Every finding on record at Polaris Rehabilitation and Care Center

Based on review of nurse schedules, and staff interview, the facility failed to ensure the services of an RN were used for at least 8 consecutive hours a day, 7 days a week. The census was 69. The findings were:1. Review of the nurse schedule from 7/1/26 through 7/22/26 showed there was not an RN scheduled for 8 consecutive hours on 7/5/26.2. Interview with the regional nurse consultant on 7/22/26 at 11:40 AM confirmed the facility was not staffed with a RN for 8 consecutive hours on 7/5/26.

Based on observation, medical record review, resident interview, policy and procedure review, review of email correspondence, and staff interview, the facility failed to provide oxygen services to 1 of 3 sample residents (#6) reviewed. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #6 had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact and s/he received supplemental oxygen. The resident had diagnoses which included a debility with cardiorespiratory conditions, acute and chronic diastolic heart failure, and renal insufficiency. Review of the physician orders showed a 12/29/25 order for the resident's oxygen tubing to be changed weekly, or as needed, and the tubing was to be dated at the time of the change. In addition, a 2/12/25 order showed the oxygen concentrator filter was to be cleaned on a weekly basis. The following concerns were identified:a. Interview with the resident on 7/21/26 at 12:05 PM revealed s/he was concerned about the filters on the oxygen concentrators not being cleaned, the humidifier bottle not being refilled, and his/her oxygen tubing not being changed on a regular basis. Observation at the time of the interview showed the oxygen concentrator was located at the foot of the resident's bed near the door. The humidifier bottle was approximately one quarter full and a gallon sized bottle of water was on the floor near the concentrator. b. Review of the resident's April, May, June, and July 2026 medication administration records (MAR) and treatment administration records (TAR) showed no documentation the resident's oxygen tubing had been changed or the concentrator filter had been cleaned.c. Interview with the DON on 7/23/26 at 9:44 AM revealed it was the facility's expectation for the oxygen concentrator filters to be cleaned and oxygen tubing to be changed at least weekly or sooner if needed.d. Review of an email provided by the business office manager on 7/23/26 from a representative of an oxygen supply company showed routine maintenance for the oxygen concentrators was limited to monthly cleaning of external air filters. e. Interview with the regional nurse consultant on 7/23/26 at 12:15 PM revealed the physician order for changing the resident's oxygen tubing and cleaning the oxygen concentrator filter was entered into the system incorrectly and confirmed no documentation was available. 2. Review of the Oxygen Administration policy showed .5. a. Follow manufacturer recommendations for the frequency of cleaning equipment filters b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on review of the Facility Assessment and staff interview, the facility failed to consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population. The census was 69. The findings were: Review of the Facility Assessment 2026 dated 1/5/26 showed the total of full-time employees; however, the assessment failed to include the evaluation of resident acuity and specific staffing needs for each shift for RNs, LPNs, MA-Cs, and CNAs to meet the needs of the residents who resided within the facility. Interview with the administrator on 4/22/26 at 3:40 PM confirmed he did not include the specific staffing needs. Further interview revealed he believed he had completed the facility assessment per requirements.

Based on observation, staff and resident interview, resident meal slip review, resident council minutes review, and policy review, the facility failed to consider resident preferences during 3 of 3 meal observations. The census was 69. The findings were: 1. Observation during three different meals between 4/21/26 and 4/22/26 showed residents were not offered substitute meal items. Further observation showed when alternative meal items were requested, staff told the residents the food item requested was not on the menu. 2. Review of resident #2's meal slips, provided by the resident, showed on 4/14/26 the resident requested 2 containers of yogurt and 2 portions of cottage cheese. The slip showed in writing the resident could only have 1 yogurt and 1 cottage cheese per the administrator. Review of a meal slip dated 4/16/26 showed Food Adds: Other-SEND YOGURT AT DINNER!! 2 servings. which was crossed out, and Not Approved was documented on the slip. Review of a meal slip dated 4/17/26 showed the resident asked for cottage cheese and documented on the slip in writing it was Not on Menu. 3. Review of resident #10's meal ticket, provided by the resident, dated 4/19/26 showed Notes: PCC: Large meat/protein.Room Delivery 2 turkey and cheddar. Documented at the bottom of the slip was No Double Sandwiches per [administrator name].4. Review of the Resident Council Meeting Minutes dated 3/23/26 showed .Residents expressed concerns regarding recent changes to food service. Several items have been removed or reduced, including vegetables for burgers, PB&J sandwiches for evening snacks, and daily ice cream desserts. These changes have led to dissatisfaction among residents. The department assigned was dietary and there was no evidence the concern was addressed. 5. Interview with resident #5 on 4/21/26 at 12:17 PM revealed no condiments including lettuce, tomato, and onion were served with hamburgers. The resident revealed the sandwiches were very thin on meat and cheese and the bread was the main part of any sandwich. The resident revealed the administrator changed the meals and what was allowed. Further interview revealed if items were not on the menu, they were not provided. 6. Interview with resident #2 on 4/21/26 at 12:24 PM confirmed no condiments including lettuce, tomato, and onion were served with hamburgers. The resident confirmed the sandwiches were very thin on meat and cheese and the bread was the main part of any sandwich. The resident confirmed the administrator changed the meals and what was allowed. Further interview confirmed if items were not on the menu, they were not provided. 7. Interview with resident #10 on 4/21/26 at 2:34 PM confirmed no condiments including lettuce, tomato, and onion were served with hamburgers. The resident confirmed the sandwiches were very thin on meat and cheese and the bread was the main part of any sandwich. The resident confirmed the administrator changed the meals and what was allowed. Further interview confirmed if items were not on the menu, they were not provided. 8. Interview with resident #11 on 4/21/26 at 4:38 PM confirmed confirmed no condiments including lettuce, tomato, and onion were served with hamburgers. The resident confirmed the sandwiches were very thin on meat and cheese and the bread was the main part of any sandwich. The resident confirmed the administrator changed the meals and what was allowed. Further interview confirmed if items were not on the menu, they were not provided. 9. Interview with RN #1 on 4/21/26 at 11:20 AM revealed the administrator cut back the availability of yogurt and cottage cheese, limiting them to breakfast only. Further the RN revealed the residents' snacks were being made in house and chips, crackers, cream pies, pudding, and ice cream were taken away.10. Interview with CNA #1, CNA #2, and CNA #3 on 4/22/26 at 11:30 AM confirmed the administrator cut back the availability of yogurt and cottage cheese, limiting them to breakfast only and confirmed the residents' snacks were being made in house and chips, crackers, cream pies, pudding, and ice cream were taken away.11. Interview with cook #1 on 4/22/26 at 9:20 AM revealed there was no dietary manager since 3/23/26 and did there not a dietitian. She revealed the administrator took over the dietary services, had cut back the amount of food ordered, and restricted what food items the residents could have.12. Interview with the Dietitian on 4/22/26 at 10:57 AM revealed she just started on Friday and had not evaluated residents or meals. 13. Interview with the administrator on 4/22/26 at 4:15 PM revealed on 12/4/25 the residents agreed to the change in alternative menu. He stated if the resident wanted chips or snacks other than what was provided, there were vending machines in the hall they could use. Further interview revealed the administrator was unable to provide information showing the alternative items available to residents met the required nutrition for meals. 14. Review of the policy titled Nutritional Management provided by the administrator on 4/21/26 at 11:05 AM showed .2. Identification/assessments: .b. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay 3. Evaluation/analysis: b. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates .

Based on observation, staff interview, and review of the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen. The census was 72. The findings were:1. Observation on 1/14/26 at 9:31 AM showed cook #1 was performing various tasks in the kitchen; doffed his gloves, and without performing hand hygiene donned new gloves; placed two pots of water on the stove to boil; and retrieved fresh tomatoes from the walk-in refrigerator. After washing the tomatoes cook #1 used his same gloved hands and began slicing the tomatoes; discarded some tomato waste into a nearby garbage can, touched the sides of the can with his gloved hands in the process, and then resumed dicing the tomatoes. [NAME] #1 placed the diced tomatoes into a stainless-steel container; moved a cart of dirty dishes into the kitchen; removed his gloves, and without performing hand hygiene donned new gloves and continued to dice the tomatoes. 2. Observation on 1/14/26 at 10:11 AM showed cook #1 doffed his gloves, washed his hands, donned new gloves, and then adjusted his face mask with his gloved hands. [NAME] #1 opened cooler #1 and retrieved a plastic container of shredded cheese and proceeded to make individual salads. [NAME] #1 used his gloved hands to transfer salad greens from a container into individual salad bowls; added diced celery and tomatoes in the same manner; and then reached into the cheese container to add cheese to the bowls. After completing the first tray of 9 salad bowls cook #1 retrieved a date marking gun to date the individual salad bowls, and placed the salads into cooler #3. [NAME] #1 continued in the same manner and prepared a second tray of 12 bowls of salad. [NAME] #2 doffed his gloves at 10:21 AM and without performing hand hygiene donned new gloves and prepared a third tray of 12 salad bowls in the same manner as before. 3. Interview with the dietary manager on 1/15/26 at 1:19 PM confirmed hand hygiene was not performed as required. 4. According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

This requirement was not met as evidenced by:Based on observation, staff interview, review of manufacturer's instructions, and policy and procedure review, the facility failed to label and provide the date medications were opened in 1 of 4 medication carts (Yellowstone hall). The findings were: 1. Observation of the Yellowstone medication cart on 1/13/26 at 3:39 PM showed a multidose vial of Lantus insulin which was opened and not labeled. 2. Interview with RN # 2 on 1/13/26 at 3:40 PM revealed that insulin vials should have been labeled with the date they were opened and confirmed the vial was opened and not dated.3. Interview with the DON on 1/13/26 at 5:22 PM confirmed that staff were expected to label insulin vials with the opening date. 4. Review of the manufacturer's instructions titled Patient Medication Information - Lantus vial last revised 12/1/21 showed opened insulin vials must be discarded after 28 days of opening. 5. Review of the policy titled Multi-dose Vials last revised 2016, showed .2. Multi-dose vials will be re-labeled with a beyond use date, 28 days after the vial is opened or punctured (unless otherwise specified by the manufacturer).

Based on facility documentation, staff interview, and policy and procedure review, the facility failed to ensure a system was in place to maintain documentation of the pharmacist's monthly medication review for 5 of 5 sample residents (#1, #2, #5, #54, #68) reviewed for unnecessary medications. In addition the facility failed to act on a pharmacy recommendation for 1 of 5 sample residents (#5) for unnecessary medications. The findings were: 1. Review of the facility's documentation showed a monthly medication review was performed on resident #1 in June, November, and December of 2025. The facility was unable to located any further documentation. 2. Review of the facility's documentation showed a monthly medication review was performed on resident #2 in November 2025. The facility was unable to locate any further documentation. 3. Review of the facility documentation showed no evidence a monthly medication review had been completed for resident #5 in December 2025. Further review showed a monthly medication review was performed in November 2025 with the pharmacy recommendation of a trial dose reduction of Olanzapine from 5mg to 2.5mg at bedtime. Review of the resident's orders showed the medication was never decreased. Further review of physician orders dated 12/6/25 showed an increase in olanzapine dose from 5mg to 7.5mg. Interview with the facility nurse practitioner on 1/15/26 at 10:13 AM confirmed Olanzapine dose was increased and not decreased. 4. Review of the facility's documentation showed a monthly medication review was performed on resident #54 in November and December of 2025. The facility was unable to locate any further documentation.5. Review of the facility's documentation showed a monthly medication review was performed on resident #68 in November and December of 2025. The facility was unable to locate any further documentation.6. Interview with the DON on 1/14/26 at 4:36 PM revealed the facility had changed pharmacies in November of 2025 and she was unable to locate the documentation from the previous pharmacy.7. Review of the Pharmacy Services Policy and Procedure, provided by the NHA on 1/15/26 at 2 PM showed .III. Drug Regimen Review A. The drug regimen of each resident shall be reviewed at least once a month by a licensed pharmacist .

Based on medical record review, staff interview, and review of the MDS 3.0 RAI (Resident Assessment Instrument) manual, the facility failed to ensure a significant change assessment (SCSA) was completed for 1 of 25 sample residents (#32) reviewed. The findings were: 1. Review of the 8/11/25 annual MDS assessment for resident #32 showed s/he received hospice care. Review of the 11/11/25 quarterly MDS assessment showed the resident was not receiving hospice care. Review of the resident's medical record showed no documentation of when the resident had been discharged from hospice. Interview with the business office manager on 1/14/26 at 2:27 PM revealed she had changed to resident's payer source on 10/24/25. Interview with the MDS coordinator on 1/14/25 at 2:18 PM confirmed a significant change MDS assessment had not been completed on the resident following his/her discharge from hospice care. 2. Review of the October 2023 CMS RAI manual version 3.0 version 1.18.11 showed An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD [assessment reference date] must be within 14 days from one of the following: 1) the effective date of the hospice CMS's RAI Version 3.0 Manual CH 2: Assessments for the RAI October 2023 Page 2-26 election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill.

This requirement has not been met as evidenced by: Based on employee record review, and staff interview, the facility failed to obtain CNA abuse prior to resident contact for registry verification in 1 of 3 (CNA #2) employee files reviewed. 1. Review of CNA #2's personnel record showed no evidence the facility had obtained CNA abuse registry verification prior to resident contact.2. Interview with the human resource manager on 1/13/26 at 4:32 PM confirmed that he was not aware the CNA abuse registry was to be verified.

Based on observation and staff interview, the facility failed to ensure effective infection control techniques were utilized during 1 of 2 dining observations. The census was 72. The findings were:1. Observation on 1/12/26 at 5:44 PM showed CNA #1 was assisting residents with eating in the assisted dining room. The CNA was observed picking up a sandwich for resident #5 with her bare hands and handed the sandwich to the resident. Interview with the CNA at 5:55 PM revealed she knew she had made a mistake; however, was trying to assist the resident because she did not want the resident to sit alone without assistance. 2. Interview with the infection preventionist on 1/15/26 at 1 PM revealed it was her expectation for staff to sanitize their hands and then use gloves if they had to touch a resident's food.

Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 sample residents (#68) reviewed. The findings were:1. Review of a 9/9/25 provider progress note for resident #68 showed the resident had Alzheimer's disease, unspecified; dementia in other diseases classified elsewhere without behavioral disturbance; and restlessness and agitation. Further review showed The patient will continue to receive supportive interventions aimed at minimizing agitation and promoting cooperation, including structured activities, calm environments, and therapeutic communication strategies. Nursing staff will closely monitor for recurrent behavioral escalation, medication side effects, or acute changes in condition. To rule out underlying medical contributors to agitation, the following laboratory studies are ordered: Urinalysis with culture and sensitivity (UA w/ C&S), Complete Metabolic Panel (CMP), and Complete Blood Count (CBC). Results will be reviewed to guide further management. The care plan for [resident name] focuses on management of acute agitation and behavioral escalation in the context of underlying cognitive and functional needs. She will continue to be supported in calm, structured environments with use of de-escalation techniques including reduced lighting, therapeutic music, and one-on-one supportive interaction as needed. Nursing staff will monitor for recurrent agitation, provide reassurance, and implement redirection strategies early to prevent escalation. The interdisciplinary team, including nursing, rehabilitation, and providers, will maintain communication regarding episodes and reinforce individualized behavioral interventions to promote safety, cooperation, and overall well-being. Review of the 12/30/25 quarterly MDS assessment showed the resident was administered an antipsychotic medication during the 7-day look-back period. The resident had diagnoses of non-traumatic brain dysfunction, cancer, hypertension, Alzheimer's disease, non-Alzheimer's dementia, unspecified pulmonary disease, respiratory failure, pain in right hip, primary thrombophilia, hearing loss, osteoarthritis, abnormalities of gait and mobility, and lack of coordination. The following concerns were identified:a. Review of the resident's care plan, initiated on 10/29/25, showed the resident used psychotropic medications related to dementia with behavioral disturbance. Review of the September 2025 medication administration record showed the resident was administered 25 milligrams of Seroquel (antipsychotic medication) two times a day for dementia with behavioral disturbances with a start date of 9/9/25. Review of the entire medical record showed no evidence the diagnosis of dementia with behavioral disturbances had been documented by a provider. b. Interview with the DON on 1/15/26 at 10:57 AM confirmed the diagnosis of dementia with behavioral disturbances was not documented in the resident's medical record.

Based on observation, medical record review, policy and procedure review, and staff interview, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications for 1 of 1 sample resident (#62) reviewed for tube feeding. The findings were: 1. Review of the 11/6/25 comprehensive MDS assessment showed resident #62 had a memory problem with moderately impaired cognitive skills for daily decision making, and had diagnoses which included respiratory failure, hemiplegia, or hemiparesis, traumatic brain injury, and cerebral edema and edema of the larynx. Further review showed the resident had a feeding tube. Review of the physician orders dated 11/21/25 showed the resident received enteral feeding through the feeding tube once daily. The following concerns were identified:a. Observation on 1/13/26 at 6 PM showed RN # 1 administer the resident his/her enteral tube feeding; however, the RN did not check placement, residual volume, nor was the resident's head of bed elevated.b. Review of the physician orders dated 10/31/25, showed residual and verification of the tube placement must be checked prior to administering enteral feeding. c. Review of the care plan, last revised on 11/7/25, showed, Check for placement and gastric contents/residual volume per facility protocol, hold feed if contents/residual is over 500 cc (cubic centimeters). Further review showed the resident's head of the bed should have been elevated 30 to 45 degrees during feeding and for 1 hour following to prevent aspiration pneumonia. d. Review of the facility policy titled Care and Treatment of Feeding Tubes provided by the DON on 11/14/26, showed .6. In accordance with facility protocol licensed nurses will monitor and check the feeding tube is in the right location.e. Interview with the DON on 1/14/26 at 9:44 AM confirmed staff were expected to check placement, residual of the stomach contents, and elevate the head of the bed prior to starting the feeding solution.

Based on observation, medical record review, staff, resident, and resident representative interview, facility incident review, and policy and procedure review, the facility failed to protect residents' right to be free from physical abuse by another resident for 1 of 6 sample residents (#1) reviewed for abuse. This failure resulted actual harm to resident #1 and resident #2. Corrective measures were implemented prior to the survey and compliance was determined to be met on 10/23/25. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a brief interview for mental status (BIMS) score of 15 out 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, renal insufficiency, diabetes mellitus, and cerebrovascular accident. Further review showed the resident had no behaviors exhibited, used a wheelchair for mobility, and was dependent on staff for transfers. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and diagnoses which included non-Alzheimer's dementia and renal insufficiency. Further review showed the resident had no behaviors exhibited, used a walker for mobility, and required supervision or touching assistance with transfers. The following concerns were identified:a. Observation on 11/13/25 at 11:28 AM showed resident #2 was in his/her room, in bed, and s/he had a cast present to his/her right hand. Interview with the resident at that time revealed s/he was unsure how the injury to his/her hand occurred; however, s/he felt s/he could benefit from counseling services.b. Review of a progress note for resident #1 dated 10/17/25 and timed 10 AM showed LATE ENTRY Note Text : On 10/17/2025 this nurse was alerted to an incident with resident and room mate. This nurse was not the first on scene. Both residents were separated immediately. Floor nurse stated he left a message with contact number on file. Resident sent to hospital for further evaluation. Resident was moved to a different room.c. Review of a facility incident report dated 10/17/25 and timed 9:45 AM showed There was a noise commotion. A staff member responded. Found one resident on the floor. Both residents holding the walker. Staff intervened and separated both residents to ensure safety. Nurse evaluated both residents and provider notified. [Resident #1] was sent to the hospital to be further evaluated. Further, the report showed [Resident #1] had a swollen jaw on the right side and was transferred to the hospital for further evaluation. [Resident #2] was bleeding on the right side of his head and transferred to the hospital for further evaluation.d. Review of a progress note for resident #1 dated 10/18/25 and timed 8:30 AM showed Note Text : Returned [Name], [ Resident #1]'s friends [sic] call from yesterday to follow up regarding the incident, to see if [s/he] had any additional questions or concerns. [S/he] said they did some blood work on [resident #1] and found some sort of blood infection, affecting [his/her] spinal chord [sic],so they are sending [him/her] to a Colorado hospital. [S/he] will follow up with [resident #1] today and get more details. [S/He] said if [s/he] has any further questions or concerns, [s/he] will contact me.e. Review of a progress note for resident #1 dated 10/20/25 and timed 3:45 PM showed Note Text : [Name] from [hospital name] called Polaris regarding [resident #1]'s return to Polaris. [S/He] states [s/he] does not wish to return to Polaris with the other resident still remaining at Polaris. [Name] asked for dialysis days and stated that she would be sending referrals to other facilities in [NAME].f. Review of a progress note for resident #2 dated 10/20/25 and timed 2:04 PM showed Note Text : On 10/17/2025 this nurse was alerted to an incident with resident and room mate. This nurse was not the first on scene. Both residents were separated immediately. Floor nurse stated he tried to contact the number on file, but the number was not working. Resident sent to hospital for further evaluation.g. Review of an emergency medicine note for resident #1 dated 10/17/25 showed the chief complaint was Assault Victim. Further review showed the resident was evaluated after a physical assault from another resident at a nursing facility and s/he was .found to have an isolated hematoma to [his/her] right lateral thigh as well as CT and MRI imaging concerning possible discitis .h. Review of an ED Provider Note for resident #2 dated 10/17/25 showed the resident was evaluated following an altercation with his/her roommate and the resident reported s/he punched [his/her] roommate. Further review showed the Clinical Impressions included a Closed nondisplaced fracture of the fifth metacarpal bone of right hand and abrasion of head.i. Interview with staff member #1 on 11/13/25 at 3:45 PM revealed she heard something in the room and when she walked in the room, she observed resident #1 on the ground and resident #2 standing over him/her. She revealed resident #1 was screaming for help. She revealed she removed the walker and observed resident #2 was bleeding, although she could not tell from where, and the blood was located from his/her temple to his/her ear. Further interview revealed nursing staff intervened and separated the residents.j. Interview with resident representative #1 for resident #1 on 11/13/25 at 1:50 PM revealed s/he had reported resident #1 was afraid of his/her roommate previously and heard resident #2 attacked another person on Saturday. She revealed resident #1 was transferred from the emergency department to another facility due to a blood infection that was affecting [his/her] spine and s/he passed away on 10/29/25 at the hospital.k. Interview with resident representative #2 for resident #1 on 11/13/25 at 4:31 PM revealed the incident occurred after a visitor entered the residents' room and asked where resident #2 was. The representative said resident #1 told the visitor resident #2 was in the bathroom; however, the visitor did not hear him/her. The Representative revealed when resident #1 attempted to tell the visitor again, resident #2 became angry and started hitting resident #1 with a walker. The representative confirmed resident #1 was sent to the emergency room and then transferred to a different location. Further interview revealed law enforcement was notified and said there was not an immediate threat since resident #1 had been transferred.2. Interview with the regional clinical director on 11/14/25 at 8:55 AM revealed the facility believed the resident to resident altercation between resident #1 and resident #2 was an isolated incident and as a result, resident #2 was placed in a room without a roommate. In addition, the facility had resident #2's medications reviewed and counseling was offered due to the resident reporting feeling down and depressed during a mini mental exam; however, the resident declined counseling at that time. The regional clinical director revealed resident #2 had an additional episode of aggression toward a staff member and the facility implemented an intervention for 2 staff members at all times when entering the resident's room. Following the incident of aggression toward staff, the resident was sent to the hospital for a psych evaluation; however, the resident did not qualify and was returned to the facility. 3. Review of the policy titled Abuse, Neglect and Exploitation dated 2025 showed .1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.4. Review of the post incident interventions showed the facility implemented the following corrective actions:a. Resident #1 and resident #2 were separated following the incident and each were went to the hospital for evaluation and treatment on 10/27/25.b. Upon return from the hospital on [DATE], resident #2 was placed in a room, without a roommate. c. Resident #1 did not return to the facility.d. Staff education on abuse was performed on 10/20/25.e. Facility audits were initiated to monitor resident redirection and de-escalation on 10/23/25.f. A QAPI meeting was performed and abuse was discussed on 10/20/25.

Based on medical record review, staff interview, and review of medication interactions, the facility failed to ensure residents did not receive unnecessary medications for 1 of 8 (#1) sample residents reviewed. This failure caused harm to resident #8 whose functional capacity declined from independent to dependent. The findings were: 1. Review of the 2/7/25 admission MDS assessment for resident #1 showed the resident was coded as being severely cognitively impaired with inattention and disorganized thinking continuously present; wandered 4 to 6 days of the look-back period; was coded as requiring supervision or setup assistance for all self-care areas and was independent with mobility. The resident was not coded as receiving an anticonvulsant medication. Review of the 5/7/25 quarterly MDS assessment showed the resident continued to be independent with mobility and was not coded as receiving an anticonvulsant medication. Review of the 8/7/25 significant change MDS assessment showed the resident was coded as being totally dependent on staff for all self-care and mobility areas. The resident was coded as receiving an anticonvulsant. The following concerns were identified: a. Interview with the resident's representative on 10/23/25 at 3:50 PM revealed he recalled the resident participated in the July 4th celebration at the facility and by July 19th was unable to function. The resident's representative stated the facility had failed to follow orders from a neurologist to discontinue the valproic acid (anticonvulsant) medication which he thought caused the resident to be overmedicated. b. Review of the 7/10/25 and 7/26/25 hospital's After Visit Summary showed the reason for the resident's visit was Altered Mental Status. Further review of the 7/26/25 After Visit Summary showed the resident had diagnoses of somnolence and a history of seizure. The discharge instructions showed Please start taking the lacosamide (anticonvulsant), in 2 days, stop the valproic acid. If breakthrough seizures, please increase the lacosamide to 100 mg twice daily. If worsening symptoms return to the Ed. Further instructions stated a follow-up appointment with a neurologist should be scheduled as soon as possible. c. Review of the July 2025 medication administration record (MAR) showed the resident was administered 5 mg of olanzapine twice daily for behaviors with a start date of 6/30/25 and a discontinue date of 7/25/25; 5 mg of olanzapine once daily for behaviors with a start date of 7/25/25; 100 mg of lacosamide two times a day for seizures with a start date of 6/15/25 and a discontinue date of 7/26/25; 50 mg of lacosamide two times a day for post traumatic seizures with a start date of 7/26/25; and 5 ml of 250 mg/5ml valproic acid oral solution 3 times a day for post traumatic seizures with an order date of 7/1/25 and a discontinue date of 8/28/25. The resident was also prescribed 1 ml of lorazepam-diphenhydramine-haloperidol-ondansetron cream to be applied topically every 4 hours as needed with a start date of 5/19/25. The resident received 1 dose on 7/1 and 7/2; 2 doses on 7/3 and 7/5; 3 doses on 7/6, 1 dose on 7/8, 3 doses on 7/9, 1 dose on 7/10, 7/12, 7/13, and 7/14. No further doses were applied and the medication was discontinued on 8/28/25.d. Review of the August 2025 MAR showed 5 ml of a 250 mg/5 ml valproic acid oral solution was to be administered 3 times per day for post traumatic seizures with a start date of 7/1/25 and a discontinue date of 8/18/25. Further review showed an order dated 8/18/25 for the same dose of valproic acid to be administered two times per day every Tuesday, Wednesday, and Thursday and then decreased to 2.5 ml once a day for 3 days and then to discontinue. The medication was discontinued on 8/29/25. e. Continued review of the resident's August 2025 MAR showed the resident was administered melatonin for insomnia starting on 5/29/25, paroxetine (antidepressant) for major depressive disorder starting on 6/6/25, and olanzapine (an atypical antipsychotic) for unspecified dementia, severe with mood disturbance, and major depressive disorder starting on 7/25/25.f. Review of a 6/25/25 nurse's note showed the resident had behaviors of wandering, intrusive pacing, clenching fists, sharp voacal (sic) tone, shrugging away staff who approach to greet [him/her] and turning [his/her] back and changing directions, 'stating, Leave me alone!g. Review of the nurses' progress notes for July 2025 failed to include when or what triggered the decline in the resident's functional status.h. Review of a 8/4/25 nurse's note showed Follow up scheduled today from previous hospital visit at neurology .Resident is unable at times to sit up in wheelchair for staff to attempt to take [him/her] .i. Review of a 8/17/25 nurse's note, showed Residents son approached this nurse and stated that he wants resident off of Valproic Acid. This nurse educated son of mechanism of action of the medication and reason for being on this medication and the risk of seizure activity when taken off the drug. Residents son stated an understanding and is willing to take the risk of resident being tapered off medication. Residents son requested keppa (sic) as a alternate. This nurse notified NP and awaiting orders. j. Interview with CNA #4 on 10/22/25 at 4:30 PM revealed the resident was ambulatory and had aggressive behaviors upon admission and had declined after the onset of seizures. The CNA stated the resident had improved and was now able to communicate in complete sentences. k. Interview with RN #1 on 10/21/25 at 4:39 PM revealed the resident was mobile upon admission; however, did not know what had caused the resident's decline from independent to dependent. The RN stated the resident used to be bed-bound and required repositioning every hour. In addition, the RN stated the resident had improved since s/he was taken off valproic acid. l. According to WebMD located at https://www.webmd.com/interaction-checker/default.htm and accessed on 11/4/25 showed significant interaction was possible and monitoring by a physician was required as valproic acid, olanzapine, and melatonin each cause an increase in sedation and drowsiness. 2. Interview with the DON and NHA on 10/24/25 at 12:40 PM revealed neither were in the facility in July. They stated they did not know what happened with the medications and the resident at that time. In addition, both the DON and NHA revealed they had identified the need to provide a better quality of care.

Based on observation, medical record review, resident representative and resident interview, review of resident council minutes, and concern forms, and staff interview, the facility failed to ensure sufficient nursing staff was available to provide the highest practicable physical, mental, and psychosocial well-being on 2 of 2 resident care units (North hall, South hall). The census was 71. The findings were: 1. Review of the 8/7/25 significant change MDS assessment for resident #1 showed s/he was determined to be severely cognitively impaired and exhibited inattention and disorganized thinking on a continuous basis, and suffered from delusions. The resident was totally dependent on staff for all areas of self-care and mobility. Review of the resident's ADL care plan, last revised 9/15/25, showed the resident was a 1 to 2 person assist with bathing and preferred showers on Tuesdays and Fridays. The following concerns were identified: a. Observation on 10/21/25 at 4:58 PM showed resident #1 was brought to the dining room and placed at the dining table with nothing in front of him/her. The resident was observed picking at the tablecloth. Meal service began at 5:07 PM and resident #1 was served his/her meal at 5:35 PM with the assistance of CNA #2. CNA #2 was observed assisting resident #9 at 5:07 PM before moving to assist resident #1. b. Observation on 10/22/25 at 8:36 AM showed the resident was brought to the dining room for the morning meal at 8:36 AM. At 8:53 AM the resident was offered a beverage; however, was not served his/her meal until 8:58 AM. c. Observation on 10/23/25 at 7:58 AM showed the resident was seated at a small table in the dining room, which faced the back wall, and had a glass of water in front of him/her. The resident's back was turned to the dining room so s/he was looking at the wall. At 8:38 AM the resident was observed to independently drink an entire glass of water, move the tablecloth around, and pick-up and examine a tissue box. At 8:48 AM the resident was served breakfast by a nursing student. The nursing student sat with the resident and attempted to assist him/her with the meal. The nursing student asked the resident if s/he would like something to drink; however, the nursing student did not provide a beverage. At 8:56 AM the resident began to eat with the assistance of the nursing student. At 9:15 AM the resident attempted to drink from the empty water glass; more water was provided. At this time the resident was observed to use a spoon with his/her left hand and was able to bring the food to his/her mouth. The nursing student removed the utensil from the resident's hand and began to feed the resident herself. At 9:28 AM the resident was removed from the table and was moved to the hallway in front of the North nurses' station where s/he sat until 10:53 AM when s/he was approached by a therapist and taken to the therapy room. From 9 AM until 9:28 AM the only facility staff member in the dining room was RA #2; no staff members trained to assist residents with eating were present to supervise the nursing student. d. Interview with restorative aide #1 on 10/22/25 at 1:30 PM revealed the resident required assistance with eating was served last so his/her food was hot. e. Interview with CNA #3 on 10/22/25 at 2:30 PM revealed only one person was assigned to the dining room during meal service and they were expected to do everything. f. Interview with CNA #2 on 10/22/25 at 4 PM revealed the dining room was only staffed with 1 person when ideally 3 people were needed. In addition, the CNA stated 2 residents required assistance with eating; one resident would be assisted while the other one had to wait. g. Review of the bathing documents provided by the facility on 10/23/25 at 5:23 PM showed the resident was given a bed bath on 10/8/25 at 11 PM and a shower on 10/16/25 (2 baths in 22 days.) Interview with LPN #1 on 10/23/25 at 5:30 PM confirmed the bathing sheets were correct. h. Interview with the resident's representative on 10/23/25 at 3:57 PM revealed the facility said they were going to bathe [him/her] but do not do it. i. Observation on 10/23/25 at 7:58 AM showed the resident was seated at a small table in the dining room, which faced the back wall, and had a glass of water in front of him/her. At 9:28 AM the resident was removed from the table and was moved to the hallway in front of the North nurses' station where s/he sat until 10:53 AM when s/he was approached by a therapist and taken to the therapy room. The resident remained in the therapy room and was a passive participant until 11:50 AM when s/he was taken back to the dining room and placed at the same table as before. The resident was offered a glass of water at 11:53 AM in which s/he drank half. At 12:11 PM the contractual wound care nurse approached the resident at the dining room table and then transferred him/her back his/her room to provide wound care. The resident was transferred using a Hoyer lift by LPN #1 and CNA #2 to his/her bed and then exited the room for the wound care team to provide care. At 12:59 PM the wound care team exited the resident's room. At 1:50 PM RA #1 was observed bringing the resident's noon meal into the room and then left stating she needed to find a nurse or CNA to assist the resident with the meal. At 1:53 PM LPN #1 and a nursing student entered the room where incontinence care was provided (approximately 6 hours). LPN #1 confirmed the resident's brief was wet. 2. Review of the 9/16/25 quarterly MDS assessment for resident #5 showed a BIMS score was not determined; however, the staff assessment for mental status showed the resident to be independent with consistent/reasonable decision making. Further review showed the resident was not coded as rejecting care during the look-back period. Review of the resident's care plan, last revised 8/20/25, showed the resident preferred a shower in the morning right after breakfast twice a week on Tuesday and Friday. Further review of the resident's care plan, initiated on 8/25/25, showed the resident was resistive to bathing/showering, at times, with interventions which included If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Document all refusals. Review of the resident's ADL care plan, last revised 9/5/25, showed the resident required a bedpan for bowel movements with the extensive assist of 2 staff members for placement. The following concerns were identified: a. Review of the Daily Shower Sheets, dated 10/3/25 through 10/24/25, for the resident showed the resident had received a bed bath on 10/10 after refusing on 10/8 and 10/9, and was in the hospital from 10/17 to 10/19. Review of the nurse progress notes showed the resident was educated on the importance of bathing on 10/9/25 and 10/15/25. There was no documentation the resident had refused to be bathed. No further documentation was available.b. Interview with the resident on 10/21/25 at 2:02 PM revealed s/he was not receiving care in a timely manner and had telephoned the facility to request help because his/her call light was not being answered. Review of a 10/20/25 concern form, provided by the resident showed the form was completed with the assistance of the business office manager (BOM). The description of the concern showed Resident had to call the facility to get assistance on the bed pan. [BOM] in the business office came to address needs. [Resident] stated [s/he] has been waiting to be put on bed pan. [S/he] stated [CNA #5] came to his/her room stated she did not have time to put resident on bedpan due to needing to complete bed baths. Call light was going off the whole-time cares were being performed and nobody covered the light. This was on for about an hour and unsure how long it was on prior. This is the second time resident had to call the facility to have [his/her] needs addressed. The first time was 10/16/25. It was also evident that pericare was not being performed. The same staff member was working from 10/20/25 and 10/16/25 (sic) was working the floor on these occasions. In addition, the concern form stated this concern had been previously voiced. b. Interview with the BOM on 10/22/25 at 1 PM confirmed the resident had phoned the facility asking for assistance. The BOM stated she was also a CNA and went to the resident's room to assist the resident with the bedpan. The BOM confirmed the resident's call light was on for approximately 1 hour while she provided care to the resident with no response from the unit staff.3. Review of the 8/25/25 resident council minutes showed Old Business: Residents had filled out a grievance form for the issues presented at the June council meeting that had not been completed.and being told short staffing is the reason for long call lights, late meals, and not getting things when needed. New Business: The grievance from the last meeting was discussed. Residents stated they are happy that the AC is back in the activities room, but they are still being told that we are short-staffed all the time. Residents discussed staffing, stating they are being told we are short-staffed, and they believe it, as they are not receiving timely bed changes and showers. Call lights take a long time to be answered, and staff are turning the lights off and stating they will be right back, which often takes a considerable amount of time for them to return. Additionally, staff sometimes forget and do not return. The minutes showed the residents completed a grievance form related to staffing. Review of the 9/22/25 resident council meeting minutes showed no evidence the grievance submitted by the resident council was acted upon. Further review showed the Open Forum section noted concerns of Lack of communication between staff and residents, call lights turned off, and staff not returning in an acceptable amount of time. Review of the Complaint/Concern/Compliment/Tracking Log showed no grievances related to staffing had been submitted on behalf of the resident council in August or September of 2025. 5. Staff interviews were conducted throughout the survey timeframe. The following concerns were identified: a. Interview with staff #1 revealed s/he was unable to perform his/her job due to having to do the CNAs tasks prior to providing rehabilitation services. Staff #1 stated residents were not receiving quality care and cited repositioning, assistance to the toilet, incontinence care, proper pericare, and call lights not within reach. In addition, staff #1 stated there was not enough staff; communication was poor; and there was no follow through. b. Interview with staff #2 revealed it was difficult to find a second person to assist with the Hoyer lift and found it difficult to complete his/her charting due to the lack of staffing. In addition, staff #2 stated the facility did not have a staff member assigned as a shower aide to assist with resident bathing and was lacking supplies such as wipes and briefs. c. Interview with staff #3 revealed s/he had never seen the facility this bad with staff being stressed. d. Interview with staff #4 revealed s/he had multiple responsibilities throughout the facility and did not have enough time to complete the additional tasks due to management continuously requiring him/her to work the floor to provide resident care. In addition, staff #4 stated lifts were being used inappropriately; there was an increase in falls due to residents not being rounded on properly; and resident bathing was not being completed in a timely manner. Further, staff #4 stated 2 CNAs on the North hall was inadequate due to the high acuity of the residents and staff were frustrated because they did not know how to fix it. e. Interview with staff #5 revealed the facility did not have adequate staff to meet the needs of the residents and stated the residents on the North hall required more assistance with activities of daily living than the residents on the South hall. Further, the facility often lacked adequate supplies and staff would have to search the building for wipes and other supplies such as denture cleaner, denture adhesive, tissues, lotion, and draw sheets. f. Interview with staff #6 revealed the low staffing level put a strain on the remaining staff; however, they were doing the best they could. Staff #6 stated it was a struggle to find a second person to assist with resident care when required; was unable to complete showers in a timely manner; the facility was short on supplies, and there was no routine in the North hall which s/he found to be challenging. g. Interview with staff #7 revealed s/he had multiple responsibilities throughout the facility and did not have enough time to complete the additional tasks due to management continuously requiring him/her to work the floor to provide resident care. In addition, staff #7 revealed the facility was often low on supplies such as wipes and glucose strips. h. Interview with staff #8 revealed the current staff did not work as a team. S/he stated it was a struggle to find a second person to assist with resident care, when required, and a lot of time was wasted searching for help which frustrated both the staff members and the residents. Staff #8 further revealed the North hall had a few residents which were needy and certain CNAs would not address their needs which led to their call lights being left on for extended periods of time. Further, the facility was short of bariatric briefs and wipes and staff would have to scramble or someone from management would be sent out to shop. i. Interview with staff # 9 revealed the therapy department was unable to work efficiently due to the residents' basic cares not being addressed, the high acuity of residents, and the lack of staff impeded the ultimate goal of discharge. Staff #9 stated 35% of the residents on the North hall and 51% of the residents on the South hall required a lift for transfers. j. Interview with staff #10 revealed s/he was unable to perform his/her responsibilities up to [his/her] own standards. Staff #10 stated s/he was overwhelmed and felt like s/he was rushing through cares; was unable to help residents with the little stuff; was not providing showers as per the schedule; was unable to round on his/her residents every two hours and oftentimes s/he would only be able to round 3 times per a 12-hour shift. k. Interview with staff #11 revealed everyday was hectic with the weekends being even worse. Staff #11 stated s/he was overwhelmed and could not give his/her best care noting showers were not being completed timely; charting was not done; meals were delivered late; and s/he admitted to transferring a resident, who required 2 staff members, without assistance because s/he could not find help. l. Interview with staff #12 revealed the day-shift staff struggled to complete resident care in a timely manner leaving residents in wet incontinence products for extended periods of time. m. Interview with staff #13 revealed s/he had observed residents which did not receive adequate pericare and timely incontinence care which made it difficult for the therapy department to provide rehabilitation services because the therapy department would have to either wait for the CNAs to perform the task or step in and perform the task themselves. In addition, staff #13 revealed facility staff were stressed as the human resource director, maintenance director, and admissions director recently were terminated from their positions, and the director of nursing had walked out. Further, staff #13 stated it was his/her opinion staff did not work as a team to provide resident care. n. Interview with staff #14 revealed the administrator had informed the staff the facility was not short-staffed and their numbers were okay. Staff #14 stated resident care was not okay. o. Interview with staff #15 revealed it was difficult to complete his/her job due to having to either wait for a CNA to provide care prior to a rehabilitation session or having to provide the care him/herself. Staff #15 stated if s/he provided the care it would cut into the minutes s/he could work with the resident. In addition, s/he had seen a decline in the last month with staff being overwhelmed. p. Interview with staff #16 revealed the facility had a lot of shake-ups lately. q. Interview with staff #17 revealed treatment plans were not being followed due to resident needs not being addressed which caused the residents' rehabilitation sessions to be rushed.6. Interview with the NHA on 10/24/25 at 12:43 PM revealed the corporation had recently developed a census tool to determine the staffing needs of the facility. The NHA stated the facility was working within the provided budget and on paper the facility was adequately staffed.7. Interview with the chief executive officer (CEO) of the corporation on 10/24/25 at 1:47 PM revealed the corporation was doing what they could and finding CNAs was challenging. The CEO stated the facility was always trying to meet the PPD established to help them to be a reliable business; however, the facility's census was currently about 20 residents short of average. In addition, the CEO stated they were doing the best they could and did not want to cut direct care.

Based on medical record review, resident representative interview, and staff interview, the facility failed to ensure routine bathing was provided for 2 of 8 sample residents (#1, #5) reviewed for activities of daily living. The findings were: 1. Review of the 8/7/25 significant change assessment for resident #1 showed s/he was determined to be severely cognitively impaired and exhibited inattention and disorganized thinking on a continuous basis and suffered from delusions. The resident was totally dependent on staff for all areas of self-care and mobility. Review of the resident's ADL care plan, last revised 9/15/25, showed the resident was a 1 to 2 person assist with bathing and preferred showers on Tuesdays and Fridays. The following concerns were identified: a. Review of the October 2025 bathing documents, provided by the facility on 10/23/25 at 5:23 PM, showed the resident was given a bed bath on 10/8/25 at 11 PM and a shower on 10/16/25 (2 baths in 22 days). Interview with LPN #1 on 10/23/25 at 5:30 PM confirmed the bathing sheets were correct. b. Interview with the resident's representative on 10/23/25 at 3:57 PM revealed the facility said they were going to bathe [him/her] but do not do it. 2. Review of the 9/16/25 quarterly MDS assessment for resident #5 showed a BIMS score was not determined; however, the staff assessment for mental status showed the resident to be independent with consistent/reasonable decision making. Further review showed the resident was not coded as rejecting care during the look-back period. Review of the resident's care plan, last revised 8/20/25, showed the resident preferred a shower in the morning right after breakfast twice a week on Tuesday and Friday. Further review of the resident's care plan, initiated on 8/25/25, showed the resident was resistive to bathing/showering, at times, with interventions which included If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Document all refusals. The following concerns were identified: a. Review of the Daily Shower Sheets, dated 10/3/25 through 10/24/25, for the resident showed the resident had received a bed bath on 10/10 after refusing on 10/8 and 10/9, and was in the hospital from 10/17 to 10/19. Review of the nurse progress notes showed the resident was educated on the importance of bathing on 10/9/25 and 10/15/25. There was no documentation the resident had refused to be bathed. No further documentation was available.3. Interview with the DON and NHA on 10/24/25 at 12:40 PM revealed they had identified the need to provide a better quality of care.

Based on medical record review, resident representative interview, staff interview, and policy and procedure review, the facility failed to ensure a notification of change of condition was given for 1 of 8 sample residents (#6) reviewed. The findings were:1. Review of the 10/9/25 admission MDS assessment for resident #6 showed the resident had a BIMS score of 12 out of 15 (moderately cognitively impaired), required partial to moderate assistance for toileting, showers, upper and lower body dressing, and putting on and taking off footwear. The resident had diagnoses which included diabetes mellitus type 2 (DM2), transient cerebral ischemic attack, Parkinson's disease, muscle weakness, and dysphagia. Review of the care plan showed NUTRITIONAL STATUS: [resident name] is at risk for nutrition related problems r/t [related to] Parkinson's, DM2, PNA [pneumonia], dysphagia, anemia, HTN [hypertension], chronic respiratory failure, transient cerebral ischemic attack, AOC respiratory failure, falls. Resident/family decline recommended NPO diet and request regular chopped textures. They have been educated on risks associated with declining recommendations and understand risks involved with PO intake given MBSS indicating aspiration on all textures. Date Initiated: 10/04/2025 Revision on: 10/09/2025, Target Date: 01/13/2026. Explain and reinforce to the resident the importance of maintaining the diet ordered. Review of the physician orders showed diet, regular texture, regular consistency. The following concerns were identified: a. Interview with resident #6 on 10/21/25 at 2:10 PM revealed s/he was getting enough food; however, was not sure what was being served as it was in the form of blobs. b. Interview with the residents' family on 10/23/25 at 4:25 PM revealed the resident was to be on a regular diet, not a mechanical soft diet. The resident's representative stated the facility did not notify them of the change in diet for the resident. c. Review of the meal card for the resident on 10/23/25 showed a mechanical soft chopped diet was specified for all 3 meals. d. Interview with the NHA on 10/24/25 at 12:50 PM revealed the resident's diet was recommended following a speech language pathology evaluation, and confirmed the family was not notified of the diet change. 2. Review of policy Change in a Resident's Condition or Status hand delivered on 10/23/25 at 5:15 PM by the NHA showed .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. there is a significant change in the resident's physical, mental, or psychosocial status .

Based on observation, medical record review, staff interview, and policy review the facility failed to ensure interventions to prevent ulcers development were implemented for 2 of 4 residents (#1, #2) reviewed for pressure ulcers. The findings were:1 Review of the 2/17/25 admission MDS assessment, showed resident #1 was coded as being severely cognitively impaired and had diagnoses which included non-traumatic brain dysfunction, dementia, severe, with mood disturbance, deep vein thrombosis, diabetes mellitus, thyroid disorder, arthritis, non-Alzheimer's dementia, malnutrition, post traumatic stress disorder, anxiety, depression, disorder of bone density and structure, and other intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain. The assessment showed the resident required assistance of supervision or setup for toileting, showers, upper body dressing, lower body dressing, putting on footwear, and personal hygiene. Further, review showed the resident was at risk for pressure ulcer development, did not have any pressure ulcers, and had a pressure reducing device in bed and chair. Review of the 5/7/25 quarterly MDS assessment showed the resident was coded as being severely cognitively impaired. The assessment showed the resident was independent with eating, oral hygiene, and required supervision/setup assistance for toileting, showers, upper body dressing, lower body dressing, putting on footwear, and personal hygiene. Further review the resident was at risk for pressure ulcer development, did not have any pressure ulcers, and had a pressure reducing chair. Review of the Skin and Wound - Total Body Skin Assessments for 6/15/25 through 10/17/25 showed new wounds 0, except on 7/30/25 which showed 1 new wound. Review of the medical records showed the left heel wound was new on 7/29/25, the left dorsum wound was new on 7/29/25, and the right medial heel wound was new on 9/1/25. The following concerns were identified: a. Review of the 8/7/25 significant change MDS assessment showed the resident was coded as being severely cognitive impaired. The assessment showed the resident was totally dependent for the ADLs of eating, oral hygiene, toilet, shower, upper body dress, lower body dress, putting on footwear, and personal hygiene. Further, review showed the resident was at risk for pressure ulcer development and had one unhealed stage 3 pressure ulcer. The resident had a pressure reducing chair and bed and was receiving pressure ulcer/injury care. b. Review of the care plan showed SKIN/CONNECTIVE TISSUE: [Residents name] is at risk for skin impairment related to. [Resident name] will maintain clean and intact skin throughout review, initiated on 2/12/25 with the target date of: 12/30/25. The intervention was weekly skin checks by licensed nurse dated 2/12/25. Further review showed other interventions were added on 10/21/25 e.g. barrier cream as needed, cushion around and under boney prominences, good nutrition and hydration, pressure reducing cushion to wheelchair, needs pressure relieving device to bed. c. Review of the Skin and Wound - Total Body Skin assessment dated [DATE] showed the residents' skin turgor was poor elasticity, skin color pale, temperature was warm (normal, moisture was normal, condition was dry, new wounds was 1. Review of the nursing progress notes showed on 7/30/25 at 1:36 PM Ensure resident to wear Gripper socks in bed and at all times., and Pt [patient] is in puff boots. d. Review of Compassionate Concierge Physicians (CCP) Mobile Wound Care note dated 7/31/25 showed .New patient Eval for Stage 3 Pressure Ulcer of Left Heel .Polaris staff reporting pressure wound to left heel that started about two weeks prior. Upon examination, there are offloading booties present. Left heel wound present with bruising . Review of the 10/20/25 wound care team notes showed .wound location: left heel, left medial foot, right heel .right hip the facility to manage. Frequency was CCP to change All dressing 2 times a week (Mon/Thurs). Polaris left heel: change 5 times a week and as needed if soiled or misplaced (Sun/Tues/Wed/Fri/Sat and as needed), All other wounds change 1 time a week and as needed if soiled or misplaced (Sat and as needed). e. Observation of the resident on 10/23/25 at 12:40 PM, while CCP was finishing wound care, showed the resident was lying on his/her back, heels down on the mattress, blue boots were on the bed, a heel lift cushion was beside the bed, a ribbed mattress, and a wedge was between the resident's legs. Interview at that time with the CCP provider revealed the resident had a new pressure ulcer to the buttock stage 1. The CCP provider stated they were going to recommend an air mattress. Further, interview revealed the facility calls the agency when they want a wound check. f. Interview with the wound care nurse on 10/22/25 at 1 PM revealed she was hired on as the wound care nurse in August. She stated she was doing the best she could with the assessments; however, she continued to be assigned to the floor to work. g. Interview with a CNA on 10/22/25 during the afternoon revealed when s/he did the bed bath for the resident the day before the pressure ulcer was identified the resident's socks were not removed during the bath The CNA confirmed s/he would not have been able to tell if there were wounds to the lower extremities. 2. Review of 8/22/25 admission MDS assessment for resident #2 showed s/he was coded as being moderately cognitive impaired, The assessment showed the resident required partial/moderate assistance with eating, toileting, showers, upper body dressing, lower body dressing, and putting on footwear. The diagnoses included repeated falls, displaced fracture of upper end of left humerus, weakness, other specified disorders of bone density and structure, and diabetes mellitus. Further, review showed the resident was at risk for pressure ulcer development, had no pressure ulcers, and had a pressure reducing chair and bed. Review of the 8/17/25 care plan showed skin/connective tissue goal to maintain clean and intact skin. The interventions included weekly skin checks by a licensed nurse. The following concerns were identified: a. Review of a nursing progress notes dated 8/30/25 at 11:12 AM showed This nurse assessed residents skin and observed a sacral would (sic). Odor is present with white appearance on wound. Wound nurse notified with pictures taken on wound care phone. Review of the nursing progress note dated 8/31/25 at 10:17 AM showed .#002: Skin issue has not been evaluated. Location: Coccyx. Issue type: Pressure ulcer / injury. Wound acquired in-house. Further review of the nursing progress noted showed on 8/31/25 at 2:09 PM SBAR Summary: Vitals Signs: BP 103/60 - 8/31/2025 13:12 Position: Other , P 60 - 8/31/2025 13:12 Pulse Type: Irregular - new onset , R 20.0 - 8/31/2025 10:36, T 98.0 - 8/31/2025 10:36 Route: Forehead (non-contact), .RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: Sepsis. b. Review of the Weekly Skin assessment dated [DATE] showed the skin turgor: good, elasticity, color: normal, temperature: warm (normal), moisture: normal, condition: normal, no new wounds noted. c. Interview with the wound care nurse on 10/23/25 at 2:50 PM revealed the resident did not have a pressure ulcer upon admission.3. Review of policy Pressure Injury Prevention Guidelines hand delivered on 10/23/25 at 4:10 PM showed To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present.Preventive Skin Care: 1 . Inspect skin while providing care, paying close attention to bony prominences.

Based on medical record review, resident and staff interview, and review of concern forms, the facility failed to provide timely incontinence care to 2 of 8 sample residents (#1, #5). The findings were:1. Review of the 8/7/25 significant change assessment for resident #1 showed s/he was determined to be severely cognitively impaired and exhibited inattention and disorganized thinking on a continuous basis, and suffered from delusions. The resident was totally dependent on staff for all areas of self-care and mobility. The following concerns were identified: a. Observation on 10/23/25 at 7:58 AM showed the resident was seated at a small table in the dining room, which faced the back wall, and had a glass of water in front of him/her. At 9:28 AM the resident was removed from the table and was moved to the hallway in front of the North nurses' station where s/he sat until 10:53 AM when s/he was approached by a therapist and taken to the therapy room. The resident remained in the therapy room and was a passive participant until 11:50 AM when s/he was taken back to the dining room and placed at the same table as before. The resident was offered a glass of water at 11:53 AM in which s/he drank half. At 12:11 PM the contractual wound care nurse approached the resident at the dining room table and then transferred him/her back his/her room to provide wound care. The resident was transferred using a Hoyer lift by LPN #1 and CNA #2 to his/her bed and then exited the room for the wound care team to provide care. At 12:59 PM the wound care team exited the resident's room. At 1:50 PM RA #1 was observed bringing the resident's noon meal into the room and then left stating she needed to find a nurse or CNA to assist the resident with the meal. At 1:53 PM LPN #1 and a nursing student entered the room where incontinence care was provided (approximately 6 hours). LPN #1 confirmed the resident's brief was wet. 2. Review of the 9/16/25 quarterly MDS assessment for resident #5 showed a BIMS score was not determined; however, the staff assessment for mental status showed the resident to be independent with consistent/reasonable decision making. Further review showed the resident had an indwelling catheter and was frequently incontinent of bowel. Review of the resident's ADL care plan, last revised 9/5/25, showed the resident required a bedpan for bowel movements with the extensive assist of 2 staff members for placement. The following concerns were identified.a. Interview with the resident on 10/21/25 at 2:02 PM revealed s/he was not receiving care in a timely manner and had telephoned the facility to request help because his/her call light was not being answered. Review of a 10/20/25 concern form, provided by the resident showed the form was completed with the assistance of the business office manager (BOM). The description of the concern showed Resident had to call the facility to get assistance on the bed pan. [BOM] in the business office came to address needs. [Resident] stated [s/he] has been waiting to be put on bed pan. [S/he] stated [CNA #5] came to his/her room stated she did not have time to put resident on bedpan due to needing to complete bed baths. Call light was going off the whole-time cares were being performed and nobody covered the light. This was on for about an hour and unsure how long it was on prior. This is the second time resident had to call the facility to have [his/her] needs addressed. The first time was 10/16/25. It was also evident that pericare was not being performed. The same staff member was working from (sic) 10/20/25 and 10/16/25 (sic) was working the floor on these occasions. In addition, the concern form stated this concern had been previously voiced. b. Interview with the BOM on 10/22/25 at 1 PM confirmed the resident had phoned the facility asking for assistance. The BOM stated she was also a CNA and went to the resident's room to assist the resident with the bedpan. The BOM confirmed the resident's call light was on for approximately 1 hour while she provided care to the resident with no response from the unit staff. 2. Interview with the DON and NHA on 10/24/25 at 12:40 PM revealed they had identified the need to provide a better quality of care.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure residents were treated with dignity and respect during 4 random observations which affected residents #1 and #5. The census was 71. The findings were:1. Review of the 8/7/25 significant change MDS assessment for resident #1 showed s/he was determined to be severely cognitively impaired and exhibited inattention and disorganized thinking on a continuous basis, and suffered from delusions. The resident was totally dependent on staff for all areas of self-care and mobility. The following concerns were identified: a. Observation on 10/21/25 at 4:58 PM showed resident #1 was brought to the dining room and placed at the dining table with nothing in front of him/her. The resident was observed picking at the tablecloth. Meal service began at 5:07 PM and resident #1 was served his/her meal at 5:35 PM with assistance provided by CNA #2. CNA #2 was observed assisting resident #9 at 5:07 PM before moving to assist resident #1 at 5:35 PM. b. Observation on 10/22/25 at 8:36 AM showed the resident was brought to the dining room for the morning meal at 8:36 AM. At 8:53 AM the resident was offered a beverage; however, was not served his/her meal until 8:58 AM. c. Observation on 10/23/25 at 7:58 AM showed the resident was seated at a small table in the dining room, which faced the back wall, and had a glass of water in front of him/her. The resident's back was turned to the dining room so s/he was looking at the wall. At 8:38 AM the resident was observed to independently drink an entire glass of water, move the tablecloth around, and pick-up and examine a tissue box. At 8:48 AM the resident was served breakfast by a nursing student. The nursing student sat with the resident and attempted to assist him/her with the meal. The nursing student asked the resident if s/he would like something to drink; however, the nursing student did not provide a beverage. At 8:56 AM the resident began to eat with the assistance of the nursing student. At 9:15 AM the resident attempted to drink from the empty water glass; more water was provided. At this time the resident was observed to use a spoon with his/her left hand and was able to bring the food to his/her mouth. The nursing student removed the utensil from the resident's hand and began to feed the resident herself. At 9:28 AM the resident was removed from the table and was moved to the hallway in front of the North nurses' station where s/he sat until 10:53 AM when s/he was approached by a therapist and taken to the therapy room. From 9 AM until 9:28 AM the only facility staff member in the dining room was RA #2; no staff members trained to assist residents with eating were present to supervise the nursing student. d. Interview with restorative aide #1 on 10/22/25 at 1:30 PM revealed the resident required assistance with eating and was fed last so his/her food was hot. e. Interview with CNA #3 on 10/22/25 at 2:30 PM revealed only one person was assigned to the dining room during meal service and they were expected to do everything. f. Interview with CNA #2 on 10/22/25 at 4 PM revealed the dining room was only staffed with 1 person when ideally 3 people were needed. In addition, the CNA stated 2 residents required assistance with eating; one resident would be assisted while the other one had to wait. g. Interview with the DON and NHA on 10/24/25 at 12:43 PM revealed the residents, which required assistance with eating, should sit at the same table and be served at the same time. 2. Review of the 9/16/25 quarterly MDS assessment for resident #5 showed a BIMS score was not determined; however, the staff assessment for mental status showed the resident to be independent with consistent/reasonable decision making. Review of the resident's care plan, initiated on 6/25/24, showed HOARDING: [resident] has a large collection of items, posing risk for falls Interventions included to Encourage [resident] to frequently declutter, Respect [resident's] right to collect items that do not pose risk, Speak respectfully and kindly when discussing [resident's] room, and Staff to help [resident] feel safe and secure. The following concerns were identified:a. Observation and interview with resident #5 on 10/21/25 at 2:02 PM revealed s/he was upset because the [NHA] had someone come into [his/her] room and go through [his/her] things while s/he was in the hospital. The resident stated the NHA had directed the social worker to inform him/her that his/her room was a fire hazard and needed to be cleaned up. Observation of the resident's room showed the area was cluttered and unorganized and the dresser drawers appeared to be broken. b. Review of a social services note, dated 10/6/25, showed we discussed organizing [the resident's] room, [s/he] does not have family to assist in this as all family lives far away. [The resident] will need bins or bookshelves in order to complete this. [S/he] will look in to getting these so staff can help assist [him/her] to organize [his/her] room.c. Interview with the social services director on 10/22/25 at 9:59 AM revealed the NHA had sent her an email asking her to approach 7 different residents to inform them their rooms needed to be cleaned up. The social worker revealed she had spoken with resident #5 and offered to assist her with cleaning up her room since she did not have any family to help her.d. Review of nursing notes showed the resident was admitted to the hospital on [DATE] and was readmitted to the facility on [DATE]. e. Interview with the EVS manager on 10/24/25 at 9:38 AM revealed she was instructed by the NHA to enter resident #5's room while the resident was in the hospital to retrieve any property which belonged to the facility. The EVS manager confirmed she had entered the resident's room without the resident's consent and had found and removed items such as linens and clothing protectors which belonged to the facility.f. Interview with the NHA on 10/24/25 at 12:43 PM confirmed she had authorized the EVS manager to enter the resident's room to remove any items which belonged to the facility.

Based on medical record review, staff interview, medication variance report review, and policy and procedure review, the facility failed to ensure residents were free of significant medication errors for 1 of 7 sample residents (#2) reviewed for medication errors. This failure resulted in actual harm to resident #2 who was hospitalized in the intensive care unit. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and diagnoses which included renal insufficiency, renal failure, or end0stage renal disease, diabetes mellitus, depression, other toxic encephalopathy, chronic pain syndrome, acquired absence of right leg below the knee, idiopathic gout, and paraneoplastic neuromyopathy and neuropathy. Further review showed the resident experienced pain frequently and reported a pain score of 8 out 10. Review of the physician orders showed the resident received fentanyl (opioid) transdermal patch 72-hour 12 mcg (microgram)/hr (hour) once every 3 days for pain ordered on 12/24/25 and morphine sulfate (opioid) ER (extended release) 30 mg (milligram) by mouth two times per day for pain ordered on 1/16/25. Review of the resident's care plan, initiated on 4/14/21 showed [Resident name] has an ADL self-care performance deficit and needs assistance with self-care tasks to include bathing, transfers, personal hygiene tasks, bed mobility, dressing, eating, toilet use, and locomotion related to impaired mobility, pain, activity intolerance. The following concerns were identified:a. Review of the medication administration record (MAR) for January 2025 showed the resident received the fentanyl patch on 1/18/25 and received the morphine sulfate in the evening on 1/16/25 then in the morning and evening on 1/17/25, 1/18/25, and 1/19/25. b. Review of a Medication Variance Report dated 1/18/25 and timed 12:45 PM showed due to application of new fentanyl patch and old fentanyl not removed. Further review showed the outcome was a change in the resident's level of consciousness and hospitalization.c. Interview with RN #2 on 8/7/25 at 9:18 AM revealed she was on duty for day shift on 1/18/25 and she did not remove the old fentanyl patch when she applied the new one because she did not see it. Further interview revealed she did not document that she had not removed the old patch. d. Interview with RN #3 on 8/7/25 at 8:36 AM revealed she was the nurse who performed the assessment of the resident prior to the hospital transfer. She revealed the resident had a decrease in his/her level of consciousness on 1/20/25. e. Review of the hospital discharge documentation provided by the facility administrator on 8/7/25 at 10:50 AM showed the resident admitted to hospital on [DATE] and returned to the facility on 1/24/25. The documentation showed Discharge Diagnosis: Principal Problem (Resolved): Opiate overdose, accidental or unintentional. Further review showed the resident was admitted to intensive care unit secondary to narcotic overdose and was started on Narcan (opioid antagonist) via intravenous therapy. 2. Review of the policy titled Controlled Substances provided by the DON on 8/6/25 at 12:29 PM showed .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II - V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).

Based on observation, staff interview, and review of policy and procedures, the facility failed to ensure transmission-based precautions (TBP) were followed during 1 of 3 observations of hydration pass. This failure resulted in an unacceptable risk to resident health and a determination of immediate jeopardy. In addition, the facility failed to ensure acceptable infection control practices were followed during 5 random observations of hand hygiene and personal protective equipment (PPE) use, 2 random observations of treatments, and 1 random observation of equipment disinfection. The census was 83. The findings were: 1. Continuous observation on 1/3/22 beginning at 12:47 PM showed RA (resident aide) #1 brought the mobile ice cart onto the northeast hall, and parked it across from room [ROOM NUMBER]. The room had signage displaying Enhanced Airborne Precautions hanging on the door, indicating gown, gloves, N95 mask, and eye protection were required, and a small cabinet of PPE supplies next to the door. Observation showed the RA wearing an N95 mask, as well as protective eyewear. She then donned an isolation gown, applied gloves, and entered room [ROOM NUMBER]. The following concerns were identified: a. On 1/3/22 at 12:47 PM the RA exited the room carrying the resident's plastic water mug, still wearing all of the PPE. She crossed the hall, set the mug on the mobile ice cart, and returned to room [ROOM NUMBER] to doff the gown and gloves, disposing of them within the room. She then exited the room, and returned to the mobile ice cart. The N95 mask was not changed, and no hand hygiene was performed after removal of the gown and gloves. She then opened the ice chest, picked up the ice scoop and resident's water mug. She held the mug over the ice chest, and began scooping ice into the mug. The ice scoop was observed making contact with the inside of the water mug. After the last scoop of ice, the cup appeared too full and had a large chunk of ice on top. The RA used the scoop to remove the ice from the mug, and scraped the contaminated ice back into the ice chest. She re-entered room [ROOM NUMBER] without performing hand hygiene or donning a gown or gloves, delivered the mug, and exited the room. No hand hygiene was performed upon exit. The aide then left the unit. Continuous observation showed although the RA left the unit, the mobile ice cart remained in the hallway. b. At 1:01 PM RA #1 returned to the unit. She entered room [ROOM NUMBER] without performing hand hygiene, and exited seconds later with the resident's plastic water mug, with no hand hygiene performed upon exit. She picked up the ice scoop and began filling the mug. The scoop was observed making contact with the inside of the resident's mug. After filling the mug, she then re-entered room [ROOM NUMBER], delivered the mug, and exited, with no hand hygiene performed upon entry or exit. She then moved the mobile ice cart outside of room [ROOM NUMBER], retrieved the resident's mug, removed the lid to the mug, and set it on the ice cart. She then filled the mug with ice, with the ice scoop making contact with the inside of the resident's mug. She re-applied the lid and returned the mug to room [ROOM NUMBER], with no hand hygiene upon entry or exit. The same observations were made while she moved down the hall to supply ice to rooms [ROOM NUMBERS], contaminating the ice scoop, mugs, and ice cart, with no hand hygiene observed during the process. c. On 1/3/22 at 1:16 PM, the surveyor intervened to stop the hydration pass. Interview with RA #1 at that time revealed she was aware full PPE was required while in rooms on contact precautions, and that she was required to perform hand hygiene when entering and exiting all rooms. She stated she was a new employee and had started about a week ago. She further confirmed the observed process of passing the ice using the ice chest, scoop, and resident mugs was her normal routine. d. Interview with the IP on 1/6/22 at 10:28 AM revealed staff were expected to change or apply a new N95 mask upon exiting rooms under Enhanced Airborne Precautions. Further interview revealed she expected staff to use a clean mug for passing ice, but if it was not possible, use methods to prevent the mug from contaminating the ice, scoop, and mobile ice cart .since everyone uses it, and more than one resident gets ice out of it. She also confirmed hand hygiene was expected to be performed between resident contact and contact with resident's items, in and out of every resident room each time, before PPE application, and after PPE removal. e. Interview with the IP on 1/6/22 at 2:22 PM revealed she does not always have enough time for infection control tasks, and sometimes only one day a week was dedicated to infection control tasks, as she was pulled to the units to cover medication passes to residents and additional tasks. Review of the surveillance audits at that time showed hand washing audits were performed on 9/13/21 and 10/4/21, a PPE audit was performed on 7/12/21, and mechanical lift cleaning audits were performed on 9/11/21, 9/12/21, 9/13/21, 9/15/21, and 9/17/21. 2. Review of facility policy Handwashing/Hand Hygiene, last revised August 2015, showed . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 3. Review of facility policy Isolation - Categories of Transmission-Based Precautions, last revised October 2018, showed Contact Precautions . 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room .b. Gloves will be removed and hand hygiene performed before leaving the room . 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. On 1/3/22 at 5:17 PM the administrator was informed of an immediate jeopardy situation in the area of infection control related to a failure to implement safe infection control practices regarding hand hygiene, donning PPE, and handling of a ice scoop while providing hydration to residents. The facility submitted an action plan which included the following immediate changes: a. All coolers, scoops, and resident water containers were pulled from the Units and Resident rooms. They were taken to the Dishwashing Room and washed/sanitized in dish machine. b. The identified Ice Machine has been emptied and placed out of service until vendor can come here to clean/sanitize the machine. The sanitized coolers have been filled with ice from the kitchen ice machine and water passed to Residents in sanitized containers. c. The facility has reviewed the Policies related to the Passing of Ice Water to prevent cross-contamination to Residents. The Facility Administrator, Director of Nursing, and Director of Clinical Operations reviewed the Hand Hygiene Policy and developed a return demonstration for the staff to complete under observation. d. The Resident Assistant who made the error was educated by the DON/designee on 1/3/2022, on the Facility policy of Passing Ice Water to Residents without causing cross-contamination and when to wash and/or sanitize her hands per guidelines. She was also asked to complete a return demonstration on hand hygiene. In addition, the RA [resident assistant] has been educated on Isolation precautions and the donning of appropriate PPE. e. All staff are being educated on appropriately Passing Ice and Water to prevent cross-contamination to Residents as well as completing return demonstration. Staff are being educated on what transmission-based precautions means and the importance of donning all appropriate PPE. All staff who have not been able to come back to receive education this night will be educated prior to working their next scheduled shift by the Staff Development Coordinator/designee. f. Newly hired staff will be educated on Transmission based Precautions, donning of proper PPE when entering a resident room, Facility policy on Hand Hygiene, the Passing of Ice and Water to Residents and will also complete a return demonstration of hand hygiene. g. DON or designee will do random monitoring of hand hygiene and passing of ice and water to residents to ensure there is no cross contamination. The action plan was accepted on 1/4/22 at 9 AM. The implementation of the action plan was verified and immediacy was removed on 1/4/22 at 5:06 PM; however, deficient practice remained at a scope and severity level of F. Concerns related to hand hygiene and use of PPE: 1. Observation on 1/5/22 at 9:56 AM showed room [ROOM NUMBER] was posted as an airborne precaution room, and the required PPE listed was: gloves, gown, N95 mask, and goggles. In addition, there was a PPE supply cart located outside the entrance of the room. The following concerns were identified: a. On 1/5/22 at 9:56 AM LPN #2 was observed exiting the posted transmission based precaution (TBP) room without wearing any goggles or eye protection. Interview at that time with the LPN confirmed she had not worn any eye protection when in the room, she stated there were none available in the PPE cart. Observation at the time of the PPE cart next to the room showed it was stocked with the exception of eye protection. b. Interview on 1/6/22 at 10:18 AM with the IP verified the nurse should have been wearing eye protection when in the TBP room, and staff knew where to find additional supplies including eye protection 2. Observation on 1/5/22 at 9:59 AM showed RN #1 and social worker #2 were working directly with residents in the therapy department and in the hallway. These staff members wore N95 masks and their personal prescription eyeglasses without additional eye shield or goggles. Interview at that time with social worker #2 revealed they were told this was okay and extra eye protection was not needed. Interview on 1/6/22 at 10:18 AM with the infection preventionist confirmed eye protection was required when working directly with the residents. Prescription eyeglasses need to be covered with a shield or goggles. 3. Observation on 1/3/22 at 11:03 AM showed CNA #2 donned gloves, and performed perineal care for resident #32. The following concerns were identified: a. After providing perineal care, the CNA continued to wear the contaminated gloves, and touched the resident's brief and clothing, and the sling used for the mechanical lift transfer. The CNA removed the glove on her left hand, and transferred the resident to the wheelchair using the mechanical lift. The CNA then removed the glove on her right hand and changed the resident's shirt. The CNA took the plastic bag with garbage out of the room to the dirty utility closet. Continued observation showed the CNA did not perform hand hygiene. b. Interview with the CNA at the end of the observation revealed she should have removed her gloves after completing perineal care. She further stated she did not wash her hands after removing the gloves because she did not feel they were dirty. c. Interview on 1/6/22 at 10:19 AM with the IP revealed the expectation after performing perineal care was to remove the gloves, perform hand hygiene, then touch clean surfaces. She further stated staff were to perform hand hygiene after completing resident care. 4. Observation on 1/3/22 at 12:57 PM showed CNA #4 exited room [ROOM NUMBER], which displayed signage showing Enhanced Airborne Precautions, with no hand hygiene performed upon exit. She had doffed her PPE while in the resident's room, and upon exiting, had a piece of the disposable gown stuck around her waist. The piece then fell to the floor as she walked down the hall, and after noticing, she picked the piece up, wadded it into a ball, and carried it down the hall, throwing it away in a trash can inside the unit nursing station. No hand hygiene was observed, and she left the unit. 5. Observation on 1/5/22 at 9:48 AM showed RN #3 exit room [ROOM NUMBER], which displayed signage showing Enhanced Airborne Precautions, The following concerns were identified: a. As the RN left the room, she continued to wear the PPE and carried un-bagged meal trash into the hallway. She set the trash on top of the PPE supply cart outside of the room, doffed her gown and gloves, wadded them up into a ball. She did not change her N95 mask, bag or contain the trash, or perform hand hygiene upon exiting room [ROOM NUMBER]. She then gathered up the ball of used PPE and trash against her body, and walked down the hall to the soiled utility room. She pressed the pass code to enter the soiled utility room, entered, disposed of the used PPE and trash, and exited the soiled utility room. b. Interview with RN #3 on 1/5/22 at 9:57 AM revealed she had forgotten to remove her PPE when leaving the room. Further, she stated it was her usual practice to take used PPE and trash from the isolation rooms to the soiled utility room because there wasn't a trash can in the room, or it was always full. 6. Interview with the IP on 1/6/22 at 10:28 AM revealed hand hygiene was expected to be performed between resident contact and contact with resident's items, in and out of every resident room each time, before PPE application, and after PPE removal. She stated she expected trash and doffed PPE to remain within the rooms on precautions; if unavoidable, items should be bagged and contained before leaving the isolation rooms. 7. Review of facility policy Standard Precautions, last revised October 2018, showed Standard precautions include the following practices: 1. Hand hygiene . b. Hand hygiene is performed with ABHR [alcohol-based hand rub] or soap and water: . (3) after contact with items in the resident's room; and (4) after removing PPE. 8. Review of facility policy Handwashing/Hand Hygiene, last revised August 2015, showed . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Concerns related to cross-contamination during treatments: 1. Observation on 1/5/22 at 9:53 AM showed LPN #3 brought wound supplies into the room to provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] a. The LPN placed gauze pads, an elastic bandage wrap, two tubes of multi-dose squeezable medicated ointments, and a spray bottle of cleansing solution, all on top of a magazine located on the resident's bedside tray table; The LPN did not ensure the table area was clean prior to placing the supplies. The LPN then performed hand hygiene and donned gloves, and removed the resident's old dressing from his/her right shin area placing it in the trash. Without changing gloves, she cleansed the wound and applied the treatment. The nurse removed her gloves and left the room with the cleansing spray bottle, and the two multi-dose tubes of medication. In the hallway, she then placed the items under her arm while performing hand hygiene. b. Continued observation showed the LPN removed the items from her under her arm, and placed them in the wound care cart without disinfecting them. Interview with the nurse at that time confirmed no barrier was on the bedside tray table, and the table had not been disinfected. Further, she confirmed the two tubes of medication had not been disinfected before placing them back in the wound care cart. c. Interview with the IP on 1/6/22 at 10:10 AM revealed her expectation was for the the medications to be put into cups and be disposed of after use, not to take multi-use tubes into a resident's room. Further, she stated there should be a barrier to ensure cleanliness of supplies. 2. Observation on 1/4/22 at 4:40 PM showed RN #2 exit room [ROOM NUMBER], which displayed signage showing Enhanced Airborne Precautions. She had doffed her PPE while in the room. The following concerns were identified: a. As the nurse exited she was observed carrying a squeezable tube of medication with bare hands; she did not change her N95 mask upon exit. She placed the tube on top of the medication cart, performed hand hygiene, and turned to talk to other staff members in the hallway. Next, she picked up the tube of medication, placed it in her pocket, and continued to talk to the other staff members. She then turned back to the medication cart, removed her keys that were located in the same pocket as the tube, unlocked the medication cart, and removed the tube from her pocket, placing it in the drawer of the medication cart. No hand hygiene was observed after the medication was placed in the cart. b. Interview with RN #2 on 1/4/22 at 5:17 PM confirmed there were no decontamination wipes inside the room or in the PPE supply drawers outside of the isolation rooms to wipe items down. However, it was observed at that time a container of bleach wipes was available on top of the medication cart. c. Interview with the IP on 1/6/22 at 10:28 AM revealed the expectation for staff regarding the squeezable tube of medication was to . dispense the medication into a cup and carry that into the room, not take the whole tube in there. She verified the nurse should have taken only enough medication in for the application, and then discarded the cup in the room. She also confirmed the nurse should have decontaminated the tube upon exit, and avoided placing contaminated items into her pockets. She confirmed hand hygiene was expected to be performed between resident contact and contact with resident's items, in and out of every resident room each time, before PPE application, and after PPE removal. Concerns regarding cleaning/disinfection of resident care equipment: 1. Observation on 1/4/22 at 3:01 PM showed CNA #3 coming out of the TBP room [ROOM NUMBER] with a sit-to-stand lift. The CNA appropriately doffed her PPE and used hand sanitizer. Realizing there were no sanitizing wipes available in the isolation supply cart, she left to locate some. The following concerns were identified: a. CNA #3 returned with a purple lid container of Super- Sani-Cloth. She used 1 wipe to disinfect the entire lift starting at the base and working her way to the top. As the CNA conducted the process, the wipe was wadded up and there was no visible wetness to the equipment. b. Interview with CNA #3 on 1/4/22 at 3:08 PM revealed she knew one type of wipe used by the facility had a 3 minute wet contact time. However, she was unsure of the contact time required for the wipe she used, and she had not checked to see if the lift remained wet for any amount of time. c. Interview with the IP and CNA #3 on 1/4/22 at 3:26 PM revealed they had discussed the wipes used to sanitize the lift, and the purple lid container required a 2 minute wet contact time. The lift was going to be re-wiped to ensure the proper contact time was achieved. The IP confirmed the wipes needed to be used in a way to ensure the item/lift was sufficiently wet to ensure the required contact time 2. Review of facility policy Cleaning and Disinfection of Environmental Surfaces, last revised June 2009, showed . 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.

Based on observation, review of infection control program data, medical record review, and staff and resident interview, the facility failed to ensure elements of the infection prevention program were effective in preventing spread of COVID-19. These elements included adherence to transmission based precautions, proper cleaning of equipment, and proper hand hygiene. This pattern of infection control breaches contributed to the continuation of the COVID-19 outbreak at the facility, resulting in harm to residents as COVID-19 infections continued to rise. The facility census was 88 (12/3/20). The findings were: Review of the infection control data provided on 12/3/20 by the infection preventionist (IP) showed there were 51 residents in the facility who were on droplet precautions related to positive results of COVID-19. Interview with the infection preventionist on 12/3/20 at 11:38 AM revealed due to the number of COVID-19 Positive cases all residents were currently being isolated in their rooms both positive and negative for COVID-19. Testing was being continued for all residents and staff as required. The expectation was for staff to wear appropriate personal protective equipment (PPE) when entering rooms for all residents who were on droplet precautions and to ensure staff did not cross contaminate between positive resident interactions and interactions for residents who were known to be negative of COVID-19. The PPE expected to be worn include: N95 mask, eye protection, gown and gloves. Review of a facility map provided by the IP on 12/3/20 showed 11 rooms scattered throughout the facility that were occupied by residents who were negative of COVID-19. The following concerns were identified: 1. Observation on 12/8/20 at 6:31 AM showed RN #3 performing a medication pass for room [ROOM NUMBER], which was on droplet precautions. She was observed standing inside the room, wearing a gown, N95 mask, and eye protection, but no gloves. Her cart was parked in front of the doorway, across its entry. After collecting the medications for one resident (#27), she donned gloves, and assisted the resident in moving her tray table and a positioning adjustment. The resident took the medications, and the nurse came back to the med cart. She did not remove her contaminated gloves, and touched the surface and drawers of the med cart, and the keyboard and mouse of the computer. She then removed her gloves, did not perform hand hygiene, then touched the keyboard and mouse again. She then touched the med cart drawer handles, and all the medications of the other resident in the room. Next, she donned gloves, and took the second resident (#28) his/her medications, along with a forearm blood pressure cuff and finger pulse oximeter. After she applied both devices to the resident, she brought them back and placed them on top of the cart, not cleansing either device after use. The nurse was then observed at 6:51 AM entering room [ROOM NUMBER], where both residents were negative for COVID and the room was not on droplet precautions. She was seen applying the contaminated finger pulse oximeter to resident #2 in this room. 2. Observation on 12/3/20 at 10:34 AM showed physical therapist (PT) #1 was observed leaving the COVID unit with a bag of trash and two bags of soiled linens. She was not wearing gloves. She then touched the keypad and door handle to enter the soiled utility room, and exited seconds later. No hand hygiene was observed. She then left the unit. 3. Observation on 12/3/20 at 10:40 AM showed occupational therapy assistant (OTA) #1 was observed coming out of room [ROOM NUMBER], which was a room on droplet precautions, wearing full PPE (face shield, N95 mask, gown, and gloves). She looked down the hall to the left and the right, came out of the room without removing any of her contaminated PPE, and began pulling open all the drawers to the supply cart outside the room in the hallway using gloved hands that had been contaminated from being inside the room on droplet precautions. 4. Observation on 12/3/20 at 12:14 PM showed RN #1 pulling a new packing of sterile gauze out of the medication cart. She opened the package, removed the top few pieces, and plunged her bare hand into the trash bin on the side of the cart to simultaneously smash the trash down and discard the pieces of gauze. No hand hygiene was performed after, and the nurse then began applying her PPE with the contaminated hands. 5. Observation on 12/8/20 at 5:33 AM showed CNA #1 exiting room [ROOM NUMBER], which was on droplet precautions, wearing full PPE. She was carrying bags of trash, and left the room without doffing any PPE. She then walked to the soiled utility room, touching the keypad and door handle with the contaminated gloves. She exited the room seconds later, still in all of her PPE. She then walked back to room [ROOM NUMBER], removed her PPE, did not perform hand hygiene, and then grabbed the ice cart with soiled hands to take with her down the hall to the next resident. 6. Observation on 12/8/20 at 5:46 AM showed CNA #1 carrying trash bags and a resident's water pitcher to the soiled utility room without gloves. She entered the soiled utility room with all items, and exited seconds later, only carrying the water pitcher. No hand hygiene was observed after exiting the soiled utility. She then walked down the hall, opened the doors to the next hallway with contaminated hands, and placed the contaminated water pitcher on a cart sitting outside the door to the kitchen. 7. Observation on 12/8/20 at 5:53 AM showed CNA #1 exiting room [ROOM NUMBER], properly doffing her PPE, but not performing hand hygiene after its removal. She then touched the keypad and door handle to the shower room, entered, and exited seconds later. She then walked to the nurse's station, and was observed touching multiple items in and around the station, including the med cart, phone, and the computer keyboard and mouse. 8. Observation on 12/8/20 at 6:16 AM showed CNA #1 and CNA #2 both entered droplet precaution room [ROOM NUMBER] after donning full PPE. A few minutes later CNA #1 was seen exiting the room with bags of trash and soiled linen. She did not doff the PPE, and wore it down the hall to the soiled utility room, touching the door handle and keypad. She exited the soiled utility room seconds later not wearing PPE, and no hand hygiene was observed. 9. Observation on 12/8/20 at 6:20 AM showed CNA #1 and CNA #3 entered the soiled utility room, and came out pushing wheeled trash cans full of garbage. Neither were wearing gloves. They pushed the containers down the hall, and out a door on the west side of the building to the outside dumpster. Upon re-entering the building, no hand hygiene was observed. CNA #3 touched the keypad and door handle to enter the soiled utility room, and both entered to return the trash cans. Upon exiting the soiled utility room, neither staff member was observed performing hand hygiene. CNA #3 then headed down the hall to the clean utility cart, touching the cart, packages of briefs, and clean towels and hospital gowns. 10. Observation on 12/8/20 at 5:20 AM showed rooms 101, 102, 104-107, 113, 120, 130-132, and 134-136 all had their doors open. All of these rooms were on droplet precautions. 11. Observation on 12/8/20 at 7:08 AM showed rooms 101, 102, 104, 105, 113, 120, 121, 124, 125, and 143 were all on droplet precautions, and their doors were open at this time. 12. Observation on 12/8/20 at 9:52 AM showed rooms 101, 105, 113, 120, 124, 125, 131, 132, 135, 136, 144, and 152 were all on droplet precautions, and their doors were open at this time. 13. Observation on 12/8/20 at 9:56 AM showed resident #26 was out wandering the hallway. He/she was wearing a visibly used N95 mask, which also had a hole in it. It was later confirmed that the resident resided in room [ROOM NUMBER], a room on droplet precautions for COVID positive residents. 14. Observation on 12/8/20 at 9:57 AM showed the activity director was exiting room [ROOM NUMBER], which was on droplet precautions. She had a cart full of activities and reading materials she was handling and taking around to the residents. She was wearing full PPE, but did not doff any of the PPE upon exiting room [ROOM NUMBER]. She then used hand sanitizer on the outside of the gloves. Next, she headed down the hall wearing all of her contaminated PPE, and entered room [ROOM NUMBER], which was also on droplet precautions. When asked about this practice, she stated . I just go to all the negative rooms first, and then do all the positives . 15. Observation on 12/8/20 at 6:39 AM showed one of the residents of room [ROOM NUMBER] was heard coughing heavily. The cough sounded very wet and forceful. Observation showed on approach to the room, the room was on droplet precautions and the door was about 1/3 of the way open. 16. Interview with the Infection Preventionist (IP) on 12/3/20 at 4:10 PM revealed the expectation was for staff to apply full PPE to enter all rooms on droplet precautions. She stated it was facility policy to perform hand hygiene after handling linens and trash. She further stated it was expected that every staff member don and doff PPE for every entry and exit of rooms on precautions, and it was not advised to use hand sanitizer to clean gloved hands. 17. Interview with the IP on 12/8/20 at 11:43 AM revealed the expectation was to . change gloves between contact with every resident, positive or not . and to . remove all PPE when exiting a droplet room . She also stated she expected all rooms on droplet precautions to keep their doors closed . as much as possible . She expected all staff to perform hand hygiene between glove donning and doffing, as well as after doffing gloves .especially after handling things like soiled linens and trash. It was also her expectation for staff to clean all equipment after use and between each resident. 18. Review of the updated map provided by the IP on 12/9/20 showed 6 residents (#1, #21, #22, #23, #24, #25) in 4 of the 11 negative rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) had become positive.

Based on observation, staff interview, wound clinic staff interview, and medical record review, the facility failed to ensure residents were free from significant medications errors for 1 of 3 sample residents (#97) reviewed. This failure resulted in harm to resident #97, who experienced a significant decline in wound status requiring admission to the hospital. The findings were: 1. Review of the medical record showed resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had scheduled wound care appointments outside of the facility 1 to 2 times per week. The following concerns were identified: a. Review of a physician order [REDACTED]. ((physician's name) will determine stop date in clinic tomorrow) Dx: heel wound infection, bilateral. Review of the March 2020 MAR indicated [REDACTED]. (Physician's name) will determine stop time. every day shift every Tue, Thu, Sat Send with patient to [MEDICAL TREATMENT]. b. Review of a nurse's note dated 3/10/20 and timed 5:48 PM showed Resident missed 4 doses of [MEDICATION NAME]. Review of the March 2020 MAR indicated [REDACTED]. The next dose was to be administered 3/7/20; this dose was documented as not given, with a reason of Vitals outside admin parameter. No supporting documentation was identified to justify the failure to administer the medication. The third dose was scheduled to be administered 3/10/20; this dose was documented as not given because the resident was hospitalized . c. Interview with the DON on 3/13/20 at 1:25 PM revealed the facility only kept a few over-the-counter medications on hand for the residents if they needed them. Otherwise, a pharmacy was contracted to supply the correct medications after the facility called or faxed the orders in. The facility was unable to provide confirmation documentation that the pharmacy had been notified or provided the order for the [MEDICATION NAME]. d. Review of a nurse's note dated 3/10/20 showed the resident was admitted to the hospital for .open wounds to the bilateral feet. e. Interview with the DON and the RN district representative at 2:16 PM on 3/13/20 revealed the facility's expectation for nurses when receiving new orders was to verify the order, place the order into the electronic health record correctly, and then fax the order to the pharmacy. The DON stated she was unsure why one dose of [MEDICATION NAME] was documented as being administered. She further revealed the facility did not have the medication on hand because it was never ordered from the pharmacy. f. Interview with wound care physician and the wound care clinic RN revealed they struggled with the facility and their nurses with follow-through and implementation of the orders we send them on a regular basis. The physician revealed during the previous appointment on 3/3/20, the resident's wounds had gotten considerably worse and looked infected, and that is why I consulted (consulting physician's name). She also stated the consulting physician ordered the resident to be placed on the [MEDICATION NAME], and for the antibiotic to be administered during the resident's [MEDICAL TREATMENT] appointments. The wound care physician stated that with the wound care she had performed, and with the additional antibiotics on board, the resident should have been doing much better; however, during the most recent appointment on 3/10/20, the resident's wounds had progressed .so bad that we had to keep (resident's name) . and the resident was directly admitted to the hospital. In addition, she stated the resident was scheduled for surgical debridement of both heels on 3/16/20.

Based on medical record review, staff interview, PACE provider interview, review of PACE provider notes, review of the State Survey Agency incident reporting database, and quality assurance information review, the facility failed to ensure pressure wounds were effectively assessed, monitored and treated for [REDACTED].#3). This failure resulted in actual harm to resident #3 who had wound deterioration related to lack of treatment provided by the facility. Corrective measures were implemented by the facility prior to the survey, and compliance was determined to be met on 5/12/19. The findings were: 1. Review of the 4/19/19 admission orders [REDACTED]. The resident had [DIAGNOSES REDACTED]. The resident's usual care was provided by a PACE organization, and the resident usually spent Monday to Friday at the organization's day facility. Review of the Nursing Admission Data Collection form dated 4/19/19 at 3:40 PM showed No the resident did not have any skin issues, and the resident was independent with mobility and walking. Review of the 4/19/19 admission care plan showed the resident wandered and used a wander alert device. Wounds and pressure ulcers were not identified on the care plan. Under the category Dressing/Splint Care the care plan showed the resident preferred to wear non-slip gripper socks. Review of the Participant Transfer Form dated 4/19/19 showed there was a wound on the resident's right foot, which was being monitored by the staff at the PACE organization. Additionally, the resident was a known wanderer and flight risk. Review of the admission orders [REDACTED]. Monitor for change, care at PACE daily. Interview on 7/30/19 at 5:22 PM with PACE RN #1 revealed the nursing facility to which the resident was admitted had been on quarantine, and the resident did not attend the PACE day program after s/he was admitted to the nursing facility. Further, the PACE RN did not see the resident at the nursing facility, however, there had been telephone communication between the facility and PACE. Review of the admission MDS assessment with an assessment reference date of 4/26/19 showed the resident had 2 stage 3 pressure ulcers and signs of infection of the foot. Review of the PACE wound care log showed the right foot pad wound had made progress since 3/6/19. The 3/25/19 entry showed wound- no drainage opening closed redressed with 2 x 2 (spouse) still dressing. No other foot wounds were noted in the PACE documentation. Further, review of the PACE progress note dated 3/25/19 at 12:45 PM showed the resident's right foot was looking good had no drainage and a dremel tool was used to grind off the callus a little. The following concerns were identified: a. Review of the nursing facility head-to-toe skin check with an effective date and time of 4/23/19 at 1:08 AM (4 days after admission) showed existing pressure ulcer. The wounds were described as pressure ulcer on plantar surface of L (left) foot, scabs to L (left) toe, scabs to dorsal surface of two R (right) toes .admitted with all sores. The wounds on the right toes were identified as stage 2 pressure ulcers. There were no measurements of any of these wounds included on this skin assessment. b. Review of the medical record showed there were no pressure wound condition reports; however, there were 2 weekly non-pressure condition reports dated 4/23/19 that showed the right and left toe wounds were identified as abrasions with onset dates of 4/22/19. c. Review of the Situation Background Assessment Recommendation (SBAR) form dated 4/23/19 at 10 PM showed RN #3 notified the physician and the PACE program RN related to wounds to bilateral feet, plantar and dorsal aspects bilaterally that started on 4/23/19. The PACE program RN gave an .OK to cover wounds with [MEDICATION NAME] and [MEDICATION NAME] (sic) until PACE was able to come see (the resident) in the a.m. d. Review of the (MONTH) 2019 TAR showed an order dated 4/23/19 at 5:53 PM to Cover wounds on bilateral feet with [MEDICATION NAME] and [MEDICATION NAME] (sic) overnight one time only related to UNSPECIFIED OPEN WOUND, RIGHT FOOT. Continued review of the TAR showed no documentation the dressing was applied. e. Review of the physician office visit note dated 4/26/19 at 1:45 PM showed the resident's wounds were debrided. The resident was .Confused; decreased sensation in both feet . 3 cm diameter deep wound with purulent discharge R (right) plantar foot region; more superficial 3 cm wound L (left) plantar foot region. Superficial dried ulcers on dorsum of bilat (bilateral) toes. Assessment: 1. Open wound of right foot, initial encounter. Deep with purulent discharge. Superficial and deep cultures taken. Sharply debrided. Plan to pack and then dress with wet to dry dressing daily . 2. Open wound of left foot, initial encounter. More superficial than above, sharply debrided. Plan for wet to dry dressing daily .Plan: As above. 14 days of Keflex 500 milligram (mg) TID (3 times a day) ordered. F/u (follow up) cultures. f. Review of the Telephone Encounter dated 4/26/19 at 5 PM showed PACE program RN #4 called the nursing facility and provided a verbal order for wound care for bilateral foot wounds. The dressings were to be changed daily, and the pharmacy would be delivering Keflex (an antibiotic) directly to the facility. g. Review of the progress note dated 4/27/19 at 6:29 AM showed New wound care orders . Pack right foot wound daily and apply wet to dry dressing daily. Dress left foot with wet to dry daily. Start Keflex 500 mg three times a day for 14 days. h. Review of the 4/29/19 timed at 2:17 PM progress note showed the PACE program nurse called to inform the facility a different antibiotic was being ordered for the resident. The Keflex was changed to Bactrim related to [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and [DIAGNOSES REDACTED] pneumoniae in the wound. i. Review of the (MONTH) 2019 TAR showed on 4/30/19 at 4:39 PM (4 days after the verbal order was provided) the order for wound care to the left foot was added to the record. However, the TAR failed to show documentation the dressing was applied on that day. Further review of the (MONTH) 2019 TAR filed to show the wound care orders for the right foot. In addition, review of the nursing notes for (MONTH) 2019 failed to show documentation the dressings were applied or changed. j. Review of the (MONTH) 2019 TAR showed an order (dated 4/30/19) for Right foot clean with wound cleaner, pack with plain packing strip, place a wet to dry dressing and secure with [MEDICATION NAME]. Every night shift for wound care and monitoring. Continue review showed the facility documented the dressing as completed on 5/1, 5/2, and 5/3 (the resident was discharged on [DATE]). Additionally, the TAR showed an order dated 4/30/19 for Left foot clean with wound cleaner, place a wet to dry dressing and secure with [MEDICATION NAME]. The review further showed the left foot dressing was not documented as being completed on 5/1/19 or 5/2/19. Review of the nursing notes for 5/1/19 to 5/2/19 failed to show evidence the left foot dressing was applied. k. Review of the care plan initiated on 5/2/19 (also the date the resident discharged from the facility) showed the resident was admitted with pressure ulcers to the plantar surface of the right and left feet. Interventions included administer treatment as ordered and observe for effectiveness . l. Interview with the resident's spouse on 7/31/19 at 9:02 AM revealed s/he had been applying the dressing for the resident at home prior to the resident's admission to the facility. S/he stated the resident had 1 open wound that was about the size of a dime on the right foot below the great toe when admitted to the nursing facility, and no wounds on the left foot. Further, the resident's spouse stated she told the facility about the resident's foot wound at the time of admission. m. Interview with PACE program RN #1 on 7/30/19 at 5:22 PM revealed the PACE program had been in contact with the nursing facility on 4/30/19 related to concerns with wound care. n. Review of the 4/30/19 at 4:48 PM Telephone Encounter showed PACE program RN #2 documented Multiple call to (name) DON today and yesterday to discuss wound care orders and antibiotic orders not being followed per provider instructions. Call to her personal cell and left message requesting call back. Unable to go over to facility to speak with her at this time as (nursing facility) is closed to visitors d/t (due to) Quarantine from NoroVirus. Review of the 4/30/19 at 5:08 PM Telephone Encounter showed PACE program RN #1 documented the facility called back and stated they did not have any known wound care orders, and thought the PACE program was going to be changing the resident's dressing daily. The PACE RN explained to the facility that verbal orders had been provided, and additionally, hardcopy orders had been delivered to the facility by the PACE RN on 4/26/19. The PACE RN provided verbal orders again at that time. o. Review of the State Survey Agency incident reporting database showed the facility made an infectious disease report on 4/22/19, and several residents had been identified with nausea, vomiting and/or diarrhea. Between 4/21/19 and 4/25/19 31 residents were identified with symptoms. p. Review of the SBAR Summary dated 5/2/19 at 6:30 AM showed the resident had a fever and worsening wounds to bilateral feet. Review of the vital signs on this summary showed they were dated 4/26/19. The SBAR summary further showed wound infection and the resident's spouse had requested the resident go to the hospital for treatment. Review of a progress note dated and timed 5/2/19 at 8:04 AM showed the resident was sent to the emergency room . Review of a progress note dated and timed 5/2/19 at 8:39 PM showed the resident was admitted to the hospital for [MEDICAL CONDITION]. q. Review of the Consultation Orthopedic Surgery notes dated 5/2/19 at 4:58 PM revealed Musculoskeletal: Right foot- ulcer under 1st mt (metatarsal) head with minimal drainage. Appears to go down to bone. Also ulcer over the dorsal aspect of (his/her) 2 and 3rd toes. Palp (palpable) pulses. No swelling. Left foot- ulcer under first mt head with surrounding dry gangrene. There is redness up to the midfoot. Foul smelling. No significant drainage today. Continued review showed .Plan: (s/he) has a difficult problem. (S/he) likely has osteo[DIAGNOSES REDACTED] with exposed bone. Amputation would be an option with a transmetatarsal amputation. (S/he) would have to be able to limit (his/her) weight bearing. There (sic) other option would be to continue to monitor things and see how (s/he) responds to abx (antibiotics), (his/her) wounds would likely never heal, but (s/he) could continue weight bearing . r. Interview with the DON, administrator, and MDS coordinator on 7/26/19 at 1:29 PM revealed they were aware of the missed wound care orders, lack of treatment documentation, and lack of assessments for the resident's wounds. However, they felt that the status of the resident's wounds upon discharge were related to the debridement. 2. Interview with the DON, the administrator, and the district director of clinical services on 7/25/19 at 4:25 PM revealed the case with resident #3 had brought issues to their attention. A root cause analysis was completed, and the facility addressed the findings through Quality Assurance Performance Improvement (QAPI). Review of the Ad Hoc QAPI Meeting Agenda/Summary showed on 5/3/19 improvement areas included: following orders, documenting medication administration and treatments, entering orders correctly, skin system education, and skin assessments. Immediate corrective actions taken showed suspension of a nurse, investigation into causes, and education to all nurses. Review of the Corrective Actions showed the following: a. The time line started on 4/29/19 with identification of wounds on feet and missing orders for care. b. Identification of others at risk was completed on 5/4/19 with a skin sweep of all residents. In addition, a review of each residents' orders (all possible forms of orders) from 4/1/19 to present was done. Corrections were made as needed. This had a completion date of 5/12/19. c. Systemic changes were made by providing education to licensed nurses with a target date of 5/31/19 and a completion date of 5/10/19. d. Monitoring was shown to be assigned to the current DON on 5/2/19. The monitoring included facilitation of medication reconciliation daily, and documenting completion and actions taken, and also to report and identify patterns/trends of concerns to the QAPI Committee monthly. These were shown with a target date of 5/2/19 and a completion date of on going. 3. In addition to 2 closed records, 3 sample residents with pressure wounds were reviewed, and no current non-compliance was identified.

Based on incident report review, medical record review, and staff interview, the facility failed to ensure the care plan was implemented to prevent falls for 1 of 5 sample residents (#85) reviewed for falls. This failure resulted in past non-compliance at actual harm to resident #85 who fell and experienced a leg fracture. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 7/6/18. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #85 was admitted with [DIAGNOSES REDACTED]. Review of the care plan with a review date of 5/15/18 showed the resident required the extensive assistance of 2 staff for dressing, bed mobility and transfers. The following concerns were identified: a. Review of the incident/accident report dated 6/17/18 and timed 6:20 AM showed Resident slid off the air mattress when a staff member was pulling her pants up .(staff member) was able to lift her into her chair from a falling position to keep her off the floor. Resident's right foot was turned to the right and dangling . Review of the nursing progress notes dated 6/17/18 and timed 11:51 AM showed, CNA was dressing the lower extremity of the resident when resident began to fall. CNA was able to get the resident into a nearby chair. CNA noted something was wrong with the resident's lower extremity and ran out to get the nurse . The resident was sent to the emergency room for evaluation . Review of the nursing notes dated 6/19/18 and timed 12:52 AM showed the resident had a fall with major injury of non-displaced fracture of tibia and fibula . b. Interview on 7/12/18 at 10:54 AM with the DON revealed the care plan carried through to the Kardex (a medical information system used by nursing staff as a way to communicate important information about their residents) which the CNAs reviewed for resident care. She also stated her expectation was for CNAs to follow the Kardex. In addition, she confirmed, only one staff member dressed the resident that day and she was not sure why the care plan was not followed. c. Interview on 7/13/18 at 11:12 AM with CNA #1 revealed she dressed the resident without assistance and the resident fell out of bed. She further revealed she did not look at the Kardex and thought the resident only required 1 staff member for assistance with dressing. 2. Review of the facility's Action Plan and interview with the corporate nurse, the administrator, and the DON on 7/16/18 at 4 PM revealed the facility implemented corrective actions to prevent re-occurrence. The actions taken by the facility included: a. Identified other residents by conducting an audit on transfer assessments for completion and accuracy. All current residents received a new fall assessment. The care plans and Kardex information for residents were reviewed and updated as needed. b. Staff were educated on the following: lift and transfer policy, reviewing the Kardex for resident needs, abuse and neglect prohibition, and fall management and prevention. Staff also performed return demonstration on 1-person and 2-person transfer using the gait belt, the sit-to-stand and the mechanical lift. Staff also received education on inflating air beds for care. c. Monitoring was accomplished by performing a review of completed transfer assessments for completion, during clinical meetings. Incident/accident reports were reviewed daily at the stand up meeting. Falls were reviewed at the weekly risk meeting to ensure interventions were appropriate and the plan of care was followed. d. An ad hoc QAPI meeting was held on 6/22/2018.

Based on staff and resident interview and medical record review, the facility failed to develop discharge plans to meet the needs and goals of 1 of 3 sample residents (#2) reviewed for appropriate discharge planning. This failure resulted in significant psychosocial harm, when the resident was discharged to a retirement home that was unable to provide assistance with toileting. The findings were: 1. Review of the medical record showed resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This review showed discharge plans were initiated in (MONTH) (YEAR) when the resident refused after multiple attempts to comply with safe smoking practices. Further review showed resident used an electric wheelchair and was discharged from the facility to a retirement home on 4/13/18. The following concerns were identified: a. Interview on 5/3/18 at 3 PM with the administrator revealed the discharge plans for the resident were arranged by a representative of an outside advocacy agency. She further stated the resident was able to perform all activities of daily living independently at the time of the discharge. b.Interview on 5/3/18 with social worker #1 revealed the facility did not communicate with the retirement home staff prior to the discharge because all arrangements were made by the representative of an outside advocacy agency. She stated discharge plans included home health nursing services for pressure ulcer care. The resident was discharged with a bedside commode, sliding board and pill locking mechanism for self medication administration. She further stated the resident had taken care of himself/herself independently prior to discharge. c. Interview on 5/3/18 at 3:45 PM with CNA (certified nurse aide) #1, RCS (resident care specialist) #1, licensed practical nurse #1, and director of nursing revealed the resident used a sliding board to transfer independently from the bed to wheelchair and to the bedside commode. CNA #1 and RSC #1 also stated the only time staff assisted the resident was when they emptied the commode after use and at times reminded the resident to use the sliding board because s/he did not consistently use it. Review of the discharge plan and summary form, dated 4/13/18, showed the resident could perform activities of daily living independently and arrangements had been made for therapy and home health after discharge. d. Review of the 3/12/18 significant change MDS (minimum data set) assessment showed the resident had a BIMS (Brief Interview of Mental Status) score of 10/15, and required extensive assistance with bed mobility, transfers, personal hygiene and toilet use. Review of the 3/12/18 care area assessment summary for triggered MDS assessed areas showed the resident required supervision while smoking; chose not to use suggested safe transfers with a sliding board; and had a history of [REDACTED]. e. Review of the care plan, revised 3/19/18, showed identified problems included safety risk due to operating motorized wheelchair unsafely, requiring supervision with smoking and at risk for falls. Further review of the care plan showed the resident needed assistance with bed mobility, personal hygiene, dressing, and transfers. f. Review of the activities of daily living documentation completed by the CNAs revealed the resident required extensive assistance with toileting 7 times, bed mobility 9 times, transfers 11 times, personal hygiene 7 times, and dressing 8 times during the 4/1/18 to 4/13/18 time period. g. Interview on 5/3/18 at 1:56 PM and again on 5/4/18 at 3 PM with the retirement home assistant manager revealed the resident arrived on 4/13/18 and within hours it was obvious the retirement home was not the appropriate setting for this resident because the resident needed a facility that provided nursing care assistance. The assistant manager stated the representative of an outside advocacy agency made all the discharge arrangements and the retirement home staff did not follow its usual process of pre-admission screening. She stated if the process had been done, they would not have accepted the resident. She stated the following events occurred the day after the resident was admitted : The resident asked for assistance with medications and to go to the bathroom. Both were services not provided by the retirement home. The fire department was called and they were unable to assist the resident to the bathroom. Then emergency medical services was called and the resident was transported to the hospital. h. Interview on 5/10/17 at 11:50 AM with resident #2 revealed the brief stay at the retirement home did not make me feel good because when the firemen tried to help him/her to the bathroom, s/he ended up on the floor, and finally they had to call the ambulance. The resident stated the retirement home was not set up for handicapped people like me and the facility staff did not tell him/her about that set up prior to the discharge. The resident also stated it wasn't a good feeling to have to go the hospital in an ambulance in order to go to the bathroom. i. Review of the facility social services follow up discharge note, dated 4/16/18, revealed social worker #1 had a conversation with the home health nurse who reported she found the resident at the retirement home on 4/14/18 on the floor covered with urine. Further review revealed the home health nurse also reported the resident was transported by ambulance to the emergency room .

Based on medical record review, resident interview, staff interview, guardian interview, incident review, and sexual abuse policy review the facility failed to ensure 1 of 3 sample residents (#2) selected to review potential abuse issues was free from abuse. This failure resulted in harm to the resident. The findings were: Medical record review showed resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the 8/1/17 quarterly MDS assessment showed the resident's BIMS (brief interview for mental status) score was 9, indicating moderate cognitive impairment, and the resident required extensive assistance of 2 staff members for transfers and bed mobility. Review of the resident's care plan showed staff were required to utilize a Hoyer lift for transfers. Further record review showed a 7/31/17 form signed by the resident's legal guardian which gave consent for the resident to engage in sexual relations with his/her spouse. Review of nursing and social services notes dated 8/3/17 showed the resident and his/her spouse utilized a room set aside in the facility for intimacy. The following concerns were identified: 1. Review of the resident's care plan showed a plan for use of the intimacy room dated 8/14/17 (11 days after the resident and his/her significant other utilized that room for intimacy). Further review of the resident's care plan revealed a 3/10/16 plan with an 8/8/17 update that showed as a focus (The resident) has a behavior problem weeping, refusing to shower/bathe, refusing pain medication then accusing staff of not treating (his/her) pain. Interventions included the following: Encourage resident and spouse to interact in public areas or leave door to resident room (open) while spouse is visiting (initiated 3/10/16), and Intervene as necessary to protect (the resident's) rights and safety. Remove from situation as indicated (initiated 7/14/17). Interview with the DON on 8/15/17 at 3:40 PM confirmed the care plan. The DON stated that she believed the intervention to leave the door open when the spouse visited resulted from a staff member observing the resident's spouse fondling the resident's breasts. 2. Interview with the resident's guardian on 8/16/17 at 1:05 PM revealed that she and the resident had never met. The guardian based the consent for the resident to engage in sexual relations with his/her spouse on a phone call with the resident and a phone call with the administrator. 3. Interview with LPNs #1 and #2 on 8/14/17 at 7:50 PM showed each nurse found the resident to be confused at times, and both questioned whether the resident had the cognitive ability to make an informed decision regarding sexual intimacy. They stated that administration was aware of their concerns. Interview with CNAs #1 and #2 on 8/14/17 at 8:10 PM showed each CNA felt the resident was often confused and had difficulty with simple decisions, and both felt the resident did not have the capacity to make an informed decision regarding sexual intimacy. They stated that administration was aware of their concerns. Interview with CNA #3 on 8/14/17 at 8 PM revealed the CNA felt the resident was intermittently confused. Interview with CNA #4 on 8/15/17 at 9:30 AM revealed the resident was confused at times and did not know what was going on. Interview with CNA #5 on 8/15/17 at 9:44 AM revealed the resident was confused at times. Interview with CNA #6 on 8/15/17 at 3:05 PM revealed she felt the resident was intermittently confused, and she felt the resident was not capable of making an informed decision regarding sexual intimacy. She added the resident would be unable to recall later in the day what s/he had eaten for breakfast. She stated that administration was aware of her concerns. 4. Interview with CNAs #1 and #2 on 8/14/17 at 8:10 PM revealed the resident utilized the intimacy room with his/her spouse on 8/3/17 around 1 PM. Medical record review showed the following documentation on 8/3/17: i. By the NHA at 13:30 (1:30 PM), NHA received a call from the therapy director stating that one of his staff was concerned about the intimate time provided to (resident and spouse). He was told that the staff member stated (the resident) was covered in bruises and blood. NHA immediately called the nurse on duty and told her what had been reported. Nurse (#1) asked why the therapist would think that and stated the CNA who got (the resident) up did not report anything. Requested that she conduct a head to toe assessment of (the resident) to see if there were injuries. ii. By the NHA at 19:30 (7:30 PM), NHA received return call from nurse (#1) who reported no blood, no bruises. She did state that (the resident's) nipples looked red and that (the resident's spouse) had shaved (the resident's) pubic area. NHA interviewed both CNAs who attended (the resident) after (the spouse) left and each stated there was no blood and no bruising. They did state that (resident's spouse) shaved (the resident's) pubic area. NHA notified DDCS of report. Police came to the facility and interviewed (the resident). The police had no findings. iii. By licensed nurse (#2) at 20:00 (8 PM), Earlier this afternoon, resident had been in the private room with (resident's spouse) who had left afterwards without anyone knowing. Resident in room staring up at the ceiling and (the resident's) face was very flush (sic). Resident very quiet. RCAs went in to clean (the resident) and get (the resident) up. Once back in (the resident's) room, I went to speak with (the resident) and (the resident) told me (the resident's spouse) had been twisting (the resident's) nipples and it hurt and (the resident) told (the resident's spouse) to stop and (the resident's spouse) told (the resident) to be quiet or (the resident's spouse) won't be able to come back to see (the resident). I checked (the resident's) nipples which were red but at this time there was no bruising. Also RCAs reported a lot of hair on the blankets, that (the resident) had been shaved in (his/her) pubic area. I asked resident about this and the resident stated (s/he) heard something when (s/he) asked (the resident's spouse) what it was and (the resident's spouse) told (the resident) it was none of (the resident's) concern and took (the resident's) electric razor (the resident's spouse) had brought from home and shaved (the resident's) pubic area and (the resident) had told (the resident's spouse) to stop. I did note (the resident's) pubic being shaved close and some areas showed razor burn. When asked why (the resident's spouse) did this (the resident) stated (the resident's spouse) does not like long. I asked if (the resident) knew the day and (the resident) didn't know, (the resident) did know what month it was. (The resident) also told me (his/her) mother always said there would come a point in your life that you just lay there and let them have their way. iv. By licensed nurse (#3) on 8/7/17 at 20:17 (8:17 PM), Resident voiced thank you to this nurse and on shift CNAs stating (s/he) liked (his/her) visit in the living room with (the resident's spouse) much better than alone in a room, resident stated (s/he) does not like how (the resident's spouse) acts with (the resident) when they are alone that (s/he) tells (the resident's spouse) no but (the resident's spouse) doesn't listen to (him/her). 5. Review of an incident investigation related to the 8/3/17 use of the facility intimacy room by the resident and the resident's spouse showed the following: i. Documentation from the customer services representative on 8/3/17 at 3:30 PM included the following, .When I returned from (unknown staff member #1's) office I saw the staff were upset at the desk, the door was open, (spouse of the resident) gone, and the staff emotions had escalated. I asked (SW #1) to talk to (the resident). (SW #1) came back visibly upset and furious that (the resident's spouse) had shaved (the resident) and that (the resident) had a dazed look on (his/her) face. (The resident) also described the incident in great detail . The staff said they didn't know about the private room and hadn't had any education on what to do. I found out at this point that the facility had called the police in the past due to (the resident's spouse) rough fondling causing (the resident) to bleed, and (the resident) crying that (the resident's spouse) was hurting (him/her) .They said they had no training in cleaning up semen and that they have had no education on how to handle this situation. Therapy staff were very vocal about what should have been done prior to any use of the private room. I advised the staff that I had told (the resident's spouse) to wait until I was finished with my meeting to continue our conversation. The staff emotions escalated to a point it had to be quieted down . ii. Documentation on 8/4/17, unsigned, related to conversation with the resident's legal guardian, Spoke to (the resident's) guardian explained what occurred and staff concerns. Education provided to staff. She continues to support (the resident's) wishes. iii. From the 8/3/17 Concern Form for CNA #7, At around 3:30 PM, a staff member asked me if I could come and help her get (the resident) out of the bed in the Intimacy Room. When we went in, the first thing I noticed was the smell. It was awful. (The resident) was laying in bed. (S/he) looked terrified. We asked (the resident) if (s/he) was okay. (The resident) told us that (s/he) was sore. Then got everything set up to change (the resident). When we pulled back the sheet that was covering (him/her), there was something on the sheets that looked like it could have either been blood or it could have been BM (bowel movement). There was pubic hair all over the bed. (The resident) had also been shaved in (his/her) pubic area. I was told 7/21/17 that (the resident's spouse) used to be abusive towards (the resident) and had been found fondling (the resident) in their room while they were alone. 6/15/17 (ish) I was told that we shouldn't leave (the resident) and (the resident's spouse) alone in the same room because (the resident's spouse) hits (the resident) .Right before dinner I talked with (customer services representative) about what I had seen while I was in (the resident's) room. (SW #1) has walked over and was getting visibly angrier at the situation . (The resident) has also been abused by (the resident's spouse) before. As someone who has been abused by her husband before, (the resident) isn't just going to throw (his/her) abuser under the bus if (the resident's spouse) hurts (him/her), for fear of being hurt again. At shift change we had also been told that (the resident's spouse) had told (the resident) that (s/he) had to tell us yes to them having sex or else. Further review of the Concern Form for CNA #7 showed she had marked yes for, Have you previously voiced concern to a staff member. iv. From the 8/3/17 Concern Form for CNA #8, On August 3, 2017 at approximately 2:00 PM (the resident) and (the resident's spouse) were together in the intimacy room. During this time (the resident's spouse) shaved (the resident's) pubic area before they proceeded to have intercourse, no cuts or wounds were found from said action . After (the resident's spouse) had left, which (s/he) did without informing anyone that they were finished and left (the resident) unattended, we found (the resident) in a state of shock, flushed, wide eyed and not talking . Further review of the Concern Form for CNA #8 showed she had marked yes for, Have you previously voiced concern to a staff member. 6. Review of the medical records, care plan, and 8/3/17 incident investigation failed to show any interventions for resident safety were developed or implemented after the 8/3/17 incident. 7. Review of progress notes and the 8/13/17 suspected abuse investigation showed the following: a. Review of a progress note dated 8/13/17 at 1400 (2 PM) documented by LPN #2 showed, When walking by resident's room CNA heard resident yelling out for help and came to get me. Went into room and (resident's spouse) was leaning over (the resident). I asked (the resident's spouse) to step out of the room. When asking resident what was wrong (the resident) stated that '(The resident's spouse) was playing with me and (s/he) was getting rough. I asked (him/her) to stop and (s/he) said no. (The resident's spouse) didn't understand for a minute and wouldn't stop being rough.' When asked if (s/he) was in pain at the moment (the resident) stated no. I stepped out of the room and (the resident's spouse) had left the building. b. Review of a progress note dated 8/14/17 at 14:30 (2:30 PM) documented by the NHA showed, NHA notified of resident concern from 8/13/17 at approximately 11:30 AM by (LPN #2). NHA interviewed (the resident) who stated to the NHA that (the resident's spouse) was 'tickling me and it got rough. I asked (him/her) to stop and (s/he) said no. (The resident's spouse) didn't understand why so I waited until someone who I knew would help me and when I saw her I called out for help, she came in and (the resident's spouse) stopped.' When asked if (the resident's spouse) touching was something that (the resident) wanted (the resident's spouse) to do, (the resident) said yes. NHA notified DDCS, sent an initial report to the state and notified the police. Officer (officer's name) arrived and interviewed (the resident) with NHA present. (The resident) told the officer the same thing. (The resident) stated (s/he) welcomed (the resident's spouse's) touch, but when it got rough (the resident) wanted (the resident's spouse) to stop (the resident's spouse) didn't until the CNA entered the room. The officer was unsure at the time that she left if there was a crime with this event. c. Review of an 8/13/17 Suspected Abuse Investigation showed the following, Resident stated (spouse) was 'tickling (the resident)' had fingers in the (genital) area. (The resident) stated (s/he) welcomed the touch but (the resident's spouse) got rough and (the resident) asked (him/her) to stop and (the resident's spouse) said no. d. Review of an unsigned statement dated 8/14/17 showed (LPN #2) came into the NHA office about 11:30 AM stating (the resident) was yelling the day before and the CNA (#6) went into the room and (the resident's spouse) was leaning over (the resident). (CNA #6) got (LPN #2) and asked (the resident's spouse) to leave the room for a moment. (LPN #2) asked (the resident) why (the resident) was yelling out. (The resident) stated, '(The resident's spouse) was playing with me and (s/he) was rough. I asked (him/her) to stop and (s/he) said no. (The resident's spouse) didn't understand for a minute and wouldn't stop being rough.' (LPN #2) asked if (the resident) was in pain and (the resident) said no. When she stepped out of the room (the resident's spouse) had left the building. e. Review of an unsigned statement dated 8/15/17 showed (CNA #5), stated she didn't see (the resident's spouse) with (the resident) or touching (the resident), but went in the room with (LPN #2). She stated that (the resident) told them that (the resident's spouse) was playing with (the resident) and was rough and (the resident) told (the resident's spouse) to stop and (the resident's spouse) said no. So (the resident) yelled out at someone in the hall and when she came in (the resident's spouse) stopped. f. Interview with CNA #5 on 8/15/17 at 1:23 PM revealed on 8/13/17 she was working at the facility. She stated another CNA on shift with her heard the resident hollering from (his/her) room, so they went in to check on the resident. The resident's spouse was seen in the room, leaning over the resident and talking. The CNAs requested the spouse to leave the room, and the CNA stated the resident made the comment that the spouse was rough and (his/her) hands were down the resident's pants. g. Interview on 8/15/17 at 3:05 PM with CNA #6 revealed she had just started her shift on the afternoon of 8/13/17 when she heard yelling coming from the resident's room. She stated she saw the resident's spouse with (his/her) hand under the resident's blanket pushing on (the resident), and the resident had said it hurt. She stated she went and got another CNA and the nurse, and they asked the resident's spouse to leave. She added the resident was pretty confused most of the time and stated she did not think (the resident) really understands it. 8. Further review of the medical record failed to show any interventions for resident safety were developed or implemented after the 8/13/17 incident. 9. Interview with the resident on 8/14/17 at 8:29 PM revealed his/her spouse had come to visit earlier that evening, and had left about an hour earlier (the day after the incident of 8/13/17, and 11 days after the incident of 8/3/17). 10. Interview on 8/15/17 at 3:40 PM with the NHA and DON revealed the facility policy if a resident expressed fear, discomfort, or the desire not to be left alone with someone was to separate those people, and if it was a staff member to do an investigation. The DON added she would treat it very differently if it was a staff member. A (spouse) is very different than staff. They stated the day of 8/3/17, after the resident and spouse had utilized the intimacy room, rumors began that the resident had bruising. At that time the NHA instructed the nurse to complete a head to toe assessment of the resident. She also stated they had considered the possibility of abuse, but ultimately determined it was the personal sexual practices of the resident and his/her spouse. The NHA added that on the night of 8/14/17, staff called the DON to say the resident's spouse was in the facility, and the DON instructed staff to tell the resident and ask what s/he wanted. They revealed the resident had given conflicting statements to different staff members regarding his/her experience in the intimacy room with his/her spouse. The NHA confirmed there was no care plan in place at the time of the 8/3/17 use of the intimacy room by the resident and his/her spouse, and that they had discussions with staff regarding resident choices, rights, and to be respectful toward the resident. The DON stated she considered the resident to be cognitive enough to make decisions regarding sexual consent and safety, but that it was a gray area. 11. Review of the policy titled, Sexual Behavior last revised on July 2016 showed the following under Residents with Cognitive Loss: Sexual activity between willing residents with cognitive loss is sometimes a concern among staff. Residents may not have full capacity to make decisions about all aspects of their lives, but they may have the capacity to consent to sexual relations. Residents' rights in such situations must be discussed with the resident and his or her legal surrogate and individual determinations made on a case-by-case basis. The following was noted under Procedure: 1. Staff will identify a resident's sexual expressions and behavior and determine whether the behavior is appropriate, inappropriate, or abusive. 2. If the sexual expression or behavior is determined to be abusive: a. Nursing staff will take appropriate action to protect the alleged victim and the rights of other residents and staff as required, b. The behavior is reported to the Director of Nursing or the Administrator and the facility policies for the identification, response and reporting of abuse to the appropriate agencies are followed, c. The residents' attending physicians and the Medical Director are notified, d. A resident Incident/Accident/Report is completed and submitted using the Risk Management Information System.

Based on medical record review, resident interview, staff interview, incident review, sexual abuse policy review and abuse and neglect policy review, the facility failed to ensure 1 of 2 abuse investigations selected for review (regarding resident #2) was reported to the State Survey Agency. In addition, the facility failed to ensure the safety of 1 of 1 resident (#2) who was the subject of an abuse investigation. This failure resulted in harm to the resident. The findings were: Medical record review showed resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the 8/1/17 quarterly MDS assessment showed the resident's BIMS (brief interview for mental status) score was 9, indicating moderate cognitive impairment. The review showed the resident required extensive assistance of 2 staff members for transfers and bed mobility. The care plan showed staff were required to utilize a Hoyer lift for transfers. Further record review showed a 7/31/17 form signed by the resident's legal guardian which gave consent for the resident to engage in sexual relations with his/her spouse. Review of nursing and social services notes dated 8/3/17 showed the resident and his/her spouse utilized a room set aside in the facility for intimacy. The following concerns were identified: 1. Review of the resident's care plan revealed a 3/10/16 plan with an 8/8/17 update that showed as a focus (The resident) has a behavior problem weeping, refusing to shower/bathe, refusing pain medication then accusing staff of not treating (his/her) pain. Interventions included Encourage resident and spouse to interact in public areas or leave door to resident room (open) while spouse is visiting (initiated 3/10/16), and Intervene as necessary to protect (the resident's) rights and safety. Remove from situation as indicated (initiated 7/14/17). Interview with the DON on 8/15/17 at 3:40 PM confirmed the care plan. The DON stated she believed the intervention to leave the door open when the spouse visited resulted from a staff member observing the resident's spouse fondling the resident's breasts. 2. Interview with CNAs #1 and CNAs #2 on 8/14/17 at 8:10 PM revealed the resident utilized the intimacy room with his/her spouse on 8/3/17 around 1 PM. Medical record review showed licensed nurse (#2) documented the following on 8/3/17 at 8 PM: Earlier this afternoon, resident had been in the private room with (resident's spouse) who had left afterwards without anyone knowing. Resident in room staring up at the ceiling and (the resident's) face was very flush (sic). Resident very quiet. RCAs went in to clean (the resident) and get (the resident) up. Once back in (the resident's) room, I went to speak with (the resident) and (s/he) told me (the resident's spouse) had been twisting (the resident's) nipples and it hurt and (the resident) told (the resident's spouse) to stop and (s/he) told (the resident) to be quiet or (the resident's spouse) won't be able to come back to see (him/her). I checked (the resident's) nipples which were red but at this time there was no bruising. Also RCAs reported a lot of hair on the blankets, that (the resident) had been shaved in (the resident's) pubic area. I asked resident about this and the resident stated (s/he) heard something when (s/he) asked (the resident's spouse) what it was and (the resident's spouse) told (the resident) it was none of (his/her) concern and took (the resident's) electric razor (the resident's spouse) had brought from home and shaved (the resident's) pubic area and (the resident) had told (the resident's spouse) to stop. I did note (the resident's) pubic being shaved close and some areas showed razor burn. When asked why (the resident's spouse) did this (the resident) stated (the resident's spouse) does not like long. I asked if (the resident) knew the day and (the resident) didn't know, (the resident) did know what month it was. (The resident) also told me (the resident's) mother always said there would come a point in your life that you just lay there and let them have their way. 3. Review of the note written by licensed nurse (#3) on 8/7/17 at 8:17 PM showed Resident voiced thank you to this nurse and on shift CNAs stating (the resident) liked (the resident) visit in the dining room with (the resident's spouse) much better than alone in a room, resident stated (s/he) does not like how (the resident's spouse) acts with (the resident) when they are alone that (the resident) tells (the resident's spouse) no but (the resident's spouse) doesn't listen to (the resident). 4. Review of an incident investigation related to the 8/3/17 use of the facility intimacy room by the resident and the resident's spouse showed the following: i. From the 8/3/17 Concern Form for CNA #7, At round 3:30 PM, a staff member asked me if I could come and help her get (the resident) out of the bed in the Intimacy Room. When we went in, the first thing I noticed was the smell. It was awful. (The resident) was laying in bed. (The resident) looked terrified. We asked (the resident) if (s/he) was okay. (The resident) told us that (s/he) was sore. When got everything set up to change (the resident). When we pulled back the sheet that was covering (the resident), there was something on the sheets that looked like it could have either been blood or it could have been BM (bowel movement). There was pubic hair all over the bed. (The resident) had also been shaved in (his/her) pubic area. I was told 7/21/17 that (the resident's spouse) used to be abusive towards (the resident) and had been found fondling (the resident) in their room while they were alone. 6/15/17 (ish) I was told that we shouldn't leave (the resident) and (the resident's spouse) alone in the same room because (the resident's spouse) hits (the resident) .Right before dinner I talked with (Customer Services Representative) about what I had seen while I was in (the resident's) room. (SW #1) has walked over and was getting visibly angrier at the situation .(The resident) has also been abused by (the resident's spouse) before. As someone who has been abused by (their spouse) before, (the resident) isn't just going to throw (his/her) abuser under the bus if (the resident's spouse) hurts (him/her), for fear of being hurt again. At shift change we had also been told that (the resident's spouse) had told (the resident) that (s/he) had to tell us yes to them having sex or else. Further review of the Concern Form for CNA #7 showed she had marked yes for, Have you previously voiced concern to a staff member. ii. From the 8/3/17 Concern Form for CNA #8, On August 3, 2017 at approximately 2:00 PM (the resident) and (the resident's spouse) were together in the intimacy room. During this time (the resident's spouse) shaved (the resident's) pubic area before they proceeded to have intercourse, no cuts or wounds were found from said action. However, before consent could be verified it was told by another CNA that (the resident's spouse) was in (the resident's) room telling (him/her) that (s/he) had to say yes and give consent or else. Therefore, (the resident) gave consent to have intercourse with (the resident's spouse). 5. Review of the medical record, care plan and the 8/3/17 incident investigation failed to show any interventions for resident safety were developed or implemented after the 8/3/17 incident. 6. Interview on 8/15/17 at 3:40 PM with the NHA and DON revealed the facility policy if a resident expressed fear, discomfort, or the desire not to be left alone with someone was to separate those people, and if it was a staff member to do an investigation. During the interview, they each agreed that an abuse investigation had been done regarding the 8/3/17 incident. However, they confirmed the facility had failed to notify the State Survey Agency of the allegation. In addition, they both confirmed there was no plan in place before or after 8/3/17 until 8/14/17 (1 day after a second incident) to ensure the resident was made safe. 7. Review of a progress note dated 8/13/17 at 1400 (2 PM) documented by LPN #2 showed, When walking by resident's room CNA heard resident yelling out for help and came to get me. Went into room and (resident's spouse) was leaning over (the resident). I asked (the resident's spouse) to step out of the room. When asking resident what was wrong (the resident) stated that '(The resident's spouse) was playing with me and (the resident's spouse) was getting rough. I asked (him/her) to stop and (s/he) said no. (The resident's spouse) didn't understand for a minute and wouldn't stop being rough.' When asked if (the resident) was in pain at the moment (the resident) stated no. I stepped out of the room and (the resident's spouse) had left the building. 8. Review of a progress note dated 8/14/17 at 14:30 (2:30 PM) documented by the NHA showed, NHA notified of resident concern from 8/13/17 at approximately 11:30 AM by (LPN #2). NHA interviewed (the resident) who stated to the NHA that (the resident's spouse) was 'tickling me and it got rough. I asked (the resident's spouse) to stop and (the resident's spouse) said no. (The resident's spouse) didn't understand why so I waited until someone who I knew would help me and when I saw her I called out for help, she came in and (the resident's spouse) stopped.' When asked if (the resident's spouse) touching was something that (the resident) wanted (the resident's spouse) to do, (the resident) said yes. NHA notified DDCS, sent an initial report to the state and notified the police. Officer (officer's name) arrived and interviewed (the resident) with NHA present. (The resident) told the officer the same thing. (The resident) stated (the resident) welcomed (the resident's spouse's) touch, but when it got rough (the resident) wanted (the resident's spouse) to stop (the resident's spouse) didn't until the CNA entered the room. The officer was unsure at the time that she left if there was a crime with this event. 9. Review of the 8/13/17 Suspected Abuse Investigation showed the following: Resident stated (spouse) was 'tickling (the resident)' had fingers in the (genital area). (The resident) stated (s/he) welcomed the touch but (the resident's spouse) got rough and (the resident) asked (the resident's spouse) to stop and (the resident's spouse) said no. 10. Review of an unsigned statement dated 8/14/17 showed the following: (LPN #2) came into the NHA office about 11:30 AM stating (the resident) was yelling the day before and the CNA (#6) went into the room and (the resident's spouse) was leaning over (the resident). (CNA #6) got (LPN #2) and asked (the resident's spouse) to leave the room for a moment. (LPN #2) asked (the resident) why (the resident) was yelling out. (The resident) stated, '(The resident's spouse) was playing with me and (the resident's spouse) was rough. I asked (the resident's spouse) to stop and (the resident's spouse) said no. (The resident's spouse) didn't understand for a minute and wouldn't stop being rough. (LPN #2) asked if (the resident) was in pain and (the resident) said no. When she stepped out of the room (the resident's spouse) had left the building. 11. Interview with CNA #5 on 8/15/17 at 1:23 PM revealed she was working at the facility on 8/13/17. She stated another CNA on shift with her heard the resident hollering from his/her room, so they went in to check on the resident. The resident's spouse was seen in the room, leaning over the resident and talking. The CNAs requested the spouse to leave the room, and the CNA stated the resident made the comment that the spouse was rough and his/her hands were down the resident's pants. 12. Interview on 8/15/17 at 3:05 PM with CNA #6 revealed she had just started her shift on the afternoon of 8/13/17 when she heard yelling coming from the resident's room. She stated she saw the resident's spouse with his/her hand under the resident's blanket pushing on (the resident), and the resident had said it hurt. She stated she went and got another CNA and the nurse, and they asked the resident's spouse to leave. She added the resident was pretty confused most of the time and stated she did not think (the resident) really understands it. 13. Further review of the medical record failed to show any interventions were put into place for resident safety after the 8/13/17 incident. 14. Interview with the resident on 8/14/17 at 8:29 PM revealed his/her spouse had come to visit earlier that evening, and had left about an hour earlier (the day after the incident of 8/13/17, and 11 days after the incident of 8/3/17). 15. Interview on 8/15/17 at 3:40 PM with the NHA and DON confirmed the resident's spouse was not told to stay away from the facility after the 8/3/17 incident or the 8/13/17 incident, until 8/14/17 after 8 PM (State surveyors entered the facility on 8/14/17 at 7:48 PM). They further confirmed staff had called the DON on 8/14/17 when the resident's spouse entered the facility. The DON stated she told the staff to ask the resident if s/he wanted a visit from his/her spouse and the resident said yes. 16. Review of the policy titled, Sexual Behavior last revised on July 2016 showed the following under Residents with Cognitive Loss, Sexual activity between willing residents with cognitive loss is sometimes a concern among staff. Residents may not have full capacity to make decisions about all aspects of their lives, but they may have the capacity to consent to sexual relations. Residents' rights in such situations must be discussed with the resident and his or her legal surrogate and individual determinations made on a case-by-case basis. The following was noted under Procedure, 1. Staff will identify a resident's sexual expressions and behavior and determine whether the behavior is appropriate, inappropriate, or abusive. 2. If the sexual expression or behavior is determined to be abusive: a. Nursing staff will take appropriate action to protect the alleged victim and the rights of other residents and staff as required, b. The behavior is reported to the Director of Nursing or the Administrator and the facility policies for the identification, response and reporting of abuse to the appropriate agencies are followed, c. The residents' attending physicians and the Medical Director are notified, d. A resident Incident/Accident/Report is completed and submitted using the Risk Management Information System. 17. Review of the policy titled, Abuse and Neglect Prohibition revised January 2017 showed the following under Protection, 1. The facility will protect residents from harm during the investigation. Under Reporting and Response showed the following, The facility will report all allegations and substantiated occurrences of abuse .to the administrator, State Survey Agency, and law enforcement officials and adult protective services .in accordance with State law through established procedures. Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation .

Based on observation, medical record review, and resident and staff interview, the facility failed to implement planned interventions to prevent falls for 1 of 2 sample residents (#2) reviewed for falls. This failure resulted in harm to a resident with a fractured hip, who continued to have falls which displaced the fracture. The findings were: Review of the significant change MDS assessment with an ARD of 11/15/16 showed resident #2 had [DIAGNOSES REDACTED]. The resident required the extensive physical assistance of two persons for ADLs such as bed mobility and transfers, and the extensive physical assistance of one person for locomotion and toileting. The resident had two falls that did not result in injury since the previous assessment. Review of the IDT post-fall notes with an effective date and time of 11/18/16 at 9:36 AM showed the resident fell out of bed in his/her room and the fall was unwitnessed. The resident was sent to the hospital due to hip pain, where a left hip fracture was diagnosed . Review of the 11/18/16 computed tomography scan results showed fixation hardware in the resident's right hip and a subtle non-displaced fracture involving the left greater trochanter. The following concerns were identified: 1. Wheelchair positioning and transfer safety: a. Observation on 5/10/17 at 10 AM showed the resident was in a wheelchair in the front lobby. The resident had slid down in the chair and was leaning to one side. The resident appeared as though s/he was uncomfortable. Interview with the resident at that time revealed s/he needed assistance to reposition. There was a receptionist at the front desk who was on the phone, and no other staff members were available in the lobby. The surveyor located an aide down the hallway and asked the aide to assist the resident. Observation on 5/10/17 at 10:23 AM showed CNA #1 and RN #1 assisted the resident to reposition in the wheelchair. At that time the resident was noted to cry out when moved up in the wheelchair. b. Observation on 5/10/17 at 11:56 AM showed LPN #1 attempted to transfer the resident from a recliner in the front lobby to his/her wheelchair. A second LPN (#2) had been assisting the resident with fluids. During the transfer LPN #2 stood back and did not provide a second physical assist while LPN #1 used a gait belt and assisted the resident to a standing position. LPN #1 asked and encouraged the resident to turn so s/he could sit into the wheelchair. The resident was unable to perform the task so LPN #1 then lowered the resident back into the recliner and a sit-to-stand mechanical lift was used with the assist of both LPNs to complete the transfer. During the observation it was noted the cushion in the resident's wheelchair was in poor condition with the front section flattened. c. Observation on 5/10/17 at 5:30 PM showed the resident was in the wheelchair in the assisted dining room. There were staff members in the room; however, none noticed the resident was poorly positioned in the wheelchair. The resident was leaning to one side, had slid forward on the seat, and had his/her legs tucked under the chair. At 5:50 PM the resident was taken from the table and transported in the wheelchair by CNA #2. The aide did not reposition the resident and the resident's feet were dragging under the chair as the CNA transported the resident down the hallway. Interview with CNA #2 on 5/10/17 at 5:52 PM revealed she was not aware of any technique or plan for the resident to prevent the feet from dragging. d. Interview with Physical Therapist #1 on 5/11/17 at 10:15 AM revealed there had been past attempts made to equip the resident's wheelchair with various foot rests and none were accepted by the resident. Further, the therapist verified in the past other chairs and cushions had been tried for the resident to allow for better positioning. However, no attempts had been made to increase the height of the seat on the resident's current chair. He verified it was possible this may help to better position the resident. The therapist stated staff should ask the resident to lift his/her legs while being transported. A later interview on 5/11/17 at 11:32 AM with the therapist verified the cushion that was being used in the resident's chair was not the correct cushion, and the cushion's condition made it ineffective for comfort or positioning. 2. Review of the SBAR notes from November 2016 to May 2017 showed the resident fell an additional 16 times after the 11/18/16 fracture. Review of the SBAR communication and IDT progress notes from these falls and their respective dates showed the following falls were unwitnessed: a. Review of the SBAR dated 11/21/16 and timed 10:19 PM showed the resident was found in room laying on the floor on back, noted incontinent of urine, had been in (his/her) w/c (wheelchair). The SBAR further showed the resident was .not able to comprehend (sic) that (s/he) is not safe enough to be up ambulating by (him/herself) and that (s/he) has a fx (fracture). And .up by nurses station so (s/he) can be monitored. Review of the IDT post fall review for this fall showed the resident was unable to demonstrate the use of the call light in the room or in the bathroom. The summary of the interdisciplinary team showed Resident while awake needs to be within sight of staff, encourage resident to remain close to nurses station. b. Review of the SBAR dated 11/24/16 and timed 11:25 PM showed the resident was found lying on floor in bathroom on L (left) side with towel rack in hand. The resident's wheelchair was in the doorway. c. Review of the SBAR dated 12/23/16 and timed at 6:46 AM showed the resident attempted to transfer him/herself from bed to chair, lost balance and fell out of bed. Review of the IDT post fall review for this fall showed the resident was unable to demonstrate the use of the call light in the room or in the bathroom. The summary of the interdisciplinary team showed Change the get up time to earlier in the morning so resident doesn't try to assist (him/herself) on getting up in the morning. d. Review of the SBAR dated 1/3/17 and timed at 10:33 AM showed the resident had an unwitnessed unassisted self transfer resulting in a fall. Review of the IDT post fall review for this fall showed the resident was in bed prior to the fall, and was unable to demonstrate the use of the call light in the room or in the bathroom. e. Review of the SBAR dated 1/18/17 and timed at 3 AM showed the resident was self- transferring from wheelchair to bed, couldn't support (his/her) weight and assisted (him/herself) to the mat on (his/her) knees . Review of the IDT post fall review for this fall showed the recommendation of the interdisciplinary team was (Resident name) will verbalize understanding of safety precautions and education provided. Will verbalize understanding of potential complications of not complying with safety recommendations. Has poor safety awareness, refuses assistance, stand by and provide help as needed. f. Review of the SBAR dated 2/16/17 and timed at 7:36 PM showed the resident was .found on the floor in the small dining room .Resident had been eating (his/her) supper there. Was noted on (his/her) right side, (his/her) w/c (wheelchair) behind (him/her). It was noted during supper, resident kept falling asleep and (s/he) had to woke (sic) several times . The SBAR further showed the resident was unable to sit up in w/c, leaning forward and falling asleep. The resident was placed in a recliner by the nurse's station. Review of the IDT post fall review for this fall showed the interdisciplinary team recommendation was ABX (antibiotics) for URI (upper respiratory infection) and ST (speech therapy) for pocketing food. The recommendation failed to describe interventions related to the resident falling asleep at the table. g. Review of the SBAR dated 2/19/17 and timed at 12:23 PM showed the Resident fell forward out of w/c (wheelchair) onto (his/her) knees. (S/he) did this twice trying to transfer (him/herself). Review of the IDT post fall review dated 2/20/17 at 9:33 AM showed the falls were unwitnessed and the falls occurred in the resident's room. h. Review of the SBAR dated 2/28/17 and times at 3 AM showed the resident to have tried to get onto bed and legs gave (sic) (s/he) sat on floor. Resident was sitting (sic) on mat when found .was in wheelchair. i. Review of the SBAR dated 4/19/17 and timed at 10:50 AM showed the resident had an unobserved fall. Review of the IDT post fall review for this fall showed the resident fell in his/her room, and the fall was unobserved. j. Review of the 4/19/17 IDT post fall review timed at 12:42 PM showed the resident had a second fall on 4/19/17. The second fall occurred at midnight when the resident fell out of his/her wheelchair in his/her room. The recommendation of the interdisciplinary team was Re- educate resident on complications associated with frequent falls. (ie major injury, hospitalization . k. Review of the SBAR dated 4/21/17 and timed at 9:46 PM showed the resident attempted .to transfer (him/herself) onto the couch in the south room and slid to floor . Review of the IDT post fall review for this fall showed the recommendation of the interdisciplinary team was Place items within reach and continue interventions on care plan. 3. Review of the current care plan with a revision date of 4/23/17 showed the resident was at high risk for falls. The problem area revealed the falls were related to decline in health status and personal choices related to safety precautions. This care plan showed 20 falls occurred while at the facility since 11/1/16. The interventions to prevent falls were shown to include the following: a. 11/1/16: educate staff to ensure wheelchair cushion is dry prior to application. b. 11/17/16: add an anti-rollback device to the resident's wheelchair. c. 11/21/16: ensure the resident was in a high visibility area while awake. d. 12/23/16 : assist resident with AM cares earlier in the morning so resident doesn't try to assist (him/herself). e. 1/20/17: ensure proper positioning, in w/c (wheelchair) & bed with each encounter, and .resident assisted (with) toileting frequently, staff to be with resident and redirect resident when resident tries to stand. f. 2/28/17: offer recliner as needed for comfort and positioning. 4. Review of X-ray results dated 12/27/16 for the left hip and lateral pelvis showed the fracture had become displaced since 11/18/16. The results showed, There is a fracture extending through the intratrochanteric portion of the proximal left femur. There is significant angulation and impaction deformity. The 1/23/17 physician consult report showed there were surgical considerations however, currently 0 (no) desire for surgery .also may consider no-op (operative) management as surgical risks are present. 5. Interview with the DON on 5/11/17 at 9:35 AM revealed the resident was his/her own person for decision making, and made poor decisions as a result of his/her mental health diagnosis. The DON verified many interventions were in place to prevent falls and the staff should follow the care plan.

Based on staff interview, medical record review, and review of the facility's clinical practice standard, the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being was provided for 1 of 1 sample residents (#5) whose change in condition required immediate medical care. This failure resulted in actual harm for the resident, who was not transported to the hospital until more than 4 hours after staff were aware of the resident's symptoms of a stroke. In addition, the facility failed to provide ongoing assessment for 1 of 3 sample residents (#6) whose change in condition required monitoring. The findings were: Review of the 6/18/16 quarterly minimum data set (MDS) assessment showed [DIAGNOSES REDACTED]. Further review showed the resident had clear speech, cognitive impairment, no swallowing difficulties and required extensive and limited assistance with most activities of daily living. Review of the Situation Background Assessment Recommendation (SBAR) communication form and progress note, dated 8/2/16, showed the resident was sitting in the wheelchair in the dining room not able to swallow, or when talking, not making sense, checked for signs of stroke, resident had slight facial droop on the left side, able to squeeze fingers with both hands, aware of name, can stick out tongue, vital signs normal . called physician at 7:45 AM. Further review of the SBAR communication form and progress note showed the relevant change in condition included decreased consciousness, decreased mobility, trouble swallowing, and garbled speech. This review showed the resident was transported to the hospital at 11:30 AM. Review of the hospital records showed the resident was admitted to the hospital on [DATE] and returned to the nursing care facility on 8/5/16. Review of the hospital discharge summary showed the resident was diagnosed with [REDACTED]. Review of the 8/6/16 physician's progress notes showed plans for the resident to receive hospice/end of life care. The following concerns were identified: a. On 9/14/16 at 10 AM the licensed practical nurse (LPN #3) who wrote the 8/2/16 SBAR communication and progress note was interviewed. During the interview she stated she tried to administer the morning medications to the resident at around 7:15 AM on 8/2/16 and noted the resident could not swallow the medications. She further stated she notified the unit manager and called the physician. During the interview she stated the resident was not transported to the hospital until 11:30 AM because staff were waiting for the physician to see the resident (this was over 4 hours after staff recognized the signs of a stroke). b. Interview with the physician on 9/14/16 at 12:20 PM revealed he supported decisions to transport residents to the hospital, and expected staff to do this when they recognized residents needed immediate medical care. c. Interview on 9/14/16 at 2:45 PM with the unit manager revealed staff recognized the resident had signs and symptoms of a stroke, called the physician, and monitored the resident until the physician arrived. She stated the facility protocol required the nurses call the director of nursing, assistant director of nursing or herself when they noted a change in a resident's condition, but nothing prohibited staff from bypassing the protocol and sending a resident to the hospital if the condition required immediate medical care. d. Review of the American Heart Association 2016 publication, at http://www.heart.org/HEARTORG, titled Warning Signs of [MEDICAL CONDITION], Stroke, and [MEDICAL CONDITION], accessed on 9/26/16, revealed the following information: The warning signs for a stroke include facial drooping, arm weakness, and speech difficulty. If the person shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get them to the hospital immediately. e. During an interview on 9/14/16 at 4 PM the director of nursing verified the resident was not transported to the hospital when staff initially recognized the signs and symptoms of a stroke. 2. Review of the 7/29/16 admission MDS assessment showed resident #6 had [DIAGNOSES REDACTED]. Further review showed the resident had moderate cognitive impairment, could ambulate without staff assistance, and was easily understood by staff. Review of the nursing notes, dated 8/16/16 and timed between 3:16 PM and 4:15 PM showed the resident complained of left sided chest pain and vomiting after eating his/her birthday meal. At that time the unit manager assessed the resident, determined the resident had upper gastric discomfort, and administered Tylenol with an antacid. The resident's blood pressure was 174/90 and the Tylenol and antacid effectively alleviated the resident's symptoms. Review of the documentation that followed, dated 8/16/16 and timed 11:45 PM, revealed the resident's blood pressure was 216/130 and s/he was again complaining of chest pain. Further review revealed after LPN #1 called the director of nursing and physician, the resident was transported to the hospital. The following concerns were identified related to ongoing assessment and communication of the resident's change in condition between nursing staff at shift change: a. Review of the medical record showed no documentation on 8/16/16 regarding the resident's blood pressure and/or chest pain from 4:15 PM to 10 PM. b. Interview with the unit manager on 9/14/16 at 2:45 PM revealed staff monitored the resident throughout the afternoon and determined the resident had epigastric discomfort because the Tylenol and antacid relieved his/her symptoms. However, she was unable to provide evidence of the monitoring, additional assessments, or staff's response when the resident's pain returned later. c. Interview with certified nurse aide #1 on 9/13/16 at 9:40 PM revealed she obtained the resident's blood pressure on 8/16/16 at 10 PM, and at that time the resident was flushed, and complaining about his/her chest hurting. She further stated the resident did not look good. d. Interview with LPN #1 on 9/13/16 at 9:50 PM revealed the resident's blood pressure was 240/136 on 8/16/16 at 10 PM. The LPN further stated he coordinated the transfer of the resident to the hospital for evaluation. e. Interview on 9/13/16 with LPN #1 at 9:50 PM and LPN #2 at 10 PM revealed the off-going day shift did not communicate to the on-coming 6 PM shift on 8/16/16 about the resident's episodes of chest pain and elevated blood pressures that occurred earlier that day. Both nurses stated it is difficult to provide continued monitoring when staff are not aware of the need to provide frequent monitoring and assessments. Review of the hospital records showed the resident was admitted to the hospital after midnight on 8/17/16 and returned to the facility on [DATE]. The hospital records also showed the resident had stabbing lower mid-sternal chest pain beginning at approximately 6 PM on 8/16/16. This review showed the chest pain had dissipated by the time the emergency department staff assessed the resident; However, his/her blood pressure remained elevated at 180/113. Further review revealed the summary of test results included aortic, tricuspid, and [MEDICAL CONDITION] valve regurgitation, elevated velocities in the right [MEDICATION NAME] artery, a variance in blood pressure in each arm, and tests for confirming a [MEDICAL CONDITION] were negative. 3. Review of the clinical practice standard, titled Change in Resident Condition, revised June 2008, provided by the director of nursing showed the following guidelines for staff: a. For life-threatening events: Call 911 if initial assessment indicates that such action is necessary. b. Changes of Condition Forms are used to assess and document changes in condition in an efficient and effective manner; provide assessment information to the physician and provide clear comprehensive documentation. c. Changes in condition are communicated from shift to shift through the 24 hour report management system. d. Changes in the resident status that affect the problems(s)/goal(s) or approach(es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers.

Based on observation, medical record review, and staff interview, the facility failed to ensure residents with pressure ulcers received treatment and services to prevent wound decline for 1 of 3 sample residents (#1) with wounds. This failure resulted in actual harm to resident #1. The findings were: Review of the 7/10/16 admission MDS assessment showed resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident required the extensive assistance of two persons for activities of daily living such as bed mobility, transfers, dressing, toilet use, and personal hygiene, and was at risk for pressure ulcers. The resident was always incontinent of both bowel and bladder. Review of the 7/3/16 Nursing Admission Data Collection form showed the resident did not have any pressure ulcers. Review of the 8/8/16 Head to Toe Skin Check showed the resident did not have any pressure ulcers. The following concerns were identified: a. Review of the medical record showed no head to toe skin checks were completed after 8/8/16. b. Review of the 8/9/16 SBAR Communication Form and Progress Note showed the resident had an abrasion to the sacrum just above the coccyx. Review of the 8/9/16 Weekly Non-pressure Condition Record showed the resident had an abrasion to the sacrum that measured 6 inches by 4 inches. c. Review of the progress note dated 8/11/16 and timed at 3:06 PM showed Resident along with (his/her) right buttocks sheering/blister wound also has some blister wounds are (sic) (his/her) lower back. All wounds have red wound beds. Right bottom wound does have some discoloration to the wound bed such as dark red/black areas. Wounds were cleansed and a small amount of skin barrier cream was applied to the open areas. Resident is going to lay in bed after meals and will be turned every 2 hours. d. Review of the Nursing Daily Skilled Charting form for 8/12/16 showed the resident had no skin issues, and no changes in skin integrity. Review of the Nursing Daily Skilled Charting forms for 8/13/16 through 8/18/16 showed the same. e. Review of the medical record showed no other assessment of the right buttock wound between 8/11/16 and 8/19/16. f. Review of the Nursing Daily Skilled Charting form for 8/19/16, timed at 10:30 AM, showed the resident had dehisced (re-opened) surgical wounds, but the form made no mention of skin breakdown on the resident's lower back or buttocks. The form further noted the resident was to go to the wound clinic later that day. g. Review of the progress note dated 8/19/16 and timed at 10:49 AM revealed .Resident goes to wound care clinic today. Wound care clinic was called to get report on resident's areas of concerns. They were informed of open blisters on lower back and right buttocks, and bi-lateral ankle incisions dehiscing due to lower extremity [MEDICAL CONDITION]. They will evaluate the areas of concerns and provide a treatment plan. h. Review of wound clinic documentation dated 8/19/16 and timed 1 PM showed the resident's right buttock wound measured 9.5 inches by 5.7 inches. The wound site was described as Dry black eschar; Moist yellow slough; Adherent yellow slough. The wound clinic also described a suspected deep tissue injury on the resident's right heel that measured 0.6 inches by 1.3 inches, and a suspected deep tissue injury on the resident's left heel that measured 1.5 inches by 1.5 inches. Further review of the resident's medical record showed neither heel wound was noted prior to the resident's visit to the wound clinic. i. Observation on 8/31/16 at 2:01 PM showed CNA #1 and CNA #2 entered the resident's room to provide care. The resident was rolled onto the left side, and the dressing on the resident's right buttock was visualized. The dressing was completely saturated with brown-colored liquid. The absorbent pad beneath the resident was also saturated with brown-colored liquid. The absorbent pad was changed, and the resident was repositioned. j. Interview with LPN #1 on 8/31/16 at 3:55 PM revealed she was the charge nurse for the resident and had received no report the resident's wound dressing was saturated. k. Observation of a dressing change on 8/31/16 at 5:47 PM with RN #1 and the DON showed the resident's right buttock wound was a large, full-thickness wound with tunneling. Interview with RN #1 and the DON at that time confirmed CNAs should report to the nurse when a dressing is saturated. l. Interview with the DON and the regional director of clinical services on 8/31/16 at 7:45 PM revealed the facility did not, at that time, have a dedicated staff member to oversee and coordinate wound assessments and services. It was further confirmed no head to toe skin assessments had been completed on the resident after 8/8/16, and no assessment was made of the resident's right buttock wound between 8/11/16 and 8/19/16 when the resident went to the wound clinic.

Based on observation, medical record review, and staff interview, the facility failed to ensure adequate care in the following areas: assessment and treatment for 1 of 11 sample residents (#30) with a change in condition, resulting in further decline; adequate coordination of care for 1 of 1 sample resident (#28) who had a non-pressure wound; adequate medication administration for 3 of 37 sample residents (#32, #51, #63); adequate pain interventions for 1 of 14 sample residents (#11) who had pain issues; and adequate post-fall neurological assessments for 1 of 3 sample residents (#1) who had falls that required neurological assessments. The findings were: Concerns with the assessment and treatment of [REDACTED]. 1. Review of the situation background assessment recommendation (SBAR) communication form dated 6/14/15 showed resident #30 was found in his/her room by a nurse to be blue in the face with altered LOC (level of consciousness) SOB (short of breath) with increased respirations. The resident's vital signs were taken at that time and showed his/her blood pressure was 208/124, pulse rate was 114 beats per minute, respirations were 24 breaths per minute, and oxygen saturation level was 50% on 4 liters per minute of oxygen via nasal cannula. Further review showed the resident had increased confusion, abnormal lung sounds, and slurred speech. Immediate interventions included repositioning, a nebulizer treatment with instructions for breathing out through pursed lips, and a non-rebreather mask. The note stated the resident was rapidly improving, with a blood pressure of 185/93, pulse rate of 92, respiration rate to 22, and oxygen saturation level of 93%. Additional intervention included Res (resident) educated on smoking cessasion (sic). Review of the 4/12/15 admission MDS assessment showed the had [DIAGNOSES REDACTED]. The following concerns were identified: a. Further review of the 6/14/15 SBAR communication form indicated the physician was notified of the resident's change of condition on that date; however, there was no indication of how the physician was notified, or whether the physician responded to the notification. b. Review of physician's orders [REDACTED]. c. Review of the physician orders [REDACTED]. Review of the physician orders [REDACTED]. saturation levels within a specified range. Review of the daily skilled summary sheets dated daily from 5/23/15 to 6/6/15 showed the resident was receiving 4 liters of oxygen via nasal cannula daily. d. Review of the nurse's note dated 6/15/15 and timed 12-6 am shift showed the resident had no concerns other than s/he states s/he is really tired and feels like s/he slept most of the day. The note further indicated the resident received nebulizer treatments two times which the resident stated helped (him/her) out very much. Additionally, the resident's oxygen saturation level was recorded at 94% on 3 liters of oxygen via nasal cannula. e. Review of the nurse's note dated 6/16/15 and timed 8:35 PM showed the resident continues to have anxiety d/t (due to) breathing difficulties. Breathing treatments given and are effective. Further review showed the space to record the resident's oxygen saturation level was left blank. f. Review of the nurse's note dated 6/17/15 and timed 12:30 PM showed the resident continues to be anxious about oxygen levels and (his/her) breathing. Further, it revealed often times res (resident) is found out in the hallway without (his/her) O2 on. The note records the resident's oxygen saturation level was 95%. g. Review of the medical record showed no notes or vital signs, including oxygen saturation level, were recorded for the resident on 6/18/15 prior to a nurse's note timed 9 PM showed the resident was absent of vitals and pronounced dead. h. Interview with RN #2 on 9/9/15 at 5:15 PM confirmed there was no evidence the doctor received the 6/14/15 SBAR communication or provided orders regarding the change in condition. She revealed the facility did not pursue additional assessments or increase monitoring of the resident as the oxygen saturation levels were above 90% and they felt things were better with the resident. She further confirmed there was no indication on the physician order [REDACTED]. Concerns with non-pressure wounds: Observation on 9/7/15 at 11:55 AM showed resident #28 had an Unna boot (supportive dressing boot) on his/her left lower leg. Interview with the resident on 9/7/15 at 1:20 PM showed s/he had a wound resulting from a spider bite prior to being admitted to the facility on [DATE] and was being treated for [REDACTED]. Medical record review showed a 6/8/15 physician order [REDACTED]. The final physician order [REDACTED]. (L) (patient's left) lower leg with NS (normal saline) and dress with silver and foam once every 2-3 days and prn (as needed) to maintain C/D/I (clean/dry/intact) dressing. Please assist patient with application of compression stocking to left LE (lower extremity). Should wear stocking while OOB (out of bed). The following concerns regarding coordination of the resident's wound care were identified: a. Medical record review showed the facility failed to include documentation for the weekly wound clinic visits with the exception of the 8/12/15 visit when wound cultures were obtained and an Unna boot was applied. During the survey, on 9/8/15, wound care nurse #1 called the wound clinic and received the documentation for those visits. b. Physician order [REDACTED]. However, review of the entire medical record showed the facility did not complete this order after the Unna boot was applied to the resident's left lower extremity on the 8/12/15 wound clinic visit. c. Care plan review showed the facility failed to address the resident's weekly wound clinic visits, the Unna boot on the resident's left lower extremity, compression stockings, and what (if anything) facility staff should do for the resident's wound between wound clinic visits if the resident's Unna boot came off, or was soiled or restricting. d. Interview with wound care nurse #1 on 9/8/15 at 2:45 PM confirmed the facility failed to coordinate care of the resident's wound with the wound clinic. She further confirmed the facility failed to clarify the physician order [REDACTED]. Finally, she confirmed the resident's care plan failed to address areas of care concerning the resident's wound including weekly wound clinic visits, the resident's Unna boot, compression stockings and any guidance to facility staff for care of the resident's wound between weekly wound clinic visits. Concerns with medication administration: 1. Review of physician orders [REDACTED]. Further review showed only 33 of the 40 doses ordered were initialed as having been administered. 2. Review of physician orders [REDACTED]. Further review showed the 8 AM and 12 PM doses that were to be administered on 6/25/15 were not initialed as having been administered; only 38 of the 40 ordered doses were initialed as having been administered. 3. Review of physician orders [REDACTED]. 4. Interview with RN #2 on 9/11/15 at 8:50 AM confirmed the facility should be recording and investigating a medication error every time a medication is omitted. 5. Interview with the regional director of clinical services on 9/11/15 at 10:35 AM confirmed the facility was unable to locate any documentation on medication errors in the facility and was unable to determine why the medication doses were omitted, or if the facility had investigated the errors. Concerns with pain interventions: 1. Review of the 7/10/15 annual MDS assessment for resident #11 showed the resident had pain frequently and received scheduled and prn (as needed) pain medication. Review of the 7/29/15 care plan showed the resident had shoulder joint pain, and approaches included: administer pain medication, observe for signs and symptoms of pain, and monitor every shift. Further review of the care plan showed the resident did not usually verbalize pain and non-verbal signs included crying and rubbing his/her arm. Review of the physician's orders [REDACTED]. Further review also showed an order for [REDACTED].> a. Review of the September 2015 MAR indicated [REDACTED]. b. Review of the 9/1/15 nursing notes revealed the resident was out of pain pills, cried most of the shift and was up and down in the bed throughout the night. c. Review of the September 2015 prn pain Medication Administration Record [REDACTED]. Review of the September 2015 MAR indicated [REDACTED]. d. Interview on 9/9/15 at 6:15 PM with the MDS coordinator revealed the medication was not available due to a problem with the communication between the physician and pharmacist. She stated staff had not reviewed the pain management approaches to determine whether changes were needed regarding the scheduled [MEDICATION NAME], since the pain assessments showed Tylenol was effective when the [MEDICATION NAME] was not available. She further stated there might have been a variation in the way different staff assessed the resident's pain. Concerns with post-fall neurological assessments: 1. Review of the MDS coordinator's 2/15/15 MDS summary nursing notes showed resident #1 required extensive assistance with ADLs, had a BIMS score of 9 (indicating moderate cognitive impairment) and occasionally could self-propel his/her wheelchair. Review of the 2/17/15 care plan showed the resident was at risk for falls due to a history of a stroke and balance problems. Review of the Interdisciplinary Post Fall Review showed the resident fell backwards in the bathroom on 2/16/15. Further review revealed the resident hit his/her head and sustained a 6 centimeter in circumference bruise and raised knot on the left temple. Review of the POS [REDACTED]. However, the facility was unable to provide evidence that staff performed additional assessments as directed by the policy and procedure for recording and monitoring the neurological condition of a resident with a head injury. 2. According to the facility's policy and procedure titled Briggs Neurological Record, 2/09: the instructions/recommendations following any injury resulting in actual or suspected head trauma, or any change in level of consciousness include neurological checks every 30 minutes x 4, hourly x 4, every 4 hours x 24 and every 8 hours for the remaining 72 hours.

Based on observation, medical record review and staff interview, the facility failed to implement interventions to promote healing and prevent avoidable worsening of pressure ulcers. This failure resulted in a negative outcome for 1 of 2 sample residents (#12) with pressure ulcers. The findings were: 1. Review of the 4/13/15 significant change MDS assessment showed resident #12 required the extensive assistance of two persons for ADLs including bed mobility, dressing, and toilet use, and was totally dependent on the assistance of two persons for transfers. Further, the assessment showed the resident had an unstageable pressure ulcer that measured 4 cm by 4 cm. Review of weekly pressure ulcer records showed an unstageable pressure ulcer, located on the resident's left ishium, was identified on 4/1/15. At that time, the ulcer measured 4 cm by 4 cm. Review of the resident's care plan for incontinence, updated 6/17/15, showed the resident was to be checked and changed every 2 hours. Review of the resident's care plan for pressure ulcers, last reviewed on 6/17/15, showed the resident was to have rest periods in bed between meals. The following concerns were identified: a. Review of the 3/15/15 SBAR (Situation Background Assessment Recommendation) communication form showed the resident had developed a previous open area to the buttocks. Not laying resident down after each meal was listed as something that made the condition worse, and laying resident down after each meal was listed as something that made the condition better. b. Review of the 3/26/15 SBAR communication form showed the resident developed a 2.5 cm reddish area to L (left) lower buttock. Positioning was listed as something that made the condition worse and better. Additionally, the communication form noted the resident needed to be repositioned every 2 hours. c. Review of the 4/8/15 nursing weekly/monthly summary showed .Pressure ulcer is now a stage II 4.0 X (by) 4.0 ulcer left ishium. Air mattress is on bed, with frequent turning, keeping (resident) dry with every 2 hour check and change.and (resident) lies down between meals to relief (sic) pain pressure on ischial tuberosity. d. Review of the 5/29/15 weekly pressure ulcer record showed the pressure ulcer to the left ishium had increased in size to 4.8 by 5.2 cm, had a large amount of purulent exudate, and the resident was being referred to a wound clinic for treatment. e. Review of 6/4/15 wound clinic documentation showed the ulcer had a large amount of drainage, had a foul odor, and measured 5.0 by 5.0 cm, with a depth of 1.5 cm. Physician orders [REDACTED]. f. Review of 6/16/15 wound clinic documentation showed the wound's healing progress was unchanged. Instructions from the wound clinic included Nurses to keep Pt (patient) off wound area left buttock area. g. Continuous observation on 6/18/15 beginning at 9:47 AM showed the resident was up in his/her wheelchair, sitting in the front area near the facility entrance. At 10 AM, the resident was taken back to the activity room. The resident was not checked for incontinence, or repositioned. The resident's participation in the activity was minimal. At 10:43 AM, the resident was wheeled back to the front area near the facility entrance and left there. The resident was not checked for incontinence or repositioned. At 11:15 AM, the resident was again taken to the activity room, which also functioned as a dining room for meals, and was not checked for incontinence or repositioned. At 1:08 PM, (3 hours and 21 minutes after the observation began) the resident was taken to his/her room and laid down in bed. The resident's incontinence brief was changed at that time, and CNA #3 revealed the brief was wet. h. Interview with CNA #3 on 6/18/15 at 1:13 PM confirmed that was the first time the resident had been laid down or checked for incontinence since we got (him/her) up for breakfast. Review of posted facility dining times revealed breakfast was served at 7:30 AM. i. Interview with the facility administrator and corporate RN #1 on 6/18/15 at 6:45 PM confirmed the physician's orders [REDACTED].

Based on observation, medical record review, and staff interview, the facility failed to ensure effective supervision and interventions were in place to prevent falls for 2 of 18 sample residents (#90, #93). The facility's failure to provide timely assessments and consistent intervention resulted in harm for resident #93. The findings were: 1. Review of the [DATE] significant change MDS assessment (most recent assessment) for resident #93 showed s/he had a fall since admission. Review of the fall risk evaluation performed on [DATE] and again on [DATE] showed the resident scored 20 (a total score of 10 or above represents high fall risk). The following concerns with fall management were identified: a. Review of the medical record showed inconsistent information in regard to the resident's mobility capability and the extent of assistance the resident required. The following inconsistencies with assistance requirements were identified: i. Review of the [DATE] significant change MDS assessment showed the resident required limited assistance of one staff for mobility. ii. Review of the undated resident care cardex worksheet showed the resident required stand by assistance when ambulating secondary to balance problems. iii. Review of the [DATE] care plan for falls showed the resident was on the falling star program and interventions included encouraging the resident to ask for assistance, provide wheelchair assistance as needed, and offer to toilet frequently. iv. Interview with the DON on [DATE] at 11:35 AM verified the inconsistencies and said she thought the resident was "mostly independent" in mobility. b. Review of the physician's notes dated [DATE] showed the resident had dizziness, falling, difficulty with ADL's (activities of daily living), and gait disturbances. Review of the [DATE] physician's notes showed the resident had increased fatigue, restlessness, a slower gait, and continued difficulty with ADL's. Review of the [DATE] nursing notes timed at 1:50 AM showed the resident was weak, was stumbling, and required hands on assistance with a gait belt for transfer and ambulation rather than the usual standby assistance or supervision. Review of the physician's notes dated [DATE] showed the resident continued to have gait disturbances and falls, weakness, ataxia (lack of coordination of movements), dizziness, generalized pain, involuntary movements, lightheadedness, numbness, tinnitus (ringing in the ears), vertigo and visual disturbances. Review of the [DATE] nursing notes timed at 9 PM showed the resident was "very unsteady". The following concerns were identified: i. Review of the medical record showed no evidence the resident was re-assessed for safety in regard to mobility after it was noted by the physician that the resident began having dizziness, gait disturbances, and falls in [DATE]. The most recent MDS assessment was completed in [DATE] and the most recent fall assessment was in [DATE]. ii. Review of the current care plan and resident care cardex showed no evidence it had been updated to reflect the resident's decline, as noted by the physician. The most recent care plan for falls was dated [DATE], six months prior to the physician's notation of the resident's decline. iii. Review of the [DATE] post-fall review showed the resident was walking unassisted, fell after tripping over another resident's wheelchair, and broke his/her hip. Interview with DON on [DATE] at 11:35 AM revealed the resident subsequently died at the hospital. 2. Review of the the medical record showed resident #90 was admitted [DATE] with [DIAGNOSES REDACTED]. The resident was identified as being at high risk for falls on the [DATE] initial MDS and on the subsequent [DATE] quarterly assessment. Both assessments showed the resident required one person assist for transfers/ambulation, had impaired decision making ability, and had impaired short and long term memory. Review of the fall risk evaluations dated [DATE], [DATE], [DATE], and [DATE] showed the resident had a high risk for falls with scores of ,[DATE] (total score of 10 or above represents high risk). Review of the medical record showed the resident had 14 falls between [DATE] and [DATE]. The following concerns were identified: a. On [DATE] at 1:30 AM the resident was found on the floor near the bed after staff heard the bed alarm. The resident stated s/he was trying to get to the wheelchair. Review of the recommendations from the post-fall evaluation dated [DATE] included the following: continue the falling star program, continue to keep alarms on the bed and wheelchair, have the resident wear non-skid socks in bed, and ensure the night light in the bathroom was turned on at bedtime. Further review of the medical record showed on [DATE] at 3:25 AM the staff again responded to the bed alarm and witnessed the resident falling to the floor. The resident was observed by staff to "bump (his/her) head on dresser." Review of the [DATE] care plan showed no evidence leaving the night light on at night was included in the care plan. b. On [DATE] at 10:45 AM the resident was found on the bathroom floor. The wheelchair alarm did not sound but the resident did pull the emergency call light. Review of the post-fall evaluation dated [DATE] showed the following recommendations: continue to keep the alarm on the wheelchair and make sure it was attached and working, and to continue the falling star program. Review of the medical record revealed no evidence staff checked the alarm on the wheelchair to determine why it did not alarm at that time. c. On [DATE] at 11:30 PM the resident was found on the floor by the bed "messing with the pressure alarm box to (his/her) wheelchair." Review of the post-fall evaluation dated [DATE] showed no evidence earlier recommendations had been implemented such as wearing non-skid socks while in bed or whether the bed alarm was functioning properly. One new intervention was recommended which was to place a fall mat next to the resident's bed. Review of the [DATE] care plan showed this recommendation was not added to the care plan as an intervention. d. On [DATE] at 7:45 AM the resident was observed sleeping in his/her wheelchair at the nurses' desk and "jerked self awake, pitched out of wc (wheelchair)." Review of the [DATE] post-fall evaluation showed the only new recommendation was to assist the resident to bed when s/he "falls asleep" in the wheelchair. Review of the [DATE] care plan showed this intervention was not added. e. On [DATE] at 9:45 PM the resident was found on the floor next to the bed. Review of the post fall evaluation dated [DATE] showed no evidence the resident was assessed to determine if the recommended interventions had been implemented to possibly prevent this fall. There was no evidence the bed alarm was working or the resident had on his/her non-skid socks while in bed. Continued review of the post-fall evaluation showed the only recommendation was to "allow resident to adjust to new room mate, if unsuccessful will eval (evaluate) for room change." f. On [DATE] at 9:45 PM the resident was found sitting on the floor mat next to the bed. There was no evidence the bed alarm was assessed to determine if it was properly working. Review of the [DATE] post-fall evaluation showed recommendations were to follow all current interventions and to obtain an occupational therapy (OT) evaluation. Review of the [DATE] OT evaluation showed the core issue related to falls was the resident's poor safety awareness. Continued review of the OT assessment showed a goal to increase the resident's safety awareness, however, no new interventions were developed or implemented over the next four weeks of therapy. g. On [DATE] at 6 AM the resident was found sitting on the floor by the bed. There was no evidence the bed alarm was assessed to determine if it was properly working. Review of the [DATE] post-fall assessment showed recommendations were to continue using the high-low bed, the fall mat next to the bed, the alarm to the wheelchair, and for "staff to encourage res (resident) to use call light for assistance." h. On [DATE] at 9:40 AM the resident was found on the floor by the door to his/her room. Review of the post-fall evaluations dated [DATE] and [DATE] showed no new recommendations were made. i. On [DATE] at 5 AM the resident was found on the floor by the bed. Review of the post fall evaluation dated [DATE] showed no new recommendations were made. j. On [DATE] at 2 PM the resident was found on the floor in the resident's room near the wheelchair and bed. Review of staff documentation showed "alarm was not sounding, but seems to work after we put back". Review of the post-fall evaluation dated [DATE] showed no new recommendations. k. On [DATE] at 7:15 AM the resident was found on the floor by the wheelchair. Review of the [DATE] nursing notes showed the resident received a laceration to the forehead and nose, and a "ST (skin tear) to (L) wrist and bruise to (L) side." Review of the [DATE] post-fall evaluation showed "will attempt tabs alarm to chair instead of pressure to decrease agitation. " However, review of the [DATE] care plan showed no evidence this was added to the care plan or any other interventions were implemented to try to decrease the resident's agitation. Review of the entire medical record showed no evidence staff assessed the impact of the resident's agitation on his/her frequent falls. l. On [DATE] at 4 PM the resident was found on the floor in front of the wheelchair near his/her room. Review of the [DATE] post-fall evaluation showed no additional recommendations were made except to encourage the resident to rest in bed when s/he was tired. Review of the [DATE] care plan showed this intervention was not incorporated into the plan. m. On [DATE] at 11 AM the resident slid to the floor during an assisted transfer from the wheelchair to the bed. Review of the [DATE] post-fall evaluation showed one new intervention which was to obtain a pharmacy consultation to determine if medications were a contributing factor in the resident's multiple falls. On [DATE] at 12:18 PM, an e-mail was sent to the pharmacy representative requesting a medication evaluation for the resident related to his/her frequent falls. The same request was made again [DATE] at 9:04 AM because the pharmacist had not yet responded. The pharmacist replied by e-mail on [DATE] at 2:41 PM, 13 days after requested. n. Review of the [DATE] care plan and the care plan reviews dated [DATE], [DATE] and [DATE] showed no evidence the interventions recommended by the fall team on their post-fall evaluations were incorporated into the plan. Recommendations that were not included were: leaving the night light on in the bathroom, assuring all alarms were working, using a high-low bed, placing a fall mat by the bed, and addressing how the resident's agitation impacted his/her falls. Interview on [DATE] at 11:15 AM with the DON revealed staff were aware of the resident's frequent and multiple falls. The DON said "(s/he) has been a hard one". The DON verified not all recommended interventions were included on the care plan. Review of the facility policy, Fall Management dated August, 2012 showed falls were communicated to the IDT (interdisciplinary team) by the nursing 24 hour report. The responsibilities of the IDT team included the review of all falls within ,[DATE] hours; revisions to the plan of care; and placing and removing residents from the falling star program. According to the same policy, the falling star is a "visual identifier/reminder" program to recognize residents at risk for falls.

Based on staff interview, review of 24 hour shift reports and facility policies and procedures, and medical record review, the facility failed to ensure staff assessed, monitored, and implemented measures to prevent and treat skin breakdown for 2 (#1, #6) of 5 sample residents who had or were at risk for skin breakdown. This lack of assessment, monitoring, and implementation of measures likely contributed to worsening of a pressure ulcer for resident #6. The findings were: 1. Review of the most recent MDS assessment, a quarterly assessment dated [DATE], for resident #6 showed s/he was at risk for pressure ulcers. Review of the 12/5/12 Braden risk assessment showed the resident was at high risk of developing a pressure ulcer. The following concerns with pressure ulcer prevention and management were identified: a. Review of the 11/17/12 nursing notes timed at 1:35 PM showed a CNA notified RN #3 there was an open area on the resident's left buttock. Review of the entire medical record showed no evidence the open area was assessed until 12/5/12 (18 days later) at which time it was unstageable. Interview with the wound care nurse/DON and unit manager on 1/3/13 at 2 PM verified the open area should have been assessed on 11/17/12 when it was first identified. They both agreed new open areas should be assessed immediately, not 18 days later. b. Review of the weekly skin check forms showed no evidence the weekly skin checks were performed after 11/12/12. Review of the November 2012 TAR showed the weekly skin checks were due on 11/19/12 and on 11/26/12, however, both of these areas were left blank indicating the skin checks were not performed on those dates. Interview with the wound care nurse/DON and unit manager on 1/3/13 at 2 PM verified the weekly skin checks were not performed weekly as they should have been after 11/12/12. c. Review of the entire medical record showed no evidence the physician, the family, or the wound care team was notified of the open area until 12/5/12, 18 days after the CNA notified RN #3. Interview with the unit manager and DON/wound care nurse on 1/3/13 at 2 PM revealed they were unaware of the pressure ulcer until 12/5/12. According to the wound care nurse/DON, on 1/3/13 at 2 PM, the wound now had a foul odor to it. 2. Review of the medical record for resident #1 showed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] showed the resident was cognitively impaired and required extensive assistance with activities of daily living (ADLs). The CAA assessment dated [DATE] showed the resident triggered for pressure ulcers. Review of the care plan updated on 3/9/12 showed interventions for pressure ulcers included: observe skin weekly and document findings. Review of the head to toe skin assessments showed the resident was admitted with a Stage II pressure ulcer on his/her coccyx which was healed in March 2012. The following concerns were identified: a. Review of the head to toe skin assessment on 12/5/12 showed the resident had an open area on the coccyx. Review of the 12/12/12 assessment showed the resident continued to have an open area on the coccyx (now 7 days). Review of the 12/5/12 and 12/12/12 treatment administration record (TAR) also showed the resident had an open area to the coccyx. Review of the 24 hour shift reports and the entire medical record, however, showed no evidence the physician and wound team were aware of the pressure ulcer. In addition, review of the medical record showed no evidence the open area on the coccyx was assessed, treated or managed by the wound team and physician. b. Review of a 12/22/12 physician's order revealed the resident was sent to the hospital emergency room for treatment of [REDACTED]. c. Interview with RN #2 on 1/3/13 at 1:55 PM revealed nurses were responsible for performing head to toe skin assessments on residents. Any new open area on the resident's skin was to be documented on the assessment forms and on the TAR, the physician and the wound care nurse were to be notified of the open area(s), and the nurse also should fill out an Inter Act form. The nurse explained the Inter Act form prompts the nurse to notify the resident's physician and family of a change in condition. The RN further said the nurse performing the assessment should notify the unit manager and the DON. Finally, the RN said the presence of an open area should be documented on the 24 hour shift report. Interview with the DON on 1/3/13 revealed she expected the nurses to follow this protocol. d. Interview with LPN #2 on 1/4/13 at 1:50 PM verified the resident had an open area at the crease of the coccyx on 12/5/12 and that she had informed the day shift unit manager. The LPN also said the protocol was " different for the night shift " . She said the night nurse informed the day shift unit manager and the manager filled out the Inter Act form, notified the physician, the resident's family, and the DON. The treatment was then to be initiated by the wound care nurse. A review of the facility policy dated 2012 showed,"skin assessments 16.D. A Change of condition form is to be completed and new physician's order obtained for new incidence of compromised skin integrity".