Every finding on record at Pine Ridge Rehabilitation and Healthcare Center

Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#5) of six residents reviewed for accident hazards out of 32 sample residents. Resident #5 was admitted on [DATE] with a diagnosis of dementia. Resident #5 was at risk for falls related to impaired mobility and cognition. Resident #5, who had a history of falls with major injury, sustained an unwitnessed fall on 8/14/25. The facility re-educated the resident on the use of the call light. However, the resident had impaired cognition and did not always remember to use the call light. On 8/22/25 the resident sustained another unwitnessed fall. The resident sustained a laceration to her hand and a fracture of the metacarpal base to her left hand The resident was sent to the hospital and received sutures to the laceration. Upon return, the facility failed to implement person-centered fall interventions and the resident sustained four more additional falls on 10/24/25, 1/12/26, 2/2/26 and 2/5/26.Specifically, the facility failed to implement effective person-centered fall interventions to prevent recurrent falls for Resident #5. Findings include:I. Facility policy and procedureThe Falls-Clinical Protocol policy, revised March 2018, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:51 p.m. It read in pertinent part, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). The staff and physician will monitor and document the individual's response to interventions in-tended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has been resolved by addressing the underlying cause. If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions.II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician's orders (CPO), diagnoses included chronic kidney disease, generalized muscle weakness, dementia with behavioral disturbance, generalized anxiety, transient ischemic attack (TIA) cerebral infarction without residual deficits (stroke), abnormal gait and mobility, history of falling and history of COVID-19.The 11/30/25 minimum data set (MDS) assessment revealed Resident #5 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #5 required substantial/maximal assistance with bathing. Resident #5 required supervision or touching assistance with all transfers, toileting, oral and personal hygiene, upper and lower body dressing as well as footwear. Resident #5 had limited range of motion to both lower extremities, used a wheelchair for mobility and required moderate assistance to move over 50 feet.The assessment indicated the resident had a fall without injury. -However, Resident #5 sustained a fall with injury on 8/22/25.B. Observation and interviewResident #5 was interviewed on 2/9/26 at 2:07 p.m. Resident #5 commented multiple times during the interview that her shirt and her pants felt wet. Resident #5 said she was not sure how often staff checked on her or what staff helped her with. The room had a faint odor of urine. Resident #5 had her touch pad call light within reach. There was not a visual reminder in the resident's room to use her call light. C. Record review1. Care plan Resident #5's fall care plan, revised 2/9/26, documented the resident was at risk for falls related to decreased mobility and unsteady gait. Pertinent interventions included attempting to provide all needed items for hygiene and toileting while Resident #5 was in the bathroom to try to help prevent her from reaching for things and potentially falling; placing needed items directly next to Resident #5 within reaching distance, re-arranging furniture items in the room, placing non-skid tape in front of bed, toilet and recliner, fall mat, reaching device, and placing a sign in the resident's room to remind her to use her call light for assistance.2. Fall on 8/14/25 - unwitnessed The progress note, dated 8/14/25 at 9:17 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 reported to staff she was trying to get out of bed and fell. The note documented Resident #5 sustained two small skin tears to the left knee.The progress note, dated 8/15/25 at 9:14 a.m., revealed an interdisciplinary team (IDT) meeting reviewing Resident #5's fall. The progress note documented the nursing recommendation was to re-educate Resident #5 on the importance of using her call light for assistance with ambulation. The progress note documented no other recommendations from other departments at this time. The progress note, dated 8/21/25 at 9:58 a.m., revealed an IDT meeting reviewing effectiveness of the current fall interventions. The progress note documented staff re-educated Resident #5 on the importance of using the call light when needing to ambulate. The progress note documented no other recommendations from other departments at this time. 3. Fall on 8/22/25 - unwitnessed The progress note, dated 8/22/25 at 4:30 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented two unidentified certified nurse aides (CNA) reported Resident #5 was found sitting on the floor in front of her bed, bleeding from her left hand. The progress note revealed the registered nurse (RN) assessed Resident #5 and found a laceration across the resident's left palm. The laceration measured two inches long, 0.5 centimeters (cm) wide and 0.5 cm deep. The progress note documented first aid was applied to the wound and Resident #5 was transported to the local area emergency room for further evaluation. The progress note, dated 8/22/25 at 9:37 a.m., revealed an IDT meeting reviewing the fall occurring on 8/22/25. The progress note documented the nursing recommendation was to rearrange the furniture in Resident #5's room for ease of transfers. The progress note documented the additional intervention of a wedge pillow between the bed and bedside table to protect the resident from sharp edges. The progress note documented no other recommendations from other departments at this time. -Additionally, the facility did not reassess moving the furniture around after the family requested for the furniture to be moved back (see interviews below).The progress note, dated 8/22/25 at 10:45 a.m., revealed Resident #5 returned to the facility from the local area emergency room. The progress note documented Resident #5 required sutures to her left palm laceration and Resident #5 sustained a metacarpal base fracture to her left hand as a result of the fall. The progress note, dated 8/22/25 at 11:55 a.m., revealed Resident #5's representative was contacted about the intervention of rearranging the furniture in the resident's room. The progress note documented Resident #5's representative was in agreement with the changes.4. Fall on 10/24/25 - unwitnessed The progress note, dated 10/24/25 at 4:43 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found on the floor in front of her bed by an unidentified CNA. The progress note documented Resident #5 said she was trying to get up without assistance and fell. The progress note documented no injuries as a result of the fall.The progress note, dated 10/24/25 at 11:51 a.m., revealed an IDT meeting reviewing recent fall and fall interventions. The progress note documented the resident declined therapy services when offered at this time. The progress note documented the nursing recommendation was to continue with all current interventions, to frequently remind Resident #5 to call for assistance and to increase monitoring.5. Fall on 1/12/26 - unwitnessed The progress note, dated 1/12/26 at 12:50 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found sitting on the floor in front of her recliner in her room. The progress note documented Resident #5 sustained a small skin tear to her right shin. The progress note documented Resident #5 said to staff she was trying to go somewhere but could not recall where. The progress note, dated 1/13/26 at 4:31 p.m., revealed an IDT meeting reviewing recent falls and fall interventions. The progress note documented the nursing recommendation to change the call light to a touch pad call light for visual reminder to use the call light. The progress note documented no other recommendations from other departments at this time.6. Fall on 2/2/26 - unwitnessed The progress note, dated 2/2/26 at 5:45 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found on the fall mattress next to her bed. The progress note documented Resident #5 appeared as though she attempted to do a flip and was unable to finish. The progress note documented the resident denied pain and appeared without injuries.7. Fall on 2/5/26 - unwitnessed The progress note, dated 2/5/26 at 5:42 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented an unidentified staff member witnessed Resident #5 slide out of her recliner onto the floor. The progress note documented Resident #5 denied pain and appeared without injuries. The progress note, dated 2/6/26 at 9:00 a.m., revealed an IDT meeting reviewing falls and fall interventions. The progress note documented the nursing recommendation was to re-educate Resident #5 about using her reaching device and to educate staff to ensure reaching device and frequently used items were in reach. The progress note documented no other recommendations from other departments at this time. IV. Staff interviewsCNA #7 was interviewed on 2/11/26 at 10:13 a.m. CNA #7 said they checked on Resident #5 frequently because she did not use her call light consistently. CNA #7 said they did not remember seeing Resident #5 falling or attempting to ambulate without assistance, but they were aware she had fallen frequently. CNA #7 said they used the fall mat next to her bed because the family wanted Resident #5 to use her own bed instead of a low bed provided by the facility. CNA #7 said Resident #5 required assistance with all transfers and could not ambulate more than a few steps without assistance. CNA #7 said Resident #5 was inconsistent when reporting her needs or if she was incontinent. The director of therapy services was interviewed on 2/12/26 at 11:21 a.m. The director of therapy services said she remembered she previously provided therapy to Resident #5 from 10/24/24 through 11/29/24 when the resident experienced a fall with a wrist fracture. The director of therapy services said she was not sure why therapy services stopped at the time. The director of therapy services said they thought they offered therapy again after another fall but Resident #5 refused. The director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The NHA said the facility started a Quality Assurance and Performance Improvement (QAPI) plan due to the facility having 21 falls in August of 2025. The NHA said the goal of the plan was to reduce the number of falls to 10 falls or less per month, and the facility met their goal by November 2025. The NHA said interventions from the QAPI plan included a post fall IDT huddle within 24 hours post fall and a weekly IDT review of all falls. The NHA said residents who had more than five falls had a root cause analysis completed. The NHA said she completed a root cause analysis for Resident #5 after her fall on 2/5/26. The NHA said the root cause analysis revealed Resident #5 frequently overestimated her abilities and attempted to ambulate without assistance due to her dementia. The NHA said the rearranging of Resident #5's furniture was also not an effective intervention because the family wanted to move the furniture back shortly after. The NHA said the family also refused to use a low bed or hospital bed as interventions. The NHA said the root cause analysis showed her the previous interventions of reminding and educating Resident #5 would not have been effective due to her impaired cognition.

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for two out of four units.Specifically, the facility failed to:- Use appropriate infection control practices related to hand hygiene.- Follow infection prevention practices during the wound care of Resident #2 Findings include: I. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, retrieved on 2/18/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, It read in pertinent part, CDC provides the following recommendations for hand hygiene in healthcare settings. Know when to clean your hands: immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal. When to use an alcohol-based hand sanitizer (ABHS): Unless hands are visibly soiled, ABHS is preferred over soap and water in most clinical situations because: it is more effective at killing germs on hands than soap; easier to use when providing care, especially when moving from soiled to clean activities on the same patient or when moving between care of patients in shared rooms; results in improved skin condition with less irritation and dryness than soap and water; improves hand hygiene adherence. When to wash with soap and water: when hands are visibly soiled; before eating; after using the restroom; during the care of patients with suspected or confirmed infection during outbreaks of C. difficile and norovirus. II. Facility policy and procedure The Handwashing/Hand hygiene policy, revised October 2023, was provided by the nursing home administrator (NHA) on 2/11/26 at 2:46 p.m. It revealed in pertinent part, Hand hygiene is indicated: immediately before touching a resident; before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations Wash hands with soap and water: when hands are visibly soiled; and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. Single-use disposable gloves should be used; before aseptic procedures; when anticipating contact with blood or body fluids; and when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. The use of gloves does not replace hand washing/hand hygiene. III. Observations On 2/10/26 at 8:52 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. Prior to the start of the room cleaning, houseHK #1 performed hand hygiene using ABHS and donned gloves. During the observation, HK #1 failed to remove their gloves and perform hand hygiene after cleaning the resident's bathroom including the toilet. HK #1 then grabbed clean hand towels from the covered linen bag on her housekeeping cart without removing the soiled gloves. HK #1 finished cleaning the room by mopping the residents bedroom floor and bathroom floor without removing the soiled gloves or completing hand hygiene. On 2/11/26 at 11:22 a.m. housekeeper #2 was observed cleaning room [ROOM NUMBER]. Prior to the start of the room cleaning, HK #2 performed hand hygiene using ABHS and donned gloves. During the observation, HK #2 failed to remove their gloves and perform hand hygiene after taking out the trash. HK #2 then used a new washcloth to clean the surfaces in the bathroom, obtained new clean hand towels from the covered linen bag, cleaned the toilet, mopped the bedroom and bathroom floor without removing the soiled gloves or performing hand hygiene. On 02/10/26 at 1:13 p.m. registered nurse (RN) #3 completed wound care for Resident #2. RN #3 completed hand hygiene and donned appropriate enhanced barrier precautions prior to the wound care. However, after removing the soiled dressing from Resident #2's heel, RN #3 changed gloves but failed to complete hand hygiene or use an ABH) before donning new gloves. RN #3 applied medihoney to the wound bed as ordered, however RN #3 used her gloved finger instead of a sterile application tip. IV. Staff interviews RN #3 was interviewed on 02/10/2026 at 1:32 p.m. RN #3 said she was not sure why the previous dressing was not dated or labeled. RN #3 said she did not complete hand hygiene or use an ABHS after removing her soiled gloves and prior to donning new gloves because she was not aware she needed to, and thought changing gloves was sufficient. RN #3 said she typically applied topical treatments to wound beds using her gloved finger and did not think to bring a sterile tip applicator. RN #3 said the sterile tip applicators were not in the bin of wound care supplies, but she knew the facility stored them somewhere. RN #3 said she planned to find the sterile tip applicators and add them to the wound care supplies for future use. HK #2 was interviewed on 2/11/26 at 11:31 a.m. HK #2 said she normally changed her gloves during the linen change, after removing the dirty linen and prior to placing the clean linen. Housekeeper #2 said she did not change gloves while cleaning the room because the resident was in bed and did not want her linens changed. HK #2 said she thought she did not need to change gloves because she cleaned the room by completing the dirtiest tasks last. The housekeeping supervisor was interviewed on 2/11/25 at 2:28 p.m. The housekeeping supervisor said housekeepers should perform hand hygiene and don gloves prior to cleaning, after cleaning was completed, and whenever they were handling a soiled item while cleaning. However, they did not necessarily need to change gloves or perform hand hygiene during the clean because each housekeeper was trained to clean from the cleanest areas to the dirtiest. The housekeeping supervisor said the last areas the housekeepers should clean were the bathroom counters and then the toilet as the last item. The housekeeping supervisor said she was not aware the housekeepers were not cleaning the toilet last as instructed, and she was not aware the housekeepers were handling clean linens while wearing soiled gloves. The housekeeping supervisor said the risk of improper hand hygiene techniques while cleaning was the chance for cross contamination. The housekeeping supervisor said each department supervisor was responsible for training their staff on proper hand hygiene. The director of nursing (DON) and the NHA were interviewed together 02/11/26 at 12:55 p.m. The DON said she completed annual hand hygiene education and competency evaluations for the nursing staff in the facility. The DON said the risk of handling clean items with soiled gloves was the possible cross contamination of bacteria or fecal matter. The DON said each department had specific areas reviewed in their annual competency evaluation, but all employees completed annual training and competency evaluations regarding hand hygiene. She said she was not certain what additional training the non nursing departments received since each department was responsible for training their staff. The DON said it was an expectation for nurses to complete hand hygiene or use an ABHS and don clean gloves after removing the soiled dressing. The DON #2 said RN #2 should not have used a glove finger when applying the topical treatment to the wound bed because you cannot guarantee the glove was not contaminated, but RN #2 might have been confused because some previous orders have specifically said not to use a sterile tip applicator. The infection preventionist (IP) on 02/11/26 at 2:47 p.m. The IP said training and competency evaluation regarding hand hygiene was completed with all staff on hire and annually. The IP said each department supervisor was responsible for additional training on hand hygiene and could give corrective education any time they observed poor hand hygiene. The IP said each supervisor could decide to audit staff hand hygiene at any time, but the facility did not currently complete audits of hand hygiene for any departments on a regular interval. The IP said housekeeping staff should be performing hand hygiene and changing gloves any time they handle a dirty item. The IP said touching clean items using dirty gloves could cause cross contamination onto the clean items or cleaning supplies. The IP said dietary staff should also complete hand hygiene frequently and with each tray pass because they may inadvertently touch resident items while assisting with meal set up, and traveling from room to room without hand hygiene could cause the spread of pathogens. The IP said it was an expected professional standard for nurses to complete hand hygiene or use an ABHS and don clean gloves after the removal of a soiled dressing. The IP said this was because gloves cannot be guaranteed to be sterile. The IP said this was also the reason staff should not use a gloved finger to apply topical treatments to a wound bed. The IP said they should use a sterile tip applicator, but may also use another sterile dressing or item. The IP said not using wound cleanser as indicated in the wound care order could increase the risk of the wound becoming infected. V. Failed to ensure nursing staff used hand hygiene appropriately during medication administration A. Observations and staff interviews On 2/11/26 at 10:48 a.m. registered nurse (RN) #1 and RN #2 (who was mentoring RN #1) entered Resident #18's room to administer medications. Both RN #1 and RN #2 did not perform hand hygiene prior to preparing medications, prior to entering the resident room to administer medications or upon leaving the resident's room. On 2/11/26 at 11:05 a.m. RN #1 and RN #2 entered Resident #25's room to administer medications. Both RN #1 and RN #2 did not perform hand hygiene prior to preparing medications, prior to entering the resident room to administer medications or upon leaving the resident's room. On 2/11/26 at 11:24 a.m. RN #1 prepared an ophthalmic (eye) ointment medication to administer to Resident #10. He did not use hand hygiene prior to preparing the medication. RN #1 was interviewed on 2/11/26 at 11:25 a.m. RN #1 said he should have used hand hygiene prior to and after administering medications to Resident #18 and Resident #25. B. Staff interviews RN #2 was interviewed on 2/11/26 at 11:26 a.m. RN #2 said he forgot to use hand hygiene in both residents' rooms. RN #2 said both RN #1 and RN #2 should have used hand hygiene prior to entering and upon leaving the residents' rooms to prevent the spread of infection. The IP was interviewed on 2/11/26 at 3:00 p.m. The IP said nursing staff should use hand hygiene prior to and after administering medications to prevent the spread of infection to other residents.

Based on observations, record review and interviews, the facility failed to ensure COVID-19 vaccinations were administered for five (#10,#24, #30, #35 and #5) of five residents out of 32 sample residents.Specifically, the facility failed to offer COVID-19 vaccine to Residents #10, #24, #30, #35 and #5, who requested one when they were offered. Findings include:I. Facility policy and procedureThe Coronavirus Disease (COVID-19) - Vaccination of Residents policy, revised August 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 5:01 p.m. It revealed in pertinent part, The COVID-19 vaccine may be offered and provided directly by the LTC facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by their designee. Vaccines are administered in accordance with CDC, ACIP, FDA, and manufacturer guidelines. Facility data on resident vaccine status is reported to the NHSN by the infection preventionist. The resident's medical record includes documentation that indicates, at a minimum, the following: The resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; each dose of COVID-19 vaccine administered to the resident (or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal; signed consent; date of administration; any adverse effects associated with administration; and type, manufacturer, lot number, and administration site of each dose of COVID-19 vaccine that was administered to the resident.II. Resident #35A. Resident statusResident #35, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included diabetes, Guillain-Barre syndrome (a neurological condition where the immune system attacks peripheral nerves), respiratory failure, quadriplegia (partial or total loss of function in all four limbs and the torso), depression and anxiety. The 1/1/26 minimum data set (MDS) assessment revealed Resident #35 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #35 was dependent on staff for toileting, bathing, lower body dressing, footwear and personal hygiene. Resident #35 required maximum assistance with upper body dressing and partial assistance with oral hygiene. The MDS assessment revealed Resident #35's COVID-19 vaccination was not up to date.B. Resident interviewResident #35 was interviewed on 2/12/26 at 1:12 p.m. Resident #35 said she remembered she was asked if she wanted the COVID-19 vaccine in October of 2025, but she never received one. Resident #35 said she was not sure why she never received the COVID-19 vaccine for this year, and she did not remember a staff member providing any update when she did not receive one. Resident #35 said she still wanted a COVID-19 vaccination for this year if the facility acquired them.C. Record reviewReview of Resident #35's electronic medical record (EMR) did not reveal the resident was administered the COVID-19 vaccine or education regarding the COVID-19 vaccine. III. Resident #30A. Resident statusResident #30, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included anemia, hypertension, paroxysmal atrial fibrillation, dysphagia and generalized muscle weakness. The 11/6/25 MDS assessment revealed Resident #30 was cognitively intact with a BIMS score of 15 out of 15. Resident #30 required supervision or touching assistance with toileting, bathing, oral and personal hygiene, upper and lower body dressing as well as footwear. The MDS assessment documented Resident #30 was up to date on his COVID-19 vaccination.-However, review of Resident #30'sEMR revealed no documentation of education, administration, or refusal of the updated 2025 COVID-19 vaccination. B. Resident interviewResident #30 was interviewed on 2/12/26 at 1:17 p.m. Resident #30 said he lived at the facility with his spouse. Resident #30 said they were both offered this season's COVID-19 vaccine sometime last fall, but he could not remember the exact date. Resident #30 said to his knowledge neither of them ever received an updated COVID-19 vaccination. He said he was not sure if they would still want the vaccine now since it was already late in the cold and flu season and he would like the facility to offer or review the information with him again.C. Record reviewReview of Resident #30's EMR revealed no documentation that the COVID-19 vaccine was administered, education or corresponding declination form.IV. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included hypertension, hyperlipidemia, presence of a left artificial hip, generalized muscle weakness, abnormal gait and mobility, dementia with mood disturbance, cognitive communication deficit, hypothyroidism, protein-calorie malnutrition. The 1/1/26 MDS assessment revealed Resident #10 had moderate cognitive impairment with a BIMS score of 12 out of 15. Resident #10 required supervision or touching assistance with toileting, bathing, oral and personal hygiene, upper and lower body dressing as well as footwear. The MDS assessment documented Resident #10 was not up to date on her COVID-19 vaccination.B. Record reviewReview of Resident #30's EMR revealed no documentation of COVID-19 vaccine administration, education or corresponding declination form.V. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included chronic kidney disease, generalized muscle weakness, dementia with behavioral disturbance, generalized anxiety, transient ischemic attack (TIA) cerebral infarction without residual deficits (stroke), abnormal gait and mobility, history of falling and history of COVID-19.The 11/30/25 MDS assessment revealed Resident #5 had severe cognitive impairment with a BIMS score of five out of 15. Resident #5 required substantial/maximal assistance with bathing. Resident #5 required supervision or touching assistance with toileting, oral and personal hygiene, upper and lower body dressing as well as footwear. The MDS assessment documented Resident #5 was up to date on her COVID-19 vaccination.B. Record reviewReview of Resident #5's EMR revealed no documentation of COVID-19 vaccine administration, education or corresponding declination form.V. Resident #24A. Resident statusResident #24, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included generalized muscle weakness, dementia with anxiety, hearing loss, depression, abnormal gait and mobility, pulmonary embolism and hypertension.The 1/8/26 MDS assessment revealed Resident #24 had severe cognitive impairment with impaired short term and long term memory. The MDS assessment documented Resident #24 had severely impaired cognitive decision making skills with disorganized speech. T. Resident #24 required supervision or touching assistance with eating. Resident #24 required moderate assistance with toileting, oral and personal hygiene, upper and lower body dressing as well as footwear. Resident #24 required substantial/maximal assistance with bathing. The MDS assessment documented Resident #5 was up to date on her COVID-19 vaccination.B. Record reviewReview of Resident #24's EMR revealed no documentation of COVID-19 vaccine administration, education or corresponding declination form.VI. Facility tracking documentAn internal tracking document, last updated 9/29/25, was provided by the director of nursing (DON) on 2/11/26 at 6:12 p.m. It revealed in pertinent part,Residents #5's representative was offered the COVID-19 vaccine but declined. Residents #10, #24, #30 and #35 and an additional 19 residents or resident representatives each answered yes when offered the updated 2025 COVID-19 vaccination.VII. Staff interviewsThe infection preventionist (IP) was interviewed on 2/12/26 at 11:12 a.m. The IP said to her knowledge, the facility had not administered the updated 2025 COVID-19 vaccination to any residents due to billing questions raised by the previous DON. The IP said the previous DON typically tracked and managed immunizations for all residents in the facility. The IP said the previous DON was working at the time of the vaccine screenings and she remembered the previous DON said she was not sure who was going to cover the cost of the vaccines, saying some families would not want to pay out of pocket for them. The IP said the previous DON left the facility shortly after and the IP said she was not sure if the current interim DON was aware if part of her duties were to manage and track resident vaccinations. The IP said all residents should have documentation of vaccine education and administration or refusal each year, even if a resident refused the COVID-19 vaccine a previous year. The DON and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The DON said she was only aware no residents in the facility received the updated 2025 COVID-19 vaccine until the survey. The DON said she was aware one of her responsibilities was to offer, track and order vaccines for the residents, but she was not aware the previous DON did not finish this task before she left last fall. The DON said they completed an annual audit of all immunizations for residents, but this system failed since they were not aware of the missed vaccine administrations. The DON said she was aware all residents needed to be offered the annual COVID-19 vaccine each year, but she was not aware each resident had to have documentation of education and either vaccine administration or declination in their EMR. The DON said she was not sure how many residents requested the updated 2025 COVID-19 vaccination and did not receive one, but she would assume each resident who answered yes on the provided tracking document would want the vaccine and none of those residents received one. The NHA said they planned to rescreen every resident in the facility, starting with all of the residents who responded yes on the provided tracking document. The DON said it was important to administer the updated 2025 COVID-19 vaccine to all residents who requested it because the population of residents in the facility were more vulnerable to serious respiratory illness compared to the average person.

Based on observations, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being one (#15) of six residents reviewed for unnecessary medications out of 32 sample residents. Specifically, the facility failed to discontinue or reevaluate a physician's order for Resident #16's as needed (PRN) lorazepam (an antianxiety medication) after 14 days. Findings include:I. Facility policy and procedureThe Psychotropic Medication Use policy, revised February 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 5:01 p.m. It revealed in pertinent part, Psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. Psychotropic medications may be used on a PRN basis in certain situations, for example: while the dose is being adjusted; to address acute or intermittent symptoms; or in an emergency. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. For psychotropic medications that are antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.II. Resident #15A. Resident statusResident #15, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included mesothelioma, history of malignant neoplasm of the prostate, malignant neoplasm of the bronchus or lung, agranulocytosis secondary to cancer chemotherapy, generalized muscle weakness, repeated falls, cerebral infarction without residual deficits, insomnia, depression, anxiety, hyperlipidemia and chronic hypoxic respiratory failure.The 12/2/25 minimum data set (MDS) assessment revealed Resident #15 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 was dependent on staff for toileting, bathing, lower body dressing, footwear and personal hygiene. Resident #15 required set up assistance to eat. Resident #15 required substantial/maximum assistance with toileting, upper body dressing, lower body dressing, footwear, personal hygiene and oral hygiene.B. Record reviewReview of Resident #15's November 2025 CPO revealed the following physician's order:Ativan (lorazepam) Oral Tablet 0.5 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for Anxiety, ordered on 11/25/25 and discontinued on 1/03/26. -This order was continued for a total 39 days, which was 25 days longer than the 14 day limit for as needed anti-anxiety medication usage. Review of Resident #15's November 2025 and December 2025 medication administration record (MAR) revealed one PRN dose was administered on 12/17/25.-A review of Resident #15's electronic medical record (EMR) revealed no documentation to indicate the physician had reevaluated the resident's PRN Ativan in order to justify the use of the medication beyond the 14-day limit for PRN medications. Review of Resident #15's January 2026 CPO revealed the following physician's order:Ativan (lorazepam) oral tablet 0.5 mg, give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days, ordered on 12/31/25. The order then specified to automatically restart four more additional times without clinical justification from the physician.Review of Resident #15's January 2026 and February 2026 MAR revealed no PRN doses were administered during the timeframe.Review of the most recent quarterly psychotropic medication review meeting, dated 11/24/25, the day prior to the start of the November 2025 PRN lorazepam order did not reveal documentation regarding the lorazepamIII. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The DON said she remembered placing the first PRN Lorazepam order for Resident #15 in November 2025 and the second set of Lorazepam orders in January 2026. The DON said she was aware PRN Lorazepam should be reviewed or discontinued after 14 days. The DON said she had just started in her role when she placed the PRN Lorazepam order in November 2025, and she did not know why the order did not include a proper end date. She said normally she spoke with the provider when the order was about to be discontinued and the provider would provide a verbal recommendation to continue to order or discontinue. The DON said she could not recall if she spoke with the provider about Resident #15's PRN Lorazepam orders. The DON said the PRN lorazepam orders for every two weeks, starting in January 2026, were all placed at the same time. The DON said the PRN Lorazepam orders were based on the recommendations from the hospice nurse. The DON said the facility keeps a supply of Lorazepam in their stat safe, and if the resident were to experience a change in condition indicating the use of PRN Lorazepam, the facility could contact the on-call provider or hospice agency at any time to obtain a new order. The DON said PRN lorazepam orders should be reviewed for continued use every 14 days because Lorazepam was a strong medication and the order should be discontinued if the resident did not need it.

Based on observations, record review and interviews, the facility failed to ensure two (#10 and #31) of eight residents out of 32 sample residents were free from abuse.Specifically, the facility failed to protect Resident #10 and Resident #31 from physical abuse toward each other. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) 2/9/26 at 1:33 p.m. It read in pertinent part, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff; other residents; consultants; volunteers; staff from other agencies; family members; legal representatives; friends; visitors; and/or any other individual. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations. Establish and implement a QAPI (Quality Assurance and Performance Improvement) review and analysis of reports, allegations or findings of abuse, neglect, mistreatment or misappropriation of property.II. Incident of resident-to-resident physical abuse between Resident #10 and Resident #31A. Facility investigationThe facility investigation was provided by the NHA on 2/11/26 at 11:27 a.m. The investigation documented that on 11/6/25 at 3:00 p.m. Resident #31 approached Resident #10 and placed her hands on Resident #10's walker. Resident #10 screamed and hit Resident #31 three times on the arm then Resident #31 hit Resident #10 once in the arm. The investigation documented the residents were separated from each other by certified nurse aide (CNA) #6.The facility investigation included a written statement by CNA #6, dated 11/6/25. The statement revealed CNA #6 witnessed Resident #31 approach Resident #10, then Resident #10 screamed and CNA #6 witnessed Resident #10 hit Resident #31 in the arm three times. The statement revealed CNA #6 then witnessed Resident #31 hit Resident #10 once in the arm. The statement revealed CNA #6 said Resident #10 thought Resident #31 was trying to steal her walker. The facility investigation included an interview with Resident #10, conducted by the NHA, dated 11/6/25. The interview revealed Resident #10 said she thought Resident #31 was trying to steal her walker, so she hit her. The facility investigation revealed Resident #31 was interviewed on 11/6/25 and had no recollection of the event. The facility investigation revealed each resident was placed on 15-minute rounds for the next 72 hours. The facility investigation included 15-minute rounds logs of Resident #10 and Resident #31 with no changes in behavior from baseline. The facility investigation revealed five additional residents were interviewed and five additional staff members were interviewed. The facility investigation revealed no other residents reported witnessing any situations in which a resident was physically harmed by a staff member or another resident, and no other residents reported feeling unsafe in the facility. The facility investigation revealed no other staff members reported witnessing or having been told any situations in which a resident was physically harmed by a staff member or another resident. The facility investigation revealed the incident was witnessed and substantiated the resident-to-resident physical abuse.The facility investigation documented Resident #10 was the assailant. The facility investigation revealed new interventions to prevent resident-to-resident physical abuse were added to Resident #10's care plan. Staff were to encourage Resident #10 to watch television (TV) in the living room and encourage Resident #10 to call for assistance when personal space was invaded.-However, despite Resident #10 and Resident #31 hitting each other, the facility investigation documented Resident #10 as the only assailant and Resident #31 as the only victim. The facility investigation revealed no changes were made to Resident #31's care plan. B. Resident #10 (assailant and victim)1. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included hypertension, hyperlipidemia, presence of a left artificial hip, generalized muscle weakness, abnormal gait and mobility, dementia with mood disturbance, cognitive communication deficit, hypothyroidism, protein-calorie malnutrition. The 1/1/26 minimum data set (MDS) assessment revealed Resident #10 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #10 required supervision or touching assistance with toileting, bathing, oral and personal hygiene, upper and lower body dressing as well as footwear.2. Record reviewResident #10's care plan, updated 11/11/25, revealed Resident #10 was at risk for resident-to-resident altercations related to individuals invading Resident #10's personal space. Interventions included educating staff regarding Resident #10's need for personal space, redirecting Resident #10 if she became aggressive toward others, offering Resident #10 her own place to sit in the common areas, offering her a quiet space when agitated when Resident #10's personal space was invaded and offering independent activities, such as drawing, writing, and watching westerns on TV. Interventions added to Resident's #10's care plan on 11/11/25 (after the resident-to-resident altercation) included encouraging Resident #10 to watch TV in the common area to protect her personal space and encouraging Resident #10 to call staff for assistance when others invaded her personal space.The progress note, dated 9/2/25 at 10:06 p.m., revealed Resident #10 was observed slapping another resident (Resident #31) on the arm. Resident #10 reported she did not want the other resident to sit next to her. The progress not documented the residents were separated and placed on frequent monitoring. The skin assessment, dated 11/6/25 at 3:21 p.m., documented Resident #10 had no new skin issues.The progress note, dated 11/6/25 at 3:49 p.m., documented Resident #10 was at psychosocial baseline and was in the common area watching TV.-Review of Resident #10's progress notes revealed no documentation of the resident-to-resident physical abuse between Resident #10 and Resident #31 on 11/6/25.C. Resident #31 (assailant and victim)1. Resident statusResident #31, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included Alzheimer's disease, diabetes, essential tremor, anxiety, depression, insomnia, hypothyroidism, hyperlipidemia and a history of falls. The 11/13/25 MDS assessment revealed Resident #31 had severe cognitive impairment with impaired short term and long term memory. The MDS assessment revealed staff assessments of Resident #31 indicated the resident had impaired cognitive skills for decision making, inattention and disorganized thinking. The MDS assessment documented Resident #31 experienced hallucinations and delusions. The MDS assessment documented Resident #31 had frequent physical behavioral symptoms directed toward others. The assessment indicated the resident did not wander. Resident #31 required supervision when eating, moderate assistance with upper body dressing, substantial assistance with lower body dressing, footwear, toileting, personal hygiene and oral hygiene. Resident #31 was dependent on staff for bathing. 2. ObservationsOn 2/9/26 at 8:43 a.m. Resident #31 was observed wandering at the end of the 200 hall. Resident #31 was pulling on cords attached to window blinds at the end of the hall. Resident #31 could not recall her name or what town she was in. Resident #31 pulled on the cords for less than five minutes before wandering back to the common area. On 2/10/26 at 11:44 a.m. Resident #31 was observed wandering into room [ROOM NUMBER]. Resident #31 left the room shortly after as the room was empty.3. Record reviewResident #31's care plan, updated 11/15/25, revealed a wandering care plan. Interventions included redirecting Resident #31 out of other residents' rooms, encouraging Resident #31 to participate in activities and implementation of a wander guard with ongoing assessments for appropriate use. -However, review of Resident #31's care plan revealed no documentation indicating Resident #31's risk for resident-to-resident altercations due to her wandering.The long-term care evaluation note, dated 10/25/25 at 2:44 p.m., documented Resident #31 was observed with chronic behaviors of wandering during the day, intermittent sleep with wandering at night and refusal of medications.The skin assessment, dated 11/6/25 at 3:31 p.m., documented Resident #31 had no new skin issues. The progress note, dated 11/6/25 at 3:50 p.m., documented Resident #31 was at psychosocial baseline. The progress note documented Resident #31 was wandering hallways visiting other staff members and at times sitting and reading paper.-Review of Resident #31's progress notes revealed no documentation of the resident-to-resident physical abuse between Resident #10 and Resident #31 on 11/6/25.III. Staff interviewsCNA #8 was interviewed on 2/11/26 at 10:13 a.m. CNA #8 said all nursing staff did their best to keep track of Resident #31 since she wandered around the facility and had been found wandering in other residents' rooms. CNA #8 said normally Resident #31 was easy to redirect to another space, but some residents did not like anyone unexpectedly entering their room or getting too close to their personal space. CNA #8 said Resident #10 was one of the residents that she knew did not like people touching her or her things. CNA #8 said they provided Resident #10 her own chair in the common area, not only to respect her space, but because the chair was also located in line of sight with staff in the nurses' station. The director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The NHA said Resident #10 was indicated as the only assailant and Resident #31 was indicated as the only victim because during the investigation, they thought Resident #31 only hit Resident #10 as a reaction to being hit by Resident #10. The NHA said she was not sure why the progress notes on the day of the resident-to-resident physical abuse between Resident #10 and Resident #31 did not describe the events, but the facility started the investigation immediately and maybe the nurse who completed the documentation thought the statements gathered during the investigation were adequate documentation of the event. The NHA said the facility had not previously considered that Resident #31 was at risk for future resident-to-resident altercations due to her wandering. The NHA said the facility planned to update the care plan for Resident #31 and educate staff.The DON and the NHA were interviewed together again on 2/12/26 at 5:13 p.m. The NHA said the facility had updated the care plan for Resident #31 and provided written education to all staff.

Based on record review and interviews, the facility failed to report an alleged violation to the state survey and certification agency in accordance with state law for one (#49) of eight residents reviewed for an injury of unknown source out of 32 sample residents.Specifically, the facility failed to report Resident #49's death which resulted from an injury of unknown source, to the state oversight office, when the resident was found on the floor, unresponsive, with her head and neck lying on a trash can, with a coroner's finding of preliminary cause of death to be positional asphyxiation (suffocation). Findings include:I. Facility policy and procedure The Abuse Investigation and Reporting Policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 12:37 p.m. It read in pertinent part, All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator or his/her designee to the following: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsmen, the resident's representative (sponsor) or record, adult protective services (where state law provides jurisdiction in long-term care), law enforcement officials, the resident's attending physician and the facility medical director. II. Facility investigationThe facility's investigation for Resident #49's accident/death was provided by the NHA on [DATE] at 3:20 p.m. The investigation included an undated handwritten statement by the NHA that she was notified on [DATE] at 5:30 a.m. that Resident #49 had been found on the floor in her room unresponsive and was deceased . The statement documented the coroner had been at the facility after Resident #49's death and returned to the facility to interview staff. -The investigation was not reported to the State Agency as required.III. Resident #49A. Resident statusResident #49, age [AGE], was admitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic respiratory failure, high blood pressure, kidney disease and neurogenic bladder (nerve damage from injury or disease).The [DATE] minimum data set (MDS) assessment identified Resident #49 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident required set-up assistance with eating, moderate assistance with personal hygiene, toileting, dressing and transferring and substantial assistance with showering.B. Staff interviewsThe coroner was interviewed on [DATE] at 8:00 a.m. The coroner said the deputy coroner contacted him on [DATE] and said Resident #49's death was suspicious. The coroner said the mystery was why the resident decided to get up without assistance. The coroner said he was waiting for additional information, but the preliminary cause of Resident #49's death was positional asphyxiation. The coroner said he did not think the facility failed to prevent an accident, and her death would probably be determined to be an accident. The coroner said his initial concern was that there was a suspicious death and the facility had not notified the coroner after her death.The director of nursing (DON) and the NHA were interviewed together on [DATE] at 9:47 a.m. The NHA said she was notified of Resident #49's death and was initially told Resident #49 was found lying face down in her room and was unresponsive. The NHA said on [DATE] at 9:15 a.m. she received a call from the social services director (SSD). She said the SSD told her the coroner had been asking questions and would come back to the facility to interview staff. The NHA said the coroner returned to the facility on [DATE] and asked for LPN #2 to clarify her progress note to match what she had told him, specifically that Resident #49 was found lying with her head on the trash can.The NHA said she knew on the day of the incident that the coroner was looking into the accident. The NHA said she did not think she needed to complete a facility investigation or report an occurrence because the coroner was investigating Resident #49's cause of death. The NHA said the facility did not report the incident as an occurrence and did not notify the police or adult protective services. The NHA said the coroner told her on [DATE] or [DATE] that he did not think anything malicious had occurred, however the NHA also said Resident #49's preliminary cause of death was asphyxiation. The NHA said a full facility investigation would include witness statements and interviews with staff, and also a timeline of events. She said at least five residents should be interviewed during investigations. The NHA said the facility could have done a better investigation. The NHA was interviewed again on [DATE] at 2:25 p.m. The NHA said based on the information that she had about Resident #49's injury of unknown source and unexpected death, the facility should have reported her death as an occurrence and investigated thoroughly. -Cross reference F610, the facility failed to thoroughly investigate an alleged violation.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of two medication storage carts.Specifically, the facility failed to:-Date residents' insulin pens and inhaler with the date they were opened; -Label a nasal spray with the resident's name;-Ensure a medication was not at the resident's bedside without an order; and,-Discard medications that have expired. Findings include:I. Professional referencesAccording to the manufacturer, Sanofi-Aventis, How to Use Your Lantus SoloStar Pen, August 2022, retrieved on 2/16/26 from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8ba629a/lantus-solostar-pen-guide.pdf After 28 days, throw your opened Lantus pen away-even if it still has insulin in it.According to the manufacturer, GlaxoSmithKline, Patient Information Advair Diskus (fluticasone propionate and salmeterol inhalation powder), June 2023, retrieved on 2/16/26 from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Inforamtion/Advair_Diskus/pdf/ADVAIR-DISKUS-PI-PIL-IFU.PDF#nameddest=PIL Safely throw away Advair Diskus in the trash one month after you open the foil pouch or when the counter reads zero, whichever comes first.II. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was provided by the nursing home administrator (NHA) on 2/11/26 at 3:46 p.m. It read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The medication label includes at a minimum: medication name, prescribed dose, strength, expiration date, when applicable, resident's name, route of administration and appropriate instructions and precautions. Only the dispensing pharmacy may label or alter the label on a medication container or package.III. Observations and interviewsOn 2/9/26 at 12:15 p.m., a used eight ounce bottle of Equate stomach relief was observed on Resident #4's bedside table. Resident #4 said she took the medication when she needed to for stomach aches. Resident #4 said she took the medication on the morning of 2/9/26. Resident #4 said she did not know if nursing staff knew she had taken the medication.On 2/11/26 at 11:44 a.m., the #1 medication administration cart was observed with licensed practical nurse (LPN) #1. The following medications were found:- A used Lantus SoloStar 100 units per milliliter (ml) injectable insulin pen for Resident #7 which was not labeled with the date it was opened.- A used Lantus SoloStar 100 units per ml injectable insulin pen for Resident #19 which was not labeled with the date it was opened.LPN #1 said there should be a date opened on both insulin pens as they were only good for 28 days after opening and the insulin pens should be discarded. LPN #1 said the insulin could be less effective if used beyond expiration.-An unlabeled bottle of Nasacort nasal spray.LPN #1 said the bottle should be labeled with the resident's name.-A used fluticasone propionate and salmeterol (Advair Diskus) inhaler 250 microgram (mcg)/50 mcg for Resident #19 which was not labeled with the date it was opened.LPN #1 said the inhaler should be labeled with the date it was opened.-An unopened floor stock bottle of famotidine 20 milligrams (mg) with an expiration date of January 2026.LPN #1 said the famotidine medication should have been discarded in January 2026.-A used bottle of Neilmed earwax softener drops (carbamide peroxide 6.5%) for Resident #16 with an expiration date of September 2025.LPN #1 said the earwax drops should have been discarded when they expired.IV. Staff interviewsThe director of nursing (DON) was interviewed on 2/11/26 at 12:55 p.m. The DON said the insulin and inhaler should have been labeled with the date opened as they could be less effective if used too long. The DON said the expired medications should have been discarded upon expiration. The DON said the nasal spray should have been labeled with the resident's name. She said all of these medications had been discarded.The DON was interviewed again on 2/11/26 at 3:30 p.m. The DON said the Equate stomach relief medication was found in Resident #4's room on 2/11/26 by nursing staff. The DON said the medication had been removed from Resident #4's room and it should be stored in the medication storage cart.The DON was interviewed again on 2/12/26 at 2:41 p.m. The DON said she discovered there had not been a physician's order for the stomach relief medication which had been at Resident #4's bedside. The DON said Resident #4 should not be permitted to store any medications at her bedside as she was unable to manage the medication administration.

Based on record review and interviews, the facility failed to fully investigate and document an investigation for one (#49) of eight residents reviewed out of 32 sample residents. Specifically, the facility failed to conduct and document a thorough investigation of Resident #49's death which resulted from an injury of unknown source, when the resident was found on the floor, unresponsive, with her head and neck lying on a trash can, with a coroner's finding of preliminary cause of death to be asphyxiation (suffocation). Findings include:I. Facility policy and procedureThe Abuse Investigation and Reporting Policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 12:37 p.m. It read in pertinent part, If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. The administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The administrator will keep the resident and his/her representative informed of the progress of the investigation. The individual conducting the investigation will, at a minimum review the completed documentation forms, review the resident's medical record to determine events leading up to the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview resident's roommate, family members and visitors, review all events leading up to the alleged incident. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator.II. Facility investigationThe facility's investigation for Resident #49's accident/death investigation was provided by the NHA on [DATE] at 3:20 p.m. The investigation included an undated handwritten statement by the NHA that she was notified on [DATE] at 5:30 a.m. that Resident #49 had been found on the floor in her room unresponsive and was deceased . The statement documented the coroner had been at the facility after Resident #49's death and returned to the facility to interview staff. The investigation included an undated handwritten statement from certified nurse aide (CNA) #2. It documented she was contacted by another CNA to go to Resident #49's room after she was found unresponsive. It documented she assisted with moving Resident #49 to the bed and assisted with providing the resident's bath after her death.The investigation included a handwritten statement from licensed practical nurse (LPN) #2 on [DATE]. It documented Resident #49 was found lying on the floor in front of her recliner with her head and neck laying in the trash can.The investigation included a statement documented on [DATE] (three weeks after the incident) by LPN #3. The investigation included three additional undated handwritten statements by CNA #1, CNA #3 and CNA #4.-All of the CNAs documented they had not seen the resident that night during their entire shift until [DATE] at 5:30 a.m., when the resident was found unresponsive. The investigation included record of call light audit for the night of [DATE] that revealed Resident #49 had not used her call light.The investigation included the resident's medication administration record.-The investigation did not include documentation of any staff or resident interviews. -The investigation did not include any communications with authorities or reporting to state agency.Cross-reference F609, reporting of alleged violations to the state oversight office. -The investigation did not include any evaluation of the incident, clarification of conflictual witness statements (see facility investigation above and interviews below) or investigative conclusions.III. Resident #49A. Resident statusResident #49, age [AGE], was admitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic respiratory failure, high blood pressure, kidney disease and neurogenic bladder (nerve damage from injury or disease).The [DATE] minimum data set (MDS) assessment identified Resident #49 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident required set-up assistance with eating, moderate assistance with personal hygiene, toileting, dressing and transferring and substantial assistance with showering.B. Record reviewA nursing progress note on [DATE] at 5:30 a.m. documented LPN #2 entered Resident #49's room to empty her catheter and found the resident lying on the floor in front of her recliner on her stomach. It documented Resident #49 was unresponsive. The note documented the nurse began cardiopulmonary resuscitation (CPR) on the resident until it was determined her code status was do not resuscitate (DNR), upon which CPR was stopped. The note documented CNAs transferred the resident to her bed. An additional nursing progress note entered as a late entry was dated [DATE] at 5:30 a.m. documented Resident #49 was found on the floor in front of her recliner with her head and neck lying on the trash can. A First Report-Coroner's Case document, dated [DATE], was provided by the coroner on [DATE] at 8:00 a.m. The report documented an interview with LPN #2 revealed she was the last person to see Resident #49 on [DATE] at 8:45 p.m. and when she returned to the room on [DATE] at 5:30 a.m., LPN #2 found Resident #49 on the floor lying face down in front of her seat lift recliner with her head resting on a small trash can against a wall. It documented LPN #2 initiated CPR until Resident #49's DNR status was determined. It documented the resident was moved by nursing staff to her bed, prior to the coroner evaluation. The report documented an interview with the medical director revealed he was notified Resident #49 was found on the floor, however the medical director was not told the resident's head was found in the trash can. The report documented interviews with nursing staff revealed the resident had always used her call light for staff to move the recliner position, yet the recliner was found in an elevated position. The report documented since the deceased had not been under hospice care and due to the circumstances it was advised to initiate a coroner investigation.C. Staff and additional interviewsLPN #2 was interviewed on [DATE] at 4:37 p.m. LPN #2 said she provided Resident #49's breathing treatment, and then left the room on [DATE] at approximately 9:30 p.m. LPN #2 said that Resident #49 did not like to be woken during the night. LPN #2 said that Resident #49 had everything in reach, including her call light. She said the next time she saw Resident #49 was at 5:30 a.m., when she went in the resident's room and found Resident #49 on the floor in front of her recliner with her head turned to the side and resting on a trash can. LPN #2 said when she turned Resident #49 over, there was a mark on the side of her neck where it had been laying on the trash can.The coroner was interviewed on [DATE] at 8:00 a.m. The coroner said the facility had provided conflicting information regarding Resident #49's death to the deputy coroner. The coroner said the facility staff had said that Resident #49 never operated her wheelchair independently and always called for assistance. The coroner said the facility had not notified the coroner of any deaths over the past year. He said after Resident #49's death he asked the facility to notify the coroner's office of all deaths until further notice, whether it was expected or not. The coroner said a resident representative told him that the facility called the representative to notify him of Resident #49's death and the facility said it appeared Resident #49 had a heart attack and was found on the floor. The coroner said he instructed the facility to leave a resident how they were found until the coroner came to the facility to investigate. The coroner said the statement from the nurse did not initially state that Resident #49 was found with her head lying on the trash can. The coroner said the deputy coroner contacted him on [DATE] and said Resident #49's death was suspicious. He said the resident had bruising on her arm and face. The coroner said the mystery was why the resident decided to get up without assistance. The coroner said he was waiting for additional information, but the preliminary cause of Resident #49's death was positional asphyxiation. The coroner said he did not think the facility failed to prevent an accident, and it would probably be determined to be an accident. The coroner said his initial concern was a suspicious death and the lack of notification to the coroner after her death.The director of nursing (DON) and the NHA were interviewed together on [DATE] at 9:47 a.m. The NHA said she was notified of Resident #49's death and was initially told Resident #49 was found lying face down in her room and was unresponsive. The NHA said on [DATE] at 9:15 a.m. she received a call from the social services director (SSD). She said the SSD told her the coroner had been asking questions and would come back to the facility to interview staff. The NHA said the coroner returned to the facility on [DATE] and asked for LPN #2 to clarify her progress note to match what she had told him, that Resident #49 was found lying with her head on the trash can.The NHA said she knew on the day of the incident that the coroner was looking into the accident. The DON said she started to ask nursing staff to write statements about the incident on or about [DATE], two weeks after the incident. The DON said she interviewed staff involved about Resident #49's death, but she was not sure when she interviewed the staff and she did not document any of the interviews. The DON said she should have documented the interviews. The NHA said she did not think she needed to do an investigation because the coroner was investigating Resident #49's cause of death. The DON said she interviewed LPN #2, LPN #3 and CNA #1, but did not document these interviews. The DON said there were other CNAs working that night, however she did not interview them. The DON said she should have interviewed anyone who went into Resident #49's room.The NHA said the facility did not report the incident as an occurrence and did not notify the police or adult protective services. The NHA said the coroner told her on [DATE] or [DATE] that he did not think anything malicious had occurred, however Resident #49's preliminary cause of death was asphyxiation. The NHA said a full facility investigation would include witness statements and interviews with staff, and also a timeline of events. She said at least five residents should be interviewed during investigations. The NHA said the facility could have done a better investigation. The NHA was interviewed again on [DATE] at 2:25 p.m. The NHA said based on the information that she had about Resident #49's injury of unknown source and unexpected death, the facility should have reported her death as an occurrence and investigated thoroughly. -Cross reference F609, Reporting of alleged violations.

Based on observation, record review and interviews the facility failed to ensure four (#11, #12, #21 and #46) out of 18 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure blood pressure medication was ordered with administration parameters for Residents #11, #12, #21 and #46. Findings include: I. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 1/19/24. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. According to [NAME], R.G., [NAME], R.J. (2022). Calcium Channel Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK482473/ retrieved on 1/19/24. Calcium channel antagonists, also known as calcium channel blockers (CCBs), have been widely used for many indications. This cardiovascular drug class is one of the leading causes of drug-related fatalities. Patients require close monitoring. The improvement of their symptoms of angina or maintenance of their blood pressure is an indication of efficacy (effectiveness for the desired result). Hypotension (low blood pressure) may be profound and life-threatening. Many factors may affect the severity of overdose, including the calcium-channel antagonist dose, the formulation, ingestion with other cardioactive medications such as beta-blockers, the patient's age, and comorbidities. These medications may also be life-threatening with as little as one tablet in small pediatric patients. Kiziior, R. J., [NAME], K. J. (2023). Lisinopril. [NAME] Nursing Drug Handbook. Elsevier. P. 704. Obtain blood pressure, apical pulse immediately before each dose in addition to regular monitoring (be alert to fluctuations). According to [NAME], L.L, [NAME], P, [NAME] K (2023) Hydrochlorothiazide. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK430766/ retrieved on 1/9/24. Hydrochlorothiazide is a medication to treat hypertension and peripheral edema. Blood pressure should be closely monitored to ensure patients on hydrochlorothiazide treatment achieve and maintain their target blood pressure, minimizing the risk of adverse effects associated with high or low blood pressure. II. Resident #11 A review of the December 2023 computerized physician orders (CPO) revealed: -Metoprolol Tartrate Oral Tablet 25 milligrams (mg). Give 0.5 tablet by mouth twice daily, started 11/29/23. A review of the December 2023 medication administration record (MAR) revealed: -Metoprolol was administered on 12/4/23, 12/11/23 and 12/15/23 when the resident's blood pressure was low with normal blood pressure being 120/80. A review of the December 2023 blood pressure summary showed Resident #11 had a blood pressure of 85/44 on 12/4/23, a blood pressure of 85/54 on 12/11/23 and a blood pressure of 70/38 on 12/15/23. II. Resident #12 A review of the December 2023 CPO revealed: -Lisinopril Oral Tablet 20mg. Give one tablet by mouth one time a day related to essential primary hypertension, started 11/2/23. A review of the December 2023 MAR revealed: -Lisinopril was given on 11/24/23, 11/30/23 and12/26/23. A review of the November 2023 and December 2023 blood pressure summary showed Resident #12 had a blood pressure of 84/56 on 11/24/23, a blood pressure of 89/57 on 11/30/23 and a blood pressure of 78/53 on 12/26/23. III. Resident #21 A review of the December 2023 CPO revealed: -Hydrchlorithiazide (HCTZ) Oral Tablet 12.5 mg. Give one tablet by mouth three times daily related to essential primary hypertension. A review of the October 2023 medication administration record (MAR) revealed the HCTZ medication was administered consistently according to the order. A review of the October 2023 medication regimen review from the pharmacist revealed the resident had a diastolic blood pressure of less than 60, six times during the previous 30 days and the medication was administered. The pharmacist recommended either eliminating the medication or adding hold parameters in order to lessen the potential fall risk associated with hypotension (low blood pressure), drug to drug interactions and side effects. IV. Resident #46 A review of the November 2023 CPO revealed: -Amlodipine Besylate Oral Tablet five mg. Give one tablet by mouth one time a day related to essential primary hypertension, date started 11/2/23 and was discontinued on 11/13/23. A review of the November 2023 MAR revealed amlodipine was given on 11/5/23. -A review of the November 2023 blood pressure summary showed Resident #46 had a blood pressure of 87/56 on 11/5/23. V. Interviews Registered nurse (RN) #1 was interviewed on 1/8/24 at 10:57 a.m. She said there were no standing orders for acceptable blood pressure ranges for residents on blood pressure medications. She said she used her own judgment when determining if the medication should be administered. She said the certified nurse aides with medication authority (CNA/MA) only took the resident's blood pressure when necessary as ordered by the physician. She said in most cases, the blood pressure was only ordered to be checked once daily. CNA/MA #1 was interviewed on 1/8/24 at 11:01 a.m. He said he checked residents' blood pressure if he was requested to and reported the results to the nurse on duty. The director of nursing (DON) was interviewed on 1/9/24 at 1:32 p.m. She said she was aware there were not currently any orders that directed staff on when it was appropriate to hold blood pressure medications. She said the CNA/MAs and nursing staff were to use good judgment and withhold medications when appropriate.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure reheated food reached the appropriate temperature; and, -Ensure beard nets were worn in the kitchen. Findings include: I. Reheated food A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. (Retrieved 1/10/24) B. Observations Cook #1 was asked on 1/7/24 at 11:52 a.m. to reheat soup that was brought by the family. The cook placed the soup in the microwave for less than two minutes. He did not rotate or stir the soup, did not take the temperature of the soup and did not allow the soup to stand covered for two minutes. Dietary aide (DA) #2 was asked on 1/9/24 at 11:12 a.m. to reheat a cinnamon roll that was in a paper bag. DA #2 placed the cinnamon roll in the original packaging in the microwave for less than two minutes. She did not take the temperature of the cinnamon roll. She did not rotate the cinnamon roll, did not take the temperature of the cinnamon roll and did not allow the cinnamon roll to stand covered for two minutes. C. Staff interviews The corporate dietary manager was interviewed on 1/9/24 at 3:20 p.m. She said cooks should be the only ones who reheat food. She preferred outside food to be sealed and in its original packaging. She said that any food that is reheated should be tested with a thermometer to ensure the food reached 165 degrees Fahrenheit. D. Facility follow-up The corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. training was provided to kitchen staff that food should be reheated to reach 165 degrees Fahrenheit. II. Hair restraints A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn effectively keep their hair from contacting exposed food. (Retrieved 1/22/24) B. Observations Cook #1 and an unidentified dietary aide were observed on 1/9/24 at 11:01 a.m. Both staff were continuously observed during the lunch meal on 1/9/24 from 11:01 a.m. until 11:48 a.m. Both staff had a beard that was less than one inch. They both did not have a beard net worn to prevent their hair from contacting exposed food. C. Staff interviews The corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. She said any dietary staff that entered the kitchen should have worn hair coverings that covered body hair including beards. She said she would talk to the kitchen staff who have beards to wear hair coverings. D. Facility follow-up The corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. She provided documentation training was provided to all kitchen staff to wear hair coverings including beard nets.

Based on record review and interviews, the facility failed to ensure two (#44 and #16) of seven residents reviewed for unnecessary medications out of 18 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident # 44 was assessed by the interdisciplinary team (IDT) prior to implementation of a psychotropic medication treatment and appropriate non-pharmacological interventions were initiated; -Ensure Resident #16's psychoactive medication, an antidepressant, was not increased without evidence and documentation of change of behaviors or attempts of non-pharmacological interventions, and, -Resident # 16's hours of sleep were documented for hypnotic medication use. Findings include: I. Facility policy The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 1/10/24 at 8:02 a.m. and read in parts: Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Consideration of the use of any psychotropic medications is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. When determining whether to initiate, modify, or discontinue medication therapy, the IDT (interdisciplinary team) conducts an evaluation of the resident. II. Resident # 44 A. Resident status Resident #44, age 83, was admitted on [DATE]. According to the January 2023 computerized physician order (CPO) diagnoses included dementia, history of urinary tract infections and type 2 diabetes mellitus. The 1/2/24 minimum data set (MDS) assessment revealed resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. Section E revealed presence of hallucinations and delusions, physical and verbal behavioral symptoms directed towards others occurred in one to three days. Rejection of care and wandering occurred in one to three days. B. Resident observations Resident #44 was observed on 1/8/24 throughout the day. She was wearing a dark coat and was carrying a purse. She was walking up and down the hallways throughout the facility and occasionally rested in the television room next to the nurses' station. She was invited to participate in the afternoon activities, however she did not stay. On 1/10/24 at approximately 9:30 a.m. the resident was observed walking on the 300 hall. She was dressed in a dark coat and was carrying a purse. She appeared upset and agitated. She said she did not know where she was and would like to go home. C. Record review Physician orders: -Seroquel oral tablet 25 mg (Quetiapine Fumarate) (antipsychotic medication), give one tablet by mouth three times a day related to unspecified dementia, mild, without behavioral disturbance. Start date 1/4/24 -Melatonin oral tablet 10 mg (Melatonin) (supplement used for insomnia), give one tablet by mouth at bedtime for insomnia. Start date12/28/23 Care plan: The comprehensive care plan review revealed the following: -(Resident) takes psychotropic medications r/t (related to) dementia with behaviors. Interventions included: Administer medications as indicated by physician orders. Consult with pharmacist/physician for gradual dose reduction if appropriate. Monitor for and report to physician adverse effects of antipsychotic medication use (drowsiness, dizziness, restlessness, weight gain, dry mouth, constipation, nausea/vomiting, blurred vision, low blood pressure, uncontrolled movements/tics/tremors, seizures, increased risk for falls). Review with resident/family/responsible person the risks vs. benefits of psychotropic medication use. Care plan was initiated on 1/7/24 -(Resident) has impaired cognitive function r/t (related to) diagnosis of dementia (dated 9/12/23). Interventions included: Encourage resident to participate in daily decision making with daily activities. Keep resident's routine as consistent as possible to avoid anxiety and frustration. Notify nurse, physician of any significant change in (Resident's) baseline cognitive status. Reassure (Resident) of safety. Redirect as needed. -The resident's care plan did not include non-pharmacological interventions for the psychotropic medication Seroquel. -The resident's care plan did not include the use of Melatonin for insomnia. Interdisciplinary notes: On 11/11/23 a nurse documented: Resident was found standing outside the door of her room crying stating 'no one likes me, no one wants me' . RN (registered nurse) provided therapeutic listening and reassurance, given cup of tea and encouraged to socialize. Then she wandered around the unit, and required encouragement to return to her room to change into pajamas. Resident's roommate voiced complaints that resident was talking loudly to self in her room. When RN arrived, resident was sleeping sitting upright in bed. RN closed room window as (resident) seems bothered by the cold. Will pass on to dayshift that new room assignment may not be best fit. On 11/15/23 a nurse documented: This resident has been up wondering the hallways t/o the noc (throughout the night). Resident will sleep for two hours and then get back up. When approached by this RN, resident states 'I just can't sleep'. On 11/17/23 a nurse documented: Resident appears to be having more issues during the night. At the beginning of the shift resident was wondering the halls but not really communicating what she was looking for, commenting she was waiting on the baby, or looking for a coat she had misplaced. Resident was then standing in the hall in front of her room being very weepy making comments that she only wanted to be nice to people. Reassured resident that all was well and encouraged her to go to bed. Later in the evening she was assisted to bed by staff and has been asleep since that time. On 12/26/23 a nurse documented: Resident redirected to stay in room several times per hour due to isolation precautions. Encouraged to wear mask when out of the room. Resident forgetful and becomes anxious, confused, and agitated. Redirected and reiterated that resident is safe and shown location of room through day. Call light within reach and resident encouraged to use as needed. On 1/1/24 a nurse documented: Resident continues to be very upset, agitated towards staff. Also continues to go into other rooms frequently upsetting other residents. Very difficult to redirect. Will not stay in her room, getting very little sleep. On 1/3/24 a nurse documented: Resident attempted to hit CNA (certified nurse aide) while being redirected out of another resident's room. Resident walking up and down the hallway shouting 'cheaters' Resident not easily redirectable at this time. Encouraged adequate space while ensuring safety. On 1/4/24 a nurse documented: Resident was arguing with another resident this evening and the altercation almost became physical. Nursing staff intervened prior to this occurring. Resident not easily redirectable. Resident was noted to be very agitated, yelling, wandering, and aggressive with other residents and staff at the beginning of this shift. Resident was walking up and down the hallway in the eve on January 3rd, 2024, and was calling staff 'liars'. Nursing staff encouraged space while ensuring safety of all residents and staff. Resident was assisted to change into pajamas and into bed at 2130 (9:30 p.m.). Resident still lying in bed resting. Call light and personal items are within reach. On 1/6/24 a nurse documented: Resident noted with verbal outbursts and verbal aggression toward staff. Pacing and upset about 'missing the bus to Texas', positive reinforcement and redirection provided but resident responds angrily and walks away. Resident allowed space and frequent visual checks continue. Staff will continue to provide a safe and hazard free environment. D. Staff interviews The medical director (MD) was interviewed on 1/8/24 at 10:35 a.m. He said the antipsychotic medication Seroquel was prescribed for dementia with behaviors. He said the nursing staff told him the resident was verbally and physically aggressive towards staff and occasionally with other residents. He said he did not consider a lower dose for the resident. He said the medication had six hours half-life and the nursing staff observed significant positive changes in resident's behaviors. The director of nursing (DON), the social service director (SSD) and the activities director (AD) were interviewed on 1/9/24 at 5:00 p.m. The DON said it was the facility policy the interdisciplinary team (IDT) should review and assess a resident's behaviors prior to asking physician for a drug, especially an antipsychotic medication. She said the nurses were frequently reminded not call the physician and ask for a psychotropic medication. The SSD said there were no non-pharmacological interventions implemented for resident increased behaviors and there was no care plan for it. She said the resident was moved to different rooms three times in the past two months and that could have triggered increased of confusion and behaviors. The AD said Resident #44 was always invited to the group activities however she would not stay long. RN #1 was interviewed on 1/9/24 at 5:30 p.m. She said Resident #44's behaviors increased during her isolation due to COVID-19 diagnosis. She would not stay in her isolation room and would not wear a facemask. She began being aggressive towards staff. RN#1 said after the COVID-19 isolation was over, the resident returned to her previous room and became more confused. She said the resident was wandering to other residents' rooms and was not easily redirectable. She said she notified the MD of Resident #44's behaviors and he prescribed the antipsychotic medication. III. Resident #16 A. Resident status Resident # 16, age 94, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO) diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD), insomnia, major depressive disorder and anxiety. The 12/5/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. She had no identified behaviors or rejections of care. The mood interview PHQ-9 (the nine questions of patient health questionnaire objectifies degree of depression severity) score was two out of 27 which indicated no depression. She was administered high risk medications included an antidepressant, hypnotic and anticoagulant. B. Resident interview Resident #16 was interviewed on 1/10/24 at 9:55 a.m. She said she was not aware her antidepressant was increased a week ago. She said she usually went to bed and fell asleep around 10:30 p.m. woke up one time to go to the bathroom and slept the rest of the night. C. Record review Physician orders: -Citalopram Hydrobromide, oral tablet 10 mg (Citalopram Hydrobromide) (antidepressant known as selective serotonin reuptake inhibitors). Give one tablet by mouth one time a day related to major depressive disorder. Start date 12/5/23. End date 1/2/24. -Citalopram Hydrobromide, oral tablet 20 mg (Citalopram Hydrobromide). Give one tablet by mouth one time a day related to major depressive disorder and anxiety disorder. Start date 1/3/24. -Temazepam oral capsule 15 mg (Temazepam) (Benzodiazepine used to treat severe insomnia). Give 15 mg by mouth at bedtime for insomnia. Start date11/22/23. Care plan The comprehensive care plan review revealed the following: -There was no care plan for the antidepressant medication in resident's record. -There was no care plan for the hypnotic medication in resident's record -There was no care plan for non-pharmacological interventions for the above medications. Review of the resident's electronic record revealed there were no behavior notes identifying any behaviors. The January 2024 CPO identified the medication Citalopram Hydrobromide for depression and anxiety was increased on 1/3/24 from 10 mg to 20 mg every day (qd). -The facility failed to have evidence of increased behaviors and attempts at non-pharmacological interventions prior to the increase of Citalopram Hydrobromide from 10 mg to 20 mg. Interdisciplinary notes On 12/5/23 a nurse documented: Citalopram 10mg started for increased anxiety. No unusual behaviors noted with no adverse reactions. On 1/2/24 a nurse documented: MD in house to see resident. Resident verbalizing increase in anxiety. New orders obtained to change Citalopram to 20mg PO QD. Orders noted and carried out. Resident made aware. D. Staff interviews The DON and MDS coordinator (MDSC) were interviewed on 1/10/24 at 8:35 a.m. The MDSC said the resident's care plan was not finished timely. She said the resident's care plan did not address the insomnia and antidepressant medications. She said there were no non-pharmacological approaches for the above medications in the resident's care plan. The DON was interviewed on 1/10/24 at 9:40 a.m. She said the resident was admitted on Tomazepam from the hospital. She said there were no hours of sleep documented. She said she was not aware the resident's antidepressant was increased and IDT did not review change in behaviors or increase in depression.

Based on observations and interviews the facility failed to ensure one of one medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised February 2023, was provided by the director of nursing (DON) on 1/9/24 at 1:00 p.m. It read in pertinent part, Controlled substances (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. II. Observations On 1/8/24 at 10:33 a.m. the medication refrigerator was observed with registered nurse (RN) #1. There were two controlled medication locked boxes in the refrigerator not permanently affixed to the refrigerator and they contained liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) and liquid morphine (pain medication). III. Staff interviews RN #1 was interviewed on 1/8/24 at 10:36 a.m. She said she was not aware that the controlled medication box in the refrigerator should be permanently affixed to the refrigerator. She said she now knew that anyone with access to the refrigerator could just take the boxes of controlled medications out of the refrigerator. The director of nursing (DON) was interviewed on 1/9/24 at 1:14 p.m. The DON said she was not aware of the requirement that the controlled medication boxes should be permanently affixed to the refrigerators.

Based on record review and interviews, the facility failed to keep residents safe from accident hazards related to elopement for two (#43 and #10) of two residents reviewed out of 25 sample residents. Specifically, the facility failed to keep residents safe from elopement with the potential for serious injury on two back-to-back occasions. Resident #43 had severe dementia, was at risk for and had a history of elopement, and was discovered missing from the facility on 4/3/22 at 1:00 p.m. She had left the building at 9:35 a.m. and staff were unaware she was gone until they viewed camera footage more than four hours later. She was found by a neighbor and former staff member and returned by law enforcement to the facility at 3:35 p.m. She had been found sitting on the neighbor's front porch. Resident #43 was not injured. She had been missing for more than six hours. The facility failed to immediately implement effective measures to keep residents at risk safe from elopement, causing a second resident to elope. On both occasions, the facility's wander guard system failed to keep residents safe from elopement. Resident #10 had severe dementia, was at risk for and had a history of elopement, and was discovered missing from the facility on 4/5/22 at 12:00 a.m. At 12:35 a.m., the manager on duty saw staff looking for something and when asked, they said they had not seen Resident #10 when they conducted midnight rounds. Camera footage revealed the resident left the building at approximately 8:00 p.m. via the chapel door. Law enforcement marked the resident as missing and sent out an alert at 3:40 a.m. on 4/5/22. The resident was not found until 7:55 a.m. the next day, on 4/5/22. He had been taken by a community member to a local hotel, spent the night there, and was found by law enforcement and escorted back to the facility at 8:30 a.m. He was not injured. The facility's failure to take immediate action for residents identified for elopement created the likelihood of serious injury or death. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/12-9/15/22, resulting in the deficiency being cited as past noncompliance with a correction date of 4/5/22. I. Immediate jeopardy for potential serious harm or death A. Situation of Immediate Jeopardy Resident #43 had severe dementia, was at risk for and had a history of elopement, and was discovered missing from the facility on 4/3/22 at 1:00 p.m. She had left the building at 9:35 a.m. and staff were unaware she was gone until they viewed camera footage more than four hours later. She was found by a neighbor and former staff member and returned by law enforcement to the facility at 3:35 p.m. She had been found sitting on the neighbor's front porch. Resident #43 was not injured. She had been missing for more than six hours. The facility failed to immediately implement effective measures to keep residents at risk safe from elopement, causing a second resident to elope. On both occasions, the facility's wander guard system failed to keep residents safe from elopement. Resident #10 had severe dementia, was at risk for and had a history of elopement, and was discovered missing from the facility on 4/5/22 at 12:00 a.m. At 12:35 a.m., the manager on duty saw staff looking for something and when asked, they said they had not seen Resident #10 when they conducted midnight rounds. Camera footage revealed the resident left the building at approximately 8:00 p.m. via the chapel door. Law enforcement marked the resident as missing and sent out an alert at 3:40 a.m. on 4/5/22. The resident was not found until 7:55 a.m. the next day, on 4/5/22. He had been taken by a community member to a local hotel, spent the night there, and was found by law enforcement and escorted back to the facility at 8:30 a.m. He was not injured. The facility's failure to take immediate action for residents identified for elopement created the likelihood of serious injury or death. The nursing home administrator (NHA) was notified of the immediate jeopardy determination on 9/15/22 at 1:00 p.m. because serious adverse outcome was likely to occur in the case of both Residents #43 and #10 due to the delay in identifying they were missing, and how long they were missing. The facility was close to several busy streets. The residents could have been lost, injured or victimized due to their status as at-risk adults with severe dementia. The facility was notified of the need to take immediate action to ensure residents who wandered or were at risk of elopement were supervised and their safety was ensured. The facility reported they took immediate action after the second resident elopement. The decision to cite at past non-compliance was pending the record of the facility's self-initiated plan of correction. B. Facility plan to remove the Immediate Jeopardy situation The facility submitted their Plan for Immediate Jeopardy Removal on 9/15/22 at 7:07 p.m., which read as follows: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The first incident on 4/3/22 was human error. The security door was not re-activated due to the 60 second wait time to re-activate. The second was also human error thinking only one resident was leaving not two, however they (staff) should have double checked outside. Corrective action began April 4, 2022, after deficient practice. Upon notification, elopement of Resident #43 due to improper activation of alarm system. Corrective action began April 5, 2022, when notified of deficient practice regarding the elopement of Resident #10 after failure to do a head count. Immediate action/resident safety: -When residents returned to the facility, they were immediately assessed (head to toe assessment). No injuries. -Education completed 4/3 and 4/4 with staff to educate on alarm system, frequent checks and frequent resident monitoring. -4/4/22 MDS (minimum data set) coordinator and administrator (NHA) looked at all residents to assess need for wander guard, updated care plans or other interventions due to occurrence. -Frequent alarm checks were done to ensure the alarm was activated between 4/5 and 4/12/22. All staff were educated, and all staff were to check the alarm (to ensure it was red not green) and active. Sign off was next to the alarm to sign off checks. If activated, staff also signed off to re-activate the alarm. Sign-off sheets in occurrence binder. -Increased monitoring of all wandering/elopement risk residents and documentation of interventions to deter wandering. -Between 4/5 and 7/5/22 (even after wander guard system/double alarms on doors installed) resident head count completed on all residents if any door alarms active. Resident count sheets in occurrence binder. 2. Address how the facility will identify other residents have the potential to be affected. Facility identifies residents who are an elopement/wander risk have the potential to be affected by same deficient practice. 3. Address what measures will be put into place or systemic change made to ensure that the deficient practice will not reoccur. Measures put into place are that re-education of staff was started the evening of 4/3/22 regarding the activation of the alarm system - education of alarm system also completed. Formal training began on 4/4/22 and implementation of checks of alarm system put into place and behavior monitoring of wandering residents and documentation. List of all wandering residents provided to nursing staff so they can be identified if not already known. Following second incident on 4/4/22, on the morning of 4/5/22 an additional intervention was implemented. Further education of staff regarding alarm system, following resident to the door, and implementation of head count of all residents following alarm activation was started. On 4/5/22 and after multiple attempts to reach (security company name) alarm system activation time was decreased from 60 seconds to 15 seconds on 4/12/22. On 4/6/22 call placed to (technology company name) to initiate purchase for wander management system (wander guard system for all fire doors). On 4/8/22 (brand name) Airtags were ordered for GPS tracking of residents. Tracking policy created 5/5/22 for approval by (facility corporation). On 6/10/22 GPS tracking was implemented on four residents to include Residents #43 and #10. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The plan of correction must be integrated into the quality assurance system. The correction date will be the latest completion day on your accepted plan of correction. a. The facility shall monitor its performance by having the Administrator and/or Director of Nursing and/or designee monitor alarm system to ensure employees are activating the system and checks are being done to ensure system is activated. Check off sheet created 4/4/22 with implementation. b. On 4/4/22 at 11:56 a.m., contacted (security company name) to change the time to re-arm security system. A second call was placed on 4/5/22 as call had not yet been returned. Activation from 60 seconds to 15 seconds with implementation of text with picture to Administrator phone on 4/12/22 any time an alarm is activated. This will not stop. c. All residents with the potential to wander (those with wander guard) have behavior monitoring (per policy and procedure) to monitor number of times exit seeking per day. Attempts will be documented daily (if necessary) and redirection of resident and frequent checks, interventions documented in notes. d. Staff educated on Missing Person/Elopement Drill (Policy 1-6.13) for review 4/4/22 or when coming on to shift. e. Re-education on use of alarm system completed for employees (employees know there is a 60 second wait time). f. Head count of residents when alarm system activated implemented 4/5/22, documentation in med room and reviewed by Administrator, Director of Nursing and/or designee. g. On 4/6/22 quote and purchase of wander guard system initiated for all fire doors (doors without current wander guard system). Pending installation (June 22, 2022 completion date). h. (Brand name) Airtag trackers ordered 4/8/22 for GPS tracking of high-risk elopement residents and received. i. GPS tracking of residents was implemented on 6/10/22 on all high-risk wander/elopement residents per policy. They will be monitored by nursing, DON (director of nursing) and Administrator. Tracking will be on Administrator phone and only used when necessary and checked per policy. 5. Include dates when the corrective action will be completed. The corrective action unacceptable for any reason you will be notified by this office. If the plan of correction is ultimately accountable for compliance and that responsibility is not alleviated in cases where notification regarding the acceptability of the facility plan of correction is not made timely. Completion date 7/5/2022. 6. Interventions still in place: All security doors (all 7 doors in facility) are always alarmed. Once all staff were educated on 4/4 and 4/5 with the following plans and interventions to include: staff education on the alarm system, staff must wait the 60 seconds to re-arm all doors to re-activate the security doors, staff must frequently check the alarm to ensure the security system is activated, resident monitoring was increased (especially those who were high-wander risk), those residents were offered distraction - direction and more to do to keep them from wandering and on 4/5/22 staff were required to count ALL residents any time an alarm was activated,. These were monitored by Administrator, DON and supervisor staff who assisted in monitoring of counting residents, and the sign off on the alarm system and doors/alarms in proper working order. On 4/5/22 the facility was in compliance. -All doors have double alarms - fire activations with 15 second re-set (since 4/12/22) -Administrator receives text with picture whenever alarm is activated/re-activated (since 4/12/22) -GPS (global positioning system) tracking on high-risk residents in place (since 6/10/22) -Continue to provide re-direction, frequent checks and diversion for wandering residents -QA (quality assurance) and QAPI (quality assurance process improvement) done. C. Removal of Immediate Jeopardy Upon follow-up interviews with the NHA and corporate maintenance (CM) staff and review of door alarm and wander guard monitoring documentation, it was determined the facility had removed the immediacy of the IJ situation on 4/5/22. Documentation of weekly monitoring and testing of the door alarm system and individual residents' wander guards was reviewed. Upon review of the facility's plan of correction and implemented measures to keep facility residents safe, it was determined that the facility failures and corrective actions constituted immediate jeopardy past non-compliance. The facility's correction plan was reviewed and approved as of 7:15 p.m. on 9/15/22. Therefore, the deficient practice was corrected prior to the recertification survey and represented past noncompliance at D level, potential harm that was isolated. II. Failure to ensure residents were safe from elopement A. Resident status 1. Resident #43, age 74, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with behavioral disturbance, tremor unspecified, depressive episodes, [CONDITION(S)], and anxiety disorder. The 8/24/22 minimum data set (MDS) assessment documented severe dementia with a brief interview for mental status (BIMS) score of one out of 15. She had [CONDITION(S)] symptoms of inattention and disorganized thinking, and mood symptoms of trouble sleeping and concentrating. She exhibited wandering behavior one to three days out of the review period, but the impact to the resident and others was not documented. She needed supervision, oversight, cueing or limited assistance for most activities of daily living (ADLs). She needed extensive assistance for toilet use and personal hygiene. She had unsteady balance and gait, and had a fall with injury since the last review period. The 2/23/22 MDS assessment documented she exhibited wandering behavior daily, posing a significant risk to herself, and intruding on the privacy and activities of others. The 5/25/22 MDS documented wandering one to three days during the review period. The care plan, initiated 4/4/22 (two months after the resident's MDS identified she wandered on a daily basis), identified wandering into unsafe situations, tendency to seek out exits of facility, attempts to leave facility have been made. The goal was close monitoring by staff and wandering would not contribute to injury. Interventions were: place resident in area where frequent observation is possible; provide diversional activities; place monitoring device on resident that sounds alarms when resident leaves building; note which exits resident favors for elopement from facility and alert staff working those areas; monitor and document target behaviors; implement facility protocol for locating an eloped resident; if wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them; designate staff to account for resident whereabouts throughout the day; approach wandering resident in a positive, calm and accepting manner; and alert staff to wandering behavior. -The care plan did not document that the resident had actually eloped from the building and was not found and returned home until more than six hours later. 2. Resident #10 Resident #10, age 70, was admitted on [DATE]. According to the September 2022 CPO, diagnoses included dementia with behavioral disturbance, heart disease, hypertension, type 2 diabetes and anxiety disorder. His 6/29/22 MDS assessment documented severe cognitive impairment with a BIMS score of five out of 15. No behavioral symptoms including wandering were documented. He needed supervision/oversight or was independent for most ADLs. He was unsteady with transfers. -Although his 6/29/22 MDS documented no wandering behavior, his prior MDS assessment on 3/30/22 documented wandering daily, posing a risk to the resident. -The MDS assessments did not consistently document wandering behavior and/or risks. The care plan, initiated 4/5/22 and not revised, identified wandering into unsafe situations. The goal was wandering would not contribute to injury. Interventions were: place resident in area where frequent observation is possible; provide diversional activities; place monitoring device on resident that sounds alarms when resident leaves building; note which exits resident favors for elopement from facility and alert staff working near those areas; monitor and document behaviors; implement facility protocol for locating an eloped resident; if wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them; designate staff to account for resident whereabouts throughout the day; approach wandering resident in a positive, calm, and accepting manner; and alert staff to wandering behavior. -The care plan did not document that the resident actually eloped from the building and was not found and returned home until 24 hours later. B. Record review and interviews regarding resident elopements 1. Resident #43's elopement on Sunday, 4/3/22 The facility investigation regarding Resident #43 revealed she attempted to exit the 500 hallway door on 4/3/22 at 9:18 a.m. Staff successfully brought the resident back inside the door and deactivated the alarm. The staff walked away during the 60-second waiting period to reactivate, and did not reactivate the door alarm, leaving six of nine facility door alarms disengaged. Camera footage revealed at 9:33 a.m. Resident #43 entered the dining room, exited the building and walked into the back staff parking lot at 9:35 a.m. She attempted to re-enter the building but could not get back in, and was seen on camera footage walking away from the facility towards a nearby street and out of the camera view. At approximately 12:45 p.m. dining room staff noticed Resident #43's tray card was not pulled for lunch, prompting nursing staff to search the facility and grounds for Resident #43. A resident head count revealed Resident #43 was missing and all other residents were accounted for. The manager on duty (MOD) was notified at 1:00 p.m. that Resident #43 was missing. The MOD reviewed camera footage and notified the nursing home administrator (NHA) at approximately 1:20 p.m. that Resident #43 was missing. A neighborhood search was initiated and community members and law enforcement were notified. Law enforcement located the resident, who had been sitting on a community member's front porch. Law enforcement and the community members returned Resident #43 to the facility at 3:35 p.m. Resident #43 was assessed to have no trauma or injuries. At 4:30 p.m. the NHA educated staff regarding the alarm system, and not leaving doors unattended until they were reactivated. 2. Resident #10's elopement on Monday 4/4/22 until Tuesday 4/5/22 On 4/4/22 at 7:54 p.m. Resident #10 exited the facility via the chapel door according to video footage. Staff were unaware Resident #10 had left. Video footage reviewed later (see below) revealed Resident #10 and another resident were walking in the hall toward the chapel; the other resident returned from the chapel area but Resident #10 did not. -There was no evidence in the investigative report that staff heard an alarm from the chapel door at that time. At 12:35 a.m. on 4/5/22 a facility nurse noticed staff were looking for something, and when asked said they were unable to lay eyes on Resident #10 since 12:00 a.m. rounding. All staff looked in all rooms, cafeteria, common areas and hallways, then searched outside the property in a one-block radius, then viewed camera footage. The former director of nursing (DON) saw on camera footage that Resident #10 and another resident had walked toward the chapel (see above) and did not return to the hallway with the other resident. Per camera footage it was determined Resident #10 left the building at approximately 8:00 p.m. The NHA and local police were notified and the search for Resident #10 continued throughout the community. The resident's out-of-town family and police department were notified. On 4/5/22 at 3:40 a.m. a local deputy advised that law enforcement had marked Resident #10 as missing and an alert was issued. At 5:00 a.m. the deputy called to advise the search continued and his supervisor possibly saw Resident #10 at 8:30 p.m. walking toward the north part of town so they would be focusing more in town for the search. The official alert went out at 6:06 a.m. On 4/5/22 at 7:31 a.m. the NHA got a call stating a community member knew where Resident #10 was. He had walked into a local caregiver agency across the street from the facility at about 8:30 p.m. on 4/4/22 and said he was trying to get to a town in a nearby state but didn't have his car. The community members were going to give him a ride but soon realized Resident #10 did not know where he was going. They booked Resident #10 a hotel room on the other side of town and stated he should still be there. They named the hotel and the room number. On 4/5/22 at 8:30 a.m. Resident #10 was escorted back to the facility accompanied by four deputies from the county sheriff's department. The resident was assessed to have no trauma or injuries. III. Administrator interview and facility plan of correction On the afternoon of 9/13/22, interview with the NHA and review of the facility's plan of correction revealed Resident #43 eloped due to improper activation of the alarm system and Resident #10 eloped and was missing overnight after staff failed to do a resident head count. Measures implemented were: -Staff re-education started the evening of 4/3/22 regarding operation and activation of the alarm system. -Formal staff training began 4/4/22 and implementation of checks of alarm system put into place along with behavior monitoring of wandering residents and documentation. A list of wandering residents provided to nursing staff so they could be identified if not already known. -Following the 4/4/22 incident, on the morning of 4/5/22 an additional intervention was implemented. Further education of staff regarding alarm system, following resident to the door, and implementation of head count of all residents following alarm activation was started. -On 4/6/22 the alarm company was contacted regarding installation of wander guard system for all alarmed doors with only one door alarm. This would double alarm all facility doors. The exact date of installation was not yet known. The NHA said during the 9/13/22 interview that all the facility doors had since been double-alarmed with security alarms and wander guard systems. Residents identified at risk for elopement wore wander guards, and residents who were at risk for elopement and exiting the facility grounds had additional GPS systems added to their wander guards.

Based on record review and interviews, the facility failed to develop and implement effective quality assurance/process improvement (QAPI) action plans to identify and address quality deficiencies regarding resident rights and resident care. Specifically, the facility failed to correct recurring deficiencies related to abuse, investigations, accident hazards, and infection control. Findings include: I. Record review Cross-reference F600 abuse: the facility failed to protect residents' rights to be free from abuse by staff and other residents. Cross-reference F610 investigations: the facility failed to investigate allegations of abuse and protect residents from further abuse during and after the investigations. Cross-reference F689 accident hazards regarding elopement: the facility failed to ensure residents were safe from elopement at immediate jeopardy level, with potential for serious injury or death. Cross-reference F880 infection control: the facility failed to maintain an effective infection control program to prevent the potential spread of infection. The above deficiencies were repeated deficiencies cited during the prior recertification survey ending on 6/10/21. F689 was previously cited related to other accident hazards including falls, smoking safety and call light accessibility for residents at risk for falls. II. Staff interview The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 9/15/22 at 8:15 p.m. They said their QAPI program was working on action plans for wandering/elopement, falls, weight loss, abuse, conducting thorough investigations, any resident concerns brought to their attention, food and vaccinations. They said they needed something better in place to keep problems from occurring and reoccurring, and said their current process improvement was not effective.

Based on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Prevent potential cross contamination during meal preparation; -Demonstrate appropriate use of gloves during the meal service; -Ensure cold food items were stored and served at proper temperature to prevent potential food-borne illnesses; and, -Ensure food surfaces were properly sanitized. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) https://www.cdc.gov/handwashing/handwashing-kitchen.html, dated 7/18/22, retrieved on 9/19/22, read in pertinent part: Handwashing is one of the most important things you can do to prevent food poisoning when preparing food for yourself or loved ones. Your hands can spread germs in the kitchen. Some of these germs, like salmonella, can make you very sick. Washing your hands frequently with soap and water is an easy way to prevent germs from spreading around your kitchen and to other foods. According the CDC, handwashing was especially important during some key times when germs could spread easily: -Before, during, and after preparing any food. -After handling uncooked meat, poultry, seafood, flour, or eggs. -Before and after using gloves to prevent germs from spreading to your food and your hands. -Before eating. -After touching garbage. -After wiping counters or cleaning other surfaces with chemicals. -After touching pets, pet food, or pet treats. -After coughing, sneezing, or blowing your nose. According to CDC guidance, Handwashing: Clean Hands Save Lives, https://www.cdc.gov/handwashing/campaign.html, dated 11/19/2020, retrieved on 9/19/22 read in part Germs are everywhere. Make handwashing with soap and water a healthy habit. - Everything you touch has germs that stay on your hands. -Your hands carry germs you can't see. -Handwashing can help prevent one (1) in five (5) respiratory illnesses. Additional CDC guidance for food safety, retrieved from https://www.cdc.gov/foodsafety/people-at-risk-food-poisoning.html, dated 1/24/19, retrieved on 9/19/22, read in part: Anyone can get food poisoning, but certain groups of people are more likely to get sick and to have a more serious illness. Their bodies' ability to fight germs and sickness is not as effective for a variety of reasons. Adults aged 65 and older have a higher risk because as people age, their immune systems and organs don't recognize and get rid of harmful germs as well as they once did. Nearly half of people aged 65 and older who have a lab-confirmed foodborne illness from salmonella, campylobacter, listeria or E. coli are hospitalized . People with weakened immune systems due to diabetes, liver or kidney disease, alcoholism, and [CONDITION(S)]/AIDS; or receiving [CONDITION(S)] or [CONDITION(S)] therapy cannot fight germs and sickness as effectively. For example, people on [CONDITION(S)] are 50 times more likely to get a listeria infection. II. Facility policy The following food policies were provided by the facility on 9/15/22: The Dietary Department Infection Control policy, undated, read in part: Proper procedures are followed at all times in order to prevent the spread of infection. Proper techniques are employed to prevent the possibility of cross-contamination and foodborne illnesses including: washing hands with germicidal soap before preparing Foods, eating, after smoking, after using the restroom, after working with potentially hazardous food, and at any other time hands becomes contaminated in any way. The Sanitary Condition of Dietary Department policy, undated, read in part: Sanitary conditions are maintained at all times in the Dietary Department. All surfaces used for the preparation of food are sanitized before the beginning of the preparation of food, between using the surface for the preparation of raw cooked food in order to prevent cross-contamination and after preparation is complete. The Food Temperature policy, undated, read in part: Foods are prepared and served at proper temperature in order to assure the safety of the residents. Potentially hazardous foods are kept at an internal temperature of 45 degrees F (Fahrenheit) or below or at an internal temperature of 140 degrees F or above during display and service. The Food Preparation and Service policy, undated, read in part: Equipment is provided and procedures established to maintain food at a proper temperature during storage and service. III. Observations On 9/12/22 at 2:10 p.m. during the initial kitchen tour, a sanitized cleaning bucket was observed in the kitchen. Cook #1 was unsure if he was to use the chlorine test strips or the quat test strips. Cook #1 decided on the chlorine test strips and tested the sanitized water with chlorine test strips. The test strip indicated the solution measured at 10 parts per million (ppm). -However, the cook used the wrong testing strip, he should have used the quat test strips to test the solution (see the corporate regional dietary consultant interview). According to the cook the solution was used to clean kitchen food surfaces. He said the buckets were changed out once per shift. The dinner service in the kitchen was observed between 3:20 p.m. and 4:45 p.m. -At 3:32 p.m. DA #1 pulled out a tray of plated pre-cut key lime pie slices out of the refrigerator and placed them on a cart to be included as the resident dinner dessert item. The slices were not covered or placed on or in a cooling surface to maintain a temperature appropriate for cold food items. -At 3:34 p.m. cook #2 took the temperatures for the hot food items. Cook #2 did not take the temperature to the pre-cut key lime pie slices. The cook said the dietary manager (DM) usually obtained the food temperatures before service. He said he has not taken the food temperatures for over a year. -At 3:42 p.m. cook #2 adjusted the back of his shirt with his gloved hands. He did not doff his gloves and perform hand hygiene. -At 3:45 p.m. cook #2 placed his right gloved hand in his apron pocket slightly pulling out a white cloth while touching his left gloved hand of his face mask. He did not doff his gloves and perform hand hygiene. -At 3:46 p.m. cook #2 left the steamline and walked to the back of the kitchen. He retrieved an open plastic water bottle out of the refrigerator with his gloved hands. He returned to the steamline. Cook #2 pulled his mask below his nose and mouth with his gloved hands and drank the remainder of the water in the bottle. Cook #2 pulled up his mask with his gloved hands and threw the empty bottle away. He did not doff his gloves and perform hand hygiene. -At 3:48 p.m. cook #2 patted the regional dietary consultant on his back and returned to the steamline. He proceeded to plate resident meals. He did not doff his gloves and perform hand hygiene prior to plating the meals. -At 3:49 p.m. cook #2 plated the resident first meal and DA #1 took the plated meal, beverages and a slice of key lime pie on a food tray. The DA expedited the meal out the kitchen service window. -At 3:52 p.m. cook #2 wiped his hands on the back pants. He did not doff his gloves and perform hand hygiene prior to plating the meals. -At 3:55 p.m. DA #1 retrieved a second tray of key lime pies from the refrigerator. As she placed the tray on the cart, her arm touched the surfaces of one of the pies. She wiped her elbow off with gloved hands, pulled her mask under her nose and mouth, walked to the other side of the kitchen and threw the pie slice away. She pulled the mask back over her nose and mouth with her gloved hands and returned to the service line. She did not doff her gloves and perform hand hygiene -At 3:56 p.m. DA #1placed two pie slices on resident trays, with her gloved thumb in the center of the eating surface of the pie plates. -At 3:59 p.m. cook #2 left the steam line and walked to the back of the kitchen. He retrieved a plastic bottle of water out of the refrigerator with his gloved hands. He returned to the steamline, pulled his mask below his nose and mouth with his gloved hands and took a sip of the water. He pulled his mask back up with his gloved hand and returned to plating food. He did not doff his gloves and perform hand hygiene. -At 4:01 p.m. cook #2 adjusted his mask with his gloved hands without performing hand hygiene. -At 4:03 p.m. cook #2 pulled his mask down with his gloved hands and took another drink of water from his water bottle. He pulled his mask back up. The corporate regional dietary consultant (CRDC) directed cook #2 to doff his gloves and perform hand hygiene. -At 4:07 p.m. DA #1 placed her gloved right hand on the wall as she spoke to the DM. -At 4:09 p.m. DA #1 touched her eye glasses with right hand then placed her gloved hand on the meal tray stack. She did not doff her gloves or perform hand hygiene. -At 4:13 p.m. DA #1 placed her right hand over the drinking surface of a filled juice glass and placed the glass on a resident meal tray. -At 4:15 p.m. DA #1 placed a plated guard over a plate of food. -At 4:17 p.m. cook #2 pulled the back of his shirt down with his gloved hands as he plated a meal. -At 4:43 p.m. a test tray was plated and prepared for sampling. -At 4:46 p.m. the key lime pie slice temperature was collected. The pie's internal temperature was 50 degrees Fahrenheit (F.) The pie temperature was above 45 degrees F. On 9/15/22 at 10:45 a.m. a red sanitizer bucket filled with sanitized water was on the counter in the dining room. The DM said the sanitizer was used to wipe down the resident dining room tables. The DM said he did not know when the water was last changed. The CRDC dipped the hydro quat strip on the bucket of water. The strip did not change in color, indicating a very low amount of sanitizer solution. The CRDC said the sanitizer did not show registered at appropriate levels and instructed the bucket to be changed with new sanitized water. IV. Staff interview The dietary director (DM), the CRDC and cook #2 introduced themself on 9/14/22 at 3:20 p.m. The DM said he recently was promoted to the position as dietary manager and was a cook prior to the promotion. The DM said he had been the facility's DM for less than a week. The CRDC said the facility was new to the corporation and he was providing consultation and would establish a regional dietary consultant for the facility. Cook #2 said he had been a cook for the past [AGE] years. Cook #2 was interviewed on 9/14/22 at 4:20 p.m. The cook said he was trained annually on hand hygiene and he should change gloves anytime he was handling food, after doffing gloves and anytime he touched contaminated surfaces. DA #1 was interviewed on 9/14/22 at 4:25 p.m The DA said she should change gloves anytime she stepped away from the service line and anytime she touched non-food surfaces. According to DA #1, surfaces such as the wall or her mask were items she should have changed her gloves and performed hand hygiene after touching. The DM was interviewed on 9/15/22 at 10:01 a.m. The DM said the facility did not log when they changed the sanitizer buckets. He said the buckets should be changed every two to three hours or less if the water was cloudy. The above infection control concerns during the meal were shared with the DM and the CRDC. The CRDC confirmed he also observed breaks in infection control during the 5/19/22 dinner observations. The key lime pie temperature on the test tray was shared with the DM and the CRDC. The CRDC said cold food could not rise above 41 degrees F because of the risk of bacterial growth. He said they should have not had a cold food tray sit for long periods at a time till served. He said the dietary department would be changing the way they handled cold food and for now would have the DA retrieve the desserts out of the refrigerated one at a time and serve immediately. The CRDC said cook #1 should have used the hydrion quaternary test strips not the chlorine test strips to test the red bucket on 9/12/22. He said the chlorine strips were to test the dishwasher. He said the sanitized solution in the read bucket should have registered at 200 ppm for adequate sanitation levels. The DM and CRDC said he would provide education with staff immediately to address the identified concerns. The CRDC said on 9/19/22 he would do an in-depth inservice with the dietary department on infection control procedures using the new corporation's training packets. According to the DM and CRDC, infection control practices would change.

Based on observations, record review and interviews, the facility failed to ensure proper infection control practices for one of one dining rooms and one of one laundry rooms. Specifically, the facility failed to ensure: -Residents were offered hand hygiene prior to meals; and, -Proper personal protective equipment (PPE) was utilized in the laundry room. Findings include: I. Facility policy and procedures The Infection Control policy, no date of inception or revision, provided by the infection and control preventionist (IP) on [DATE] at 12:00 p.m. read, there was an active facility wide infection control program with effective measure to control and prevent infections acquired or brought in the facility from the community or other health care facilities. There was a practical system for reporting, evaluating, and maintaining records of infections among residents, including assignment of responsibility for ongoing collection and analysis of data and required follow up. II. Hand hygiene A. Observations Dinner meal service was observed on ,d+[DATE]-[DATE] at 4:00 p.m. The dining room was divided into residents who required assistance with meals and residents who did not. The residents on the side who did not require assistance were not offered hand hygiene prior to their meals. On [DATE] at 2:08 p.m a bottle of hand sanitizer on a resident dining room table upon entry on the non-assistance side of the dining room was expired as of [DATE]. B. Interviews Dietary aides (DA) #3 and #4 were interviewed on [DATE] at 4:40 p.m. Both staff acknowledged that it was up to the certified nurse aides to assist residents with hand hygiene, and it was just their responsibility to ensure hand sanitizer was available on the table. The IP was interviewed on [DATE] at 11:00 a.m. She said hand sanitizer was on all resident dining tables and all staff should be offering and encouraging residents to use it prior to all meals and this was important to prevent cross contamination. The director of nursing (DON) was interviewed on [DATE] at 7:30 p.m. She said all residents were to be offered hand hygiene upon entering the dining room by any staff member. She said hand sanitizer should be on everything at the dining room table and utilized. III. Laundry room A. Observations The laundry room was inspected with the housekeeping director (HKD) on [DATE] at 2:18 p.m The HKD demonstrated the process of which laundry was handled from start to finish. She demonstrated the process for sorting soiled laundry intake and said only gloves were worn by staff when sorting soiled laundry. She said aprons or additional PPE were not needed and only work for things like COVID rooms soiled laundry. B. Interviews The IP was interviewed on [DATE] at 11:00 a.m. She said laundry staff should be wearing gloves, aprons, and a mask when sorting any and all soiled laundry. She said this was important to prevent cross contamination. The DON was interviewed on [DATE] at 7:30 p.m. She said laundry staff should be wearing gowns, gloves, and potentially goggles as well when sorting soiled laundry.

Based on interviews and record review the facility failed to ensure residents were free of abuse for six (#17, #45, #26, #28, #41 and #16) of eight out of 25 sample residents. Specifically, the facility failed to ensure: -Residents #17 and #45 were free from verbal abuse from staff; -Repeated resident-to-resident physical abuse incidents by Resident #16 directed toward other residents including Residents #26, #28 and Resident #41; and, -Physical abuse by Resident #22 against Resident #16 on two occasions. Cross-reference F610: failure to investigate an allegation of abuse. Findings include: I. Facility policy and procedure The Resident Safety policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 9/14/22 at 5:50 p.m. documented in part, it was the policy of the facility to maintain a work and living environment that was professional and free from threat and/or occurrence of harassment, abuse, (verbal, mental, or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Making reasonable efforts to provide a safe environment for the residents was one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relations with residents makes ethical and professional behavior essential. Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. II. Resident #17 and #45 kept free from staff abuse A. Resident #17 1. Resident status Resident #17, age 78, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 7/14/2022 minimum data set (MDS) the resident has 13 out of 15 on the brief interview for mental status exam indicating the resident was cognitively intact. 2. Resident interview Resident #17 was interviewed on 9/12/2022 at 2:47 p.m. He said a certified nurse aide (CNA) at the facility was mean to him purposefully (referring to CNA #3). He said he had chronic pain in his legs since losing the ability to walk, and when she would come in and change his brief she would purposefully push on his legs to cause him pain and discomfort. He said he asked her not to push on his legs several times but she did anyway. He said the CNA would not knock on the door when she entered and would bark orders at him, and would call him crybaby and tell him she hated taking care of him. Resident #17 said he had reported the CNA purposefully pushing on his legs and her name calling to a registered nurse (RN) at the facility a couple months ago, and nothing came of it because he later found out the RN was friends with the CNA. He said he continued to report these issues to staff and finally a few weeks ago the director of nursing (DON) came down to talk to him, and he thought that was about three weeks ago. He said he expressed his concerns to the DON at that time about the staff member and reported the issues with her pushing on his legs purposefully. He said the staff member was moved to day shift and now was getting more supervision from staff in an attempt he thought to salvage her because they could not afford to lose any staff. He said he was afraid the staff member would attempt to try to get even with him. He said the staff member despite being moved to a different shift would still come in his room, but with a second staff member now. B. Resident #45 1. Resident status Resident #45, age 72, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 5/25/22 minimum data set (MDS) the resident scored a 12 of 15 on the brief interview for mental status exam indicating the resident's cognition was moderately impaired. 2. Resident interview Resident #45 was interviewed on 9/14/22 at 8:30 a.m. She said she did not like certified nurse aide (CNA) #3 because she was mean and rough (no specifics were given by the resident but the resident was tearful). She said she felt it did feel like abuse and she was afraid of the staff member. She said she had reported these concerns to the director of nursing (DON) and nursing home administrator (NHA) but nothing had been done about it. C. NHA/DON notification The NHA and DON were notified of the abuse allegations on 9/14/22 at 8:38 a.m. They said they were unaware of the abuse allegations by residents and would cancel/suspend CNA #3 and begin and investigation. D. Record review The facility investigation related to the allegations was provided by the NHA. It detailed as follows: First known time following discussion with state surveyor who made DON and NHA aware of allegations of two residents (#17 and #45). CNA #3 was immediately suspended upon being made aware of allegations until investigation was complete and a final decision was made. 9/14/22 at 8:47 a.m. Resident #45's interview with DON and NHA. Resident #45 was interviewed regarding CNA. The DON and NHA assured the resident actions would be taken and DON/NHA were not aware she was fearful of the CNA. Resident #45 stated, I didn't know I was afraid of her until this morning. I never expressed it. She signed her statement. She reiterated she's mean, it's her personality. Resident #45 reported she did not like the way she talked to her as she was impatient and did things quickly and she knew she did this to other residents. She said she had not seen it with other residents but a staff member had told her. Resident #45 stated, I want CNA #3 fired. The facility entered the occurrence into the state system on 9/14/22 at 10:01 a.m. with two resident allegations of the CNA being impatient, gruff, and mean with one resident expressing fear of staff member. Resident #17 was noted to be interviewed. There were no notes detailing the staff's interview with the resident. The facility contacted local law enforcement with the allegations on 9/14/22 at 11:00 a.m. The deputy assigned had interviewed both residents (#17 and #45) on 9/14/22 at 1:00 p.m. Resident #6 was interviewed on 9/14/22 at 1:54 p.m. and stated the staff were wonderful. He said he had a problem with a nurse in the past, but she apologized and has had no issues since. He reported no issues with CNAs and was not fearful of staff and felt safe in the facility. RN #1 was interviewed on 9/14/22 at 2:13 p.m. and she stated a resident had told her in the past she did not like CNA #3. The RN stated the resident (unknown) was crying but did not report an allegation of abuse. The RN said CNA #3 could come off as abrasive and it was just her personality. Resident #27 was interviewed on 9/14/22 at 2:30 p.m. by the social services director (SSD). The resident denied any complaints about staff. A resident interviewed on 9/14/22 at 3:30 p.m. that was not listed in the sample reported I don't like the ugly aide, she is rude and hateful. She complains that I am hard to take care of. He reported he was not fearful of her but stated, fire that (expletive). The resident did not report concerns regarding any other staff. CNA #4 was interviewed on 9/14/22 at 3:56 p.m. who worked partial nights with CNA #3. He had not heard of any complaints regarding CNA #3 or any other staff members. Resident #4 was interviewed on 9/14/22 at 5:06 p.m. and had no concerns with staff. This concluded the investigative summary provided by the facility. E. Interviews The NHA was interviewed on 9/15/2022 at 7:30 p.m. The NHA said she did follow up with Resident #17 and he let it all go, and he reported he was very upset from his interactions with CNA #3. The NHA said she was the abuse officer for the facility and she had substantiated verbal abuse for Resident #17 and #45 by CNA #3. She said she did not have enough in the course of her investigation to substantiate physical abuse for Resident #17. She said she confirmed the resident identifying the staff member as the ugly aide in the course of her investigation was CNA #3. She said she was pursuing termination for CNA #3. III. Resident-to-resident abuse involving Residents #16, #22, #26, #28 and #41 A. Resident status 1. Resident #16, age 88, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/11/22 MDS assessment documented severe cognitive impairment with a BIMS score of three out of 15 and [CONDITION(S)] symptoms involving inattention. No behavioral symptoms were documented. She needed extensive assistance with most activities of daily living (ADLs) and used a wheelchair for ambulation. 2. Resident #22, age 84, was admitted on [DATE]. September 2022 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/22/22 MDS assessment documented severe dementia with a BIMS score of three out of 15 and no behavioral symptoms. She needed limited assistance with most ADLs and used a wheelchair or walker for ambulation. 3. Resident #26, age 95, was admitted on [DATE]. The 7/25/22 MDS assessment included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She needed extensive assistance with most ADLs and used a wheelchair. 4. Resident #28, age 92, was admitted on [DATE]. The 7/29/22 MDS assessment included a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . One behavioral symptom, care rejection occurring one to three days over the review period, was documented. She needed supervision and/or limited assistance for most ADLs and used a wheelchair. 5. Resident #41, age 70, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/17/22 MDS assessment documented she was cognitively intact with a BIMS score of 15 out of 15 and no behavioral symptoms. She needed supervision/limited assistance or was independent with most ADLs and used a walker. B. Physical abuse by Resident #16 against Resident #41 Resident #41 was interviewed on 9/13/22 at 9:00 a.m. She said another facility resident picks on me, pinches and scratches me. She named and described Resident #16, said she had received injuries from Resident #16 including a black spot on my arm, it had happened four times and she had reported it to her nurse. She said she was not afraid but she liked to stay in her room to avoid Resident #16, although she had to be in the dining room at the same time as her. Review of progress notes and facility investigations for the past six months revealed on 5/2/22 Resident #26 grabbed Resident #41 by the arm when she was near her in the dining room, leaving red marks that turned into bruising. Interviews with medical records, director of nursing (DON) and nursing home administrator (NHA) during late afternoon on 9/14/22 revealed none had heard the allegation this had occurred four times, or that Resident #41 did not want to leave her room. They said they had residents with behavioral issues and tried to keep them separated. Residents #41 and #16 did not sit close together in the dining room. The NHA said there was a previous incident between the two residents where Resident #41's forearm was injured, but that was the only altercation she was aware of. She said in light of this new information she would initiate an investigation. The social services director interviewed Resident #41 who said Resident #22 used to pinch her but she had not had any problems with her for about three weeks. She said she knew to avoid Resident #22 and she had no concerns with any other residents. C. Physical abuse by Resident #16 against Resident #28 Review of facility investigations revealed on 1/31/22, Resident #16 attacked Resident #28 in the common area without prior provocation, scratching her right forearm and leaving red marks. The certified nurse aide (CNA) was in line of sight and intervened immediately. Resident #28 had red marks on her arm but her skin was not broken, she said she was fine, and she did not voice fear of Resident #16, saying She's just like that. D. Physical abuse by Resident #22 against Resident #16 Review of facility investigations revealed on 4/11/22, Residents #22 and #16 were yelling, name calling, cursing and attempting to kick and hit each other. Resident #22 was named as the assailant and Resident #16 was the victim. Neither resident was physically injured. The plan going forward was to keep the residents in line of sight and separate from each other. However, the incident occurred when the residents were within line of sight of staff in a common area. E. Physical abuse by Resident #16 against Resident #26 Facility investigations revealed on 6/5/22 Resident #16 backhanded Resident #26 across the face, causing swelling under her right eye. The response was that Resident #16 was closely monitored for behaviors and triggers, and was to be kept in line of sight by staff. However, staff were in line of sight and running to intervene when Resident #16 backhanded Resident #26. F. Physical abuse by Resident #22 against Resident #16 Facility investigations revealed on 7/19/22 Resident #16 swung at Resident #26, who retaliated by slapping her across the face, leaving a red mark. The facility response was that both residents had very low BIMS and dementia diagnosis. Neither resident had a recollection of the event. Reviewed care plans, notes, and spoke with staff. Resident #16 had been stable on her medications, resident was very closely monitored for behaviors, triggers, etc. and kept in line of sight. Despite all of this, both residents very quickly became escalated but staff quickly intervened. G. Staff interview The NHA and DON were on 9/15/22 at 8:03 p.m. They said keeping Resident #16 in line of sight and away from other residents who also had strong personalities was key. She was easily redirectable with activities, but her reactions are quick, like if someone accidentally bumps into her and she reacts, then we intervene. The facility failed to keep residents free from abuse. All the incidents above involved Resident #16. (Cross-reference F744, dementia care)

Based on interviews and record review, the facility failed to take timely action to follow up on grievances of the resident council group. Specifically, residents who regularly participated in resident council said facility staff did not take action on their grievances involving: -Residents who did not receive adequate staff supervision and dignified treatment, and repeatedly set off alarms and wandered into other residents' rooms; and, -Food quality and palatability, snacks and dining room concerns/choices. Residents said nothing ever gets done in resident council, and the concerns they brought forward were unresolved and ongoing. Residents further stated the concerns they discussed in resident council were not documented in the minutes. Findings include: I. Facility policies The undated Resident Council policy, provided by the facility on 9/15/22, included the following: All residents had the right to a quality of life supportive of independent expression, decision making and independence of action. Staff and residents would work together to attempt to resolve any issues/problems within 60 days. The resident council format included that minutes would be taken to include if issues had been resolved or action was being taken, who was involved, what action was being taken, and ask for comments and concerns. The undated Grievance Procedure policy, provided by the facility on 9/15/22, included the following: Ensure prompt resolution of all grievances regarding resident rights. The grievance official shall be responsible for the timely follow up (5 days) of the corrective action to ensure resolution of the recorded concern and the satisfaction of corrective action. The staff designee shall make contact with the complainant 14 days after the date of initial complaint to ensure full satisfaction with corrective measures. II. Resident council minutes Review of resident council minutes for the past six months revealed: On 3/30/22, seven facility staff and 10 residents attended. The previous month's minutes were read and approved. Concerns about the dietary (department) voiced by residents were: coffee is cold, food is cold, the cooks were not reading the tickets, and the posted chalkboard menus were difficult to read. The staff's documented response was that kitchen staff were being retrained in their positions and white chalk was being used on the chalkboard menus for readability. -No other resident concerns were documented in the minutes. -There was no documented discussion of resident rights. On 4/27/22, seven staff and four residents attended. The previous minutes were read and approved. There was no documentation of action taken on the previous resident concerns. Concerns about dietary voiced by residents were: food is served cold and the kitchen staff were not asking residents what they would like to eat. Staff's documented response was new staff training. Residents voiced that nursing staff were slow to respond to call lights. The staff response was more staff were hired to fix the problem. -Repeated dietary concerns from the previous month were documented, but there was no evidence of discussion about the lack of action taken and resolution. On 5/25/22, seven staff and eight residents attended. The previous minutes were read and approved. Concerns about dietary were voiced that food was cold for room trays. The staff response was that kitchen staff had hustled to get room trays out faster to solve the cold food problem. On 6/29/22, seven staff and four residents attended. The residents voiced concerns again about cold food, said the meat was too tough to chew, and they would like smaller portions as there was too much wasted food. Staff responded that the dietary director had a meeting with staff. On 7/27/22, seven staff and four residents attended. Residents said the meat was too tough to eat. The resolution was the dietary director stopped ordering the pork chops. On 8/31/22, seven staff and three residents attended. Residents said they would like more snacks, cornbread without sugar, cornbread browned, and bacon in the beans. One resident said he would like bottled water as he did not like the filtered water in the facility. The staff response was they would purchase water for the resident who requested it. Plans for resolution of the other dietary concerns were not discussed. -There was no evidence of grievances generated as a result of resident council discussions, and no evidence that staff discussed resolutions to resolve ongoing dietary concerns voiced by resident council. III. Resident group interview Residents #4, #6 and #23, including the resident council president and two residents who regularly attended, and were cognitively intact and interviewable, were interviewed on 9/13/22 at 2:30 p.m. When asked if the facility considered the views of the resident group and acted promptly upon grievances and concerns, they responded, No. When asked if a rationale was provided when the facility was unable to make changes as requested, they said, No. They did not know how to file a grievance. They said, Nothing ever gets done and that resolutions to the concerns they brought up during resident council were always ongoing. The residents said they sometimes felt like inmates because the door alarms were set off so frequently by confused residents who tried to elope. They said some certified nurse aides (CNAs) were not well trained and thought they had to make people do things, by saying to confused residents, No, you can't do that and the residents did not understand because they think they have to leave and there's really no place for them to go, but they're always testing the doors. They just want someone to walk around with them. They named Residents #3, #7, #22 and#43. They said these residents wandered into other residents' rooms including theirs and you have to get them out. They said it was disturbing and disgusting to them at times, and that was why they had stop signs on their doors. They described examples where a resident urinated in their laundry basket, another resident dropped trash into their laundry basket, and a third resident entered their room and said she was going to take a nap in their roommate's bed and proceeded to do so. They said they did not feel that staff adequately supervised and engaged confused residents in activities to prevent them from encroaching on the privacy and rights of other residents. The residents said there were unresolved food concerns, that food choices and food palatability were a problem. The corn bread was still a problem in that it had a sweet taste they did not like, foods were served that did not go well together, there was no bacon in the beans as requested, and the food was sometimes served cold. A resident said he saw his food sitting in the kitchen window for 10-15 minutes before being served to him, and it was cold. There was too much food waste and requests for small portions were not honored. They said sufficient flavorful, substantial snacks of their choice were not provided, dinner was served early and from 4:00 p.m. until the next morning is a long time to go on soup and a sandwich. They said dinner was only served until 5:00 p.m. and that's it, and then the dining room was closed. They said several days could go by where there were no drinks, no sodas, no juices, the fridge will just be empty. They had requested specific snacks that were not provided, such as V8 juice, Oreos and Fig Newtons. IV. Nursing home administrator follow-up The nursing home administrator (NHA) was interviewed on the afternoon of 9/13 and 9/15/22. She said she was not previously aware of some of the above resident concerns, but she was aware of resident concerns involving food, snacks and dining room issues. She said she would follow up with the residents regarding their concerns, would follow up to engage wandering residents so they did not violate other residents' rights, and would establish a food committee to help with resolving food and dining room concerns.

Based on observations, record review and interviews, the facility failed to effectively address the treatment and service needs of three (#16, #39 and #22) of five residents reviewed for dementia care of 25 sample residents. Specifically, the facility failed to: -Provide dementia care and services to ensure Resident #39 was provided an appropriate level of meal assistance while promoting a dignified meal experience. -Provide dementia care and services to provide for resident needs and address repeated incidents of resident-to-resident aggression and abuse for Resident #16; and, -Provide dementia care and services for Resident #22. Findings include: I. Facility policy The Dementia-Clinical Care policy, March 2015, was provided by the nursing home administrator (NHA) on 9/19/22 via email. The policy read in pertinent part: For individuals with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. The facility will strive to optimize familiarity through consistent staff resident assignments. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. The IDT will identify and document the residents condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation. Progressive or persistent worsening of symptoms and increased need for staff support will be reported to the IDT. II. Resident #39 A. Resident status Resident #39, age 86, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 8/23/22 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for a mental status score of three out of 15. Resident #39 required limited assistance from one person with eating. B. Observations Resident #39 was observed on 9/12/22 at 4:08 p.m. during the dinner meal. The resident's meal was placed in front of him. He picked up his fork in right hand. He proceeded to gently poke the napkin with prongs of the fork multiple times before he made his way to find the plate. After looking down at his meal for several moments, the resident was able to take a small bite of food using his fork. The resident lifted a large slice of tortilla with his fork to his mouth. Resident #39 took a bite of the tip of the tortilla but did not chew through it. The resident sat at the table for over a minute with a large slice of tortilla hanging from his mouth with multiple staff walking past the resident. The staff did not offer to assist Resident #39 in cutting up the tortilla. After a minute, the resident was able to chew through the tortilla hanging on his mouth and the remainder of the tortilla dropped down to the plate. On 9/13/22 at 3:59 p.m. Resident #39 was assisted to his dining table. The resident was awake and alert. -At 4:27 p.m. the resident still was not served his meal. Most of the other residents in the dining room were already served. The resident fell asleep at the table. -At 4:32 p.m. Resident #39 was served. The dietary aide woke the resident up, poured his can of soda and pointed to the resident's utensils wrapped in a napkin. The resident looked at his plate and closed his eyes, opening his eyes a few moments later to look around the room. -At 4:37 p.m. Resident #39 struggled to retrieve his fork from his folded napkin. Once the fork was free from the napkin, he attempted to lift the butter knife with the fork. The resident then poked at the napkin with the fork, holding the fork upside down. The resident was not offered assistance. After a few minutes focusing on the napkin, the resident moved the fork to the plate and proceeded to feed himself. Throughout the meal the resident stopped eating and looked at the plate and then would slowly start eating again. C. Resident interview A group interview was conducted on 9/13/22 at 3:12 p.m. with three residents (#4,#6, and #23) the facility assessed and deemed as alert, oriented, and interviewable. The sample group represented resident experience living in the facility. The residents expressed concerns with the delay in meal service and assistance. Members of the group said they have seen Resident #39 go hungry. They said Resident #39 had use of only one hand and fed himself. They said he would be served his meal but could not yell when he needed help. The residents said sometimes Resident #39 would have to sit and wait to be served while everyone else was eating. According to one of the group interview members, Resident #39 had told him he wanted speech therapy. An exit interview on 9/15/22 at approximately 8:40 p.m. was conducted with two residents. A general overview of the survey findings were reviewed with the residents. The findings did not disclose resident names or resident details. One resident during the interview stated that he hoped for the facility to provide more meal assistance for Resident #39. D. Record review The 2/25/2020 long term stay care plan identified Resident #39 ate his in the dining room. The care plan directed staff to offer the resident snacks between meals, provide a regular diet, and monitor and record intake. The care plan did not identify what type of meal assistance the resident required. The 8/31/22 nutrition evaluation under recommendations identified that staff should continue to encourage good meal intakes, encourage snacks of choice and encourage good fluid intakes with and in between meals and continue to monitor. The evaluation did identify recommendations to provide Resident #39 assistance with his meals. The review of September 2022 care plan for Resident #39 identified the resident required assistance with bed mobility, ambulation, bathing, hand hygiene, and toileting assistance, however, the care plan did not identify the Resident #39 needed limited assistance from one staff member with eating as indicated by the 8/23/22 MDS assessment. The MDS activities of daily living (ADL) question log also known as smart charting between 7/24/22 and 9/15/22, under Eating-ADL Self Performance. The log indicated the resident primarily required supervision and limited assistance with eating. The Eating-ADL Support Provided indicated the resident primarily received no set up or physical help from staff or received set help only. On 8/1/22, the resident was identified to need extensive assist and received one person's physical assistance. On 8/15/22, the resident was identified to need limited assistance and received one person's physical assistance. -The review of the resident's medical record did not identify the resident had current or recent weight loss. E. Staff interviews The activity director (AD) was interviewed on 9/15/22 at 2:50 p.m. She said she and other staff had seen a recent change in Resident #39 and staff were still trying to figure out what would work best for him. The AD said during the IDT team meetings, it was discussed that Resident #39 has had a noticeable decline. She said they noticed when he ate, he would stop eating and then would have difficulty to start eating again. She said interventions have not been implemented because staff were still trying to figure out what was going on. Licenced practical nurse (LPN) #1 was interviewed on 9/15/22 at 4:15 p.m. She said Resident #39 had a steady decline over the last couple of weeks. She said she was not aware of changes in the resident's eating. She said he needed to set up assistance and then could feed himself. The LPN said the resident needed to have his utensils and his drinks set out for him. The minimum data set coordinator (MDSC) was interviewed on 9/15/22 at 4:23 p.m. She said when she completed the MDS assessment and coded a resident required limited assistance with one person physical assistance because she determined a resident needed partial assistance with eating and/or not safe eating on his own. She said a staff member should be physically present during the meal offering supervision, guidance, cueing and physical assistance as needed. The MDSC reviewed the 8/23/22 MDS assessment for Resident #39 and confirmed she identified and coded the resident needing the higher level of assistance of limited physical assistance. She said she reviewed the smart charting, observed Resident #39 at meals and interviewed staff to determine he needed more assistance than supervision, or supervision with set up. She said he sometimes needed more cueing and support during his meals. The MDSC said changes in resident ADL care needs as eating would be discussed with the IDT team. She said changes in care level would usually be communicated on the 24 hour report, the communication board and face-to-face communication at time when the need was identified. She said she did not know who she informed of the changes. The MDSC said the changes in meal assistance should have also been discussed in the weekly nutrition at risk (NAR) meetings and documented in the progress notes. The MDSC reviewed the progress notes and said Resident #39 was not discussed in the past 30 days. The MDSC said he has not had weight loss but he should have been discussed in NAR because of the change in meal assistance needed. The MDSC said the high level of meal assistance needed should have been on the care plan. The MDSC reviewed the care plan and identified he did not have a care plan conveying to staff the level of meal assistance he currently needed. She said she would review him in the next NAR meeting, update the care plan and refer him to physical and occupational therapy. Certified nurse aide (CNA) #1 was interviewed on 9/15/22 at 5:31 p.m. The CNA said Resident #39 usually needed meals to be set up but was not aware of any other meal assistance needed. She said sometimes he gets confused with his fork and spoon. She said he needs some cueing and handing him his coffee cup handle. She said he did not receive any other assistance with meals. The CNA said sometimes he would just look at his food. The NHA and the director of nursing (DON) were interviewed on 9/15/22 at 7:35 p.m. They said the IDT team discussed the changing needs of Resident #39 during the week of the survey. They said they discussed referring the resident to speech therapy. They said the staff needed to provide Resident #39 with cueing during meals and they would provide staff education. II. Resident #16 A. Resident status Resident #16, age 88, was admitted on [DATE]. According to the September 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/11/22 minimum data set (MDS) assessment documented severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15 and [CONDITION(S)] symptoms involving inattention. No behavioral symptoms were documented. She needed extensive assistance with most activities of daily living (ADLs) and used a wheelchair for ambulation. B. Record review revealed failures in provision of dementia care and services September 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigative reports revealed Resident #16 was involved in all six resident-to-resident abusive incidents over the past eight months, which occurred on 1/31, 4/11, 5/2, 6/5 and 7/19/22. Nursing progress notes reviewed for the same time period revealed Resident #16 was frequently verbally and physically abusive to staff, and needed line of sight monitoring by staff to prevent altercations from other residents. Only three activity notes were found in the progress notes: on 3/16, 3/17 and 4/1/22, regarding her enjoyment of the St. Patrick's Day party, social events and movies, and live music. Resident #16's most recent activities assessment, dated 7/11/22, identified she was a retired teacher. Her activity interests included socialization, one-on-ones (visits), hobbies, exercise and sports, religious/spiritual, television, movies, and musical activities. Her preferred activity time was late afternoon two to three times per week. Activity participation records reviewed for the previous six months revealed Resident #16 was frequently not engaged in activities. Documented activities were reminisce, family and friend visits, nail care (one time on 3/16/22), beauty shop (one time on 8/15/22) and outside visiting (one time on 8/12/22). There were large gaps of days or weeks between documented activities. She participated in five activities during March, none in April, four in May, two in June, three in July, six in August, and none in September 2022. The care plan for verbally (and occasionally physically) aggressive behavior, initiated on 7/19/21 and not revised, listed the following interventions: talk in calm voice when behavior is disruptive, remove from public area when behavior is disruptive and unacceptable, reinforce unacceptability of verbal abuse, praise for demonstrating desired behavior, monitor and document target behaviors, elicit family input for best approaches to resident, do not argue with resident, discuss options for appropriate channeling of anger, assist in selection of appropriate coping mechanisms, administer behavior medications as ordered by physician, provide diversional activities (magazines, offer cold drink, etc.). The care plan for activities, initiated on 9/18/19 and not revised, listed the following interventions: assess resident's response to new activity plan, modify as needed; remind when activities are scheduled; assist to preferred activities; provide environment that respects privacy; create activity plan based on resident preferences; a monthly calendar is placed in her room. -The care plans were not person-centered, were not updated following abusive incidents, did not identify triggers or specific methods to engage the resident to avoid or quickly diffuse potentially abusive situations, and did not include keeping the resident within line of sight in order to intervene before she became abusive to other residents. (Cross-reference F600, freedom from resident-to-resident abuse) C. Staff interview The NHA and DON were interviewed on 9/15/22 at 8:00 p.m. They said they would develop comprehensive plans and interventions to engage Resident #16 to meet her dementia care, behavioral and quality of life needs, and protect other residents' safety and quality of life. III. Resident #22 A. Resident status Resident #22, age 84, was admitted on [DATE]. September 2022 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/22/22 MDS assessment documented severe dementia with a BIMS score of three out of 15 and no behavioral symptoms. She needed limited assistance with most ADLs and used a wheelchair or walker for ambulation. B. Record review revealed failures in provision of dementia care and services September 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigative reports revealed Resident #22 was involved in two resident-to-resident abusive incidents over the past eight months, both with Resident #16, on 4/11/22 and 7/19/22. Nursing progress notes revealed Resident #22 frequently disturbed other residents by wandering into their rooms, had loud verbal outbursts, exhibited verbal and physical aggression, tried to provide care for other residents, perseverated on looking for her dog, argued with other residents, attempted to hit other residents, and was difficult to redirect. A few activity notes were included in the progress notes regarding enjoying the St Patrick's Day party on 3/17/22, enjoying bingo and social events on 3/16/22, live music on 4/1/22, socializing well with other residents on 5/31/22, at the round table with others watching television on 6/6/22, two movies and socialization with snacks on 7/15/22, socializing with others and looking at magazines on 7/30/22, snacks with TV and coloring on 8/13/22, and enjoying the luau on 8/26/22. Her most recent activities assessment on 3/9/22 identified her activity interests as socialization activities and one-on-ones in the late afternoon. The activity participation records, reviewed for the past six months, documented she attended reminisce, visits with family and friends, had outside visits twice and beauty shop once. There were large gaps of days or weeks between activities. She was documented to participate in activities five times in April, five times in May, 10 times in June, four times in July, eight times in August, and none in September 2022. Resident #22's behavioral care plan, initiated 7/20/22 and not revised, included exactly the same title and interventions as Resident #16's (see above) and was not person-centered. No revisions, trigger identifications or specific methods to diffuse aggressive situations were included in the care plan. Her dementia care plan, initiated 1/17/22 and not revised, listed the following interventions: monitor and document behaviors; divert or redirect attention; provide one-on-one; offer snacks/fluids; approach warmly and positively; encourage family visits and support; approach in a calm manner, calling her by name; encourage her to attend activities of choice; speak to her in clear concise sentences and allow for her to answer; do not hurry or rush. -No activities care plan could be found. C. Staff interviews CNA #2 was interviewed on 9/15/22 at 2:00 p.m. and said they tried to keep Residents #16 and #22 apart and redirected or engaged in something more interesting than arguing or being aggressive, which tended to happen more in the evenings. CNA #1 was interviewed on 9/15/22 at 5:10 p.m. and said they had enough staff to provide the necessary ADL care for residents, but not to engage with the residents, spend time with them, anticipate their needs to address behavioral symptoms The NHA and DON were interviewed on 9/15/22 at 8:00 p.m. They said they would develop comprehensive plans and interventions to engage Resident #16 to meet her dementia care, behavioral and quality of life needs, and protect other residents' safety and quality of life.

Based on interviews and record review, the facility failed to investigate allegations of abuse for two (#17 and #45) out of 25 sample residents. Specifically, the facility failed to investigate abuse allegations against a staff member brought forward by Resident #17 and Resident #45. Cross-reference F600 for abuse. Findings include: I. Facility policy and procedure The Resident Safety policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 9/14/22 at 5:50 p.m. documented in part, it was the policy of the facility to maintain a work and living environment that was professional and free from threat and/or occurrence of harassment, abuse, (verbal, mental, or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Making reasonable efforts to provide a safe environment for the residents was one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relations with residents makes ethical and professional behavior essential. Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Reporting suspected or reported violations: Any suspected, observed or reported violation of this resident safety policy would be reported to the supervisor on duty immediately. The supervisor on duty shall report any suspected violations of this resident safety policy immediately to the administrator and to the director of nursing or their designee as soon as practicable. Procedure for investigation: -The quality assurance manager and/or supervisor on duty will assess the resident and document the date, time, and location of the reported or suspected incident. -The supervisor would ensure that the resident was protected from harm during the investigation. -An incident report would be completed. -An employee suspected of violation of the resident safety policy may be suspended pending the results of the investigation. -The quality assurance manager and/or supervisor on duty would attempt to interview the resident as well as all nursing, housekeeping, laundry, dietary, activity, social service staff, any visitors or others who may have knowledge of the occurrence or who may had been in the vicinity at the time the incident happened. The quality assurance manager and/or supervisor on duty would prepare a written summary of each interview. II. Resident #17 Resident #17 was interviewed on 9/12/2022 at 2:47 p.m. He said a certified nurse aide (CNA) at the facility was mean to him purposefully (referring to CNA #3). Resident #17 said he had reported the CNA purposefully pushing on his legs and her name calling to a registered nurse (RN) at the facility a couple months ago, and nothing came of it because he later found out the RN was friends with the CNA. He said he continued to report these issues to staff and finally a few weeks ago the director of nursing (DON) came down to talk to him, and he thought that was about three weeks ago. He said he expressed his concerns to the DON at that time about the staff member and reported the issues with her pushing on his legs purposefully (cross-reference F600). III. Resident #45 Resident #45 was interviewed on 9/14/22 at 8:15 a.m. She said she did not like certified nurse aide (CNA) #3 because she was mean and rough (no specifics were given by the resident but she was tearful during the interview). She said she felt it did feel like abuse and she was afraid of the staff member. She said she had reported these concerns to the director of nursing (DON) and nursing home administrator (NHA) previously but nothing had been done about it (cross-reference F600). IV. Record review A nursing progress note for Resident #17 by licensed practical nurse (LPN) #2 dated 7/10/22 at 3:30 a.m. read, Resident continues this evening to swear at staff, call staff names. Calls for assistance and is noted to immediately yell at staff, verbalize multiple complaints regarding his positioning, as well as all departments in the facility. States he expects his call light to be answered immediately, resident non receptive to any form of waiting. He has made multiple accusations this evening, he is advised to discuss these with administration, he follows this suggestion with comment that he has been in touch with his attorney and speaks to his attorney every Monday regarding his complaints. Staff has been instructed to provide care for this resident with 2 staff members present at all times. A Complaint & Concern form dated 8/24/22 completed by the DON under nature of concern showed Resident #17 stated he was unhappy with care from a night shift CNA. Resident stated the staff member did not speak to him while providing care. He also stated the CNA did not help assist him with changing his hearing aids. The resident chose not to state the name of the CNA. Under response on the form the suspected CNA was moved to day shift per the CNA's request and for observation. The CNA was instructed to not enter Resident #17's room without another staff member. This change was made in early September and dated 9/1/22. -The Complaint & Concern form did not include information about the staff member pushing on his legs or calling him names. A Complaint & Concern form dated 9/9/22 completed by the NHA for Resident #45 showed the nature of the concern as Resident #45 reported CNA #3 was impatient and gruff. She stated stated she did not like CNA #3, and CNA #3 had walked into her room and shut off her call light without addressing the residents' needs. Under the response and action taken it was noted the staff member was educated and encouraged to slow down and approve the resident with a gentle voice and manner, and communicate and approach the resident with additional aid (staff member) if needed. An Educational Forms document dated 9/9/22 showed CNA #3 was given a verbal warning for a resident stating she was impatient and gruff. The staff member verbalized understanding of resident dignity and was given a handout. A statement by Resident #45 provided by the facility on 9/14/22 at 8:47 a.m. showed Resident #45 stated she did not know she was afraid of the staff member until this morning, and she never expressed it. The CNA was mean and it was her personality. The resident signed the statement. V. Interviews The DON and NHA were initially interviewed on 9/14/22 at 8:45 a.m. The DON said Resident #17 had reported to her some concerns about a CNA. The resident had not given her a name, but she was able to identify the staff member as CNA #3. She said the concerns were initially brought to her sometime in August 2022, and Resident #17 had reported the issues of CNA #3 pushing on his legs. She said she did not know if the staff member had been doing it on purpose or not. She said she did not complete an investigation at the time about it (cross-reference F600). She said the staff member was moved to day shift on 9/1/22 for more supervision and was not moved earlier because of staffing issues in the facility. She said it was not reported to her the staff member had called the resident cry baby or any other verbal issues. The DON and NHA said they felt for Resident #45 the concerns brought forward to them from the resident did not meet the level of abuse, so an investigation was not done. Both staff acknowledged they felt it was the way and tone of the CNA when she spoke to the resident. They said the resident had not reported she was afraid of the staff member until it was brought to their attention during the survey. The NHA said it was not ok for staff not to be cordial with residents. They said they had interviewed some nurses about the CNA and they decided again the staff member should provide care in pairs with another staff member for Resident #45. Both staff acknowledged they did not interview other residents about CNA #3, but said Resident #17 and #45 had come forward with concerns about the staff member and no investigation had been done (cross-reference F600). LPN #2 was interviewed on 9/15/22 at 2:00 p.m. She said she was fairly certain the accusations being made from her note in July 2022 were about CNA #3. She said she knew it was about a CNA because if it were her she would have said in her note that it was about her, but that she did not name other staff in her notes. She said she thought it was about CNA #3 pushing on his legs purposefully, and she did not recall any verbal abuse accusations. She said she would have told whoever was coming on the next morning the resident was making accusations and she trusted they would follow up with administration as they were not on during the night and it was a Sunday night. She said she did not follow up with administration herself and notify them about the accusations from Resident #17, and she was unaware if an investigation was done. She said she was at fault and dropped the ball. She said she should have notified administration herself as that was the process at the facility. She said she did not remember who she asked to forward the allegation to administration the next morning, and she put her trust in them that it would be done and it was not. The DON and NHA were interviewed on 9/15/22 at 7:30 p.m. The NHA said if the facility received an allegation she would immediately make sure the resident was safe. She would suspend the staff member pending an investigation. She said they would follow the reporting process with occurrences and notify law enforcement and the ombudsman. She said she would sometimes interview residents about the allegations first and right away because it was fresh in their minds. She said she would interview other residents as well to ensure the abuse was not spreading. She said the staff were educated to let her know immediately about allegations even if they were not sure it met the criteria of abuse as she would rather know about it than not. She said the LPN #2 should have let them know right away about the allegations from July 2022 and an investigation should have been done right away. She said an investigation had been done into CNA #3 during the survey and she had substantiated verbal abuse for that staff member and she was pursuing termination of CNA #3 (cross-reference F600). The NHA and DON both acknowledged if LPN #2 had come forward with her concerns in July 2022 the substantiated verbal abuse for Resident's #17 and #45 could have been possibly mitigated, and the importance of conducting investigations was to prevent and stop further abuse. The DON said an investigation was not done in August 2022 when she spoke to Resident #17. It was only reported to her on the grievance form that CNA #3 was rude and did not speak to him when she performed care. She said he had called her the roughest CNA, but he did not report the issues with her pushing on his legs at that time. -There was conflicting information provided by the DON interviews of the time of when she made aware of the staff member allegedly purposely pushing on Resident #17's legs.

Based on resident and staff interviews and record review, the facility failed to ensure residents were free from physical and sexual abuse for two (#10 and #16) out of seven residents reviewed for abuse out of 26 sample residents. Resident #10 was involved in three separate incidents of resident to resident abuse while residing in the facility. He was the victim of two of incidents of abuse involving Resident #20 and Resident #200. Resident #10 also sexually abused Resident #16's by touching her breast. The facility's failure to prevent abuse subjected Resident #10 and Resident #16 to abusive situations. Resident #10 experienced a cut lip and scratched face (separate incidents) and Resident #16 experienced a change in psychosocial condition immediately following a sexual abuse incident. The facility did not develop plans to prevent future incidents of abuse from happening. Resident #10 and Resident #200 no longer reside in the building. Cross-reference F610, failure to thoroughly investigate alleged violations of abuse. Findings include: I. Facility policy and procedure The Resident Safety policy, with no date when initiated, was provided by the nursing home administrator (NHA) on 6/7/21 at 7:44 p.m. The policy documented in pertinent part, It is the policy of our facility to maintain a work and living environment that is free from threat and/or occurrence of harassment, abuse (verbal, mental or sexual), and neglect. Residents must not be subjected to abuse by anyone. Including, but not limited to facility staff, other residents. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault; Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. II. Resident #10 A. Resident status Resident #10, age less than 65, was admitted to the facility on [DATE] and discharged [DATE]. According to the May 2021 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 3/17/21 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview of mental stats (BIMS) of eight out of 15. He had no moods or behaviors identified. B. Record review A behavior care plan, initiated 4/8/21 and revised 7/8/21, identified the resident had the potential for physically aggressive behavior. The resident's goal was to have no incidents of physically aggressive behavior. Interventions included the resident was to be in line of sight of staff at all times until deemed appropriate to lift the interventions and to refer to social services for evaluation if needed. A behavior care plan, initiated 5/16/21, identified the resident as socially inappropriate with disruptive behavior. The resident's goal was to not place other residents in an unsafe or at risk situation and staff would monitor and intervene if behaviors were present. Interventions included in part to remove from the public area when behavior was disruptive and unacceptable, monitor and document behaviors of inappropriate touching with female residents, refer to social services and do not argue with the resident. A nurse's note dated 5/22/21 documented in part the resident was on frequent checks by nursing staff and was observed grabbing a female resident's hand and she stated, don't touch me. The resident proceeded to grab the female resident's breast and she yelled out. The nursing staff intervened and the female resident told the nurse she did not like that. The (male) resident was immediately redirected. The clinical record did not include documentation of regularly timed and scheduled frequent checks to show evidence Resident #10 was being monitored appropriately. The facility was asked to provide any documentation from the clinical record regarding Resident #10's involvement with all alleged allegations of abuse from 4/7/21 to 5/22/21. Progress notes were provided from 5/16/21 through 5/30/21 which described the 5/22/21 altercation (above). No other documentation was provided. Further, the facility was asked to provide evidence of behavior monitoring and tracking around the time frame of the abuse incidents #10 was involved in, and there was no documentation provided or in the clinical record as of 6/25/21 of the 3/17/21 or 4/7/21 incidents. III. Resident #200 A. Resident status Resident #200, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to March 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 3/29/21 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. He had moods to include little interest or pleasure in doing things and feeling down, depressed or hopeless. He did not have any behaviors. B. Record review A care plan, initiated 12/10/2020, with a review date of 3/10/21, identified the resident with signs and symptoms of depression. The goal was signs and symptoms of depression would decrease this quarter. Interventions included in part to monitor and document target behaviors and administer medications as ordered. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An administrative progress note dated 3/18/21, documented as a late entry from 3/17/21, revealed in part that the resident approached another male resident who was sitting in the front living room watching television and wanted his chair. The two exchanged words and Resident #200 swung at the other male resident (#10) and made contact causing a cut on his lip. An incident report was done along with a report to the state agency. The police were notified and Resident #200 was issued a citation. Nursing staff assessed Resident #10's lip and no further treatment was required. There was no further documentation found of the 3/17/21 altercation between Resident #200 and #10 or that close monitoring was occurring to ensure safety of both residents and other residents. IV. Resident #20 A. Resident status Resident #20, age 71, was admitted on [DATE]. According to the June 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/13/21 MDS assessment, the resident was cognitively intact with a BIMS of 14 out of 15. He had moods of feeling tired or having little energy, trouble concentrating on things such as reading the newspaper or watching TV. He had [CONDITION(S)] to include delusions. B. Record review A nurse's note dated 4/7/21 documented in part that Resident #10 was in the front living room turning up the volume on the television. Resident #10 yelled at Resident #20 calling him a curse word in Spanish. Resident #20 fell on top of Resident #10 and scratched him on the face causing a superficial scratch. Nursing cleaned the scratch and applied a bandaid. Another resident in the area yelled out for staff attention. The two residents were separated and interviewed. Resident #20 did not have any injuries. The incident was caught on video camera and reviewed. A care plan, initiated 4/8/21 with a review date of 7/8/21, identified the resident as having physical aggressive behavior toward another specific resident. The goal was physically aggressive behaviors would decrease and not cause harm to the resident or any other person. Interventions included in part to talk to him in a calm voice when behavior was disruptive, remove from public areas when behavior was disruptive and unacceptable, monitor and document target behavior, identify causes for behavior and reduce factors that may provoke aggressive behaviors and provide diversional activities. There was no further documentation provided to demonstrate that monitoring or frequent checks were conducted for Resident #10 and #20. V. Resident #16 A. Resident status Resident #16, age 87, was admitted on [DATE]. According to the June 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/14/21 MDS assessment, the resident had severe cognitive impairment with a BIMS score of six out of 15. She had moods to include little interest or pleasure in doing things, feeling down, depressed or hopeless and feeling tired or having little energy. She had behaviors to include delusions and verbally aggressive symptoms directed towards others. B. Record review A care plan, initiated 4/20/21 with a review date of 7/20/21, identified the resident had socially inappropriate behavior related to delusions of marriage to male staff/residents. The goal was the behavior would not physically or emotionally impact the residents or others and she would remain safe without incident. Interventions included in part to talk in a calm voice when behavior is disruptive, remove her from public areas when behavior was disruptive and unacceptable, monitor and document target behaviors of believing she was married to male staff and male residents and provide diversional activities. A nurse's note dated 5/22/21 documented in part a certified nurse aide (CNA) witnessed male resident #10 grabbing Resident #16's hand and then he proceeded to grab her breast. She yelled at him to stop and the CNA immediately intervened and redirected Resident #10. Registered nurse (RN) #1 was informed and instructions were given to inform the family, complete an incident report and continue to frequently monitor Resident #10 and keep the two separated. The sheriff was notified and no charges were filed. Resident #16 was kept close to the nursing staff throughout the shift. A nurse's note dated 5/23/21 documented in part the resident experienced several outbursts this evening as well as one incident of attempting to hit another resident. She was redirected and separated from the other resident to reduce the possibility of further outbursts. An administrative note dated 5/24/21 documented in part the resident was interviewed while she was sitting in the common area reading a magazine. She appeared to be at her baseline and did not appear to recall the incident that occurred on 5/22/21. She stated that she felt safe and she appeared to be in a good mood and smiling. There was no further documentation found to demonstrate the facility was monitoring her for any non-verbal residual effects from the incident on 5/22/21. VI. Leadership interview The NHA was interviewed on 6/10/21 at 5:00 p.m. She said that following the incident between Resident #10 and #200, Resident #200 had received a citation for assault from the police and a 30-day discharge notice from the facility. She said both residents were kept in line of sight at all times when outside of their rooms and that frequent checks were conducted throughout the day. She said nursing staff were expected to document these were being done in the clinical record. She said they used to be roommates so Resident #10 was moved to another room/hallway. She said that should be documented in their records. She said they do not do 15-minute checks. She said for the incident involving Resident #10 and #20, the residents were kept in line of sight and any follow up documentation would be in their records. She said that Resident #10's medications had been adjusted. There was no further documentation found in the clinical record that residents were kept in line of sight or that frequent checks were occurring. She said Resident #10 was immediately separated from Resident #16 and he was kept in line of sight. She said that she had reported all three incidents to the State agency web portal and that those were her investigations. She stated she did not realize she needed to conduct her own internal investigation and keep documentation of the findings. She said she thought when she completed the report to the State agency, that completed her investigation. The NHA was interviewed on 6/10/21 at approximately 8:00 p.m. She said she had not shared the above abuse investigations with the facility's quality assurance (QA) committee yet, but would bring it to their next QA meeting scheduled at the end of the month. She said she was not aware that she had to show that she had completed a thorough investigation or to have written evidence of her investigation to include additional resident and staff interviews and statements to show how she determined her conclusion of three allegations above. VII. Follow-up interview with NHA The NHA was interviewed a second time on 6/18/21 at 8:45 a.m. regarding what more the facility did to ensure the safety of other residents. She said Resident #10 and #200 were kept in line of sight when they were around other residents and that Resident #200 was mostly in his room by choice. She said Resident #200 discharged on [DATE] by choice to live with friends and that the facility arranged homebound services and other community resources. She said in the incident between Resident #10 and #20, Resident #10 was kept in line of sight due to his increased behaviors since early March 2021. Both residents were supervised by staff if they were in the same room. She said that Resident #20 checked in with her almost daily since the incident with Resident #10. She said Resident #20 told her he did not have a problem with Resident #10 but that he was mad when Resident #10 called him a name. She said that Resident #20 promised her he would not lay hands on Resident #10 again and that he would go to her or social services for support. She said Resident #16 was monitored for three to four days following the incident and she appeared to be at her baseline and that she regularly had delusional behaviors of believing she was married to the male staff.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for [MEDICATION NAME] administration out of three sample residents did not experience a significant medication error. Resident #1 was admitted to the facility for skilled rehabilitation after a fall with multiple inoperable fractures. The resident had scheduled and as-needed (PRN) [MEDICATION NAME] (narcotic [MEDICATION NAME]) orders for pain management. Over the course of five days (,[DATE]-[DATE]), the resident experienced a significant medication error with multiple doses of scheduled and PRN [MEDICATION NAME] resulting in duplicative doses, which required two doses of [MEDICATION NAME] to reverse the effects of an [MEDICATION NAME] overdose. The facility's failures to properly administer and monitor the resident's [MEDICATION NAME] administration contributed to lethargy and rapid decline. The resident died on [DATE]. Findings include: I. Professional reference According to Fundamentals of Nursing by Perry, Potter, Stockert and Hall, 9th Edition (copyright 2017), page 626: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1.The right medication 2.The right dose 3.The right patient 4.The right route 5.The right time 6.The right documentation. II. Facility policies and procedures The Medication Administration policy, undated, was provided by the nursing home administrator (NHA) on [DATE] at 10:00 a.m. The policy documented in part, It is the responsibility of the staff nurse to maintain control and accountability of all medications, their utilization, and administration during the shift for which he/she is responsible. -Medication shall be checked against physician 's orders, if giving a narcotic or controlled medication, sign the narcotic count sheet as soon as you prepare the drug and before you give it. Routine medication will be recorded on the daily medication record and PRN medication record, all medication and adverse drug reactions shall be reported immediately to the attending physician . The Physician 's Orders policy, undated, was provided by the NHA on [DATE] at 10:00 a.m. The policy documented in part, The blank physician 's order forms are used to document and receive written medical/treatment orders from the admitting physician .an RN may write in a verbal or telephone order from the physician. The RN in charge must check the orders to make sure they are transcribed accurately. The RN is ultimately responsible for doctor 's orders. The RN coming on the next shift will check that all new orders written during the previous shift are correctly instituted. All nurses are responsible for all orders every shift. All orders are to be transcribed to the medication sheets and drug order log as appropriate . III. Resident #1 A. Resident status Resident #1, age 86, was admitted on [DATE] and died on [DATE]. According to [DATE] computerized physician orders [REDACTED]. According to the minimum data set (MDS) assessment, dated [DATE], the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance with bed mobility and transfers. She was identified to have verbal and non-verbal pain daily during the assessment period that affected her day to day activities with a pain scale of seven out of ten. She received scheduled and PRN pain medication as well as non-pharmacological pain management. She received opioids two times during the review period. B. Record review There was no pain care plan found in the resident 's clinical record. 1. Physician 's orders from [DATE] to [DATE] revealed in pertinent part the following: -Assess pain twice per shift and document using ,[DATE] verbal or face pain scale. Observe for non-verbal signs of pain, i.e. grimacing, agitation, diaphoresis, etc. Start [DATE]; -Tylenol 500mg (milligram) tablet, give two 500 mg tablets to equal 1,000mg three times a day. Do not exceed 3 Grams in a 24 hour period. Start [DATE]; -[MEDICATION NAME] HCL 5mg tablet, give one-half tablet to equal 2.5mg by mouth three times daily for pain. (schedule to be given at 6:00 a.m., 12:00 p.m. and 6:00 p.m.). Start [DATE]; -[MEDICATION NAME] 5mg tablet, give one-half tablet to equal 2.5mg by mouth every three hours as needed (PRN) for pain. Start [DATE]. A written physician 's telephone order dated [DATE] revealed in pertinent part that the PRN order read: .for BTP (breakthrough pain). 2. Narcotic sheet for scheduled and PRN [MEDICATION NAME] Review of a narcotic count sheet revealed that both the scheduled [MEDICATION NAME] and the PRN [MEDICATION NAME] were being recorded on the same sheet. The narcotic sheet document in pertinent part the following based on the order written on [DATE] (above): -[DATE]-Three PRN doses of 5.0mg were given at 7:40 a.m., 2:09 p.m. and 10:00 p.m. A scheduled dose of 2.5mg was given at 6:00 p.m. She received a total of 17.5mg on this day (Based on the new order above to give 2.5mg every three hours PRN, she received three extra doses of 2.5mg demonstrating that the order was not being followed correctly). -[DATE]-Three PRN doses of 2.5mg were given at 8:40 p.m., 3:20 p.m. and 9:00 p.m. Three 2.5mg as scheduled doses were given at the specific times indicated. She received a total of 15 mg on this day. (The narcotic sheet showed she received the [MEDICATION NAME] every three hours up until 9:00 p.m.). -[DATE]-Three PRN doses of 2.5mg were given at 12:00 a.m., 4:00 a.m., 9:07 a.m. and 4:15 p.m. Three 2.5mg as scheduled doses were given per the 6:00 a.m., 12:00 p.m. and 6:00 p.m. time schedule. She received a total of 15mg on this day, however; she was given a PRN dose too close to the next scheduled dose (4:00 a.m. and then again at 6:00 a.m.). -[DATE]-Three PRN doses of 2.5mg were given at 5:15 a.m., 9:51 a.m. and 2:20 p.m. Three 2.5mg as scheduled doses were given. She received a total of 15mg on this day, however; she was given a PRN dose too close to the next scheduled dose (5:15 a.m. and then again at 6:51 a.m.). -[DATE]-Four PRN doses of 2.5mg were given at 4:00 a.m., 8:35 a.m., 12:21 p.m., and 3:56 p.m. Three 2.5mg as scheduled doses were given. She received a total of 17.5mg for the day, however; she was given the PRN doses too close to the next scheduled dose (i.e., 4:00 a.m. to 6:00 a.m., two hours. 6:00 a.m. to 8:35 a.m. two and a half hours. Then starting again at 11:25 a.m. to 12:21 p.m., one hour in between. Then starting again at 3:56 p.m. to 5:08 p.m., one hour and 12 minutes. There were no entries found on the Narcotic sheet provided for the scheduled or PRN doses of [MEDICATION NAME] from [DATE] to [DATE]. There were, however; documented entries on the ,[DATE] MAR that PRN doses were given on these dates (see below). 3. Medication administration record (MAR) In addition to the narcotic sheet entries (above), the ,[DATE] MAR documented in part the scheduled doses of [MEDICATION NAME] 2.5mg for [DATE] were given at 6:00 a.m. but not given at 12:00 p.m. and 6:00 p.m. due to the resident being lethargic. The resident did receive PRN [MEDICATION NAME] 2.5mg at 1:19 a.m. and 7:36 a.m. On [DATE] the 6:00 a.m. scheduled dose was given. The 12:00 p.m. and 6:00 p.m. scheduled dose was not given. She did receive two PRN doses at 12:51 a.m. and 4:50 a.m. (The 4:50 a.m. dose and the 6:00 a.m. dose were given an hour and ten minutes apart). 4. Change of condition The clinical record documented the resident experienced a significant change of condition and rapid decline beginning on [DATE]. She choked on a piece of sausage during breakfast and required the [MEDICATION NAME] maneuver to dislodge the food which was successfully completed by a staff member. Nurse and therapy notes from [DATE] to [DATE] documented in part the resident began showing signs of decline as evidenced by decline in activity participation and increase in lethargy. The family was made aware of her change of condition. A nurse note dated [DATE], time stamped at 3:54 p.m., documented the physician gave new orders to discontinue the PRN [MEDICATION NAME] and continue with the scheduled [MEDICATION NAME] three times a day. A nurse note dated [DATE], time stamped at 4:48 p.m. documented in part the resident was having Cheyene stoke breathing and her lungs presented with rales (coarse, moist breath sounds) bilaterally. Her husband and physician were notified. A nurse note, dated [DATE], time stamped at 5:27 p.m., documented in part that [MEDICATION NAME] (a drug given to reverse opioid effects), 4mg was administered and three minutes later a second dose was given. The resident 's breathing was less labored. Orders and written prescriptions for [MEDICATION NAME] and [MEDICATION NAME] were given by the physician to use only for end of life care. The family was by the bedside. A nurse note dated [DATE], time stamped at 10:55 p.m., documented the resident had expired and the family was at the bedside. IV. Staff interviews Registered nurse (RN #1) was interviewed on [DATE] at 5:30 p.m. She said their process was that residents and family were notified of any new orders or changes in orders. She said once the order was obtained from the physician it was faxed to the pharmacy and a copy of the written order was sent to medical records. She said the next step was to place it in the MAR and the 24-hour report. She said they would then chart on the resident for 72 hours for any potential side effects. She said if a resident requested a pain medication she would first look up the order and check the time that it can be given and then administer the medication. She said residents are assessed for verbalization of pain twice a shift, or, if they are not alert and oriented she would look for non-verbal cues. She said she would first attempt non-pharmacological interventions to alleviate the pain first and if that did not work try Tylenol and go from there. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 6:00 p.m. She said that Resident #1 had a scheduled and a PRN order for [MEDICATION NAME]. She said that she gave her both, based on how the order was written, and she documented the time and amount given on the narcotic sheet. She said the scheduled and PRN doses were both documented on the same narcotic sheet. She said if the resident 's scheduled dose was not effective, she would give her a PRN as it was ordered. She said as the medication nurse and as an LPN she would confer with her charge nurse if she had any questions about a medication. She said she did not notice any concerns with the resident being lethargic. She said the resident was in a lot of pain and would cry out with pain. She said the resident continued to be alert with confusion throughout the time she took care of her. LPN #2 was interviewed on [DATE] at 9:53 a.m. She said if a resident verbalized pain or had signs and symptoms of pain (unable to verbalize) she would look at their orders. She said if they had more than one order for a pain medication she would start with the less stronger one such as Tylenol. She said if the medication was not effective after checking back with the resident in an hour she would give a stronger pain medication. She said she would also try non-pharmacological methods. She said if none of that was effective she would give a narcotic if they had one ordered. She said when giving narcotic medication, you had to be cautious because it could cause increased sedation. She said if she was going to give a narcotic, she would check the orders to see what amount could be given. She said if a resident had an order for [REDACTED]. She said she could give a medication one hour before or one hour after the scheduled time it was to be given. She said she took care of Resident #1 and that she yelled out in pain quite a bit and was confused. She said the resident also had anxiety. She said that her scheduled [MEDICATION NAME] helped her pain and if the resident appeared lethargic she would hold the medication and not give it and document that. She said she did not give the resident PRN [MEDICATION NAME] very often. The DON was interviewed on[DATE] at 1:52 p.m. She said they looked into the matter regarding the medication error. She said that the scheduled [MEDICATION NAME] order and the PRN order were put into the electronic MAR as it was written by the physician. She said the nurses were giving the [MEDICATION NAME] as written. She confirmed they were using the same narcotic sheet to sign for the scheduled and the PRN doses. She said the problem they identified was that the nurses were not checking to see if it was time to give the PRN doses and some doses were given too close together. She said the nurses were not paying attention to when the last time the medication was signed off as given on the narcotic sheet. She said the scheduled [MEDICATION NAME] popped up automatically on the system when they were scheduled to be given. She said when the nurse clicked on the PRN order the system was not recognizing that it was too soon for another dose of the [MEDICATION NAME]. She said they were input into the system as two separate orders. She said that they had also spoken to the physician about how his order was not specific. She said they are working with the physician to ensure PRN orders are more clear. She said they have changed their process and that the nurses had been educated on paying closer attention. She said she did not start any audits but that the team had reviewed other residents who also received scheduled or PRN pain medications and did not find any concerns. The nursing home administrator (NHA) was interviewed on [DATE] at 3:49 p.m. She said that when they first discovered the medication error in [DATE] they were not aware there had been a problem. She said when they reviewed Resident #1 's records they discovered that the resident 's entire narcotic sheet was missing. She said they immediately began an internal investigation. She said they identified that all the nurses were interpreting the [MEDICATION NAME] order the same way and it was confusing. She said they talked to the physician about how he wrote the PRN order for the [MEDICATION NAME] and that he should have put in the order to not give too close to the scheduled dose. She said they have educated the physician on this and now orders are double and triple checked. She said the IDT team will review all new orders at the morning meeting. The physician has requested that we send him a picture of verbal orders given over the phone so he can verify they were taken down correctly. She said the nurses have all been educated and provided evidence of this. There was no medication error report provided. She said she herself tried to review progress notes of all residents' records weekly, review incident reports and tried to pick up on any discrepancies. She said she relied on her DON and her medical records person to also review all new orders. She said that they had not yet initiated a formal PIP (process improvement plan). She said they had addressed and put quite a few things in place and identified that there had been some errors. She was not able to present a written plan of correction, once the issue was identified. She said at their next QAPI meeting, they would be implementing a plan to ensure this issue does not occur again.

Based on observation, record review, and physician, resident and staff interviews, the facility failed to provide sufficient supervision to ensure resident safety for four of 11 sample residents (#1, #3, #4, and #7) and residents dining in the dining room. Specifically, the facility: -Failed to ensure that the suction machine in the dining room was accessible for use. -Failed to provide safe transfer technique for resident #1. -Failed to prevent skin tears for resident #3. -Failed to devise, plan and implement interventions that would protect residents (#1, #4, and #7) from falls. These failures contributed to resident #7 sustaining a fall and suffering a fractured pelvis. Findings include: A. FALL PREVENTION 1. Resident #7, an [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The 3/27/10 Minimum Data Set (MDS) revealed resident #7 had short- and long-term memory loss, moderate impairment in cognitive skills for daily decision-making; required total assistance for transfers; did not ambulate; had an unsteady gait; required assistance with dressing, hygiene and bathing; needed set up assistance for eating; was incontinent of both bladder and bowel; had fallen in the last 30 days; and had sustained a fracture from a fall in the last 180 days. a. Observations On 6/14/10 at 2:12 p.m., resident #7 was observed lying in bed in a diagonal position. The bed was in the low position and there was a fall mat next to the bed. However, there were no bolsters on the bed and her meri-walker was sitting next to her bed. According to her care plan (see below) she was to have bolsters on her bed, and her meri-walker should have been stored in the bathroom, as fall prevention interventions. At 5:51 p.m. on 6/14/10, resident #7 was observed ambulating slowly down the hallway in her meri-walker. A Certified Nurse Aide (CNA) was holding on to a gait belt around resident #7's waist to steady her. At 7:53 a.m. on 6/15/10, resident #7 was observed sitting in a regular chair in the dining room at the table. There was no alarm attached to resident #7. The alarm was observed still attached to her meri-walker that had been stored in an adjacent room to the dining room. b. Record Review Review of resident #7's record was initiated at 3:49 p.m. on 6/14/10. Prior to her fall on 2/27/10 when she sustained a fractured pelvis, resident #7 was assessed on her 12/29/09 MDS to have balance problems and an unsteady gait. She was also assessed on 2/8/10 to have a fall risk score of 12 ("a total score of 10 or above deems high risk for falls and should be monitored closely for fall precautions"). Also, according to her Care Plan, on 10/15/09, resident #7 was "found sitting on her knees leaning over her bed" which demonstrated that she had a fall prior to 2/27/10. Her admission care plan, dated 9/25/10, assessed resident #7 to be "at risk for falls due to new environment, unsteady gait, poor vision and poor safety awareness with [DIAGNOSES REDACTED]." The approaches on her care plan included: "1. Orient to surroundings, 2. Encourage family to stay as much as possible during first few days of admission, 3. Keep environment free from clutter, 4. Monitor whereabouts closely, 5. Falls committee to review and evaluate ways to keep her safe, 6. Low bed in place upon admission, 7. Bed/body alarm on when in bed and when up in wheelchair . . ." - On 10/15/10, after resident #7 was found "sitting on her knees leaning over the bed," "bolsters to bed" was added to the care plan. The following is chronologically compiled from various documentation related to the resident's falls: -Fall on 2/27/10 when resident sustained [REDACTED]. According to the Accident/Incident Report Form, at 6:30 p.m. on 2/27/10, resident #7 "was walking down hallway with walker, ankle turned under, knocking res off balance. She fell to the floor on her left side. Assessment done, res crying, stated she had pain on palpation of left arm, shoulder, hip and knee. Would not move ULE (upper left extremity) or LLE (lower left extremity). Paramedics called." The form stated the resident/staff perception of reason for accident as "resident without walker." Of note was that the Remedial Measures to Prevent Recurrence section of the form was blank. The CNA who witnessed the fall completed a form that stated, "What do you think caused the incident? 'Not walking with her walker'; Why do you think the accident happened? 'She didn't have her walker'; What can we do to prevent this from happening again? 'Make sure she doesn't walk without her walker.'" The Investigation Follow-up, dated 2/27/10, described the situation as, "fell in hallway while attempting to ambulate without walker and without assistance." The Summary of Investigation said, "Resident attempting to walk without walker, seen by staff walking down the hallway by self, lost her balance and fell . Crying and upset, refused to move extremities, EMS called to transport to hospital." Past Interventions Attempted included, "Needs to use walker with standby assist." Recommendations/New Interventions: Has had decrease in some psych meds, behaviors have improved, now ambulating with others (assist). The Post Fall Nurses Notes, dated 2/27/10, indicated that the paramedics were called, a physical exam was completed, observations of the resident were made, her bed was not in low position, there was no mat on the floor, and there was no bed/body alarm on the resident. Her care plan at that time revealed that her bed should have been in the low position, and a bed/body alarm should have been attached to her, while she was either in bed or in her chair. The Resident Fall Tracking Log, showed resident #7 suffered a fall on 2/27/10 and the related "summary/conclusion/plan" stated, "3/3/10 Plan - Admit to falls. Fx (fracture) on 2/27/10. Draw sheet to position, Hoyer (lift) in use for transfers. F/U (follow-up) Dr. appt 3/4/10. Reassess X1wk." - 3/10/10, "May transfer with weight bearing per order 3/4/10. Will encourage staff to walk resident more frequently - to bathroom, to meals, etc. ..." - 3/24/10, "Will ask for eval from new therapy company for (resident). Hoping for a change from wt. bearing transfer only. Reassess in one week." - There was no reference to what interventions were implemented to prevent resident #7 from falling again. The Nurses Notes recorded, in pertinent part: - *2/27/10, 3:40 a.m., "Resident returned from (hospital) with [DIAGNOSES REDACTED]. ER doctor from (hospital) recommended bed rest until PT could evaluate. . . " *This is probably an incorrect date and should have been 2/28/10. According to other documentation resident #7 was sent to the hospital at 6:30 p.m. on 2/27/10. - A copy of the ER report was requested on 6/16/10 but was not received prior to exit on 6/17/10. Resident #7 continued to suffer from falls. -Fall on 4/11/10 On 3/8/10 when assessed for fall risk, the resident's score increased to 18, from 12 on 2/8/10 (see scoring system noted above). According to the Accident/Incident Report Form, at 12:30 p.m. on 4/11/10 resident #7 fell and, "Pt. (patient) tried going to bathroom on her own, probably tripped over her wheelchair pedals. Pt. found by another resident's family member. She was lying on her right side stating that her head hurt. No injuries noted, able to move all extremities." Actions taken included "Neuros and VS (vital signs), frequent checks and (pain med) given." - Of note was that the Remedial Measures to Prevent Recurrence section of the form was blank. The Post Fall Nurses Notes, dated 4/11/10 stated, "Pt. tried to go to restroom by herself, probably tripped over pedals to wheelchair as they were still down," a physical exam was completed, observations of the resident were made, and a body alarm was noted as being on the resident. The report did not indicate if the body alarm was working or not, or that the resident had been closely monitored. No Investigation Follow Up for this fall was submitted for review. The Resident Fall Tracking Log showed resident #7 suffered a fall on 4/12/10, and the next related "Summary/Conclusion/Plan" was dated almost two weeks later on 4/23/10. The plan stated, "Seat belt in wheelchair for safety on 4/20/10. Meds changed to decrease agitation if possible. Continue with interventions. Reassess 2 weeks." Added to her existing Care Plan on 4/20/10 was a note which stated, "4/12/10 Found on floor in bathroom" and an added approach, "Seatbelt secured when up in wheelchair." -Fall on 4/29/10 According to the Accident/Incident Report Form, at 11:30 p.m. on 4/29/10 resident #7 fell and it was documented, "Pt. was very agitated and crying, trying to get out the front door to go home. Brought pt. back in several times, finally took her to her room. She did not want to eat lunch. When I went to check on her 10 minutes later, she was lying on the floor in front of her meri-walker. No injuries noted." Actions taken included "VS (vital signs) and neuros, pt lying in bed." Of note again was that the Remedial Measures to Prevent Recurrence section of the form was blank. The Post Fall Nurses Notes 4/29/10 indicated, "Pt. was very agitated and trying to get out the front door. We brought her to her room. When I came to check on her 10 minutes later, she was out of the meri-walker on the floor lying on her right side." The notes also documented that resident #7's body alarm was not attached to her at the time of the incident. The Investigation Follow-up, dated 4/29/10, described the situation as follows: "Resident found on floor in her room in front of the meri-walker." The Summary of Investigation said, "Resident very agitated during the day, crying and wanting to leave. Redirected to her room by day nurse. Nurse returned a few minutes later and found her on the floor. No injury noted." Past Interventions Attempted included, "Low bed, bed/body alarm, meri-walker 4/26/10." Recommendations/New Interventions included, "Resident had been ambulatory with walker before fall 2/27/10. Attempt at using meri-walker to increase strength and mobility with goal of resident reaching previous ability." The Resident Fall Tracking Log did not record resident #7's fall on 4/29/10, and nothing was added to her existing Care Plan after this fall. -Fall on 5/6/10 According to the Accident/Incident Report Form, at 7:00 p.m. on 5/6/10 resident #7 fell and "Found res on floor in her room lying on right side. Complained of pain in hips. Unable to move due to pain. Called 911." Action taken included, "Taken to hospital for x-ray. Dx was hip contusion. Back in facility with no pain and able to transfer with one assist." Of note was that the Remedial Measures to Prevent Recurrence section of the form was blank. The Post Fall Nurses Notes, dated 5/6/10, stated, "Found res lying on right side in the middle of her room on the floor. She was crying and stated she was in pain." The notes indicated that the bed was in low position, the body alarm was on and there was a mat on the floor. However, this contradicted the Care Plan that shows the mat on the floor beside the bed was not implemented until after resident #7's next fall on 5/22/10. The Investigation Follow-Up, dated 5/7/10 described, "Resident found on the floor on right side," and the Summary of Investigation stated, "Resident attempted to transfer without assist and fell to floor. Resident has increased confusion, was not able to tell exactly how occurred." Past Interventions Attempted included low bed, bed/body alarm, meri-walker." There was no evidence submitted that resident #7's monitoring by staff had increased. Again the Recommendations/New Interventions was left blank. The 5/6/10 Resident Fall Tracking Log's Summary/Conclusion/Plan stated, "Resident with other med change. Also is in meri-walker for ambulation. Adjusting well. Reassess 2 weeks. " -Fall on 5/22/10 On 5/7/10 when assessed for fall risk, resident's score increased from 18 to 20. According to the Accident/Incident Report Form, at 1:45 a.m. on 5/22/10 resident #7 fell and, "CNA found resident sitting on floor facing entry (to her room). States, 'Help me. Help me.' Staff went to assess VS (vital signs). Assisted pt up after assessment completed. No alarm attached. Pt. states, 'Removed alarm to get jacket.'" Action Taken included, "Assist up with X3 staff to put pt. in bed. Changed gown." Of note was that the Remedial Measures to Prevent Recurrence section of the form was blank. The Post Fall Nurses Notes, dated 5/22/10, stated, "Pt was sitting on floor. 'Help me. Help me.' Assess VS (vital signs). No apparent sign of bruising, right knee is reddened." The notes indicated that the bed was in low position, the body alarm was on, and there was no mat on the floor. The Nurses Notes, dated 5/22/10, stated there was a "shortening of lower of extremity, right knee swelling, resident urinated on the floor and slipped . . . the alarm was on and there was no fall mat on the floor." The Investigation Follow-Up, dated 5/25/10, described the situation as, "Found on floor in room in front of bathroom. The Summary of Investigation reported, "Got herself up from bed, confused, stating she was getting a coat in order to leave, fell in front of bathroom." Past Interventions Attempted included, "Low bed, fall mat, bed/body alarm, meri-walker." - However, this contradicted the Care Plan that documented the fall mat was not initiated until after the fall on 5/22/10. The Recommendations on the Investigation stated, "Med change has shown overall decrease in agitation." The existing Care Plan was updated on 5/22/10 with the approach, "Mat on floor beside bed." On 5/26/10, another approach was added, "Meri-walker to be stored in bathroom." Also, there was no evidence in the record that neurological assessments were performed after this unwitnessed fall. (Cross-Reference F309 - Care and Services - No neurological assessment performed after an unwitnessed fall for resident #7.) -Current relevant fall documentation included: The final entry in the Resident Fall Tracking Log, dated 6/9/10, regarding resident #7, the following was documented, "Interventions working well, D/C (discharge) from falls." The June 2010 Computerized physician's orders [REDACTED].#7. There was no assessment in the record for the use of a meri-walker for resident #7. (Cross-Reference F309 - Care and Services - No assessment for meri-walker or other fall prevention devices for resident #7.) A current copy of the CNA daily worksheet (care plan) was obtained from the Medical Records Director at 3:25 p.m. on 6/16/10. For resident #7 it stated, "Fall risk, wanderer, low bed, uses walker." The worksheet did not include those interventions/approaches identified on the care plan that indicated resident #7 should have a tab alarm on her walker, bed and chair, a fall mat next to her bed, or bolsters on her bed. (See observations above.) Interviews The Medical Director returned a phone call on 6/21/10 at 2:32 p.m. and said, "Yes, I attend the QA meetings . . . once a month . . . Review falls? Yes we go over injuries, skin tears, etc. and we talk about what interventions to put in place to prevent further falls . . . (Resident #7)? No, I am not her physician . . . I have a vague recollection that we had a discussion about how her fall (on 2/27/10) happened. They (staff at facility) do track and trend the falls and we review them." A Registered Nurse was interviewed at 1:29 p.m. on 6/16/10 and stated, "(Resident #7 is) not on my hallway . . . but I do remember it (the fall on 2/27/10) . . . We saw her in the hallway without her walker, she tripped and fell . . . I think it was at change of shift . . . I don't remember if the bed/chair alarm was going off or not." At 2:32 p.m. on 6/16/10, a CNA who routinely cared for resident #7 was asked about her fall on 2/27/10. The CNA said, "We needed to be constantly on her, she would forget to use her walker . . . so we put her on a body alarm." On 6/16/10 at 2:20 p.m. a restorative CNA said, "I have been here when she has fallen. I wasn't in her room at the time. We do assist her with a gait-belt in her meri-walker." On 6/15/10 at 2:00 p.m. the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) were interviewed. During the survey, the facility had no Director of Nursing. When asked the expectations about the nursing staff following the care plan, the NHA responded, "If it (the intervention/approach) is on the care plan, the staff should make sure it's done." The ADON said that there was a "falls committee . . . it's the IDT (interdisciplinary team) and meets every Wednesday afternoon . . . All incident reports are reviewed." When asked why a resident would be discharged from falls review by the falls committee, no response was offered. On 6/16/10 at 8:30 a.m. the ADON and NHA were interviewed. When asked about resident #7's falls specifically, the ADON stated, "Well, she came to us from another facility on anti-psychotics and anti-anxiety medications . . . She was too sedated so we got her off of those with gradual dose reductions but we had to put her back on them with lower doses due to her behaviors . . . she (resident #7) came in a wheelchair, she worked with a therapist and the intent was to get her to use a walker, but she would forget to use it . . . so we put her in a meri-walker." Documentation of monitoring for falls was requested; no documentation that staff were frequently monitoring resident #7 as part of her fall prevention management was ever received. The facility's policy and procedure for falls prevention was requested during this interview. The NHA said that she didn't think they had one specifically for falls prevention and stated, "Just what I gave you yesterday in the Abuse Policy." No policy and procedure for falls prevention was ever submitted for review. When asked if they thought having a policy and procedure for falls prevention would be beneficial, the ADON said, "I think it would be good for the team to have more direction (from a policy and procedure)." The NHA said, "It (policy and procedure) would help us identify and assess what residents need." In summary, upon admission, resident #7 was assessed to be at high risk for falls and interventions were care-planned to prevent injury from falls. However, when resident #7 fell on [DATE], none of the interventions, i.e. bed/body alarms, bed in low position, or close monitoring, were in place. These fall-prevention failures contributed to resident #7 suffering a fall from which she sustained a fractured pelvis. After this fall with injury, her falls continued. The facility failed to consistently implement preventive interventions, although care-planned, to prevent the resident's falls. 2. Resident #4 - Failure to provide adequate assessment, supervision, or monitoring of transfers to prevent repeated falls. Interviewable resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. a. Risk for injury The 3/31/10 significant change Minimum Data Set (MDS) documented the resident to understand and be understood, and to be moderately impaired in cognition for daily decision-making. He had full loss of range of motion and voluntary movement on one side; required extensive assistance for toilet use, hygiene, and bathing; supervision with transfers and bed mobility; and not ambulatory. Resident #4 required partial physical support to attempt balance while standing but maintained position while sitting. He was noted to have a height of 69 inches and a weight of 285 pounds, and to have fallen in the past 30 days. The physician's orders [REDACTED]. Seven of the daily medications reviewed included potential side effects that included confusion, a drop in blood pressure, vertigo, or muscle weakness as follows: Amaryl 4 mg (milligrams), one, daily; Aldactone 25 mg (1/2) tablet, daily; Imdur 30 mg, one tablet, daily; Lasix 20 mg, one daily; Cortef 5 mg, two tablets, twice daily; and Zocor 80 mg, one daily. Review of his falls Nursing Care Plan, revision dated 4/05/10, revealed the resident had a potential for weakness and unsteady gait. The care plan goal read, "Free from any serious injuries from any falls for the next 90-days," and the approaches included: -Assist with ALL transfers daily, -Instruct how to use call light, -Side rails up as ordered, -Keep wheelchair in locked position when transferring to/from wheelchair and transferring to his bed from the wheelchair, -Keep obstacles from Aisle ways, -Check on him frequently for repositioning, -Remind him not to get up by himself. A 6/14/10 Fall Risk Evaluation documented a score of "11" (see scoring system above). b. Repeated falls Review of resident #4's clinical record on 6/14/10 at 4:00 p.m. revealed a Post Fall Nurse's Notes entries that read as follows: Fall #1 -3/12/10 at 8:00 a.m. "Resident found sitting on floor. States he was going from bed to chair and wheelchair moved away from him. States he forgot to put brake on." Fall #2 -3/13/10 at 2:41 a.m. "Resident between wheelchair/bed. CNA found him while wheelchair starting to slide. CNA helped him gently to the floor. " Fall #3 -4/12/10 at 2:40 a.m. "Resident trying to get from bed to chair and slid to sitting position on the floor." The facility failed to implement and monitor interventions to prevent resident #4 from repeated falls during transfers from bed to chair. c. Observation On 6/15/10 at approximately 9:00 a.m., resident #4 was observed by the surveyor seated in a large wheelchair which was parked adjacent to the nurse's station. He was noted to be pleasant and alert, obese, and to have a right lower arm prosthesis. When asked for a quality of life interview by the surveyor, resident #4 agreed to a 10:00 a.m. interview. d. Interviews On 6/15/10 at 10:00 a.m., the interview was conducted with resident #4. Resident #4 was asked by the surveyor to describe his falls, and he stated, "The first time (3/12/10), when I went from the chair to the bed, the wheelchair brakes didn't stay locked. I asked maintenance to look at them but that hasn't happened yet. The second time (3/13/10) I was trying to get from the wheelchair to my bed and a CNA helped me out." The last time (4/12/10) I slid off the bed trying to get into my wheelchair." When asked about calling for help from the staff for transfers, resident #4 said, "Sometimes I do, but they are busy." On 6/15/10 at 3:30 p.m. a licensed nurse (LPN) who implemented the nursing care plans for resident #4 was interviewed about his transfer safety and falls. When asked about resident #4's assessments for transfer needs, the LPN said, "The ADON and I went and observed how he was transferring. We took off the wheelchair arm and used a green pad so there wouldn't be any more shearing." (Cross-reference F314 - Pressure Ulcers.) At 11:30 a.m. on 6/16/10 the maintenance supervisor was queried with regard to resident #4's wheelchair brake malfunction. The maintenance supervisor said, "I fixed his toilet seat and his window blinds but I hadn't heard anything about his wheelchair brakes. --At 11:45 a.m. the maintenance supervisor reported back to the surveyor and stated, "I checked his brakes and they aren't tight enough. For as big as he is the brakes don't lock tight enough. I'm taking the wheelchair to tighten them up." On 6/16/10 at 12:50 p.m. a CNA who regularly provided care to resident #4 was interviewed with regard to resident #4's transfer needs. The CNA said, "When resident #4 first came here he needed help with transfers, but now he transfers himself. He seems to be able to handle it OK even with his upper arm prosthesis." During an interview with the ADON on 6/16/10 at 8:30 a.m., she was asked for her expectation of assessment for safe transfer for resident #4. The ADON said, "He won't use a transfer board. He will take the arm off his wheelchair so he can transfer and seems to do well with it." During an administrative meeting on 6/16/10 at 4:15 p.m., with the NHA, she was made aware of the findings above. The NHA nodded and stated, "We do have a falls committee and residents with falls are reviewed on a weekly basis." There was no evidence the facility provided adequate assessment, supervision or monitoring to ensure resident #4's safety during transfers. 3. Resident #3 - Failure to provide adequate investigation, supervision, or monitoring to prevent skin tears. Non-interviewable resident #3, a [AGE] year-old female, was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. According to her 4/08/10 admission MDS, resident #3 understood staff and usually was understood. She was coded to be moderately impaired in cognitive skills for daily decision-making; required supervision with eating was totally dependent on staff with dressing, toilet use, and hygiene; she required extensive assistance for bed mobility and locomotion using a wheelchair for transportation. In Section E, Mood and Behavior Patterns, resident #3 was assessed to make verbal expressions of distress that included, "Where do I go?" The MDS coded resident #3 to be 59 inches tall, to weigh 71 pounds, and was void of documentation of the presence of skin tears. Review of resident #3's care plan, revision dated 5/03/10, revealed resident #3 had a potential for skin breakdown due to fragile and thin skin and the goal was to keep her free of skin breakdown. Approaches in part included: -Check skin weekly and as needed, -Apply lotion to skin as needed, -Encourage her to eat all meals and to drink all liquids at meals, and -Long sleeve blouses and long pants. Nurse's Notes were reviewed from 3/26/10 through 6/14/10 and revealed an entry on 5/03/10 at 2:30 p.m. that read, "Noted skin tear to left wrist area. Cleansed with sterile saline and 3 steri-strips applied. Resident doesn't know how it occurred. Family and doctor notified. Will monitor." On 6/15/10 the facility investigation of the 5/03/10 skin tear was requested and received. The 5/03/10 report read as follows: -Date of incident: "5/03/10" -Time of accident: "time of accident unknown." -Witnesses: "None." -Type of Accident: "Skin tear which is deep, punctured or lacerated." -Resident/staff perception of reason for accident: "Unknown." -Location of accident: "Unknown." -Details of accident: "Unknown." -Action taken: "Cleansed with sterile saline, 3 steri strips applied." -Remedial measures to prevent recurrence: Void of entry. -CNA interview by facility dated 5/03/10, "Bumped it somewhere." The report was void of entry to document the character of the skin tear. The investigative follow-up dated 5/04/10 was reviewed and found to be void of entry to identify past interventions attempted to prevent skin tears. On 6/16/10 at 9:30 a.m., during an administrative meeting the NHA and the ADON were made aware of the above findings. The NHA commented, "I don't like the forms we are using to investigate falls and skin tears." There was no evidence the facility provided adequate interventions to prevent resident #3 from receiving a skin tear. 4. Resident #1 - Failure to provide supervision and safe transfers Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Fall management Observations During the initial tour of the facility, which commenced on 6/14/10 at 2:00 p.m., resident #1's room was noted to have a fall mat and bed bolsters in place. She was observed on 6/15/10 at 10:27 a.m. sleeping in her wheelchair in her room. The wheelchair did not have a high back, nor was it a tilt-back wheelchair. During an observation on 6/16/10 at 10:35 a.m., she was seated in her recliner, slumped to the right side. The recliner was not tilted back. An alarm was attached to her shirt, and the call light was attached to the recliner. Her wheelchair had attachments on the back to prevent tipping backwards, but it did not have a high back. She was observed again on 6/16/10 at 4:00 p.m. in her wheelchair. It was not a tilt-back style chair. A call light was attached to the wheelchair. Record Review Resident #1's 6/5/10 MDS identified her as having moderately impaired cognitive skills for daily decision-making. She was coded as having short-term memory problems. She had minimal difficult with hearing. No behavioral symptoms were identified. Resident #1 was totally dependent on the assistance of one person for bed mobility, transfers, ambulation dressing, toilet use and personal hygiene. She required one-person assistance with part of the bathing activity. She used a wheelchair as her primary mode of locomotion, needed both manual and mechanical lift. She was continent of bowel but incontinent of bladder, she had fallen in the past 30 days. Care Plan Resident #1's care plan identified "risk for falls due to unsteady gait." The care plan was most recently reviewed and revised on 3/9/10. Hand-written entries under "Problem" were as follows: -3/11/10 Slid out of bed, abrasion to L (left) knee -5/9/10 Found sitting on floor in front of w/c (wheelchair) -5/21/10 Found on floor near her chair -5/24/10 Aide attempting to transfer from wheelchair to recliner and resident fell to her knees -6/1/10 Found sitting on mat beside bed. Approaches initiated on 3/9/10 included: -Encourage (resident) to ask for assistance with transfers -Keep call light in reach at all times when in room -Monitor (resident) frequently for safety and comfort and needs -Assist with all transfers -Low bed in place -Bolsters on bed -Mat on floor beside bed -Bed/body alarm on when in bed and when up in recliner and wheelchair. Hand-written entries to approaches included: -3/11/10 assessed for injuries -5/19/10 referred to therapy for eval(uation) -5/21/10 assessed for injuries -5/24/10 assessed for injuries, instructed proper use of gait belt. Nurse's Notes The following nurse's notes were related to falls: -12/30/09 Falls Committee -"Found on floor in room, table beside recliner was moved to against wall to make more room for wheelchair & walker use/accessibility. Admit to falls (committee) and reassess in two weeks." -1/13/10 Falls Committee - "No further issues, dc (discharge) from Falls." (Gap in nursing notes 1/26/10-1/31/10) -2/1/10 "No adverse reaction noted from previous fall. Neuro (checks) WNL (within normal limits). Res(ident) confused & pale looking. Needed assist x 2 for transfer to bed." -2/23/10 "Resident was found by housekeeper on floor in her room, resident is confused & unable to tell us the details of the fall." -2/24/10 Falls Committee- "On 2/23/10 found on floor by wheelchair, unknown for sure-possibly ambulating (without) holding onto anything & got pulled back by O2 (oxygen) tubing. Admit to falls (committee), discussed with nurse's aides to take her to toilet & to assist her more (with) ADLs (activities of daily living) & transfers, change wheelchair to tilted position (back) and apply anti-thrust cushion to wheelchair. Reassess in 1 wk." -3/3/10 Falls Committee - "Walker taken out of room, apply bolsters to bed, mat on floor beside bed, and reassess in 1 wk." -3/10/10 Falls Committee - "Intervention (anti-thrust cushion) placed in seat of wheelchair and changed to tilted seat wheelchair (with) high back. Seem to be working at this time, reassess 1 wk." -3/17/10 Falls; "On 3/11/10 found on floor beside bed, will place mat on floor beside bed when mat is available. Reassess in 2 wks." -4/6/10 "Found res (with) knees on mat, (upper) body still on bed. Stated she was trying to get (up) to go to BR (bathroom)." 5/9/10 "Found resident @0630 (6:30 a.m.) sitting on floor in front of w