Every finding on record at Pikes Peak Post Acute

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#4) of three residents reviewed for discharge planning out of 16 sample residents.Specifically, the facility failed to document the discharge planning process, complete the discharge summary and follow up after Resident #4 discharged in order to ensure services were in place.Findings include:I. Facility policy and procedureThe Transfer or Discharge policy and procedure, revised March 2025, was provided by the nursing home administrator (NHA) on 8/20/26 at 11:38 a.m. It revealed in pertinent part, Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. When a facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: the basis for the transfer or discharge; that an appropriate notice was provided to the resident and/or legal representative; the date and time of the transfer or discharge; the new location of the resident; the mode of transportation; a summary of the resident's overall medical, physical, and mental condition; disposition of personal effects; disposition of medications; others as appropriate or as necessary; and the signature of the person recording the data in the medical record.II. Resident #4A. Resident statusResident #4, age [AGE], was admitted on [DATE] and discharged home on 3/27/26. According to the March 2026 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure) and hyperlipidemia (high cholesterol). The 3/27/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision to minimal assistance with activities of daily living (ADL).B. Resident interviewResident #4 was interviewed on 8/18/26 at 10:11 a.m. via telephone. Resident #4 said she was admitted to the facility in September 2025. She said when she was first admitted , she told social services she was only allowed to stay in the facility for a certain period of time because if she stayed longer, she would lose her government-subsidized housing. She said her goal was always to return home and never to stay in the facility under long-term care. She said she felt pushed to stay long-term by the facility staff.Resident #4 said she had homecare services that came to her home a few times per week and helped cook her meals and clean her home. She said she had conversations with social services on multiple occasions prior to her discharge asking for her to ensure services were arranged prior to discharging home. Resident #4 said she sent an email on 3/24/26 because she had not heard back from social services if the homecare had been arranged. She said the case manager responded back to her that she was eligible to stay longer and was all set. Resident #4 said she responded that she again did not want to stay long-term and had to discharge home by 3/27/26.Resident #4 said the case manager assured her that she sent in the paperwork for her homecare services. She said to this day (8/18/26) her services were still not set up. She said the homecare services company never received the appropriate referral and paperwork from the facility. She said she had to rely on family members to assist her until the services were reinstated. She said the facility finally sent over the paperwork recently, but she was still waiting for services to be reinstated as of 8/18/26.C. Record reviewThe discharge care plan, initiated on 9/28/25, documented Resident #4 would remain at the facility for long-term care for assistance with ADLs and medication management. Pertinent interventions included documenting changes to the discharge goal per the resident and referring the resident to local contact agencies as indicated.The March 2026 CPO documented the following physician's order:Resident to discharge home on 3/27/26 with occupational therapy, physical therapy and certified nurse aide (CNA) services with a start of care on 3/30/26, ordered on 3/27/26.Okay to send the resident home with medications per the on-call provider, ordered 3/27/26.The 3/27/26 nursing progress note documented the resident discharged from the facility at 11:40 p.m. with her family. The nurse provided her discharge paperwork and medications.The 3/26/26 discharge summary and post-care instructions documented Resident #4 discharged on 3/27/26 to the community because the resident's health had improved sufficiently and the resident no longer required the services provided by the facility. Her daughter transported her home in a private vehicle. Several sections on the discharge summary, including social services, activities, comments about discharge, multiple nursing sections, including mobility and functional limitations, care coordination and signatures from the resident and facility staff were left blank. The discharge summary indicated not applicable for community support services.III. Staff interviewsThe social services director (SSD) and the case manager were interviewed together on 8/19/26 at 5:40 p.m. The SSD said she had been recently hired into her position by the facility. She said the case manager had overseen the discharge planning process.The case manager said she was responsible for coordinating discharges for the facility. She said the facility's interdisciplinary team (IDT) met twice per week to discuss each resident's progress under skilled therapy and determine when they were ready to discharge.The case manager said discharge planning took place a couple days before residents were discharged . She said she assisted in arranging home health, outside resources if needed and an appointment with their primary care physician (PCP). She said a discharge summary was completed upon the resident's discharge, and each discipline was responsible to complete their portion.She said Resident #4 discharged home from the facility in March 2026. She said she was only told about the resident's need for homecare services two days before her discharge. She said she had met with the resident multiple times over her stay at the facility but did not document any of the conversations. She said she sent the referral information to the homecare agency the day before the resident was discharged , but she never followed up to ensure services were started. She said in July 2026 she was asked to look into the situation and found the homecare agency never received the paperwork. She said she could not remember who told her to look into the situation. She said she never had a problem in the past setting up services, so she never followed up for any discharge. She said she did not document that she sent the referral information for Resident #4.The case manager said she did not document the discharge planning process for Resident #4. She said the discharge summary should have been filled out by each member of the IDT. She said she did not know if it had been completed for Resident #4.The NHA, the director of nursing (DON) and the clinical nurse consultant were interviewed on 8/20/26 at 11:02 a.m. The DON said the discharge planning process began before the resident was admitted and should continue throughout the resident's stay at the facility. She said the discharge planning process should be documented in the resident's medical record. She said the comprehensive care plan should be updated throughout the resident's stay to reflect their discharge goals.The DON said the case manager was responsible for the discharge planning process. She said the facility recently hired a new SSD and planned to hire another social worker to help remodel the discharge planning process. She said she was aware of the lack of documentation of the discharge planning process.The DON said she was aware the discharge summary for Resident #4 was not being completed by every discipline. She said the facility identified the concern during the survey process.The DON said she was not working at the facility during Resident #4's stay at the facility. She said she was not aware services were not set up for Resident #4 upon her discharge.

Based on observations, record review and interviews, the facility failed to ensure two (#8 and #5) of four residents out of 16 sample residents were kept free from abuse.Specifically, the facility failed to:-Protect Resident #8 from physical abuse by Resident #7; and,-Protect Resident #5 from physical abuse by Resident #6.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Preventions Program policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 11/20/26 at 11:38 a.m. It revealed, in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.II. Incident of physical abuse by Resident #7 towards Resident #8 on 4/28/26A. Facility investigationThe facility abuse investigation was provided by the NHA on 8/19/26 at 4:10 p.m.The abuse investigation documented that on 4/28/26, the activities assistant was walking down the hallway. She saw Resident #7 and Resident #8 standing in their room talking by the privacy curtain. Resident #7 began yelling and she saw him grab Resident #8 by the left arm. Resident #8 was pushing at Resident #7 to get away. She yelled for help and two certified nurse aides (CNA) assisted to separate both residents. Resident #7 was yelling that Resident #8 had gone through his belongings. The CNA told Resident #7 that she had cleaned up his side of the room.Resident #8 was taken down the hallway to keep both residents separated and said he was going to break Resident #7's nose.Resident #8 sustained bruising and a skin tear to the left arm. The facility staff provided treatment to Resident #8's left arm.Resident #7 was interviewed and said before he left for his outing with his friend, the key to the locked drawer was on the dresser. When he came back, the key had been moved. He said Resident #8 had gone through his locked drawer while he was on the outing. Resident #7 said he asked Resident #8 and Resident #8 got smart about it. He denied touching Resident #8.Resident #7 was moved to another room on another hallway of the facility.The facility substantiated physical abuse.B. Resident #8 (victim)1. Resident statusResident #8, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included major depressive disorder and anxiety disorder.The 7/10/26 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. He was independent with all activities of daily living (ADL).The assessment indicated the resident did not exhibit any behaviors during the assessment look-back period.2. Resident interviewResident #8 was interviewed on 8/19/26 at 5:01 p.m. Resident #8 said Resident #7 was his previous roommate. He said Resident #7 entered the room with a friend (on 4/28/26) and started yelling that someone had been going through his things. He said he looked over to Resident #7's side of the room, moved closer and said he did not think anyone had been in his stuff and it did not look like it had been gone through. He said Resident #7 grabbed his arm and threatened him. He said a staff member heard the commotion, entered the room and got Resident #7 to release his arm. He said he had bruises on his arm for a long time that he had to keep explaining what happened to other residents. He said it was frustrating. He said he felt like Resident #7 had been physically abusive toward him.Resident #8 said the staff originally said he would have to move, which upset him and he refused. He said the facility ended up moving Resident #7 to another room. He said Resident #7 was not moved immediately after the incident, but he could not remember when he was moved. He said he saw Resident #7 often walking down the hallway and he would just avoid him. He said he wanted to make a gesture at him, but he would not stoop to his level. He said he tried to rise above. He said he was still upset about the incident.3. Record reviewThe 4/28/26 situation, background, assessment and recommendation (SBAR) documented a staff member reported she was in the hallway when she heard loud voices coming out of Resident #8's room. She saw the roommate (Resident #7) grabbing Resident #8 by his left arm. Other staff members entered the room to assist in removing Resident #7 from Resident #8. Resident #8 reported that Resident #7 accused him of going through his belongings and grabbed him by the arm.An assessment was completed with bruising and a skin tear noted to Resident #8's left arm.C. Resident #7 (assailant)1. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the August 2026 CPO, diagnoses included major depressive disorder and anxiety.The 5/16/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was independent with all ADLs and ambulated independently.The assessment indicated the resident had episodes of delusions, physical and verbal symptoms directed toward others and rejection of care one to three days during the assessment look-back period.2. Record reviewThe mood/behavior care plan, initiated 10/1/25 and revised 3/30/26, documented Resident #7 had a mood/behavior problem with physical behaviors, poor impulse control and reactive behaviors. Resident #7 had a history of being accusatory of staff and other residents stealing his belongings, angry outbursts, labile mood, hallucinations/delusions and verbal/physical aggression. On 4/28/26, the resident got into a physical altercation with his roommate. Both were separated and the resident was eventually moved to a different unit. The pertinent interventions included analyzing key times, places, circumstances, triggers and what would de-escalate the resident's behavior; approaching the resident in a calm manner; assessing and addressing contributing sensory deficits; assessing the resident's needs; providing physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist in setting goals for more pleasant behavior; encouraging the resident to see staff support for distressed mood; and psychiatrist consult as indicated.The 4/6/26 nursing progress note documented Resident #7 refused to take a shower the previous night.The 4/29/26 interdisciplinary team (IDT) progress note documented staff reported hearing a loud verbal escalation coming from the resident's room. Upon entering, the staff observed the resident physically grabbing his roommate by the left arm. Staff immediately called for assistance and CNAs responded to separate both residents. The facility staff separated both residents, notified the provider, conducted 15-minute post altercation checks, evaluated the need for a room change and reinforced with staff early identification of escalating behaviors and prompt intervention.The 7/8/26 behavioral health provider progress note documented Resident #7 was becoming more distrustful of people's intentions the past week and informed the psychologist he was no longer taking any of his medications.The 8/10/26 nursing progress note documented Resident #7 and his roommate were heard arguing loudly at each other about who was urinating on the bathroom floor. Resident #7 had been declining to take pertinent medications for months.The 8/14/26 nursing progress note documented Resident #7 reported there was a verbal altercation between him and his roommate. The resident reported his roommate was making sounds, hitting the wall and yelling out in the middle of the night. Resident #7 was not currently taking his medication and would benefit from behavioral health services.The 8/17/26 nursing progress note documented Resident #7 appeared to be more aggressive, combative and was perseverating on different thoughts. He refused to take his medications.The 72-hour charting documented that on 8/14/26, Resident #7 reported his roommate called him names and wanted him to relocate. The facility staff relocated the roommate. On 8/15/26, Resident #7 was asked by the facility staff to stay away from his previous roommate and keep a respectful distance. The facility staff felt Resident #7's refusal of medications was affecting his mood and demeanor to be more angry, aggressive and combative.III. Incident of physical abuse by Resident #6 towards Resident #5 on 6/26/26A. Facility investigationThe facility abuse investigation was provided by the NHA on 8/19/26 at 4:10 p.m. On 6/23/26 at approximately 5:48 p.m. the CNA reported she was in the living room when she heard scuffling. She went around the corner and saw Resident #6's arm around Resident #5's throat while he was screaming. Resident #5 was also yelling. Both residents were separated and moved to different areas. Initially, Resident #6 declined to move his arm from around Resident #5's neck when staff intervened. Staff were eventually able to get him to let go of Resident #5. Resident #5 did not display respiratory distress and was still able to make noise. Resident #6 returned to his room.Earlier in the day, Resident #6 had a verbal altercation with the nurse and hit her on the hand. The nurse reported to the provider that Resident #6 had been having difficulty sleeping and increased agitation.Resident #6 was placed on one-to-one supervision for 72 hours.The investigation documented Resident #5 was interviewed and did not recall the incident or demonstrate any psychosocial distress.-However, Resident #5 had a communication deficit (see care plan below) and was unable to communicate his needs and spoke in nonsensical noises without distinct words.Physical abuse was substantiated by the facility.B. ObservationsDuring a continuous observation on 8/19/26, beginning at 11:55 a.m. and ending at 12:20 p.m., Resident #5 and Resident #6 were observed going up and down the hallway, repetitively, Resident #5 was using his wheelchair and Resident #6 was walking. Resident #5 passed by Resident #6 on multiple occasions. Resident #5 would reach out to Resident #6. Resident #6 would side step him and occasionally look back at him as he walked past.Resident #5 was unable to verbalize his needs, was nonsensical and would reach out to residents and staff as he self-propelled past.Resident #6 did not talk to anyone as he walked up and down the hallway.Both Resident #5 and Resident #6 were directed to the dining room for lunch by facility staff. Resident #6 sat down at the table with two other residents and did not speak, even though others attempted to talk to him.Resident #5 was wheeled up to a table next to Resident #6. Resident #5 rocked back and forth in his wheelchair at the table. Resident #5 left his spot at the table and wheeled himself over to Resident #6. Resident #6 did not look at Resident #5 and Resident #5 was redirected back to his table. The unidentified staff member locked one of the wheels on Resident #5's wheelchair. Resident #5 began trying to move his wheelchair across the room with the locked brake, pulling on the walls to help him move. An unidentified dietary staff member unlocked Resident #5's wheelchair brake so he could roam back down the hallway.C. Resident #5 (victim)1. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the August 2026 CPO, diagnoses included vascular dementia with anxiety and aphasia.The 8/2/26 MDS assessment revealed the resident had short-term and long-term memory impairment with severe impairment in making daily decisions. He was dependent upon staff assistance with all ADLs. He was able to self-propel using a wheelchair.The assessment indicated the resident had episodes of refusing care daily. He did not exhibit any other behaviors during the assessment look-back period.2. Record reviewThe mood/behavior care plan, initiated on 11/11/22 and revised on 6/29/26, documented Resident #5 exhibited physical behaviors such as striking out, grabbing others, becoming combative verbally or physically, resistant to care and urinating in public places due to a diagnosis of dementia. Resident #5 at times would become overstimulated with too much noise or commotion around him. Resident #5 wandered in and out of other residents' rooms. It indicated on 6/23/26, Resident #5 was allegedly assaulted by another resident.Pertinent interventions included moving the resident to a private room; assessing and anticipating the resident's needs; diverting the resident and giving him alternative objects or activities; allowing the resident to calm down and reapproach at a later time; offering snacks, drinks and popsicles for de-escalation; guiding the resident from the environment while speaking in a calm voice; and placing a stop sign on the aggressor's door to detour other residents from entering his room.The communication care plan, initiated on 8/31/22 and revised on 8/1/26, documented Resident #5 had impaired communication evidenced by impaired cognition, difficulty understanding others, difficulty making himself understood and had unclear and nonsensical speech. The pertinent interventions included using short phrases that required yes or no answers; monitoring and documenting any changes to the provider; speaking in a normal tone clearly and slowly; stressing key words and pausing between statements; reducing external noise when communicating; ensuring the resident was in close proximity to the speaker; and speaking facing the resident.The 6/11/26 psychologist progress note documented Resident #5 presented with severe cognitive impairment and required memory unit placement due to safety concerns including elopement and wandering risk. Behavioral symptoms included episodes of crying throughout the morning with unclear etiology, possibly related to anxiety or pain. The resident demonstrated nonsensical responses and jibber-jabber speech patterns. Resident #5 had a history of verbal and physical aggression. Successful redirection included snacks.The 6/23/26 nursing progress note documented that at 5:48 a.m., Resident #5 was in the hallway in his wheelchair when he was physically assaulted by another resident (Resident #6). Resident #6 had his arm around Resident #5's neck in a chokehold. It took approximately three minutes to break them up. An assessment was completed with vital signs of oxygen saturation of 90% (percent), blood pressure of 109/70 millimeters of mercury (mmHG) and 16 respirations per minute. Resident #5 sustained two skin tears on the back of his right hand and an abrasion to the bridge of his nose.D. Resident #6 (assailant) 1. Resident statusResident #6, age less than 65, was admitted on [DATE]. According to the August 2026 CPO, diagnoses included dementia without behavioral disturbance, depression and personal history of a traumatic brain injury.The 4/30/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. He required supervision with all ADLs. He was able to ambulate independently.The assessment indicated the resident did not exhibit any behaviors during the assessment look-back period.2. Record reviewThe psychosocial behavior care plan, initiated and revised on 6/23/26, documented Resident #6 exhibited behavioral symptoms such as striking out, grabbing others, being combative, verbally and physically abusive due to delirium and a diagnosis of dementia. It indicated that on 6/23/26, Resident #6 physically assaulted another resident and was placed on increased monitoring. Pertinent interventions included: conducting an activities assessment to determine diversional activities; administering medications as ordered; anticipating the resident's needs; documenting and recording behavioral episodes; assessing the resident's room for safety; and establishing a rapport. -The care plan failed to identify resident-specific interventions when the resident became physically and verbally aggressive.IV. Staff interviewsCNA #1 was interviewed on 8/20/26 at 10:35 a.m. CNA #1 said Resident #7 was independent with his ADLs and would ask for help if he needed it. She said Resident #7 had poor hygiene and would refuse care. She said that day, Resident #7 did not want to change his bedding. She said, when he left, the CNAs would sneak into his room and change his bedding and clean up his room.CNA #1 said Resident #7 was moved onto his current hallway because he got into a verbal and physical altercation with his former roommate. She said she did not know what caused the incident. She said Resident #7 had difficulty with roommates once he moved into this new room. She said he recently got into a verbal altercation with his roommate and the roommate was moved to another room.CNA #1 said Resident #7 did not like other people touching his belongings and liked things a certain way. She said he was often delusional and paranoid. She said he often thought people were touching his belongings. She said she did not realize that going into his room and cleaning it without his permission could contribute to his paranoia.CNA #2 was interviewed on 8/20/26 at 10:25 a.m. CNA #2 said Resident #6 liked to walk down the hallways constantly. She said he would walk back and forth almost all day. She said she kept a close eye on him and would try and direct him to his room at times. She said Resident #6 did not communicate his needs very often, but was usually calm. She said he had episodes of urinating in public.CNA #2 said Resident #6 did not like it when others got into his personal space. She said he would start to become aggressive verbally, but he was usually easy to redirect.CNA #2 said Resident #5 had a difficult time staying still and would wheel himself up and down the hallway constantly. She said he wandered throughout the unit and into other residents' rooms all day. She said she would provide redirection, but because he was unable to sit in one area, the redirection did not last very long. She said it was easier to remove others than to remove Resident #5 from a situation or environment.CNA #2 said Resident #5 was non-verbal and would make nonsensical noises. She said he was not able to communicate his needs. She said when he would wheel by someone, he constantly reached out to others. She said she thought he liked the physical contact.CNA #2 said she had not witnessed the altercation but was aware of an incident between Resident #6 and Resident #5. She said she was informed Resident #6 had placed Resident #5 in a chokehold. She said since the incident, Resident #5 still went up to Resident #6. She said Resident #6 would usually just go around him, but sometimes he would shake his hand.The NHA, the director of nursing (DON) and the clinical nurse consultant were interviewed on 8/20/26 at 11:02 a.m. The DON and the NHA said they were new to the facility with the DON having been there for a couple months.The DON said Resident #7 had increased confusion, aggression and delusions. She said Resident #7 often refused to take his medications and would become verbally aggressive toward others. She said she was not aware of the incident between Resident #7 and Resident #8. She said recently, Resident #7 had a verbal altercation with his most recent roommate and the facility determined to move the roommate to another room.The DON said Resident #7 was very territorial over his belongings and did not like them to be touched. She said he often felt that others were touching his stuff, taking his belongings or moving things. She said he would fixate upon those thoughts.The DON said she was not aware the CNAs were entering Resident #7's room on days he would refuse when he was not around, cleaning the room and changing the linen. She said that act could contribute to his paranoia about his belongings being touched and verbal aggression, because they were touching his items without his permission. She said she would provide education to the CNAs not to touch the resident's belongings without his knowledge.The DON said physical abuse included actions such as punching, hitting and unwanted physical contact which was willful. She said the incident between Resident #7 and Resident #8 was considered physical abuse.The DON said she was aware of the incident between Resident #5 and Resident #6. She said it was her understanding that Resident #6 put Resident #5 in a chokehold but did not cut off his breathing. She said Resident #5 was still able to yell out.The DON said she would not want to be placed in a chokehold and felt the incident between Resident #5 and Resident #6 was considered physical abuse.

Based on observations, record review and interviews, the facility failed to ensure three (#2, #3 and #5) of three residents were kept free from abuse out of nine sample residents. Specifically, the facility failed to:-Protect Resident #2 and Resident #3 from being physically abused by Resident #1; and,-Protect Resident #5 from being physically abused by Resident #4.Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation policy and procedure, revised 11/17/25, was provided by the nursing home administrator (NHA) on 11/20/25 at 5:11 p.m. It read in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse toward a resident can occur as resident-to-resident abuse, staff-to-resident abuse, or visitor-to-resident abuse. Physical abuse includes but is not limited to hitting, slapping, biting, punching or kicking. The Resident-to-Resident Altercations policy, dated 2001, was provided by the NHA on 11/20/25 at 5:11 p.m. It read in pertinent part, All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, director of nursing services and to the administrator. Facility staff to monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors or staff. Behaviors that may provoke a reaction by residents or others include: verbally aggressive behavior, physically aggressive behavior, sexually aggressive behavior, taking, touching, rummaging through others' belongings, wandering into others' rooms or space. If two residents are involved in an altercation, staff should separate the residents and institute measures to calm the situation. Identify what happened, including what might have led to aggressive conduct, review the events with the nursing supervisor and director of nursing services and evaluate the effectiveness of the interventions. Make any necessary changes to the care plan approaches to any or all of the involved individuals. Document in the resident's clinical records all interventions and their effectiveness. II. Incident of physical abuse of Resident #2 by Resident #1 on 10/14/25 A. Facility investigation The investigation documented that a certified nurse aide (CNA) witnessed Resident #1 slap Resident #2's right hand after a verbal escalation. The investigation documented the two residents were immediately separated and placed on increased rounding and line of sight. The investigation documented that neither resident recalled the incident and neither resident had any signs or symptoms of injury. The facility substantiated the incident as abuse because the incident was witnessed. B. Resident #1- assailant 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the November 2025 computerized physician orders (CPO), diagnoses included dementia with psychotic disturbance, major depressive disorder, anxiety disorder and post-traumatic stress disorder. According to the 8/22/25 minimum data set (MDS) assessment, Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment further revealed Resident #1 had verbal behavioral symptoms directed towards others. The assessment revealed Resident #1 needed partial assistance with most of her activities of daily living (ADL) and needed supervision or touching assistance with walking. The MDS assessment documented that Resident #1 did not have physical behavioral symptoms directed towards others. -However, interviews and record review revealed Resident #1 did have physical behavioral symptoms towards others (see record review and interviews below). 2. Observations During a continuous observation on 11/19/25, beginning at 10:28 a.m. and ending at 11:36 a.m., the following was observed: At 10:28 a.m. Resident #1 was standing in her doorway, there was an isolation bin outside of her room due to her recent diagnosis of COVID-19. At 10:40 a.m. Resident #1 wandered a few steps out of her room and then went back into her room. At 10:58 a.m. Resident #1 came out of her room and began touching everything sitting on top of the isolation bin. At 11:11 a.m. Resident #1 came out of her room and walked halfway to the common area and then was redirected by staff to go back to her room. At 11:20 a.m. a nurse went down to Resident #1's room to check on the resident. The nurse did not go into Resident #1's room but stood outside the doorway and spoke to Resident #1 from the hallway. At 11:27 a.m. Resident #1 pushed her bedside table out into the hallway and came out of her room and handed a staff member an N95 mask that she took from the isolation cart. She then went back to her room. At 11:36 a.m. Resident #1 was yelling in her room, however, staff did not go down to check on her. 3. Record review The behavior care plan, revised 10/22/25, documented Resident #1 had been observed with physical and verbal aggression towards staff and other residents due to lack of orientation, delusional thought processes. The care plan further documented Resident #1 had poor impulse control and was reactive to stimuli in her environment. The care plan documented Resident #1 had hit or pushed another resident as recently as 10/14/25. Interventions included 15-minute checks or a sitter as needed, analyzing key times, places, triggers and what de-escalated the behavior and documenting, providing physical and verbal cues to alleviate anxiety, assessing and anticipating the resident's needs, encouraging the resident to seek out a staff member when agitated, evaluating medication side effects, monitoring, documenting and reporting to the medical provider of danger to self or others and psychiatric evaluation consult as indicated. -The care plan failed to include the resident's 10/21/25 altercation with Resident #3 (see below). The trauma-informed care plan documented Resident #1 was at risk for decreased psychosocial well-being and adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual well-being related to diagnosis of post-traumatic stress disorder and a history of domestic violence. The care plan documented Resident #1's trigger as unwelcomed guests going into her room. The interventions included a stop sign placed on Resident #1's door, allowing the resident time to make choices in her care, encouraging active decision making, approaching the resident in a calm, reassuring manner, encouraging family to visit and encouraging the resident to participate in activities of choice. A change in condition note, dated 10/14/25 at 9:06 p.m., documented Resident #1 initiated physical aggression with Resident #2 by slapping Resident #2 on her hand. The note documented that the residents were separated and no injuries were noted. The note further documented that the physician was notified and the physician recommended to monitor Resident #1 and gave no new orders. A social services note, dated 10/15/25 at 7:32 p.m., documented Resident #1 was being observed for psychosocial impact following an incident of aggression that she initiated. The note documented Resident #1 had increased aggression and agitation towards staff related to lack of orientation and delusional thought process. -However, the note did not mention aggression towards other residents. An interdisciplinary team (IDT) note, dated 10/16/25 at 9:52 a.m., documented the physical aggression that Resident #1 initiated and documented that Resident #1 did not recall the incident. The note further documented that staff was to monitor Resident #1 for overstimulation when she attended group activities. C. Resident #2- victim 1. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included dementia with other behavioral disturbance, mixed receptive-expressive language disorder (affects the ability to understand and produce language) and unspecified lack of coordination. The 10/13/25 MDS assessment revealed Resident #2 had severe cognitive impairment with a BIMS score of zero out of 15. The assessment revealed Resident #2 was dependent on staff for all of her ADLs and needed supervision or touching assistance when self-propelling in her wheelchair. The assessment further revealed Resident #2 did not have any verbal or physical behavioral symptoms towards others and did not wander. -However, interviews and further record review revealed Resident #2 did wander and have verbal aggression (see below). 2. Observations On 11/19/25 at 1:34 p.m. Resident #2 was in the common area in her wheelchair. On 11/19/25 at 1:52 p.m. Resident #2 was self-propelling down the hallway, away from the common area. On 11/19/25 at 2:16 p.m. Resident #2, along with an unknown male resident, was trying to get out of the gated area that led to another unit. No staff members redirected them. On 11/19/25 at 2:50 p.m. Resident #2 went into room [ROOM NUMBER], which was not her room. Staff did not redirect her out of the room. 3. Record review The psychosocial well-being care plan, revised 10/22/25, documented Resident #2 was the recipient of a resident-to-resident altercation. Interventions included a one-to-one sitter, 72-hour monitoring for psychosocial well-being, then one time a week for four weeks and keeping the residents separated. The mood care plan, revised 10/28/25, documented Resident #2 was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual well-being due to dementia with behaviors. The care plan further documented Resident #2 wandered throughout the unit and could become reactive to stimuli and the environment. The care plan revealed Resident #2 had been observed striking-out at others if startled or if others were confrontational. Interventions included activities staff were to evaluate and provide visits as needed, assessing clinical issues that may be causing or contributing to the resident's mood pattern, encouraging participation in activities, maintaining a calm, slow, understandable approach, observing for signs and symptoms of depression/emotional distress and notifying the physician and reviewing medications. A change in condition note, dated 10/14/25 at 4:18 p.m., documented Resident #2 was slapped by another resident. The note documented there was no injury, pain or skin issues. The note documented the physician recommended monitoring Resident #2 and reporting any changes. A nurse progress note, dated 10/14/25 at 8:37 p.m., documented a CNA reported to the nurse that Resident #2's right hand was slapped by Resident #1. The note documented a registered nurse (RN) assessed Resident #2 and did not find any injuries and the resident's skin was intact. A social services note, dated 10/15/25 at 1:57 p.m., documented Resident #2 was being observed for psychosocial well-being following an incident of aggression. The note documented Resident #2 appeared to be at baseline. An IDT note, dated 10/16/25 at 8:53 a.m., documented the team reviewed the physical aggression event between Resident #2 and Resident #1. The note documented Resident #2 did not remember the event. The note documented that social services would follow up with Resident #2 in 72 hours, then weekly for four weeks. III. Incident of physical abuse of Resident #3 by Resident #1 on 10/21/25 A. Facility investigation The investigation documented Resident #1 was observed wheeling Resident #3 out of her room and hitting Resident #3 on the back while yelling, Help, she's stealing my things! Resident #1 reported that Resident #3 went into her room and was touching her and grabbing her things. The investigation reported the residents were immediately separated and placed on a line-of-sight with no further incident. No pain or injuries were observed or reported. The facility substantiated the incident as abuse. B. Resident #1 - assailant 1. Record review A behavior note, dated 10/21/25 at 3:01 p.m., documented Resident #1 reported another resident (Resident #3) went into her room and was touching and grabbing Resident #1 and her belongings. The note documented that the nurse witnessed Resident #1 wheeling the other resident out of her room while yelling, Help, she's stealing my things! The note documented the nurse saw Resident #1 hitting Resident #3 on the back. A behavior note, dated 10/21/25 at 3:11 p.m., documented Resident #1 was heard by a CNA yelling at a nonverbal resident for being too close and pointing at her. A social services note, dated 10/22/25 at 8:28 p.m., documented Resident #1 was provided with a one-to-one sitter following an incident of initiated aggression. The note documented Resident #1 presented with self-deprecating, persecutory thought processes and low affect and was not easily consoled. The note documented the physician and family were aware of the change. A social services note, dated 10/22/25 at 8:32 p.m., documented an increase in Resident #1's antidepressant due to increased aggression, persecutory thought processes, self-deprecation and low mood. Staff was to monitor for medication effectiveness. C. Resident #3- victim 1. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included dementia severe with other behavioral disturbances and cognitive communication deficit. The 11/5/25 MDS assessment revealed Resident #3 had severe cognitive impairment with a BIMS score of zero out of 15. The assessment further revealed Resident #3 needed substantial to maximal assistance with most of her ADLs but was able to move independently in her wheelchair. The assessment revealed Resident #3 did not have physical behavioral symptoms towards others and did not wander. -However, interviews, observations and further record review revealed Resident #3 did grab others and wander (see below). 2. Observations During a continuous observation on 11/19/25, beginning at 10:28 a.m. and ending at 12:02 p.m., the following was observed: At 11:14 a.m. Resident #3 was in her room with the door closed. At 11:25 a.m. Resident #3 was self-propelling in the hallway. At 11:48 a.m. Resident #3 was in another resident's room with a brush in her hand and pulling the hair out of the brush and throwing the hair on the floor. At 11:54 a.m. Resident #3 went into room [ROOM NUMBER]. She was touching another resident and digging through the trash. At 12:00 p.m. a nurse took Resident #3 from room [ROOM NUMBER] and put her in her room and closed the door. At 12:02 p.m. Resident #3 opened her room door and came out into the hallway. During a continuous observation on 11/19/25, beginning at 1:34 a.m. and ending at 2:50 p.m., the following was observed: At 1:34 p.m. Resident #3 was in her room with the door closed At 1:46 p.m. Resident #3 came out of her room and tried to open different doors (storage doors that were locked). At 1:50 p.m. Resident #3 went into room [ROOM NUMBER]. Staff brought her out of the room. Resident #3 then took a female resident's napkin off of her table and put it in her wheelchair. At 1:53 p.m. Resident #3 was alone in the dining room pushing around stools with wheels on them. At 2:00 p.m. the nurse took Resident #3 from the dining room area and took her back to her room and closed the door without saying anything to her. At 2:06 p.m. Resident #3 came out of her room and went and opened another resident's door but did not go into their room. At 2:10 p.m. Resident #3 was in the way of another resident in the dining room and the other resident yelled Move it! at Resident #3. Resident #3 moved and wheeled herself into room [ROOM NUMBER] and closed the door. At 2:17 p.m. Resident #3 was still in room [ROOM NUMBER]. She opened the door and then closed it. At 2:20 p.m. the activities assistant (AA) offered Resident #3 a snack and she came out of room [ROOM NUMBER]. At 2:22 p.m. Resident #3 went back into room [ROOM NUMBER]. Resident #3 was patting and touching the resident's legs in the recliner in room [ROOM NUMBER]. Resident #3 was pulling up the bedding on the bed and then was moving and pulling the fan on the bedside table. Resident #3 was opening and closing the bathroom door and she took the personal wipes out of the bathroom. The resident in the recliner began to yell at her in a different language. Resident #3 left the room. Staff did not intervene. At 2:35 p.m. Resident #3 went into room [ROOM NUMBER]. She picked up a red colored drink in a small plastic cup on the B side of the room and drank it. At 2:40 p.m. the nurse put Resident #3 in her room and closed the door without saying anything to her. At 2:45 p.m. a female resident yelled at Resident #3, asking her where she was going as she was going into room [ROOM NUMBER]. At 2:46 p.m. Resident #3 came out of room [ROOM NUMBER] and went back into room [ROOM NUMBER] where she bundled up the privacy curtain and put it on the bedside table and spilled a drink on side A of the room. -Staff failed to intervene and provide meaningful redirection for Resident #3. Cross reference F744 for failure to provide appropriate dementia care services. 3. Record review The behavior care plan, revised 10/2/23, documented Resident #3 would go into others' rooms and take other residents' items out of their room. Interventions included redirecting the resident from other residents' rooms as needed. Staff was to return items that were taken as needed. The physical aggression care plan, revised 7/16/25, documented Resident #3 had the potential to be perceived as being physically aggressive due to her grabbing others to try to get their attention. The care plan documented Resident #3 had a communication deficit due to her limited English. Interventions included using the communication board as needed, monitoring any signs or symptoms of Resident #3 posing danger to herself or others. A behavior note, dated 10/21/25 at 3:02 p.m., documented Resident #3 went into room [ROOM NUMBER] (Resident #1's room) and started to grab Resident #1's belongings. Resident #1 got frustrated and became verbal with Resident #3. A social services note, dated 10/22/25 at 4:54 p.m., documented Resident #3 appeared at baseline following the incident. A social services note, dated 10/23/25 at 10:38 p.m., documented Resident #3 appeared at baseline following the incident. -However, none of the notes documented that Resident #3 was hit or if she sustained any injuries. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 11/20/25 at 12:26 p.m. LPN #1 said Resident #1 was fairly independent and very territorial. She said Resident #1 was not normally physically aggressive. She said she was not there when the incident happened between Resident #1 and Resident #2. She said she was not sure where it happened. She said Resident #2 was not as cognitively intact as Resident #1. She said Resident #2 may have hit Resident #1 when she was self-propelling in her wheelchair but she was not sure. LPN #1 said Resident #3 normally stayed in the area closest to the dining area. She said she was not sure when the incident happened between Resident #1 and Resident #3. She said the floor nurses did not update the care plan. She said the nurses would tell the director of nursing (DON) and the assistant director of nursing (ADON) about the incident and they would update the care plans. CNA #1 was interviewed 11/20/25 at 12:54 p.m. CNA #1 said that Resident #1 was half darling and half growly. She said Resident #1 could have dark moods, where she thought nobody cared about her. She said Resident #1 could be very territorial depending on who was going into her room. She said she could be very accusatory and most of her altercations had been verbal but she had become more physically aggressive. CNA #1 said Resident #2 was normally very sweet but there were times when she would get into moods where she would swear a lot. She said Resident #2 would sometimes wander. CNA #1 said Resident #3 wandered everywhere on the unit. She said Resident #3 would grab people to get their attention. She said she would take other residents' things which would be an issue for the other residents. She said all of the staff knew to redirect #3 from other residents' rooms. She said that Resident #3 would slap staff members but not other residents. The DON and the NHA were interviewed together on 11/20/25 at 3:10 p.m. The DON and the NHA said the facility substantiated the incident between Resident #1 and Resident #3. The DON and the NHA said the facility put a larger stop sign on Resident #1's door and implemented 15-minute checks until the facility was sure the stop sign was working. The DON and the NHA said they substantiated the incident between Resident #1 and Resident #2. The DON and the NHA said they implemented 15-minute checks and line-of-sight until the investigation was complete and that they were sure the interventions were working for the residents. The DON and the NHA said they were not sure where the incident happened but most likely it happened near or in Resident #1's room. The DON and the NHA said Resident #1's trigger for her behaviors was unwanted guests in her room. The DON and the NHA said that the IDT came up with and entered new interventions during the IDT meeting. V. Incident of physical abuse of Resident #5 by Resident #4 on 10/31/25 A. Facility investigation The 10/31/25 facility investigation documented Resident #5 went to the nurses' station and showed the nurse a skin tear to her right distal lateral forearm. She said Resident #4 pushed her, which caused her to fall onto the floor and scratch her arm. The incident was not witnessed and staff said they did not hear a commotion or altercation. Resident #5 denied pain, her skin tear was stable and she did not present with fear or psychosocial concerns. The investigation documented Resident #4 wandered the unit due to a diagnosis of advanced dementia and was non-interviewable. Resident #4 denied pushing anyone and staff said they did not witness the incident. The residents were immediately separated and a one-to-one supervision was put in place for Resident #4. The nurse assessed Resident #5 and documented a seven centimeter (cm) skin tear to the right forearm. The nurse cleaned the wound, reapproximated the skin and applied steri strips per physician's orders. The investigation documented there were no witnesses; however, the documentation showed a new skin tear consistent with the allegation. Resident #4 had no prior aggression toward residents, although she had previously been aggressive with staff and had thrown objects. One-to-one supervision remained in place to maintain resident safety. The investigation concluded the occurrence was unsubstantiated because there were no witnesses and both residents had a low BIMS score. -The facility failed to identify and implement effective interventions to prevent Resident #4 from entering other residents' rooms and demonstrating escalating physical and verbal behaviors toward others. B. Resident #4 (assailant) 1. Resident status Resident #4, age [AGE], was admitted on [DATE] and discharged on 11/18/25. According to the November 2025 CPO, diagnoses included Alzheimer's disease and dementia. The 10/14/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. She required supervision or touching assistance for all ADLs. The MDS assessment documented the resident exhibited verbal and physical behavioral symptoms toward others during the assessment period. 2. Record review The 10/9/25 social services progress note revealed Resident #4 wandered the halls without purpose and became agitated and aggressive with redirection. The note documented she entered other residents' rooms, paced the halls, and attempted to exit. The resident was moved to the secured memory unit due to safety concerns. The 10/11/25 nursing progress note revealed Resident #4 paced the hallway repeatedly beginning at 3:30 a.m. and entered another resident's room multiple times. Staff redirected her four times before she stopped returning to the same room. The 10/19/25 nursing progress note revealed Resident #4 was found asleep in her roommate's bed, causing the roommate to become upset. The note documented Resident #4 attempted to dress in the roommate's clothing, wandered into additional rooms and became physically aggressive by hitting and kicking the nurse during redirection. The 10/21/25 nursing progress note revealed Resident #4 continued to enter other residents' rooms and lie in their beds, which caused distress to peers. Staff redirected her and documented she refused some care. The 10/22/25 nursing progress note revealed Resident #4 was found in another resident's bed. Resident #4 became combative when staff attempted to redirect her and she attempted to kick the nurse. The 10/24/25 nursing progress note revealed the nurse attempted to redirect Resident #4 out of another resident's room and the resident punched the nurse in the chest. Staff gave her space and later redirected her to another area. The 10/31/25 nursing progress note revealed one-to-one supervision was initiated for Resident #4 due to a physical altercation with another resident. The 11/3/25 nursing note revealed the one-to-one CNA said Resident #4 hit her on two occasions when she attempted to redirect her from entering another resident's room. The note documented the resident pushed the CNA while the CNA attempted to block the entry into another room. The 11/4/25 nursing progress note revealed Resident #4 wandered in and out of rooms and beds throughout the shift with minimal effect from redirection. The 11/16/25 nursing progress note revealed Resident #4 hit the CNA in the face who provided the one-to-one supervision as the CNA attempted to redirect her from entering another resident's room. The note documented continued agitation, attempts to enter rooms and exit seeking. The behavioral care plan, initiated 10/22/25 and revised 11/2/25, documented Resident #4 had physical and verbal aggression, poor impulse control, and reactivity to environmental stimuli. Pertinent interventions included providing care in a calm and non-threatening manner, assisting with conflict resolution, attempting redirection when the resident exhibited agitation, observing for behavioral triggers and providing one-to-one supervision during waking hours to ensure the safety of other residents. The 11/4/25 IDT review documented Resident #4 continued to exhibit agitation, physical and verbal aggression, impulsivity, and negative verbalizations and required ongoing monitoring with non-pharmacological interventions to maintain safety. C. Resident #5 (victim) 1. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included dementia and anxiety disorder. The 10/6/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. She required supervision or touching assistance with bathing, oral hygiene, and dressing. The MDS assessment did not exhibit verbal or physical behaviors toward others during the assessment period. 2. Record review The trauma informed care plan, initiated 11/3/25, documented Resident #5 was at risk for decreased psychosocial well-being, emotional distress and ineffective coping skills related to physical contact made to her face by another resident on 9/10/25, and again on 10/31/25 and 11/3/25, which resulted in a skin tear. Pertinent interventions included monitoring for signs and symptoms of emotional distress, encouraging verbalization of feelings, providing calm reassurance, offering a quiet place to relax and reporting abnormal psychosocial findings to the physician. D. Staff interviews LPN #1 was interviewed on 11/20/25 at 11:58 a.m. LPN #1 said all allegations or incidents of abuse should be reported to the resident's responsible party, the physician, the DON and the ADON. LPN #1 said when a resident wandered into another resident's room, the resident should be redirected to an activity, another area, or back to their room if they wanted to lie down. She said she referred to the resident's care plan and the electronic medication administration record (eMAR) for each resident's individual interventions. She said during an active altercation, staff redirected residents and completed a change in condition for physical aggression and risk management. She said she would verbally redirect residents but would not get between two fighting residents for her own safety, especially when residents with dementia were sometimes unable to be redirected. LPN #1 said she had worked at the facility for four months, but she was not working on the day of the incident on 10/31/25 between Resident #4 and Resident #5. She said the night shift nurse informed her Resident #4 and Resident #5 had been involved in a physical altercation. She said Resident #4 pushed Resident #5 and Resident #5 sustained a skin tear on her arm. She said she had no doubt Resident #4 pushed Resident #5 due to Resident #4's ongoing pattern of aggression. LPN #1 said Resident #4 had a long history of wandering into other residents' rooms and was difficult to redirect. She said it often took three to four staff members to get Resident #4 out of a resident's room. She said Resident #4 had been physically aggressive with both staff and residents and had been placed under one-to-one supervision. She said a week ago, Resident #4 punched a CNA in the face; hard enough to bend the CNA's glasses. She said Resident #4's triggers usually occurred during care such as showering and changing. She said Resident #4 remained on one-to-one supervision from 10/31/25 until she was discharged to another facility. CNA #1 was interviewed on 11/20/25 at 1:10 p.m. CNA #1 said that when a resident wandered into another resident's room, she would provide redirection. She said she did not know where written interventions were documented for each resident. She said she had worked at the facility for two years and felt she knew each resident well enough to know what interventions worked. She said all allegations or incidents of abuse were reported to the abuse coordinator. CNA #1 said prior to one-to-one supervision, Resident #4 wandered freely throughout the unit, going in and out of other residents' rooms. She said that if a room door was open, Resident #4 would go inside. She said some days, Resident #4 was able to be redirected and other times she could not be redirected at all. She said the one-to-one supervision began after the incident on 10/31/25 with Resident #5 and continued for at least two weeks before she was discharged to another facility. She said she believed the lack of staffing directly contributed to the incident between Residents #4 and #5. CNA #1 said when she came on shift on 10/31/25, she was informed Resident #4 had entered Resident #5's room and hit her. She said Resid

Based on observations, record review and interviews, the facility failed to ensure one (#3) of seven residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being out of nine sample residents.Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #3.Findings include:I. Facility policy and procedureThe Dementia-Clinical protocol, dated 2001, was provided by the nursing home administrator (NHA) on 11/20/25 at 5:53 p.m. it read in pertinent part, As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with impaired cognition. The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes. Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the interdisciplinary team. The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. The interdisciplinary team (IDT) will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. The physician and staff will review the effectiveness of and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated.II. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the November 2025 computerized physician orders (CPO), diagnoses included dementia, severe with other behavioral disturbances and cognitive communication deficit. The 11/5/25 minimum data set (MDS) assessment revealed Resident #3 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The assessment further revealed Resident #3 needed substantial to maximal assistance with most of her activities of daily living (ADL) but was able to move independently in her wheelchair. The assessment revealed Resident #3 did not have physical behavioral symptoms towards others and did not wander. -However, interviews, observations and further record review revealed Resident #3 did grab others and wander.Cross reference F600 for failure to protect Resident #3 from abuse. B. ObservationsDuring a continuous observation on 11/19/25, beginning at 10:28 a.m. and ending at 12:02 p.m., the following was observed:At 11:14 a.m. Resident #3 was in her room with the door closed.At 11:25 a.m. Resident #3 was self-propelling in the hallway.At 11:48 a.m. Resident #3 was in another resident's room with a brush in her hand and pulling the hair out of the brush and throwing the hair on the floor.-Staff did not intervene to redirect the resident out of the other resident's room.At 11:54 a.m. Resident #3 went into room [ROOM NUMBER] she was touching another resident and digging through the trash.At 12:00 p.m. a nurse took Resident #3 from room [ROOM NUMBER] and put her in her room and closed the door. At 12:02 p.m. Resident #3 opened her room door and came out into the hallway. During a continuous observation on 11/19/25, beginning at 1:34 p,m, and ending at 2:50 p.m., the following was observed:At 1:34 p.m. Resident #3 was in her room with the door closed.At 1:46 p.m. Resident #3 came out of her room and tried to open different doors (storage doors that were locked).-Staff did not attempt to redirect the resident. At 1:50 p.m. Resident #3 went into room [ROOM NUMBER] and staff brought her out of the room. Resident #3 then took a female resident's napkin off of her table and put it in her wheelchair. At 1:53 p.m. Resident #3 was alone in the dining room pushing around stools with wheels on them.-Staff did not attempt to redirect the resident. At 2:00 p.m. the nurse took Resident #3 from the dining room area and took her back to her room and closed the door without saying anything to her. At 2:06 p.m. Resident #3 came out of her room and went and opened another resident's door but did not go into their room. At 2:10 p.m. Resident #3 was in the way of another resident in the dining room and the other resident yelled Move it!at Resident #3. Resident #3 moved and wheeled herself into room [ROOM NUMBER] and closed the door. At 2:17 p.m. Resident #3 was still in room [ROOM NUMBER]. She opened the door and then closed it. At 2:20 p.m. the activities assistant (AA) offered Resident #3 a snack and she came out of room [ROOM NUMBER]. At 2:22 p.m. Resident #3 went back into room [ROOM NUMBER]. Resident #3 was patting and touching the resident's legs in the recliner in room [ROOM NUMBER]. Resident #3 was pulling up the bedding on the bed and then was moving and pulling the fan on the bedside table. Resident #3 was opening and closing the bathroom door and she took the personal wipes out of the bathroom. The resident in the recliner began to yell at her in a different language. Resident #3 left the room. -Staff did not intervene when Resident #3 was touching the other resident. At 2:35 p.m. Resident #3 went into room [ROOM NUMBER]. She picked up a red colored drink in a small plastic cup on the B side of the room and drank it. At 2:40 p.m. the nurse put Resident #3 in her room and closed the door without saying anything to her. At 2:45 p.m. a female resident yelled at Resident #3 asking her where she was going as she was going into room [ROOM NUMBER]. At 2:46 p.m. Resident came out of room [ROOM NUMBER] and went into room [ROOM NUMBER] where she bundled up the privacy curtain and put it on the bedside table and spilled a drink on side A of the room.-Staff failed to intervene and provide meaningful redirection for Resident #3. During a continuous observation on 11/20/25, beginning at 9:55 a.m. and ending at 11:00 a.m., the following was observed: At 10:02 a.m. Resident #3 went into room [ROOM NUMBER] and then went into the dining room.At 10:05 a.m. the nurse brought Resident #3 out of the dining room and pushed her into the hallway.At 10:06 a.m. Resident #3 went back into the dining room area.At 10:09 a.m. Resident #3 was patting a female resident's hand.At 10:10 a.m. Resident #3 opened room [ROOM NUMBER]'s door and partially went in.At 10:15 a.m. Resident #3 pushed another female resident's arm and then began touching her wheelchair. The other resident became frustrated with Resident #3 being in her way and began pushing Resident #3 and telling her that she was in her way. Staff did not intervene but did ask the other resident if she wanted to go to an activity.At 10:20 a.m. Resident #3 was in the dining room pushing chairs around.10:25 a.m. Resident #3 was turning off the lights over the nurses' station, then began eating crumbs off of her wheelchair cushion.-Staff did not intervene to redirect the resident. At 10:30 a.m. Resident #3 was opening room doors. A certified nurse aide (CNA) took her to the activity in the common area.At 10:34 a.m. Resident #3 was wheeling into the other residents in the activity. The AA was trying to redirect her by playing catch with a ball. Resident #3 left the group and was touching other residents. At 10:44 a.m. Resident #3 went into room [ROOM NUMBER] and a CNA tried to redirect her. The CNA wheeled her out of the room and back into the hallway.-However, the CNA failed to provide the resident with anything meaningful to distract her.At 10:51 a.m. Resident #3 started wheeling towards the common area and tried opening the doors along the way (the doors were locked). She went into room [ROOM NUMBER]. Staff members walked past the resident as she was attempting to open the doors but they did not redirect her. At 10:55 a.m. CNA redirected her out of the room and closed the door. Resident #3 reopened the door and went back into room [ROOM NUMBER]. At 10:56 a.m. the CNA saw Resident #3 in room [ROOM NUMBER], however, the CNA did not redirect the resident out of the room.At 10:57 a.m. Resident #3 came out of room [ROOM NUMBER].At 11:00 a.m. Resident #3 was playing with a radio that was plugged in close to the nurses' station. She was pulling on the radio cord and then touching the outlet. The outlet had some wiring coming out of it. The nurse took Resident #3 without saying anything and put her in her room and then closed the door.-The nurse failed to provide Resident #3 with anything meaningful to distract or redirect the resident. On 11/20/25 at 12:20 p.m. Resident #3 reached out and grabbed another resident. The other resident swatted at Resident #3, however, staff did not intervene to redirect the resident. On 11/20/25 at 1:17 p.m. the nurse took Resident #3 into her room and closed the door without saying anything to her. C. Record reviewResident #3's behavior care plan, revised 10/2/23, documented the resident would go into other residents' rooms and take other residents' items out of their rooms. Interventions included redirecting the resident from other residents' rooms as needed and staff was to return items that were taken as needed. The preferences care plan, revised 11/19/24, documented Resident #3 self-initiated activities. The care plan documented Resident #3 enjoyed reading magazines, listening to Vietnamese music, pet visits, snacks in between meals, visits from dogs, and participating in socials with groups of people.The physical aggression care plan, revised 7/16/25, documented Resident #3 had the potential to be perceived as being physically aggressive due to her grabbing others to try to get their attention. The care plan documented Resident #3 had a communication deficit due to her limited English. Interventions included using the communication board as needed, monitoring any signs or symptoms of Resident #3 posing a danger to herself or others. The elopement risk care plan, revised 2/28/23, revealed Resident #3 was at risk for elopement related to impaired cognition due to dementia. Interventions included diverting Resident #3 by giving her alternate objects or activities, encouraging Resident #3 to participate in activities and redirecting Resident #3 if she was near exits or doorways. -However, observations during the survey revealed Resident #3 was not always redirected, preferences in activities were not offered and the communication board was not used with her. III. Staff interviewsThe AA was interviewed on 11/20/25 at 12:10 p.m. The AA said some of the main activities the facility provided on the secured unit were music, trivia and food activities. She said for the residents that were not able to actively participate in the activities, the facility offered residents a one-to-one visit program. She said the program provided residents with one-on-one time and support. She said there was no official documentation process for the one-to-one visits but, she said sometimes they would write a progress note. She said Resident #3 did not like activities. She said Resident #3 was not on the one-to-one program. She said Resident #3 was very tactile and liked to touch things. She said for residents that had a communication deficit she would use hand gestures to try and communicate. Licensed practical nurse (LPN) #1 was interviewed on 11/20/25 at 12:26 p.m. LPN #1 said Resident #3 would usually stay in the area closest to the dining room. She said there was a communication board that Resident #3's daughter made. She said she would put Resident #3 in her room to let her know that it was her space. She said she did it to help prevent behavioral escalations with other residents. CNA #1 was interviewed on 11/20/25 at 12:54 p.m. CNA #1 said Resident #3 wandered everywhere on the unit. She said Resident #3 would grab people to get their attention. She said she would take other residents' things, which would be an issue for the other residents. She said all of the staff knew to redirect her from other residents' rooms. She said that Resident #3 would slap staff members but not other residents. The director of nursing (DON) and the NHA were interviewed together on 11/20/25 at 3:10 p.m. The DON and the NHA said the facility kept residents that wandered safe from aggressive residents by redirecting them as much as possible, by giving them activity boxes and trying to engage the residents with distractions. The DON and the NHA said when there was a communication barrier with a resident, the staff should be using hand gestures, communication boards and redirection. The DON and the NHA said the facility trained staff on dementia when staff was hired and then at least annually. The DON and the NHA said their activities director (AD) did all of the dementia training. The DON and the NHA said staff should not be putting Resident #3 in her room and closing the door as an intervention for her wandering. The AD was interviewed on 11/20/25 at 4:16 p.m. The AD said she did a four hour dementia training when people were hired, annually, and then as needed. She said she also did on-the-spot training with staff on the secured unit. She said for Resident #3, there was a busy box for her but it would disappear. She said Resident #3's daughter would bring in snacks and there was a stash of her favorite snacks for staff to offer her. She said regular staff members were aware of Resident #3's interventions.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12-months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #4, CNA #5 and CNA #6. Findings include: I. Facility policy and procedure The Performance Evaluations policy and procedure, revised September 2020, was provided by the regional director of clinical services (RDCS) on 1/30/25 at 3:33 p.m. It read in pertinent part, The job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period and at least annually thereafter. II. Record review Annual performance reviews were requested on 1/29/25 at 4:05 p.m. The facility was unable to provide annual performance evaluations for 2024 for CNA #4 (hired on 12/9/23), CNA #5 (hired on 12/26/23 ) and CNA #6 (hired on 10/7/2020). -CNA #4, CNA #5 and CNA #6 did not have an annual performance review completed and did not have an in-service education plan based on the outcome of the review. III. Staff interviews The RDCS was interviewed on 1/30/25 at 3:25 p.m. The RDCS said the facility did not have the performance reviews for CNA #4, CNA #5 and CNA #6. The RDCS said she understood the importance of performing annual performance evaluations so that proper in-services could be conducted following the reviews. The director of nursing (DON) was interviewed on 1/30/25 at 4:05 p.m. The DON said she was new to her role of DON as of 11/15/24. The DON said performance reviews needed to be completed for CNAs annually, but she said she did not know where the former DON kept the records for the staff. The DON said she would start the performance reviews of the CNAs as soon as possible and then provide them with the in-service training they may need.

Based on observations, record review,and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents for four (#135, #40, #37 and #51) residents out of seven residents reviewed for grievances out of 53 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to individual grievances for Resident #135, Resident #40, Resident #37 and Resident #51. Findings include: I. Resident group interviews and observations A group interview was conducted on 1/30/25 at 10:30 a.m. with four residents (#135, #40, #37 and #51). The residents were interviewable per the facility and assessment. Resident #135 said when he had a concern , he provided the grievance to a member of the social service staff. He said many times he had not received a follow up on how his grievance was resolved or if it was resolved. Resident #40 said she had filled out two formal grievance forms and provided the forms to staff but received no follow up from social services or administration. She said she was aware of the grievance process and was aware the staff should have spoken with her after she submits a grievance form. Resident #37 said it took approximately two weeks for her to receive any notification of follow up to her grievances and many times she did not receive any follow up at all. She said due to her visual deficits, she required staff to assist her in completing a grievance form. She said this was difficult for her because she must trust the staff were filling the form out correctly and submitting it on her behalf. She said the staff did not read back to her what they had written on her grievance form. Resident #37 said several times she had asked staff to help her fill out a grievance form, was told they were too busy at the time and no one ever returned to complete the form with her. Resident #51 said he submitted a formal grievance to the maintenance assistant regarding a clog in his sink several weeks ago and had not received any follow up. On 1/30/25 at approximately 11:30 a.m. Resident #51's bathroom sink was observed to begin to fill up if the water ran for more than approximately three minutes continuously. II. Record review Facility grievances for the last six months were reviewed. Individual grievances were provided by the social services director (SSD) on 1/30/25. The grievances revealed the following; A grievance dated 11/3/24, was submitted by Resident #37. The grievance pertained to oxygen and medication administration. The date the resolution was discussed with the resident was 12/5/24. -The grievance was not reviewed with the resident for more than 30 days from the date she had initiated the grievance. A grievance dated 9/28/24, was submitted by Resident #37. The grievance pertained to dietary concerns. The date the resolution was discussed with the resident was 9/30/24. -However, the resident did not sign the resolution, the registered dietitian consultant (RDC) signed in the resident's place. A grievance dated 1/10/25, was submitted by Resident #135. The grievance pertained to resident dignity. The date the staff followed up with the resident after he submitted his grievance was not until 1/20/25. -The grievance was not reviewed with the resident for 10 days after he filed his grievance. No grievances were located by the SSD for a six month look back period for Residents #51 or Resident #40. III. Staff interviews The SSD was interviewed on 1/30/25 at 2:23 p.m. The SSD said she explained the grievance process to new employees during general orientation. She said she expected staff to assist residents who need assistance with completing a grievance form or to locate a member of social services to assist. She said the staff were to provide residents with a grievance form if they could not complete it independently and turn the form in for them if the resident needs assistance. The SSD said during the morning management meeting, the SSD would pass out grievances to the appropriate department to follow up on. She said she requested status updates on outstanding grievances. The SSD said she expected a follow up to be made to the resident within 24 to 48 hours to provide a resolution or to provide an acknowledgment the grievance was being worked on. She said if it took more than a week to resolve, she said the resident was to continue to receive updates. She said once resolved, the department manager would go back and let the resident know the resolution and have the resident sign on the form the resolution was satisfactory. The SSD said she had not received grievances in the last six months for Resident #51 or Resident #40.

Based on observations, record review and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in a safe, sanitary and working condition. Findings include: I. Observations On 1/27/25 at 9:30 a.m. the initial kitchen tour was conducted and the following was observed: -An approximate twelve-inch by twenty-four inch puddle of water was observed coming from underneath the kitchen employee's hand washing sink. -Under the three compartment dishwashing sink, a large silver mixing bowl was observed directly underneath the water pipes. The mixing bowl was collecting the drops of water from a leak in one of the pipes. -Two broken floor tiles by the sink were detached from the floor and floating on top of an accumulation of water. On 1/28/25 at 11:18 a.m. observations of the kitchen revealed there were no changes to the condition of the leak coming from underneath the kitchen employee's hand washing sink, the leak coming from the pipe underneath the three compartment dishwashing sink or the broken floor tiles that were floating on top of an accumulation of water. On 1/28/25 at 1:52 p.m. observations of the kitchen revealed there were no changes to the condition of the leak coming from underneath the kitchen employee's hand washing sink, the leak coming from the pipe underneath the three compartment dishwashing sink or the broken floor tiles that were floating on top of an accumulation of water. II. Staff interviews The dietary manager (DM) was interviewed on 1/28/25 at 1:26 p.m. The DM said the facility used an electronic work order system to enter work orders to the maintenance department for repairs. The DM said the kitchen staff were to notify him or one of his night supervisors to put repair orders into the system. The DM said he had been aware of the leaking pipe underneath the three compartment dishwashing sink for at least a week. He said he told someone in maintenance about it but could not recall who he had told or when he had done this. -The DM entered a work order to repair the leak, after it was observed during the survey. The DM said he was unaware of the leak and puddle of water underneath the employee's hand washing sink. He did acknowledge it was the main employee hand washing sink when the staff first came into the kitchen. He said his expectation was for the staff to go to the sink and wash their hands before performing any tasks in the kitchen. He said the outcome for leaks that were not addressed was water damage, resulting in the potential for mold in the kitchen. An environmental tour of the kitchen was conducted with the maintenance director (MTD) and the nursing home administrator (NHA) on 1/28/25 at 1:52 p.m. The MTD said he had ordered the part to repair the pipe leak underneath the three compartment dishwashing sink on 1/27/25 (during the survey). He said prior to the survey, he was unaware of the leak and had not received a work order from the DM. The MTD said the leak coming from underneath the employee's hand washing sink was due to a disconnected drain pump from the ice machine next to the sink. He said the disconnected drain pump was causing the water leak to come from underneath the ice machine and travel underneath the hand washing sink. It was observed the material at the base of the hand washing sink was soft and warped consistent with water damage. The MTD said he would reconnect the drain pump and repair the warped base of the sink. The NHA said a work order should have been submitted in the electronic work order system in order for the MTD or the maintenance assistant (MTA) to repair the leaks. The MTD said during new hire employee orientation, he provided education to staff on the electronic work order system and how to enter work orders. -During the interview, the work order system training for the DM was requested from the MTD and the NHA, along with the agenda for the new hire orientation section on work orders. III. Facility follow up On 1/28/25 at 2:20 p.m. the regional director of clinical services (RDCS) provided an email with an attached document titled Maintenance Education. The document included instructions on how to enter a work order, the contact numbers for the MTD and the MTA, the maintenance problems to direct to the MTD and MTA and the fire alarm code. -However, the Maintenance Education document was not dated with the date the education was provided and did not include any staff signatures to identify who received the education.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease on three of nine units. Specifically, the facility failed to: -Ensure housekeeping staff wore gloves and performed appropriate hand hygiene while cleaning residents' rooms; -Ensure housekeeping staff wore masks appropriately while the facility was in a flu outbreak; and, -Ensure staff sanitized dining tables and the floor prior to the next meal. Findings include: I. Housekeeping failures A. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the regional director of clinical services (RDCS) on 1/30/25 at 2:39 p.m. It read in pertinent part, Use heavy-duty gloves and other personal protective equipment (PPE), as indicated, for housekeeping tasks. Gloves, protective eyewear and masks may be indicated to reduce exposure levels to disinfectant chemicals as well as to protect employees from exposure to blood and OPIM (other potentially infectious materials) while cleaning or disinfecting. Perform hand hygiene after removing gloves. B. Observations On 1/29/25 at 8:42 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. HK #1 reached her ungloved hand into a clean bucket, retrieved a mophead and applied the mophead to her mop. After using the mop, HK #1 removed the dirty mophead and disposed of it with ungloved hands. -HK #1 did not perform hand hygiene after removing the dirty mophead with her ungloved hands. HK #1 proceeded to empty the trash can with her ungloved hands. -HK #1 did not perform hand hygiene after emptying the trash can. HK #1 licked her fingers and opened a clean trash bag with her ungloved hands, which she had not sanitized after removing the dirty mophead with her ungloved hands or emptying the trash can. HK #1 did not perform hand hygiene after licking her fingers. On 1/29/25 at 8:50 a.m., HK #1 was observed cleaning room [ROOM NUMBER]. HK #1 reached her ungloved hand into a clean bucket, retrieved a mophead and applied the mophead to her mop. After using the mop, HK #1 removed the dirty mophead and disposed of it with ungloved hands. -HK #1 did not perform hand hygiene after removing the dirty mophead. HK #1 proceeded to reach her ungloved hand into the bucket of clean mopheads again to retrieve another mophead. C. Staff interviews HK#1 was interviewed on 1/29/25 at 9:00 a.m. HK #1 said she should have worn gloves to obtain and dispose of the mophead. She said she should have used hand sanitizer after touching the dirty mophead. HK #1 said some residents' trash cans looked clean so she did not always wear gloves. HK #1 said she should have worn gloves to empty the trash. -During the interview, HK#1 was observed wearing a mask under her nose, despite the fact that the facility was in a flu outbreak during the survey. The housekeeping supervisor (HKS) was interviewed on 1/29/25 at 9:30 a.m. The HKS said HK#1 should have worn gloves and changed gloves between tasks when cleaning the residents' rooms, including when removing trash from the rooms and when she discarded the dirty mopheads. The HKS said HK #1 should have used hand sanitizer before applying gloves and between changing gloves. The infection preventionist (IP) was interviewed on 1/29/25 at 1:55 p.m. The IP said HK #1 should have worn gloves at all times while cleaning the residents' rooms and changed gloves and performed hand hygiene between dirty and clean tasks. The IP said HK#1 should have washed her hands with soap and water after licking her fingers. The IP said HK #1 should have covered her nose when wearing her mask. II. Failure to sanitize dining tables and the floor between meals A. Observations On 1/27/25 at 11:32 a.m. the dining room in the 100 hallway was observed. There were five tables in the dining room. There were bread/dessert crumbs on three dining tables and beverage cup liquid markings and other stains present on four of the dining tables. At 12:09 p.m. stains and crumbs were still present on the 100 hallway dining tables and there were four residents sitting at the tables waiting for lunch and drinking beverages. At 12:43 p.m. meal service began and the dining tables in the 100 hallway dining room had not been cleaned. On 1/28/25 at 9:15 a.m. the dining room on the 100 hallway was observed again. There were crumbs on the floor and dirty marks/dried beverage spots on two of the four dining tables after the breakfast meal. At 12:26 p.m. there were still crumbs on the floor and the same spots on the tables in the 100 hallway dining room. Three residents were sitting at the dining tables awaiting lunch. On 1/29/25 at 11:30 a.m. the dining room on the 100 hallway was observed. There were bread/dessert crumbs on three of the dining tables, crusty substances on three of the dining tables' edges and beverage spots on one dining table. The dining table closest to the entrance of the dining room still had liquid spots in the same locations observed on 1/27/25 and 1/28/25 (see above). Crumbs were present on a chair and on the floor under the dining tables. A plastic cup lid was on the floor. At 11:55 a.m. a housekeeper was cleaning the 100 hallway and walked with the housekeeping cart past the dining room. The housekeeper did not clean the dining room. At 12:41 p.m. the 100 hallway dining room was observed in the same condition. The dining tables, chair and floor had not been cleaned. At 12:56 p.m. two residents were observed in the 100 hallway dining room. They sat at a dining table and began drinking coffee. The dining tables had not been wiped/sanitized and the room was in the same condition. At 12:57 p.m. a resident sat at another dining table that had not been wiped/sanitized. At 12:59 p.m. meal service began in the 100 dining room and the dining tables had not been cleaned. At 3:49 p.m. the dining tables were in the same condition with crumbs and dried beverage stains. In addition, there were two plastic beverage cup lids on the floor and additional crumbs on the floor. At 5:15 p.m. two of the beverage stains on a dining table were able to be partially removed when wiped with a wet paper towel. At 5:31 p.m. two residents were observed eating at a dining table which had not been cleaned. B. Resident interview Resident #40 was interviewed on 1/30/25 at 10:30 am. Resident #40 said many times the dining room was not cleaned after meals. Resident #40 said she had gone into the dining room for Bingo at 2:30 p.m. on several occasions and there was still food on the tables or trays with food stacked in racks in the dining room. C. Staff interview The dietary manager (DM) was interviewed on 1/29/25 at 5:39 p.m. The DM said the dietary aides were responsible for cleaning the dining room tables and serving areas in the 100 hallway dining room. He said the dietary aides were supposed to clean the dining rooms after every meal. The DM said there were cleaning logs for the other dining rooms, however, he said he did not think there was a cleaning log for the 100 hallway dining room. The DM said there should be a cleaning log for the 100 hallway dining room. The DM said the staff should ensure the tables were clear of food debris and stains and remove trash so residents would feel comfortable sitting at the tables. The DM said the cleaning of the 100 hallway floor was the responsibility of the dietary aides and housekeeping was also responsible for cleaning the floors. The DM said he was going to communicate with the nursing staff to assist with cleaning the 100 hallway dining room. The DM said he would also communicate with the housekeeping supervisor to establish a 100 hallway dining room cleaning schedule for the housekeeping department.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents out of 53 sample residents. Specifically, the facility failed to ensure staff were aware of and following the care planned interventions for Resident #4 in order to prevent further falls. Findings include: I. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, osteoporosis, muscle weakness, unspecified lack of coordination and left artificial hip. The 11/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments. The resident could not complete the cognitive assessment therefore a staff assessment was completed. The staff assessment revealed the resident had short and long term memory deficits, impaired decision making, and was only oriented to herself. The MDS assessment documented the resident used a wheelchair for mobility and required moderate assistance from staff for bed mobility and transfers. The MDS assessment indicated the resident required supervision and hands-on assistance with ambulation. The MDS assessment indicated the resident had not had any falls since the prior assessment. B. Resident observations On 1/27/25 at 11:30 a.m. Resident #4 was ambulating in the hallway with sock-like slippers on. She was pushing another resident in their wheelchair. She was observed with a raised, large hematoma (a pool of blood under the skin or in the body caused by a broken blood vessel) on the left side of her forehead with bruising to the left forehead area and under her left eye. Registered nurse (RN) # 4 walked past Resident #4, but did not discourage the resident from ambulating on her own or pushing the other residents' wheelchair. At 11:34 a.m., four minutes after initially walking past Resident #4, RN #4 returned and asked the resident not to push other residents' wheelchairs. RN #4 took Resident #4's hand and guided the resident away from the other resident's wheelchair. On 1/28/25 at 11:20 a.m. Resident #4 was ambulating independently with an unsteady gait and sock-like slippers on her feet. Several staff members were present in the area but did not provide ambulation assistance to the resident. On 1/29/25 at 11:51 a.m. Resident #4 was ambulating independently with an unsteady gait and sock-like slippers on her feet. Several staff members were present but did not provide ambulation assistance to the resident. On 1/29/25 at 4:46 p.m. Resident #4 was ambulating independently with sock-like slippers on her feet and holding another resident's hand while pulling the other resident in their wheelchair. The memory care director (MCD) came up to Resident #4 and asked to hold her hand so she would stop pulling the other resident in their wheelchair. C. Record review Resident #4's fall care plan, revised 10/17/24, revealed the resident was at risk for falls due to dementia, gait/balance problems, history of falls and history of femur fracture and rib fracture. Interventions included anticipating and meeting the resident's needs (initiated 9/21/23), encouraging and assisting the resident to use a wheelchair for ambulation (initiated 10/30/23), ensuring the resident was wearing non-skid socks or non-skid footwear (initiated 5/13/24), educating the staff to keep the resident in line of sight (initiated 1/14/25) and ordering a therapy evaluation for the use of a four-wheel walker (FWW) (initiated 1/20/25). A post-fall review assessment, dated 1/15/25, revealed the resident had a fall on 1/14/25. A post-fall review assessment, dated 1/20/25, revealed the resident had a fall on 1/20/25. A review of Resident #4's progress notes from 1/14/25 through 1/30/25 revealed the following: A 1/14/25 change of condition assessment progress note revealed Resident #4 had a fall. The physician ordered a new prescription for as needed pain medication. A 1/14/25 change of condition fall progress note dated revealed a housekeeper had found Resident #4 lying on the floor at the end of a hallway in her unit. When the nurse arrived to assess the resident, the resident was standing up and screaming out. She was observed to be holding the hand of another resident who had helped her stand up. No injuries were observed by the nurse. A 1/15/25 interdisciplinary team (IDT) fall note dated revealed the new interventions put into place for the 1/14/25 fall included educating the staff to keep Resident #4 within sight in common areas and to update the care plan. A 72-hour charting note, dated 1/17/25, revealed Resident #4 was observed walking the unit unassisted and constantly attempting to engage with the nursing staff, however, the resident was unable to articulate herself. -The note did not indicate if staff attempted to assist the resident with ambulation. A 1/20/25 change of condition assessment progress note revealed Resident #4 had suffered a fall after ambulating in the hallway and letting go of a hand rail which caused her to fall. The resident was observed with discoloration to her forehead and the physician ordered the resident be sent out to the hospital for a contusion to her head. A 1/20/25 nursing note revealed the resident had returned from the hospital with a hematoma to her scalp, was grimacing and verbally complaining of pain and pointing at her right hip. A 1/21/25 IDT skin note revealed Resident #4 had a contusion to the left forehead with edema and discoloration. A 1/21/25 resident safety note revealed occupational therapy issued a FWW for Resident #4 to use. The staff were provided education to watch the resident while the new device was being initiated. The resident demonstrated good results for use. A 72-hour charting note, dated 1/21/25, revealed physical therapy worked with the resident on her use of the FWW. This was effective until the resident saw another resident she liked to hold hands with and then she let go of the walker. Redirection with the resident was effective. -However, staff were not observed during the survey to be assisting Resident #4 with ambulation, redirecting the resident when she was ambulating unassisted or encouraging the resident to utilize the FWW (see observations above). II. Staff interviews RN #4 was interviewed on 1/27/25 at 11:30 a.m. RN #4 said Resident #4 used to be a nurse and thought she was working. She said the resident liked to assist and push other residents in their wheelchairs. RN #4 said the resident's fall interventions were to keep her within their line of sight when she was out of her room. RN #4 said she thought the resident's walker was in her room but the resident did not use it. Certified nurse aide (CNA) #3 was interviewed on 1/29/25 at 11:58 a.m. CNA #3 said Resident #4 could ambulate independently without a walker or wheelchair. -However, according to the resident's 11/25/24 MDS assessment, care plan and progress notes, Resident #4 required hands-on assistance with ambulation or the use of a wheelchair or FWW (see resident status and record review above). The director of nursing (DON) was interviewed on 1/30/25 at 12:54 p.m. The DON said when a resident had a fall, the nurses were to complete an assessment of the resident's condition. The DON said an immediate new fall intervention was determined and the managers attempted to identify the root cause of the fall. The DON said once a new intervention was put into place, a manager was assigned to monitor the intervention's implementation. The DON said the new interventions for Resident #4's fall on 1/14/25 were to educate the staff regarding keeping her in their line of sight and monitoring her for 72 hours. The DON said the new interventions put into place post fall on 1/20/25 were to have the therapy department evaluate the resident for a FWW. The DON said she did not know why the staff were not encouraging the resident to use her walker for ambulation. The DON said she was unaware Resident #4 had been wearing slipper-like socks instead of non-skid socks or footwear.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and services to maintain vision abilities for one (#137) of three residents reviewed for vision services out of 53 sample residents. Specifically, the facility failed to ensure Resident #137's new eyeglasses were obtained in a timely manner. Findings include: I. Facility policy and procedure The Hearing and Vision Services policy (undated), was provided by the regional director of clinical services (RDCS) on 1/28/25 at 5:10 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social services designee is responsible for assisting residents, and their families, in locating and utilizing any available resources for the provision of the vision and hearing services the resident needs. II. Resident #137 A. Resident status Resident #137, age 83, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, heart disease, hypothyroidism (thyroid gland did not produce enough hormone) and chronic pain. The 12/24/24 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not completed. The resident had a memory problem and his cognitive skills were severely impaired. The resident required substantial assistance from staff for oral hygiene, toileting, dressing, personal hygiene and required supervision for transferring. The MDS assessment documented the resident had adequate vision and did not require corrective lenses. -However, documentation from an eye consult office visit revealed the resident required glasses (see record review below). B. Resident observation and resident representative interview On 1/27/25 at 3:00 p.m. Resident #137 was sitting in the dining room. The resident was not wearing glasses. Resident #137's representative was interviewed on 1/28/25 at 11:10 a.m. The representative said Resident #137 had worn eyeglasses since he was a child. The representative said Resident #137's eyeglasses had been missing for several months. The representative said Resident #137 saw an optometrist and was provided a prescription for eyeglasses but the eyeglasses were never ordered. The representative said he had asked a facility representative about the eyeglasses on several occasions and was not provided updates regarding the status of Resident #137's eyeglasses. C. Record review The 8/5/24 eye exam note, entitled Summary Ocular Progress Note, was provided by the RDCS on 1/30/25 at 1:05 p.m. The eye exam note included instructions to deliver Resident #137's prescribed eyeglasses two weeks from the receipt of payment. A nursing progress note, dated 10/1/24 at 7:37 p.m., revealed Resident #137's representative was notified that the resident's glasses were on order and management had reached out to the eye doctor for an estimated time for when they would be delivered. -Review of Resident #137's electronic medical record (EMR) on 1/30/25 did not reveal documentation to indicate the resident had received his new eyeglasses. D. Staff interviews The social services director (SSD) was interviewed on 1/30/25 at 12:09 p.m. The SSD said Resident #137 should have received his eyeglasses. The SSD said the facility changed vision providers and said this could have contributed to the delay. The SSD was interviewed a second time on 1/30/25 at 12:49 p.m. The SSD said she was responsible for ensuring Resident #137 received his eyeglasses in a timely manner. The SSD said she had been trying to catch up with residents' ancillary needs since she started in her position at the facility in April 2024. The director of nursing (DON) and the RDCS were interviewed together on 1/30/25 at 1:52 p.m. The DON said Resident #137's eyeglasses were ordered on 1/30/25 (during the survey). The RDCS said there were gaps in the process to order the eyeglasses for Resident #137. The RDCS said she would expect the process to obtain new eyeglass prescriptions to not take longer than six to eight weeks.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services and assistance for bathing for two (#48 and #77) of four residents reviewed out of 53 sample residents. Specifically, the facility failed to provide complete grooming with shower/bed bath for Resident #48 and Resident #77 in order to maintain personal hygiene, including shaving of beard, washing of hair and trimming of fingernails. Findings include: I. Facility policy and procedure The Activities of Daily Living, Supporting policy and procedure, revised March 2018, was provided by the regional director of clinical services (RDCS) on 1/29/25 at 6:35 p.m. It read in pertinent part, Residents who are unable to carry out activities of daily living (ADL) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). II. Resident #48 A. Resident status Resident #48, age 75, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included disorders of bladder, paralytic syndrome following cerebrovascular (CVA) disease affecting left dominant side (stroke), paraplegia (paralysis of the lower half of body) and emphysema. The 11/11/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff assistance with oral hygiene, toileting hygiene, bathing, upper/lower body dressing, personal hygiene (including combing hair and shaving), bed mobility and all transfers. He used a motorized wheelchair for mobility. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interviews and observations Resident # 48 was interviewed on 1/28/25 at 9:48 a.m. He had long jagged fingernails on both hands with brown matter visible underneath the nails. Resident #48 said he preferred to have a shower twice a week but the staff did not have time for it. Resident #48's hair was greasy and uncombed. Resident #48 said the staff usually combed his hair and he relied on them to do it. Resident #48 had a full bushy beard, mustache and side burns. Resident #48 said he preferred to have a clean shave since being in the military. Resident #48 said the staff did shave him occasionally, maybe once a week. Resident #48 said he did not know which days he could expect a shower or a shave, as it occurred whenever the staff got around to it. Resident #48 was interviewed a second time on 1/29/25 at 5:12 p.m. Resident #48's hair was long, messy and unkempt. Resident #48 said it had been hectic around his unit. Resident #48 said he was promised a shave but the staff member who promised him the shave never came back to do it. Resident #48 had a full unkempt beard and his fingernails continued to be long and jagged with visible brown matter underneath the nails. C. Record review Review of the bathing care plan, revised 10/4/23, revealed Resident #48 required assistance and was dependent for ADL care related to impaired mobility/cognition due to paralytic syndrome following CVA, chronic pain and muscle weakness. Resident #49's shower preference was for two times per week and he had no caregiver preference. -The care plan failed to include shaving the resident's beard or providing nail care. Review of Resident #48's bathing record from 12/31/24 to 1/28/25 revealed the resident had received six showers over the 30-day period with no resident refusals. The bathing record revealed the resident was dependent on staff for bathing. -However there was no documentation that indicated the resident's fingernails were trimmed or his beard was shaved. III. Resident #77 A. Resident status Resident #77, age 75, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included pressure ulcer of sacral region, heart disease, hemiplegia (paralysis on one side of the body) affecting right dominant side, contracture (permanent shortening and stiffening of muscles and other tissue) of the right hand and major depressive disorder. The 12/3/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She was dependent on assistance with bathing, chair/toilet/bed transfers, and sit-to-stand transfers. She required partial/moderate assistance with bed mobility, oral hygiene, toileting hygiene, upper/lower body dressing and personal hygiene (including combing hair). She required a manual wheelchair for mobility. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interviews and observations Resident #77 was interviewed on 1/27/25 at 11:58 a.m. Resident #77's hair was dirty and greasy and was not combed. The resident's fingernails were long with brown matter visible under the nails. The resident's right hand was contracted and her fingernails touched into her palm. Resident #77 said she preferred her fingernails short. Resident #77 said she had not been getting out of bed, per her choice, so she had only received bed baths, not showers. Resident #77 was interviewed a second time on 1/29/25 at 5:08 p.m. Resident #77's hair was greasy and unkempt. Resident #77 said she should be getting her hair washed tomorrow (1/30/25), however, she said when the staff did the bed bath, they did not offer to wash her hair unless she insisted they go get the waterless shampoo cap. Resident #77's fingernails were long with brown matter visible under the nails. Resident #77 said she liked her nails short, but the staff had been really busy. Resident #77 said she would ask the staff to trim her nails since they had been too busy to offer. C. Record review Review of the ADL care plan, revised 6/2/24, revealed Resident #77 had an actual self-care deficit and was at risk for further ADL/mobility decline and required assistance related to contractures, history of CVA with hemiparesis, recent hospitalization , weight loss and failure to thrive. -The ADL care plan failed to include bathing or nail care for the resident. Review of Resident #48's bathing record from 12/31/24 to 1/28/25 revealed the resident had received seven bed baths over the 30-day period with one resident refusal. The bathing record revealed the resident was dependent on staff for bathing. -However, there was no documentation that the resident's fingernails were trimmed or her hair was washed. IV. Additional observation On 1/29/25 beginning at 5:46 p.m. the director of nursing (DON) interviewed and observed Resident #48 and Resident #77. The DON confirmed that both residents had long jagged fingernails with brown matter visible under their nails and their hair was greasy and uncombed. The DON said a lack of care with the nails and hair could cause skin infections and skin integrity problems. The DON confirmed with both residents that they wanted to have short, clean fingernails. Resident #48 verified with the DON that he would like his beard shaved and he would like to keep his mustache. The DON acknowledged the residents' grooming concerns and said she would make sure the residents received the necessary services right away. V. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/29/25 at 5:17 p.m. LPN #3 said residents should receive a shower two to four times per week, per their preference. LPN #3 said the certified nurse aides (CNA) would tell her if a resident refused grooming, and she would encourage them. LPN #3 said the CNAs charted the residents' showers in the electronic medical record (EMR). LPN #3 said it was important for the residents to receive a shower to keep skin clean, prevent skin break down and promote good hygiene. The DON was interviewed on 1/29/25 at 5:36 p.m. The DON said she recommended a shower at least two times per week. The DON said a shower/bath was important for cleanliness, good hygiene and to minimize risk of infection. The DON said the facility used to have a shower aide but she left, so now the CNAs were doing the showers. The DON said the process for fingernail care was to offer during activities with a manicure, if the resident was not diabetic or the CNAs would offer and ask the residents if they would like their fingernails trimmed during the bathing task. The DON said the bathing task, whether a shower or bed bath, included hair shampoo, nail care, soap and water clean, face washing and teeth/oral care. The DON said beard shaving could be part of the bathing task or some residents had an electric razor, or the CNA would do the shaving upon the residents' request.

Based on record review and interviews, the facility failed to honor resident choices for one (#30) of one resident reviewed for self-determination out of 53 sample residents. Specifically, the facility failed to promote, facilitate and support a room change for Resident #30, per her preference. Findings include: I. Facility policy and procedure The Resident Self-Determination and Participation policy and procedure, revised August 2022, was provided by the regional director of clinical services (RDCS) on 1/29/25 at 6:35 p.m. It read in pertinent part, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. In order to facilitate resident choices, the administration and staff inform the residents and family members of the residents' right to self-determination and participation in preferred activities, gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record, including information gathered about the resident's preferences in the care planning process. Residents are encouraged to make choices about aspects of their lives in the facility, including rooming with the person of their choice and providing both individuals consent to the choice. II. Resident #30 A. Resident status Resident #30, under age 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included cerebral palsy (a disorder that affects ability to move and maintain balance and posture caused by brain damage), thoracic scoliosis, pain in the right hip and depression. The 12/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with toileting, bathing, dressing, personal hygiene and transfers. She used a motorized wheelchair for mobility. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interview Resident #30 was interviewed on 1/27/25 at 2:47 p.m. Resident #30 said her roommate had sundowning (late-day confusion affecting people with dementia) and was loud and her neighbor across the hall yelled out all night due to dementia. Resident #30 said she needed to wear her headphones in order to sleep at night. Resident #30 said it seemed like many of the residents around her had significant cognitive issues and she was not sure her room location and her roommate was the best fit for her since she was younger and had no cognitive issues. Resident #30 said when she first admitted to the facility, she was in the rehabilitation unit and her room was great but later she was moved to her current room. Resident #30 said the last time she talked to the unnamed social worker (SW), the SW had said if she put in a request for a new roommate she may get a worse one. Resident #30 said she knew four other younger residents and thought they may be a better match for her and mainly not to have her sleep disturbed. Resident #30 said the SW had discouraged her from pursuing a formal request for a room/roommate change. Resident #30 said she had had a care conference last month (December 2024) and voiced her wishes but said there had been no follow up from the meeting. C. Record review The respite stay care plan, initiated 9/16/24 and revised 10/8/24, revealed Resident #30 was originally admitted for a 21-day respite stay but later made the decision to stay for long-term care related to 24/7 (twenty-four/seven) care needs. Interventions included to provide an arena such as IDT (interdisciplinary team) care conference for resident, family and/or interested parties to address plans for discharge and participate in the discharge planning process as indicated, social services to document changes to discharge goals per resident preference as indicated and social services to schedule IDT care plan meetings upon admission, quarterly and as needed. -However there were no updates to the care plan interventions following Resident #30's decision to remain in the facility for long-term care. Review of the IDT conference summary, dated 12/5/24, revealed it was a quarterly conference. The activities comment revealed the resident continued to be active and attend groups of interest weekly such as church, bingo, music, entertainment and social. The resident used an electric wheelchair for mobility but needed staff assistance to take her to and from groups of interest and she could make her needs known. The care conference summary revealed that the resident attended the care conference but the social services progress note summary was blank. -Resident #30 said she had told social services of her room/roommate concerns during the IDT case conference, however, the care conference summary note failed to reveal documentation from social services regarding the resident's concerns or any follow up. III. Staff interviews The social services director (SSD) was interviewed on 1/29/25 at 1:54 p.m. The SSD reviewed the care conference summary note dated 12/5/24 and said she could not tell from the note what concerns were discussed in the meeting and what were the outcomes because the social services portion of the progress note had not been documented and was blank. The SSD said typically the social services assistant (SSA) would write in the progress note section at the bottom of the form. The SSD said since the SSA did not document anything from the meeting, she did not know what was talked about and discussed. The SSD said she would want social services to write a progress note in the care conference summary because it was important to document what was talked about in the care conference and indicate the facility was discussing ancillary services or any resident concerns. She said social services should additionally document the plan to follow up on residents' concerns, depending on what the concerns were, in a progress note. The SSD said it was important to know what the follow up plan was so she could follow up and make sure the residents were getting the care they needed. The SSD said she had not heard anything about Resident #30 wanting to move to a different room. The SSD said she knew of a good place/room that Resident #30 could move to that might meet her needs better. The SSD said residents were always permitted to request a room change that would better meet their needs. The SSD said the social services department recently made some changes to the department's staff. IV. Facility follow up On 1/29/25 at 2:40 p.m. the SSD said she had spoken with Resident #30 and arranged for a room change for the resident. She said Resident #30 toured the new room and was quite happy with the new room and location. The social services progress noted, dated 1/29/25 at 3:06 p.m. revealed the social services department had spoken with Resident #30 about a room move. The resident verbalized she would like to move to a different room. Available rooms were discussed and the resident toured and chose a new room. The resident was introduced to her new roommate and it was decided that the room move would happen first thing in the morning (1/30/25). Resident #30 verbalized understanding and gave consent for the room change.

Based on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#26) of one resident reviewed for accommodation of needs out of 53 sample residents. Specifically, the facility failed to ensure Resident #26's bed side rails were installed as requested by the resident and as recommended by the rehabilitation services department staff. Findings include: I. Resident #26 A. Resident status Resident #26, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included paraplegia (inability to voluntarily move the lower parts of the body), pressure ulcer to the right buttock, neuromuscular dysfunction of the bladder (condition where the nerves controlling bladder function are damaged), anxiety and depression. The 12/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #26 required set up assistance for eating and oral hygiene and was dependent on staff for toileting and showering. The resident required substantial assistance from staff for dressing, rolling from left to right and moving from a sitting to a lying position in bed. B. Resident observation and interview Resident #26 was interviewed on 1/27/25 at 2:42 p.m. Resident #26 was sitting in her wheelchair. There were no side rails on Resident #26's bed. Resident #26 said she was able to move her arms. Resident #26 said she needed bed side rails near the head of her bed in order to be able to move in the bed without significant assistance. Resident #26 said she asked staff for bed side rails on 11/15/24 (the date she was admitted to the facility) and had asked for side rails several times since then. Resident #26 said when someone was paraplegic, the lack of side rails was a restraint, because it did not allow for independence and movement. Resident #26 said if there were side rails on the bed, she would be able to move side to side and would be more independent. C. Record review Resident #26's therapy notes were provided by the regional director of clinical services (RDCS) on 1/29/25 at 10:41 a.m. The therapy notes revealed the following: On 11/16/24, occupational therapy notes documented the resident would benefit from bilateral bed rails for increased independence with bed mobility and repositioning. On 11/30/24, the short term physical therapy goals documented the resident would be able to roll in bed left to right (and back) with bed mobility rails and minimum assistance for pressure relief. D. Staff interviews Registered nurse (RN) #1 was interviewed on 1/28/25 at 3:55 p.m. RN #1 said Resident #26 needed help to reposition in bed. RN #1 said Resident #26 could likely move herself better in bed if there were side rails on the bed. RN #3 was interviewed on 1/29/25 at 9:29 a.m. RN #3 said it could be helpful for Resident #26 to have side rails for her bed. RN #3 said Resident #26 could use her upper arms and the side rails would allow her to turn easier. Certified nurse aide (CNA) #1 was interviewed on 1/30/25 at 12:18 p.m. CNA #1 said Resident #26 asked at the beginning of December 2024 for bed side rails so she could reposition herself in bed. CNA #1 said she told the nurse on duty of the resident's request. CNA #1 said all staff, including the therapy department, knew Resident #26 wanted side rails for her bed. CNA #1 said Resident #26 would be able to reposition herself much better and would gain more independence if she had the side rails on her bed. The physical therapy assistant (PTA) and the occupational therapist (OT) were interviewed together on 1/30/25 at 12:21 p.m. The OT said Resident #26 had requested side rails for her bed. The OT said after the initial OT evaluation, she documented in the resident's electronic medical record (EMR) and sent a text message to the director of rehabilitation to request side rails for Resident #26's bed on 11/16/24 at 11:25 a.m. The PTA said bed rails would allow Resident #26 to reposition herself in bed and would promote her independence. The PTA said she thought Resident #26 would feel more confident in her abilities with the side rails present. The assistant director of rehabilitation (ADOR) was interviewed on 1/30/25 at 12:36 p.m. The ADOR said he did not know whether the bed rails were requested for resident #26. He said the director of rehabilitation (DOR) would know, but was not available. The ADOR said the process to determine if it was safe for a resident to use bed side rails, and then approve and install the bed side rails should take no more than a few days. The director of nursing (DON) was interviewed on 1/30/25 at 1:45 p.m. The DON said she was not aware Resident #26 had requested, nor that therapy had recommended, the side rails. The DON said she would expect the DOR to enter a communication note and to bring a bed side rail request to a daily morning Skilled Review meeting. The DON said the DOR had not entered this request. The DON said Resident #26 could have benefited from bed side rails, as it could assist her with repositioning and independence. The DON said there was a lack of communication which led to the request not being processed. The DON said a request for bed rails could be approved and installed within a few hours. The DON said she was going to confirm that Resident #26 could safely have side rails, and the side rails would be installed on 1/30/25 (during the survey).

Based on observations, record review and interviews, the facility failed to ensure residents were free from abuse for two (#88 and #54) of four residents reviewed for abuse out of 53 sample residents. Specifically, the facility failed to protect Resident #88 and Resident #54 from physical abuse from Resident #144. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised April 2021, was provided by the regional director of clinical services (RDCS) on 1/28/25. It read in pertinent part, Protect residents from abuse and neglect by anyone including but not necessarily limited to: facility staff and other residents. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, and handling verbally or physically aggressive resident behavior. Implement measures to address factors that may lead to abusive situations, for example, adequately prepare staff for caregiving responsibilities. Identify and investigate all possible incidents of abuse, neglect or mistreatment., Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations. Establish and implement a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or findings of abuse, neglect, or mistreatment. II. Incident of resident to resident physical altercation between Resident #144 and Resident #88 on 1/17/25. A. Facility investigation The facility's investigation revealed a physical altercation between Resident #144 and Resident #88 occurred in Resident #88's room on 1/17/25. Staff heard verbal commotion down the hall. When staff reached Resident #88's room, Resident #144 was standing next to Resident #88's bed. Staff did not witness any physical action, but Resident #88 stated Resident #144 hit him. Immediately, the nurse removed Resident #144 from the room and placed him on one-to-one supervision and behavior monitoring for the next 72 hours. Staff redirected Resident #144 away from Resident #88's room. Resident #144 was assessed and found to have a skin tear on his right ring finger. The local police department, ombudsman, the residents' physicians and both residents' representatives were notified. Resident #88 was interviewed by staff on 1/17/25 at 3:45 p.m. Resident #88 said Resident #144 came into his room and hit him on his left temple, cheek, side of his chin and several places on his left arm. Resident #88 was assessed after the incident and had no bruising, redness or scratches. The resident denied fear or distress. He was placed on one-to-one observation and psychosocial wellbeing monitoring for the next 72 hours. Resident #144 was interviewed by staff on 1/17/25 at 4:00 p.m. and had no recollection of the incident. Resident #144's psychiatrist initiated medication changes, and the facility initiated referrals to other facilities. Resident #144 was sent to the emergency department for evaluation. Five other residents were interviewed and reported no concerns with Resident #144 or being fearful of the resident. The witness statements were as follows: Certified nurse aide (CNA) #7 said he heard yelling down the hall. When he arrived to Resident #88's room he saw Resident #144 standing over Resident #88 and Resident #88 yelled that Resident #144 had hit him. CNA #7 approached Resident #144 and noticed he had a bleeding cut on his hand. CNA #7 asked Resident #144 what happened and the resident said that Resident #88 was also hitting him. CNA #7 tried to escort Resident #144 out of the room but the resident got agitated and aggressive and started pushing CNA #7 and yelling. CNA #7 said he put gloves on and gently escorted Resident #144 to the day room. He notified nursing staff of the incident and the resident's injured hand. Licensed practical nurse (LPN) #2 said she was told by CNA #7 that Resident #144 and Resident #88 were fighting. She said she saw Resident #144 try to hit CNA #7. She said she approached Resident #144 and tried to redirect him to the recliner. She assessed Resident #144 and cleaned his right hand ring finger, which had a small skin tear. She asked Resident #88 what happened and he said that Resident #144 hit him three times on his face. She said that Resident #88 pointed to the left side of his face, told her that Resident #144 hit him up and down his arm, and then pointed to his left arm. Resident #88 denied pain, and said Resident #144 needed to go. LPN #2 noted no evidence of injury to Resident #88. B. Resident #144 (assailant) 1. Resident status Resident #144, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included cerebral infarct (blocked blood flow to the brain/a stroke), Alzheimer's disease with early onset and unspecified dementia with behavioral and psychotic disturbances. The 12/30/24 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems and had severely impaired cognition and decision making, per staff assessment. He walked independently but was dependent on assistance for bathing and required assistance for all other activities of daily living (ADLs). The assessment indicated the resident had wandered one to three days during the seven-day assessment look-back period. 2. Resident interview An attempt was made to interview Resident #144 on 1/28/25 at 10:43 a.m., however, the resident was not interviewable due to his cognitive impairment. 3. Record review Resident #144's psychosocial care plan, revised 12/12/24, identified the resident was at risk for poor impulse control and decreased well-being related to his adjustment to long-term care. The care plan further identified that the resident had aggressive behaviors and then forgot what happened. It identified his wife's visits as triggers for behaviors. Interventions included assessing clinical issues that may have contributed to the resident's mood pattern, maintaining a calm, slow, understandable approach with the resident and redirecting and reorienting the resident to his environment and routine. The psychosocial care plan further revealed Resident #144 had the potential to be physically and verbally aggressive related to dementia. Interventions included redirecting the resident with snacks and a calm environment when he was yelling, cussing, and balling his fist (initiated 11/28/24), attempting de-escalation techniques, such as providing the resident space and a calm environment (initiated 11/30/24) and having the resident evaluated by his psychiatrist (initiated 11/30/24). -Review of Resident #144's behavior care plan failed to reveal new interventions put into place to prevent further resident to resident altercations after the 1/17/25 incident with Resident #88. Review of Resident #144's pharmacy care plan, revised 12/12/24, revealed the resident required antipsychotic medication related to psychosis. Interventions included administering antipsychotic medications as ordered and gradually reducing the doses as indicated/condition improves, administering non-pharmacological approaches prior to medication administration, providing a quiet and dark environment, assessing the presence of pain/discomfort, keeping the resident as comfortable as possible, providing back rubs as needed, offering warm beverages and observing and reporting signs of hallucinations. A review of Resident #144's January 2025 CPO revealed the following physician's orders: Behavior monitoring for antidepressant every shift as evidenced by combative with cares, anxiety, agitation and self-isolation, ordered 10/7/24. Monitor behaviors for antipsychotic use as evidenced by hitting walls and inanimate objects. Document every shift in behavior progress note any behaviors observed and any nonpharmacological interventions utilized, ordered 12/10/24. 72-hour monitoring related to aggressive behaviors with staff and agitation, ordered 1/7/25 through 1/10/25. One-to-one monitoring for 72 hours related to a resident to resident incident, ordered 1/17/25. 72-hour behavior monitoring for increase in agitation and/or aggression, ordered 1/17/25 through 1/20/25. A change in condition report, dated 1/17/25 at 4:22 p.m., revealed Resident #144 had altered mental status and behavioral symptoms, including psychosis or agitation. He was noted to have new/worsening memory loss and increased confusion. Behavior changes included physical and verbal aggression. The report indicated the resident was a danger to himself or others. Review of Resident #144's electronic medical record (EMR) revealed the following progress notes: A behavior monitoring progress note, dated 12/29/24, revealed Resident #144 banged and slammed another resident's door and was yelling and cussing. A behavior monitoring progress note, dated 1/7/25, revealed Resident #144 tried to hit a CNA. Another progress note, dated 1/18/25, revealed Resident #144 continued on one-to-one monitoring. The resident was started on Seroquel 12.5 milligrams (mg) every afternoon for severe, unspecified dementia with psychotic disturbance, ordered 1/17/25. A progress note, dated 1/19/25, revealed Resident #144 still had one-to-one monitoring due to incidents of agitation, restlessness and irritability. The resident had episodes when he could not verbalize his needs or make full complete sentences. The resident denied pain and was assisted by staff when walking in the hallway. The resident could not keep his clothing on for long periods, and could not void independently in the bathroom, he voided on the bedroom floor. Staff continued to offer all non-pharmalogical interventions, monitor him, and assist him with all his needs. A progress note, dated 1/20/25, revealed that Resident #144 was asked immediately after the altercation with another resident on 1/17/25 and found to have no recollection of the incident. Interventions included initiation of referrals to two other facilities. The physician initiated medication changes, one-to-one supervision was provided for 72 hours and the resident was sent to the emergency room for evaluation and treatment. The care plan was updated to reflect interventions. Monitoring was ongoing. -However, there were no updated interventions documented on Resident #144's behavior care plan following the incident with Resident #88 on 1/17/25 (see care plan above). C. Resident #88 (victim) 1. Resident status Resident #88, age 79, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease. The 11/17/24 MDS assessment documented the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He used a wheelchair or walker for mobility. The assessment indicated the resident had no behaviors. 2. Resident interview Resident #88 was interviewed on 1/28/25 at 9:32 a.m. Resident #88 said he had no issues with other residents and had had no fights. He said he did not want to talk and everything was fine. 3. Record review The comprehensive care plan, revised 12/5/24, identified a psychosocial/behavior focus. The resident exhibited or was at risk for behavioral symptoms, such as grabbing others, being combative, verbally or physically abusive and inappropriately disrobing due to Alzheimer's disease. The resident had a history of sexually inappropriate behaviors and yelling at other residents. Interventions included staff were to attempt de-escalation if these behaviors were seen, intervening before agitation escalated, guiding the resident away from the source of distress, engaging the resident calmly in conversation, walking away calmly and reapproaching the resident later if his response was aggressive, separating, redirecting, distracting and other appropriate methods for ensuring safety of both parties, placing the resident on one-to-one observation until the situation was resolved if de-escalation attempts were unsuccessful, observing and documenting changes in behavior, including frequency of occurrence and potential triggers, including a high stimuli environment and offering a low stimuli environment during meals. A physician's progress note, dated 12/5/24, revealed Resident #88's behaviors were discussed during the interdisciplinary team review (IDT) meeting. Resident #88 had significant and frequent inappropriate sexual behaviors towards staff. He had been physically and verbally inappropriate on a daily basis. He had also been verbally abusive toward at least one other resident and a police report was filed as a result of his behaviors. III. Incident of resident to resident physical altercation between Resident #144 and Resident #54 on 1/27/25 A. Facility investigation The facility's investigation, which was in-progress, for the incident between Resident #144 and Resident #54 on 1/27/25, was received from the director of nursing (DON) on 1/30/25 at 1:00 p.m. The investigation revealed the incident occurred in Resident #54's room. Resident #144 was interviewed by staff immediately after the incident and his responses were unintelligible. Resident #54 was interviewed by staff immediately after the incident and she said she was hit in the face (by Resident #144), but had no injuries she was aware of. She said she did not feel safe with Resident #144 there. Resident #54 was observed lying in bed at the time of her interview, with baseline confusion. On 1/27/25, a witness statement was received from CNA #7. CNA #7 said he was helping another resident when he heard yelling coming out of another room. He saw Resident #144 walking in the hallway. He said by the time he got there, Resident #144 was walking into Resident #54's room. He said he ran down the hall and as soon as he got to Resident #54's door, Resident #144 was yelling and hitting the side of Resident #54's bed. CNA #7 said he told Resident #144 to stop. Resident #144 then hit Resident #54 five times in the rib cage area. CNA #7 said he escorted Resident #144 out of the room and brought him to the day room. He said he notified the nurse and nursing supervisor and then checked on Resident #54. Resident #54 was interviewed again by staff on 1/27/25 at 4:00 p.m. Resident #54 said Resident #144 came into her room and punched her in the face on the right cheek area. She then said he hit her once and left the room. Resident #144 was interviewed again by staff on 1/27/25 at 4:10 p.m. Resident #144 had no recollection of the incident. Five additional residents were interviewed. No other residents said they had been treated roughly by Resident #144 nor were they afraid of him. The investigation revealed the local police department was notified to complete the investigation. Staff and resident interviews revealed Resident #144 entered Resident #54's room and a physical altercation resulted. There were no precipitating signs or behaviors that would have predicted this incident. Resident #144 was calm and cooperative and engaging with staff prior to the incident. -However, Resident #144 had been the assailant in another resident to resident physical altercation 10 days prior, on 1/17/25 (see 1/17/25 incident above). While the investigation was being conducted, Resident #144 was placed on one-to-one monitoring. Resident #54 was offered an immediate room change off the unit, however the resident and her representative declined. The caregiver that regularly visited Resident #54 was noted to be scheduled for a visit that night (1/27/25). Staff continuously rounded to ensure safety on the unit. Social services visits with Resident #54 continued. The local police department, Adult Protective Services (APS), the residents' physicians and the residents' representatives were notified. Resident #54 was assessed by LPN #2 after the incident and no skin changes were noted. The resident reported pain to her left arm. Her psychosocial well-being was assessed and noted to be different from her baseline. A follow-up assessment revealed Resident #54 had returned to her baseline and did not remember the details of the event. She continued to have no skin alterations and no pain. The resident was engaged in activities and socializing with staff and residents. Resident #54 was interviewed multiple times regarding the incident and continued to say that Resident #144 hit her, but the location changed with each interview. The resident said she had no injuries. B. Resident #144 (assailant) 1. Record review -Review of Resident #144's behavior care plan failed to reveal new interventions put into place to prevent further resident to resident altercations after the 1/27/25 incident with Resident #54. Review of Resident #144's January 2025 CPO revealed the following physician's order following the resident's incident with Resident #54: One-to-one monitoring for 72 hours related to a resident to resident incident, ordered 1/28/25. 72-hour behavior monitoring for increased agitation and aggression related to the incident, ordered 1/28/25 through 1/31/25. C. Resident #54 (victim) 1. Resident status Resident #54, age 87, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included severe unspecified dementia with psychotic disturbance. The 11/27/24 MDS assessment documented the resident had short term and long term memory problems and had moderately impaired cognition and decision making per staff assessment. She used a walker or wheelchair for mobility. The assessment indicated the resident had intermittent inattention, constant disorganized thinking and altered level of consciousness, but no behaviors. 2. Resident interview Resident #54 was interviewed on 1/29/25 at 3:56 p.m. Resident #54 was not fully interviewable due to cognitive impairment, but she said she thought someone hit her yesterday (1/28/25) on her shoulders. She said she thought it was a man and said it did not hurt. She said she felt safe. 3. Record review Review of the social services care plan, revised 12/12/24, identified Resident #54 was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control and adverse effects on function and wellbeing related to diagnosis of post-traumatic stress disorder (PTSD). She had severe, unspecified dementia, with psychotic disturbance. The resident had cognitive loss related to dementia. Interventions included anticipating her needs and meeting them promptly, explaining all care before providing them to reduce resident tension and promote a comfortable experience, approaching her in a calm, reassuring manner, assessing the resident's coping strategies and respecting the resident's wishes, to the extent possible to address the resident's anxiety disorder (initiated 12/12/24). Review of Resident #54's EMR revealed the following progress notes: A change in condition progress note, dated 1/27/25, revealed Resident #54 had been hit by another resident. The resident's physician recommended to continue monitoring Resident #54 and notifying the physician of any further changes. A psychosocial progress note, dated 1/27/25 (after the incident), revealed Resident #54 appeared calm with no visible signs of distress. The resident reported that she was doing better and wanted to get some rest. A physician's progress note, dated 1/28/25, revealed the physician spoke with Resident #54 the day before (1/27/25) and she was confused (her baseline) about the incident on 1/27/25 and said it did not happen. Her representative requested five days of skin checks every shift. The resident appeared tired and was laying in her bed and said she did not wish to get up at the time of the interview. The physician performed a skin check on her torso. There were no abnormalities found. Review of Resident #54's January 2025 CPO revealed a physician's order for five days of skin monitoring. Monitor for redness or bruising on the right side/rib area and to write a progress note if anything appeared abnormal, ordered 1/27/25. IV. Staff interviews CNA #8 was interviewed on 1/29/25 at 4:05 p.m. CNA #8 said she had worked at the facility since October 2024 and had worked with Resident #144 for a while. CNA #8 said when Resident #144 was first admitted to the facility, he was nice and did not have many behaviors, but he declined quickly. She said she thought the resident now got over-stimulated, and then got angry and lashed out. She said he got over-stimulated from noise, people and his surroundings. CNA #8 said toileting Resident #8 had become challenging. She said he forgot where he was at times and needed to be reassured often. CNA #8 said Resident #144 wandered and went in/out of other residents' rooms so staff had to redirect him. She said he probably needed one-to-one supervision permanently now and thought so far it had made a big difference in terms of the altercations he had. She said she thought Resident #144 had had increased supervision for a few weeks following his altercations. She said she was not working during the altercations, but she heard they were resident to resident contact situations and he was going into other residents' rooms. Said a night shift agency CNA had to chase Resident #144 down the hallway. She said she heard that the resident punched Resident #54 in the ribs. She said she heard there was another incident a few weeks prior where he made contact with another male resident (Resident #88). CNA #9 was interviewed on 1/29/25 at 5:28 p.m. CNA #9 said Resident #144 could not be left alone because his incidents came out of nowhere and could not be anticipated. She said she knew some of his triggers, for example, if he started getting agitated in the shower, she knew to step back and give him a minute. But she said other residents wouldn't necessarily know to do that. The DON was interviewed on 1/30/25 at 11:27 a.m. The DON said she had talked with the psychiatrist regarding Resident #144's decline. She said the psychiatrist said Resident #144's decline was much faster due to his diagnoses of both Alzheimer's disease and Parkinson's disease. The DON said the facility was trying to find a good medication regimen for him. The DON said Resident #144 had problems with impulse control and had poor short-term memory. She said the facility had eliminated some things that triggered the resident's behaviors, such as his wife visiting. She said meeting with his wife virtually had helped some with his behaviors. The DON said she had heard him in the past sitting in his recliner and then he suddenly started to throw dishes. She said she would check on him and ask what was going on and if he was okay. She said Resident #144 never had any recollection of what happened and would say he was fine. The DON said Resident #144 was in the military, so it was possible he had some PTSD which contributed to his outbursts. The DON said Resident #144 had an incident a few weeks ago (1/17/25) with Resident #88. She said there was no contact witnessed between the residents, but Resident #88 said Resident #144 hit him in the face/arm. She said Resident #88 had no evidence of being hit. The DON said Resident #88's memory recall was a little better than Resident #144's and the two residents had never had an issue before. She said the 1/17/25 incident with Resident #88 was Resident #144's first physical altercation incident with another resident. She said Resident #88 was eventually moved to another hallway at his representative's request. The DON said after the 1/17/25 incident with Resident #88, Resident #144 was immediately placed on one-to-one monitoring with documentation being completed every 15 minutes for 72 hours. She said according to the 72-hour documentation, Resident #144 was back to baseline, had no unsafe wandering and no behaviors. She said since a resident to resident physical altercation had only happened once for Resident #144 and the fact that the resident's psychiatrist changed some of his medications soon after, the facility decided to trial the resident off of the one-to-one monitoring. She said the facility had still been tracking his behaviors every shift. She said she thought Resident #144 had started to get more agitated again, but he was doing it all in his room and not coming out of his room. The DON said the facility still had not been able to identify any additional triggers for Resident #144's behaviors. She described his behavior as impulsive and said she had not seen any precipitating behaviors that would have led to the second incident with Resident #54. The DON said after the incident with Resident #54, Resident #144 was probably going to have a full-time one-to-one supervision sitter, unless another medication helped improve the situation. She said the facility had sent referrals for Resident #144 to other facilities due to his behaviors. She said the facility had tried different caregivers for Resident #144 to see if that made any difference for him and it did not.

Based on record review and interviews, the facility failed to ensure four (#2, #9, #10 and #8) of four resident reviewed for abuse out of 10 sample residents were kept free from abuse. Specifically, the facility failed to ensure multiple residents, including Resident #2 and Resident #8, were kept free from physical abuse by addressing Resident #1's physically aggressive behavior. Resident #1 physically assaulted Resident #2 on four occasions and continuously targeted Resident #2. The facility was aware Resident #1 was territorial over his space and did not like to be touched. Facility staff failed to intervene timely on multiple occasions to prevent multiple physical abuse incidents by Resident #1 toward Resident #2. By failing to put effective person-centered interventions into place, Resident #1 physically assaulted multiple residents on both secured units on eight occasions within less than three months, including Resident #2 on four occasions. Findings include: I. Facility policy and procedure The Resident to Resident Altercation policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 12:31 p.m. It revealed, in pertinent part, All altercations, including those that may represent resident to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff. Behaviors that may provoke a reaction by residents or others include: verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; physically aggressive behavior such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing; taking, touching or rummaging through other's property; and wandering into others' rooms/space. If two residents are involved in an altercation, staff: separate the residents, and institute measures to calm the situation; identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; notify each resident's representative and attending physician of the incident; review the events with the nursing supervisor and director of nursing services, and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents; consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; make any necessary changes in the care plan approaches to any or all of the involved individuals; document in the resident's clinical record all interventions and their effectiveness; consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. II. Failure to address Resident #1's physically aggressive behavior A. Resident #1 1. Resident status Resident #1, age 73, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the September 2024 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance and major depressive disorder. The 6/13/24 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory impairment and had severe impairment in making decisions regarding tasks of daily life. He required supervision with all activities of daily living. It indicated that the resident exhibited verbal behavioral symptoms and rejection of care one to three days out of the assessment period. 2. Record review The September 2024 CPO documented the following prescribed medications: -Risperdal oral tablet (antipsychotic medication) 1 mg (milligram), give one tablet by mouth two times a day for agitation; ordered on 8/7/24; -Sertraline (Zoloft) HCI oral tablet (antidepressant medication) 50 mg, give 50 mg by mouth every day shift for unspecified dementia, unspecified severity with behavioral disturbance, ordered on 8/26/24; -Trazodone HCI oral tablet (antidepressant medication) 50 mg, give 100 mg by mouth at bedtime for dementia with severe behavioral disturbance, ordered on 8/26/24; -Trazodone HCI oral tablet 50 mg, give 25 mg by mouth two times a day for dementia with severe behavioral disturbance, ordered on 8/27/24; -14 day behavior monitoring related to change in environment from moving units every day and night, ordered 8/22/24; and, -Monitor behaviors for antipsychotic use as exhibited by (aeb) physical aggression, agitation every shift and as needed, ordered on 8/6/24. The activities of daily living (ADL) care plan, revised on 2/8/24, documented Resident #1 had a self-care deficit and required assistance with ADLs related to cognitive impairment. It documented Resident #1 ambulated independently but required supervision for safety on the secured unit due to the resident's elopement risk. The cognition care plan, revised on 6/20/24, documented Resident #1 exhibited cognitive loss related to a diagnosis of dementia with behavioral disturbance. The interventions included encouraging routine daily decision making; explaining all care before providing to reduce resident tension and promote a comfortable experience; inviting, encouraging, reminding and escorting the resident to activity programs; monitoring changes in cognition and notifying the physician. The behavioral care plan, revised on 5/30/24, documented Resident #1 exhibited physically aggressive behaviors and had a history of a physical altercation with another resident. The interventions included diverting Resident #1 by giving him alternative objects or activities (5/30/24); if the resident becomes physically aggressive, staff to attempt to de-escalate the situation through use of separation, redirection, distraction and other appropriate methods to ensure safety of both parties. If de-escalation attempts are unsuccessful, the resident will be placed on one to one observation until the situation has resolved (5/30/24); listening to the resident and try to calm him (5/30/24); observing for non-verbal signs of physical aggression e.g., rigid body position, clenched fist, etc. (5/30/24); removing the resident from the environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice (5/30/24); if the resident becomes agitated, activities to take the resident off the 700 hall to a less stimulating environment in the facility until he is able to calm down (7/19/24); referring the resident to a long-term care dementia unit that suites the residents' needs (8/5/24); redirecting the resident with snacks and activities to de-escalate and distract the resident (8/6/24); medication review and adjustment (8/7/24); ensuring a functioning door knob on the resident's room door to ensure personal space was reserved for the resident per personal preference (8/7/24); and moving Resident #1 to the 900 hall (8/20/24). The 7/7/24 physician progress note documented that Resident #1 was discussed during the interdisciplinary team (IDT) meeting on 6/20/24. The physician documented that the resident had been admitted to the facility for four months and he became aware of his significant behavioral issues on 6/20/24. The physician documented, When seen, he presents as a large man weighing 240 lbs (pounds). He stated that he does not belong here and that he would like to leave this facility. He has significant impairments of cognition, insight and judgment. Given the repeated incidents of aggressive behavior which occurred over a timeframe of four and half months, one can conclude that he is not merely adjusting. He was given a significant amount of time to adjust to his new environment but his behaviors do not appear to be lessening without a trial of psychotic medication. Given his repeated episodes of physical aggression, this writer chose to prescribe Risperidone. Risperidone was ordered at 0.25 mg in the morning and 0.5 mg in the evening. This writer had been informed by nursing staff that the treatment with Risperidone appeared to be effective. There were still occasions where he became agitated, but he was more easily redirected and he does not appear to have become physically aggressive. III. Incidents of physical abuse A. Incident of verbal abuse toward Resident #9 on 7/8/24 The 7/8/24 nursing progress note documented, at lunch at approximately 12:20 p.m. in the dining room, Resident #1 was sitting at a table and Resident #9 was sitting at another table. Resident #1, yelled at Resident #9, You are a [expletive] [expletive] that needs to leave. He gets on my nerves making that sound with his [expletive] tongue hanging out. The progress note documented Resident #1 was told by the nursing staff that while he was in the dining room, he needed to be respectful, however Resident #1 continued making statements towards the other resident. The nurse documented she moved Resident #9 closer to her and engaged him in watching the television so he would not hear Resident #1's comments. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the verbal abuse incident by Resident #1 toward Resident #9 on 7/8/24. There was no further documentation of the incident. -The facility failed to provide documentation that person centered interventions had been implemented to prevent further incidents of abuse. B. Incident of physical abuse toward Resident #2 on 7/8/24 The 7/8/24 IDT progress note documented the nurse watched as the aggressor (Resident #1) was talking to another nurse on the unit. Resident #2 tapped Resident #1 on the shoulder, as sometimes she did to other residents on the unit. Resident #1 turned around and shoved Resident #2 into the wall with his left arm on her chest before the nurse could stop him. Resident #2 hit the wall with the back of her head. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the physical abuse incident by Resident #1 toward Resident #2 on 7/8/24. There was no further documentation of the incident. -The facility failed to provide documentation that person-centered interventions were put into place to prevent further incidents of abuse. C. Incident of physical abuse toward Resident #2 on 7/13/24 The 7/13/24 e-interact change of condition assessment documented when Resident #1 was asked why he punched Resident #2, he said Resident #2 does not belong here. The nurse encouraged the resident to avoid Resident #2 and removed him from the area. The NHA and director of nursing (DON) were notified. The 7/13/24 e-interact change of condition documented the nurse was talking to Resident #1 when Resident #2 walked up and touched Resident #1 on the back. Resident #1 turned around and punched Resident #2 in the abdomen. Resident #2 cried for a little bit and then was redirected back to her room with no further signs or symptoms of pain or grimacing. The 7/16/24 IDT progress note documented that Resident #1 was talking to the nurse when Resident #2 came behind him and touched his back. Resident #1 moved around and punched Resident #2 on the abdomen. The intervention included for the resident to be seen by the physician and adjust medications as necessary. The 7/14/24 abuse investigation documented Resident #1 was talking with the nurse when Resident #2 came from behind Resident #1 and touched his back. Resident #1 turned around and punched Resident #2 in the abdomen, saying Resident #2 did not belong there. The facility document]ed that based on the internal investigation, it did not seem there was contact made between Resident #1 and Resident #2. -However, according to the nurses' documentation, Resident #1 punched Resident #2 in the abdomen using his left arm, which would indicate physical abuse. Resident #2, who had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15, was able to express pain immediately after being punched, but unable to recall the incident the next day, and, therefore, likely unable to remember that in touching Resident #1 on his back, she would trigger an aggressive response from Resident #1. D. Incident of physical abuse toward Resident #2 on 7/20/24 The 7/21/24 nursing progress note in Resident #2's medical record documented that there were no issued post altercation on 7/20/24 when a male resident (Resident #1) slapped the left side of Resident #2's face before dinner. -There was no further documentation in Resident #2's medical record. The 7/22/24 nursing progress note in Resident #1's medical record documented there were no issues post altercation on 7/20/24 with a female resident. -There was no further documentation in Resident #1's medical record of the incident. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the physical abuse incident by Resident #1 toward Resident #2 on 7/20/24. The 7/24/24 nursing progress note documented Resident #1 attempted to swat at another resident that evening when the other resident was in his space. Resident #1 also began cursing at the other resident. The nurse provided Resident #1 re-direction and he calmed down. The 7/29/24 nursing progress note documented Resident #1 had been exit seeking multiple times throughout the day and exhibiting multiple episodes of aggressive verbal behaviors toward other residents. It indicated Resident #1 made verbal statements such as, Get the [expletive] away. E. Incident of physical abuse toward Resident #2 on 8/3/24 The 8/3/24 nursing progress note documented the nurse saw Resident #1 holding Resident #2's throat with his right hand while pushing Resident #2 against the wall. The nursing staff immediately intervened and separated the residents. Resident #1 was exit seeking, stating, I need to get out of here. Resident #1 said, I told her to get away from me. The IDT progress note documented Resident #1 was found holding Resident #2's throat and pushed her up against the wall. The interventions included reviewing Resident #1 during the psych-pharm meeting to address medication changes and possible transfer to another facility. The 8/4/24 abuse investigation documented the conclusion with the following: Documentation review concluded that there were no prior indicators that any physical aggression would be displayed by either parties. Staff was unharmed and able to redirect residents after the incident with no complications. -However, this incident of physical aggression by Resident #1 toward Resident #2 had not been the first occurrence and Resident #1 was frequently aggressive toward Resident #2. In addition, Resident #1 was witnessed by staff grabbing Resident #2 by the throat and pushing her up against the wall, which indicated physical abuse. F. Incident of physical abuse toward Resident #10 on 8/7/24 The 8/8/24 nursing progress note documented Resident #1 was pulling another male resident (Resident #10) backwards with his hands around the other male residents' waist out of Resident #1's room. The nurse was at the other end of the hallway and told Resident #1 to stop. Resident #1 then threw Resident #10 to the floor, he landed on his left side and slid toward the wall from the force of Resident #1's throw. Resident #1 said, What the [expletive] are you doing in my room. The nurse and the certified nurse aide (CNA) removed Resident #10 away from Resident #1. Resident #1 entered his room and shut the door. Frequent monitoring of Resident #1 was put into place. The 8/7/24 IDT progress note documented the interventions included ensuing functioning of the door knob on Resident #1's room door to ensure personal space is reserved for Resident #1. The 8/7/24 abuse investigation documented Neither resident showed the ability to have willful intent in the situation and neither resident showed any type of distress following the situation. Residents were monitored and never showed signs of baseline behavior or mood changes or injuries from the event. -However, Resident #1, who was consistently physically aggressive when other residents entered his personal space, physically grabbed Resident #10, pushed him out of his room, and then threw him across the hallway, so forcefully, that Resident #10 fell to the ground and slid into the opposite wall. Resident #1 clearly and willfully chose to remove Resident #10 from his room in a physically aggressive manner, which indicated physical abuse. The 8/7/24 nursing progress note documented after dinner, Resident #1 was verbally aggressive and tried to stomp his feet at another resident who was standing in front of him outside of the dining room. G. Incident of physical aggression toward another resident on 8/8/24 The 8/8/24 nursing progress note documented Resident #1 was seen by staff attempting to kick and hit another resident throughout the day. -Resident #1's medical record did not include any further documentation of the incidents. H. Additional incidents of verbal and physical aggression displayed by Resident #1 The 8/16/24 nursing progress note documented Resident #1's power of attorney (POA) was informed of the resident's behavior and a possible room change to another secured unit within the facility, when a room became available. The POA was agreeable, however voiced Resident #1 would not do well with a roommate. The 8/17/24 behavior monitoring documented Resident #1 was aggressive toward some residents until he went to bed. It did not include any other information regarding Resident #1's aggressive behavior. The 8/18/24 behavior monitoring documented Resident #1 became frustrated with another resident yelling and attempted to hit. It did not include any further information. The 8/19/24 nursing progress note documented Resident #1 was more agitated than usual that morning. Resident #1 kept trying to exit the door and asked when he was able to leave. Resident #1 was irritated by other residents and commented a couple of times, What are those [expletive] doing here. The 8/20/24 psychiatrist progress note documented a recommendation to increase the Risperidone to 1.5 mg daily (0.75 mg in the morning and 0.75 mg in the evening) due to Resident #1's increased agitation. The psychiatrist recommended active monitoring of the resident and his surroundings to minimize known stressors such as loud noises, excessive lighting and multiple residents being too close. The 8/20/24 nursing progress note documented at night on 8/19/24, Resident #1 was speaking with a female resident in a wheelchair. Resident #1 became agitated and raised his right hand toward the female resident. The facility staff intervened quickly and removed the female resident prior to being struck. The resident was later moved to the 900 unit. The 8/22/24 nursing progress note documented Resident #1 was restless, was rearranging things in his bedroom, verbally aggressive and agitated. Resident #1 was looking for a knife to cut his oxygen tubing. The oxygen tubing was removed after Resident #1 attempted multiple times to tie the tubing around his neck. I. Incident of physical abuse toward Resident #8 on 9/6/24 The 9/4/24 nursing progress note documented Resident #1 was cursing and pushing on the doors, asking to leave. Resident #1 was swatting at another resident for being loud on the phone. The 9/6/24 abuse investigation documented Resident #1 appeared agitated while he was sitting next to Resident #8, who was talking on the phone. The nurse heard three punching sounds and saw Resident #8 with his left arm raised, trying to block Resident #1. Resident #8, who insisted he stayed on the phone with his spouse, was assisted to his room to talk on the phone. Resident #8 said he did not know why Resident #1 hit him, as he was just speaking to his spouse on the phone. Resident #8 was observed with two skin tears on his left arm (left wrist and left forearm). Resident #1 was discharged to another facility. The conclusion documented the following: The facility does not believe that abuse occurred in this situation. It was reported due to the unknown nature of the skin tears and the fact that the resident was unable to share how it happened. The interviews show no knowledge of how this may have occurred and no allegations towards any person. There has been no baseline behavioral changes and the resident denies being in pain or fear. -However, the nurse distinctly heard three punching sounds, saw Resident #8 with his left arm raised to block Resident #1 and Resident #8 had skin tears to his left wrist and left forearm. Resident #8 was interviewed in the moment, for which he said he did not know why Resident #1 hit him for speaking on the phone with his spouse, which would indicate physical abuse. The 9/9/24 IDT progress note documented staff and the resident were educated on providing a cordless phone to Resident #8 to use in his room during personal communication with his spouse. Resident #8 was hard of hearing and spoke loudly, interrupting others. IV. Staff interviews The clinical consultant (CC) and the DON were interviewed on 9/16/24 at 12:45 p.m. The CC said every resident had the right to be free from abuse. She said Resident #1 had been a difficult resident because he was very physically and verbally aggressive since his admission to the facility. She said Resident #1 no longer resided at the facility. The assistant director of nursing (ADON), the DON and the CC were interviewed on 9/16/24 at 2:14 p.m. The DON said Resident #1 was a difficult resident. She said he was physically and verbally aggressive toward other residents and sometimes staff. She said there were oftentimes Resident #1 was easily re-directed away from an aggressive situation. The DON said Resident #1 did not like anyone in his personal space, did not like it if another resident entered his room and did not like loud noises. She said when triggered, Resident #1 would become physically and verbally aggressive. The CC said the facility had not investigated several incidents of physical abuse documented in the medical record. She said there had been turnover in the NHA and the DON position and felt that led to the lack of investigations and follow through. Cross reference F610: the facility failed to conduct an investigation after incidents of physical aggression by Resident #1. Cross reference F609: the facility failed to report incidents of abuse to the state survey agency (SSA) which involved Resident #1. The DON said Resident #1 had a tendency to go after Resident #2. She said Resident #1 was easily triggered by Resident #2. The DON acknowledged Resident #1 had physically assaulted Resident #2 on multiple occasions. She said they both had resided on the same secured unit. The DON said Resident #1 was not moved off the secured unit (700 unit) to the other secured unit (900 unit) until 8/20/24 because there was not an available bed. She said once a bed became available, the facility moved Resident #1. The DON said the staff on the secured unit (700 unit) were aware Resident #2 triggered Resident #1. She said Resident #1 should have been within line of sight at all times. She said she did not know if that was consistently happening, other than when they scheduled a one to one staff member with Resident #1 immediately following an incident of abuse. She said the one to one staff member would typically last three days. The DON said on 9/4/24, Resident #1 was swatting at Resident #8 because Resident #8 was talking to his spouse on the phone and saying the same thing over and over. She said Resident #1 was irritated and swatted at Resident # 8. She said on 9/4/24, Resident #1 did not make contact. The DON said on 9/6/24, Resident #1 made contact with Resident #8 when he was talking on the phone with his spouse. The CC said the facility missed an opportunity on 9/4/24 to identify that Resident #8 talking on the phone with his spouse was a trigger for Resident #1 and a precursor to the incident of abuse that took place on 9/6/24, two days later. The CC said the facility management had not been reviewing progress notes as part of their daily practice to review and identify circumstances such as the 9/4/24 to the 9/6/24 incident and placed Resident #1 on an immediate one to one to prevent physical abuse. She said she had not realized this until the survey process. The CC said she had assisted the facility, during the survey process, in developing a performance improvement plan which centered around identifying these triggers and circumstances and putting preventative measures in place to prevent physical abuse. The CC said the incidents involving Resident #1 on 7/13/24, 8/3/24, 8/7/24 and 9/6/24 were considered physical abuse. She said she had provided training to the management at the facility during the survey process. The social services director (SSD) was interviewed on 9/16/24 at 2:33 p.m. The SSD said the facility had been trying to move Resident #1 to another facility, however because of his payor status and the resident's family living out of town, it was difficult. She said the facility had identified that Resident #1 had a friend from Alcoholics Anonymous (AA) that would visit. She said after the friend would visit, Resident #1 was easily triggered and would attempt to leave the secured unit. The SSD said she communicated that trigger to Resident #1's family and they had an in-person meeting to speak with the friend where it was determined if the friend came to visit, they needed to sit in a common area. The SSD said Resident #1 was very territorial. She said he did not like to be touched, someone to enter his personal space, nor enter his room. She said it was difficult to manage his triggers at times since he was on a secured unit where residents would wander. The SSD said the ultimate goal of Resident #1's family was to move him out of state to be with them, but that would be in the future. She said Resident #1 was discharged to another facility which was fully secured instead of being on a smaller unit. She said she felt that he would have more space in that environment.

Based on record review, the facility failed to investigate incidents of physical aggression involving one (#1) of four residents reviewied out of 10 sample residents. Specifically, the facility failed to conduct investigations of physical abuse involving Resident #1. Findings include: I. Facility policy and procedure The Resident to Resident Altercations policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 12:31 p.m. It revealed in pertinent part, All altercations, including those that may represent resident to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. II. Incidents of abuse A. Incident of verbal abuse toward Resident #9 on 7/8/24 The 7/8/24 nursing progress note documented, at lunch at approximately 12:20 p.m. in the dining room, Resident #1 was sitting at a table and Resident #9 was sitting at another table. Resident #1, yelled at Resident #9, You are a [expletive] [expletive] that needs to leave. He gets on my nerves making that sound with his [expletive] tongue hanging out. The progress note documented Resident #1 was told by the nursing staff that while he was in the dining room, he needed to be respectful, however Resident #1 continued making statements towards the other resident. The nurse documented she moved Resident #9 closer to her and engaged him in watching the television so he would not hear Resident #1's comments. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the verbal abuse incident by Resident #1 toward Resident #9 on 7/8/24. There was no further documentation of the incident. B. Incident of physical abuse toward Resident #2 on 7/8/24 The 7/8/24 interdisciplinary team (IDT) progress note documented the nurse watched as the aggressor (Resident #1) was talking to another nurse on the unit. Resident #2 tapped Resident #1 on the shoulder, as sometimes she did to other residents on the unit. Resident #1 turned around and shoved Resident #2 into the wall with his left arm on her chest before the nurse could stop him. Resident #2 hit the wall with the back of her head. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the physical abuse incident by Resident #1 toward Resident #2 on 7/8/24. There was no further documentation of the incident. C. Incident of physical abuse toward Resident #2 on 7/20/24 The 7/22/24 nursing progress note in Resident #1's medical record documented there were no issues post altercation on 7/20/24 with a female resident. -There was no further documentation in Resident #1's medical record of the incident. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the physical abuse incident by Resident #1 toward Resident #2 on 7/20/24. D. Incident of physical aggression toward another resident on 8/8/24 The 8/8/24 nursing progress note documented Resident #1 was seen by staff attempting to kick and hit another resident throughout the day. -Resident #1's medical record did not include any further documentation of the incidents. An investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the incident of physical aggression by Resident #1 toward another resident. III. Staff interviews The clinical consultant (CC) and the director of nursing (DON) were interviewed on 9/16/24 at 12:45 p.m. The CC said, during the survey process, the facility had realized they did not have a good amount of abuse investigations, which were requested. She said there had been turnover in the NHA and the DON position recently and they were unable to determine if some incidents of abuse had been investigated. The CC said some of the incidents of abuse that were requested during the survey process were not investigated. The CC said the incidents involving Resident #1 on 7/8/24, 7/20/24 and 8/8/24, 8/7/24 should have been investigated. The CC said she had called the NHA, who was not at the facility, and provided over the phone education on the process of investigating abuse and reporting abuse to the SSA. The CC said all incidents of abuse or allegation of abuse should be investigated. The assistant director of nursing (ADON) was interviewed on 9/16/24 at 2:59 p.m. The ADON said she had reported the incident on 7/20/24 involving Resident #1 and Resident #2 to the DON and the NHA. She said she had documentation on her cell phone that she contacted the former DON on 7/20/24 at 4:35 p.m. and the current NHA at 4:38 p.m.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for three (#1, #9 and #2) of four residents reviewed for abuse out of 10 sample residents. Specifically, the facility failed to report incidents of physical abuse involving Resident #1 to the State Survey Agency (SSA). Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 12:31 p.m. It revealed in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of investigations are documented and reported. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility. II. Record review A. Incident of verbal abuse toward Resident #9 on 7/8/24 The 7/8/24 nursing progress note documented, at lunch at approximately 12:20 p.m. in the dining room, Resident #1 was sitting at a table and Resident #9 was sitting at another table. Resident #1, yelled at Resident #9, You are a [expletive] [expletive] that needs to leave. He gets on my nerves making that sound with his [expletive] tongue hanging out. The progress note documented Resident #1 was told by the nursing staff that while he was in the dining room, he needed to be respectful, however Resident #1 continued making statements towards the other resident. The nurse documented she moved Resident #9 closer to her and engaged him in watching the television so he would not hear Resident #1's comments. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. B. Incident of physical abuse toward Resident #2 on 7/8/24 The 7/8/24 interdisciplinary team (IDT) progress note documented the nurse watched as the aggressor (Resident #1) was talking to another nurse on the unit. Resident #2 tapped Resident #1 on the shoulder, as sometimes she does to other residents on the unit. Resident #1 turned around and shoved Resident #2 into the wall with his left arm on her chest before the nurse could stop him. Resident #2 hit the wall with the back of her head. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. C. Incident of physical abuse toward Resident #2 on 7/20/24 The 7/22/24 nursing progress note in Resident #1's medical record documented there were no issues post altercation on 7/20/24 with a female resident. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. D. Incident of physical aggression toward another resident on 8/8/24 The 8/8/24 nursing progress note documented Resident #1 was seen by staff attempting to kick and hit another resident throughout the day. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. III. Staff interviews The clinical consultant (CC) and the director of nursing (DON) were interviewed on 9/16/24 at 12:45 p.m. The CC said, during the survey process, the facility had realized they did not have a good amount of abuse investigations, which were requested. She said there had been turnover in the NHA and the DON position recently and they were unable to determine if some incidents of abuse had been investigated. The CC said some of the incidents of abuse that were requested during the survey process were not reported to the state survey agency. The CC said the incidents involving Resident #1 on 7/8/24, 7/20/24 and 8/8/24, 8/7/24 should have been reported to the SSA. The CC said she had called the NHA, who was not at the facility, and provided over the phone education on the process of reporting abuse to the SSA. The CC said all incidents of abuse or allegation of abuse should be reported to the SSA.

Based on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per physician orders for four (#2, #10, #12 and #13) of four residents reviewed for respiratory care out of 13 sample residents. Specifically, the facility failed to: -Ensure physician's orders for oxygen were obtained for Resident #2 and Resident #10 prior to administering oxygen; -Ensure oxygen saturation levels (SpO2) were being monitored consistently for Resident #2, Resident #10 and Resident #12; -Ensure Resident #12's physician's order for oxygen accurately identified the correct oxygen flow rate; and, -Ensure staff were providing the correct flow rate of oxygen per the physician's order to Resident #13. I. Facility policy The Oxygen Administration policy, revised October 2010, was received by the director of nursing (DON) on 3/14/24 at 12:30 p.m. It read in pertinent part, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Before administering oxygen, and while the resident is receiving oxygen therapy, assess . vital signs. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: date and time that the procedure was performed . The rate of oxygen flow, route, and rationale. II. Resident #2 A. Resident status Resident #2, age 79, was admitted to the facility on [DATE] and passed away at the facility on 2/12/24. According to the March 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, chronic congestive heart failure, emphysema and end stage renal disease. The 1/16/24 minimum data assessment (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision and assistance with most activities of daily living. B. Record review The 12/19/23 care plan identified Resident #2 was at risk for respiratory complications due to congestive heart failure, emphysema and chronic respiratory failure with hypoxia (low levels of oxygen in the body's tissues). Pertinent interventions included supplying oxygen therapy as ordered and monitoring for signs and symptoms of hypoxia. The 1/18/24 care plan identified Resident #2 had behavior problems. Pertinent interventions included spot checking Resident #2's SpO2 as needed. The March 2024 CPO revealed physician's orders to spot check the SpO2 for Resident #2 as needed. -The physician's order did not specify parameters/indications for when Resident #2's SpO2 should be spot checked. -There was no physician's order for supplemental oxygen for Resident #2. -The January 2024 and February 2024 medication administration records (MAR) for Resident #2 did not reveal any SpO2 documentation. The 12/19/23 physician notes revealed Resident #2 was on chronic supplemental oxygen at 3 liters per minute (LPM). -However, there was no physician's order for supplemental oxygen in Resident #2's electronic medical record (EMR). The 2/6/24 notes from the MDS coordinator revealed Resident #2 was wearing oxygen via nasal cannula and denied having any shortness of breath. -However, there was no physician's order for supplemental oxygen in Resident #2's EMR. C. Staff interview The director of nursing (DON) was interviewed on 3/14/24 at 1:59 p.m. The DON said physician orders to spot check SpO2 as needed should be checked once per shift unless the resident had an acute change of condition or if they showed signs or symptoms of being hypoxic. The DON said the facility did not have a clear process for identifying when as needed SpO2 levels should be obtained. The DON said oxygen required a physician's order to administer. III. Resident #10 A. Resident status Resident #10, age 90, was admitted to the facility on [DATE]. According to the March 2024 CPO, diagnoses included congestive heart failure, hypertension and atherosclerotic heart disease. B. Observations On 3/13/24 at 2:40 p.m., Resident #10 was lying in bed. He was receiving oxygen via an oxygen cannula. The oxygen concentrator was set at 4 LPM of oxygen. On 3/13/24 at 4:28 p.m., with LPN #2 present, the resident continued to receive 4 LPM of oxygen via nasal cannula. C. Record review The 11/19/23 care plan identified Resident #10 had congestive heart failure. Pertinent interventions included checking breath sounds and monitoring for labored breathing and oxygen therapy as ordered or as indicated. The 3/8/24 care plan identified Resident #10 required pulmonary hygiene interventions due to acute complication of the respiratory system. Pertinent interventions included assessing pulse, respirations and oxygen saturation as ordered. -The March 2024 CPO did not reveal any orders for supplemental oxygen or measuring SpO2. The 12/30/23 progress notes revealed Resident #10 was on 2 LPM of supplemental oxygen via nasal cannula. -However, there was no physician's order for supplemental oxygen in Resident #10's EMR. The 1/12/24 progress notes revealed Resident #10 was on 4 LPM of supplemental oxygen via nasal cannula. -However, there was no physician's order for supplemental oxygen in Resident #10's EMR. Physician notes from 3/2/24 revealed Resident #10 received supplemental oxygen via nasal cannula. -However, there was no physician's order for supplemental oxygen in Resident #10's EMR. -The physician's note did not specify the rate of oxygen flow Resident #10 should receive. D. Staff interviews The DON was interviewed at 4:42 p.m. on 3/13/24. The DON said she could not find Resident #10's physician's order for supplemental oxygen. The DON said there were issues with the process for oxygen management. Licensed practical nurse (LPN) #2 was interviewed on 3/13/24 at 4:28 p.m. LPN #2 identified Resident #10's supplemental oxygen flow rate was set at 4 LPM. LPN #2 could not find a physician order for this oxygen, and said she was going to call the doctor to verify Resident #10's orders. LPN #2 said that oxygen was considered a medicine and required a physician's order to administer. IV. Resident #12 A. Resident status Resident #12, age 66, was admitted to the facility on [DATE]. According to the March 2024 CPO, diagnoses included dementia and liver disease. B. Observation On 3/13/24 at 2:45 p.m., Resident #12 was lying in bed. She was receiving oxygen via an oxygen cannula. The oxygen concentrator was set for 3 LPM of oxygen. On 3/13/24 at 4:35 p.m., with LPN #1 present, the resident continued to receive 3 LPM of oxygen. C. Record review The March 2024 CPO revealed the following: -An order for supplemental oxygen at 2 to 4 LPM via nasal cannula to keep SpO2 above 90%, initiated 1/29/24; -An order to do spot checks of SpO2 as needed, initiated 1/29/24; and, -An order for supplemental oxygen at 2 LPM via nasal cannula as needed for shortness of breath related to COVID-19, initiated on 1/28/24. The March 2024 MAR revealed a scheduled treatment for supplemental oxygen at 2 LPM via nasal cannula as needed for shortness of breath related to COVID-19. -The treatment was scheduled as needed, and was not signed off as being administered for any days in March 2024. Resident #12's vital signs were taken on 3/3/24 at 7:37 p.m. Her SpO2 was 94% on 2 LPM of oxygen -The last documentation of the resident's SpO2 levels, prior to 3/3/24, was 2/6/24. D. Staff interview LPN #1 was interviewed at 4:18 p.m. on 3/13/24. LPN #1 identified Resident #12 was receiving supplemental oxygen at 3 LPM. LPN #2 said the order for the 2 LPM oxygen was old, and that the 2 to 4 LPM order was the one that should be followed for Resident #12. LPN #2 said for as needed SpO2 checks, the nursing staff measured vital signs at random times of the day. LPN #2 said she took Resident #12's vitals that morning, but that Resident #12's measurements were not showing up in the vital signs section of the EMR or on her MAR. LPN #1 said oxygen was considered a medication and required a physician's order. V. Resident #13 A. Resident status Resident #13, age 73, was admitted to the facility on [DATE]. According to the March 2024 CPO, diagnoses included anemia, liver cirrhosis and thrombocytopenia. B. Observations On 3/13/24 at 2:40 p.m., Resident #13 was lying in bed. He was receiving oxygen via an oxygen cannula. The oxygen concentrator was set for 4.5 LPM of oxygen. On 3/13/24 at 4:45 p.m., with LPN #2 present, the resident continued to receive 4.5 LPM of oxygen. C. Record review The 2/21/24 care plan, revised 3/8/24, identified Resident #13 was at risk for respiratory complications due to a history of hypoxia and anemia. Pertinent interventions included providing oxygen therapy as ordered and assessing the resident for signs and symptoms of hypoxia. Resident #13's vital signs revealed the resident's SpO2 was measured at least once a day over the previous thirty days. The March 2024 CPO revealed Resident #13 had a physician's order for supplemental oxygen to be administered at 2 LPM. -However, observations revealed the resident was receiving oxygen at 4.5 LPM (see observations above). D. Staff interview LPN #2 was interviewed at 4:28 p.m. on 3/13/24. LPN #2 identified Resident #13 was receiving supplemental oxygen at 4.5 LPM. LPN #2 reviewed Resident #13's orders and confirmed that the physician's order stated the resident was to receive 2 LPM of oxygen. LPN #2 said she knew there were orders to titrate Resident #13's oxygen flow rate but could not find them. LPN #2 said Resident #13's oxygen should be on 2 LPM as ordered but as a nurse she was authorized to turn it up if needed. LPN #2 said oxygen was considered a medicine.

Based on record review and interviews, the facility failed to revise the care plan for one resident (#1) out of three residents reviewed, to reflect, respond, and alert staff to the resident's behaviors that placed Resident #3 and others at risk for harm. Record review revealed on 10/13/23 at approximately 5:30 a.m., a certified nurse aide (CNA) entered Resident #1's room and found Resident #1 sitting in his chair next to the bed of his roommate, Resident #3. Resident #1 was holding a foot pedal to his wheelchair and his roommate had injuries to his face and body. Further record review revealed two days earlier, on 10/11/23, Resident #1 had transferred to the memory unit and into a room with Resident #3 who used a continuous positive airway pressure (CPAP) machine and oxygen at night. An interdisciplinary team note (IDT) dated 10/12/23 read that Resident #1 voiced anger about having noise all night and said he turned off his roommate's oxygen and changed the oxygen output, setting it to the maximum amount; he did not want his roommate's oxygen machine running at night while he slept. Resident #1, who was severely cognitively impaired, was instructed not to touch what was not his, and staff were to closely monitor him. The facility failed to effectively and timely intervene to prevent the incident on 10/13/23. Specifically, other than the progress note on 10/11/23, the facility failed to alert staff of Resident #1's anger and actions on 10/11/23 toward his roommate. Although the resident's behavior care plan recognized that Resident #1 had threatened staff and could be physically aggressive, it had not been updated since 1/20/23. It failed to include information about the incident on 10/11/23, or a directive to staff to be alert to Resident #1's behavioral triggers, as well as instructions to monitor the resident closely. Findings include: A. RECORD REVIEW 1. Resident #1 Resident #1, age 87, was admitted on [DATE]. According to the November 2023 computerized physician orders, diagnoses included Alzheimer's disease with late-onset, chronic pain, and dysphagia. The 9/20/23 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a score of 99 on the brief interview for mental status, which indicated he was not able to recall any of the answers. The MDS coded the resident as independent in mobility and as having no behaviors. Record review revealed Resident #1 was transferred to the memory care unit around 10/11/2023 (the electronic medical record failed to show the exact date of the resident's move) and placed in a room with Resident #3, who had diagnoses that included hemiplegia, hemiparesis following cerebral infarction and vascular dementia. Resident #3 had orders to wear a continuous positive airway pressure (CPAP) machine and oxygen at night. 2. Although the MDS (see above) coded Resident #1 as not having behaviors, a review of the resident's record revealed the facility knew the resident could be aggressive verbally and physically toward others. Specifically: -On 1/20/23, the facility initiated a behavior care plan that identified the resident had impaired/decline in cognitive function or impaired thought process related to dementia with behaviors. It further read the resident had an incident of threatening staff with a cane after he moved rooms and documented he could be physically aggressive with other residents. Pertinent interventions included engaging the resident in simple structured activities of his preference that avoid overly demanding tasks, evaluating behavioral symptoms of underlying causes, and providing a consistent trusted caregiver and structured daily routine. -On 7/24/23, a nursing progress note documented in pertinent part that the CNA entered the room to assist Resident #1's roommate with positioning. When she went to bend down, Resident #1 hit her in the right shoulder with a closed fist. The resident stated he owned the building and he would hit whoever he wanted. -On 7/27/23, a nursing progress note documented in pertinent part that Resident #1's mental health/behavior was reviewed. It read that physical behaviors, directed toward others occur up to 5 days a week. Verbal behaviors, directed toward others, occur up to 5 days a week. 3. Record review revealed no evidence the facility was implementing the interventions outlined in the resident's behavior care plan (see above). When requested on 11/29/23 at approximately 11:00 a.m. from medical records and the nursing home administrator (NHA), the facility was unable to present behavior tracking for Resident #1 in an attempt to understand Resident #1's behavioral triggers to develop person-centered, effective interventions to keep residents safe from Resident #1 aggressive behaviors. Likewise, a record review revealed no evidence the interdisciplinary team was evaluating underlying causes for the resident's behavioral symptoms as care planned to develop person-centered interventions to keep residents safe from harm. 4. Incident 10/11/23 - failure in facility response A progress note dated 10/11/23 documented that Resident #1 stated he did not want his roommate's oxygen machine running at night while he slept. The resident said he turned off his roommate's oxygen and changed the oxygen output setting to the max(imum) amount. The resident voiced anger about having that noise all night. The note read staff would continue to closely monitor him. Record review revealed the facility failed to effectively and timely revise Resident #1's care plan to alert staff of his behavior on 10/11/23. Although the resident's behavior care plan recognized that Resident #1 had threatened staff and could be physically aggressive (see above), it remained without updates after the 10/11/23 incident. Specifically, it failed to include information about the incident on 10/11/23, failed to include a directive to staff to be alert to Resident #1's behavior, and failed to include specific instructions to monitor the resident closely, as documented in the 10/11/23 progress note. 5. Incident on 10/13/23 Two days after the incident on 10/11/23 (see above), a facility investigation read in part that on 10/13/23, in the morning on 10/13/23 at approximately 5:30 a.m. the CNA entered Resident #1 and #3's room and saw Resident #1 sitting in his chair next to Resident #3's bed. The CNA observed Resident #1 holding a foot pedal to his wheelchair and Resident #3 with injuries to his face and body. The facility investigation of the incident included written statements by CNA #1 and registered nurse (RN) 1. CNA #1 wrote in part that when she entered the residents' room, Resident #1 was in a chair at the foot of Resident #3's bed holding a wheel chair pedal. Resident #3 was in bed and was covered in blood and had been beat over the head. RN #1 wrote in part that Resident #1 said he hit (Resident #3) because he was making too much noise. Hospital records revealed Resident #3 was diagnosed with facial trauma, pre-orbital edema right eye, lacerations to the face, bilateral subdural hematoma, subarachnoid hemorrhage (bleeding in the brain in the area that surrounds to brain), and closed facial fracture of the nasal bone. Record review revealed Resident #1 was placed on one-to-one staff supervision starting on 10/13/23 immediately after the altercation occurred through the ressident's discharge on 10/27/23. B. INTERVIEWS 1. The NHA was interviewed on 11/28/23 at 3:39 p.m. The NHA said he was told the CNA went into Resident #3's room and found Resident #1 holding a foot pedal to a wheelchair. As a result, Resident #3 received multiple injuries to the face and was transferred to the hospital. He said after the incident, the investigation showed the psych(iatric) physician reviewed the record and said the 10/13/23 incident could not been predicted and would not recommend any psychiatric medications. The NHA said the resident had been moved to Resident #3's room for only a night or two. He said they did not have any feeling that a resident-to-resident altercation would occur. He said Resident #3 was not interacting with others and was less likely to be disturbed. He said they were attempting to remove Resident #1 from stimulus. At the time, the facility thought it was the best thing for Resident #1. 2. The social service director (SSD) was interviewed on 11/29/23 at 3:05 p.m. The SSD said she had not been at the facility but a few days before the resident-to-resident altercation and she was not familiar with Resident #1's behaviors. 3. The charge nurse (CN) coming on duty on 10/13/23 was interviewed on 11/29/23 at 2:00 p.m. The CN said she received a call at 6:15 a.m. on 10/13/23 from the director of nurses and was asked to come in early as there had been a resident-to-resident altercation. She said when she got to the facility Resident #3 was on the stretcher heading to the hospital and Resident #1 was on one-on-one supervision. She said Resident #1 had moved to the memory care unit a few days before the altercation. She said she was told the resident had some issues with his prior roommate and the oxygen. She said she understood that the room with Resident #3 was the only open room. She confirmed Resident #3 used both a CPAP machine and oxygen. She said the thought was that Resident #1 moving rooms with a change of scenery would make a difference in his behaviors as Resident #3 was quiet and never got out of bed on his own, unlike Resident #1's previous roommate. See Resident #1's behavioral care plan above. There was no reference to limiting Resident #1's stimulation or to issues with roommates and oxygen in Resident #1's care plan.

Based on record review and interviews, the facility failed to ensure the resident's responsible party was notified when a change in medication occurred for one (#2) out of three residents reviewed for notification out of 13 sample residents. Specifically the facility failed to: -Ensure the responsible party was notified when a psychotropic medication was ordered and administered for Resident #2. Findings include: I. Resident #2 A. Resident status Resident #2, age 90, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included failure to thrive, and anxiety. The 11/15/23 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 99 out of 15. The resident was dependent on staff for assistance with all activities of daily living (ADLs) B. Record review The October 2023 CPO showed an order for Abilify (an antipsychotic medication) 2 mg (milligrams) to be given at bedtime for agitation. The start date of the order was 10/23/23. -The electronic medical record (EMR) failed to show the resident's responsible party was notified of the start of the Ability. -The EMR failed to show a psychotropic medication consent form was obtained from the resident's representative. C. Interview The director of nurses (DON) was interviewed on 11/29/23 at 11:00 a.m. The DON said the licensed nurse taking the order was responsible for ensuring the resident's responsible party was notified of the medication change and obtaining the signed consent. The DON reviewed the EMR and could not find documentation indicating the resident's responsible party was notified of the medication order or that a signed consent was obtained. The charge nurse (CN) was interviewed on 11/29/23 at 3:00 p.m. The CN said the nurse obtaining the order was responsible for ensuring the resident's responsible party was notified of the change of medication. She said a signed consent should be obtained from the resident's responsible party. She said if a signed consent could not be obtained the same day, then two licensed nurses were to sign after receiving a verbal consent. D. Follow up The DON provided a psychotropic medication administration disclosure on 11/29/23 at approximately 4:00 p.m. The disclosure was dated 11/29/23 for verbal consent from Resident #2's responsible party for the psychotropic medication.

Based on record review, observation and interviews, the facility failed to ensure five (#116, #31, #111, #87 and #26) of nine out of 70 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to identify and put nutritional interventions in place to prevent severe weight loss for Resident #31, Resident #111, Resident #26 and Resident #116; and a gradual weight loss for Resident #87. Record review, observations and interviews revealed the facility failed to implement nutritional interventions to address significant weight loss which turned into severe weight loss. The facility kitchen staff failed to provide double portions or fortified foods at the registered dietitian's (RD) request to address the nutritional needs of the residents. Cross reference F803: the facility failed to follow the menu and provide the appropriate portion sizes to residents. I. Facility policy and procedure The Medical Nutrition Therapy: Assessment and Care Planning policy and procedure, revised September of 2017, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It read in pertinent part, A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutritional professional is responsible for the completion of a comprehensive nutrition assessment for all residents/patients for the purpose of identifying and planning the nutrition care based on the needs, goals, and preferences of each resident/patient. The resident/patient nutrition status will be assessed upon admission and monitored at least quarterly thereafter. The RDN or other clinically qualified nutrition professional will be responsible for the completion of a comprehensive assessment annually, upon referral, or as indicated by the clinical condition of the resident. The RDN or other clinically qualified nutrition professional may delegate tasks associated with the assessment process, such as data collection, data entry, to the Diet Technician, Registered (DTR) or the Dining Services Director within the scope of their practice and validated competency. The RDN or other clinically qualified nutrition professional will be responsible for ensuring follow up and appropriate documentation of recommended changes in the plan of care. The RDN or other clinically qualified nutrition professional will be responsible for ensuring that all assessments meet current standards of practice. The RDN or other clinically qualified nutrition professional will be responsible for ensuring that the plan of care for each resident is in concert with the residents' expressed wishes for care and services. II. Resident #116 A. Resident status Resident #116, under age 65, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included early onset Alzheimer disease and anxiety disorder. The 7/19/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. She required only supervised assistance with transfers, dressing, toileting, personal hygiene and eating. It indicated she had a weight loss of five percent (%) or more in the last month or loss of 10% in the last six months. B. Observations On 8/16/23 at 1:00 p.m. Resident #116 was observed sitting in the dining area. Her plate consisted of sliced ham, broccoli, mashed potatoes, and ice cream for dessert. She was observed eating mashed potatoes and broccoli. Resident #116 began to stand from the table. An unidentified staff member encouraged Resident #116 to remain seated and assisted the resident with cutting the sliced ham into bite size pieces. Resident #116 began to stand up again and the same unidentified staff member walked towards her and encouraged the resident to sit down and eat her lunch. Resident #116 told the staff member she did not want to be in the dining room anymore and wanted to get her phone. Resident #116 was walked to her room by the staff member. Resident #116 consumed 50% of the mashed potatoes and broccoli and a couple of pieces of ham. She did not eat the ice cream. The unidentified staff member did not bring the resident back to the table to finish her meal or encourage the resident to finish her meal. C. Record review The nutritional care plan, reviewed 6/2/23, documented Resident #116 had a nutritional risk related to progressing Alzheimer's disease. It indicated that the resident's oral intake was inadequate at times due to forgetfulness with a goal that Resident #116 would eat 75% of her meals. The interventions included offering and encouraging fluids of choice and offering snacks of preference (cookies, pudding and yogurt) between meals; providing the house supplement once daily as ordered and monitor acceptance; and encouraging the resident to go to the dining room for meals. -No other significant nutritional interventions were put into place to address the resident's continued gradual weight loss. The 6/7/23 nutritional progress note revealed Resident #116 triggered for a significant weight loss of 13 lbs over three months, weight was at 136 lbs. Her weight range was between 135-145 lbs. She received a regular diet with no dietary restrictions which included cottage cheese once a day. It had been documented that Resident #116 consumed 50-100 % of meals, with dinner being the exception at less than 50% consumed. Resident #116's diagnosis of Alzheimers and increased sadness related to family dynamics was noted to be a contributing factor altering nutritional intake. The registered dietitian (RD) recommended to increase breakfast portions for Resident #116 and continuing to monitor the resident's food intake. -It did not include any additional nutritional interventions. The 7/5/23 nutrition progress note revealed Resident #116 had a weight of 133 lbs and continued to trigger for significant weight loss now being 17 lbs in six months (the resident lost an additional three lbs in one month). It indicated the resident's weight loss was attributed to a diagnosis of Alzheimer's disease and testing positive for COVID-19. Nursing staff reported Resident #116 was being encouraged to eat related to forgetfulness. The RD document concluded that the resident's weight loss may be unavoidable related to the progression of Alzheimer's disease and to continue with large breakfast portions. -However, no new nutritional recommendations were implemented. The 7/10/23 nutrition progress note revealed Resident #116 had a weight of 130.6 lbs (an additional 2.4 lbs in five days). The RD recommended continuing to monitor the resident's weight, oral nutritional supplement (ONS) (chocolate drink) once daily, large breakfast portions and cottage cheese as a snack. The August 2023 CPO revealed an order for a house supplement one time a day for weight support, with a start date of 7/11/23. The 7/20/23 and 7/23/23 nursing notes revealed during meal times Resident #116 required increased staff attention, cuing and the resident was eating a very little amount. The 8/3/23 nutrition note revealed Resident #116 continued to trigger significant weight loss for three consecutive months. RD noted to have met with Resident #116 who was said to have had an overall functional decline within the past year, needed constant reminders during meal times, and had an average food intake of less than 25%. RD noted Resident #116 would continue with current interventions of large breakfast, cottage cheese provided as snacks, chocolate ONS once daily. The RD documented no new interventions would be implemented related to an overall decline in the resident's function. It indicated the weight loss may be unavoidable with progression of the disease. -However, the RD did not implement additional interventions to determine if the weight loss truly was unavoidable other than a nutritional supplement once per day. On 8/5/23 weight summary for Resident #116 revealed a weight of 115.6 lbs (20.4 lb weight loss in two months). From 8/1/23 to 8/16/23, Resident #116 consumed 100% of the shake on six days, 50% on three days, 25% on one day and 0% or value read not applicable (NA) on 5 days. The meal intake percentages from 7/19/23 to 8/16/23 revealed the following: -Breakfast reflected the following percentages: 0% on one occasion, 25% on eight occasions, 50% on six occasions, 75% on six occasions and 100% on three occasions. -Lunch reflected the following percentages: 25% on one occasion; 50% on 10 occasions, 75% on five occasions and 100% on seven occasions. -Dinner was not reflected in the documentation except 75% on 7/24/23, 50% on 7/25/23 and 24% on 8/14/23. Resident #116's weights were documented in her medical record as follows: On 2/1/23, the resident weighed 150.4 lbs; On 3/1/23, the resident weighed 148.2 lbs; On 4/5/23, the resident weighed 144.2 lbs (6.2 lbs/4.12 % weight loss in two months); On 5/4/23, the resident weighed 140.0 lbs (10.4 lb /6.91 % weight loss in three months); On 6/1/23, the resident weighed 135.6 lbs (14.8 lbs/10.24 % weight loss since in four months); On 7/1/23, the resident weighed 132.8 lbs (17.6 lbs/11.7% weight loss in five months); On 7/9/23, the resident weighed 130.6 lbs (an additional 2.2 lbs /13.16% weight loss); and On 8/1/23, the resident weighed 115.6 lbs (34.8 lbs/23.14% weight loss in six months). This indicated the resident had met the threshold for a severe weight loss. -The facility failed to implement nutritional interventions to address Resident #116's gradual significant weight loss which allowed the weight loss to become severe after a 34.8 lbs/23.14 % weight loss in six months. D. Staff interviews The RD was interviewed on 8/17/23 at approximately 2:00 p.m. She said she was aware of the consistent weight loss for Resident #116. She said Resident #116 received large portions at breakfast, cottage cheese as snack and was provided a daily nutritional shake. She said the most recent weight taken on 8/1/23 115.6 lbs could be inaccurate due to a faulty scale that was used. She said the weight had not been taken again for accuracy. She said she had not requested the weight be done again. She said Resident #116's weight loss was due to a progression with her Alzheimer's diagnosis causing increased forgetfulness. She said Resident #116 had been offered more snacks throughout the day until it was realized she was hoarding them in her room, so they stopped giving her extra snacks. She said when that was realized she did not put any other nutritional interventions into place to address the residents significant gradual weight loss. She said upon calculating the resident's weight loss, she said the resident met the threshold for severe weight loss of 23.14% or 34.8 lbs in six months. She said she did not put any additional nutritional interventions into place to address the resident's severe weight loss. 46022 III. Resident #31 A. Resident status Resident #31, age 76, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included dysphagia (difficulty swallowing), cerebrovascular disease (disease affecting blood flow in the brain), depression and contracture of the left hand. The 6/9/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of two people for bed mobility, transfers, toileting and personal hygiene. She required extensive assistance of one person for dressing and eating. The MDS revealed the resident was 64 inches tall (five foot four inches) and weighed 116 lbs. The resident had lost 5% or more in the last month or 10% or more in the last six months and it was not physician prescribed. The resident was on a mechanically altered diet. B. Record review 1. Nutritional care plan The nutritional care plan, initiated on 5/20/19 and revised on 7/25/23, revealed the resident was at nutritional risk related to potential for weight loss due to needing a texture modified diet, consistently poor oral intake, refuses breakfast and typically refuses snacks. Resident #31 accepted oral nutrition supplements twice a day. Resident #31 was at risk for altered fluid status related to dysphagia with the need for thickened liquids. Resident #31 was dependent for assistance with foods and fluids. Resident #31 had a diagnosis of major depressive disorder and the resident's choice was to spend her days in bed, which had the potential to affect her nutritional status. Resident #31 was appropriate for a liberalized diet as she was at risk for hypoglycemia with variable oral intakes. On 6/9/23 Resident #31 admitted to hospice care. The interventions included: offering nutritional supplements and other fluids with breakfast meal as she often skipped breakfast (6/27/22), discontinue routine facility weights as weight loss was expected with progression of disease (12/20/22), differing weights to hospice (12/20/22), house shake supplement twice a day (3/3/23), providing assistance with food and floods (5/20/19), monitoring intakes at all meals (5/20/19), providing diet and fluid consistency as ordered (5/20/19) and offering snacks (5/20/19). -After Resident #31 sustained a significant weight loss on 6/5/23, no new nutrition interventions were implemented. The activities of daily living (ADL) care plan, initiated on 5/22/19 and revised on 7/7/23, revealed Resident #31 required assistance for ADL care related to impaired mobility due to a stroke with left sided hemiparesis (difficulty moving right side). The interventions included, in pertinent part, encouraging Resident #31 to attend meals in the dining room and providing a pureed diet with nectar thick liquids. 2. Resident #31's weights Resident #31's weights were documented in the medical record as follows: -On 12/5/23, the resident weighed 123.5 lbs. -On 1/10/23, the resident weighed 125.1 lbs. -On 2/6/23, the resident weighed 126 lbs. -On 3/3/23, the resident weighed 124.6 lbs. -On 4/5/23, the resident weighed 127.6 lbs. -On 5/4/23, the resident weighed 128 lbs. -On 6/5/23, the resident weighed 115.9 lbs. -The resident had 9.5% (12 lbs) weight loss, which was considered significant from 5/4/23 to 6/5/23 in one month. -Resident #31 was not weighed by the facility after 6/5/23. 3. Physician orders The August 2023 CPO revealed Resident #31 had the following physician orders related to nutrition: -House supplement, two times a day for weight support and wound healing vanilla or strawberry house shake, ordered on 3/28/23. -Regular diet, dysphagia puree texture, thick liquids-nectar consistency, nectar thick per resident and power of attorney (POA) request. Patient to be seated in chair upright and under direct supervision, one on one feedings for all meals and snacks, ordered 4/14/2020. 4. Nutrition assessments/progress notes The 2/22/23 nutrition progress note documented the RD recommended to discontinue to house supplement that was in place three times a day due to the resident's weight being appropriate for age. The note documented the RD was encouraging food first interventions such as ice cream, finger food cream of wheat at breakfast, chocolate milk twice a day and fortified pudding. The resident's current weight was 126 lbs and her BMI was 21.6, which was appropriate for her age. The progress note documented the resident was not appropriate for the house shake as she was on nectar thick liquids and Magic Cup (ice cream supplement) was not available due to supply chain shortages. The 3/28/23 nutrition progress note documented the RD recommended to increase the resident's house shake supplement to twice a day. The note documented the RD would continue to monitor. The 5/23/23 nutritional assessment documented the resident weighed 128 lbs on 5/4/23 and her usual body weight was 122 lbs to 128 lbs. The resident was on a regular diet, pureed texture with nectar thick liquids. The resident was receiving a house supplement two times a day. The progress note documented the RD met with the CNA on the unit to discuss the resident. The resident had a hospice evaluation order placed on 5/22/23. The CNA reported to the RD that the resident continued with poor oral intakes and refused breakfast. The CNA said the resident accepted all of the oral nutrition supplement that was provided twice a day for weight support. The assessment documented the current interventions were appropriate as the resident's weight was stable. The resident required one-on-one feeding assistance. The resident did not have any chewing or swallowing difficulties. The resident had gained 7.6% in six months. The resident was consuming 0-25% of her meals and 100% of the oral nutrition supplement twice a day. The resident had diabetic ulcers to her lower extremities. The assessment documented the resident was likely meeting her estimated nutrition needs as evidenced by weight stable times one year. The resident had overall poor oral intakes, but accepted the oral nutrition supplement twice a day. The resident was at nutrition risk for weight loss related to variable meal intakes, need for assistance for meals and beverages and the resident was bedridden. The 6/5/23 social services progress note documented a hospice referral was emailed to the hospice liaison. The 6/6/23 weight note documented Resident #31's current body weight was 115.9 lbs, her BMI was 19.9 which was underweight for her age. Resident #31 triggered for a significant weight loss of 9.4% or 12 lbs in one month. The note documented prior to the significant weight loss, Resident #31's weight had been stable between 122 lbs and 129 lbs for one year, except for the documented weight on 11/1/22 of 119 lbs. Resident #31's weight had trended down since admission in February 2013. Resident #31 was on a regular diet, pureed texture, nectar thick liquids and an oral nutrition supplement twice a day for weight support. Resident #31 required assistance for meals and refused breakfast. The note documented according to the nursing staff Resident #31 ate approximately two bites of lunch and dinner and accepted 100% of the oral nutrition supplement. Resident #31's weight loss was likely related to her poor oral intakes, dependence on assistance for meals, major depressive disorder and resident being bedridden leading to muscle wasting and atrophy. Resident #31 refused food first nutrition interventions, but accepted the oral nutrition supplement twice a day. Resident #31 had an order for hospice evaluation on 5/22/23 and the resident was going to be admitted to hospice soon. The progress note documented that due to the resident with no desire or motivation to change diet and nutrition behaviors to help with weight support, the RD had no new nutrition recommendations at that time. The RD would continue to respect the resident's diet and nutrition interventions. The resident's nutrition plan of care was reviewed. -However, according to interviews, the RD said she was unable to increase the resident's oral nutrition supplements because of the budget for supplements she was given (see interview below). -A new nutrition intervention was not implemented after the resident sustained a 9.4% significant weight loss in one month. C. Staff interviews The RD was interviewed on 8/17/23 at 11:45 a.m. The RD said Resident #31 had sustained a significant weight loss on 6/5/23. The RD said she had trialed Resident #31 on food first interventions a couple months prior to that, such as fortified foods. The RD said the kitchen did not make the fortified foods as ordered, so she often did not recommend them. The RD said no new nutrition interventions were implemented after Resident #31 sustained a significant weight loss on 6/5/23. The RD said she was given a tight budget for nutritional supplements and it was not within the budget to increase Resident #31's oral nutrition supplement to three times a day. The DM joined the interviewed at 11:59 p.m. He said several nutritional supplements were disposed of on 8/16/23 due to improper labeling and storage (cross-reference F812). CNA #4 was interviewed on 8/17/23 at 1:03 p.m. CNA #4 said she had known Resident #31 for several years. CNA #4 said Resident #31 preferred not to eat breakfast. CNA #4 said Resident #31 typically consumed approximately 25% of her meal, unless it was an item she really liked such as spaghetti and meatballs. CNA #4 said Resident #31 enjoyed chocolate milk and the oral nutritional shakes that she was given twice a day. CNA #4 said Resident #31 would drink more than two nutritional shakes a day if she was ordered to have more. The RD was interviewed again on 8/17/23 at 1:59 p.m. She said when Resident #31 admitted to hospice in June 2023, she deferred all weights to hospice. The RD said she did not have access to the hospice documentation and was not sure if Resident #31 had lost additional weight. The RD acknowledged it was the facility's responsibility to monitor Resident #31's nutritional status and implement interventions as needed. The NHA was interviewed on 8/17/23 at 2:21 p.m. The NHA said he had not had a discussion with the RD regarding the budget of supplements since he started on 7/20/23. The NHA said he would assess the budget for supplements and discuss with the RD and the DM. The DON was interviewed on 8/17/23 at 6:29 p.m. The DON said it was the facility's responsibility to communicate with the hospice provider to ensure the residents' weights were being monitored. The DON said the RD should collaborate with the hospice team regarding residents' nutritional status, nutrition plan of care and weights. 47960 IV. Resident #26 A. Resident status Resident #26, age 85, was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 CPO diagnoses included type 2 diabetes mellitus (DM) and adult failure to thrive. The 6/6/23 MDS assessment documented the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. It indicated the resident's height was 67 inches and she weighed 215 lbs at the time of the assessment. She did not have a swallowing disorder and required supervision and set up assistance with meals. Resident #26 was not coded for weight loss and was not on a physician-prescribed weight loss regimen. B. Record review Resident #26's record revealed she experienced a severe, unplanned weight loss of 24.6 lbs and 11.51% from 5/31/23 to 8/8/23. The nutritional risk care plan, initiated 6/2/2023, documented that the resident was at nutritional risk related to obesity and a diagnosis of type two DM. The interventions included providing the resident diet education and counseling related to weight and T2DM management; offering and encouraging fluids; obtaining weights and alerting the dietitian and physician to any significant loss or gain; monitoring for changes in the resident's nutritional status (changes in intake, ability to feed self, unplanned weight loss or gain, abnormal labs) and reporting to the RD and the physician. -It did not include any nutritional interventions that addressed the resident's severe weight loss. (see the below weights) The resident's medical record documented the following weights: -On 6/5/23, the resident weighed 215.4 lbs. -On 6/17/23, the resident weighed 206.2 lbs, a 9.2 lbs (4.27%) weight loss since the resident's admission. -On 7/8/23, the resident weighed 200.3 lbs, a 15.1 lbs (7.02%) weight loss in one month, which was considered severe. -On 8/8/23, the resident weighed 190.6 lbs, a 24.6 lbs (11.51%) weight loss in two months, which was considered severe. The 7/10/23 and 7/19/23 nutrition progress notes documented Resident #26 was identified as having a significant weight loss. A reason for the weight loss was not identified but the RD progress note assumed it was from frequent diarrhea and variable intakes. -It did not identify any nutritional interventions to address the resident's severe weight loss. The 8/14/23 nutrition progress notes documented Resident #26 had a significant weight loss. A reason for the weight loss was not identified but the RD progress note assumed it was from variable intakes due to the restrictive diet of gluten-free and dairy-free not being accommodated. It indicated that the RD made the kitchen manager aware of the situation in an attempt to meet the resident's nutritional needs. -It did not identify any nutritional interventions put into place by the RD. -The facility failed to follow the resident's dietary restrictions as well as put nutritional interventions into place to address the residents' continued severe weight loss of 24.6 lbs (11.51%) in two months. C. Staff interviews The RD was interviewed on 8/17/23 at 2:13 p.m. She said she was aware Resident #26 had a significant weight loss. She said she did not realize it had risen to the level of severe. She said she made recommendations to the kitchen manager for gluten-free and dairy-free options such as gluten-free toast, fried eggs and extra protein at each meal but the recommendations were not being followed. She said she had considered fortified foods for the resident, however she said the kitchen did not follow her recommendations for fortified foods. She said she had spoken with the kitchen staff and manager and taught them how to fortify foods, but it was not followed. She said she had not put any nutritional supplements or nutritional interventions into place to address the resident's severe weight loss, even after she was aware the kitchen staff were not following her recommendations. She said she should have found and ordered a nutritional supplement for the resident that meets her dietary needs, but she had not thought to do that to meet the resident's nutritional needs. The kitchen manager was interviewed on 8/17/23 at 4:00 p.m. He said that the kitchen staff often did not follow the RD recommendations because they did not understand the recommendations. He said by not following the RD's recommendations, the facility was not meeting the nutritional needs of the residents. 48114 V. Resident #111 A. Resident status Resident #111, age 75, was admitted on [DATE]. According to the August 2023 CPO, the resident's diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 7/12/23 MDS assessment revealed the resident was severely impaired with a brief interview for mental status score of zero out of 15. He required extensive assistance with dressing, toileting, and personal hygiene. He required supervision oversight, encouragement and cuing with eating. -It did not indicate the resident experienced weight loss. B. Observations On 8/14/23 at 2:18 p.m. Resident #111 ate 100% of his lunch of oven fried chicken, buttered parslied noodles, green beans with a dinner roll and fresh fruit cup. When he finished eating his lunch, he got up and went to another table where a resident left their dessert behind. He took the dessert off the tray and ate it. An unidentified staff member redirected the resident back to his table, asked if he would like more to eat, and then brought the resident two cups of peaches. -The resident did not receive large or double portions for lunch. On 8/15/23 at 3:54 p.m. the resident was given a peanut butter and jelly sandwich, graham crackers, a cookie, and water to drink. On 8/16/23 at 9:35 a.m. an unidentified staff member guided the resident to the dining room to eat breakfast. The resident ate 100% of his oatmeal, stood up and wandered around the dining room. CNA #8 guided him back to his chair where he drank 100% of the chocolate milk. Resident #111 then got up, went up to another resident and took a drink from their cup. CNA #8 redirected the resident to sit back down in his seat. -At 9:57 a.m. an unidentified staff member brought the resident his tray of food which had eggs and waffles. He ate 100% of his breakfast. -He did not receive large or double portions for breakfast. -At 1:27 p.m. the resident was observed in the dining room eating his lunch. The resident was served ham, broccoli, fried potatoes cut up, a dinner roll, and a vanilla ice cream cup. He ate 100% of his lunch. C. Record review The August 2023 CPO read: -Regular diet and regular texture-ordered 1/26/23; and -Weigh every day shift on Sundays. The nutritional care plan, revised on 2/17/23, documented that the resident was at nutritional risk related to potential for altered intakes due to history of weight loss and a diagnosis of dementia. It indicated the resident was very active, had increased energy needs due to increased energy expenditure, a history of wandering throughout the dining room and taking food off other resident's plates at times. The interventions included allowing the resident sufficient time to eat meals at his own pace; providing redirection and encouragement as needed; weighing per facility protocol and alerting the dietitian and physician to any significant loss or gain; monitoring for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and reporting to the physician as indicated; monitoring intake at all meals; offering alternate choices as needed; providing diet as ordered; large portions; offering snacks; and supervising, cuing, and assisting as needed with meals. -However, based on the observations above, the resident did not receive large portions, which was documented as a nutritional intervention. The nutrition progress note dated 4/17/23 read the resident's weight was 155 lbs (pounds) and the resident did not have any significant weight changes in one, three and six months. It indicated the resident's weight was trending down since admission four months prior (six to 12 pounds). -However, the resident's electronic medical record (EMR) did not indicate a weight had been obtained for the resident since 3/18/23, which indicated the resident had a 6.6 lbs (3.94 %) weight loss. The RD indicated no new nutritional recommendations and would continue with large portions and other special requests. The resident's EMR documented the following weights: -On 2/11/23, Resident #111 weighed 167.2 lbs; -On 3/18/23, the resident weighed 160.6 lbs, with a weight loss of 6.6 pounds (3.95%)in one month; -On 5/2/23, the resident weighed 154.8 lbs, with a weight loss of 12.3 lbs (7.42%) in three months; -On 7/10/23, the resident weighed 150.8 pounds, with a weight loss of 16.4 lbs (9.81%) in five months; and -On 8/10/23, the resident weighed 147.0 pounds, with a weight loss of 20.2 lbs (12.08%) in six months. -The facility failed to obtain weights weekly, which was ordered by the physician. The nutrition progress note dated 6/26/23 read a nutritional assessment was completed and indicated the RD had no nutritional concerns for the resident. -However, the resident had lost 12.3 lbs (7.42%) in three months and the facility had failed to obtain the resident's weight for June 2023. (see weights above) The nutrition progress note dated 8/11/23 read that the resident was underweight for his age and triggered for a significant weight loss for six months (12% or 20 pounds). It indicated the resident's weight loss appeared to be related to energy expenditure due to the resident being very active on the unit. The resident had an excellent appetite with documented meal intakes for the previous 30 days at 100% and the resident often picked off other resident's trays. The current nutritional interventions included large portions of e[TRUNCATED]

Based on observations, interviews and record review, the facility failed to ensure six (#5, #9, #10, #7, #6 and #8) of 10 residents reviewed for dignity out of 10 sample residents had the right to a dignified existence. The facility failed to ensure residents experienced a dignified living experience by not promptly answering call lights for Resident #5, Resident #9 and Resident #10. Resident #5 was admitted to the facility on [DATE]. She needed extensive assistance with activities of daily living (ADLs). The resident required assistance with incontinence care and was concerned that staff would not promptly answer her call light. On 10/18/22 at 3:15 a.m. the resident was observed lying in bed with her call light initiated. The resident was interviewed on 10/18/22 at 3:30 p.m. She said she initiated her call light as she had an incontinence episode and needed to be changed. She said it was embarrassing to sit in her own waste. She said she typically waited at least 30 minutes for staff to assist her. Resident #9 was admitted to the facility on [DATE]. She needed extensive assistance with ADLs. The resident required assistance with incontinence care. The resident said it was awful to wait so long for staff to assist her in cleaning herself up. She said she was embarrassed, disgusted and humiliated sitting in her soiled brief for extended periods of time. Resident #10 was admitted to the facility on [DATE]. She needed extensive assistance with ADLs. The resident needed assistance with incontinence care. The resident said she had laid in bed in her soiled undergarments for about an hour before she was provided assistance. Resident #10 said she was embarrassed sitting in her room in her soiled undergarments. Additionally, Residents #5, #6, #7, #8, #9 and #10 had expressed ongoing frustration over the inconsistent meal times in the facility. The facility failed to ensure meals were delivered to residents in a timely manner. Findings include: I. Failure to ensure call lights were answered in a timely manner after residents had experienced incontinence episodes A. Facility policy and procedure The Resident Rights Under Federal Law policy and procedure, revised 3/1/22, was provided by the nursing home administrator (NHA) on 10/20/22 at 2:30 p.m. It revealed in pertinent part, Patients/Residents (hereinafter 'resident' ) have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. Centers will comply with resident rights under Federal law. Purpose: to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. The Call Lights policy and procedure, revised 6/1/21, was provided by the NHA on 10/20/22 at 2:30 p.m. It revealed in pertinent part, All (name of facility) patients will have a call light or alternative communication device with their reach at all times when attended. Staff will respond to call lights and communication devices promptly. The Nursing Services policy and procedure, revised 6/1/21, was provided by the NHA on 10/20/22 at 2:30 p.m. It revealed in pertinent part, Centers will have sufficient nursing staff, including nurse aides, with the appropriate competencies and skills sets to provide nursing and related services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient, as determined by patient assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing care includes, but is not limited to, assessing, evaluating, planning and implementing patient care plans and responding to patient's needs as well as the provision of all prescribed medications and treatments, personal care, hygiene, and nursing interventions in response to physical, emotional, or behavioral needs/problems. B. Resident #5 1. Resident status Resident #5, under the age of 70, was admitted to the facility on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/9/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required extensive assistance of two staff members for bed mobility, toileting and personal hygiene. She had an ostomy for bowel and was always incontinent of bladder. The resident did not have any rejection of care. 2. Record review The gastrointestinal care plan, initiated on 9/12/22, revealed the resident was at risk for gastrointestinal symptoms or complications related to a [CONDITION(S)]. The interventions included, in pertinent part: ostomy care daily and as needed. C. Resident #9 1. Resident status Resident #9, age 92, was admitted to the facility on [DATE]. According to the October 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/3/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance from two staff members for bed mobility, transfers and toileting. She required extensive assistance of one staff member for dressing and personal hygiene. She was occasionally incontinent of bladder and always incontinent of bowel. The resident did not have any rejection of care. 2. Record review The ADL care plan initiated on 8/8/19 and revised on 9/11/2020, revealed the resident required assistance for bathing, personal hygiene, grooming, dressing, eating, bed mobility, transfers and locomotion related to left sided weakness. The interventions included: providing cueing for safety and providing support on the residents weaker side when assisting the resident with ADLs. The bladder and bowel care plan initiated on 1/21/16 and revised on 5/5/21, revealed the resident was incontinent of urine and occasionally incontinent of bowel. The interventions included: encouraging the resident to consume all fluids during meal, monitoring for signs and symptoms of infection, offering assistance with toileting upon arising, before meals, at bedtime and as needed, providing incontinence care as needed, using absorbent products as needed. D. Resident #10 1. Resident status Resident #10, age 73, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the October 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/27/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required limited assistance of one staff member for bed mobility and dressing. The resident required extensive assistance of two staff members for transfers and total dependence of one staff member for toileting. The resident was always incontinent of bladder and bowel. The resident did not have any rejection of care. 2. Record review The ADL care plan, initiated on 9/16/22 and revised on 9/29/22, revealed Resident #10 was at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion and toileting related to amputation of bilateral lower extremities. The interventions included: monitoring conditions that may contribute to ADL decline, monitoring for pain, monitoring for complications of immobility, monitoring for symptoms of shortness of breath, providing cueing for safety and arranging the residents environment to facilitate ADL performance. The bladder and bowel care plan, initiated on 9/29/22, revealed Resident #10 was incontinent of urine. The interventions included: assisting with incontinence care as needed, completing an incontinence assessment, monitoring for signs and symptoms of infection, monitoring her skin for redness, therapy to evaluate as needed and utilizing appropriate continent products. E. Observations and staff interviews During a continuous observation on 10/18/22 beginning at at 3:15 p.m. and ended at 4:10 p.m. the following was observed: -At 3:15 p.m. Resident #5 was lying in bed with her call light initiated. She required assistance with incontinence care (see interview below). -At 3:20 p.m. the admission director (AD) entered Resident #5's room and turned off the resident's call light. The AD did not assist the resident with incontinence care. . Resident #5 was interviewed at 3:30 p.m. She said she had initiated her call light since she had an incontinence episode. She said it was embarrassing to sit in her own waste for long periods of time. She said she typically waited at least 30 minutes for staff to assist her. Resident #9 was interviewed at 3:40 p.m She said she initiated her call light as she had soiled herself and needed assistance. She said it was awful to wait so long for staff to assist her in cleaning herself up. She said she was embarrassed, disgusted and humiliated sitting in her soiled brief for extended periods of time. Resident #10 was interviewed at 3:44 p.m She said she initiated her call light to get assistance in getting cleaned up after an incontinence episode. She said a certified nurse aide (CNA) did answer her call light, but told her there were several other residents that needed to get up. Resident #10 said she had laid in bed in her soiled undergarments for about an hour before she was provided assistance. Resident #10 said she was embarrassed sitting in her room in her soiled undergarments. -At 3:45 p.m. licensed practical nurse (LPN) #7 entered Resident #9's room and turned her call light off. LPN #7 told Resident #9 that she needed to find another staff member to assist the resident. LPN #7 left the resident's room. LPN #7 was interviewed at 3:46 p.m. She said four residents on the 600 unit needed bathroom assistance. She said the CNA was on her lunch break, so she was the only staff member on the unit. LPN #7 said she was trying her best to answer all of the call lights. LPN #7 said one CNA for the hallway was not enough help to ensure all of the residents received timely incontinence care. The AD was interviewed at 3:55 p.m. She said she answered Resident #5's call light. The AD said Resident #5 needed incontinence care. The AD said she was not a CNA and did not help Resident #5. The AD said she turned off the call light and told the resident someone would come to assist her. The AD said since she turned off the call light nursing staff were not aware the resident still needed help. -At 4:01 p.m. Resident #9's call light was answered and she was provided incontinence assistance. Resident #9's call light was initiated prior to the start of the observation, but was initiated for 21 minutes during the observation period. -At 4:08 p.m. CNA #1 assisted Resident #5. CNA #1 said she was working on the 200 unit that was on the other side of the facility. She said she had gone to the kitchen to get a snack for a resident and was stopped to assist in answering call lights on the 600 unit. She said there were no other CNAs assisting the residents on the 200 unit that she was assigned to when she was pulled to answer call lights. CNA #1 said there was not enough staff scheduled to ensure the residents received timely assistance. Observations revealed Resident #5 waited at least 53 minutes. The call light had already been initiated when the observation began. Cross-reference F725 the failure to consistently provide adequate nursing staff. II. Failure to ensure residents experienced a dignified living experience by ensuring meals were served timely A. Facility policy and procedure The Meal Distribution policy and procedure, revised September 2017, was provided by the NHA on 10/20/22 at 2:30 p.m. It revealed in pertinent part, Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal care and present it to the resident/patient or care staff for delivery to the resident/patient. The Department Staffing policy and procedure, revised September 2017, was provided by the NHA on 10/20/22 at 2:30 p.m. It revealed in pertinent part, The Dining Services department will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services in a manner that is safe and effective. Adequate staffing will be provided to prepare and serve palatable, attractive, nutritionally adequate meals, at proper temperatures, at appropriate times and to support proper sanitary techniques being utilized. B. Record review The posted meal service times were as follows: -Breakfast: 7:30 a.m. -Lunch: 11:30 a.m. -Dinner: 4:30 p.m. C. Observations On 10/18/22 at 2:39 p.m. CNAs were observed passing meal trays on the 100 unit. The lunch meal was being delivered to the 100 unit three hours and nine minutes after the posted meal time. On 10/18/22 the meal cart was delivered to the north units (100, 200, 300 and 400) at 5:00 p.m. The lunch meal was delivered two hours and 21 minutes after the posted meal time. The dinner meal was delivered to the north units 30 minutes after the posted meal time, which was approximately three hours after lunch was served. On 10/19/22 the meal cart was delivered to the 200 unit at 8:16 a.m. -At 8:29 a.m. the meal cart was delivered to the 300 unit. -At 8:41 a.m. the meal cart was delivered to the 400 unit. The breakfast meal was delivered 46 minutes after the posted meal time on the 200 unit, 59 minutes on the 300 unit and 71 minutes after the posted meal time on the 400 unit. D. Resident interviews Resident #6 was interviewed on 10/18/22 at 2:25 p.m. She said her meals were delivered at different times each day. She said sometimes her breakfast would come at 6:00 a.m. and other times it would come at 9:00 a.m. She said she had received her lunch at 2:30 p.m., which was normal lately. She said the CNAs were responsible for passing the meal trays. She said the CNAs already had enough to do let alone make them pass meal trays as well. Resident #7 was interviewed on 10/18/22 at 2:30 p.m. She said she had just received her lunch tray. She said her meals were always delivered late and the times were very inconsistent. She said her lunch was often delivered between 2:00 p.m. and 3:00 p.m. Resident #8 was interviewed on 10/18/22 at 2:40 p.m. She said she had recently been admitted to the facility. She said in the few days she had been at the facility the meal times were very inconsistent. She said she had received her lunch at 2:30 p.m., which was too late. She said dinner was often served at 5:00 p.m. She said she was not hungry at 5:00 p.m., since she had just received her lunch a couple hours earlier. Resident #5 was interviewed on 10/18/22 at 3:30 p.m. She said all of the meals were often delivered late. She said the meal times were very inconsistent. Resident #9 was interviewed on 10/18/22 at 3:40 p.m. She said all of the meals were often delivered late. She said the meal delivery times were very inconsistent. Resident #10 was interviewed on 10/18/22 at 3:45 p.m. She said all of the meals were often delivered late. She said the meal delivery times were very inconsistent. E. Staff interviews CNA #8 and CNA #9 were interviewed on 10/18/22 at 2:39 p.m. They said the meals were delivered to the units at different times each day. CNA #8 and CNA #9 said breakfast came between 7:30 a.m. to 10:30 a.m. They said lunch often came after 1:30 p.m. and dinner was often delivered between 5:00 p.m. and 7:00 p.m. CNA #8 and CNA #9 said they were often told that the dining department was short staffed. They said the CNAs were responsible for serving drinks and meals to the residents. They said they were also responsible for obtaining the residents' meal orders. Licensed practical nurse (LPN) #5 was interviewed on 10/19/22 at 8:15 a.m. She said she was an agency nurse and had worked in the facility for about eight weeks. She said the meals were never served at the same time. LPN #5 said breakfast was delivered to the units between 8:00 a.m. and 11:00 a.m. and lunch was served between 11:30 a.m. and 3:00 p.m. She said the CNAs were responsible for delivering the meals. She said since the meal times were variable it made it difficult for the CNAs to finish their daily tasks. Cook #1 and dietary aide (DA) #1 were interviewed on 10/19/22 at 8:32 a.m. They said they were responsible for plating the food and putting the trays into the hot boxes. They then delivered the hot boxes to the units. DA #1 said it was not their responsibility to serve the residents their meals. CNA #2 was interviewed on 10/19/22 at 8:43 a.m. She said the CNAs were responsible for serving the meals to the residents. She said they were also responsible for brewing coffee for the residents, which required her to leave the unit she was assigned to. CNA #12 was interviewed on 10/19/22 at 8:46 a.m. She said the CNAs were responsible for serving the meals to the residents. Registered nurse (RN) #1 was interviewed on 10/19/22 at 8:50 a.m. He said the CNAs were responsible for serving the meals to the residents. He said he attempted to assist the CNAs with this task when he had time. CNA #1 was interviewed on 10/19/22 at 8:53 a.m. She said the CNAs were responsible for serving the meals to the residents. The dietary account manager (DAM) was interviewed on 10/19/22 at 10:30 a.m. He said breakfast was at 7:30 a.m., lunch was at 11:30 a.m. and dinner was at 4:30 p.m. He said these times were when the kitchen began plating food for the residents. He said some meals took longer to plate than others, which caused variable meal times. The DAM said he was aware the meals were often delivered late. He said the lunch was delivered late on 10/19/22 as the kitchen did not have enough staff. The director of nursing (DON) and the administrator in training (AIT) were interviewed on 10/19/22 at 11:57 a.m. The AIT said he was aware the meal delivery times were not good. He said the kitchen staff were contracted. He said he had been in contact with the contracted agency to improve several issues that had been brought to his attention. The AIT said the meals should be delivered to the residents at the posted meal times. Cross-reference F802 the failure to ensure a sufficient number of food and nutrition staff were available.

Based on record review, observations and interviews, the facility failed to ensure four (#123, #50, #339 and #13) out of six residents reviewed out of 62 sampled residents were as free from accident hazards as possible and received adequate supervision and assistive devices to prevent accidents. Specifically, the facility to ensure: -Resident #123 received the care and services necessary to prevent a fall. The resident, identified as at risk for falls, had a diagnosis of weakness and reported weakness on 3/11/21. Three days later, she sustained an unwitnessed fall with serious injury (hematoma and bleed). The facility lacked evidence it had recognized and addressed her fall risks, including weakness, in an effort to keep her safe. (Cross-reference F684). -Resident #50, care planned to have an assistive device with staff assistance when ambulating to prevent falls, received such assistance while while ambulating with staff. She fell and sustained a leg fracture. -Resident #339's physician orders, documented on the treatment record, were implemented and communicated to staff. Resident #339 had a history of 11 falls in the facility. -Resident #13's security bracelet was checked for functionality. Findings include: I. Facility policy The fall management policy, dated 9/15/01 and revised on 2/18/20, was provided by the director of nursing (DON) on 3/18/21 at 4:45 p.m. It read in pertinent part: Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. The practice standards section of the policy revealed in pertinent part: Communicate patient's fall risk status to caregivers. Develop an individualized plan of care. Update care plan to reflect new interventions. II. Failure to ensure Residents #123, #339, #13, and #50 were as free from accident hazards as possible and received adequate supervision and assistive devices to prevent accidents. A. Resident #123 1. Resident status Resident #123, age 65, was admitted on [DATE]. According to the March 2021 computerized physician orders (CPO), the diagnoses included weakness, repeated falls, depression, anxiety, [CONDITION(S)], muscle weakness, [CONDITION(S)] (blood clot), pulmonary embolism (blood clot in the lungs), esophagitis with stenosis (swelling and narrowing of the esophagus). The 2/23/21 minimum data set (MDS) assessment revealed the resident was moderately cognitively intact with a brief interview for mental status score of 11 out of 15. She required two-person physical extensive assistance with mobility, transfers, toilet use and one-person limited assistance with dressing and personal hygiene. She had fallen four days after she was admitted . She was taking an anticoagulant (blood thinning) medication. She did not use supplemental oxygen and required a wheelchair for mobility. A 3/12/21 care plan revealed the resident was at an increased risk for falls because of impaired mobility and a history of falls. The interventions were to provide verbal cues for safety and remind and place call light in reach to use for assistance to transfer or use the toilet. 2. Observations and resident interview On 3/11/21 at 9:30 a.m., Resident #123 laid on her bed with her head up about 45 degrees. Both of her legs were outstretched in front of her. She said she required more assistance with transfers and meals set up to eat than she received. She stated, I need help with a lot of things, like getting into my wheelchair, going to the bathroom. She said she required assistance with transferring to her wheelchair and toileting. She used a wheelchair to move about in her room and in the facility. As she pointed to her bowl of oatmeal with the lid on it beside her on the bedside table, she said, I have been waiting to get help taking this lid off. I am so weak right lately and I need to eat. She said the doctor had told her she was malnourished and needed to eat better. 3. Fall with significant injury 3/14/21 Record review: A nursing progress note dated 3/14/21 at 1:40 p.m. read a certified nurse aide (CNA) alerted registered nurse (RN) #1 that Resident #123 was found on the floor. A 3/15/21 facility to hospital transfer form, dated at 6:00 p.m., revealed the resident was transported to the hospital per a physician order for further evaluation due to an altered mental status with drowsiness, confusion and unclear speech. The transfer form read the resident's vital signs were different from her usual numbers with increased heart rate, lower blood pressure and lower oxygen saturation with oxygen delivery with a nasal cannula. The 3/15/21 hospital records, provided by the DON on 3/22/21 at 4:00 p.m., revealed Resident #123 arrived at the hospital non-responsive except to touch with eye movement and incoherent words. The 3/16/21 computed tomography scan (CT scan) revealed she had a hematoma (pocket of blood inside the body) with a slow bleed. The injury was inoperable because of her frail state and she was transferred to an inpatient hospice unit. The resident passed away on 3/17/21. The facility's fall investigation, received at survey exit on 3/23/21, identified the root cause of the fall was lethargy and oxygen saturation levels were low. Interviews: CNA #5 was interviewed on 3/22/21 at 11:50 p.m. She stated on 3/14/21 when she found the resident on the floor, she believed the resident had been sitting in her wheelchair and fell off and down to the floor on her buttocks. CNA #5 said she and RN #1 used a mechanical lift and assisted the resident into bed. She said the resident was tired the rest of the day. RN #1 was interviewed on 3/23/21 at 3:00 p.m. She said she covered the primary nurse's residents. She said following the resident's fall on 3/14/21, she assisted the resident to bed, performed her assessment and initiated the unwitnessed fall protocol with neurological checks and continued monitoring per the facility standard. She said the resident did not have any injuries at the time of the first assessment. She reported the incident to the primary nurse, licensed practical nurse (LPN) #4, when she returned to duty and she (RN #1) was relieved of monitoring and did not need to monitor the resident after that point. She further said she was not requested to reassess the resident. Resident #123's daughter was interviewed on 3/23/21 at 9:30 a.m. She said Resident #123's spouse was notified of the resident's fall on 3/14/21 and he reported that when he spoke with the resident, she was speaking incoherently. The next day, on 3/15/21, they were notified at 6:00 p.m. that the resident had gone to the hospital and they met her at the emergency room . She said Resident #123 was unresponsive when her family saw her at about 9:30 p.m. The doctors had discussed the treatment for the hematoma with a small bleed that would need surgery. She said the doctors at the hospital told her and her father, the resident now was in a more fragile state because she suffered a large blood loss, and hospice would be most appropriate for her. She said the resident was admitted to a hospice inpatient unit and passed away on 3/17/21 from the injuries of her fall. (Cross-reference F684) 4. Facility failure The facility lacked evidence it had recognized and addressed her fall risks, including weakness, in an effort to keep her safe. See care plan above; contrary to facility policy - to individualize a resident's plan of care and to communicate the resident's fall risk status to caregivers - the level of the resident's fall risk, the factors that created her risk, and directives to staff to minimize them, were not identified. Specifically, there was no reference to the weakness the resident expressed (see above) and no individualized interventions to reduce her risk and to minimize injury given her history (muscle weakness, repeat falls, [CONDITION(S)]), her expressed weakness, and her risk of injury with a fall due to receiving anticoagulant medication. B. Resident #50 1. Resident status Resident #50, age 73, was admitted on [DATE]. According to the March 2021 CPO, the resident's diagnoses included: Alzheimer's disease, history of falling, dizziness, muscle weakness, depression and hypertension. The 1/2/21 MDS assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score of 2 out of 15. She required extensive one person assistance with bed mobility, transfers, walking in her room, dressing, eating personal hygiene and toilet use. She was frequently incontinent of the bladder and always incontinent of bowel. She had a recent history of falls with injury. The resident's care plan, last revised on 10/25/2020, read she was at risk for falls because of her cognitive loss and mobility and lack of safety awareness. Interventions in place were to provide the resident with extensive assistance as well as an assistive walking device. 2. Observations On 3/18/21 at 12:30 p.m. the resident was walking and holding onto a staff member's arm. She did not have an assistive device for walking. 3. Record review - fall and facility failure The 3/21/21 progress note stated the resident was walking with CNA guidance, and tripped (on something) with her right foot and fell on her left side. She complained of pain and was not able to get off the floor due to pain. A fall investigation, received at survey exit on 3/23/21, read the CNA could not prevent the resident from falling. Neither the progress note nor the facility fall investigation indicated the resident was using an assistive device in addition to staff assistance at the time of fall. 4. Interviews Licensed practical nurse (LPN) #8 was interviewed on 3/23/21 at 12:00 p.m. She stated Resident #50 was walking with a nurse aide and fell . She went to the hospital over the weekend with a lot of pain in her leg. The DON was interviewed on 3/23/21 at 11:15 a.m. She said that Resident #50 was admitted to the hospital after a fall on 3/21/21. She had a fracture to her left upper leg due to the fall and needed surgery to repair the fracture. C. Resident #339 1. Resident status Resident #339, age 68, was admitted on [DATE]. According to the 2/18/21 computerized physician orders (CPOs), diagnoses included Alzheimer's disease, dementia, a history of falling, anxiety disorder, dysphagia (difficulty swallowing), type 2 diabetes mellitus, muscle weakness, and pelvis stress fracture. The 1/25/21 MDS assessment revealed the resident had cognitive impairments and had severely impaired decision making skills, based on the staff assessment for mental status. The resident required extensive assistance with transfers, bed mobility, dressing, eating, toilet use and personal hygiene. The resident required total dependence for showering. The resident was frequently incontinent of bladder and always incontinent of bowel. 2. Record review The CPO dated 12/22/19 and revised on 2/18/21 revealed, the resident was to have a fall mat at the bedside when the resident was in bed. The care plan dated 3/17/21 was reviewed and revealed the resident had 11 recorded falls on: 12/5/19, 12/22/19, 3/13/2020, 4/20/2020, 5/20/2020, 7/11/2020, 9/24/2020, 11/7/2020, 11/25/2020, 12/29/2020, and 2/9/21. The treatment administration record (TAR) dated 3/21 was reviewed and revealed the resident was to have a fall mat at the bedside when the resident was in bed every day and night shift when the resident was in bed. The record documented the resident had a fall mat both day and night at the resident's bedside on 3/10 and 3/11/21 and on 3/16/21, although observations (see below) revealed otherwise on these dates. 3. Observations Resident #339 was observed in her bed sleeping on the days and times below. The bed was 22 inches above the floor. The bed was up against the wall on the left side. The right side of her bed was unobstructed and there was no fall mat on the floor next to the bed. -3/10/21 at 11:15 a.m. -3/11/21 at 8:53 a.m. and 3:00 p.m. -3/16/21 at 1145 a.m. -3/17/21 at 8:45 a.m., 9:21 a.m., 10:18 a.m., 10:56 a.m., 11:33 a.m., and 1:14 p.m. -3/18/21 at 12:20 a.m. and 12:20 p.m. 4. Staff interviews CNA #3 was interviewed on 3/18/21 at 12:28 p.m. in Resident #339's room. CNA #3 looked for a fall mat on the side of the resident's bed, under the bed and in the resident's bathroom. She said Resident #339 did not have a fall mat in her room or it would be seen in one of these places. She said she did not recall the resident ever having a fall mat in her room. Licensed practical nurse (LPN) #3 was interviewed on 3/18/21 at 1:58 p.m. in Resident #339's room. LPN #3 said she did not know the resident had a physician's order to have a fall mat by her bed when the resident was in bed. She said she was never instructed that the resident had a fall mat. LPN #3 looked for a fall mat in the resident's bathroom, next to the resident's bed and under the bed. After looking for a fall mat, she said she could not find a fall mat. She said the resident had lived in a different room in the facility and maybe when they changed rooms the fall mat did not move with the resident to the new room. LPN #3 said she would get a fall mat and put it in the resident's room today. D. Resident #13 Policy and procedure The Patient Security Bracelet policy was received from the director of nursing (DON) on 3/18/21 at 4:45 p.m. The policy documented in pertinent part, Resident/patient security bracelets (e.g. Wanderguard) will be inspected per manufacturers recommendations but at a minimum of every shift for placement and daily for function. 1. Resident status Resident #13, age 59, was admitted on [DATE] and readmitted on [DATE]. According to the March 2021, CPO, pertinent diagnoses included vascular dementia with behavioral disturbance, restlessness, agitation, traumatic brain injury and transient ischemic attacks (TIA) with cerebral infarction (stroke). The 3/1/21 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 8 out of 15. He required supervision of one person with bed mobility, transfers, and toileting. He required limited one-person assistance with dressing and personal hygiene. He ambulated with supervision and a cane or walker. Resident #13 wandered daily and wore an elopement alarm (Wanderguard) bracelet daily. 2. Record review The March 2021 physician's orders were reviewed.The orders dated 9/23/2020 documented OK to place Wanderguard on resident. The March 2021 TAR documented to check the Wanderguard to the left wrist for placement twice daily. However, the TAR did not indicate the Wanderguard was ever checked to ensure it was functioning. It did not indicate when the Wanderguard bracelet was to be changed. The care plan initiated 2/17/2019 documented the resident was at risk for elopement, and had eloped on 1/3/20 and 3/24/20, and attempted to elope on 11/19/20. On 1/4/20 Wanderguard was added to the care plan. There were no instructions for checking the Wanderguard's placement, when to replace it, or checking the function. An elopement assessment completed 2/27/21 documented Resident #13 was at risk for elopement. The assessment documented he had dementia with a history of actual elopement. It documented his wandering placed him at significant risk of getting into a potentially dangerous place. The assessment documented his wandering intruded on the privacy of others and he was hyperactive with frustration, restlessness or agitation, and had impulsiveness. 3. Interviews LPN #5 was interviewed on 3/18/21 at 11:19 a.m., she said we just visualize the Wanderguard is on. We do not check it for anything else. The assistant director of nursing (ADON) was interviewed on 3/18/21 at 11:22 a.m. He said the Wanderguard is checked for placement. He did not know if it was checked for function. He said he did not know how that would be done. He said he did not know if the Wanderguards expire and are run on a battery. The ADON did not know when the Wanderguard had been changed last. He said he would look into it. The ADON was interviewed again on 3/18/21 at 3:00 p.m. He said the facility had only been checking placement of the Wanderguard, not function. He said he had begun training licensed nurses today on how to check function with a device supplied by the manufacturer. He said once activated, the Wanderguard was good for 90 days. The DON was interviewed on 3/22/21 at 12:28 p.m. She said the facility had begun checking the function of the Wanderguards on 3/18/21 (during survey). The DON said there was the potential for elopement if the device was not checked for function and was not working. 4. Facility follow up On 3/18/21, the March 2021 physician orders were updated to include, check Wanderguard for placement and function every shift for elopement. Wanderguard due to poor safety awareness and expires on 6/18/21. Wanderguard needs to be replaced.

Based on observation, interviews and record review, the facility failed to ensure an adequate pain management program was in place for one resident (#386) of 62 sample residents. Specifically, the facility failed to ensure: -Resident #386 had pain scale parameters in place to determine proper pain medication dosages; -Resident #386 received a thorough pain evaluation upon admission to the facility; and -Resident #386's pain management program was adjusted and new interventions were attempted when her pain levels continued to increase. These facility failures contributed to the resident experiencing chronic unmanaged pain that was not effectively treated with the pain management program provided by the facility. Findings include: I. Facility policy and procedure The facility pain management policy, last revised 11/1/19, was provided by the director of nursing (DON) on 3/18/21 at 4:45 p.m. It read in pertinent part: Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/readmission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. Pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient's goals and preferences is provided to patients who require such services. An individualized, interdisciplinary care plan will be developed and include: -Addressing/treating underlying causes of pain to the extent possible; -Non-pharmacological and pharmacological approaches; -Using specific strategies for preventing or minimizing different levels or sources of pain or pain related symptoms. Patients receiving interventions for pain will be monitored for the effectiveness and side effects (e.g., constipation, sedation) in providing pain relief. Document: -Non-pharmacological interventions and effectiveness; -Effectiveness of PRN [pro re nata, as the need arises] medications. -Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/APP [advanced practice provider] notification; -Side effects, if present, and notification of physician/APP. II. Resident #386 A. Resident status Resident #386, under the age of 50, was admitted to the facility on [DATE]. She was admitted with hospice care. According to the March 2021 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/17/21 minimum data assessment (MDS) assessment had not completed the brief interview for mental status (BIMS) at the time of survey. Based on resident interviews, observations (3/10 - 3/23/21) and diagnoses, Resident #386 had no cognitive deficits. She required supervision and setup help only for bed mobility, transfers, walking in her room, eating, and dressing. She required supervision and one person assistance with toileting and personal hygiene. B. Resident observations and interviews On 3/11/21 at 9:34 a.m., Resident #386 was in her room sitting on her bed. She said she was in too much pain to talk. She was grimacing and said that her pain is from the wounds on her back which per interview were from placement of a nephrostomy tube and coccyx wound. On 03/16/21 at 11:24 a.m. Resident #386 was in her room sitting on her bed. She said she was in a lot of pain and rated her pain as an 8 out of 10 (with 10 being the worst pain). She said the nurse had given her pain medication earlier but she was still in a great deal of pain. On 03/18/21 at 11:45 a.m. Resident #386 was in her room sitting on her bed. She said her pain level was 7 out of 10. She said she received one pain medication in the morning and would get more later for the pain from her lower back wound. C. Record Review 1. Pain assessment The 2/11/21 nursing documentation admission assessment revealed Resident #386 had pain located in the sacral area, her reported level of pain was 3 out of 10 upon admission, and she was on prescribed medications for pain management and hospice for comfort care. No additional pain evaluation or documentation was discovered or provided during the survey (3/10 - 3/23/21). The nursing home administrator (NHA) provided additional documentation via email on 3/24/21 at 4:20 p.m. The additional documentation contained a hospice initial visit assessment from 1/21/21. The hospice initial visit assessment revealed the resident had a goal of keeping her pain level at 5 out of 10. It also revealed the resident had constant pelvic pain and bilateral lower leg pain. It revealed the resident felt that narcotic medications made her incontinent, which she did not like. It revealed that physical exertion and positioning worsened both pelvic and lower extremity pain, and that rest, position changes, prescription medications, and stretching helped relieve pain. It also revealed that on the numeric pain scale, 7-10 was indicative of severe pain. The information found in the 1/21/21 hospice assessment was not reflected in the resident's care plan or any of the facility documentation reviewed during the survey (3/10 - 3/23/21) Additionally, the 1/21/21 hospice assessment was completed prior to the resident's admission to the facility on [DATE] and did not reflect the resident's reported pain from her nephrostomy tube and coccyx wound. 2. Care plan The pain section of the comprehensive care plan, last updated 2/12/21, identified Resident #386 was at risk for alterations in comfort related to chronic pain. The goal was for the resident to achieve acceptable levels of pain control through the review period. Interventions listed in the care plan were: utilize pain scale, monitor for non-verbal signs/symptoms of pain and medicate as ordered, and assist the resident to a position of comfort, utilizing pillows and appropriate positioning devices. No resident pain goals, acceptable levels of pain or pain threshold numbers, or non-pharmacological interventions were documented in the care plan. No new pain management interventions were added after 2/12/21. 3. CPOs The March 2021 CPOs revealed orders for pain monitoring every day shift and every night shift. The orders read as follows: Pain Monitor (able to communicate) Are you free of pain or hurting? If no, indicate response through chart code: PI (if new or change in pain, complete pain eval). The March 2021 CPOs revealed the following pain medications, all with order and state date of 2/11/21 for Resident #386: -[MEDICATION(S)]-Acetaminophen tablet 5-321 milligrams (MG): Give one tablet by mouth every four hours as needed for mild/moderate pain; -[MEDICATION(S)]-Acetaminophen tablet 5-325 MG: Give two tablets by mouth every four hours as needed for severe pain; -[MEDICATION(S)] tablet 200 MG: Give 200 mg by mouth every eight hours as needed for pain; -[MEDICATION(S)] (Concentrate) Solution 20 MG/milliliter (ML): Give 0.25 ml by mouth every one hours as needed for pain; -[MEDICATION(S)] ER Tablet Extended Release 15 MG: Give 30 MG by mouth two times a day for pain. The orders did not identify the parameters between mild/moderate pain levels and severe pain levels. 4. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, see observations above on 3/16/21 (resident reported pain at level 8) and documented reported pain levels for the two dates were 9 and 10 respectively. The March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -3/11/21: Pain level of 8; -3/11/21: Pan level of 5; -3/12/21: Pain level of 4; -3/12/21: Pain level of 6; -3/13/21: Pain level of 8; -3/17/21: Pain level of 8; -3/20/21: Pain level of 6; -3/21/21: Pain level of 6; -3/22/21: Pain level of 10; -3/22/21: Pain level of 7; -3/23/21: Pain level of 8; -3/23/21: Pain level of 7 The March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -3/14/21: Pain level of 7; -3/15/21: Pain level of 9; -3/15/21: Pain level of 8; -3/16/21: Pain level of 9; -3/19/21: Pain level of 5; -3/20/21: Pain level of 7 The CPOs and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received different prn medication dose levels for various levels of pain, contributing to inadequate pain medication when severe pain was reported (per the hospice evaluation of her pain on 1/21/21). Further, there was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 3/11/21 at 9:41 a.m. She said Resident #386 had chronic pain and much of her pain was related to the wounds she had on her lower back. LPN #2 said that the resident typically did not want to take extra pain medications because they made her constipated. LPN #2 was interviewed again on 3/22/21 at 12:26 p.m. LPN #2 said Resident #386 received scheduled [MEDICATION(S)] extended release 30mg three times per day and had several prn medication options for breakthrough pain. She said she would check on the resident in the morning and offer her prn medications of [MEDICATION(S)] or [MEDICATION(S)]. -She said the resident preferred [MEDICATION(S)] and felt that the [MEDICATION(S)] did not help her pain, although the physician increased her scheduled [MEDICATION(S)] dosage on 3/18/21. LPN #2 said the resident seemed to be in pain all the time and thought her pain regimen may need to be addressed again. However, she did not indicate the resident's report that [MEDICATION(S)] was ineffective had been reported to the physician. -She said the resident was fairly independent and could reposition herself independently, so medications were the only thing used to address her pain. She said she could not think of any non-pharmaceutical interventions used for the resident's pain. -She said she was unable to find a pain assessment in the resident's medical records and said a pain assessment should have been completed upon admission.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening, for three (#62, #103, and #121) of six residents reviewed out of 62 sample residents. Facility failures contributed to Resident #62, an at risk resident, developing avoidable pressure injury to the left heel and worsening pressure injury to the right heel. Specifically, the facility failed to timely identify the resident's wheelchair footrest was inadequate, causing unrelieved pressure to the resident's heels. Moreover, the facility did not notify the responsible party or the primary care physician of the new left heel wound and failed to develop a person-centered care plan for the left heel wound. The facility's failures contributed to Resident #62's prior right heel callus progressing to an unstageable pressure injury and contributed to her developing a new deep tissue injury to the left heel. Additionally, the facility failed to: -Ensure Resident #103, who was at high risk for skin breakdown, did not develop an avoidable pressure injury and an identified water blister was accurately documented; and, -Ensure Resident #121 had interventions in place to prevent the development of a pressure injury, and to keep it from worsening. Findings include: I. Professional reference A. The National Pressure Ulcer Advisory Panel (2016) NPUAP Pressure Injury Stages, retrieved 3/26/21 from:http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages revealed the following pertinent information: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. -An unstageable pressure injury is an injury with obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. -A deep tissue pressure injury (DTPI) is a persistent non-blanchable deep red, maroon or purple discoloration resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. II. Facility policy and procedure The facility's pressure injury policy was requested from the wound care nurse (WCN) on 3/22/21 at 4:40 p.m., and not received. III. Resident #62 A. Resident status Resident #62, age 73, was admitted on [DATE]. According to the March 2021, computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/25/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. She required extensive assistance of two persons with bed mobility, transfers, dressing and toileting. She required extensive one person assistance with personal hygiene. She had two unstageable pressure injuries, one of which was present on admission. B. Record review Right heel, pressure injury unstageable: The admission nurse note dated 12/31/20 was reviewed. The note documented Resident #62 had a dark area surrounded by thick dry callous to the right heel. There was no further description of the callus. The note documented the area as other, not pressure. There was no documentation of a wound to the left heel. The Braden skin risk assessment scale dated 1/14/21 was reviewed. The resident scored 17, and was documented as at risk for skin breakdown. Her risk was partially due to being chairfast with limited mobility, and the potential for shearing. On 1/6/21, six days after the calloused area to the right heel was documented on admission, the wound care notes documented an unstageable pressure injury which measured 3.8 cm (centimeters) by 4.5 centimeters. The depth was unable to be determined. It was documented as 100% eschar (dead tissue). The wound care notes documented on 2/3/21 that the right heel wound was worse. It measured 4.0 by 2.0 cm and the depth was unable to be determined. The wound care notes dated 3/1/21 documented the right heel wound measured 4.5 by 3.0 cm and the depth was unable to be determined. The note documented there was moderate serosanguinous (bloody, watery) drainage and the area around the wound was red. It further documented the resident was on an antibiotic (see below). The wound care note documented the wound was worse. The wound care notes dated 3/22/21, during the survey, read the right heel wound measured 4.0 by 2.2 cm and the depth was 0.1 cm and the wound was again debrided. The primary physician's notes dated 3/19/21 were reviewed. The physician documented a pressure ulcer to the right heel with an unspecified stage. There was no documentation of a pressure injury to the left heel. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current treatment orders dated 3/3/21 for the right heel included: cleanse with normal saline or wound cleanser, pat area dry, apply [MEDICATION(S)] to heel and cover with abdominal pad, wrap with kerlix every other day and as needed. Left heel, pressure injury deep tissue injury (DTPI): The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Although it could not be determined which physician (primary care or wound care physician) wrote the order, see primary care physician interview below that he was unaware of the left heel injury. The nurses' notes were reviewed. There were no nursing notes related to the left heel wound on or before 3/8/21, when the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no further documentation. There was no documentation the family was notified. The first note provided by the facility regarding the left heel wound was dated 3/15/21. All wound care notes were requested from the WCN. The left heel was not staged or documented as a DTPI on this assessment. The size was documented as 1.7 cm by 2.2 cm area with undetermined depth. The wound care notes documented on 3/22/21 that the left heel wound was a deep tissue injury and measured 1.7 by 2.1 cm with undetermined depth. Care plan The care plan was reviewed. The care plan initiated 1/21/21 documented the resident had actual skin breakdown to the right heel. It documented the right heel had an unstageable pressure injury. There was no care plan for the left heel. -The goal was documented as resident will remain free of skin tears and or bruising throughout the review period. The goal was not to heal or prevent pressure injuries. -Many of the interventions were not added to the care plan until 3/10/21, after the second wound developed on the left heel. Interventions included: the wound related pain will be managed at an acceptable level for the patient (initiated on 3/10/21), provide preventative skin care such as lotions, barrier creams as ordered (initiated 1/28/21), provide treatment to skin tear per order and observe for signs of infection until healed and report changes (initiated on 3/10/21), observe skin for signs and symptoms of skin breakdown, redness, cracking, blistering, decreased sensation, and skin that does not blanche easily (initiated on 3/10/21), observe skin condition daily with ADL (activities of daily living) care and report abnormalities (initiated on 3/10/21, off load and float heels while in bed with pillows or pressure reduction boots (initiated 2/4/21), lower extremity protectors (initiated 3/10/21), observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered (initiated 2/4/21), obtain dietitian consult as needed or ordered (initiated 3/10/21), obtain skilled therapy evaluation to improve functional mobility (initiated 3/10/21), pressure redistribution surfaces to chair as per guideline (initiated 3/10/21), provide wound treatment as ordered (initiated 2/4/21), weekly skin assessment (initiated 3/10/21), weekly wound assessment (initiated 2/4/21). Additionally, the diabetic care plan documented, diabetic foot check daily. Observe feet, toes, ankles, soles, heels noting alteration in skin integrity, color, temperature, and cleanliness. Toenails for shape, length and color. Inspect shoes for proper fit (initiated 2/26/21). The treatment administration record (TAR) and nurses' notes were reviewed. There was no documentation of a daily diabetic foot check. C. Interviews Licensed practical nurse (LPN) #5 was interviewed on 3/18/21 at 10:52 a.m. LPN #5 said she was the nurse for Resident #62. She said she was an agency nurse and did not know Resident #62 had any wounds. She then reviewed her report sheet and said the resident had wounds, but she did not know anything about them. The WCN was interviewed on 3/22/21 at 4:40 p.m. She said she was a LPN and was not wound care certified. She said she was the nurse who did wound rounds with the wound care physician weekly. -The WCN said, when there was a new wound, the nurse should initiate a change of condition and document the location of the wound, notify the physician and obtain treatment orders. She said the resident should have then been put on 72 hour charting and had a care plan initiated. -The WCN nurse said it was acceptable for the nurse to document new area with no further description. The WCN said she would then measure and describe the wound on the next wound rounds. -The WCN said the right heel wound for Resident #62 was acquired in house. The WCN said the left heel wound was a deep tissue pressure injury (DTPI) and was acquired while at the facility. She said the wounds were better for a while and then worse and now were stable. -The WCN said the wounds were due to the pressure from the resident's footrests. She said therapy had adjusted the footrests now and added the resident wear pressure reducing boots. The WCN was interviewed again on 3/23/21 at 11:13 a.m. She said the resident's right heel wound was present on admission and the left heel was a deep tissue injury due to her footrests. -She said the footrests were too short and the resident's feet rested on top of the edge of the footrests which caused the wound to the left heel to develop and the right heel wound to worsen. -She said she was notified of the left heel wound on 3/8/21. The WCN said the nurse discovered the wound on 3/8/21 and notified her because that was the day of wound rounds. -She said the nurse should have completed a change of condition and notified the physician and family. However, she said she was unable to locate a change of condition or notification of the family. Resident #62's power of attorney (POA) was interviewed via telephone on 3/23/21 at 1:24 p.m. She said Resident #62 had a chronic callous to the right heel and she frequently applied lotion to when she lived at home. She said she was not notified of a pressure injury to the left heel. The WCN was interviewed again on 3/23/21 at 1:24 p.m. She said therapy was responsible for fitting the resident in the correct wheelchair with footrests on admission. She said Resident #62 should have had daily foot checks because she was a diabetic. The WCN said the diabetic foot checks would have been documented on the TAR. She said it was on the care plan and she did not know why it was not on the TAR. The WCN said there was no care plan for the left heel wound because she had not done it yet. The Director of Rehabilitation (DOR) was interviewed on 3/23/21 at 2:05 p.m. He said the therapy department evaluated new admissions for a wheelchair including footrests. He said Resident #62 was evaluated on 1/6/21 and given a wheelchair and footrests. The DOR said he did not know why or how the footrests would have been too small or short causing the resident's foot to rest on the edge of the footrests. He said he had not been informed of this. The DOR said he would speak to the occupation therapist (OT) who had treated the resident. The OT was interviewed on 3/23/21 at 2:43 p.m. He said he had seen the resident for wheelchair positioning on admission, and her condition declined since then. He said he had assessed her wheelchair and issued standard leg rests on 2/22/21. He said the nursing staff had not notified him that the leg rests were too short or that the resident's feet were resting on the edge of the footrests. He said she had become more rigid and her hips may have not been all the way back in the wheelchair, causing her feet to rest on the footrest edge. The OT said if he had been notified, he could have intervened and possibly added a footrest extender. The OT said he had placed her in a new wheelchair on 3/10/21, after the development of the left heel wound. The director of nursing (DON) was interviewed on 3/23/21 at 3:22 p.m. She said the nurse should have completed a change of condition for the new left heel wound that developed on 3/8/21. She said she should have documented that the family and primary care physician were notified (see physician interview below). The DON said she did not know what the root cause was of the wounds to both heels. She said if the wounds were caused from the wheelchair footrests being too short, the nurse should have notified the OT. She said the nurse could have called them or left them a written message. The wound care physician was interviewed on 3/23/21 at 6:18 p.m. via telephone. He said the right heel was an unstageable pressure injury. He said he debrided (removal of dead or necrotic skin tissue) the right heel this week. The wound care physician said the left heel was a deep tissue injury (DTPI) from having the heel resting on the edge of the footrest. He said he did not know if it was the angle of the footrest or the height. He said the left heel could open up into a stage 3 or 4 wound. The wound care physician said there was no reason the wounds should not heal if the pressure was relieved. The primary care physician was interviewed via telephone on 3/25/21 at 12:50 p.m. He said he was aware of the pressure injury to the right heel. He said he was not notified of the DTI pressure injury to the left heel. The physician said the resident had no nutritional or vascular concerns and the wounds should heal. D. Observations The wounds were observed on 3/22/21, at 4:11 p.m. with LPN #6. The resident was lying in bed with light blue soft boots to both feet. She grimaced and cried when the nurse removed the boots. She said her heels hurt and the nurse offered her Tylenol. The right heel was covered in gauze and unable to be observed; the nurse had already changed the dressing. The left heel had a wound, dry blister appearing, which was approximately 4 cm, circular, with blood noted in the center approximately 2 cm. There was no dressing on the left heel. IV. Resident #103 A. Resident status Resident #103, over age 90, was originally admitted on [DATE] and readmitted on [DATE]. According to the March 2021 CPOs, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/4/21 MDS assessment revealed the resident had severe cognitive impairment and was unable to complete a BIMS. She required extensive assistance and two-person physical assistance with all activities of daily living (ADLs). The MDS revealed the resident was at risk of developing pressure ulcers; however, she had no unhealed pressure ulcers at stage 1 or higher at the time of assessment. B. Record review The skin breakdown section of the comprehensive care plan, last revised 2/23/21, revealed the resident was at risk for skin breakdown related to recent fracture with limited mobility, actual skin breakdown, advanced age, decreased activity, and incontinence. Pertinent interventions included: -Provide preventative skin care (lotions, barrier creams) as ordered, initiated 1/18/19; -Observe skin condition daily with ADL care and report abnormalities, initiated 1/18/19; -Off load/float heels while in bed, initiated 1/18/19; -Lower extremity protectors, initiated 8/24/2020; and, -Upper extremity protectors, initiated 8/24/2020 The 2/4/21 Braden scale for predicting pressure sore risk revealed the resident was at high risk for pressure injuries due to very limited sensory perception, occasionally moist skin, chairfast activity level, very limited mobility, probably inadequate nutrition, and problems with friction and shearing when moving. The 3/1/21 situation, background, assessment and recommendation form (SBAR) revealed a certified nurse aide (CNA) noticed a small pinpoint size water blister on the lower back/left buttocks area of Resident #103 after the resident received a shower. The primary care clinician was notified on 3/1/21 at 3:00 p.m. and recommended to monitor the area and apply healing barrier cream twice daily. The March 2021 CPOs revealed an order, initiated 3/3/21, for moisture barrier cream to be applied twice daily to buttocks after incontinence care for skin protection. Review of the progress notes revealed the following: -3/2/21 nursing documentation note read the resident had an open area on her left lower back, no drainage noted, and barrier cream was applied. -3/3/21 nursing documentation note read the resident had a small red area noted to her left lower back and barrier cream was applied. -3/4/21 nursing documentation note read the resident had redness to the left lower back and barrier cream was applied. -3/5/21 nursing documentation note read the resident had bruising to the left leg and left upper arm. There was no documentation regarding the redness to the left lower back. The 3/7/21 skin check revealed the resident had bruises on her left upper arm and bilateral lower extremity redness with a purple bump to the left leg. The water blister discovered on 3/1/21 was not identified on the 3/7/21 skin check, and no documentation was found to support that the water blister had resolved. C. Staff interview The wound care nurse (WCN) was interviewed on 3/18/21 at 3:30 p.m. The WCN said if a change in the condition of a resident ' s skin was identified, new interventions would be added to the care plan and a change of condition nursing note would be documented every 8 hours regarding the issue for the next 72 hours. If after the first 72 hours the issue got worse, a new change of condition assessment would be completed and the physician would be notified. -The WCN said a skin assessment was completed weekly which would track and monitor the skin injury and indicate if the skin injury was improving, worsening, or the same. She said when a skin issue was identified and triggered a change in condition, it would be documented on the care plan with the correlated interventions in place and the resolved date if it did resolve. -The WCN did not know why Resident #103 ' s skin concern identified on 3/1/21 was not documented on the care plan or if the skin concern was resolved since there was no documentation indicating it was resolved. V. Resident #121 A. Resident status Resident #121, age 80, was admitted to the facility on [DATE] and discharged on [DATE]. She began receiving hospice services on 1/27/21. According to the March 2021 CPOs, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/9/21 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of ten out of 15. She required extensive assistance and one person physical assistance with bed mobility, transfers, toileting, dressing, eating, personal hygiene, and dressing. The 2/9/21 MDS assessment also revealed the resident had one unstageable deep tissue injury that was present upon admission; however, the 1/9/21 MDS admission assessment and the 1/3/21 skin check revealed the resident had no unhealed pressure injuries or skin concerns upon admission. B. Record review The skin breakdown section of the comprehensive care plan, last updated 2/4/21, revealed the resident was at risk for skin breakdown related to extremely dry skin to bilateral lower extremities. The goal was for the resident to remain free of skin tears and/or bruising. Pertinent interventions included: -Apply barrier cream with each cleansing, initiated 2/4/21; -Turn and/or reposition and check skin frequently as determined by tissue tolerance, initiated 2/4/21; -Evaluate for any localized skin problems (dryness), initiated 1/3/21; -Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered, initiated 2/4/21; and, -Weekly wound assessment to include measurements and description of wound status, initiated 2/4/21. Review of the progress notes revealed: -1/9/21 care plan evaluation note read due to her age and fragile skin she is at risk for developing pressure ulcers, and skin checks (have) not identified skin issues post admission. -1/26/21 SBAR revealed an open area one centimeter (cm) in diameter to coccyx and a scratch to the inner left vaginal lip were identified. The physician and the family were notified on 1/26/21 at 7:00 p.m. -1/31/21 skin check assessment revealed no skin injury/wounds were noted. -2/8/21 skin check assessment revealed a pressure injury to the sacrum -2/15/21 skin check assessment revealed a pressure injury to the sacrum -2/22/21 skin check assessment revealed a pressure injury to the sacrum -2/23/21 general note revealed an air mattress was ordered for the resident and the resident was being seen by the wound care team for rounds due to the wound on her coccyx. The resident was educated about the importance of allowing repositioning to prevent additional pressure to the wound site. The 1/27/21 wound team document revealed the resident had a deep tissue injury to the sacrum which measured 3.5cm by 4cm by 0cm. It had no drainage and was 100% epithelial tissue (light pink in color). The periwound (tissue surrounding the wound) was healthy. The treatment was to apply [MEDICATION(S)] barrier cream twice daily and provide cushions. The 2/3/21 wound team document revealed the sacrum deep tissue injury had improved and measured 2cm by 1cm by 0cm. It had no drainage and was 100% epithelial tissue. The periwound was described as scaly. The treatment was to apply both [MEDICATION(S)] barrier cream and silicone barrier cream twice daily. The 2/8/21 wound team document revealed the sacrum deep tissue injury had worsened and measured 5cm by 3cm by 0cm. The wound had minimal serosanguinous (clear fluid with some blood) drainage and was 100% epithelial tissue. The periwound was healthy. The treatment was to apply [MEDICATION(S)] barrier cream twice daily. The 2/15/21 wound team document revealed the sacrum deep tissue injury had improved and measured 1.5cm by 4.5cm by 0.2cm. The wound had scant drainage (wound dressings only slightly moist) and was now 100% granulation tissue, which indicated the wound was healing. The periwound was healthy. The treatment was to apply both [MEDICATION(S)] barrier cream and silicon barrier cream twice daily and as needed. The 2/22/21 wound team document revealed the sacrum injury had changed to a Kennedy ulcer (unavoidable skin breakdown as part of the dying process) which measured 2cm by 5cm by 0.2cm. The wound had moderate serosanguinous drainage and was 90% epithelial tissue and 10% granulation tissue. The periwound was healthy. The treatment remained the same. The notes section of the document revealed the skin worsening was unavoidable due to malnutrition, immobility and incontinence. The 3/1/21 wound team document revealed the sacrum Kennedy ulcer had worsened and measured 5.2cm by 4.8cm by 0.3cm. The wound had minimal drainage and was made of 60% epithelial tissue, 20% granulation tissue, and 20% eschar (dead tissue). The periwound was healthy, though the wound was described as tender. The treatment remained the same. The resident was discharged to a different facility on 3/2/21. C. Facility failures See care plan above; there were no updates or revisions to the resident's care plan past 2/4/21 although her wound worsened leading up to her discharge on 3/2/21. Although educated on the importance of repositioning, there was no direction to staff regarding repositioning in the care plan. Review of the record from 1/26 to 3/1/21 revealed no documentation the resident's power of attorney was notified after it was initially discovered, of the resident's worsening wound. D. Power of attorney interview Resident #121's power of attorney (POA) was interviewed on 3/17/21 at 6:16 p.m. She said the resident had developed a wound on her lower back while at the facility and was put on hospice care on 1/27/21. The POA said the resident had been mobile and used a walker when she first got to the facility. She said her compassion visits had been restricted by the facility mid-February so she had no idea how bad the resident's wound had gotten until she was discharged to the new facility. She said when the resident got to the new facility, the wound was horrific and the resident had such significant diaper rash that her vaginal area was unrecognizable.

Based on record review, observations and family and staff interviews, the facility failed to ensure five (#63, #62, #79, #123 and #71) residents out of 62 sample residents received treatment and services necessary in accordance with professional standards of practice. Specifically: Resident #123, who was receiving anticoagulant medication, was found on the floor after an unwitnessed fall on [DATE] at 1:40 p.m. (Cross-reference F689) The facility failed to accurately and timely document and monitor Resident #123's neurological status after the fall, as well as, signs and symptoms of bleeding. An initial assessment by a registered nurse (RN) was followed by an assessment by a licensed practical nurse (LPN) 41 minutes later. At that time, the resident had an altered mental status with signs of increased confusion and lethargy. There was no documentation of further monitoring. A transfer note read she was sent to the hospital on [DATE] at 6:00 p.m. with progression of lethargy, confusion and unclear speech. Hospital records revealed the resident developed a hematoma inside her body with a slow bleed. The hematoma from the fall was inoperable and she passed away on [DATE]. In addition, the facility failed to ensure Residents #79 and #71, on anticoagulant therapy, were monitored for signs and symptoms of bleeding, that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Failure to monitor resident status after unwitnessed fall A. Professional reference The Agency for Health Care Research and Quality article Fall Response, [DATE], read in pertinent part: Residents should have increased monitoring for the first 72 hours after a fall. Each shift, the nurse should record in the medical record a review of systems, noting any worsening or improvement of symptoms as well as the treatment provided. Reference to the fall should be clearly documented in the nurse's note. Retrieved [DATE] from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html B. Resident #123 1. Resident Status Resident #123, age 65, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident was moderately cognitively intact wild impairment with a brief interview for mental status score of 11 out of 15. She required two-person physical extensive assistance with mobility, transfers, toilet use and one person limited assistance with dressing and personal hygiene. She had fallen four days after she was admitted . She was taking anticoagulant medication (blood thinning medication). She did not use supplemental oxygen. Resident #123 was interviewed on [DATE] at 9:30 a.m. She was alert and spoke clearly and purposefully while she explained the issues she faced. She said she required more assistance with transfers and meals set up to eat than she received. She stated, I need help with a lot of things, like getting into my wheelchair, going to the bathroom. She said she required assistance with transferring to her wheelchair and toileting. She used a wheelchair to move about in her room and in the facility. As she pointed to her bowl of oatmeal with the lid on it beside her on the bedside table, she said, I have been waiting to get help taking this lid off. I am so weak right lately and I need to eat. She said the doctor had told her she was malnourished and needed to eat better. The resident's care plan, dated [DATE], revealed Resident #123 had a high risk of injury related to anticoagulation therapy with the goal for the resident not to have signs or symptoms of bleeding. The care plan did not direct staff what signs of bleeding to monitor the resident for or direct staff to document indications of abnormal bleeding. 2. Fall [DATE] and resident decline On [DATE] at 1:40 p.m., a nursing progress note stated a certified nurse aide (CNA) alerted registered nurse (RN) #1 that Resident #123 was found on the floor. A mechanical lift was used to assist the resident into bed. RN #1 performed an initial assessment. The resident's vital signs revealed her oxygen saturation was low and oxygen was administered per physician orders. On [DATE] at 2:21 p.m. (41 minutes after the RN's initial assessment), LPN #4 completed a change in condition because the resident had increased confusion; Resident #123 was responding with slurred speech and the LPN was unable to comprehend what the resident was saying. It was noted the resident was on an anticoagulant medication. A note at 2:28 p.m. read the resident was lethargic and drowsy. A pain assessment was conducted without a response from the resident. There was no further monitoring of the resident's neurological or physical status until a progress note read on [DATE] at 7:13 p.m. that read, hospital. A [DATE] facility to hospital transfer form, dated at 6:00 p.m., revealed the resident was transported to the hospital per a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The transfer form read the resident's vital signs were different from her usual numbers with increased heart rate, lower blood pressure and lower oxygen saturation with oxygen delivery with a nasal cannula. The [DATE] hospital records, provided by the DON on [DATE] at 4:00 p.m., revealed Resident #123 arrived at the hospital non responsive except to touch with eye movement and incoherent words. The [DATE] computed tomography scan (CT scan) revealed she had a hematoma (pocket of blood inside the body) with a slow bleed. The injury was inoperable because of her frail state and she was transferred to an inpatient hospice unit. Resident #123's daughter was interviewed on [DATE] at 9:30 a.m. She said Resident #123's spouse was notified of the resident's fall on [DATE]. On [DATE], they were notified at 6:00 p.m. that the resident had been transferred to the hospital and they met her at the emergency department. She said Resident #123 was unresponsive when they saw her at about 9:30 p.m. The doctors had discussed that the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the family was informed the resident was in a more fragile state because she suffered a large blood loss, and hospice would be a better option. The daughter said Resident #123 began hospice care and died on [DATE] as a result from the fall with the injury. The DON was interviewed on [DATE] at 6:00 p.m. She said she was updated that Resident #123 admitted to the hospital on [DATE] because of swelling and bleeding found in her esophagus. The assistant director of nursing (ADON) was interviewed on [DATE] at 2:50 p.m. He said he noticed a change in Resident #123's cognition on [DATE]; the resident was able to speak to him in a conversation and then later in the afternoon she sounded different and was sent to the hospital for altered mental status. 3. Facility failures a. The facility did not accurately document or monitor Resident #123's neurological status for an unwitnessed fall per standards of practice. The DON and the Senior Rapid Response Coordinator (SRRM) were interviewed on [DATE] at 6:10 p.m. The DON stated the standard of practice for residents with an unwitnessed fall was that the resident needed documented monitoring for a minimum of 72 hours after an unwitnessed fall or if the resident hit their head during a fall. RN #1 was interviewed on [DATE] at 3:00 p.m. She stated she covered for LPN #4 while she went to lunch break and was the nurse who performed the initial assessment of the resident. She said at that time, Resident #123 appeared to be alert and oriented and did not have any notable injuries. She said that she completed an initial assessment and began neuro checks (neurological assessment and monitoring), then gave a report to the resident's primary nurse, LPN #4. She said she was not asked to re-evaluate the resident by the resident's primary nurse. No record of neurological monitoring after Resident #123's fall and RN #1 initial assessment on [DATE] was found in her record. On [DATE] at 11:00 a.m., the [DATE] post fall neurological monitoring of Resident #123 was requested from the nursing home administrator (NHA). It was not provided. On [DATE] at 11:15 a.m., the post fall neurological monitoring was requested from the director of nursing (DON). It was not provided. On [DATE] at 6:15 p.m., a follow up for the requested neurological monitoring for Resident #123 was requested from the DON a second time. It was received with the same information as documented in the progress notes and the transfer form. b. The facility failed to monitor Resident #123 for signs and symptoms of abnormal bleeding while the resident was taking an anticoagulation medication. CNA #5 was interviewed on [DATE] at 2:00 p.m. She stated the resident had blood when she had bowel movements. It had happened a couple days and she told RN #3 what she saw. However, there was no documentation of this in the resident's record and further review of the resident's progress notes from her admission to [DATE] revealed no documentation the resident was monitored for abnormal bleeding either routinely or after her fall [DATE]. The DON was interviewed on [DATE] at 5:40 p.m. She said anticoagulation therapy was monitored when a resident was admitted to the facility, began or changed anticoagulant medications. Documented monitoring for resident's signs and symptoms of bleeding was revised or began on [DATE] (during survey) with corrected orders done by her for more accurate monitoring. II. Failure to monitor for signs/symptoms of bleeding while on an anticoagulant/antiplatelet medication A. Resident #71 1. Resident status Resident #71, age younger than 70, was admitted on [DATE], and readmitted on [DATE]. According to the [DATE] CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. The resident required two-person extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. He required the use of an anticoagulant medication. 2. Record review Review of Resident # 71's [DATE] CPO revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 75 mg via percutaneous endoscopic gastrostomy (PEG) tube one time a day. The order had a start date of [DATE]. There was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Facility follow up On [DATE], during the survey, the facility obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . See DON interview above. B. Resident #79 1. Resident status Resident #79, age 83, was admitted on [DATE]. According to the [DATE] CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment revealed that the resident had moderate cognitive impairment with a BIMS of 11 out of 15. The resident required one-person limited assistance with bed mobility, transfers, dressing, and toilet use. She required one-person extensive assistance with personal hygiene. 2. Record review Review of Resident # 79's [DATE] CPO revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 75 mg by mouth one time a day for stroke prevention. The order had a start date of [DATE]. There was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #79's comprehensive care plan revealed the resident did not have a care plan to monitor for signs and symptoms of bleeding related to the use of an antiplatelet or anticoagulation medication. See DON interview above. III. Failure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A. Facility policy and procedure The Medication Administration policy, revised [DATE], was received from the DON on [DATE] at 4:45 p.m. The policy documented in pertinent part, administer medication, monitor patients for adverse reactions and effectiveness of medication. B. Resident #62 1. Resident status Resident #62, age 73, was admitted on [DATE]. According to the [DATE], computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of 6 out of 15. She required extensive assistance of two persons with bed mobility, transfers, dressing and toileting. She required extensive one person assistance with personal hygiene. 2. Record review The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was documented: -On [DATE], [MEDICATION(S)] Tablet 75 mg (milligrams), give 75 mg one time a day for hypertension. Hold if the systolic blood pressure was less than 110 mmhg (millimeters mercury) or pulse less than 60 beats per minute. The order was discontinued on [DATE]. There were no documented blood pressure or pulse checks prior to administration of the medication from [DATE] through [DATE]. -On [DATE], [MEDICATION(S)] Tablet 50 mg (milligrams), give 75 mg two times a day for hypertension. Hold if the systolic blood pressure was less than 110 mmhg (millimeters mercury) or pulse less than 60 beats per minute. On [DATE], the resident's blood pressure was documented as ,d+[DATE], there was no pulse documented. There were no further blood pressure or pulse checks documented prior to the administration of the medication, from [DATE] through [DATE]. - On [DATE], [MEDICATION(S)] tablet, 10 mg, give 10 mg by mouth one time a day for hypertension and congestive heart failure (CHF). Hold if the systolic blood pressure was less than 110 mmhg. The order discontinued on [DATE]. There were no blood pressure checks documented prior to the administration of the medication from [DATE] to [DATE]. -On [DATE], [MEDICATION(S)] tablet, 5 mg, give 10 mg by mouth one time a day for hypertension and congestive heart failure (CHF). Hold if the systolic blood pressure was less than 110 mmHg. There were no blood pressure checks documented prior to the administration of the medication from [DATE] to [DATE]. -[MEDICATION(S)] tablet 20 mg, give 20 mg by mouth one time a day for CHF. Hold if the systolic blood pressure was less than 110 mmhg (millimeters mercury) or pulse less than 60 beats per minute. There were no blood pressure or pulse checks documented prior to the administration of the medication from [DATE] to [DATE]. The vital signs and weights tab documentation in the electronic medical record (EMR) was reviewed. There were no blood pressure or pulse checks documented directly before the administration of the medications. 3. Interviews LPN #5 was interviewed on [DATE] at 10:02 a.m. She reviewed the orders on the MAR for Resident #62. She said, I cannot find where the blood pressure and pulse were documented before the medications were given. LPN #5 said the blood pressure and pulse should be checked and documented before the administration of the medication. She said the medication should be held per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The assistant director of nursing (ADON) was interviewed on [DATE] at 11:01 a.m. He said the blood pressure and pulse should have been checked before giving the medication per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he could not locate where the vital signs had been documented prior to the administration of the medication. He said normally there was an attached area to document the vital signs if there was an ordered parameter to hold the mediation. The ADON said he would complete a medication error report and investigate the situation. The ADON said he would notify the DON for follow up. The DON was interviewed on [DATE] at 3:31 p.m. She said a medication error would be completed and the physician and family would be notified. She said the person who transcribed the order did not add an area for the vital signs to be documented. She said, regardless, the order told the nurse to check the blood pressure and/or pulse and this was not done. 4. Facility follow up The DON was interviewed again on [DATE] at 12:40 p.m. She said an area had been added to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the physician had been notified. The DON said she reviewed other residents' records for similar concerns for those on cardiac medications. The DON said she had educated the nurse on entering orders into the computer system when a parameter was ordered. The DON said she did not inservice the nurses on taking time to read the actual order which documented to check the blood pressure and/or pulse before administering, and holding the medication according to the parameter. The inservice sign in sheet dated [DATE] was reviewed. The presenter was Nursing. There were 14 signatures. The form documented When entering cardiac medication and parameters are given. Supplement documentation needs to be added (BP, HR). If medication is given outside the parameters it is considered a medication error. IV. Failure to schedule follow up appointment Resident #63 A. Resident status Resident #63, age 80, was admitted on [DATE]. According to the [DATE]CPO, pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment did not document a BIMS score. His long and short term memory was not documented. The MDS documented he was aphasic (unable to understand speech) and had dementia. He required extensive assistance of two persons with bed mobility, transfers, dressing, toileting, and personal hygiene. He was extensive one person assistance with eating, and he had a feeding tube. B. Record review The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #63 had an order dated [DATE] that read: Okay to administer tube feeding, water and medications through G-tube with perforation sealed with Suresite. Follow up with Gastro for replacement [DATE]. On [DATE] at 12:00 p.m., the nurses' notes documented,Resident has a small perforation to g-tube. Unable to visualize however a small amount of leaking was noted. Area was secured with a transparent nonpermeable dressing and secured with medication tape. Gastro was notified, awaiting orders to determine if tube would be safe/effective to use in its current condition or to schedule appt to have it replaced. On [DATE] at 6:58 a.m., the nurses' notes documented the resident pulled out his feeding tube around 6:00 a.m. On [DATE] at 8:37 a.m., the nurses' notes documented the resident was sent out on night shift [DATE] to [DATE] after pulling out his PEG (percutaneous endoscopic gastrostomy) tube and the PEG tube was replaced. C. Interviews RN #4 was interviewed on [DATE] at 12:45 p.m. She said Resident #63 had pulled out his feeding tube last night. She said he was sent to the hospital to have it replaced and returned this morning. RN #4 said she was glad he pulled it out because it had a hole in it for several weeks, and had not been replaced. The unit clerk (UC) was interviewed [DATE] at 4:01 p.m. She said she had called the gastroenterology office on [DATE] and notified the ADON of the need for the appointment. The UC said she had faxed the clinic the requested documentation on [DATE], and called them on [DATE], and left a voice message. She said she did not hear back from them. The UC said she had not followed up with the clinic from [DATE] to [DATE] when the resident pulled out the tube. The DON was interviewed on [DATE] at 12:35 p.m. She said Resident #63 had pulled out his G-tube on [DATE] and it was replaced. She said she would investigate why an appointment with gastroenterology was not scheduled as ordered on [DATE]. The DON was interviewed again on [DATE] at 5:15 p.m. She said the gastroenterology office had been calling the family to schedule the appointment instead of the facility. The DON said the UC should have followed up after [DATE], when she did not hear back, to get an appointment scheduled. She said the UC did not follow up after [DATE]. The medical records coordinator (MRC) was interviewed on [DATE] at 5:00 p.m. She said she called the gastroenterology office today, and scheduled the resident an appointment for [DATE].

Based on observations and resident and staff interviews, the facility failed to treat four (#1, #8, #11 and #12) of 13 sample residents, and residents who dined in the 900 unit dining room, with respect and dignity. Specifically, the facility failed to ensure: -Resident #1 was not left in a dark room alone and assisted with her lunch meal after having a bowel movement until her brief had been changed; -Resident #11 was not made to wait for 58 minutes to be transferred to bed after turning on her call light, having staff turn off her call light and complaining of pain while sitting in her wheelchair; -Residents were not called feeders in the 900 unit dining room; -Showers were not discussed for Resident #12 in the 900 unit dining room by a hospice certified nurse aide (CNA) in front of other residents; and -Resident #8 was not called honey and sweetie by the social worker. Resident #1 was placed alone in her room and was fed lunch in a condition she would found upsetting prior to her cognitive decline, therefore causing the resident to undignified and horrified. Findings include: I. Facility policy and procedure A dignity policy was requested on 9/27/19; the director of nursing (DON) #2 said at 11:30 a.m. the facility did not have a policy and procedure on dignity. II. Resident #1 Resident status Resident #1, under the age of 68, was admitted on [DATE]. According to the 7/13/19 minimum data set (MDS) assessment, [DIAGNOSES REDACTED]. The 7/13/19 MDS documented staff completed the brief interview for mental status (BIMS) which revealed the resident was severely impaired. The resident required extensive assistance with all activities of daily living (ADLs). She was incontinent of both bladder and bowel. Observations and staff interview On 9/26/19 at 12:12 p.m. Resident #1 was observed sitting in her wheelchair in the dark in her room. The blinds were closed, the light was off, and her call light was hooked to the wall and out of reach. On 9/26/19 at 12:17 p.m. Resident #1 remained in her room in the dark without her call light. On 9/26/19 at 12:22 p.m. CNA #8 entered the room and said that the nurse had put the resident in her room for a few minutes. She said the nurse had told her that she wanted Resident #1 to eat in her room on this day. She said whenever she put a resident in her room the call light should be within reach. She said the nurse, licensed practical nurse (LPN) #4, had decided today to put Resident #1 in her room and have her eat lunch in her room. She said the nurse had told her she seemed uncomfortable today but was not sure what that meant. She said the resident usually ate in the dining room but seemed uncomfortable today and LPN #4 had told her she wanted to get Resident #1 into bed as soon as possible. On 9/26/19 at 12:30 p.m. CNA #8 gave the resident her lunch tray, in her room. On 9/26/19 at 12:34 p.m. LPN #4 was interviewed. She said at 11:50 a.m. she had given the resident her breathing treatment and provided insulin. She said she was starting to have a bowel movement and she caught her whiff. She said she had told the CNA that she wanted the resident to eat in her room because she had a bowel movement. She said she was going to have to get the hoyer lift and help the nurse transfer her to bed and change her. She confirmed that she had left the resident in her room while she had a bowel movement and was going to get the CNA so she could help her. She said she should not have her lunch tray yet. At 12:36 p.m. LPN #4 entered the resident ' s room, and observed the resident receiving assistance with her lunch by CNA #8. The LPN said to CNA #8 she should not be eating yet, and told the CNA, We need to change the resident, even though that will take an extra time with the hoyer (lift). The CNA appeared unaware of this information. C. Family interview The resident ' s spouse was interviewed on 10/10/19 at 9:35 a.m. He said Resident #1 had seasonal affective disorder (SAD) and does not like to be alone in a dark room. He said he had told the facility this multiple times. He said she was always very social, clean and well kept and would have obviously been horrified to be sitting in her own bowel movement while eating a meal. He said hopefully after the survey the facility would do better and that he had high hopes for the new DON. D. Staff interviews Unit manager (UM) #2 and director of nursing (DONs) #1 and #2 were interviewed on 9/27/19 at 10:35 a.m. DON #2 said LPN #3 should have communicated to the CNA the resident had started having a bowel movement and that she needed to be changed before eating. They agreed Resident #1 should have also had her call light within reach. They said that it was not acceptable to assist the resident with her meal while she was soiled from a bowel movement. III. Resident #11 Resident status Resident #11, age 72, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 9/19/19 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required supervision with eating and was totally dependent on staff for all other ADLs. Observations and staff and resident interviews On 9/26/19 the following observations were made: -At 6:35 p.m. the resident ' s call light was observed on above her door. -At 6:40 p.m. Resident #11 said she had been waiting to go to bed and was told by the nurse that the CNA had to go to the bathroom then would come and help her. -At 6:45 p.m. Resident #11 was observed sitting in her reclining wheelchair, with her call light in her lap. CNA #7 came in the room, turned off her call light and leaned over the resident to fix her shirt which was sliding off of her shoulder. The resident asked the CNA to elevate the back of her wheelchair slightly which she did. The CNA told the resident she would be back to help her to bed, then the CNA left the room. -At 6:46 p.m. the resident said, She went and smoked, I could smell smoke when she leaned over. The nurse said she was going to go to the bathroom and then help me. -At 7:00 p.m. CNA #7 came in and put the resident ' s sheet on her bed and told her she would get the nurse to help her transfer to bed. -At 7:06 p.m. registered nurse (RN) #2 came into the room and told Resident #11 that someone would be in soon to help. She left the room less than a minute later. The RN did not ask the resident if there was anything she could do for while she waited. -At 7:11 p.m. the activity director assisted the resident with her remote control. -At 7:12 p.m. the resident I have to wait and I ' m in pain then said I hate to turn on the light but I hate when they turn it off and not help me. -At 7:14 p.m. the resident said, They just leave me sit here and it hurts. RN #2 and CNA #7 entered the room with the hoyer lift and began to get the resident ready for bed. -At 7:27 p.m. CNA #7 and RN #2 left the room and the resident was in bed, 58 minutes after the initial call light observation Staff interviews UM #2 and DONs #1 and #2 were interviewed on 9/27/19 at 10:35 a.m. They said they would address the long wait time and the issue of pain. IV. Unit 900 dining room Observations The 900 unit dining room was observed on 9/27/19 from 8:25 a.m. until 9:00 a.m. The following observations were made: -At 8:34 a.m. CNA #4 said, while standing in front of 13 residents who were seated in the dining room receiving breakfast, Who else are feeders? -At 8:38 a.m. a hospice CNA entered the room and approached Resident #12. She spoke to LPN #3 about giving the resident a shower and then said, She is wearing the same pants from Tuesday. She asked the resident if she wanted to take a shower and the resident refused. The CNA continued to talk about the resident with the LPN, while standing near the seated resident, loudly and in front of multiple residents. She was discussing whether the resident was wearing clean jeans, saying that she had given her multiple showers in the past and that she was surprised that the resident had refused a shower today. At 8:42 a.m. the CNA confirmed she was from hospice, and was familiar with the facility and the resident for whom she provided showers. -At 8:57 a.m. the social worker entered the dining room, approached Resident #8 and asked her, How are you doing, sweetie? The social worker then leaned down to talk to the resident and said, Eat your breakfast, honey. Staff interviews CNA #4 was interviewed on 9/27/19 at 9:00 a.m. She said she knew she was not supposed to call residents who needed assistance with meals feeders, but should ask who required assistance instead. LPN #3 was interviewed on 9/27/19 at 9:15 a.m. She said she knew that residents should be called by their name and not honey or sweetie. She said she was also concerned when the hospice CNA began to discuss the resident and her showers in the dining room loudly. She said it was never acceptable to refer to residents as feeders. UM #2 and DONs #1 and #2 were interviewed on 9/27/19 at 10:35 a.m. They agreed that calling residents feeders, honey or sweetie was not appropriate. DON #2 said they would complete more staff training on dignity and respect for the residents.

Based on record review and interviews, the facility failed to ensure one (#26) of three residents reviewed for accidents of 57 sample residents remained free from falls Resident #26 was transferred inappropriately with one certified nurse aide (CNA) rather than two or a mechanical lift from his bed to his Broda (tilt-in-space positioning) chair and experienced a fall and dislodgement of his feeding tube. Subsequently, because of this action by the CNA #8, the resident was sent to the emergency room to have a surgical procedure to replace the J-tube. (J-tube,[DEVICE] and PEG tube are used interchangeably for the purpose of this citation). Additional failures included the facility failed to ensure the care plan was updated with the residents specific transfer status before the resident fell , and failed to complete neuro checks timely after the fall, and failed to complete a thorough investigation after the fall. Findings include: 1. Facility policies and procedures The Falls Management policy revised on 3/15/16 was provided on 4/23/19 at 2:05 p.m., by the nursing home administrator (NHA). The policy revealed a resident would be assessed for a fall risk as part of the nursing assessment injury. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall would receive appropriate care and investigation of the cause. The Neurological Assessment (NA) policy revised on 10/1/12 was provided on 4/23/19 at 2:05 p.m. by the NHA. The policy revealed neurological assessments would be performed as indicated or ordered. When a resident sustained [REDACTED]. The purpose was to monitor the resident for neurological compromise. Some neurological compromise concerns may include [MEDICAL CONDITION], unexplained pain, decreased alertness, poor cognitive abilities, decreased alertness, muscle weakness, partial or complete paralysis or loss of sensation, difficulty in reading or writing. II. Resident status Resident #26, age 57, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/22/19 minimum data set (MDS) assessment had a score of 99 which indicated the resident had four or more question items which were coded as zero because the resident chose not to answer or gave a nonsensical response. The resident had both short and long term memory problems. The resident was severely impaired in his cognitive skills for daily decision making. The resident required two + staff physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident had a percutaneous endoscopic gastrostomy (PEG) feeding tube. The resident has not had any falls since admission. III. Family interview The resident ' s father was interviewed on 4/17/19 at 11:33 a.m. He said he was told two different explanations regarding a fall his son had on 4/10/19. He said the first explanation was that his son fell out of bed and required surgery to repair a broken feeding tube. He said he was also told a certified nurse aide (CNA) #8 was in the room with his son and when she turned around he fell out of his bed. IV. Family typed note The clinical record contained a typed letter dated 4/17/19 at 4:15 p.m., by the social services director (SSD). The letter was an interview with the resident ' s parents. The pertinent part of this letter revealed the resident had a fall on 4/10/19 and the resident ' s mother was told CNA #8 was in the room and behind the door. The mother asked the nurse unit manager (NUM) if she had been given an accident report for this fall and she answered no. V. Record review A physician's order [REDACTED]. The tube length was 20 cm (centimeters). Also before meals for [DEVICE] patency check. The care plan (CP) revised on 1/16/19, revealed the resident required assistance and was dependent on staff for activities of daily living (ADL) cares for bed mobility, transfers, grooming, bathing, personal hygiene, toileting related to his debility associated with a recent hospitalization . Some of the pertinent interventions were to provide ADL cares as necessary. To monitor for decline in his ADL function and to refer to rehabilitation therapy if ADL decline was observed. Arrange the resident ' s room environment as much as possible to facilitate ADL performance. Provide the resident with assistance with transfers including the use of a walker, rolling walker, quad cane, straight cane, pivot transfer, slide board as prescribed and as needed. A revision was made to this CP on 4/18/19 to transfer the resident with two staff person using a Hoyer lift. This revision was made eight days after the resident had a fall with a one person transfer using a pivot technique. The CP revised on 4/10/19 revealed the resident was at risk for falls due to cognitive loss, lack of safety awareness, impaired mobility, [MEDICAL CONDITION], cerebral cysts, and muscle wasting atrophy. Place a fall mattress on the floor at his bedside while in bed due to impulsivity. The resident had a history of [REDACTED]. Staff were to ensure to monitor, turn and reposition the resident every two hours when in bed to monitor for safety. The resident had an actual fall on 4/10/19. Some of the pertinent interventions were for staff to lay the resident down in bed when he seemed restless in his wheelchair. Assist the resident with safe positioning in bed as he allows when restless. Place the fall mattress on the floor at bedside while the resident was in bed. Assess for changes in medical status, pain status, mental status and report changes to his physician as indicated. Provide verbal cues for safety and sequencing when needed. Maintain a clutter-free environment in the resident's room and consistent furniture arrangement. This CP was revised on the day of the fall and it did not include to transfer the resident with two staff person using a Hoyer lift. The electronic medical record computerized Kardex (a medical information system used by nursing staff as a way to communicate a quick summary of important information on their residents) revealed to transfer the resident utilizing two staff persons with a Hoyer lift. A general note dated 4/10/19 at 7:51 a.m., by a licensed practical nurse (LPN) noted the resident was found lying on the floor in his room. The resident ' s J-tube was out of the resident ' s abdomen and lying on the floor. The on-call hospice contact was notified and orders were given to send the resident to the emergency room (ER). The resident left the facility by ambulance. This note revealed this was an unwitnessed fall and neurological assessments should have been started. The NA flow sheet dated 4/10/19 revealed the residents assessments were started at 9:10 a.m. The resident was alert, his pupils were equal and reactive to light, his hand grasps were equal, no documentation for the extremities motor functions, he had an appropriate pain response, his vital signs were noted and the observations noted the resident had been sent to the hospital. The resident had an unwitnessed fall at 6:30 a.m., on this date and assessments should have started at this time. The situation, background, assessment, recommendation (SBAR) communication form and progress note developed by the director of nursing (DON) on 4/10/19 at 10:00 a.m., revealed the resident had a fall on 4/10/19. The form noted the resident had pulled his PEG out. The resident did not have any pain or neurological changes. The resident was sent to the emergency room for PEG reinsertion. The SBAR did not document the time of the fall and it did not document if the fall was witnessed or unwitnessed. An event summary report (ESR) prepared by the DON on 4/10/19 at 10:00 a.m., revealed the resident had an unwitnessed fall in his room on 4/10/19 at 9:00 a.m He was found on the floor with no injuries. The report revealed the resident was observed on the floor in his room while staff were doing rounds. There was no acute injuries noted and no nonverbal signs or symptoms of pain were observed. The resident was transferred to the hospital at 10:00 a.m., the root cause of the fall was poor safety awareness. The report noted the resident was assessed by a registered nurse (RN) but there was no assessment on this report. This report reveals the resident had an unwitnessed fall at 9:00 a.m. A change of condition note by the DON dated 4/10/19 at 12:43 p.m., revealed the resident had a change of condition with symptoms of a fall and a blood pressure readings of 101/58 this morning. Orders were obtained to send the resident to the ER for PEG reinsertion at 10:00 a.m. The hospital (named) nutritional assessment dated [DATE] at 2:22 p.m., revealed the resident was admitted to the hospital on [DATE] with a malfunctioning PEG - J tube and for a fall from his bed. A nurse documentation note (NDN) dated 4/13/19 at 1:40 a.m., revealed the resident was monitored for returning from the hospital where he received a new PEG tube. The site looked good and his vital signs were stable. No fall risks were identified in the reviewed areas. A NDN dated 4/13/19 at 9:00 p.m., revealed to monitor status/post PEG placement for PEG tube resident. No fall risks were identified in the reviewed areas. A signed handwritten letter by certified nurse aide (CNA) #8 dated 4/23/19 revealed this was her statement regarding the resident ' s fall on 4/10/19. It read around 6:30 a.m., she was told by a nurse to transfer and change the resident. She changed the resident and transferred him with a gait belt. During the transfer the resident pivoted the wrong direction and she lowered him to the floor. This note was not in the clinical record at the time of the survey. It was dated eight days after the survey started and 13 days after the resident fell . A late entry general note dated 4/23/19 at 4:31 p.m., by registered nurse supervisor (RNS) revealed she was called to the 300 hall before breakfast to assess the resident for a fall on 4/10/19. No injuries were noted and no change in mentation. The residents PEG tube was pulled out. The hall nurse was to call the resident ' s physician for instructions. This progress note was not in the resident ' s clinical record at the start of the survey. It was placed in the clinical record 13 days after the resident fell in his room. VI. Staff interviews The clinical reimbursement coordinator (CRC) #2 was interviewed on 4/23/19 at 1:19 p.m. She said for the 1/22/19 minimum data set (MDS) assessment the resident was coded to require extensive staff physical assistance utilizing a two plus staff members for bed mobility and transfers. She said extensive staff assistance meant the staff hands were on the resident and they were bearing up more than 50% of the resident ' s weight between them. She said this resident would always required two staff members extensive assistance for bed mobility and transfers. She said the coding for bed mobility and transfers came from the information placed in PCC computerized charting system by the CNAs. She reviewed the resident ' s CP and agreed there was no documentation the resident required extensive staff physical assistance utilizing a two plus staff members for bed mobility and transfers prior to the revision date of 4/18/19. This revision was eight days after the resident fell in his room. She said the CP should have been updated to reflect the resident ' s specific needs in the ADLs area of bed mobility and transfers as noted in the 1/22/19 MDS. The CNA #8 was interviewed on 4/23/19 at 12:44 p.m., She said the resident had a fall on 4/10/19 around 6:30 a.m. She said a nurse told her the resident needed to be transferred from his bed to his Broda chair. The CNA said the resident usually took one staff member for transfers unless he became combative and then it took two staff members. She said on this date she attempted to transfer the resident by herself. She said she sat the resident up on his low bed and she told him to stand up. When he stood up he twisted himself and his [DEVICE] came out of him. She demonstrated to the surveyor the portion of the tube that came out of the resident was the small tubing from the feeding machine. She said the remainder of the apparatus was still inside the resident. She said the resident continued to twist and she slowly lowered him to the floor and not on his bed. She said as he was lying on the floor by his bed and he began to wiggle on the floor toward the entrance door of his room. She said she called the nurse to come to the room. The nurse arrived and they transferred the resident to his Brado chair. She said the nurse did not do an assessment of the resident prior to the transfer from the floor to the chair. She said the resident did not have any injuries and he did not hit his head when he was lowered to the floor. She said she was not sure if lowering a resident to the floor was considered a fall. The DON was interviewed on 4/23/19 at 2:04 p.m. She said when a resident was lowered to the floor or had changes in a plane (elevation) from one plane to another without intention this was considered a fall. She said the resident had a fall. She said today was the first time she had heard of this version of the fall by CNA #8. The time of the event was 6:30 a.m., and not 9:00 a.m., as written on the event summary report (ESR). She said the ESR revealed this was an unwitnessed fall however CNA #8 was in the room with the resident. The ESR should have noted CNA #8 as a witness. The DON said the nurse should have listed the resident ' s vital signs on the ESR and she did not. The DON said she was told by staff the resident was found on the floor during rounds and his [DEVICE] was pulled out. She said according to staff his plastic [DEVICE] was no longer in his body and was on the floor. She said the balloon must have deflated and it did not cause any trauma to the resident. She said the resident was sent to the ER for reinsertion of the [DEVICE]. She said the resident left the facility at 7:54 a.m., by ambulance. She agreed the neurological assessment flow sheet (NAFS) started assessments at 9:10 a.m., which was one hour and 16 minutes after the resident left the facility for the ER. She agreed if the resident had an unwitnessed fall as revealed in the ESR, then neurological assessments should have been started at started at 6:30 a.m., and continued at 7:00 .m., and 7:30 a.m, in accordance to the assessment frequency listed on the NAFS, prior to his departure to the ER. The NHA was interviewed on 4/24/19 at 9:16 a.m. She said the interdisciplinary Team (IDT) was responsible for taking the MDS assessment information and the development of a CP to reflect the assessment. She said the nurse managers were responsible for taking the MDS assessment information and incorporating it into the CP. She said the CNAs used a hand held tablet that they could review the Kardex daily and document all provided cares. The hospice registered nurse (HRN) was interviewed on 4/23/19 at 6:05 p.m. She said she documented on the client occurrence report the resident had a fall out of his Broda chair on 4/10/19 at 7:25 a.m., and pulled out his J-tube. She said an emergency room visit was required for a new tube placement. She said this incident was told to her by facility staff via the phone. She said she was not in the facility at the time of the fall. VII. Conclusions -The facility used the terminology of [DEVICE] and J-tube interchangeably. A [DEVICE] was an opening that connects the feeding tube on the outside of the body to the stomach or intestine on the inside of the body. A PEG (percutaneous endoscopic gastrostomy) and is often used to describe all [DEVICE]s. A J-tube is a soft plastic tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food, water and medicine inside the resident. -The resident ' s family were told two different versions regarding the resident ' s fall. -The MDS assessment dated [DATE] revealed the resident required two plus staff assistance for bed mobility and transfers. The resident had a one person pivot transfer with a fall on 4/10/19. The resident's PEG tube was pulled out during the fall. -The resident ' s CP dated 1/16/19 for falls did not note the resident required two plus staff assistance for bed mobility and transfers until it was updated on 4/18/19 or eight days after the fall. An updated CP for falls was developed on the day of the fall (4/10/19) and it did not note the resident required two plus staff assistance for bed mobility and transfers. -The computerized Kardex for nursing staff revealed to transfer the resident utilizing two staff persons with a Hoyer lift. Fall version #1 -A general note dated 4/10/19 at 7:51 a.m., revealed the resident was found lying on the floor in his room. The resident ' s J-tube was out of the resident ' s abdomen and lying on the floor. This note reveals this was an unwitnessed fall and neurological assessments should have been started. -The NA flow sheet dated 4/10/19 revealed the residents assessments were started at 9:10 a.m. The nurse note dated 4/10/19 at 7:51 a.m., revealed the resident left the facility at this time. The first neurological assessment was noted to be at 9:10 a.m. or one hour and 19 minutes after the resident left the facility. -An ESR prepared by the DON on 4/10/19 at 10:00 a.m., revealed the resident had an unwitnessed fall in his room on 4/10/19 at 9:00 a.m. The report revealed the resident was noted on the floor in his room while staff were doing rounds. The resident was transferred to the hospital at 10:00 a.m., the root cause of the fall was poor safety awareness.The report did not mention anything about the resident's PEG tube. -The SBAR developed by the DON on 4/10/19 at 10:00 a.m., revealed the resident had a fall and pulled his PEG out. The SBAR did not document the time of the fall and it did not document if the fall was witnessed or unwitnessed. b. Fall version #2 -A signed handwritten letter by certified nurse aide (CNA) #8 dated 4/23/19 revealed on 4/10/19 around 6:30 a.m., she was told by a nurse to transfer and change the resident. She changed the resident and transferred him with a gait belt. During the transfer the resident pivoted the wrong direction and she lowered him to the floor. This note was not in the clinical record at the time of the survey. It was dated eight days after the survey started and 13 days after the resident fell . This note contradicts the facility documentation that the fall was unwitnessed. -A late entry general note dated 4/23/19 at 4:31 p.m., by registered nurse supervisor (RNS) revealed she was called to the 300 hall before breakfast to assess the resident for a fall on 4/10/19. The residents PEG tube was pulled out. This progress note was not in the resident ' s clinical record at the start of the survey. It was placed in the clinical record 13 days after the resident fell in his room. -The CNA #8 was interviewed on 4/23/19 at 12:44 p.m., She said the resident had a fall on 4/10/19 around 6:30 a.m. She said a nurse told her the resident needed to be transferred from his bed to his Broda chair. When the resident stood up he twisted himself and his [DEVICE] came out of him. She said the resident continued to twist and she slowly lowered him to the floor and not on his bed. She said as he was lying on the floor by his bed and he began to wiggle on the floor toward the entrance door of his room. She said she called the nurse to come to the room. The nurse arrived and they transferred the resident to his Brado chair. She said the nurse did not do an assessment of the resident prior to the transfer from the floor to the chair. She he did not hit his head when he was lowered to the floor. -The DON was interviewed on 4/23/19 at 2:04 p.m. The time of the event was 6:30 a.m., and not 9:00 a.m., as written on the event summary report (ESR). She said the ESR revealed this was an unwitnessed fall however CNA #8 was in the room with the resident. The ESR should have noted CNA #8 as a witness. The DON said she was told by staff the resident was found on the floor during rounds and his [DEVICE] was pulled out. She said according to staff his plastic [DEVICE] was no longer in his body and was on the floor She said the resident left the facility at 7:54 a.m., by ambulance. She agreed the neurological assessment flow sheet (NAFS) started assessments at 9:10 a.m., which was one hour and 19 minutes after the resident left the facility for the ER. She agreed if the resident had an unwitnessed fall as revealed in the ESR, then neurological assessments should have been started at started at 6:30 a.m., and continued at 7:00 .m., and 7:30 a.m, in accordance to the assessment frequency listed on the NAFS, prior to his departure to the ER. C. Fall version #3 -The HRN was interviewed on 4/23/19 at 6:05 p.m. She said she documented on the client occurrence report the resident had a fall out of his Broda chair on 4/10/19 at 7:25 a.m., and pulled out his J-tube. She said this incident was told to her by facility staff via the phone. She said she was not in the facility at the time of the fall.