead tissue (yellow, tan, gray, green or brown) and or eschar (dead tissue (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 stage three or stage four. 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. The nurse performing weekly wound rounds would document, the location, size of the ulcer (when measured in centimeters length, width, and depth), stage (if stageable), exudates, pain, characteristics of the wound bed, and the description of wound edges and the surrounding tissue as appropriate in the observations of Matrix Care, the electronic medical record. At the time of identification the physician and family would be notified. This notification would be documented in the progress notes. If the ulcer did not show evidence of healing and improvement, the physician would be notified every two to four weeks for a change in the treatment orders. If the current treatment was to be continued a rationale for this approach would be documented. Additionally, the nurse would notify the registered dietician and other health care professionals for additional needed assessments and interventions." B. Resident Status: Resident #3, age 98, was admitted to the facility on [DATE], according to the facility face sheet. His/her pertinent [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident had severe cognitive (memory) deficits (problems). S/he had unclear speech, was rarely/never able to make her needs known, and rarely/never understood others. S/he required total assistance from one to two staff members for activities of daily living (ADL ' s). S/he was always incontinent of his/her bowels and bladder. S/he was at risk for developing pressure ulcers, and did not have one or more unhealed pressure ulcers at the time of the assessment. C. Observations An observation of incontinence care for the resident was conducted on 9/4/14 at 2:34 p.m. in the presence of the director of nursing (DON). An undated, unlabeled, white bordered gauze dressing was noted on the resident ' s left hip. The DON was asked if the staff was monitoring and measuring the area. The DON stated that at this time s/he was unsure and would need to check with the wound care team. D. Record Review --Braden Scale assessment According to the Braden scale assessment for predicting pressure sore risk dated 7/11/13, 7/29/13, 10/17/13, and 1/13/14 the resident had a total score of 15 (total score of 15-18 indicated at mild risk). Computer Printed Physician order [REDACTED]. The 8/14 CPOs failed to reveal a preventative or current wound treatment to the resident ' s left hip. Furthermore the CPOs revealed that staff was to conduct weekly skin assessments. Physician Telephone Orders (TOs) TOs dated 8/1/14 through 9/3/14 failed to reveal a preventative or active wound treatment orders for the resident ' s left hip. The TOs dated 9/4/14 through 9/5/14 revealed the following pertinent orders - 9/4/14 (during complaint survey): Left hip unstageable pressure ulcer, cleanse with saline, apply skin prep peri-wound (around the wound), apply a nickel thickness of thera-honey gel to the wound bed, and cover with boarded foam and change every 72 hours and as needed (PRN). - 9/5/14: Therapy to evaluate wheelchair for positioning Care plans Pressure ulcer -The pressure ulcer care plan, last revised on 7/15/14, revealed that the resident was at RISK for impaired skin integrity/pressure ulcers due to immobility, [MEDICAL CONDITIONS] with left sided weakness, incontinence of bowel and bladder, and [MEDICAL CONDITION]. The careplan failed to reveal that the resident had a pressure ulcer. -The long term goal of the care plan was for the resident ' s skin to remain intact. - The facility's approaches included; avoid shearing the resident ' s skin during positioning, transferring, and turning, conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences, diet as ordered, encourage the resident to drink at least 1,500 cubic centimeters (cc) of fluid daily, unless clinically contraindicated, keep bony prominences from direct contact with one another with the use of pillows foam wedges, etc ..., keep linens clean, dry, and wrinkle free, pressure reduction mattress when resident is in bed, incontinence care after each incontinent episode, turn and reposition at frequent intervals and as needed ... - The care plan approaches failed to indicate that the resident chooses to lie on his/her left side in a fetal position with violent objections to being repositioned. Behavioral symptoms - The behavioral symptoms care plan initiated on 4/7/14 read, "The resident has a history of socially inappropriate/disruptive behavioral symptoms (combative during ADL care) as evidenced by striking out, pinching, and biting staff. - The goal of the care plan was for the resident to refrain from being combative during ADL care. - The care plan approaches were to praise the resident when behavior was appropriate, and to move the resident to a quiet, calm environment and/or leave the resident to calm down. Wait a few minutes and approach again. The care plan approaches failed to indicate that the resident chooses to lie on his/her left side in a fetal position with violent objections to being repositioned." ADLs - The residents ADLs care plan initiated last revised on 7/15/14 read: - The resident was dependent for mobility and ADL ' s, required assistance to eat and drink adequately. Staff were to anticipate the resident's needs for bed mobility, transfers, using a Hoyer lift with two person assistance, locomotion on/off the unit, dressing, toileting, and personal hygiene. - The goal of the care plan was that the resident would have his/her needs met daily - The pertinent care plan approaches read, "Resident can become combative during care, use caution. If the resident becomes combative stop care, assure resident is safe, step back, and notify the nurse." - The care plan approaches failed to indicate that the resident chooses to lie on his/her left side in a fetal position with violent objections to being repositioned. Resident progress notes The resident ' s progress notes dated 6/10/14 through 9/3/14 failed to reveal that the resident had any skin issues noted to his/her left hip (see below interviews) or that the physician had been notified regarding a potential or actual concern. The resident ' s progress note dated 9/4/14 at 4:23 p.m. read, "A small stage two pressure ulcer on the left hip, wound MD (medical doctor) evaluated and ordered a treatment to be preformed every 72 hours and as needed (PRN)." The treatment plan was now located in the Medication Administration Record [REDACTED] The resident ' s progress noted dated 9/6/14 at 7:36 p.m. read. "Late entry for 9/4/14, wound rounds was completed with (physician ' s name). The resident was noted to have an unstageable pressure ulcer to his/her left trochanter (hip) ..." physician progress notes [REDACTED]. The physician progress notes [REDACTED]. Pressure ulcer documentation The pressure ulcer documentation dated 9/6/14, revealed that on 9/4/14 (during the complaint survey) an unstageable pressure ulcer was noted to the resident's left trochanter. The unstageable pressure ulcer measured 1.7 centimeters in length x 1.4 centimeters in width. The character of the wound bed noted granulation tissue - pink or red tissue with shiny, moist, granular appearance. There were no tunneling, undermining, sinus tracts, exudates, or odors noted. The surrounding tissue was noted to be intact. A note under the section " describe progress " read, "Wound bed noted with 50% granulation." MD (medical doctor) wrote new treatment orders to include low air loss alternating pressure mattress. Occupational therapy plan of care The occupational therapy plan of care dated 9/9/14 (during complaints survey) read: "The resident presented with positioning deficits as a result of resisting caregivers to reposition him/her in bed. The patient had always chosen to sleep on his/her left side in a curled up fetal position, since living here at (name of facility), with violent objections when trying to turn him/her. The caregivers noticed a blister/wound to his/her left hip in the last few days. Nursing had exchanged his/her regular mattress for an air mattress, but would like another opinion about how to best prevent this from happening again." The assessment also read, "The resident chooses to lay on his/her left side every time s/he was in bed and refused to be repositioned on his/her right side as demonstrated by swinging, yelling, and scratching;" however, this information was not reflected in the resident's care plans (see above). Weekly skin assessments The CPO (see above) and treatment administration records (TARs) dated 6/14 through 8/14 revealed the resident was to have a weekly skin assessment every Thursday, on the 6 p.m. to 6 a.m. shift. The staff initialed that the skin assessments had only been completed on 6/12/14 and 6/19/14. The remainder of the TARs were blank, indicating that the skin assessments had not been completed as ordered. Certified nurse aide (CNA) skin observations records The CNA skin observations records (bathing records) dated 6/1/14 through 9/4/14 revealed only four skin observations had been completed during the past three months. The following findings were noted: - 6/12/14: The resident ' s skin was noted to be normal (no skin issues). - 7/24/14: The resident ' s skin was noted to have redness and excoriation to the resident ' s buttock, an old scratch to the back of the resident's left heel and a peripherally inserted catheter (PICC) in the resident ' s right upper arm. - 7/31/14: The picture on the form had a circle around the buttock area with a note that read fragile skin, a circle around the right upper arm area with a note that read PICC line, and a circle around the right foot with a note that read redness on side of foot. - 9/1/14: The pictures had circles around bilateral upper arms and a note to the side that read old bruises, bilateral feet were circled and a note to the side that read red toes, and a circle around the buttock with excoriation/red noted to the side. Failure to obtain necessary treatment and services According to staff interviews (see below) the resident had an area to her left hip for approximately two to four weeks. The staff failed to obtain necessary treatment orders and services (see above) to prevent the deterioration of the resident ' s pressure ulcer, subsequently a reddened area progressed to an unstageable pressure ulcer. E. Interviews The DON was interviewed on 9/9/14 at 1:30 p.m. in the presence of the nursing home administrator (NHA) and corporate consultant (CC). The DON stated that on 9/4/14, s/he started an investigation regarding the observation noted during the resident's incontinence care (see above). The DON stated that s/he spoke with a licensed practical nurse (LPN #12) who reported noting a reddened area to the resident ' s left hip approximately two weeks prior. The DON stated that the LPN reported that the nurses were communicating this between each other during report, were monitoring the area, and that a physician's order [REDACTED]. The DON stated that that s/he would have expected the LPN to do an initial treatment, notify the physician, and wound nurse, obtain treatment orders, document the change on the 24 hour report, and update the resident's care plan. The corporate consultant added that the wound nurse would have then documented on the resident's wound weekly, had s/he known about the wound. A certified nurse aide (CNA, #15) familiar with the resident's care was interviewed on 9/10/14 at 8:47 a.m. S/he stated that the resident had a bandage in place on his/her left hip for the past month. The CNA reported that the bandage was there due to the resident having a pressure sore on his/her left hip. The CNA reported that the resident ' s skin was very thin and sensitive and if s/he (resident) was left on one side for too long s/he would get a red spot, so staff had to turn and reposition her a lot. The resident ' s physician was interviewed on 9/20/14 at 9:20 a.m. and stated that s/he was not aware the resident had an unstageable pressure ulcer on his/her left hip. The physician stated that he would expect the staff to notify his/her nurse practitioner (NP) regarding the resident's change in status. The NP, who was wound care certified, would then complete an assessment and if the wound did not improve would have the facility's wound doctor assess the resident's wound. The physician was unable to state if the NP had been notified about the resident's left hip wound. The third floor unit manager (UM #2) was interviewed on 9/10/14 at 11:01 a.m. in the presence of the DON, NHA, and CC. The UM stated that she was not aware the resident had a wound on her left hip until it was brought to her attention on 9/4/14 (during complaint survey). The UM stated that a licensed practical nurse (LPN #12) reported to her on 9/4/14 that she (LPN#12) had placed a bandage on the resident's left hip on Saturday 8/30/14 and the area was closed. The UM stated that the LPN reported that RN #21 worked days on 8/31/14, 9/1/14, and 9/2/14. The UM stated that RN #21 was interviewed and denied placing a dressing to the resident's left hip, because there was no order to do so. The UM stated that she spoke to RN #10 who reported doing a dressing change to the resident's hip as a favor for LPN #12. The UM stated that she spoke with RN #17 who reported that s/he had not changed the resident's dressing, and that s/he always dated and signed his/her dressings. The UM stated that s/he had been unable to get a hold of the charge nurse #20 and that s/he had not returned his/her phone calls. The UM stated that she would expect when a certified nurse aide was providing care to residents and skin issues were noted, the nurse should be notified. The nurse was then to complete an incident report, notify the physician and family, and get a treatment in place until the wound had resolved. The UM acknowledged that these expectations had not been met. The assistant director of nurses (ADON), who also identified himself/herself as the wound nurse, was interviewed in the presence of the DON, NHA, and CC on 9/10/14 at 11:10 a.m. The ADON stated that s/he was notified of the resident's wound last Thursday on 9/4/14, while s/he was doing wound rounds with the wound doctor. The ADON stated when s/he and the wound doctor looked at the resident's left hip the resident was noted to have an unstageable pressure ulcer. The ADON reported that (name of wound doctor) wrote new treatment orders (see above). The ADON stated that s/he would expect staff to notify him/her when a skin issue had been identified. The ADON acknowledged that s/he had not been notified regarding the resident's left hip wound until it was brought to his/her attention on 9/4/14 (during a complaint survey). RN #10 was interviewed on 9/10/14 at 10:40 a.m. in the presence of the DON, NHA, and CC. The RN stated that the last time s/he had placed a dressing on the resident's left hip was approximately three weeks ago. S/he stated that the day nurse (LPN #12) gave him/her a dressing for the resident's left hip which needed to be changed before the resident went to bed. The RN reported that s/he told the CNAs to wait before putting the resident to bed because s/he needed to apply the dressing to the resident's left hip. The RN reported that s/he did not see any open areas at that time and thought that the dressing was for prevention. The RN acknowledged that there was not a physician order [REDACTED]. LPN #12 was interviewed on 9/10/14 at 10:44 a.m. in the presence of the DON, NHA, and CC. The LPN stated that it was brought to his/her attention from the night nurse that staff were protecting the resident ' s left hip, because the resident ' s daughter requested them to do so. The LPN stated that s/he believed that the night shift nurses were changing the dressing. The LPN reported that s/he was not aware if the physician had been notified, but thought that the NP had been notified. The LPN reported that s/he did not think that s/he had ever changed the resident's dressing. The LPN stated that s/he had looked at the area to make sure that there had not been any breakdown, and the last time she looked at the area was on 8/29/14, the area was pink and s/he did not see skin breakdown. The LPN stated that another nurse was placing the dressing on the resident's left hip, s/he thought (contrary to the DON and UM investigations, see above). A registered nurse (RN #17) familiar with the resident's care was interviewed on 9/10/14 at 1:16 p.m. The RN reported that the resident has had a red area on his/her hip for about a month. The RN reported that some of the reddened area was blanchable (reddened area that loses its redness when touched) and other areas were not blanchable. The RN acknowledged that there were no orders for a dressing to be applied to the resident's left hip and stated that if s/he sees issues with resident ' s skin s/he would document the findings in the resident ' s progress notes. Charge nurse #20 was not available for an interview and had not returned the facility's phone calls before the exit of the complaint survey on 9/10/14. F. Facility actions - 9/4/14: The DON spoke with wound team regarding resident ' s skin issues (see above) and requested them to see the resident. The wound care team assessed the resident and an unstageable pressure ulcer was noted on the resident's left hip. The wound physician ordered a new wound treatment (see above). - 9/5/14: A physician ' s telephone order was written for therapy to assess the resident ' s wheelchair for positioning (see above). The nutritional status care plan was updated to include the resident's left hip wound. - 9/7/14: The pressure ulcer care plan was updated to include an air mattress; however the care plan was not updated to reflect the resident ' s unstageable pressure ulcer. - 9/9/14: Occupational therapy assessed the resident for positioning (see above). the resident's care plan failed to reflect the occupational therapist's findings.

Based on record review, and interviews the facility failed to ensure one of eight sampled residents (#27) received sufficient fluids to maintain proper hydration and health, and seven of eight (#24, #12, #20, #22, #23, #26, and #28) sampled residents were offered sufficient hydration. Specifically -the facility failed to ensure the hydration needs of resident #27 were met and subsequently the resident was hospitalized twice -the facility failed to offer appropriate hydration interventions to residents. Findings Include: A. Status prior to admission to the facility The hospital history and physical dated 6/29/14, read in part that resident #27 had a left cerebellar infarct (stroke), dehydration, which was manifest in terms of his/her mucous membranes, and his/her increased creatinine level. S/he had poor oral intake throughout the day, because of the acute medical event. Intravenous (IV) fluids were provided and his/her [MEDICATION NAME] (diuretic) was placed on hold. B. Resident status after admission to the facility Resident #27, age 72, was admitted to the facility on [DATE], according to the facility face sheet. His/her admission [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident had no cognitive (memory) deficits (problems). S/he had clear speech, was able to understand others, and was able to make his/her needs known. S/he required supervision for bed mobility, and eating, limited assistance from one staff member for transfers, and ambulation, and extensive assistance from one staff member for dressing, toileting, and personal hygiene. C. hospitalization s after admission to the facility The hospital discharge summary dated 7/25/14, revealed the resident was admitted to the hospital on [DATE] due to acute on [MEDICAL CONDITION], dehydration, and [MEDICAL CONDITION]. The medical problems listed included: acute [MEDICAL CONDITION], dehydration, acute kidney injury, and metabolic [MEDICAL CONDITION]. The hospital history and physical dated 9/5/14, revealed the resident's chief complaint was an altered mental status and a fall. Upon evaluation the resident was lethargic with an altered mental status, and s/he was unable to provide any history ... The patient was noted to have a decreased mentation and increased lethargy over the past two to three days, with decreased oral intake. S/he was also noted to have two un-witnessed, but presumed mechanical falls on the day of admission (9/5/14). The physician ' s assessment and plan revealed the following pertinent information: - Urinary tract infection and s/he was started on antibiotics. - Altered mental status, most likely secondary to underlying infection with urinary tract infection [MEDICAL CONDITION], and possibly decreased oral intake resulting in dehydration. - Acute kidney injury versus [MEDICAL CONDITION]. The resident ' s serum creatinine was 1.6. She appeared intravascularly depleted, which would suggest that it might be a reflection of acute kidney injury; however, her serum creatinine when reviewing his/her history appeared to be around 2. His/her seemed creatinine was 2.0 in March 2008, and 1.9 at the time of discharge on 7/25/14. At this point the physician will just watch her creatinine while providing gentle fluids. Nephrology Progress note - The nephrology progress note dated 9/5/14, revealed the resident had an acute on chronic non-oliguric [MEDICAL CONDITION]. The resident had improved renal function following gentle volume expansion. D. Record Review Physician orders The admission physician orders [REDACTED]. The readmission physician orders [REDACTED]. Physician telephone orders (TOs) The TOs dated 7/2/14 through 9/5/14 revealed the following pertinent information: - 7/21/14: Transfer to (name of hospital) for left sided weakness and increased confusion. - 7/25/14: Discontinue [MEDICATION NAME] 40 mg orally every day. - 8/1/14: Discontinue [MEDICATION NAME] - 8/8/14: No sugar added (NSA) mighty shake, four ounces (oz) orally four times a day with medication pass. Record the amount taken. - 8/30/14: [MEDICATION NAME], 40 mg, orally every day for a [DIAGNOSES REDACTED]. - 9/5/14: Send to (name of hospital) for an evaluation and treatment. Care Plans The resident ' s dehydration/fluid maintenance care plan initiated on 8/4/14, read that the resident was at risk or had actual urinary tract infection. The goal of the care plan was for the resident to be free of urinary infection and to have no signs and symptoms of dehydration related to infections. The care plan failed to reflect the resident ' s use of diuretics. The facility approaches included: medications as ordered, monitor for side effects related to antibiotic use, report to the nurse and physician if noted; rash, itching, nausea, vomiting, and diarrhea, offer and encourage intake of fluids, offer cranberry juice as an alternative juice, post antibiotic lab work as ordered by the physician, report to physician worsening signs and symptoms of urinary tract infections or lack of improvement from treatment, and vital signs every shift until antibiotic was completed, and notify the physician of abnormal vital signs. The nutritional status care plan initiated on 8/8/14 noted the resident had a significant weight loss over the past 30 days related to suboptimal oral intakes with stated lack of appetite secondary to a decline in cognitive status and a recent [DIAGNOSES REDACTED]. The care plan approach included: liberalized diet to limited concentrated sweet diet, nutritional supplement shakes as ordered, assistance with meals as needed, monitor weights, intakes, and labs. physician progress notes [REDACTED]. The physician progress notes [REDACTED]. The physician noted that the resident ' s magnetic resonance imaging (MRI) revealed aging of a previous left cerebella infarct: Possibly two small sub acute [MEDICAL CONDITION]. The resident had acute on [MEDICAL CONDITION] and would require IV fluids and a re-evaluation at the hospital. The physician discontinued the resident's diuretic medication. The physicians progress note dated 7/26/14, revealed the resident returned from the hospital on [DATE], after receiving treatment for [REDACTED]. The resident was more alert on Saturday with worsening mental status again on Sunday and today (7/25/14). Nutritional Assessment According to the initial nutritional assessment dated [DATE] the resident ' s weight was 190 pounds (lbs), and s/he was 70 inches tall (5 feet and 8 inches). The resident's usual body weight was 190 lbs; and his/her ideal body weight was 150 lbs +/- 10 percent (%). The total fluids required to meet the resident ' s daily needs was 2190 milliliters (ml). Resident Progress Notes The resident progress note dated 7/26/14 read that the resident was readmitted to the facility with acute [MEDICAL CONDITION] related to dehydration ...fluids encouraged. The resident progress note dated 8/8/14, completed by the registered dietician, read that the resident had a 6.1% weight loss over the past 30 days. The resident had variable oral intakes averaging 25-50 percent (%) at best. The resident was also noted to have increased periods of confusion. The resident was attending meals in the dining room for lunch and dinner only. S/he would not attend breakfast in the dining room. The dietician would liberalize the resident ' s diet to limited concentrated sweats and initiate a NSA (no sugar added) mighty shake, 4 ounces with medication pass, four times a day; for an additional 800 calories and 24 grams of protein. The resident's estimated nutritional needs were 71 grams of protein, 1633-1775 (20-30calories/kilogram) calories, and 2100 ml of fluid per day. Labs The resident ' s pertinent diagnostic labs were as follows: - Basic metabolic panel (BMP) dated 7/3/14, revealed a normal creatinine level of 1.2 (normal: 0.4-1.5), an elevated blood urea nitrogen (BUN) of 27 (normal: 7/25), and normal sodium level of 143.0 (normal: 135-145). - BMP dated 7/6/14 revealed an elevated BUN of 43, a normal creatinine level of 1.4, and a normal sodium level of 145.0. - BMP dated 7/17/14 revealed an elevated BUN of 50, an elevated creatinine of 2.7, and a normal sodium level of 144.0. - 7/28/14: urinalysis revealed resident was positive for a urinary tract infection. - BMP dated 7/29/14 revealed an elevated BUN of 33, an elevated creatinine of 2.1, and normal sodium level of 143.0. - BMP dated 7/31/14 revealed an elevated BUN of 37, an elevated creatinine level of 2.0, and a normal sodium level of 144. Hydration records The facility's hand written meal intake records for July 2014, only had 15 entries, for a total recorded fluid intake of 6,610 ml from 7/2/14 through 7/31/14 (note the resident was hospitalized from [DATE] through 7/25/14). The facility's hand written meal intake records for 8/1/14 through 8/14/14, only had 12 entries. The total recorded fluid intake was 1,996 ml (note: the facility implemented computerized charting on 8/14/14). The facility's computerized fluid intake records dated 8/14/14 through 8/31/14 revealed the resident received a total of 4,660 ml of fluids, plus the resident was receiving 4 oz mighty health shakes (4 oz = 118.294 ml) four times a day (8,517.168 ml) for total fluid intake of 13,177.168 ml over 18 days. This averaged 732.0 ml of fluids per day (13,177 / 18 = 732.0 ml). The resident's daily required fluid needs were 2100 ml per day (see above). The facility's computerized fluid intake records dated 9/1/14 through 9/8/14 failed to reveal any fluid intakes. The resident was discharged to the hospital on [DATE]. E. Interviews Resident #24 was interviewed on 9/10/14 at 8:34 a.m. The resident was upset that the staff was having issues on 9/7/14 and s/he did not receive any fluids with his/her lunch, until after s/he was finished with his/her meal. The resident stated that s/he reported this to the nursing home administrator (NHA) on 9/8/14. The resident stated that staff did not pass fluids; generally s/he has to go and get them him/herself. The resident stated that s/he went out to the emergency room last night because s/he had a urinary tract infection and that they told her/him he needed to drink more fluids. A group interview was conducted on 9/8/14 at 1:07 p.m. with six randomly selected residents (#12, #20, #22, #23, #26, and #28) and one visitor. All six of the residents were in agreement that the staff did not always pass the residents fresh ice water throughout the day. The residents stated that it was more of an issue with the evening shift. One resident (#28) stated that s/he was able to ask for fresh water if s/he wanted it. A certified nurse aide (CNA #14) was interviewed on 9/10/14 at 9:00 a.m. The CNA reported that staff did not always pass fresh ice water to the residents. The CNA reported staff barely had time to do all the other tasks they had to do. The CNA reported that not every shift was passing ice and it was more of an issue on the evening and night shifts. The CNA added that if residents wanted ice water they had to come and ask for it. Resident (#27) was interviewed on 9/10/14 at 9:04 a.m. The resident stated that staff did not always bring him/her fresh ice water every shift; however, the staff was generally good about filling her pitcher when she asked them to do so. The resident stated that it really depended on who the staff member was and what their case load was. The director of nursing (DON) was interviewed on 9/9/14 at 1:07 p.m. in the presence of the nursing home administrator (NHA) and corporate consultant (CC). The DON stated that the facility provided ice and water at the resident ' s bedside and staff provided fluids with meals. The DON stated that the registered dietician (RD) assessed the residents upon admission to determine their needs. The DON stated that residents also received fluids upon request, during activities, and each nurses station had a water container that residents could access. The DON was interviewed a second time on 9/10/14 at 11:24 a.m. in the presence of the NHA, and CC. The DON stated that hydration was the facility's routine during meals. The CNAs served fluids and after each meal they were recording their intakes. The residents kept water pictures in their rooms and staff made sure that they were filled from shift to shift. The facility only monitored resident intakes with a physician order. The DON stated that she would expect staff to document the residents' meal intakes and fluid intakes at the end of each shift, and the unit manager or charge nurse should be running a daily point of care (POC) report to double check and make sure the CNAs were documenting on their residents. Through reviewing the facility's meal and fluid intake documentation the DON was not able to determine if the resident ' s needs were being met or not because of the many omissions. The resident ' s physician was interviewed on 9/10/14 at 9:04 a.m. in the presence of the Nursing Home Administrator (NHA), Director of Nursing (DON), and corporate consultant (CC). The physician stated that s/he assessed the resident on 7/21/14, and discharged him/her to the hospital. The physician stated that the resident had been having issues for about a week. The physician reported that the therapy and nursing departments reported that the resident was less responsive, more confused, and leaning to the left side. The physician reported that the resident ' s mental status fluctuated up and down. S/he had confusion to the point of hallucinations and being psychotic. The physician reported that the resident had two issues going on that day (7/21/14), an altered mental status with similar changes, which lead them to order the MRI; s/he was also on [MEDICATION NAME] due to peripheral bilateral lower extremity [MEDICAL CONDITION]. The physician stated that the resident ' s daughter wanted him/her to put the resident back on the [MEDICATION NAME] because of the [MEDICAL CONDITION]. The physician stated that the resident had a history of [REDACTED]. The physician stated that this was not concerning because his/her BUN was at 43 and his/her creatinine level was at 1.4 and went up to 2.7 (note: this resident entered the facility on 7/2/14, her BUN on 7/3/14 was 27 and her creatinine level was 1.2, see above). The physician stated that the plan was to administer IV fluids: however, s/he decided to send him/her to the hospital because of the new [MEDICAL CONDITION] noted on his/her MRI, which could have occurred when s/he was on blood thinners, and the hospital would be able to rehydrate him/her quicker than the facility could. The physician stated that when s/he came back to the facility his/her BUN and creatinine level did not dramatically change. His/her BUN was 30, and her creatinine was 2.0. The physician stated that even with receiving the IV fluids s/he did not see a lot of changes in the resident ' s mental status and felt his/her mental status changes were more neurological then metabolic. The physician stated that his/her overall picture of the resident on 8/11/14, was [MEDICAL CONDITION], altered mental status, hallucinations, possibly [MEDICAL CONDITION] (TIAs) and s/he continued on [MEDICATION NAME] (an antiplatelet). The physician stated that there was a discussion to see if they needed to treat the resident ' s behavioral problems; however, s/he did not think [MEDICAL CONDITION] medications were appropriate at this time. The physician stated that the resident converted over to long term care and s/he resumed the resident ' s [MEDICATION NAME] and night time [MEDICATION NAME], all at the insistence of the resident ' s daughter.

Based on observations, interview and record review, the facility failed to ensure that one (resident #5) of 41 sample residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this was not possible. Specifically, the facility failed to conduct a complete assessment and identify the source of and effective approaches to address resident #5's severe unplanned weight loss. The findings included: Resident #5, age [AGE] years, was admitted to the facility on [DATE]. According to the February 2014 Computerized physician's orders [REDACTED].#5 had [DIAGNOSES REDACTED]. Review of the 10/4/13 quarterly Minimum Data Set (MDS), which was the most recent MDS available for resident #5, revealed: -The MDS showed resident #5 was 62 inches in height and weighed 115 pounds. -Resident #5 was totally dependent upon staff for intake of nutrition. -The MDS showed resident #5 received tube feedings. - Resident #5 received 51% or more of nutrition from tube feeding. -Resident #5 had unclear speech but was usually understood by others and usually understood communication from others. -Resident #5 had severe cognitive impairment as evidenced by a Brief Interview Mental Status score of 5/15. -During the MDS observation period, resident #5 continuously exhibited signs of [MEDICAL CONDITION] including inattention and disorganized thinking. -Resident #5 experienced delusions and behaviors that manifested as physical behaviors toward others on four to six days of the MDS observation period. -Resident #5 rejected care on four to six of the days of the MDS observation period. -Resident #5 required extensive assistance from one staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. -Resident #5 required supervision for mobility on and off the unit. The 7/4/13 admission MDS showed that resident #5 weighed 120 pounds at admission and was 62 inches in height. Per the admission MDS, resident #5 received tube feedings prior to admission to the facility. A. Weights and Weight Loss On 2/28/14 the clinical record for resident #5 was reviewed. The weight records for resident #5 revealed the following weights in pounds: -7/1/13 = 120.1 -7/8/13 = 120.0 -7/16/13=121.8 -7/22/13=120.0 -8/5/13=119.9 -9/1/13=114.5 This weight represented a 4.5% weight loss from the previous weight. -10/7/13=106.6 This weight represented a 6.9% weight loss from the previous weight and an 11.2% weight loss in 90 days. -11/4/13=104.6 This weight represented a 12.8% weight loss in 90 days. -12/2/13=104.2 -12/16/13=103.4 This weight represented a 3.6% weight loss in one month and a 15.1% weight loss in 5 months. -1/6/14 = 108.0 -1/13/14 = 112.0 -2/4/14 = 111.0 -2/11/14 = 112.0 -3/3/14 = 106.2 This weight represented a 4.3% weight loss in one month. The nutritional assessment completed on 7/1/13 showed the resident's current body weight was 120.1 pounds. The section for usual body weight was not completed. The assessment calculated the resident's nutrition needs at 1375 to 1485 calories daily. A nutrition note dated 7/25/13 noted that resident #5's weight was stable at 120 pounds. The accuracy of the weight was not questioned. The note stated that resident #5 received 1422 calories daily from her tube feedings, which should meet her calorie needs. A nutrition note dated 8/27/13 noted that resident #5 experienced a seven and one half pound weight loss in one week which was verified as accurate. The noted indicated that the RD did not know the etiology of the unplanned weight loss. The RD noted that she increased the resident's tube feeding so that resident #5 now received 1778 calories daily from her tube feeding. A nutrition note dated 12/4/13 noted that resident was down to 104.2 pounds. The note stated resident #5's calorie needs were 1655 daily and that her current tube feeding regimen exceeded the calorie needs. Resident Interview: On 3/4/14 at 1:00 p.m., resident #5 was interviewed. According to resident #5, she had lost weight since admission. Resident #5 reported being weighed at least weekly. Resident #5 stated she had lost weight recently, stating she felt like she had lost "about a pound a day." Resident #5 denied wanting to lose weight and expressed concern with the unplanned weight loss. Staff Interviews: On 3/6/14 at 9:41 a.m., a Certified Nurse Aide (CNA) that cared for resident #5 was interviewed. The CNA reported that she believed resident #5 was on weekly weights. The CNA reported that weights were measured by the restorative department. On 3/6/14 at 9:44 a.m., the Restorative Aide (RA) was interviewed. The RA stated resident #5 was now on weekly weights. The RA stated that residents were weighed in the morning, but that they may not be weighed at the same time so some weights may be before breakfast and after toileting and other weights may be gathered after breakfast. The RA stated he handwrites the weights and submits them to dietary for entry into the electronic record system. On 3/6/14 at 10:30 a.m., the Registered Dietician (RD) was interviewed about resident #5's weights. The following was revealed: -The RD acknowledged that resident #5 was not on a planned weight loss plan. -The RD acknowledged that resident #5 had experienced weight loss that could be classified as severe since admission to the facility. -The RD stated she felt the initial admission weights for resident #5 may have been incorrect. -The RD acknowledged that there were five separate, consistent weights over a one month period for resident #5 at the time she was admitted . -The RD did not contact resident #5's family, prior care setting or the admitting hospital to determine resident #5's weights prior to admission. -The RD acknowledged the usual body weight section of the nutrition assessment was incomplete. -The RD stated that the weight measurement was moved from floor CNAs to the RAs in October 2013 due to concerns about weight measurement consistency. -The RD stated the change in resident #5's weight from 114 pounds in September 2013 to 106 in October 2013 was thought to be due to the RA staff measuring and recording weights. -The RD stated for this resident she reviewed weights every Monday. -The RD stated that she assessed and reassessed resident #5's calorie needs and that resident #5 was receiving nutrition that exceeded her needs from the tube feedings. On 3/6/14 at 12:48 p.m., the Director of Nursing (DON) was interviewed about resident #5's weight loss. The following was revealed: -The DON stated she believed the admission weight of 120 pounds was incorrect. -The DON was unable to explain how five separate weights in the resident's first month of residency were consistently at about 120 ponds. -The DON did not contact resident #5's family, prior care setting or admitting hospital to obtain information about resident #5's weight prior to admission to their facility. -The DON stated she felt resident #5's weights were stable between 101 and 112 pounds. The DON did not express an understanding that weight fluctuations of 11 pounds were significant in a person of resident #5's size. B. Tube Feeding and Feeding Refusals The June 2013 Medication Administration Records (MAR) for resident #5 showed that at admission, resident #5 received four cans of [MEDICATION NAME] 1.5 daily via bolus tube feeding. Resident #5 received two cans (480 mL) of [MEDICATION NAME] 1.5 at 8:00 a.m., and one can (240 mL) each at 12:00 p.m., and 6:00 p.m. According to the history and physical dated 4/27/13 from resident #5's previous facility, resident #5 had been on this feeding regimen on arrival to the previous facility. The Nutrition Notes dated 7/25/13 calculated this feeding regimen provided 1422 calories, which would meet the estimated calorie of the resident previously calculated on the initial nutrition assessment as being 1375 to 1485 calories daily. The August 2013 MAR showed that resident #5 had a change in her feeding regimen on 8/27/13. Resident #5 had an increase in [MEDICATION NAME] 1.5 at the 12:00 p.m., and 6:00 p.m., feedings from one can of [MEDICATION NAME] 1.5 at each of these feedings to one and one half cans of [MEDICATION NAME] 1.5 (355 mL) for each of these feedings. A telephone order dated 11/7/13 increased the feedings at noon and 6:00 p.m., from one can of [MEDICATION NAME] 1.5 to two cans of [MEDICATION NAME] 1.5 at each feeding. The order also directed staff to begin documenting the amount of the [MEDICATION NAME] received at each bolus feeding. Review of the MARs from June 2013 through October 2013 showed that staff documented only the administration or refusal of the tube feeding and not the volume of the feeding administered/accepted. A telephone order dated 1/2/14 and timed at 12:00 p.m., directed a change in resident #5's tube feeding times to 8:00 a.m., 2:00 p.m., and 8:00 p.m. A telephone order dated 2/4/14 directed staff to decrease the 8:00 p.m., bolus tube feeding from two cans of [MEDICATION NAME] 1.5 to one can of [MEDICATION NAME] 1.5 . On 2/28/14 the care plan for resident #5 was reviewed. A 10/13/13 behavior care plan acknowledged resident #5 refused feedings; however no resident specific approaches related to feeding refusals, particularly those related to a dislike of certain staff, were present on the care plan. No other care plans that mention care refusals were present in the clinical record. On 3/6/14 the MAR and nurse's notes were reviewed for documented feeding refusals by resident #5. -In March 2014 resident #5 refused four feedings, including all tube feedings on 3/2/14. -In February 2014 resident #5 refused four feedings. All refusals were for the eight in the evening feedings. -In January 2014 resident #5 refused four feedings. All refusals were for the eight in the evening feedings. -In December 2013 resident #5 had no tube feeding refusals noted on the MAR, however there were three days in December where resident #5 was noted to have refused her tube feedings per the nurse's notes. -In November 2013 resident #5 had two instances of refused tube feedings according to the front of the MAR; however none were documented on the back of the MAR. The nurses notes showed resident #5 refused her morning and afternoon tube feedings on 11/21/13. -In October 2013 there were 21 instances of circled initials for tube feedings on the front of the MAR; however there were only four instances of feeding refusals documented on the back of the MAR. The nurse's notes documented ten instances for feeding refusals for the month. -In September 2013 there were no tube feeding refusals documented on the front or the back of the MAR. Nurse's notes also showed no refusal of tube feeding for the month. -In August 2013 resident #5 had no tube feeding refusals documented on the back of the MAR; however there were 12 instances of circled initials for the tube feeding on the front of MAR. -In July 2013 resident #5 had 21 instances where the tube feeding signature was circled, however there were only four refusals documented on the back of MAR. No nurse's notes could be located in the electronic record for this month. -In June 2013 resident #5 had no refusals of tube feedings. A nutrition note dated 10/14/13 noted that resident #5 had refused tube feeding in the past. A nutrition note dated 11/7/13 noted that nursing investigated resident #5's refusal of tube feeding, and found that it was intermittent. Staff Interview: On 3/4/14 at 2:05 p.m., the Registered Nurse (RN) that assisted resident #5 with her midday tube feeding was interviewed. The RN stated that resident #5 did refuse tube feedings at times. The RN stated that resident #5 fixated on certain nurses and did not let those nurse's assist her. The RN stated that resident #5 liked her and accepted tube feedings from her without difficulty. On 3/6/14 at 9:47 a.m., the Licensed Practical Nurse (LPN) for resident #5 was interviewed about meal assistance and feedings for resident #5. The LPN stated that there were some nurses that resident #5 did not like. The LPN stated that resident #5 frequently refused medication and feedings from the nurses she did not like. The LPN stated she was not aware of a care plan that directed staff how to approach and gain cooperation from resident #5 when she refused care. The LPN stated there were times when resident #5 refused feedings from her because resident #5 perseverated on the LPN being someone she did not like. On 3/6/14 at 12:48 p.m., the DON was interviewed about resident #5's weight loss. The following was revealed: -The DON stated the feeding refusals by resident #5 contributed to the unplanned weight loss. -The DON stated feeding refusals should be documented on the MAR with notes of the refusal documented on the back of the MAR. -The DON counted up the feeding refusals documented on the MARs for resident #5 from November 2013 to February 2014. The DON stated resident #5 refused four or fewer meals per month. -The DON acknowledged she missed more meals than that in a month due to work demands. -The DON acknowledged four refusals a month would not lead to severe weight loss. -The DON stated she was not aware that resident #5 refused cares from certain nurses and was unaware of the resident's dislike of certain nurses. -The DON stated that she could not locate a care plan that directed staff on approaches to take when resident #5 began refusing cares. C. Assessment of Alternate Causes for Weight Loss Record Review: On 2/28/14 the clinical record for resident #5 was reviewed. The following was noted: A hospital history and physical dated 4/22/13 stated that resident #5 had been living at home alone prior to admission to the hospital. The resident was noted to have a history of [MEDICAL CONDITION] and cavernous hem[DIAGNOSES REDACTED]. The resident was noted to be receiving her nutrition and hydration needs through a feeding tube because the resident was unable to accept nutrition by mouth. A history and physical from a different care facility dated 4/27/13 was reviewed. Resident #5 was noted to have a history of [MEDICAL CONDITION] and cavernous hem[DIAGNOSES REDACTED]. The history and physical writer noted that no details about the [MEDICAL CONDITION] or hem[DIAGNOSES REDACTED] were available. A handwritten history and physical on 6/30/13 completed by the resident's current physician was reviewed. The physician noted that the resident moved from a different care facility to the current one to be closer to family. The physician noted that resident #5 had a history of [REDACTED]. The physician's progress notes in the clinical record were reviewed. The following was noted: -None of the notes in the chart (8/21/13, 9/26/13, 10/31/13, 11/12/13, 12/22/13, 1/14/14, 1/21/14 and 2/22/14) mentioned resident #5 unplanned weight loss. -None of the physician's progress notes included a medical assessment of resident #5's unplanned weight loss. -No recommendations for labs or screenings related to the weight loss were present in the physician's notes. -No additional mention of resident #5's history of [MEDICAL CONDITION] was present in the physician's notes. -No significant illness was identified that would contribute to unplanned weight loss. The monthly pharmacy review log revealed no mention of a request to review resident #5's medication for possible contribution to unplanned weight loss. A review of resident medications showed that resident #5 was receiving medications that included: -[MEDICATION NAME] 30 mg daily via peg tube for dementia with depression. -[MEDICATION NAME] 750 mg daily via peg tube for neuro care. According to the manufacturers package insert for [MEDICATION NAME], "Altered Appetite and Weight - Significant weight loss, especially in underweight depressed or bulimic patients, may be an undesirable result of treatment with [MEDICATION NAME]." In pertinent part, the manufacturer's package insert for [MEDICATION NAME] stated, " ...the following have been reported in patients receiving marketed [MEDICATION NAME] worldwide. The listing is alphabetized ... weight loss. The clinical record for resident #5 had a negative urine analysis with culture and sensitivity on 1/23/14. The resident had clinical serology for complete blood count, [MEDICAL CONDITION] stimulating hormone, pre-[MEDICATION NAME] and basic metabolic panel on 7/25/13. The findings included: -Pre-[MEDICATION NAME] of 14.8 with a reference range of 17.6 to 36.0. This result showed the resident had low pre-[MEDICATION NAME]. -[MEDICAL CONDITION] stimulating hormone of 0.56 with a reference range of 0.47 to 4.68. This result showed the resident's [MEDICAL CONDITION] functioned at the more [MEDICAL CONDITION] level of the normal value spectrum. -The results were marked as being provided to the physician. Staff Interviews: On 3/6/14 at 10:30 a.m., the RD was interviewed about resident #5's weights. The following was revealed: -The RD stated that she assessed and reassessed resident #5's calorie needs and that resident #5 was receiving nutrition that exceeded her needs from the tube feedings. -The RD stated that the facility weight committee, which they called the "par" committee, included dietary, nursing, the RD and the DON. The par committee reviewed weights and nutrition concerns weekly. -The RD stated that the DON kept the documentation for the committee. -The RD stated that lack of nutrition had been ruled out as a weight loss cause for resident #5 because the tube feeding calories provided daily exceeded her estimated needs. -The RD stated she did not know what was causing resident #5's weight loss suggesting it could be from an unknown medical cause. -The RD acknowledged there were no recent labs for the resident that might suggest a medical review into a cause of the weight loss. -The RD stated she did not recall if the physician or the pharmacist was specifically asked to review resident #5 for possible medication or medical causes into the unplanned weight loss. -The RD stated that she was not aware of what a medical condition like a re-emergence of [MEDICAL CONDITION] would do in terms of contributing to unplanned weight loss. On 3/6/14 at 12:48 p.m., the DON was interviewed about resident #5's weight loss. The following was revealed: -The DON reviewed the clinical record for resident #5 and then acknowledged her physician never documented an awareness of resident #5's unplanned weight loss. -The DON stated that resident #5's physician received a list of weights each week. The DON explained she presumed the physician would notice the weight loss. -The DON stated she had no documentation or notes to show that the weekly nutrition committee approached resident #5's physician for medical consultation related to resident #5's unplanned weight loss. -The DON was unable to recall having a conversation with resident #5's physician about resident #5's weight loss. -The DON stated that she thought resident #5's physician was approachable and would be open to assessing resident #5 for a medical cause for the weight loss. -The DON reviewed the labs in resident #5's clinical record. The DON acknowledged that other than a test for a urinary tract infection, resident #5 had had no labs since 7/25/13. -The DON acknowledged that the [MEDICAL CONDITION] stimulating hormone value for resident #5 was on the [MEDICAL CONDITION] side of the normal spectrum. -The DON reviewed the pharmacy review documentation in resident #5's clinical record. -The DON acknowledged their monthly review showed no evidence that the pharmacist was asked to review resident #5's medications for possible contribution to the unexplained weight loss. -The DON stated she did not recall asking the pharmacist to review resident #5's medication regimen for possible medication contributions to the unplanned weight loss.