Every finding on record at Poudre Canyon Rehabilitation and Nursing, LLC

Based on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for accidents and hazards received adequate supervision to prevent an elopement out of 26 sample residents. Resident #6 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, chronic respiratory failure and traumatic brain injury. Beginning in January 2026, the resident began displaying elopement seeking behavior and was telling staff he wanted to leave the facility. His exit-seeking behaviors escalated, which prompted a review from the physician, who recommended a wanderguard device and expressed serious concerns regarding his safety, poor insight, and impaired judgement. On 3/23/26 facility leadership told Resident #6 he would no longer be permitted to leave the facility unsupervised, after an assessment by his physician determined the resident was no longer safe in the community. The resident got angry with this information and became increasingly agitated. The resident argued with facility staff and threatened that he was leaving against medical advice (AMA). Despite the entire facility being securely locked and alarmed at each entrance/exit doors, being accessible for residents to exit when staff deactivated the lock doors, to let residents in and out of the building Resident #6 found a way to elope for the building without staff knowledge. On 3/23/26 Resident #6 went outside on the secured back patio, where he was observed by another resident to be pushing on the gate. Resident #6 was able to break the gate open and elope from the facility unsupervised by staff. The resident who observed this, reported the incident to staff. The facility was unable to locate the resident following a search of the neighborhood. The facility did not learn of the resident's whereabouts until 3/27/26 (four days after he left the facility) when the hospital contacted the facility. After eloping from the secured back patio, Resident #6 walked approximately three miles, where he was found by emergency medical services (EMS) lying on the side of the highway by a local hotel. As a result of his fall, the resident sustained a hip fracture and left elbow fracture, which required surgery. The resident was additionally treated for pneumonia.On 7/5/26, Resident #6 again eloped from the facility, through a window in an office. The facility was unsure how long the resident was missing for. The resident was found sitting underneath a tree outside of the facility. Specifically, the facility failed to: -Implement adequate interventions to prevent Resident #6 from eloping from the secured community building on 3/23/26, which resulted in the resident being missing from the facility for four days before being located in a local hospital after being treated for his injuries; and, -Prevent Resident #6 from eloping from the facility again (on 7/5/26), three months after he eloped on 3/23/26. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/20/26 to 7/28/26, resulting in the deficiency being cited as past noncompliance with a correction date of 7/16/26.I. Facility plan of correctionThe facility's plan of correction was provided by the corporate nurse consultant on 7/23/26 at 11:00 a.m. The plan of correction documented the facility took action after Resident #6's 7/5/26 elopement to examine the root cause of his ability to elope out of the building without staff's awareness and to look at the factors in his ability to successfully exit the building.The corrective actions taken included providing education to staff that when a resident was actively exit-seeking, the resident was not to be left alone until the interdisciplinary team (IDT) determined the resident was no longer an elopement risk. The maintenance staff secured all of the facility's windows so they were only able to open six inches. The maintenance staff additionally secured all of the office doors to be kept locked when unoccupied by a staff member. In addition, Resident #6's care plan was reviewed for appropriate interventions and updated accordingly. The facility examined all residents in the facility who were at risk of elopement and assessed their care plans for accurate person-centered intervention and educated staff of any updates. All corrective actions were in place as of 7/16/26.II. Facility policy and procedureThe Elopement and Wandering policy implemented 4/30/25 and revised 6/2/26 was provided by the nursing home administrator (NHA) 7/23/26. It read in pertinent part, This facility ensures that residents who exhibit wandering behavior and or are at risk for elopement, receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team. Charge nurses and unit managers will monitor the implementation of interventions, and responses to interventions will be documented. Effectiveness of interventions will be evaluated and changes will be made as needed.III. Resident #6A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physicians orders (CPO), diagnoses include dementia with behavioral disturbance, chronic respiratory failure and traumatic brain injury. According to the 5/12/26 minimum data set (MDS) assessment, the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment indicated the resident did not have symptoms of inattention or disorganized thinking. -However, a physician's note, dated 4/14/26, documented the resident had significant deficits in attention, insight and judgment, with the inability to understand or reason. The assessment documented the resident was ambulatory and able to walk at least 150 feet with only verbal cues and or touching/steadying assistance.B. Record reviewThe elopement risk care plan, initiated 4/3/26 revised 4/7/26, revealed Resident #6 was at risk for elopement related to a history of elopement attempts, anger over his placement in the facility and a strong desire to leave the facility. Pertinent interventions included providing frequent checks related to poor safety awareness, identifying triggers for wandering or elopement, offering to assist the resident to the enclosed courtyard and offering approved tobacco products.The nurse practitioner (NP) note, dated 2/23/26, revealed Resident #6 was unable to demonstrate understanding of the purpose of a wanderguard device or the risks and safety concerns associated with wandering into the community without staff support. The resident held a fixed belief that he would not get lost while out in the community unsupervised. During the assessment, the resident was distractible and unable to demonstrate understanding of the purpose of the wanderguard. He was unable to explain why staff were concerned about wandering or articulate potential risks associated with leaving the secured area. When asked about possible consequences, he repeatedly stated that he would not get lost and was unable to engage in further reasoning regarding personal safety. The resident demonstrated impaired attention, insight, and judgment with inability to understand, appreciate, or reason through the safety implications of wanderingThe note documented since the resident lacked medical decision making capacity, the recommendation was to continue safety measures to prevent elopement.A community assessment, dated 3/23/26, revealed Resident #6 had a desire to leave the facility independently. The assessment documented the resident's physician had several concerns regarding the resident's declining cognition and his current ability to demonstrate safe decision making/choices when in the community unsupervised. Despite having a BIMS score revealing intact cognition and being alert and oriented to person, place and time, he was not oriented to situational matters, the resident had a St. Louis University Mental Status Exam (SLUMS) score of 12, which indicated the resident had moderate cognitive impairment driven by a diagnosis of dementia. The resident had a substance use disorder and his recovery status was unknown. Additionally, the resident was prescribed psychotropic and antiseizure medications to manage symptoms of agitation and paranoia. The assessment documented his symptoms were well managed when he took the medications. The resident was unsteady while walking without an assistive device and he demonstrated poor safety awareness while in a community (unstructured) setting. The resident was at risk of injury in high vehicle traffic areas as evidenced by a prior history of getting into the street and being struck by a motor vehicle and was seriously injured when he lived in a prior setting back in March of 2022. The recommendation after this assessment was to no longer allow Resident #6 the ability to leave the facility and be in the community unsupervised. The resident was informed of this assessment and the resident did not agree. The nursing note, dated 3/23/26, documented Resident #6 had a history of leaving against medical advice several times in the past. He insisted on getting out of the building and tried exiting multiple entry doors; however, alarms went off each time. Resident #6 was advised that he should not leave the building unplanned without food and shelter. The resident told the staff I don't care, if you don't open the door, I will kick the door open and leave. Resident #6 later managed to get out of the building through the smoking courtyard gate.The missing person incident report, dated 3/23/26, revealed Resident #6 was informed that he could not go into the community alone because his physician assessed him to not be safe outside of the facility unsupervised. Upon receiving notice that he could not leave the facility, the resident grew increasingly agitated. He argued with staff and IDT members. He threatened that he was leaving against medical advice. The resident was seen by another resident in the secured courtyard, pushing his weight on the gate until he was outside of the facility grounds. That resident reported Resident #6's elopement. A search of inside the facility and the facility grounds was conducted and staff were unable to locate Resident #6. The incident report documented the facility's leadership team conducted a root cause analysis and determined that a failure to implement adequate elopement risk interventions after a change in a resident's capacity; lack of care plan update following physician documentation of incapacity; an insecure gate in the courtyard and insufficient staff monitoring and supervision of a known at-risk resident contributed to Resident #6's ability to elope from the facility and become a missing person.The emergency room provider note, dated 3/23/36 at 11:01 p.m., revealed Resident #6 was brought in by ambulance after being found at the side of the highway three miles away from the facility. Clinical impressions included dehydration, generalized weakness, lightheadedness, COPD exacerbation and pneumonia to both lungs. A 3/24/26 staff education, regarding Resident #6's 3/23/26 elopement, documented staff were educated that if staff noticed signs of an impending elopement, they should redirect the resident and notify the supervisor immediately. If a resident was actively exit-seeking or trying to leave the facility, staff were educated not to leave the resident unsupervised.The hospital note, dated 3/26/26, documented Resident #6 underwent a left elbow open reduction internal fixation (surgical repair) as well as a left femur intramedullary rod insertion trochanteric (surgical repair of a broken left hip using a metal rod inserted directly into the center of the thigh bone) on 3/26/26. The hospital after-visit note, dated 4/3/26, documented Resident #6 was treated in the hospital from [DATE] to 4/3/26.A wandering/elopement risk evaluation, dated 5/12/26, revealed Resident #6 was at high risk for eloping due to anger over his placement in the facility, previous elopement attempts, a history of substance use disorder, short and long-term memory impairment and impaired decision-making skills. The incident report, dated 7/5/26 at 4:15 p.m., documented Resident #6 had been exit-seeking and had made several attempts that day to exit the building without staff awareness. Due to these behaviors, the nurse was rounding on him at regular intervals, approximately every 30 minutes. The investigation documented that the nurse said while she was doing rounds, she was unable to locate the resident. The nurse said she notified all of the staff and they began looking for the resident. The nurse located Resident #6 outside, sitting on the sidewalk beneath the peach tree on the east side of the building. -However, the investigation did not investigate if any other staff members were monitoring the resident's whereabouts after he expressed a desire to leave the facility and had been making several attempts to elope for the building, despite the plan of correction indicating the staff were provided education regarding missing persons after the 3/23/26 missing person incident. The staff had previously been educated to not leave a resident alone if they were actively exit-seeking following the 3/23/26. The 7/5/26 incident report documented that during the search for Resident #6, facility staff observed a door to an unoccupied office was open. Upon searching the office, the resident was seen outside, sitting under a peach tree on the east side of the building. Upon further observation of the office, it was noted that the window was open and the screen was pushed out. Upon interviewing Resident #6, he told staff he wanted to leave and opened the window, pushed out the screen and climbed out of the window. The resident was assessed and no injuries were observed. As a part of the investigation, the IDT conducted a root cause analysis of the elopement incident and revealed the resident had poor safety awareness, behavioral causes related to history of traumatic brain injury, and impaired decision-making. -However, the root cause analysis failed to investigate why the resident was able to elope out of a window in a staff office without staff awareness. The documentation did not indicate if the facility reviewed the interventions in place to assess if they were still appropriate. The 7/25/26 incident investigation documented new interventions included frequent checks for safety on Resident #6 during times of attempted elopements, until he was no longer displaying elopement behavior; unused spaces were to be kept secured; and window openings were to be adjusted to not exceed six inches of open clearance.IV. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 7/23/26 at 9:15 a.m. CNA #3 said Resident #6 was monitored closely when he was wandering in the hallways for risk of elopement and if he displayed elopement behaviors he was to be observed by staff every 15 minutes for safety. CNA #4 was interviewed on 7/28/26 at 10:44 a.m. CNA #4 she said Resident #6 was checked on frequently between care. CNA #4 said this included when meal trays were passed, during hydration/fluid pass and during routine check and change rounds, which occurred every two hours. CNA #4 said Resident #6 would sometimes get upset when he missed supervised smoking times and that was when he became agitated and displayed unsafe behaviors. The NHA, the director of nursing (DON) and the corporate nurse consultant were interviewed together on 7/28/28 at 4:00 p.m. The NHA, the DON and the corporate nurse consultant said Resident #6 was checked on every 15 minutes after an elopement incident or attempt. The corporate nurse consultant said the 15-minute checks were then tapered off, per nursing judgement, when the resident was no longer displaying elopement behaviors. The corporate nurse consultant said Resident #6 was checked on every one to two hours at present to monitor for elopement behaviors.

Based on observations and interviews, the facility failed to provide a safe, sanitary and comfortable homelike environment for five out of five units.Specifically, the facility failed to:-Maintain comfortable temperature levels in residents' rooms and common areas;-Ensure residents' were provided clean linens; -Ensure the staff's dog(s) who visited regularly had the proper vaccinations and health care treatments; and,-Ensure the dog was sufficiently monitored by staff so that the staff could perform their job while ensuring the dog was not creating any safety concerns throughout the building with any resident or visitors in the facility. Findings include:I. Temperature failuresA. professional reference History of temperatures in the community As the National Weather Service points out, the heat index quantifies what the air actually feels like by combining air temperature and relative humidity. Even though Colorado generally features lower humidity, consecutive days of temperatures climbing into the mid-to-upper 90s (and peaking at 99 F in late July) still push feels like parameters into caution zones. This prolonged environmental stress causes distinct physical, behavioral, and clinical impacts on the elderly population.According to the National Institute on Aging, Hot Weather Safety for Older Adults, September 2022, retrieved 8/6/26 from https://www.nia.nih.gov/health/safety/hot-weather-safety-older-adults Too much heat is not safe for anyone. It is even riskier if you are older or have health problems. It is important to be cautious and get relief quickly when you are overheated. Otherwise, you might start to feel sick or risk a heat-related illness that could cause serious health issues. Hotter days can cause difficulty in the body's ability to regulate its temperature. This can be challenging for older adults who typically do not adjust as well as others to sudden temperature changes. Additionally, older adults are more likely to have chronic medical conditions that affect the body's response to temperature, and to take prescription medicines that alter the body's ability to control temperature or sweat. Being overheated for too long or being exposed without protection to the sun can cause many health problems. Heat-related illnesses include the following: Heat syncope a sudden dizziness. Heat cramps: a painful tightening or spasms of muscles in your stomach, arms, or legs. Heat edema, a swelling in your ankles and feet when you get hot. Heat rash, a skin irritation from heavy sweating. Heat exhaustion, a warning that your body can no longer keep itself cool. Heat stroke, a medical emergency in which the body's temperature rises above 104 F.B Facility policy and procedureThe Safe and Homelike Environment Policy, dated 4/11/25, was provided by the corporate nurse consultant on 7/23/26 at 11:00 a.m. It revealed in pertinent part, The facility will provide residents with a safe, clean, comfortable, and homelike environment. Comfortable and safe temperature levels means the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents.C. Observations and resident interviewsThe temperatures in the facility were observed from 7/20/26 to 7/27/26. The temperatures were as followsOn 7/20/26 At 12:32 p.m., the wall thermostat ambient temperature of the 400 hallway read 84 degrees Fahrenheit (F). At 1:05 p.m., the wall thermostat ambient temperature of the 200 hallway read 85 degreesAt 1:35 p.m., the wall thermostat ambient temperature in hallway 300 was set to 60 degrees F and the thermostat was reading 85 degrees F. At 2:01 p.m., the ambient temperature in hallway 400 was 85 degrees F.At 4:10 p.m., the ambient temperature in hallway 400 was 84 degrees F.At 4:48 p.m, the resident in room [ROOM NUMBER] was seated at the bedside facing her tower fan, which had a thermostat that was reading 84 degrees F. A second box fan was also in use in the room. The resident said despite having two fans in her room, it was still uncomfortably hot. At 4;50 p.m., the resident in room [ROOM NUMBER] said she was unable to sleep during the night of 7/19/26 because the temperature in her room reached 85 degrees F. The heat made her sweat all night and she would have liked for staff to have changed her bed linens and to have provided her with a cooling bath but that did not happen. She said she was still waiting for staff to assist her with this care. On 7/21/26At 1:44 p.m., the resident in room [ROOM NUMBER] said her room had been hot since the first week of May 2026. Resident #1 said the facility installed a window air conditioner unit in her room the previous Thursday (7/16/26), but the unit was not sufficient to cool the room despite being set to high on the lowest temperature setting. Despite the installation of the air conditioner and repeatedly reporting her concern to facility staff had not taken sufficient action to make the temperature comfortable. At 1:45 p.m., the temperature reading on the resident's fan thermostat in room [ROOM NUMBER] read 81 degrees F. The resident said it was extremely hot and uncomfortable for her. The temperature in her room would get up to 85 degrees F from early afternoon to evening. The resident's face had droplets of sweat and her skin was flushed and deep pink. On 7/22/26 At 9:25 a.m., the wall thermostat ambient temperature in hallway 400 read 81.At 9:49 a.m. the ambient temperature in room [ROOM NUMBER] was 82 degrees F. At 2:31 p.m., an environmental tour was conducted with the maintenance director. Temperatures were obtained in multiple resident rooms and common areas. Temperature in the hallways and resident rooms ranged between 75 degrees F and 84 degrees F. -The ambient temperature in hallway 400 was 84 degrees F; -The ambient temperature in room [ROOM NUMBER] was 83.6 degrees F; and, -The ambient temperature in room [ROOM NUMBER] was 80 degrees F.-By this time, the facility had purchased two large portable swamp coolers and nine fans to place throughout the facility (purchase date 7/20/26) (see the NHA interview below).On 7/27/26Room and hallway temperatures were assessed throughout the building from 11:36 am to 1:45 p.m. \, the ambient temperature readings were as follows:room [ROOM NUMBER]'s ambient temperature was 81.3 degrees F;Hallway 500's ambient temperature was 81.7 degrees F;room [ROOM NUMBER]'s ambient temperature was 82.4 degrees F;There were four swamp coolers and several fans blowing in the hallways throughout the building;room [ROOM NUMBER]'s ambient temperature was 82.9room [ROOM NUMBER]'s ambient temperature was 82.4room [ROOM NUMBER]'s ambient temperature was 83.5 room [ROOM NUMBER]'s ambient temperature was 83.5room [ROOM NUMBER]'s ambient temperature was 83.1 room [ROOM NUMBER]'s ambient temperature was 84.0 . The resident in the room said it was way to hot in his room for him. Hallway 400's ambient temperature was 84.6The resident in room [ROOM NUMBER] was interviewed at 1:12 p.m. She said the temperatures, in the building, especially in her room, were very uncomfortable for her and had been since May 2026. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 7/20/26 at approximately 3:00 p.m. LPN #2 said several residents had complained their rooms were excessively hot. She said they had been compiling since May 2026. She said the cooling system was not adequately cooling certain resident rooms and the common areas. She said the staff encouraged the residents to drink fluids. She said the staff provided fans to the residents if they were available. She said she reported the concern to the maintenance department since the uncomfortable temperatures occurred back in May 2026.LPN #2 said the staff were aware of the ongoing temperature concerns and the residents continued to express discomfort due to the excessive heat. She said the maintenance department was notified in early May 2026. She said the cooling issues had not been resolved.LPN #2 and CNA #4 said the air conditioning stopped working by June 2026. LPN #2 and CNA #4 said there were days when the building felt cooler because a maintenance staff member from the facility's sister building came to work on the system in an attempt to improve the temperature. LPN #2 and CNA #4 said the air conditioning problem continued.The maintenance director was interviewed on 7/22/26 at 2:31 p.m. The maintenance director said he began working at the facility four months ago. He said he was unsure when the air conditioning broke. He said when he started at the facility, the air conditioning was already broken. The maintenance director said the swamp cooling system had not been working for some time but did not know the history of the functionality or maintenance of the system since he just started working in the facility. He said the facility contracted with an outside heating and cooling company on 6/7/26 to service the cooling units. The contractors had to replace the missing copper piping and damaged electrical wiring to get the units up and running. The contractor was able to repair nine of the 15 swamp cooling units; however, the units still needed to be cleaned and serviced before they could be activated. The maintenance director said he cleaned the units and activated the system; however, the system was not sufficient even if all 15 swamp cooler units were working to adequately cool the building.The maintenance director said the facility corporation had made a decision to install central air to the building but they were still obtaining quotes and it was going to take several weeks to finalize the selection of the bids and get funding approval; then it would take time to install the system due to the required work to reconfigure the ducting system in the building. In the meantime, the facility was installing fans and air conditioners in the building to help cool the resident rooms and common spaces. The maintenance director said he had been instructed the temperature of the building should not exceed 81 degrees F.The NHA was interviewed on 7/21/26 at 5:03 p.m. The NHA said the facility began receiving formal complaints regarding the excessive heat in May 2026. He said the temperatures in the building became more uncomfortable by 5/30/26 and they made a decision to call in an emergency contractor to make repairs to the existing swamp cooling system. As of June 2026, the facility was receiving more formal complaints and they started to distribute fans to the residents for use in their rooms. The NHA said the maintenance staff went out yesterday (7/21/26) to purchase two big swamp coolers and additional fans to cool the building and they started checking ambient temperature in the building more regularly. The NHA said the delays in resolving the uncomfortable temperature complaints were due to the corporate process and the need for the central air conditioning project to be approved by the governing body. In the interim, the facility had made a decision to replace the six swamp coolers that were still inoperable to give the residents relief from the heat until the central air conditioning was installed; they were just waiting on quotes for the swamp cooler units so they could be purchased and installed. The NHA said the staff had been instructed to encourage residents to increase their fluid intake. The NHA provided a purchase receipt revealing that the facility purchased two large portable swamp coolers on 7/20/26 at 1:02 p.m., on the day the survey started and additional receipts for the purchased nine fans to place throughout the facility. The NHA said the facility was going to purchase an additional portable swamp cooling unit for the building during the week. The NHA said the facility had requested quotes for replacement of the cooling system and the quotes had been submitted to the corporate office for review and approval. They anticipated the results to take several weeks.Resident reviewOn 5/21/26, a resident council meeting was held and several residents complained about the temperature in the facility is uncomfortable and the rooms are too hot or too cold, which was addressed to the maintenance staff.II. Linen failures, environmental conditions and odors in the buildingA. Facility policy and procedureThe Safe and Homelike Environment Policy, dated 4/11/25, was provided by the corporate nurse consultant on 7/23/26 at 11:00 a.m. It revealed in pertinent part, The facility will provide residents with a safe, clean, comfortable, and homelike environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the Housekeeping Department. The housekeeping cleaning schedule was provided by the NHA on 7/21/26 at 11:oo a.m It read in pertinent part, Immediately clean spills, body fluids or soiled linens. Daily cleaning includes high touch surfaces and bathrooms. Deeper cleaning of resident rooms were to be done weekly, including wiping walls, window sills and furniture. Monthly cleaning includes overhead light fixtures and HVAC vents, scrub baseboards and clean behind equipment and furniture. Terminal cleaning of resident rooms as needed after transfer, discharge or closure.B. Observations and resident interviewsOn 7/20/26 at 12:25 p.m. The handrails throughout the facility were sticky and the floors were heavily scuffed and visibly dirty and black scuffs. The baseboards and baseboard heat vents, as well as ceiling vents, were coated in black grime; the surrounding drywall was crumbling in several areas, which had scattered dried fluid spills on the walls. Many resident rooms were in a similar condition; floors were sticky; personal items were piled on surfaces and on the floor. The facility was observed on 7/22/26 from 9:00 a.m. to 12:40 a.m., observations included: At 9:18 a.m., room [ROOM NUMBER] had a strong smell of urine.At 9:18 a.m., room [ROOM NUMBER] bed A had a strong odor of fishy smelling urine. The bed by the door was wet and soiled with fishy smelling urine that covered the sheets and blankets on the bed. At 9:42 a.m., room [ROOM NUMBER] bed A's sheets were heavily soiled and stained with brown and yellow marks. At 12:38 p.m., the bedding in room [ROOM NUMBER] bed A the bed was unmade and the fitted sheet was stained with yellow and brown substances. The pillow cases were soiled with brown stains and the pillow's plastic covering was cracked, exposing its unprotected inner surface (a potential for pathogens to seep into the inner pillow filling. The frame was caked with a thick layer of brown and orange debris that had accumulated on the surface and in the crevices. A broken jagged mirror was on the bed. The resident said he used the mirror daily and did not want to throw it away. He sad no one had offered to convert jagged edges for his safety. The bathroom toilet and toilet seat in room [ROOM NUMBER] were stained with a heavy layer of thick urine and stuck on hair around and under the toilet seat. His wheelchair was covered with thick dirt and food crumbs on the footrests all over the wheels and around the edges of the seat. On 7/22/26At 9:22 a.m., in room [ROOM NUMBER], bed A's fitted sheet was heavily soiled with black stains and chunks of black debris. The pillowcase was also heavily stained black stains and the room had a strong smell of body odor.At 9:44 a.m., room [ROOM NUMBER] strong smell of urine.At 9:47 a.m., room [ROOM NUMBER] bed A had the same soiled sheets and pillowcase as observed the day prior (see observation above). In addition, the toilet rim was still soiled with dried urine and hair The resident who resided in room [ROOM NUMBER] was interviewed on 7/22/26 at 2:45 p.m. The resident said she wanted her bed linens changed more than once a week, but the staff would only change them once a week on shower days.On 7/27/26 At 1:39 p.m., room [ROOM NUMBER] smelled like urine and the sheets were soiled at the foot of the bed with brown and black stains.On 7/28/26 At 11:25 a.m., room [ROOM NUMBER] had a strong smell of urine.At 4:49 p.m., the resident's bed linens had brown and black stains.III. Staff interviewCNA #1 was interviewed on 7/22/26 at 9:20 a.m. He said the residents' bed sheets were changed two times per week on the residents' shower day. He said if the sheets were visibly soiled, he would change them. CNA #5 was interviewed on 7/22/26 at 9:32 a.m. CNA #5 said the residents' wheelchairs were to be cleaned on a routine basis on the night shift.HK #2 was interviewed on 7/22/26 at 9: 20 a.m. HK #2 said he cleaned the floors in the hallways and the common areas daily. He said he mops the floors by hand because the electric buffer was out of service.Housekeeper (HK) #1 was interviewed on 7/22/26 at 9:30 a.m. HK #1 said she deep cleaned one resident room per day. She said when she deep cleaned a room, she cleaned the bed frames, windows and furniture. She said there was not a formal record kept of when rooms were cleaned. She said residents' wheelchairs were cleaned by CNAs.The corporate nurse consultant was interviewed on 7/23/26 at 2:47 p.m.The corporate nurse consultant said she was not sure how often the housekeepers cleaned the resident rooms. She said she was not sure how the housekeeping staff kept track of which rooms needed to be cleaned. III. Animal failuresA. Facility policy and procedureThe Safe and Homelike Environment Policy, dated 4/11/25, was provided by the corporate nurse consultant on 7/23/26 at 11:30 a.m. It read in pertinent part, It is the policy of this facility to provide a home-like environment and enhance our residents' quality of life by allowing companion animal visits.The Companion Animal Visits policy, dated 4/11/25, was provided by the corporate nurse consultant on 7/23/26 at 11:00 a.m. It revealed in pertinent part, The facility had adopted a companion Animal for visits and it is requiring companion animals to: be well-behaved and well-trained; be supervised by persons familiar with the animal and its behavior during visits; and be removed from the facility if the animal demonstrated behavior indicating it was not well-behaved or well-trained. Companion animals, which include animals visiting the facility as part of an activities program, must meet the following criteria in order to enter the facility: the animal must be well-behaved and well-trained, if the animal demonstrates that they are not well-behaved or well-trained, the animal handler/owner will be asked to remove the animal from the facility, the animal must be in good health and up-to-date with recommended immunizations and prophylactic medications (heartworm prevention) determined by a veterinarian based on local needs and recommendations, the animal must be routinely screened for enteric parasites and/or have evidence of a recently completed anthelminthic regimen; and, proof of the animal's current vaccination and veterinary treatment record must be provided to the activities director, or designee, prior to the animal's first visit to the facility. All visits must be supervised by persons who know the animal and their behavior.-However, the facility did not have the dog's records on file at the time of request. B. Observations and resident interviewsOn 7/20/26 at 11:00 a.m. the dog barked at a group of visitors who were carrying tables and then one of the staff disciplined the dog with a remote control device and the dog backed off but then started barking after a few more seconds and the staff had to made the dog to go back behind the nurses station.LPN #4 was interviewed on 7/20/26 at 11:01 a.m. LPN #4 apologized for the dog barking and said the dog barked at people carrying equipment.Resident #7 was interviewed on 7/20/26 at 1:44 p.m. The resident said she was afraid of the staff dog who was in the facility several days a week because it barked at her and also at her husband when he came to visit her.C. Record reviewThe dog's veterinarian records revealed the staff's dog was not a trained service dog and had no record of obedience training. Current vaccination records documenting the dog had all his vaccinations; however, the dog was not screened for parasites and heartworms. Additionally, the dog was not on any type of heartworm preventive treatment as required by the facility policy. D. Staff interviewsLPN #2 and CNA #4 were interviewed on 7/20/26 at 4:42 p.m. LPN #2 and CNA #4 said the dog belonged to CNA #4 and had been coming to the facility since it was a puppy. They said the dog barked at people that he was not familiar with. They said the dog would bark at people if they were carrying big items. LPN #4 was interviewed on 7/27/26 at 1:43 p.m. LPN #4 said when she was passing medications, her dog remained at the nurses' stations. She said some of the other staff would watch the dog for her. She said most of the time the dog just laid there behind the nurse desk because he was lazy. LPN #4 said the resident had a shock collar and she would buzz him when he barked in order to stop his barking. LPN #4 said sometimes the dog would stop barking when he was buzzed and sometimes she had to show him the remote before he stopped barking.LPN #2 was interviewed on 7/27/26 at 1:46 p.m. LPN #2 said when LPN #4 was passing medications or busy with residents, one of the other nurses or CNA's would watch the dog.The corporate nurse consultant was interviewed on 7/28/26 at 4:16 p.m. She said the leadership was implementing a new policy for dogs in the building. Any staff wanting to bring in their dog will need to be screened by the NHA and approved for visitation. The dog will need to have all vaccinations and health treatments as per the facility policy and be well mannered. When the nurse is working, the dog will have to be leashed or in a secure area. The corporate nurse consultant said the NHA talked to LPN #4 about leashing the dog at all times and the dog will not be back in the facility until all medical treatments are completed.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#12) of one resident out of 26 sample residents. Specifically, the facility failed to ensure an assessment was completed to determine whether the self-administration of medications was clinically appropriate for Resident #12.Findings include:I. Facility policy and procedureThe Resident Self Administration Medication dated 4/11/25, was provided by the corporate nurse consultant on 7/23/2026 at 1:30 p.m. It read in pertinent part, The facility policy is to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: the medications appropriate and safe for self-administration; the resident's physical capacity to: swallow without difficulty, open medication bottles, administer injections; the resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; the resident's capability to follow directions and tell time to know when medications need to be taken; the resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff. Once evaluated for ability to self-administer medication orders are obtained from the medical provider to self-administer and the individual orders are updated to indicate self-administration. II. Resident #12A. Resident statusResident #12, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician's orders (CPO), diagnoses included acute chronic diastolic congestive heart failure, acute pulmonary edema, morbid obesity, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, fibromyalgia, and obstructive sleep apnea.The 6/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.B. Observations and interviewsResident #12 was interviewed on 7/22/26 at 10:00 a.m. During the interview, there was a small round white pill left in a medication cup on the resident's bedside table. Resident #12 she had not noticed the pill until it was pointed out to her. Resistant #12 said it was usually for the nurses to leave her medications on the bedside table when she was asleep. Resident #12 recognized the pill as a pill she took around 11:00 a.m., but could not remember the name of the medication. Licensed practical nurse (LPN) #3 was interviewed on 7/22/26 at 11:18 a.m. LPN #3 said he could not remember what the pill was that was left in Resident #12's room. LPN #3 entered Resident #12's room and said the pill was lasix (diuretic medication) that was scheduled for administration at 11:00 a.m. Resident #12 was interviewed on 7/27/26 at 11:39 a.m. During the interview, there was a larger white pill in a medicine cup sitting on the resident's bedside. The resident said she did not see the nurse leave the medicine at her bedside; she might have been asleep at the time. Resident #12 said she did not take the pill because she was not sure what it was and she wanted to ask the nurse what it was before taking the pill. The nurse on duty was called to the resident's room but the resident took the pill before the nurse arrived. C. Record reviewA review of Resident #12's comprehensive care plan revealed the care plan did not have a care focus for the resident to self administer any medications. Review of the self-administration assessment, dated 1/7/26, revealed the resident was assessed and approved to self administer fluticasone propionate (nasal spray) and cough drops and no other medications. The resident was assessed to keep the medication at bedside and administered unsupervised. Review of the July 2026 CPO did not reveal a physician's order that the resident could self administer any of her prescribed medication. -However, observations revealed a pill medication was left at the resident's bedside (see observations above). D. Staff interviewsLPN #3 was interviewed at 1:05 p.m. LPN #3 said he looked in the resident's CPO and was unable to find an order that the resident was permitted to self administer her own medication. He said there was a self medication administration assessment, dated 1/7/26, that documented the resident was able to self administer a nasal spray and cough drops. -However, a pill was found at the resident's bedside (see observations above).The corporate nurse consultant and the director of nursing (DON) were interviewed on 7/28/26 at 3:56 p.m. The corporate nurse consultant said if a resident requested to self administer medication the nurse performed an assessment to determine if the resident was able to understand the medication orders and what the medication if prescribed to treat. The corporate nurse consultant and the DON said if the resident was assessed to be competent to self administer their medication. The DON and the corporate nurse consultant said if the resident was approved to hold their medication at the bedside they were given and instructed to use a locked box to secure their medications. She said sometimes the nurse kept the medication in the medication cart until the resident requested them.The corporate nurse consultant said they would assess Resident #12 to determine if she would be competent to self administer her medications. The corporate nurse consultant said if she was able they would request an order from the physician to permit the resident to self administer her own medications.

Based on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#8) of three residents reviewed for accommodation of needs out of 26 sample residents.Specifically, the facility failed to ensure Resident #1, who relied on bedside bed rails and transfer poles for mobility, had appropriate accommodations after the facility removed all bedside bed rails and transfer poles from the resident's room.Findings include:I. Facility policy and procedureThe Use of Assistive Devices policy, revised 6/15/26, was provided by the corporate nurse consultant on 7/23/26 at 3:15 p.m. It read in pertinent part, The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and or dignity. The use of assistive devices will be based on the residents comprehensive assessment in accordance with the residents care plan. II. Resident #8A. Resident statusResident #8, age less than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO) diagnosis include hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction affecting the left side.The 6/10/26 minimum data set (MDS) assessment revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had limited mobility in his upper extremities (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). He needed substantial to maximal assistance to roll left and right; from lying on back to left and right side, to return to lying on back on the bed; to move from a sitting position to lying position from sitting on side of bed to lying flat on the bed; and from a lying position to sitting on side of bed. He was dependent on staff for surface to surface transfers. B. Resident interviewResident #8 was interviewed on 7/21/26 at 12:25 p.m. Resident #8 said he was not happy and was frustrated after the facility made the decision to remove his transfer pole and bed rails. He said the decision significantly impacted his ability to transfer from bed to chair as well as impacted his ability to move freely in bed without having to call staff for assistance. Resident #8 said he fell out of bed while trying to reposition himself in bed as a direct result of the facility removing his bed rails (see fall incident report 5/18/26 below). He said the process of using the sit to stand mechanical lift was time consuming and inconvenient for both himself and staff and had negatively impacted his quality of life because he had to wait longer to transfer and staff seemed frustrated due to the transfer taking longer. C. Record reviewThe impaired mobility care plan, revised on 3/16/26, revealed the resident had limited mobility related to hemiplegia and hemiparesis affecting his left side. Pertinent interventions included: evaluating the need for assistive devices, providing an assist rail while the resident was in bed.According to a quality assurance and performance improvement (QAPI) document initiated 5/5/26, it was determined that bed rails and other assistive devices were in place at facilities when risk outweighs the benefits of use. The facility would eliminate unnecessary bed rails and other assistive devices to ensure compliance. A physical therapy evaluation, dated 5/8/26, the resident trialed use of a sit to stand mechanical lift for functional transfers from bed to wheelchair. On the first attempt the resident demonstrated difficulty with pulling into a full stand to allow for paddles to be lowered under hips for safe transfer. The resident became upset and reported that he would not attempt to use the lift again. The interdisciplinary team (IDT) note dated 5/18/26 documented, the IDT reviewed unwitnessed fall occurring 5/18/26 at approximately 2:30 a.m. The root cause was believed to be that the resident slid off of the side of bed while repositioning himself in bed. The note documented bolsters were to be added to the mattress to assist to define edges of the bed. A physician note, dated 5/18/26, documented the resident was evaluated post-fall after sliding out of bed. The resident denied injury, trauma, or pain, though he expressed anger and frustration regarding removal of bedrails causing a decrease in his ability to preposition himself. An occupational therapy (OT) evaluation, dated 7/22/26 (during the survey), documented the resident required supervision or touching assistance to transfer from surface to surface. The resident completed the transfer with a transfer pole and required only supervision to complete the transfer. The resident reported that utilizing the transfer pole was more effective than using the sit to stand mechanical lift.-However, the facility removed the resident's transfer pole on 5/5/26.The 7/22/26 OT evaluation revealed for the resident to perform bed mobility the resident required substantial to maximal assistance when the bed rails were not installed and with the bed rails in place he needed minimal assist to full turn; however, the resident was unable to turn to the right side. The resident utilized the gait belt to pull, but this method was ineffective and not always accessible. The evaluation revealed the resident would benefit from bed rails to increase independence with rolling laterally as well as increasing participation in supine to sit transitions. The wesident was able to safely complete a transfer utilizing a transfer pole in the restroom to get from chair to toilet. The assessment documented the resident utilized a grab bar and reported less efficiency and needing increased assistance from the certified nurse aides (CNA) to complete the transfer compared the level of assistance he needed when using the transfer pole. The assessment revealed the resident would benefit from utilizing transfer poles to increase participation and maximize independence in transfer and other activities of daily living (ADL). D. Staff interviewsCNA #4 was interviewed on 7/21/26 at 12:25 p.m. CNA #4 said it was much easier and more efficient to assist Resident #8 to transfer from his bed to his wheelchair with the transfer pole then the sit to stand lift. The corporate nurse consultant and the DON was interviewed on 7/23/26 at 3:00 p.m. The corporate nurse consultant said the facility removed all of the transfer poles and bed rails for the resident room to avoid a potential regulatory citation as a directive from the corporate office in May 2026. She said the equipment was in the resident's room when the corporation took over the building and it was determined that the devices would cause regulatory issues. The corporate nurse consultant said the facility followed corporate direction and removed the devices. The corporate nurse consultant said the facility did not have record of the initial evaluations for the installation of the assistive devices (bed rails and transfer poles) and they did not complete assessments and risk benefits statements of the devices prior to their removal. The corporate nurse consultant said they did not currently have a maintenance record for the maintenance oversight of the transfer devices for the one resident who still had installed bed rails. The corporate nurse consultant said they reassessed the three residents who wanted their transfer devices back for safety and appropriateness of use and were providing them the appropriate assistive devices as their assessments indicate.

Based on record review and interviews the facility failed to thoroughly investigate in order to prevent further potential abuse after a resident-to-resident physical altercation for one of three allegations of abuse. Specifically the facility failed to:-Complete a thorough investigation and maintain documentation of efforts to determine a root cause of the resident's abusive actions to prevent repeated resident-to-resident physical abuse incident by Resident #6 towards Resident #15; -Assess Resident #6's behavior to determine the possible root cause of why the resident suddenly presented with physically aggressive behavior towards another resident when he had never been aggressive towards another resident in the past; -Develop and implement care plan interventions to prevent Resident #6 from engaging in a physically aggressive manner towards another resident; and,-Develop a comprehensive care plan for Resident #15 regarding her risk of being a victim of resident-to-resident abuse related to her trauma informed care needs, wandering behavior and communication deficit.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, revised 7/15/26, was provided by the nursing home administrator (NHA) on 7/23/26 at 11:00 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Establish policies and procedures to investigate any such allegations. Prospective residents will be screened to determine whether the facility has the capability to provide the necessary care and services for each resident. An assessment of the individual's functional and mood/ behavioral status will be reviewed prior to admission.II. Incident of physical abuse by Resident #6 towards Resident #15 on 6/5/26The 6/5/26 facility investigation documented a resident-to-resident altercation between Resident #6 and Resident #15 occurred on 6/4/26 at 5:35 p.m. The investigation documented both residents were self-propelling themselves in manual wheelchairs in opposite directions down the hallway. Resident #6 struck Resident #15 in the face with a closed fist on her left cheek, seemingly without provocation, as witnessed by certified nurse aide (CNA) #4 who was standing behind Resident #15 at the time of the incident. Resident #15 said oh and continued self-propelling herself down the hall. CNA #4 separated the residents immediately and reported the incident to the director of nursing (DON).The investigation began on 6/4/26. The DON interviewed both residents. Resident #6 said he knew he should have not done it and said he heard a voice in his head that said If I didn't hit her, she would never have moved. The investigation revealed Resident #6 did not have a history of auditory hallucinations or physical aggression towards staff or other residents. After the incident, Resident #6 said he would not do it again. Other residents were interviewed and none were able to give any details of what happened or did not see what happened, but all of them said they felt safe. The investigation documented both residents were immediately separated and Resident #6 was placed on every 15 to 30 minute checks.CNA #4 was interviewed following the incident. CNA #4 told investigators she observed the resident-to-resident altercation She said Resident #6 and Resident #15 were both self-propelling themselves in manual wheelchairs down the hallway going in opposite directions. She said Resident #6 struck Resident #15 in the face with a closed fist on her left cheek, without any observed provocation. CNA #4 said she was standing right behind Resident #15 when this occurred. She said Resident #15 responded oh when hit and continued self-propelling herself down the hallway. CNA #4 said she stayed with Resident #6 and took him to see the charge nurse and then the DON at that time. -However, the timeline of events and where the incident occurred differed from interviews at the time of the survey (see interviews below).Resident #6 was interviewed on 6/5/26 at 12:14 p.m. after the incident. Resident #6 told the facility investigators he knew he should not have hit Resident #15 but he heard a voice that told him if he did not hit her she would never move. Resident #6 said he would not do it again and never should have hit Resident #15. Resident #15 was interviewed following the incident and did not recall the incident. She stated yes when asked if she felt safe. No injuries to Resident #15 were observed. -However, there was contradictory information between the investigation and in the witness accounting of events reported weeks later, during the survey from 7/20/26 to 7/28/26. During the survey, both the NHA and CNA #4 said that the altercation between Resident #6 and Resident #15 occurred in the dining room and not in the hallway as was previously reported after the incident. There was no justification provided about the discrepancy of the account of the events and what might have led up to the findings and root cause of the altercation (see the NHA and CNA# 4's interviews below).III. Resident #6 (assailant) A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physicians orders (CPO), diagnoses include dementia with behavioral disturbance, chronic respiratory failure and traumatic brain injury. The 5/12/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. B. Record reviewThe mood and behavior care plan, revised 6/10/26, revealed Resident #6 had a history of alteration in mood or exhibition of behavioral symptoms related to major depressive disorder and a history of traumatic brain injury. His behaviors included wandering; exit seeking; auditory hallucinations; agitation and physical aggression; inappropriate behaviors and unmet needs. Pertinent interventions included monitoring and documenting each behavioral event; allowing the resident time to calm down and approaching at a later time; providing psychological counseling; and interacting in an empathetic and supportive manner-However, the recommendations following the 6/7/26 psychiatric assessment were not included in the care plan, including managing symptoms of aggression, hallucinations and precautions for administering ativan (see psychiatric note below). A nurse note, dated 6/5/26, documented Resident #6 remained on alert charting following an altercation with another resident. Resident #6 was observed throughout the shift and was noted to be calm and cooperative with staff and peers. No aggressive behaviors, verbal outbursts, threats, physical aggression, or attempts to strike others were observed during the shift.A psychiatry note, dated 6/9/26, documented Resident #6 was seen for urgent psychiatric follow-up after a recent resident-to-resident altercation reportedly associated with a one-time auditory hallucination. The note documented the resident's presentation was most consistent with dementia with behavioral disturbance, with recently reported auditory hallucination associated with physical aggression.The note documented delirium superimposed on dementia was ruled out due to acute behavioral change, cognitive impairment, hospice status, medical frailty, chronic respiratory disease, seizure history, and lack of ongoing psychosis after the incident. Resident #6 was unable to meaningfully participate in the visit due to cognitive impairment. Per staff report, no ongoing hallucinations, paranoia, responding to internal stimuli, verbal threats, physical aggression, or attempts to strike others had been observed since the incident. The note documented Ativan (anti-anxiety medication) was not used prior to the event, making benzodiazepine-related disinhibition less likely. The note documented that the provider recommended that the facility continue monitoring and non-pharmacological interventions. The note documented that if auditory hallucinations, paranoia, agitation, or aggression recurred, low dose antipsychotics may be considered for comfort and safety after coordination with the hospice provider, the primary care physician and the resident's guardian/power of attorney. The psychiatrist's recommendations included in pertinent part: continue non-pharmacological interventions, including calm approach, reassurance, redirection, low stimulation environment, consistent staff approach, and avoiding crowding during care when possible; monitor for recurrence of auditory hallucinations, paranoia, responding to internal stimuli, agitation, threats, or physical aggression; and, monitor for possible triggers, including pain, dyspnea, toileting needs, constipation, hunger, fatigue, poor sleep, overstimulation, or resident-to-resident conflict. The note documented if hallucinations, paranoia, agitation, or aggression recurred, may consider low-dose antipsychotic for comfort and safety after hospice/guardian/primary care physician coordination. The note documented to continue Ativan as needed, as ordered by hospice; use cautiously due to risk for sedation, falls, worsening confusion, respiratory suppression, and paradoxical agitation. The note recommended continuing other psychotropic medications as ordered.-However, not all recommendations were assessed and developed into a person-centered care plan with appropriate interventions for Resident #6 (see care plan above).A physician's note, dated 6/10/26, documented,the resident was seen for follow-up after the behavioral health services evaluation for auditory hallucinations and aggression toward another resident. The resident reported no acute concerns today and no recurrent auditory hallucinations since the incident. A behavioral health services evaluation was performed on 6/9/26. No ongoing psychosis or recurrent aggression has been reported since the incident. No scheduled antipsychotic was recommended at this time. Recommendations include: continuation of nonpharmacologic interventions (calm approach, reassurance, redirection, low-stimulation environment, consistent staff approach) and ativan as needed per hospice order, used cautiously, with monitoring for recurrence of psychosis or aggression and monitoring for possible triggers.IV. Resident #15 (victim)A. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the July 2026 CPO diagnosis included dementia, without behaviors, psychotic or mood disturbance, anxiety, and failure to thrive.The 7/14/26 MDS assessment revealed the resident had severely impaired cognition for decision making and recall ability with inattention and disorganized thinking per staff assessment. Resident #15 was able to navigate her environment in a manual wheelchair and needed maximal assistance from staff to complete most activities of daily living. B. Record reviewReview of Resident #15's care plan revealed a care plan focus for trauma-informed care, initiated 12/31/26, due to a history of trauma that affected her negatively. Pertinent interventions included being conscious of the resident's position when in groups, activities and the dining room to promote proper communication with others; and, providing a safe environment.-However, her care plan failed to identify the type of trauma or identifiable triggers. Additional interventions included administering medications as ordered; encouraging the resident to express her feelings, concerns, and thoughts in a safe space; and monitoring the resident's health status. A nursing note, dated 6/5/26, documented Resident #15 remained on alert charting following an incident in which the resident was punched by another resident (Resident #6) on the previous day (6/4/26). An assessment was completed. Resident #15 was observed self-propelling throughout the facility in her wheelchair and participating in her usual activities without difficulty. Resident #15 appeared comfortable with no facial grimacing, guarding, bruising, swelling, redness, or other signs of pain or injury noted. Resident #15 denied pain or discomfort when questioned. No acute distress was observed. Resident #15 continued to be monitored per facility protocol, and no adverse effects related to the incident were noted at that time.A physician's note, dated 6/7/26, documented Resident #15 was seen for follow-up after an incident in which she was punched by another resident. She was doing well with no acute concerns. She had no complaints and stated she felt safe. The family was notified of the incident. The nursing assessment found no bruising, swelling, or pain on palpation of the temporal areas; neurological checks and vital signs were at baseline. The resident was self-propelling throughout the facility and was functionally at baseline, per nursing notes.V. Staff interviews CNA #4 was interviewed on 7/28/26 at 10:44 a.m. CNA #4 said she was in the dining room when, from across the room, she witnessed the physical altercation between Resident #6 towards Resident #15. She said the incident took place in the dining room during the evening meal. She said Resident #6 was sitting in Resident #15's spot at the dining table, when Resident #15 propelled herself in her wheelchair past Resident #6. CNA #4 said suddenly and without warning, Resident #6 struck Resident #15 in the cheek with his fist. She said she intervened and separated the two residents.-However, the investigation did not match CNA #4's previous 6/4/26 interview (see investigation above). The investigation documented the incident occurred in the hallway as the two residents passed by each other, and documented that CNA #4 was standing right behind Resident #6 (see investigation above). CNA #4 said the incident was unprovoked and out of character for Resident #6. CNA #4 said she had not known Resident #6 to be physically aggressive towards other resident's and to her knowledge, Resident #6 had not displayed violent behavior since the incident. She said the only time she saw Resident #6 get angry and agitated towards the staff was when he missed his smoking time and had to wait until the next scheduled smoking time to have a cigarette. The NHA was interviewed on 7/28/26 at 12:27 p.m. The NHA said he had just spoken with CNA #4 to clarify the location and details of where the incident between Resident #6 and Resident #15 occurred. He said CNA #4 told him Resident #6 was seated in the dining room at a table located at the entrance between the dining room and the common hallway. The NHA said CNA #4 told him that Resident #15 wheeled herself passed Resident #6 and Resident #4 struck Resident #15 in the face. The NHA said the incident was unprovoked. The NHA said he did not know why CNA #4's incident details had changed.

Based on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for two (#12 and #4) of two residents reviewed for respiratory services out of 26 sample residents. Specifically, the facility failed to:-Ensure there was a physician's order in place for Resident #12's respiratory therapy, bilevel positive airway pressure (BIPAP) machine and routine cleaning of the BiPAP;-Ensure there was a physician's order in place for the maintenance, cleaning and storage of Resident #4's continuous positive airway pressure (CPAP);-Ensure Resident #12 and Resident #4's comprehensive care plan had a care focus for the use of the BiPAP and CPAP treatment; and, -Ensure Resident #12 BiPAP and Resident #4's CPAP supplies were stored in a sanitary manner. Findings include: I. Professional reference According Resmed manufacturer recommendations, dated 2026, retrieved on 7/31/26 from https://www.resmed.com/en-us/sleep-health/resources/cleaning-cpap-equipment/ ResMed CPAP mask and head gear should be gently cleaned with mild soap and water, placed on a flat surface on top of a towel. The mask has three parts, head gear, cushion and frame. The cushion should be cleaned daily while the head gear and frame should be cleaned weekly. Empty the humidifier tub and wipe it thoroughly with a clean disposable cloth daily. Allow it to dry out of direct sunlight. The humidifier tub should always be clean, clear and free of discoloration. Rinse the inside and the outside of the air tubing with mild soap and water weekly. According to [NAME] Respironics manufacturer's recommendation, dated 4/17/26, retrieved on 8/5/26 from https://www.[NAME].com/ifu [NAME] Respironics recommends, apply cleaning agent to a soft lint-free cloth or use a disposable wipe, the cloth or wipe should be saturated but not dripping, wipe cleaning agent over the entire exterior surface and touchscreen of the ventilator, continue wiping until all visible contaminants and soiling are removed, rinse with a clean, water-dampened cloth and allow to dry completely before reuse. The approved cleaning agents for use on the touchscreen and exterior surfaces of the ventilator was soapy water with Medivators Intercept Detergent, mixed per manufacturer's recommendation at 1/3 of an ounce (10 milliliters) per gallon of warm tap water. II. Facility policy and procedure The Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) policy, dated 6/15/26, was provided by the corporate nurse consultant on 7/23/26 at 1:30 p.m. It read in pertinent part, It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. The CPAP, BiPAP, AVAPS, or Trilogy device must be set up and maintained by a licensed nurse or respiratory therapist following provider orders. The nurse or respiratory therapist will verify the settings on the machine prior to use. Follow manufacturer instructions for the frequency of cleaning and replacing filters and servicing the machine. III. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician's orders (CPO), diagnoses included acute chronic diastolic congestive heart failure, acute pulmonary edema, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and obstructive sleep apnea. The 6/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was on oxygen therapy and used a non-invasive mechanical ventilation device (BIPAP). B. Resident interview and observation Resident #12 was interviewed on 7/21/26 at 1:50 p.m. Resident #12 said she cleaned her BIPAP mask with antibacterial wipes every night. She said the machine was stored on her commode chair when in use because there was no other space for the device that was close enough for her to place the mask on her face and to also have the commode accessible for use, if needed. Resident #12 said the certified nurse aides (CNA) helped her set up her machine at night and helped her to store it during the day time on her dresser when not in use. During the interview, the CPAP machine was sitting on top of her commode and the mask was not in any type of protective container. On 7/22/26 at 9:49 a.m. the resident's BIPAP machine was sitting on top of her bedside commode, the mask was draped across the commode toilet seat and the mask was hanging inside the bedside commode. (The commode was empty at the time of the observation). C. Record review Review of the July 2026 CPO revealed there was no physician's order for the resident use of BIPAP therapy duration and frequency of the therapy and there was no documentation of the machine settings. Additionally, there were no orders for the care, maintenance or cleaning of the BIPAP machine and equipment. Review of Resident #12's comprehensive care plan revealed there was no care plan docs or care plan intervention for the resident use of BIPAP therapy. Additionally, there were no interventions for the maintaining the equipment for infection control purposes. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 7/22/26 at 11:30 a.m. LPN #3 said the BIPAP mask should be cleaned after each use and then stored in a plastic bag. He said Resident #12's BIPAP was on the commode because there was not enough room for the night stand to be moved closer to the bed and still allow her to use the bedside commode. He said the BIPAP should be stored on her dresser when not in use and not left on her commode because she used the commode throughout the day. He said he would replace the mask since it was hanging in the commode bucket which was not sanitary. III. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the July 2026 CPO diagnosis included chronic respiratory failure, chronic bronchitis hemiplegia (paralysis) and hemiparesis (weakness) affecting the left side. According to the 5/16/26 MDS assessment, Resident #4 was cognitively intact with a BIMS score of 15 out of 15. The resident required special treatments including a non-invasive mechanical ventilator (CPAP). B Observation and resident interview On 7/21/26 at 10:30 a.m.Resident #4's CPAP equipment was hanging off the side of his dresser next to his personal belongings and scattered wrappers. The mask was touching the floor. The mask was not in any type of protective covering. Resident #4 said the staff did not clean the CPAP equipment. The mask was not in any type of protective covering. On 7/23/26 at 10:30 a.m. Resident #4's CPAP machine was surrounded by the resident's personal belongings. The tubing and mask were hanging off of the side of the dresser, the mask was touching the floor and not in any type of protective covering. C. Record review Review of the July 2026 CPO revealed the following physician's orders: CPAP at home settings on room air. CPAP scheduled starts at bedtime during hours of sleep every night shift. The resident prefers to use the device between 11:00 p.m. and 1:00 a.m., ordered on 4/3/26. CPAP daily maintenance: 1. Disconnect mask and tubing from CPAP. 2. Empty humidifier chamber and discard remaining water. 3. Wipe the humidifier chamber with a clean disposable cloth and allow it to air dry. 4. Clean mask cushion with warm water and mild soap; rinse thoroughly. 5. Allow all components to air dry. 6. Refill the humidifier chamber with fresh distilled water before use, every day shift. The infection control nurse can delegate tasks to a CNA, ordered on 6/23/26 and discontinued on 7/17/26. -The facility failed to ensure a new order for CPAP daily cleaning was restarted. CPAP weekly maintenance: 1.Disconnect CPAP from power source. 2. Wash mask frame, headgear, tubing, and humidifier chamber in warm water with mild soap. 3. Rinse thoroughly with clean water. 4. Air dry completely before reassembly. 5. Wipe the exterior of the CPAP machine with a clean, dry cloth. 6. Inspect tubing, mask, and chamber for cracks, discoloration, or damage and report concerns to nursing. 7. Reconnect CPAP to power source. 8. Refill Inspect and rinse CPAP/BiPAP filter weekly; replace as needed if soiled or damaged. Wipe the exterior of the machine using mild soap and water. every day shift every Sun-Order Date07/17/2026 1816 fresh distilled water before use if ordered weekly on Wednesdays. The infection control nurse can delegate tasks to a CNA, ordered on 6/23/26 and discontinued on 7/17/26. -The facility failed to ensure a new order for CPAP weekly cleaning was restarted Inspect and rinse CPAP filter weekly; replace as needed if soiled or damaged. Wipe the exterior of the machine using mild soap and water. every Sunday, ordered on 7/17/26. -However there were no physician's orders to store the CPAP mask and other related equipment in a sanitary manner to prevent possible pathogens from contaminating the mask and tubing apparatus. Review of Resident #4's comprehensive care plan did not reveal a focus regarding the resident's use of the CPAP machine. D. Staff interview Registered nurse (RN) #2 was interviewed on 7/23/26 at 9:10 a.m. RN #2 said the CPAP machines and components were to be cleaned every night shift. She said the mask should be cleaned after use and stored with the machine. The corporate nurse consultant and the director of nursing (DON) were interviewed on 7/23/26 at 1:00 p.m. The corporate nurse consultant said the CPAP and BiPAP machines, masks and tubing should be maintained in a sanitary manner. She said the mask should be cleaned after each use air dried and stored in a bag after cleaning to prevent possible contamination of any pathogens. She said the tubing and mask should be kept off the floor. She said she and the DON would look into the concern. The corporate nurse consultant and the director of nursing (DON) were interviewed on 7/28/26 at 11:00 a.m. The corporate nurse consultant said after she learned about the observations and other concerns about lack of physician's orders; care plan focus and proper cleaning and storage of the respiratory equipment (see above) she and clinical leadership audited all residents with respiratory equipment to verify and confirm appropriate order for respiratory treatments as applicable to the resident(s) and updated the residents care plans.

-Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety throughout the facility. Specifically, the facility failed to ensure meal trays were promptly removed from the residents' rooms to ensure food was not available to residents at unsafe temperatures. Findings includeI. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 8/3/26. It revealed in pertinent part, Time/Temperature control for safety food, hot and cold holding at 135 degrees F (Fahrenheit) or higher and 41 degrees F and lower. (Chapter 3).II. Observations and interviewsOn 7/20/26 at 1:01 p.m., in room [ROOM NUMBER], the resident's breakfast tray was still in the room with uneaten food. The breakfast tray was delivered at approximately 8:00 a.m. On 7/20/26 at 4:50 p.m., in room [ROOM NUMBER], there was a lunch tray with uneaten food still at the resident's bedside. The tray contained a plate of food and a cup of milk. The tray had been sitting on the resident's bedside table unrefrigerated for over five hours. At 5:28 p.m., an unidentified certified nurse aide (CNA) delivered the dinner tray and removed the lunch tray from the room. On 7/27/26 at 1136 a.m., in room [ROOM NUMBER], the resident still had his breakfast tray in his room and he was eating his breakfast meal, which consisted of a breakfast burrito, oatmeal and milk. Breakfast trays are delivered at approximately 8:00 am. On 7/27/26 at 11:38 a.m. in room [ROOM NUMBER], there was a breakfast tray (from 8:00 a.m.) was still sitting on the resident's bedside table. A CNA arrived at 11:39 a.m. and delivered the resident's lunch tray, setting it on the resident's dresser. The resident was not in the room. The CNA said they would not take the breakfast tray away because the resident wanted it left in the room in case he wanted to eat the food. Both trays remained in the resident's room unrefrigerated. -At 11:50 am the dietary manager (DM) was requested to take temperatures of the resident's food. The breakfast meal consisted of pancakes, bacon, uncovered milk, oatmeal and an uncovered chocolate cake like pastry. There was a fly crawling on the cake. The DM took the temperature of the food. The milk tempted at 79 degrees Fahrenheit(F) the pancakes tempted at 78 degrees F. The lunch tray recently delivered consisted of a cheese enchilada, uncovered milk and uncovered lettuce salad also on the lunch tray. This meal was still within the safe zone for consumption. The DM said meal trays should not sit for more than an hour before they were removed from the residents' room to ensure the food was safe to eat. The DM said he could not remove the resident's breakfast tray. Cross-referenced to F584 for a failure to maintain comfortable ambient temperatures and have an adequate cooling system during unusually high temperatures. III. Staff interviewsCNA #6 was interviewed on 7/27/26 at 12:00 p.m. CNA #6 said the resident who resided in room [ROOM NUMBER] bed A preferred to eat at his own pace. She said the staff left the trays in his room as long as he requested to accommodate his preference. CNA #3 was interviewed on 7/23/26 at 9:30 a.m. CNA #3 said he left a breakfast tray at the resident's bedside to allow him sufficient time to eat. He said he removed the resident's meal trays when he delivered the next meal. He said the breakfast tray would remain on the resident's bedside table until the lunch tray was delivered at around 11:30 a.m. The NHA, corporate nurse consultant and the director of nursing (DON) were interviewed on 7/28/26 at 4:00 p.m. The NHA said they were accommodating resident rights by leaving their meal trays in their rooms (for extended periods of time) until the resident allowed them to remove the trays. The regional nurse said they had four residents who would not allow the staff to pick up their trays after the tray even when the meal trays had been left out of refrigeration for more than an hour after being delivered. She said the residents were insistent on this process and they did not want to remove the trays because they would then have to deal with escalating negative behaviors. The recreational nurse said it was the resident's right to consume the food even if it was in the temperature danger zone.

Based on record review and interviews, the facility failed to ensure one (#10) of five residents reviewed for medication management were free from significant medication errors out of 22 sample residents. Resident #10 was admitted to the facility on [DATE] with a diagnosis of dementia. On 4/29/25 a nurse administered Resident #10 Lisinopril (used to treat high blood pressure), Metformin (used to treat diabetes), Seroquel (used to treat mental health conditions) and Ramelteon (used to treat insomnia). The resident began to experience severe hypotension (a dangerously low blood pressure) and was sent to the hospital. The resident received intravenous fluids and was monitored. Specifically, the facility failed to ensure Resident #10 did not receive another resident's (Resident #20) medications. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure The Medication Administration policy, revised 4/11/25, was provided by the nursing home administrator (NHA) on 5/7/25 at 10:38 a.m. It read in pertinent part, Identify resident by photo in the MAR (medication administration record). Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation. The Medication Error policy, revised 2025, was provided by the NHA on 5/7/25 at 10:38 a.m. It read in pertinent part, The facility shall ensure medications will be administered as follows: according to physician's orders, per manufacturer's specifications and in accordance with accepted standards and principles which apply to professionals providing services. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. The facility must ensure that it is free of medication error rates of five percent or greater as well as significant medication error events. III. Resident #10 A. Resident status Resident #10, age 83, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included dementia, epilepsy (seizure disorder) and dysphagia (difficulty swallowing). The 2/17/25 minimum data set (MDS) assessment indicated the resident had short term and long term memory problems and her cognitive skills for daily decision making were moderately impaired, per staff assessment. Resident #10 was dependent on staff for personal hygiene, toileting and transferring. C. Record review The 4/29/25 incident report was documented at 7:00 p.m. by registered nurse (RN) #3. The incident reported documented RN #3 obtained the wrong medications for Resident #10. RN #3 documented Resident #10 did not have a picture in the electronic medication record (EMR) and her name was not on the door. RN #3 documented she had not worked on the resident's hall previously and was not familiar with the residents. RN #3 documented upon entering Resident #10's room, the resident's representative was at the bedside. RN #3 addressed Resident #10 by another resident's first name (to whom she thought was administering the medications) and the family responded without correction. RN #3 documented the following medications were administered to Resident #10 that were not ordered for her: Lisinopril 20 milligrams (mg), Metformin 500 mg, Seroquel 100 mg and ramelteon 8 mg. The April 2025 CPO revealed Resident #10 had physician's orders for the following daily scheduled medications: mirtazapine (used to treat depression) 45 mg, olanzapine (used to treat mental health conditions)10 mg, tramadol (used to treat pain) 50 mg and divalproex sodium (used to control seizures) 125 mg. -Resident #10 did not have physician's orders for Lisinopril, Metformin, Seroquel or ramelteon. The 4/29/25 hospital visit, documented at 10:24 p.m., revealed Resident #10 had an accidental drug ingestion of another resident's medications. It documented Resident #10 experienced hypotension (low blood pressure) and tachycardia (high heart rate). The resident was administered 1000 milliliters (ml) intravenous fluids and was observed for six hours at the hospital. Resident #10 was initially discharged from the hospital on 4/30/25 at 1:49 a.m., however, Resident #10's blood pressure decreased again en route to the nursing facility and she was again transported back to the hospital, where she was observed for an additional two hours with no additional interventions needed. A hospice nurse progress note, dated 4/30/25, documented Resident #10 had experienced a medication administration error the night of 4/29/25 and the resident had been transferred to the hospital. The progress note documented Resident #10's blood pressure was 73/33 millimeters of mercury (mmHg) on 4/30/25. The resident was speaking clearly and said she was doing fine. The 4/30/25 physician's progress note, documented at 11:42 a.m., revealed the physician visited Resident #10 on 4/30/25 due to a medication error on 4/29/25. The physician documented a medication error occurred, hospice was notified and Resident #10 was stable at the time of the progress note. The NHA provided the facility's investigation of the medication error on 5/7/25 at 10:38 a.m. The investigation documented that on 4/29/25, RN #3 administered the wrong medications to Resident #10. Resident #10's representative was present at the time of administration. After RN #3 returned to the medication cart, she realized she had given Resident #10 another resident's medications. Resident #10's representative then said that she found it odd that RN #3 had mentioned a blood pressure medication. RN #3 notified the provider, who advised her to obtain the resident's vital signs (blood pressure, heart rate and respiratory rate). The resident had a decrease in blood pressure and her respirations increased. The physician ordered Resident #10 to be administered Midodrine (used to treat low blood pressure) to counteract the blood pressure medication. The resident was then sent to the emergency room , was given fluids and monitored. The resident returned to the facility the following day. The investigation documented RN #3 was interviewed. RN #3 said she had not worked on Resident #10's unit previously and the medications given to Resident #10 were ordered for another resident (Resident #20) whose name was next to Resident #10's on the MAR. RN #3 said Resident#10 had poor hearing and the representative did not correct RN #3 with the correct name when RN #3 said the other resident's name prior to administering the wrong medications to Resident #10. The investigation documented RN #3 was educated on medication administration. Following the incident, the director of nursing (DON) completed a medication administration observation of RN #3. All residents' charts were audited for accuracy, including resident identification and their room identification. It was determined that the root cause of the error was related to Resident #10's picture missing in her chart as well as her name outside of her room. It was identified that a total of 17 residents either did not have a picture in the EMR or a name by their door. The investigation documented the interventions that were put into place to prevent a recurrence included RN #3 received formal disciplinary action, was educated on medication administration and was observed administering medications. All nursing staff were educated and also observed administering medications. The admissions coordinator was educated regarding the importance of obtaining and updating residents' identification including adding pictures to the EMR and door identification. An admission audit was updated to include the identification information completed. The conclusion of the investigation included there was a deviation from the facility's policy and procedure and multiple facility systems failed, which included Resident #10's name and identification was not properly obtained prior to administering medications. The incident was substantiated as the medication error resulted in Resident #10's hospitalization . IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/6/25 at 10:40 a.m. LPN #1 said Resident #10 had no previous diagnoses of hypertension or hypotension (high or low blood pressures). LPN #1 said Resident #10 did not have physician's orders for blood pressure medications. LPN #1 said Resident #10's blood pressure readings varied, but usually averaged 110/60 mmHg. LPN #1 said Resident #10's blood pressures had been lower over the past week. The DON was interviewed on 5/6/25 at 11:10 a.m. The DON said Resident #10 was administered Lisinopril 20 mg, Metformin 500 mg, Seroquel 100 mg and ramelteon 8 mg in error on 4/29/25. The DON said Resident #10 did not have physician's orders for any of those medications. The DON said Resident #20 should have received the medications given to Resident #10 and did receive the medications later that day. The hospice RN was interviewed on 5/6/25 at 11:19 a.m. The hospice RN said Resident #10's condition was stable and she was eating well. The hospice RN said she was notified that the facility administered the wrong medications, including Lisinopril, to Resident #10 on 4/29/25. She said Resident #10's blood pressure was usually 85/65 mmHg. The hospice RN said she saw Resident #10 on 4/30/25, and her blood pressure was still low at 73/33 mmHg. The rounding physician was interviewed on 5/7/25 at 10:50 a.m. The rounding physician said RN #3 contacted her after she had administered the wrong medications to Resident #10 in error on 4/29/25. The rounding physician said RN #3 told her, that she called Resident #10 another resident's name, and the resident's name she mentioned could also have been used or interpreted as a term of endearment. The rounding physician said she instructed RN #3 to monitor Resident #10, including her vital signs, which included blood pressure, heart rate and respiratory monitoring. The physician (PHY) said she told RN #3 to inform the hospice agency of the error. The PHY said Resident #10's blood pressure dropped and she was transferred to the hospital. The PHY said the resident was awake and talking the next morning, after she returned from the hospital. The PHY said the DON investigated and then ensured all residents' names were on their doors and their pictures were in their EMRs. The PHY said she thought the likelihood for the medications to cause a significant drop in Resident #10's blood pressure was low and she was surprised Resident #10's blood pressure dropped as significantly as it did. The PHY said the ramelteon may have played a role with the Lisinopril and caused Resident #10's blood pressure to decrease. The PHY said the one time dose administered of Metformin and Seroquel were not of concern for a possibility of contributing to a condition change. The pharmacist was interviewed on 5/7/25 at 12:00 p.m. The pharmacist said he was told RN #3 was not used to working with the residents on the unit and she administered the wrong medications to Resident #10 on 4/29/25. The pharmacist said he was contacted by nursing staff on 4/29/25 after the medication error. The pharmacist said he told the nurse to monitor Resident #10's blood pressure. The pharmacist said Resident #10 already had lower blood pressures and was on hospice services. The pharmacist said she was concerned Resident #10's blood pressure would drop and she might be more sedated from the Lisinopril and ramelteon. The pharmacist said the starting dose for Lisinopril was usually much lower than 20 mg and the dose could begin as low as 2.5 mg. The pharmacist said for this reason, he knew Resident #10's blood pressure was going to drop, it was just a question of how low it would drop. The pharmacist said Resident #10's blood pressure dropped low enough to require her to be transferred to the hospital. LPN #3 was interviewed on 5/7/25 at 12:10 p.m. LPN #3 said sometimes newer residents did not have their names on the doors. She said this had gotten better recently. The speech therapist (ST) was interviewed on 5/7/25 at 12:20 p.m. The ST said the lack of names on residents' doors worsened in September 2024. The ST said recently she had noticed residents' names were more consistently labeled on the doors. The DON was interviewed a second time on 5/7/25 at 12:34 p.m. The DON said it was possible the name used by RN #3 to identify the resident for medication administration was misinterpreted by Resident #10's family as a term of endearment. The DON said RN #3 notified her of the medication administration error on the night of the incident (4/29/25). The DON said RN #3 should have followed the six rights of medication administration and ensured she identified the resident prior to medication administration. The DON said RN #3 monitored Resident #10 after the error and Resident #10 was transferred to the hospital when her blood pressure did not respond to the physician's ordered medication to counteract the Lisinopril medication. The DON said Resident #10 was monitored after her return from the hospital and no further interventions were required beyond encouragement of increased fluid intake. The DON said during the investigation, she discovered that RN #3 was not familiar with the residents on the unit and there was not a picture of Resident #10 in the EMR, which would assist with identification. The DON said after the incident on 4/29/25, all nurses were provided one-to-one medication administration education which included review of the medication administration policy which focused on the six rights of medication administration, including the identification process for each resident. The DON said the audit tool for resident admissions was updated to include adding photo identification in the EMR and ensuring the correct names on resident doors for both admission and after any resident room changes. The DON said the admission coordinator was provided additional education to ensure his prompt attention during residents' admission to ensuring pictures and door identification were added. The DON said she was conducting weekly audits of the photo identification in the residents' EMRs and the names on resident doors. The DON said RN #3 had made another medication administration error on 4/9/25. The medication which RN #3 administered, Lyrica (used to treat pain and seizures), was administered in a larger dose than what was ordered. The DON said RN #3 pulled the wrong medication card which contained the wrong dose. The DON said the medication error was reported to the physician and no additional monitoring was required for that resident. The DON said after the error on 4/9/25, RN #3 was provided reminders of the six medication rights to include right identification. She said no additional education was provided at that time. The DON said after the error on 4/29/25, RN #3 received disciplinary action and was provided additional one-to-one medication administration and error prevention education. She said RN #3 was observed performing medication administration. The DON said all nursing staff were observed performing medication administration and the facility would continue four to eight random medication administration observations per month. The DON said all medication administration errors were reviewed at the quality assurance performance improvement (QAPI) meetings each month. She said the root causes of the 4/29/25 medication error included the nurse not following the six rights of medication administration, the resident pictures not being entered into the EMR and the resident's name not being placed on the door. The DON said all residents were audited and 17 residents were found to have either no picture in their EMR or no name on their door. The DON said all residents had both photos in the EMR and names on the door at the time of interview. RN #3 was interviewed on 5/7/25 at 2:40 p.m. RN #3 said she was unfamiliar with the residents and administered the wrong medications to Resident #10 on 4/29/25. RN #3 said she went into the wrong resident's room. RN #3 said she did not confirm the room number or ask the resident or representative the resident's name, though the resident was not familiar to her. RN #3 said she called Resident #10 by the first name of the resident who was to receive the medication (Resident #20). RN #3 said the resident and the representative did not correct RN #3 when she said the wrong name. RN #3 said she recognized the error immediately after leaving Resident #10's room. RN #3 said she contacted the resident and representative, the physician, the DON and hospice. She said she monitored Resident #10 for a change of condition, including her blood pressure readings. RN #3 said Resident #10 did not want to go to the hospital, however her representative encouraged the resident to go to the hospital as her blood pressure decreased to 58/34 mmHg. RN #3 said Resident #10 was transferred to the hospital for evaluation. RN #3 said she should have ensured it was the correct resident prior to administering the medications. RN #3 said she looked at the wrong room number on her report sheet. RN #3 said it would have been helpful if Resident #10's picture was in the EMR and her name was on the door. RN #3 said after the incident, she received an inservice about the six rights of medication administration and she was observed during administration of medications. RN #3 said she had recently had issues with her concentration and had not felt as cognitively sharp, and it was helpful for her to not be assigned to different units for her shifts. RN #3 said she was now assigned to the same units for each shift where she knew residents better. The DON was interviewed a third time on 5/8/25 at 1:35 p.m. The DON said she recently discovered RN #3's concern regarding her concentration and cognition and the DON had developed a performance improvement plan (PIP) to ensure RN #3 was not more likely than any other nursing staff to make another medication error. The DON said the plan included RN #3 would report to the DON any cognitive symptoms that might affect performance and the DON would address the concern by finding a replacement for RN #3 on the particular shift. The DON said she was confident the disciplinary action and education provided had impacted RN #3 and caused her to be much more cautious and attentive to the requirements of medication administration. The DON said RN #3 would also be audited during medication administrations to include three to five resident observations weekly. The DON said RN #3 would remain assigned to the 400 and 500 units, where she was most comfortable and knew the residents she was assigned. The medical director (MD) was interviewed on 5/8/25 at 2:50 p.m. The MD said he was aware that Resident #10 received another resident's medication on 4/29/25. The MD said he was not surprised Resident #10's blood pressure dropped, as her blood pressure typically ran lower and her status as a hospice resident may have made her more sensitive to the medications. The MD said all nursing staff received education regarding medication administration as the most important. V. Facility follow-up A PIP was provided by the NHA on 5/8/25 at 3:04 p.m. The plan was initiated on 4/30/25 and revised on 5/7/25 and 5/8/25 (during the survey). The action items included the following: RN #3 will receive additional training related to prevention of medication errors, including the six rights of medication administration, facility medication administration policy and procedure and medication error policy (completed 4/30/25). RN #3 will be observed administering medications to ensure competency (completed 5/1/25). RN #3 will receive consistent staffing assignments to assist with developing a rapport with the residents and decrease opportunity for error (5/8/25 and ongoing). RN #3 reported that she may have symptoms that impact her work performance. In the event she is experiencing symptoms, she will report them immediately to the DON or another nurse manager (5/7/25 and ongoing). RN #3 will receive weekly med pass observations unless not scheduled, as she is an as needed (PRN) employee. Medication pass observations will include at least 25 opportunities across multiple residents including a variety of routes (beginning 5/13/25 and ongoing, for a minimum of three months). RN #3 will have weekly check-ins with her supervisor to provide an opportunity for coaching and feedback for a minimum of three months (beginning 5/13/25 and ongoing for three months).

Based on observations, interviews and record review, the facility failed to take steps to protect residents from abuse for four (#9, #7, #8 and #4) of 20 residents reviewed for abuse out of 22 sample residents. Specifically, the facility failed to: -Protect Resident #9 from repeated instances of sexual abuse by a visitor; -Protect Resident #7 and Resident #8 from physical abuse by each other; and, -Protect Resident #4 from physical abuse by Resident #22 in two separate incidents. I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 4/11/25, was provided by the director of nursing (DON) on 5/6/26 at 12:22 p.m. It read in pertinent part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include resident-to-resident altercations. It includes sexual abuse and physical abuse. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. II. Incidents of alleged sexual abuse between Resident #9 and Resident #9's visitor on 2/1/25, 4/12/25 and 4/23/25. A. Facility investigation of the alleged sexual abuse on 2/1/25 The 5/13/25 interdisciplinary (IDT) nurse progress note (written during the survey) revealed a certified nurse aide (CNA) reported Resident #9's boyfriend was observed with his hands inside the resident's shirt, touching the resident's breast (on 2/1/25). The CNA asked the boyfriend to move to a common area. The CNA notified the nurse, who said the facility talked to Resident #9's mother and the mother was okay with the interactions. The facility had interviewed the nurse the CNA reported the incident to on 2/1/25. The nurse did not recall the incident or being notified of the incident. The nurse remembered having a conversation with the mom about the boyfriend and his visits. The nurse said the resident was more vocal when the boyfriend was around. The nurse said Resident #9's mother said she was okay with the resident's boyfriend visiting the resident and she had no concerns about him. She said he had been visiting him for a long time and had never had any issues at other visits. The note documented the risk factors and root cause were that Resident #9 had a history of anoxic brain damage, impeding her ability to communicate and express her thoughts and feelings. The visitor was her boyfriend at the time of the incident that caused the resident's brain injury. The resident's parents were her legal representatives and continued to encourage a relationship between the resident and her boyfriend. The resident's parents provided transportation for the boyfriend to visit and he was typically only able to visit on weekends. Resident #9's parents did not stay for the visits and preferred for the staff to manage the interactions between the resident and her boyfriend. The facility was unable to substantiate or unsubstantiated the allegation of sexual abuse because the resident was unable to communicate her side of the incident. The investigation had been turned over to the local police department and adult protective services (APS) for further investigation. The new interventions included that the boyfriend was not permitted to visit at the time (effective 5/13/25). A care conference was set up with both of Resident #9's parents, the ombudsman, APS, the police department and the social services director (SSD). B. Facility investigation of the alleged sexual abuse on 4/12/25 The witness statement, dated 4/12/25 and written by an unknown CNA (per the NHA), documented Resident #9's boyfriend touched Resident #9 in what appeared to be an inappropriate manner. The resident, who was non-verbal, was screaming. The CNA entered the room and advised the boyfriend they needed to go to the television (TV) room. The witness immediately reported the incident to the nurse, and the nurse took over from there. The 4/12/25 nurse incident note revealed the staff reported the incident between Resident #9 and her boyfriend to the NHA. The nursing staff called the police to report Resident #9's boyfriend, as the staff felt there was inappropriate touching happening in the lounge and the resident was not able to consent to the interactions. The resident was deemed safe, as the boyfriend was no longer in the facility. A skin assessment was completed on Resident #9 with no unusual findings. The family was notified of the incident. The 4/14/25 IDT event note revealed the CNA notified the nurse and the NHA, as she felt Resident #9's visitor was touching her inappropriately. The resident did not have the capacity to consent to the advances. The resident's boyfriend denied the interactions, however, he left shortly after the incident. The note indicated the risk factor and root cause identified was the resident had a history of anoxic brain damage, impeding her inability to communicate and express her thoughts and feelings. Her visitor was her boyfriend at the time of the incident leading to the brain injury. The resident's parents were her representatives and continued to encourage a relationship between the resident and her boyfriend. The parents provided transportation for him to visit and he was typically only able to visit on weekends. Resident #9's parents did not stay for the visits and preferred for the staff to manage interactions between the resident and the boyfriend, as they wanted to remain a neutral party. The note indicated the prior interventions were anticipating the resident's needs, encouraging out-of-room activities, encouraging relationships with family and friends, allowing space and limiting touch when able. New interventions were the resident's parents would like visits to continue with the boyfriend as the parents believed the interactions were good for the resident. The staff were to ensure visits happened in line of sight and the boyfriend was not permitted to be in the resident's room without staff or the resident's parents present. The 4/14/25 NHA progress note revealed the NHA spoke to Resident #9's parents regarding what happened over the weekend (on 4/12/25). He said he wanted to talk to the resident's boyfriend to get his side of the story. The parents understood the facility's position and wanted to stay out of it to not have any ill-will with the boyfriend. The NHA expressed he understood their position but he was not concerned about their feelings, but the safety of the resident. The 4/23/25 NHA note revealed the NHA had a private discussion with the resident's boyfriend. The NHA said he was a mandated reporter for certain things. The NHA informed the boyfriend of an incident that staff observed on 4/12/25 during his visit with Resident #9 and how the staff thought they witnessed something that made them uncomfortable. The NHA said the police were called. The boyfriend was shocked at the allegation and was completely confused as to what was going on. The NHA expressed to him this was standard protocol, that an investigation was being conducted and no one was being accused or labeled as anything. The resident's boyfriend left the NHA's office, said goodbye to the resident and immediately left. The resident's father picked him up, as he had relied on the resident's family to always bring him to the facility. The 4/24/25 NHA note revealed the NHA received a phone call from the resident's mother wondering how the conversation with the resident's boyfriend went and if the NHA needed anything from her. The NHA reiterated that the police and the State Agency were notified of the 4/12/25 incident. The NHA said the boyfriend needed to stay away until the investigation was completed. The 5/1/25 NHA note revealed the NHA received a phone call from Resident #9's boyfriend that he wanted to visit the resident and asking if that was allowed. The NHA said it would be okay but there were new ground rules for visiting the resident. The visits had to be in the TV room and around people. The NHA said he needed to make sure the boyfriend's hand would stay above Resident #9's waist and only on her hands or shoulders. The NHA said kisses had to be kept to the forehead only. The NHA said since the resident could not verbalize, everything had to stay nice and innocent. The 5/12/25 NHA note revealed the NHA called the boyfriend to let him know the facility was putting all visits from him to Resident #9 on hold until he heard from the NHA again. The boyfriend said he understood. The 5/12/25 SSD note revealed a care conference was scheduled for Resident #9 on 5/15/25 at 1:00 p.m. The resident's parents and the regional ombudsman were invited. The facility's conclusion of the internal investigation was that the incident on 4/12/25 was unsubstantiated (see NHA's interview below). -Review of the 4/12/25 investigation revealed there was no documentation to indicate there was immediate education to staff to keep the resident safe while the investigation was in process. By not having immediate education in place, a second alleged allegation was made on 4/23/25 (see investigation below). -However, the facility failed to conduct a timely and thorough investigation of the incident, to include interviewing Resident #9's boyfriend, in order to prevent another potential sexual abuse incident from occurring. Due to this, an additional allegation of sexual abuse occurred on 4/23/25 (see investigation below). Cross-reference F610 for failure to fully investigate an allegation of sexual abuse. -Additionally, the facility failed to submit a final report of the investigation to the State Agency until 4/24/25, seven days after the final report was due. Cross-reference F609 for failure to report an allegation of sexual abuse. C. Facility investigation of the alleged sexual abuse on 4/23/25 The 5/15/25 IDT nurse progress note (written during the survey) revealed that during the 2/1/25 alleged sexual abuse investigation staff interviews, a CNA reported that she noted Resident #9's boyfriend had his hands between her legs moving up and down (on 4/23/25). The CNA notified nursing that day and the NHA. The boyfriend and the NHA had a conversation on 4/23/25 and the boyfriend left. The resident's representatives, the medical director (MD), the DON, the police department , APS and the ombudsman were notified. The note documented the risk factors and root cause were Resident #9 had a history of anoxic brain damage, impeding her ability to communicate and express her thoughts and feelings. The visitor was her boyfriend at the time of the incident leading to the brain injury. The resident's parents were her representatives and continued to encourage a relationship between the resident and her boyfriend. The resident's parents provided transportation for him to visit and he was typically only able to visit on weekends. Resident #9's parents did not stay for the visits and preferred for the staff to manage the interactions between the resident and her boyfriend. The facility was unable to substantiate or unsubstantiate the allegation, as the resident was unable to communicate her side of the incident. The investigation had been turned over to the police department. The new interventions included that the boyfriend was not permitted to visit at the time (effective 5/13/25). A care conference was set up with both parents, the ombudsman, APS, the police department and the SSD. The police department and APS were investigating. D. Resident #9 - victim 1. Resident status Resident #9, age less than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included anoxic brain damage, hepatitis C, bipolar disorder, and contracture of muscles in multiple sites. The 4/2/25 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. 2. Record review The communication care plan, revised 12/20/24, revealed Resident #9 had impaired cognition and communication deficits related to anoxic brain injuries. Interventions included staff to ensure visits with the boyfriend happened in community areas and the boyfriend was not permitted to be in a room with the resident without staff or the resident's parents present. -However, the intervention was not initiated until 4/18/25, six days after the alleged incident on 4/12/25. The psychosocial well-being care plan, initiated 4/12/25 and revised 5/7/25, revealed Resident #9 had a potential for alteration to psychosocial well-being related to being a victim of alleged sexual abuse. Interventions included monitoring and documenting the resident's verbal reactions to situations that may indicate her feelings, initiated 4/12/25. Additional interventions , initiated on 5/7/25 (during the survey), included encouraging Resident #9 to participate in meaningful relationships. The resident was in a romantic relationship prior to her accident and her family felt it was beneficial for her to maintain her relationship. If her boyfriend visited, they should meet in a common area or in the presence of the resident's parents. The 5/7/25 interventions additionally included monitoring the resident's mood and behavior, providing opportunities for the resident and family to participate in care and the resident was assessed as not having the capacity to consent to sexual activity. The trauma informed care plan, revised 11/1/24, revealed Resident #9 had a history of trauma that affected her negatively. Interventions included that the resident's boyfriend was not allowed visitation. If he showed up at the facility, staff was to notify the police (initiated 5/7/25 and revised 5/13/25). A sexual activity capacity for consent was completed on 4/14/25. It revealed Resident #9 had a history of anoxic brain injury, she was unable to communicate effectively, and she was unable to determine the level of cognitive status. Due to the resident's inability to communicate effectively and describe her thoughts and feelings, the IDT determined the resident could not make or express her desire to engage in sexual intimacy with others. -However, despite the determination that Resident #9 did not have the capacity to consent to sexual intimacy, the facility failed to put effective interventions in place to protect the resident from another alleged sexual incident with the boyfriend on 4/23/25 (see investigation above). E. 5/15/25 facility care conference A care conference was observed (during the survey) on 5/15/25 from 1:04 p.m. until 2:32 p.m. Resident #9, the resident's father, the resident's mother, the NHA, the DON, the SSD, the ombudsman, a local police detective, an APS representative, regional nurse consultant (RNC) #1, RNC #2, regional vice president of operations (RVPO) and the medical director (MD) were present. The DON said the facility wanted to have the care conference to establish what was in the best interest for Resident #9 in regards to the boyfriend's visits, review the CNAs concerns and to hear from the resident's parents what was best for the resident for her quality of life. The DON said three different CNAs saw Resident #9's boyfriend touch the resident down her pants, in between her legs and down her shirt. The APS representative said she was at the care conference because there was concern about whether or not the resident could consent and understand an intimate type of relationship. The police detective said he had concerns that Resident #9 did not have the capability to have a sexual relationship and did not have the capability to consent. The police detective said he was going to talk to the boyfriend directly and recommended no alone visitations. The DON said the resident was not able to fully communicate if she was okay or not okay in regards to the sexual abuse allegations. The DON, the NHA, the RVPO and Resident #9's mother agreed the resident's boyfriend could visit and it would be a supervised visit by the NHA or the DON. The DON said the facility would write up a plan for the visits and document Resident #9's reactions so the facility knew when the resident wanted the boyfriend around and when she did not want the boyfriend around. F. Staff interviews The physician (PHY) was interviewed on 5/7/25 at 11:03 a.m. The PHY was familiar with Resident #9. She said the resident did not have the ability to consent to sexual intimacy with others. She said she was not part of the sexual activity capacity for consent assessment. She said she did hear about Resident #9's boyfriend allegedly fondling the resident. She said the boyfriend had been her boyfriend for several years before her anoxic brain injury. She said the boyfriend was not happy with the decision the facility made regarding the new rules for when he visited the resident. The NHA was interviewed on 5/7/25 at 2:05 p.m. The NHA said the alleged sexual abuse incident with Resident #9 and her boyfriend occurred on Saturday, 4/12/25. He said he contacted the resident's parents on Monday, 4/14/25, to obtain the boyfriend's contact information. He said prior to the allegation, the facility did not have the boyfriend's contact information. The NHA said the boyfriend visited the resident on the weekends and the resident's parents provided transportation. The NHA said if the boyfriend visited on a Saturday, he would not visit on a Sunday. The NHA said he thought the resident was safe and he did not need to contact the parents for the boyfriend's contact information until the Monday following the allegation. The NHA said the CNA who made the allegation normally did not provide care for Resident #9 and she did not know the resident yelled if she was happy or if she was unhappy with the care provided. The NHA said the CNA made the allegation because the resident was yelling when the boyfriend was visiting. Licensed practical nurse (LPN) #1, LPN #5 and CNA #8 were interviewed together on 5/8/25 at 9:53 a.m. LPN #1 said if she saw or heard alleged abuse, she would separate the residents and ensure the residents' safety and inform the NHA. LPN #5 said she would do the same and she said she would start the incident report, which included a summary of what happened, notify the family and the physician and complete a pain assessment and a skin assessment. LPN #5 said in addition to the incident report, she would document a progress note. CNA #8 said she would separate the residents and ensure the residents' safety and inform the NHA. CNA #8 said she documented the alleged abuse as a behavior in the resident's electronic medical record (EMR). CNA #8 said she would write her statement of what she saw or heard and then someone in management would interview her. LPN #1, LPN #5 and CNA #8 said Resident #9 was unable to make her own decisions because she had a traumatic brain injury. LPN #5, LPN #1 and CNA #8 said the resident yelled frequently through their shift. LPN #1 and LPN #5 said they last saw the boyfriend on a Wednesday. They said they did not know which Wednesday it was. LPN #1 said they stayed in the common areas. LPN #5 and CNA #8 said the last time the boyfriend was here he was extremely upset and told the resident he was not able to visit anymore. CNA #5 was interviewed on 5/8/25 at 10:03 a.m. CNA #5 said if she saw or heard alleged abuse, she would try to stop the alleged abuse and tell the nurse. She said she would report the alleged abuse to the NHA. CNA #5 said she would write a statement on paper and then someone in management would interview her. CNA #5 said she was familiar with Resident #9 and said she was unable to make her own decisions. She said Resident #9's boyfriend visited the resident and she only saw him make visits in her room. She said she only saw the boyfriend make visits during the week and he made visits about once a week between 2:00 p.m. to 3:00 p.m. She said she would see him touch the resident's thighs, kiss her forehead and he would try to shut the resident's door. She said she had not seen him since the alleged sexual abuse incident. CNA #6 was interviewed on 5/8/25 at 10:39 a.m. CNA #6 said she was familiar with Resident #9. She said she was sometimes scheduled to work on the unit Resident #9 resided on. She said there was one time in February 2025 when she went into Resident #9's room for toileting care and she saw Resident #9's boyfriend in the room. She said she saw the boyfriend touch the resident's breast down the front of the resident's shirt. She said she told the nurse what she saw but she was not sure which nurse she told. She said she was told the resident's parents were notified and the resident's mother said it was okay. CNA #6 said she thought it was weird because Resident #9 did not have the capacity to consent. CNA #6 said she heard other staff members made complaints about the boyfriend and what they saw but staff did not see any changes in regards to the boyfriend's visits until the alleged incident in April 2025. The DON was interviewed on 5/8/25 at 11:32 a.m. The DON said she was familiar with Resident #9 and the alleged sexual abuse on 4/12/25. She said Resident #9 was unable to make her own decisions. She said Resident #9 was unable to make her own decisions since before she was admitted to the facility. She said the sexual activity capacity for consent assessment was completed by the DON, the SSD, the unit manager, the assistant director of nursing (ADON) and the NHA. She said the medical director and the ombudsman were not part of the decision. She said the sexual activity capacity for consent assessment for Resident #9 was not completed until April 2025. She said it was completed in response to the 4/12/25 alleged sexual abuse incident. The DON said Resident #9's boyfriend visited her on Saturdays when the parents brought him to the facility. The DON said prior to the allegation, there were no restrictions on where he could visit in the facility. The DON said some staff reported to her that Resident #9's her boyfriend tickled her, held her hand, and kissed her on her cheek. She said she was not aware of the prior sexual abuse allegations (brought up by CNA #6 during the survey on 5/8/25 - see CNA #6 interview above) and the facility would start an investigation into that allegation on 5/8/25. The NHA was interviewed again on 5/8/25 at 1:27 p.m. The NHA said he was not aware of the alleged sexual allegation made by CNA #6 on 5/8/25 regarding the 2/1/25 incident with Resident #9 and her boyfriend, but he said the investigation into the allegation would start on 5/8/25. The DON and the NHA were interviewed together on 5/15/25 at 9:08 a.m. The DON said if Resident #9's boyfriend attempted to visit the resident, the clinical staff were instructed to immediately ask him to leave. The DON said if the boyfriend refused to leave, the staff were to call the police. She said the facility did not have a picture of the boyfriend but most clinical staff knew what the boyfriend looked like. The DON said the front and back door entrances were locked. The DON said when a visitor came to visit, a staff member opened the door and the visitor told the staff who they were there to visit. The DON said if the visitor did not say who they were there to visit, the staff asked who they were to visit. The DON said any staff member, clinical and non-clinical staff, could unlock the door. The DON said all clinical staff were educated on 5/12/25 to not let Resident #9's boyfriend enter the building. The DON said she was not sure what education was provided to non-clinical staff. The NHA said he did not provide education to non-clinical staff on what to do if the boyfriend attempted to visit the resident. The DON said, prior to 5/12/25, when Resident #9's boyfriend was allowed to visit, the boyfriend could visit the resident in a supervised area. The DON said the instruction to her staff was to notify the DON if he visited so someone could be assigned to supervise the visit. The DON said there was not a set plan if he were to show up unplanned. The NHA said Resident #9's mother told the NHA when the boyfriend would visit one to two days prior to the visit. The NHA said he knew the boyfriend was going to visit on 4/23/25 in the early morning, around 8:30 a.m. The NHA said he and the DON went into a meeting on 4/23/25 from 9:15 a.m. to 9:45 a.m. The NHA said the boyfriend had not arrived by the end of the 9:45 a.m. meeting. The NHA said the DON went into another meeting and he went across the street for ten minutes. The NHA said around 10:00 a.m. the boyfriend was observed with Resident #9 in the common area with no staff member assigned to monitor the visit. LPN #4 was interviewed on 5/15/25 at 9:10 a.m. LPN #4 said he knew a visitor was not allowed to visit a resident if they were not on a list posted at the nurses' station. He said management told him verbally. LPN #4 said it was also in the resident's medical chart. He said if he saw a visitor who was not allowed to visit a resident, he would ask the visitor to leave. He said if the visitor did not leave, he would tell the NHA or the DON and then call the police. He said Resident #9's boyfriend was not allowed to visit but he said he did not have a picture of the resident's boyfriend. LPN #4 said he was told Resident #9's boyfriend could not visit the resident a couple of weeks ago, but he said he was not sure of the exact date. LPN #4 said prior to the boyfriend not being able to visit the resident, he was told the boyfriend could visit in a public space. He said he never saw staff sit with the resident and her boyfriend when the boyfriend was in the facility. CNA #9 was interviewed on 5/15/25 at 9:10 a.m. CNA #9 said the NHA and the DON communicated what visitors could not visit a resident. She said if the NHA or the DON did not tell her who could not visit, a nurse told her. She said there were pictures of visitors who could not visit the residents. She said if she saw a visitor who could not visit a resident, she would ask the visitor to leave. She said she would tell the NHA or the DON and call the police. CNA #9 said Resident #9's boyfriend could not visit. She said she was told a couple of weeks ago that he could not visit. She said there should be a picture of him at the nurses' station, but there was not one posted yet. She said when he did visit with the resident previously, it was unsupervised and she was never told to monitor his visits. CNA #5 was interviewed a second time on 5/15/25 at 9:15 a.m. CNA #5 said visitor restrictions were in the residents' care plans and she received education from management. She said if a visitor was in the building who was not allowed to be, she would let the NHA or the DON know and call the police. She said Resident #9's boyfriend could not visit. She said she was told at the end of last week or the beginning of this week (between 5/8/25 and 5/12/25). She said there was communication in Resident #9's EMR and a posting one day last week that he was allowed to visit in the common area, but then it was changed to no visitation at all. She said there was no restriction to his visits prior to last week. She said she only saw Resident #9's boyfriend at the facility previously with the resident's parents. CNA #7 was interviewed on 5/15/25 at 9:25 a.m. CNA #7 said she knew if visitors were not allowed to visit by their pictures posted on the wall. She said she just started working at the facility. CNA #7 said if she were to let anyone visit any resident, she would check with the nurse to ensure they could visit. She said the visitor restrictions were in the Kardex (an abbreviated care plan). She said if a visitor tried to visit who was not allowed to visit, she would tell the visitor they were not allowed to visit and tell the nurse. She said Resident #9's boyfriend was not allowed to visit the resident. She said she was told this on 5/6/25. The activity director (AD) was interviewed on 5/15/25 at 9:28 a.m. The AD said the facility usually had a picture of visitors who were not allowed to visit or the facility would provide a description of the person. She said if a visitor tried to visit who was not allowed to visit, she would let the nurse and management know. She said Resident #9 had a boyfriend who could not visit. She said if she saw him, she would direct him out of the building. LPN #1 was interviewed a second time on 5/15/25 at 9:33 a.m. LPN #1 said visitor restrictions were usually documented in the residents' care plans or in a communication note in the residents' EMRs. She said if a visitor tried to visit who was not allowed to visit, she would tell them they could not visit and tell the DON or the NHA. She said Resident #9 had a boyfriend who could not visit. She said there was a communication note from 5/13/25 that said the boyfriend could not visit. She said, prior to 5/13/25, he was allowed to visit the resident only in the common areas. She said he had to be within the view of the nurse's station. She said staff were not required to sit with them, but they would be within eyesight of the resident and the boyfriend. LPN #5 was interviewed a second time on 5/15/25 at 9:37 a.m. LPN #5 said she was told on 5/8/25 that the boyfriend for Resident #9 could not visit. She said there was a communication board in the EMR system she looked at each morning. She said on 5/13/25 the communication board said the resident's boyfriend was not allowed to visit. She said if the boyfriend attempted to visit, she would ask him to leave and call the police. She said she would contact the DON and the NHA. She said there were pictures of visitors who were not allowed to visit. She said prior to last week, there were no restrictions on when Resident #9's boyfriend could visit. She said she was told the residents had the right to have visitors. The DON and the NHA were interviewed together a second time on 5/15/25 at 2:58 p.m., following the care conference. The DON and the NHA said Resident #9's parents and the facility did not know if the resident wanted the boyfriend to visit or if the resident wanted physical touch from him. The DON and the NHA were interviewed a third time on 5/15/25 at 4:55 p.m. The NHA said, based on the care conference, he was unable to substantiate the 2/1/25 and 4/23/25 sexual allegations because the boyfriend was important to Resident #9's quality of life. The DON said the facility needed to establish what Resident #9's wants were. The NHA said the facility waited until 5/12/25 to tell the boyfriend not to visit Resident #9 because the ombudsman met with the SSD and the DON on 5/12/25. The NHA said the ombudsman recommended the boyfriend be told to hold off on visiting Resident #9 until after the care conference on 5/15/25. III. Incident of physical abuse of Resident #7 by Resident #8 on 4/8/25 A. Facility investigation The investigation of the alleged altercation between Resident #7 and Resident #8 was provided by the NHA on 5/6/25 at approximately 3:30 p.m. The 4/8/25 physical aggression incident note revealed Resident #7 was walking around the facility and entered another resident's room (Resident #8). This caused Resident #8 to become upset and yell at Resident #7. The yelling caused Resident #7 to become upset and both residents began hitting each other. Both residents were separated and assessed for injuries. The 4/9/25 IDT note revealed Resident #7 was admitted on [DATE] with several diagnoses that may increase risk for wandering and in turn physical aggression, including but not limited to, encephalopathy (brain dysfunction), schizoaffective [TRUNCATED]

Based on record review and interviews, the facility failed to report alleged violations of sexual and physical abuse to the State Survey and Certification Agency in accordance with state law for four of seven alleged abuse violations. Specifically, the facility failed to: -Submit a final report of the facility's investigation of two separate physical abuse allegations involving Resident #5 and Resident #4 to the State Agency within five calendar days of the incidents; -Submit a final report of the facility's investigation of a physical abuse allegation involving Resident #7 and Resident #8 to the State Agency within five calendar days of the incident; and, -Submit a final report of the facility's investigation of a sexual abuse allegation involving Resident #9 and a facility visitor to the State Agency within five calendar days of the incident. Findings include: I. Facility policy and procedure The Compliance with Reporting Allegations of Abuse/Neglect. Exploitation policy, reviewed on 5/7/25 (during the survey), was provided by the chief nurse officer (CNO) on 5/8/25 at 10:55 a.m. The policy revealed the facility would ensure all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property were reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Resident abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident-to-resident altercations. This also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Resident sexual abuse was the non-consensual sexual contact of any type with a resident. The facility would report all alleged violations and all substantiated incidents to the State Agency and to all other agencies as required, and take all necessary corrective actions, depending on the results of the investigation. The facility would analyze the occurrences to determine what changes were needed, if any, to policies and procedures to prevent further occurrences. The administrator or designee would report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified within five working days of the incident. II. Abuse allegations and State Agency reporting A. Physical abuse allegation on 3/10/25 at 10:15 a.m. involving Resident #5 and Resident #4 The facility submitted an initial report of a physical abuse allegation to the State Agency reporting site on 3/10/25 at 11:41 a.m. The final report of the facility's investigation of the incident was due on 3/15/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/8/25 at 3:22 p.m., which was 24 days after the final report was due. B. Physical abuse allegation on 3/10/25 at 6:00 p.m. involving Resident #5 and Resident #4 The facility submitted an initial report of a physical abuse allegation to the State Agency reporting site on 3/10/25 at 7:23 p.m. The final report of the facility's investigation of the incident was due on 3/15/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/8/25 at 3:53 p.m., which was 24 days after the final report was due. C. Physical abuse allegation on 4/8/25 at 1:00 p.m. involving Resident #7 and Resident #8 The facility submitted an initial report of a physical abuse allegation to the State Agency reporting site on 4/8/25 at 2:36 p.m. The final report of the facility's investigation of the incident was due on 4/13/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/24/25 at 5:38 a.m., which was 11 days after the final report was due. D. Sexual abuse allegation on 4/12/25 at 2:45 p.m involving Resident #9 and a facility visitor The facility submitted an initial report of a sexual abuse allegation to the State Agency on 4/12/25 at 4:24 p.m. The final report of the facility's investigation of the incident was due on 4/17/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/24/25 at 5:56 a.m., which was seven days after the final report was due. III. Staff interviews The nursing home administrator (NHA) and the regional vice-president of operations (RVPO) were interviewed together on 5/8/25 at 10:40 a.m. The NHA said he had to notify the appropriate authorities, including the State Agency, immediately or as soon as possible, but no later than 24 hours, after receiving a report of an abuse allegation. He said in the case of serious bodily injury to a resident, the allegation was to be reported no later than two hours after the incident. The NHA said he had to have the final report of the facility's investigation into an abuse allegation submitted to the State Agency within five days of the incident. The NHA agreed with the final submission reporting dates that were documented in the State Agency's reporting system. He said the investigations of the allegations were completed timely but he submitted the final reports late. He said it was his poor timing skills that resulted in the late submissions and he said he was aware of the five-day time constraints. The NHA said he now reported weekly to the RVPO and the regional clinical nurse (RCN) to ensure that any abuse investigations were completed and reported appropriately. 48112

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two of seven abuse allegations. Specifically, the facility failed to: -Thoroughly investigate an allegation of sexual abuse on 4/12/25 for Resident #9 in order to prevent a second incident from occurring on 4/23/25; and, -Thoroughly investigate an allegation of physical abuse between Resident #7 and Resident #8. I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 4/11/25, was provided by the director of nursing (DON) on 5/6/26 at 12:22 p.m. It read in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, the alleged perpetrator, witnesses, and others who might know about the allegations; focusing the investigation on determining if abuse has occurred, the extent, and the cause; and providing complete and thorough documentation of the investigation. II. Incident of alleged sexual abuse between Resident #9 and her boyfriend on 4/12/25 A. Facility investigation The investigation of the alleged sexual abuse incident between Resident #9 and her boyfriend was provided by the NHA on 5/6/25 at approximately 3:30 p.m. The witness statement, dated 4/12/25 and written by an unidentified CNA (according to the NHA), documented that Resident #9's boyfriend touched Resident #9 in what appeared to be an inappropriate manner. The resident, who had severely impaired cognition and who was non-verbal, was heard screaming. The CNA entered Resident #9's room and advised the boyfriend that he and Resident #9 needed to go to the television room so staff could monitor the visit. The CNA immediately reported the incident to the nurse on duty, and the nurse took over from there. The 4/12/25 nurse incident note revealed that nursing staff reported the incident to the NHA and called the police regarding Resident #9's boyfriend, reporting an allegation of sexual abuse, because they did not believe Resident #9 was able to consent to sexual contact of that nature. The resident's boyfriend left the facility soon after the incident of inappropriate touching. The resident was deemed safe by the facility, as the boyfriend was no longer in the facility. CNA #7, CNA #8, CNA #9 were interviewed on 4/14/25. The interview questions were: Do you feel safe here? Do you have specific concerns? Have you ever been hurt, frightened, or made uncomfortable here? Who made you uncomfortable here? If made uncomfortable here, did you report it? -However, the questions for the staff interviews failed to ask staff if they had any knowledge of the incident on 4/12/25 or prior incidents. -The investigation failed to reveal that an interview was completed with the CNA who witnessed the 4/12/25 incident to determine what the CNA specifically saw related to inappropriate touching of Resident #9 by her boyfriend. -The investigation failed to reveal documentation to indicate that an interview was completed with the alleged assailant, Resident #9's boyfriend. -The investigation failed to reveal documentation that the alleged assailant was unable to enter the facility during the investigation process, or what intervention was put in place to keep the resident safe. -The investigation failed to reveal documentation on what education was provided to the staff to keep the alleged victim safe while the investigation was in progress. B. Staff interview The DON was interviewed on 5/8/25 at 11:32 a.m. The DON said she was familiar with Resident #9 and the alleged sexual abuse on 4/12/25. She said Resident #9 was unable to make her own decisions since before she was admitted to the facility. She said the sexual activity capacity for consent was completed by the DON, the SSD, the unit manager, the assistant director of nursing (ADON) and the NHA. She said the medical director and ombudsman were not part of the decision. She said Resident #9's sexual activity capacity for consent was not completed until 4/14/25, after the alleged sexual abuse incident. -Review of the 4/14/25 sexual activity capacity for consent provided by the facility revealed Resident #9 had an inability to communicate effectively and describe her thoughts and feelings. The interdisciplinary team (IDT) determined the resident could not make or express her desire to engage in sexual intimacy with others. -However, despite the determination that Resident #9 did not have the capacity to consent to sexual intimacy, the facility failed to put effective interventions in place to protect the resident from another alleged sexual incident with the boyfriend on 4/23/25. Cross-reference F600 for failure to keep residents free from abuse. The DON said the resident's boyfriend visited on Saturdays when Resident #9's parents brought him to the facility. The DON said prior to the allegation, there were no restrictions on where he could visit with the resident in the facility. The DON said some staff reported to her that Resident #9's boyfriend tickled her, held her hand, and kissed her on her cheek. She said she was not aware of prior allegations. The NHA was interviewed on 5/7/25 at 2:05 p.m. He said the incident between Resident #9 and her boyfriend occurred on Saturday, 4/12/25. He said prior to the allegation, the facility did not have the boyfriend's contact information to inform him that he could not visit until after the incident was fully investigated. He said he contacted the parents on Monday, 4/14/25, two days after the incident occurred to obtain the boyfriend's contact information. The NHA said the boyfriend visited the resident on the weekends and the resident's parents provided transportation. The NHA said if the boyfriend visited on a Saturday, he would not visit on a Sunday. The NHA said he thought the resident was safe and he did not need to contact the parents for the boyfriend's contact information until Monday. The NHA said he was responsible for the questions management used for the resident and staff interviews. The NHA said the interview questions asked of the staff during the investigation for Resident #9 did not make sense for the investigation process. He said the questions were more relevant to ask residents instead of staff members. The NHA was interviewed a second time on 5/8/25 at 1:27 p.m. The NHA said he did not obtain an interview from the CNA who witnessed the incident with Resident #9 and her boyfriend on 4/12/25 to clarify exactly what she saw. The NHA said the witness statement lacked specific information in regards to what the CNA saw related to inappropriate touching of the resident on 4/12/25. The NHA said the investigation did not include an interview from the alleged assailant and an interview or observation from the alleged victim. The NHA said the interview questions for staff were incomplete and did not ask if they witnessed any other potential concerns or incidents with Resident #9 and her boyfriend prior to the 4/12/25 incident. The NHA said since there was a lack of interviews and statements and it was difficult to determine if the allegation was unsubstantiated. The NHA said, looking at the timeline of when the care plan was updated on 4/18/25 to ensure the boyfriend was only in the highly observable areas, to when the NHA contacted the boyfriend on 4/23/25, the investigation process was not completed in a timely manner in order to protect Resident #9 from another allegation of sexual abuse on 4/23/25. III. Incident of physical abuse between Resident #7 and Resident #8 on 4/8/25 A. Facility investigation The investigation of the resident-to-resident altercation between Resident #7 and Resident #8 was provided by the nursing home administrator (NHA) on 5/6/25 at approximately 3:30 p.m. The 4/8/25 incident note revealed that Resident #7 was observed entering Resident #8's room without permission. This caused Resident #8 to become upset and yell at Resident #7. The yelling caused Resident #7 to become upset and both residents began hitting each other. Both residents were separated and assessed for injuries. The facility investigation revealed that the investigator, who was the assistant director of nursing (ADON) interviewed certified nurse aide (CNA) #1, registered nurse (RN) #1, dietary aide (DA) #1, licensed practical nurse (LPN) #1, and the social services director (SSD). -However, the staff interviews were not specific to the incident between Resident #7 and Resident #8 and did not indicate if any of the staff members interviewed witnessed or overheard the resident-to-resident altercation. -The investigation failed to reveal that either Resident #7 or Resident #8 were interviewed following the incident to gain understanding of what potentially led to the incident in order to prevent any further incidents from occurring. B. Staff interviews The DON was interviewed on 5/8/25 at 11:32 a.m. The DON said if a facility staff member became aware of resident abuse, they should notify the abuse coordinator, who was the nursing home administrator (NHA), after ensuring the safety of the resident. She said the CNA should document the behavior in the residents' electronic medical records (EMR), on the residents' daily tasks records. She said the nurse was also responsible for initiating an incident report that included completing a skin assessment and pain assessment, notifying the family and notifying the physician. She said the nurse was responsible for developing an immediate intervention to keep the resident safe during the investigation process. The DON said the nurses documented everything they saw and what they did following the incident in the incident report. The DON said the alleged abuse and interventions were communicated to the next shift during the investigation process by a written report called a shift-to-shift report and a verbal report. She said a statement was obtained by the abuse coordinator (the NHA). The DON said she was familiar with the altercation between Resident #7 and Resident #8 on 4/8/25. She said she completed the physical aggression incident report because she heard the yelling between the two residents. She said she was not sure if CNA #1, RN #1, DA #1, LPN #1, or the SSD saw or heard the altercation but she said she was sure other staff members must have heard the yelling based on where Resident #8's room was located in proximity to the nurses' station. The DON said she was not certain which staff witnessed the resident-to-resident abuse because the investigator (the ADON) did not interview all staff on duty. The DON said there was no specific behavior linked to the resident-to-resident abuse that occurred between Resident #7 and #8, per the investigation statements obtained by the NHA. The NHA was interviewed on 5/7/25 at 2:05 p.m. The NHA said when he investigated an abuse allegation, he asked the staff member who saw the resident altercation/abuse to write a statement. He said if he did not directly interview staff, he designated someone in management to conduct the interviews. The NHA said he tried to obtain a statement and interview from the alleged assailant and victim. He said residents and staff interviews were completed by someone in management. He said there should be an intervention put in place to keep the residents safe while the investigation was in process. The NHA said he attempted multiple times to obtain Resident #7's statement, but he did not document the attempts. He said he obtained a statement from Resident #8 but he did not document his statement. The NHA said when he obtained Resident #8's statement, Resident #8 said he put his hands on Resident #7. The NHA said the immediate actions to keep the resident safe was the stop signs in front of Resident #8's room. The NHA said the sign was placed on 5/5/25. The NHA said he should have substantiated the alleged physical abuse. The NHA was interviewed again on 5/8/25 at 1:27 p.m. He said if staff saw or heard alleged abuse, they should notify him after ensuring the safety of the resident. He said any staff member who saw an alleged abuse incident should write a statement and then they should be interviewed by management.

Based on interviews and record review, the facility failed to protect and promote an environment free from resident-to-resident sexual and physical abuse. The facility failure affected five of five residents reviewed for abuse (#1, #18, #168, #25 and #169) out of 38 sample residents. The facility's failure contributed to incidents of abuse by Residents #50 and #43 and created the potential the abuse would recur. Resident #50 had a history of sexually inappropriate behaviors. On 1/1/25, he was observed rubbing Resident #1's back and putting his hand down the front of her shirt. Resident #1 reported to the facility that he had done the same to other residents. Resident #50 was placed on 15-minute checks; however, interviews with staff on 1/14/25 revealed not all staff were aware of the resident's inappropriate behavior, aware he was to be monitored every 15 minutes, or educated on how to respond to his behavior toward female residents. The facility's failure to monitor Resident #50's sexually inappropriate behavior before and after the incidents on 1/1/25 put other residents at risk for sexual abuse. Resident #43 had a history of physical altercations and hit Resident #168, pushed Resident #169, and grabbed and shoved Resident #25. The facility failed to take steps to keep Residents #168, #169, and #25 free from abuse and the potential for harm. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Resident #50, who was admitted to the facility in September 2023, had a history of sexually inappropriate behaviors. The facility failed to prevent Resident #50 from massaging Resident #1's back and breast on 1/1/25. Resident #1 indicated during the facility investigation of the incident that Resident #50's touching made her uncomfortable. Further, Resident #1 reported Resident #50 had done the same things to other residents, identifying Resident #18 who, per her care plan, was at risk of being a victim. The facility's response to the incident on 1/1/25 was to implement every 15-minute safety checks for Resident #50. However, the safety checks were not consistently implemented based on staff interviews which further identified staff was not aware of Resident #50's behavior or the intervention of the safety checks. The facility's failure to monitor Resident #50's sexually inappropriate behavior before and after the incidents on 1/1/25 put other residents at risk for sexual abuse. The lack of awareness and sufficient monitoring created a likelihood of serious harm to residents at risk. On 1/15/25 at 6:00 p.m., the nursing home administrator (NHA) was notified the facility's failure created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 1/16/25 at 2:25 p.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: Immediate Action: Nursing Home Administrator (NHA) has assigned a one-to-one staff member to ensure that Resident #50 is prevented from perpetuating further sexual abuse of resident 1, 18 and other residents. This will ensure that Resident #1, #18 and other residents are protected from Resident #50. The 1:1 staff assignment will continue until the interdisciplinary team is able to coordinate with Behavioral Health Solutions provider, speech therapist and medical director to determine a less restrictive plan of care that will safely and effectively mitigate the risk for sexual behaviors directed towards others. Completed: 1/15/25 Beginning 1/15/25, NHA or designee will inservice the one-to-one staff member regarding the responsibilities of the 1:1 staff member before the start of the shift to ensure the 1:1 staff member understands their responsibilities. Beginning 1/14/25, Director of Nursing (DON) or designee will complete education with all staff before their first shift back to work to ensure they receive updated training and education on Resident #50's care needs and behavioral interventions as documented in the care plan and Kardex. Completion date: 1/16/25 Beginning 1/15/25, DON or designee will complete a comprehensive medical record review and interviews with direct care staff to identify any residents with sexually inappropriate behaviors and update the comprehensive care plan and Kardex with effective interventions based on the identified risk factors to keep other residents safe from sexual abuse. Completion date: 1/16/25 Identification of Other Residents Potentially Affected by the Deficient Practice: DON or designee will complete interviews with all residents or resident representatives to identify any residents who have experienced unwanted touching and initiate abuse reporting and update the comprehensive care plan with effective interventions based on the identified risk factors to keep other residents safe from sexual abuse. Completion date: 1/15/25 Measures to Ensure the Deficient Practice Does Not Recur: Beginning 1/15/25, DON or designee will complete education with all staff before their first shift back to work to ensure they receive updated training and education on resident-specific behavior interventions, reporting expectations including reporting any observed physical touching between residents to the abuse coordinator, accessing care plans and Kardexes and expectations for review of care plans and Kardexes at the start of each shift for any changes. C. Removal of immediate jeopardy On 1/16/25 at 2:25 p.m., the nursing home administrator (NHA) was notified that the facility's plan to remove the immediate jeopardy was accepted based on the facility's plan and evidence of implementation of the measures outlined in the plan. However, the deficient practice remained at an E level, the potential for more than minimal harm at a pattern. II. Failure to prevent sexual abuse - incidents involving Residents #50, #1, and #18 A. Facility abuse policy The facility's abuse policy, revised on 6/11/24 was received from the NHA on 1/22/25 at 4:15 p.m. It read in pertinent part: Every resident has the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. This facility does not condone resident abuse and shall take every precaution to prevent resident abuse. All occurrences of resident abuse, suspected abuse, neglect and injuries of unknown source shall be promptly reported to the facility abuse coordinator for investigation. Pre-assessment of potential residents is done during the admission process to screen for potential signs of abusive behavior. Residents whose medical, physical, mental, behavioral or psychosocial needs cannot be met based on the facility's staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment and equipment shall not be admitted . Residents identified in the pre-admission assessment period to be at risk to have aggressive or abusive behaviors shall have comprehensive care plans written to include approaches to reduce or eliminate the risk for abuse. The facility will ensure that all residents are protected from physical and psychosocial harm during and after abuse investigations, including but not limited to: -Responding immediately to protect the alleged victim; -Examining the alleged victim for any sign of injury, including a physical examination and/or psychosocial assessment as indicated; -Increased supervision of the alleged victim and other residents as indicated; -Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; -Protection from retaliation; and -Providing emotional support and/or counseling to the resident during and after the investigation as needed Residents with aggressive or abusive behaviors shall have their care plans written and revised as needed to include approaches to reduce or eliminate the risk for abuse. B. Incident 1/1/25 - Sexual abuse of Resident #1 by Resident #50 A progress note in Resident #50's record on 1/1/25 documented in part: This resident was observed by (a) speech therapist to be rubbing (Resident #1's) back and went down the top front of her shirt. I talked with (Resident #1) to see if she had given consent and she had; she said she was also ok with him going in the front of her shirt; they were at the puzzle table by therapy. C. Resident #50 1. Resident status Resident #50, age 68, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), the resident's diagnoses included Parkinson's disease without dyskinesia, with fluctuations, cognitive communication deficit, chronic lymphocytic leukemia of B-cell type, anxiety disorder, gastro-esophageal reflux disease without esophagitis, and unspecified dementia, unspecified severity, with other behavioral disturbance. The 1/15/25 minimum data set (MDS) assessment, revealed the resident was cognitively intact, with a brief interview for mental status (BIMS) score of 15 out of 15. He required assistance from one person with activities of daily living (ADLs). The care plan for the use of psychotropic medications, dated 11/3/23, revealed the resident was taking medications for depression and anxiety. 2. Record review revealed documentation of the resident's history of inappropriate sexual behavior. An 8/1/23 neurology note revealed Resident #50 had a history of impulsive behaviors for which pharmacological measures and non-pharmaceutical and lifestyle measures were prescribed to decrease sexual behaviors, and it indicated the resident required 24-hour supervision. An activities care plan, initiated on 9/15/23 and revised on 12/11/24, revealed the resident's daughter asked staff not to take the resident on public outings due to sexually inappropriate behaviors and self-exposure. However, contrary to facility policy (see above), record review revealed there was no care plan directing staff to monitor the resident for sexually inappropriate behaviors in the facility. 3. Resident interview Resident #50 was interviewed on 1/15/25 at 2:55 p.m. He said he remembered the incident on 1/1/25 and confirmed he touched Resident #1's breast without her consent. He said, It feels like an impulse that I cannot control and I feel bad after I do it. D. Resident #1 Resident #1, age 65, was admitted on [DATE]. According to the January 2025 CPO, the resident's diagnoses included generalized idiopathic epilepsy and epileptic syndromes, cognitive communication deficit, history of traumatic brain injury, sleep apnea, depression, and gastro-esophageal reflux disease without esophagitis. The 12/10/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required assistance from one person with activities of daily living (ADLs). No behaviors were noted. 1. Record review The current care plan revealed the resident had post-traumatic stress disorder (PTSD), and poor safety awareness. She required reminders regarding safety concerns. 2. Interviews Resident #1 was interviewed on 1/13/25 at 9:30 a.m. Resident #1 did not mention or recall the incident on 1/1/25. However, the resident's interview documented on the facility incident report (see below) read Resident #50 made her uncomfortable by touching her, and licensed practical nurse (LPN) #1, interviewed on 1/14/25 at 4:15 p.m., stated Resident #1 complained about Resident #50 massaging her because he touched her breast. The record did not reveal evidence the resident's ability to consent to sexual behaviors had been assessed. Documentation in the facility incident report (see below) revealed Resident #1 also reported Resident #50 had exhibited the same behavior toward Resident #18. E. Resident #18 Resident #18, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, the resident's diagnoses included unspecified schizoaffective disorder, unspecified protein caloric malnutrition, delusional disorder, major depressive disorder, mild cognitive impairment of unknown etiology, personal history of mental and behavioral disorders, psoriasis, paroxysmal atrial fibrillation, muscle wasting and atrophy, type 2 diabetes mellitus, and cirrhosis. The 11/12/24 MDS assessment revealed Resident #18 was cognitively intact with a BIMS score of 15 out of 15. However, she had the potential for impaired cognitive function with a diagnosis of minor cognitive impairment. She was alert and able to make her needs known; however, she required time to process and respond to others. She had an ADL self-care performance deficit and required assistance with ADLs and mobility. Her physical abilities fluctuated, requiring extensive assistance. Resident #18, in an interview on 1/13/25 at 11:15 a.m., said she was treated with respect and dignity and did not observe/experience any situations of abuse in the facility. However, the resident's care plan, initiated on 3/2/21, stated Resident #18 was at risk of being the victim or involved in a resident-to-resident altercation related to behavior or instigating altercations. It also stated she should not be involved in any altercations, should be monitored during activities, and should not be close to residents with whom she could have a negative interaction. An interview with LPN #1 on 1/14/25 at 4:15 revealed the LPN had observed Resident #50 touching Resident #18's back on at least one occasion. She said she asked Resident #18 about it when it occurred and Resident #18 said she did not mind the touch. A review of the resident's care plan did not mention that Resident #18 was involved in a consensual relationship with Resident #50 or that she was okay with him touching her. Further, record review revealed no evidence that the resident's ability to consent had been assessed. E. Facility Response to the incident on 1/1/25 involving Resident #50 and Resident #1 1. Facility incident report The 1/1/25 facility incident report revealed a staff member witnessed Resident #50 removing his hands from Resident #1's chest. The report read: -The facility staff separated the residents, called the police, and followed the procedures regarding sexual abuse, including reporting it to other authorities. -Immediate interventions included to request an assessment by a behavioral health therapist (for Resident #50), to monitor Resident #50 in common areas, and to redirect the resident when he attempted to give massages. -An interview with the victim, Resident #1, revealed that Resident #50 made her uncomfortable by touching her and she reported that he had done it to other residents, naming Resident #18. 2. Neurological evaluation of Resident #50 Documentation of an evaluation of Resident #50 by a neurologist on 1/2/25 read: (Resident #50) was recently placed on alert charting due to a resident-to-resident altercation involving sexual advances towards another resident who did consent. (But see above; conflicting information on Resident #1's consent to Resident #50's behavior.) Continued monitoring is in place to address this behavioral issue. Plan: Continue alert charting and monitoring for inappropriate sexual behavior. F. Failures in facility response 1. Failure to chart and monitor Resident #50 for inappropriate sexual behavior as planned (see above). A review of progress notes, medication administration orders (MARs), and treatment administration orders (TARs) revealed that starting 10/9/24, the resident was monitored for signs and symptoms of psychosis, delusions, mood changes, and physical aggression. However, there was no mention of monitoring for inappropriate sexual behaviors, monitoring the resident in common areas, redirecting and tracking sexually inappropriate behaviors as recommended after the 1/1/25 incident. A review of progress notes revealed monitoring the resident every 15 minutes was documented only once in the progress notes on 1/2/25. -A review of the logs for 15-minute checks revealed the resident was monitored on 1/1/25, and 1/3/25 - 1/10/25. 2. Failure to assess Resident #1 and Resident #18's ability to consent to sexual behaviors. See above; there was no evidence that the two residents identified as being touched by Resident #50 were assessed for their ability to consent. 3. Failure to investigate whether other residents, including those cognitively impaired on the unit, had been touched inappropriately by Resident #50. The facility incident report and interviews with staff (see below) revealed no evidence that the facility investigation included an evaluation of the relationship of other residents on the unit with Resident #50 after Resident #1 reported he had done it to others. F. Staff interviews Staff interviews revealed not all staff were aware of Resident #50's inappropriate sexual behavior, not aware of the expectation his behaviors would be monitored every 15 minutes and charted, and not educated on what the appropriate response to observed sexual behavior by Resident #50 should be. 1. LPN #1 was interviewed on 1/14/25 at 4:15 p.m. She said Resident #50 was an alert and oriented resident. He did have sexually inappropriate behaviors and was on 15-minute checks to ensure he was not close to other female residents. 2. Certified nurse aide (CNA) #4 was interviewed on 1/14/25 at 4:30 p.m. She said Resident #50 was alert and oriented and able to move independently in his wheelchair throughout the building. She said she heard from other staff members that the resident occasionally had sexually inappropriate behaviors toward staff but never toward residents. She said she was not aware of any special monitoring for Resident #50. 3. CNA #5 was interviewed on 1/14/25 at 4:45 p.m. She said Resident #50 was an alert and oriented resident, he was pleasant, and likes to give massages to ladies. She said she observed Resident #50 giving a massage on the back to Resident #18 on a couple of occasions. She said she did not separate the residents when she observed it because Resident #18 seemed not to mind it. 4. CNA #6 was interviewed on 1/14/25 at 5:00 p.m. She said she did not know Resident #50 well and was not aware of any behaviors that she should be observing him for. 5. CNA # 7 was interviewed on 1/14/25 at 5:20 p.m. She said Resident #50 was independent in an electric wheelchair and could move around the building. She said he did not have any inappropriate behaviors, but said there was an incident two weeks ago. She said Resident #50 occasionally rubbed Resident #18's back but she did not think it was inappropriate because it was on the back. She said Resident #18 was independent as well and she could have moved away from Resident #50 at any time. 6. The director of nursing (DON), NHA, and the regional director of quality and compliance (RDQC) were interviewed on 1/14/25 at 5:30 p.m. The DON mentioned she was unaware of Resident #50's sexual behavior history. They stated that after the incident (on 1/1/25), we separated them, established every 15-minute checks on Resident #50, and he has been redirected and told that he should not be touching others. The NHA stated Resident #50 had a history of sexually inappropriate behaviors; however, he had not displayed any behaviors until the incident on 1/1/25. After the incident, the resident was placed on 15-minute checks to ensure staff were aware of his location and whereabouts. The NHA said all staff were educated on the plan of care for Resident #50. The NHA stated she was not aware that staff were not following 15-minute checks for Resident #50. She said she would start immediate education for all staff on duty. She said Resident #18 was not formally assessed for consent, but was asked about the situation and she did not mind the backrubs as long as they did not go any further. 7. The NHA was interviewed in the presence of the DON and the RDQC on 1/15/25 at 12:30 p.m. She said all staff in the building were educated before starting their shift on what could be considered inappropriate sexual behavior. She said Resident #50 had been placed on a 1:1 monitoring to ensure he was not in close contact with female residents. In addition, all other residents were reviewed to ensure they did not have a history of inappropriate behaviors that should be monitored. 50315 III. The facility failed to ensure Residents #168, #169, and #25 were free from physical abuse from Resident #43. Resident #43 had a history of physical altercations. He hit Resident #168, pushed Resident #169, and grabbed and shoved Resident #25. A. Facility policy and procedure The Abuse policy and procedure, revised on 6/11/24, was provided by the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, Every resident has the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. B. Incident on 5/13/24 between Resident #43 and Resident #168 1. Facility investigation A 5/13/24 abuse investigation documented there was a witnessed physical altercation between two residents. The residents were separated, assessed, and placed on one-to-one monitoring. Resident #168 said her fingers hurt and an x-ray was ordered. Resident #43 was interviewed on 5/13/24 and when asked if he grabbed another resident, he shook his head no. When Resident #43 was asked if he hit another resident, he shook his head Yes. When Resident #43 was asked if another resident grabbed him, he shook his head no. Resident #168 was interviewed on 5/13/24 and did not remember the incident. She complained of her fingers hurting. Four residents were interviewed with no additional information. Five staff members were interviewed. CNA #1 was interviewed on 5/13/24 and said she heard yelling from the hallway. She exited a room to find Resident #43 holding the hand of Resident #168. CNA #1 reported Resident #168 appeared to be pulling her hand away from Resident #43 and Resident #43 was agitated and unable to communicate with staff what occurred. Both parties were separated and easily directed. LPN #1 said resident #43 had been on edge lately and had recently had a gradual dose reduction. The incident was not substantiated. 2. Resident #43 a. Resident #43's status Resident #43, age 63, was admitted on [DATE]. According to the January 2025 CPO, the resident's diagnoses included cerebral infarction (stroke), aphasia (difficulty with expression), and cognitive communication deficit. The MDS assessment revealed the resident was rarely/never understood and a brief interview for mental status (BIMS) was not completed. The staff assessment for mental status revealed his memory was okay. He required set-up assistance with eating and was independent for hygiene, bathing, transfers, and dressing. It indicated the resident did not have verbal behavioral symptoms directed toward others such as threatening others, screaming at others, or cursing at others. b. Record review The behavior care plan, revised on 2/23/23, revealed the resident was at risk for resident-to-resident altercations and that he had a history of physical altercation with another resident. The interventions included to: analyze times of the day, places, circumstances, triggers, and what deescalates the behavior and document as needed, assess for roommate compatibility, encourage the resident to not assist with clearing the dining room tables until after residents have left, increase supervision while the resident was in communal areas where he may be likely to attempt to care for others and when the resident became agitated, to intervene before the agitation escalated (guide away from the source of distress, engage calmly in conversations). The nursing progress note, dated 5/13/24 at 12:13 p.m., documented that the resident was on continued charting for an altercation with another resident. There were no other altercations that shift. 3. Resident #168 a. Resident #168's status Resident #168, age 73, was admitted on [DATE] and discharged on [DATE]. According to the CPO, the diagnoses included dementia, dependence on wheelchair, and bipolar disorder. The 4/8/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required set-up assistance for eating and oral hygiene. She required partial/moderate assistance with bathing and supervision for transfers. b. Record review The behavior care plan, revised 2/2/23, documented Resident #168 had a behavior problem and that she made false allegations about other residents and staff about hitting and kicking her. She took other resident's belongings and refused cares, like bathing and changing clothes. Interventions included: taking medications as ordered, anticipating her needs, caregivers to provide opportunity for positive interaction, intervening as necessary to protect the rights and safety of other residents, monitoring behavior episodes, redirecting with music/foods/fluids, and changing her environment. The nursing progress note dated 5/13/24 documented that it was reported to the nurse that Resident #168 had her hair pulled and her fingers pulled by another resident. The primary care provider (PCP), DON, and power of attorney (POA) were notified. An x-ray was ordered and results were pending. Scheduled pain medication was administered as ordered. C. Incident on 5/18/24 between Resident #43 and Resident #169 1. Facility investigation A 5/18/24 abuse investigation documented there was a witnessed physical altercation between two residents. The residents were separated, assessed, and placed on one-to-one monitoring. Resident #43 was interviewed on 5/18/24 and when asked if he grabbed another resident, he shook his head no. When Resident #43 was asked if he pushed anyone, he shook his head yes and pointed to his feet. When Resident #43 was asked if the victim hit his foot, he shook his head Yes. When asked if he was afraid of anyone, Resident #43 shook his head No. Resident #169 was interviewed on 5/13/24 and said she was trying to go to her spot in the dining room when her foot slipped and accidentally kicked Resident #43. Resident #43 then grabbed her by her shirt collar and pushed her away from him. She denied being hurt or afraid of Resident #43. Four residents were interviewed with no additional information. Five staff members were interviewed. CNA #2 was interviewed and reported she witnessed the incident. She reported seeing both residents cross paths in the dining room and she saw Resident #169 kicking her foot out to propel herself backward. CNA #2 could not tell but thought the resident's foot slipped while propelling and thought Resident #43 may have thought she was kicking at him. She reported Resident #43 then grabbed the shirt collar of Resident #169 and pushed her away from him. CNA #2 reported the two residents seemed to go about their business and not interact further. The incident was not substantiated. 2. Resident #43 a. See the resident's status and behavioral care plan above b. Record review A nursing progress behavior note, dated 5/17/24, documented Resident #43 did not want to take his medications. Another nursing progress note, dated 5/18/24, documented that staff came to the nurse to say Resident #43 was accidentally run into by another resident and Resident #43 got upset. Resident #43 grabbed the victim by the front of her shirt on the chest and shoved/pushed her backward in the wheelchair. The victim went wheeling backward. Both residents were separated and placed on one-to-ones for the rest of the shift. 3. Resident #169 a. Resident #169's status Resident #169, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the CPO, the diagnoses included end-stage renal disease, depression, anxiety, and type II diabetes. The 6/9/24 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score of 13 out of 15. She required substantial assistance for bathing and partial assistance for dressing and hygiene. She required supervision for transfers. b. Record review The nursing progress note, dated 5/18/24, documented a change in condition for Resident #169. It was documented that Resident #169 was forcefully grabbed by her clothing by another resident. There were no injuries acquired. There was nothing documented in Resident #169's care plan regarding behaviors or the resident-to-resident altercation. D. Incident on 7/3/25 between Resident #43 and Resident #25 1. Facility investigation A 7/3/24 abuse investigation documented there was a witnessed physical altercation between two residents. The residents were separated, assessed, and placed on one-to-one monitoring. Resident #25 sustained a skin tear to his right hand. Resident #43 was interviewed on 7/3/24 and was unable to verbally articulate. When asked if he was attacked, he shook his head No. When Resident #43 was asked if he attacked anyone, he shook his head No. When asked if he was afraid of anyone, Resident #43 shook his head No. Resident #25 was interviewed on 7/3/24 and reported he did not know why Resident #43 grabbed him. He reported he was just sitting there waiting for his food. He reported he could not really remember what happened; he knew he was grabbed and that he had a scratch on his hand. He had to pull his shirt away from Resident #43 to get away. Resident #25 reported he was not fearful but that he did not want to be around Resident #43. Four residents were interviewed with no additional information. Five staff members were interviewed. The resident aide (RA) was interviewed on 7/3/24 and reported she was passing drinks in the dining room when she saw Resident #43 coming into the dining room and grabbing the shirt of Resident #25. She reported Resident #25 was trying to pull away and she went to get the nurse. They assisted in separating the two residents. The incident was substantiated. 2. Resident #43 a. See Resident #43's status and care plan above b. Record review The nursing progress note, dated 7/2/24, documented that the nurse heard Stop it, let him go! The nurse grabbed her medications and went into the dining area. Resident #43 had Resident #25 pulled up from his chair toward him in the wheelchair. Resident #43 had Resident #25's shirt clenched in his hand. The nurse informed Resident #43 to let go of the shirt as the nurse assisted the resident's hand away from the shirt. A nursing student also assisted with separating the two residents. The nursing student was instructed to assist Resident #43 back to his room. The RA was instructed to make sure Resident #25 had eaten breakfast and had something to drink. The abuse coordinator was notified. 3. Resident #25 a. Resident #25's status Resident #25, age 81, was admitted on [DATE]. According to the January 2025 CPO, the resident's diagnoses included chronic heart failure, anxiety, and alcohol dependence. The 1/3/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 8 out of 15. He required partial/moderate assistance for bathing and set-up assistance for hygiene, dressing, toileting, and transfer. b. Record review The trauma-informed care plan, revised 8/13/24, documented Resident #25 was at increased risk for the development of mood or behavioral symptoms. Interventions included: assessing the resident's need for additional services and therapeutic support and exploring/offering peer support services with relevant cultural similarities as requested by the resident. The nursing progress note, dated 7/3/24, documented that Resident #25 had an altercation with another resident. The

Based on observations, record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for two (#23 and #28) of five residents reviewed for accidents out of 38 sample residents. Resident #23, who was admitted on [DATE], required the use of a Hoyer lift (mechanical lift) and two-person staff assistance for transfers. Interviews during the survey revealed the resident had erratic body movements due to her diagnosis of anoxic brain damage (a condition caused by the brain being deprived of oxygen and leading to brain cell death). On 1/12/25, Resident #23 was being transferred by two staff members and hit her head on the bar of the Hoyer lift. The resident sustained a laceration to her head. Due to the facility's failures to ensure staff closely monitored the resident for erratic movements during Hoyer lift transfers, Resident #23 sustained a laceration to her head which required a transfer to the emergency department (ED) for seven sutures. Additionally, the facility failed to implement timely safety interventions for Resident #28 after the resident left the facility unsupervised on two separate occasions. Findings include: I. Failed to prevent an injury to Resident #23 during a Hoyer lift transfer A. Facility policy and procedure The Safety Precautions, Lifting policy, revised December 2009, was received from the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It read in pertinent part, Hoyer lifts shall be operated with the use of at least two employees. Tell the resident what you are doing. Make sure you have room to move freely. Do not hurry the procedure. Before lifting or moving residents, make sure that equipment is secure (wheelchair, beds, stretchers). Report any defective equipment to your supervisor as soon as practical. B. Resident #23 1. Resident status Resident #23, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included, anoxic brain damage , muscle weakness, cognitive communication deficit and intracranial abscess and granuloma (collections of pus or inflammatory tissue in the brain). The 10/21/24 minimum data set (MDS) assessment revealed the resident was rarely or never understood through staff assessment. The resident had short-term and long-term memory deficits and was severely impaired in daily decision-making through staff assessment. The resident was dependent on staff for all activities of daily living (ADL) and mobility. 2. Resident representative interview Resident #23's representative was interviewed on 1/15/25 at 9:29 a.m. The representative said Resident #23 had only been in the facility since October 2024 so the resident was still getting acclimated to the care that was provided. The representative said she was not happy to hear that Resident #23 had to have seven stitches due to hitting her head on the Hoyer lift. 3. Observation On 1/14/25 at 3:37 p.m. certified nurse aide (CNA) #5, CNA #7 and CNA #12 were conducting a Hoyer lift transfer with Resident #23. The three CNAs told Resident #23 they were going to lay her down. Resident #23 began to become very vocal. The CNAs told her they understood that she did not like using the Hoyer lift for transfers and they would make it as quick as possible for her. The sling was left underneath the resident and was made of mesh with a hole for the resident's bottom. One CNA positioned and maneuvered the Hoyer lift while the other two connected the straps to the lift and watched the resident while the lift was being moved. They used the purple colored loops on all four straps to lift the resident. Resident #23 became more vocal and louder while she was being lifted and moved from her wheelchair to the bed. During this time she did not move erratically or move her head forward and back or from side to side. She was in more of a lying position rather than a sitting position during the transfer. 4. Record review The 1/12/25 nurse's note, entered at 7:30 p.m., documented that a CNA came out of Resident #23's room at shift change and reported that during the Hoyer lift transfer, Resident #23 was moving erratically and hit her head on the lift and was bleeding from her head. The nurse documented that the staff put pressure on the wound until the paramedics came to transfer the resident to the ED. The 1/12/25 ED after visit summary documented that Resident #23's diagnosis was a minor head injury with facial laceration. The ED did a computed tomography (CT) scan and the results were normal. The resident had seven sutures applied to her forehead above her right eye and sustained bruising to her right eye. The 1/14/25 interdisciplinary team (IDT) note documented the facility would evaluate the strap placement on the sling to prevent Resident #23's close proximity to the Hoyer lift grab bar during transfers. It further documented that during Resident #23's Hoyer lift transfers, there would be a third staff member present to evaluate the effectiveness of the interventions for 72 hours. Review of Resident #23's ADL care plan, updated 1/14/25, revealed that during the residents Hoyer lift transfers the sling must be on the last loop to increase the room if she started moving during the transfer. 5. Staff interviews CNA #13 was interviewed on 1/15/25 at 10:20 a.m. CNA #13 said there was always supposed to be two people present for Hoyer lift transfers, however, she said for Resident #23 currently, there were supposed to be three people because of the incident that happened with her hitting her head on the Hoyer lift. She said the third person was there to make sure that the transfer happened safely. CNA #13 said during Hoyer lift transfers, one staff member was in charge of the lift and the other staff member was there to watch the resident, to make sure that their legs did not hit the lift and to move the resident into position. She said the staff had started to watch Resident #23's head position now that the incident happened. She said Resident #23 would move erratically every once in a while but she had never seen the resident thrashing her head around. She said Resident #23 had only wiggled her body when she was transferring her. She said before the incident on 1/12/25, the staff was using the closet loop on the lift sling so that they could position resident in more of a sitting position, but she said now the staff was using the last loop on the transfer sling which positioned the resident in more of a laying position so she was less likely to hit her head. Licensed practical nurse (LPN) #4 was interviewed on 1/15/25 at 10:39 a.m. LPN #4 said Resident #23 was a Hoyer lift transfer, which normally was a two-person transfer, but she said for the next 72 hours, Resident #23 would be a three-person transfer to ensure the resident's safety. LPN #4 said the three-person transfer was the only intervention that she had heard of. CNA #9 was interviewed on 1/15/25 at 11:09 a.m. CNA #9 said Resident #23 was normally a two-person Hoyer lift transfer, but she said for the next 72 hours, she was to be a three-person Hoyer lift transfer. She said it was because of the incident that had happened on 1/12/25 when the resident hit her head on the Hoyer lift. CNA #9 said the staff were using the purple loops on her sling to position the resident in a better position to keep her head safe. III. Failed to implement timely safety interventions for Resident #28 who left the facility unsupervised on two separate occasions A. Facility policy and procedure The Elopements and Wandering policy, revised December 2007, was provided by the RDQC on 1/22/25 at 4:55 p.m. It read in pertinent part, It is the goal of the facility to provide a safe environment using the least restrictive measures available in caring for residents who exhibit wandering or exit-seeking behavior to prevent elopements. Wandering is defined as moving around the facility in a non-goal oriented manner without attempts to leave the premises. Elopement is defined as leaving from a supervised area to an unsupervised area without staff knowledge or the appropriate level of staff supervision. The wander/elopement risk evaluation shall be completed for all residents upon admission to the facility and then quarterly thereafter or with changes in condition. Residents who score 7 (seven) or higher on the wander/elopement risk evaluation are considered to be at high risk for wandering/elopement and should have upgraded interventions developed and implemented by the interdisciplinary team (IDT), beginning with the least restrictive interventions. The interventions shall be documented in the resident's plan of care. Elopement occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so. Residents identified to be at high risk for elopement shall not be permitted to be on facility grounds or non-resident areas of the facility without staff supervision. If an employee discovers that a resident is missing from the facility, he/she shall: -Determine if the resident is out on an authorized leave or pass; -If the resident was not authorized to leave, initiate a search of the building(s) and then the premises if resident is not located within the building; -If the resident is not located on the premises, notify the administrator and the director of nursing services, the resident's legal representative (sponsor) if not self-responsible, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (emergency management and rescue squads); -Provide search teams with resident identification information; and, -Initiate an extensive search of the surrounding area. When the resident returns to the facility, the director of nursing services or charge nurse shall: -Examine the resident for injuries; -Contact the attending physician and report findings and conditions of the resident; -Notify the resident's legal representative (sponsor) if not self-responsible; -Notify search teams that the resident has been located (if applicable); -Complete and file an incident report with all appropriate agencies; and, -Document relevant information in the resident's medical record. B. Resident # 28 1. Resident status Resident #28, age 83, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included senile degeneration of the brain (decline in cognitive function), polyneuropathy and dementia. The 11/12/24 MDS assessment revealed that Resident #28 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident was independent with her walker and the majority of her ADLs. The assessment indicated that wandering was not exhibited. 2. Resident representative interview Resident #28's representative was interviewed on 1/21/25 at 4:26 p.m. The representative said that Resident #28 had left the faciity on ce to go to the gas station for candy. She said the facility called her the day that it happened (9/22/24). She said she was surprised that Resident #28 had the cognitive ability to cross the busy street in front of the facility, pay for her candy and then cross the busy street again. She said that the facility's plan was to put a wander guard on the resident on 9/22/24, but the facility did not have any wander guards because they were on back order. The representative said Resident #28 had only left the building one time. -However, Resident #28 had left the facility unsupervised on 7/20/24, prior to the 9/22/24 incident (see record review below). 3. Record review Review of Resident #28's wander risk care plan, initiated 11/27/24, revealed the resident was at risk for wandering/elopement. Interventions included assessing the resident for emotional psychological distress, assessing the resident for physical distress, encouraging the resident to stay in common areas of the building, and placing a wander guard on the resident (placed on 11/27/24). The 5/20/24 Wander/Elopement Risk evaluation documented that Resident #28 was not an elopement or wander risk. The 7/20/24 nurse note, written at 8:13 p.m., documented that Resident #28 was found outside of the building. An unknown staff member had heard the comments of her being outside and was able to bring her back into the building. The 7/20/24 nurse note, written at 8:25 p.m., documented that Resident #28 wanted to go to the store to buy candy bars. Review of Resident #28's electronic medical record (EMR) revealed there were no interventions put into place after Resident #28 left the building on 7/20/24. The 8/20/24 Wander/Elopement Risk evaluation documented that Resident #28 did not have a history of wandering or elopement and was not at risk for wandering or elopement. Review of a 9/22/24 facility investigation revealed that Resident #28 was seen by staff returning to the facility on [DATE], after being off facility grounds for an unknown amount of time and without staff knowledge. The investigation documented that Resident #28 reported going to the gas station for a snack. The investigation documented that she was last seen at 1:00 p.m and did not acquire any injuries. The investigation further revealed that Resident #28 had a lack of insight to her own limitations and was forgetful and was at risk of being unable to return to the facility. The investigation revealed that Resident #28 was placed on frequent checks, her care plan was updated, she was assessed for a wander guard and a wander guard was placed. -However, the care plan was not initiated until 11/27/24, four months after the resident first left the facility unsupervised on 7/20/24 and two months after the resident's second incident of leaving the facility unsupervised on 9/22/24 (see care plan above). -Additionally, a wander guard was not placed on Resident #28 until 11/27/24, despite the facility documenting a wander guard was placed on the resident following the 9/22/24 incident (see facility investigation above). -Review of Resident #28's EMR revealed the facility failed to conduct a Wander/Elopement Risk evaluation following the resident's second incident of leaving the facility unsupervised on 9/22/24. The 1/20/25 Wander/Elopement Risk evaluation (completed during the survey) documented that the resident was a high risk for elopement. 4. Staff interviews LPN #4 was interviewed on 1/15/25 at 3:45 p.m. LPN #4 said she knew that Resident #28 had a wander guard on because she had left the building before. She said she had only heard of the resident leaving the building once before and she was unaware if the resident had left the facility unsupervised more than once. CNA #8 was interviewed on 1/16/25 at 12:02 p.m. CNA #8 said Resident #28 did not wander but he said he had seen her come out of her room to get something to drink. He said he had not seen Resident #28 outside of the building before. CNA #10 was interviewed on 1/16/25 at 12:38 p.m. CNA #10 said she had never seen Resident #28's wander guard and she had never heard of the resident leaving the building. CNA #10 said all the doors to the outside of the facility had a wander guard alarm system on them. LPN #4 was interviewed again on 1/16/25 at 12:45 p.m. LPN #4 said she had never seen Resident #28 try to exit the building. She said the resident did wander but she did not exit-seek. CNA #11 was interviewed on 1/21/25 at 12:45 p.m. CNA #11 said Resident #28 wandered to the front sitting area but she had never seen her outside by herself. She said she did not think that the resident had ever been allowed outside by herself. CNA #11 said the facility had a binder with a list of residents who were on elopement and wander precautions. LPN #5 was interviewed on 1/21/25 at 1:00 p.m. LPN #5 said Resident #28 was only allowed to go outside with either family or staff members. She said she was unaware of the resident ever being outside by herself. The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 1/21/25 at 2:00 p.m. The DON said Resident #28 had a history of wandering and exit seeking and she needed redirection and reorientation to where she was. The NHA said Resident #28 left the building on 9/22/24 and the interventions that were placed after the incident were frequent checks. She said no other interventions were placed. She said Resident #28 was never independent to be outside by herself. She said Resident #28 reported to her that she went to the gas station and came back. She said the facility had a care conference with her daughter on 9/24/24 and had a discussion about the wander guard and decided that frequent checks were appropriate at that time. The NHA said Resident #28 had not had any incidents of leaving the building since September 2024. However, she said in November 2024 the IDT decided to place a wander guard on the resident for extra precautions. The NHA said Resident #28 was reassessed for the wander guard based on her history of leaving the building and the incident in September 2024. She said new interventions added in November 2024 included behavior monitoring, care plan updates, a wander guard assessment and placing a wander guard. She said the current management, including herself, was not aware Resident #28 had left the building in July 2024, as they had not worked in the building at that time.The NHA said there was no investigation of the 7/20/24 elopement incident for Resident #28. The NHA said the facility would re-educate the staff on how to properly complete a Wander/Elopement Risk assessment, because when the facility reassessed the resident, they realized that the wander assessments were not done correctly.

Based on observation, record review and interviews, the facility failed to serve food that was palatable and attractive. Specifically, the facility failed to ensure that the resident's food was palatable in taste, texture and appearance. Findings include: I. Resident interviews Resident #39 was interviewed on 1/13/25 at 11:49 a.m. He said that the food did not taste good and was not presentable. Resident #59 was interviewed on 1/13/25 at 2:10 p.m. He said that the food was not good. He said the taste of the food depended on who was cooking and what staff was working. Resident #44 was interviewed on 1/13/25 at 3:23 p.m. She said that the food tasted horrible and that the food does not look presentable. Resident #217 was interviewed on 1/13/25 at 3:37 p.m. She said the facility did not have an alternate menu. She said the kitchen would often close by the time she got her meal, so if she did not like what was served she could not get something else. Resident #50 was interviewed on 1/14/25 at 9:43 a.m. He said the food was not good. He said the food did not taste good. He said the facility did not have an alternative menu., Resident #46 was interviewed on 1/14/25 at 10:21 a.m. He said the meat and vegetables were served over cooked. He said the canned fruit tasted like the can. He said he would like some fresh fruit. II. Resident group interview The resident group interview was conducted on 1/15/25 at 1:04 p.m. The group consisted of five residents (#2, #37, #51, #39 and #58) who were interviewable based on assessment by the facility. All of the residents in the group interview said the food was not palatable. Some of the comments were as follows: -The food was questionable at best; -The food did not look good; -Some of the food was too spicy; and, -The dietary manager (DM) did not listen to the residents or fix the issues. III. Record review The food committee meetings from October 2024 through January 2025 were reviewed. The 10/7/24 food committee minutes documented that the residents wanted more fruit added to the menu and that some of the food was too salty. The 12/2/24 food committee minutes documented that they would like brussel sprouts and some other vegetables off the menu. -The minutes did not mention what actions were taken regarding expressed concerns and if residents were satisfied with resolution. IV. Observations On 1/15/25 at approximately 12:30 p.m. a test tray of a regular diet was immediately evaluated by four surveyors after the last resident was served their room tray for lunch. The test tray was not served palatable and consisted of white rice pilaf, white gravy, four meatballs, steamed brussel sprouts, white bread roll and a slice of angel food cake with canned peaches over the top. The rice pilaf was crunchy and under cooked. The gravy was salty. -The outside of the meatballs were crunchy and hard to bite through. The brussel sprouts were slightly yellow and greyish in color, the consistency was mushy and were overcooked. The angel food cake and the peaches that were on tope were sweet. V. Staff interview The DM was interviewed on 1/22/25 at 4:30 p.m. He said he met with residents every month to discuss food feedback and choices. He said to his knowledge residents were satisfied with food choices they had. The DM said he did taste the rice pilaf on 1/15/25 lunch time and he did not think it was undercooked. 37166

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse that rose to the level of immediate jeopardy. Findings include: I. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies. F600 Abuse prevention During a recertification survey on 7/13/23, F600 was cited at a G level scope and severity, isolated, actual harm. The facility had identified and corrected the deficient practice prior to the survey and therefore F600 was cited at past non-compliance. -However, the facility failed to maintain compliance. During a recertification survey on 1/15/25, F600 was cited at K level scope and severity, pattern, immediate jeopardy to residents health and safety. Failure to monitor sexually inappropriate behavior for the resident with a history of such behaviors. F759 Medication administration error rate above five (%) percent During a recertification survey on 7/13/23, F759 was cited at a D level scope and severity, isolated, no actual harm with potential for more than minimal harm. During a recertification survey on 1/15/25, F759 was cited at a D level scope and severity, isolated, no actual harm with potential for more than minimal harm. II. Staff interviews The nursing home administrator (NHA) was interviewed on 1/15/25 at 5:30 p.m. The NHA said Resident #50 was admitted to the facility prior to change of ownership. She said the resident's history of sexually inappropriate behavior was mentioned in his medical records, however he did not display any inappropriate behaviors until the incident on 1/1/25. She said the facility reviewed all of the residents who might have had a history of sexually inappropriate behaviors to ensure proper interventions were put in place. The medical director (MD) was interviewed on 1/16/25 at 9:50 a.m. The MD said he was not aware that Resident #50 had a history of sexually inappropriate behaviors. He said it was brought to his attention this week. He said primary care and mental health providers were involved in identifying the best course of treatment for this resident. The NHA was interviewed a second time on 1/22/25 at 5:30 p.m. The NHA said QAPI meetings were conducted monthly. She said sexually inappropriate behaviors and Resident #50 were not brought up in the meetings and have not been identified as a problem.

Based on observations, record review and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two (#167 and #64) of five residents reviewed for quality of care out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #167's physician was notified in a timely manner when attempts to start an intravenous (IV) line were unsuccessful and staff could not administer IV fluids per the physician orders; and, -Ensure Resident #64's laboratory (lab) blood work was addressed by the resident's physician in a timely manner. Findings include: I. Facility policy The Change in a Resident's Condition or Status policy and procedure, revised 12/19/16, was received from the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, The nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there has been a change in condition, including a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's medical treatment significantly. II. Resident #167 A. Resident status Resident #167, age 70, was admitted on [DATE] and discharged to the hospital on 11/11/24. According to the January 2025 computerized physician orders (CPO), diagnoses included carotid artery aneurysm (bulge in the artery that supplies brain/head with blood flow), dysphagia (difficulty with swallowing) and depression. The 10/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive/maximal assistance with toileting, bathing, hygiene, sit to stand transfers and chair to bed transfers. B. Record review A nursing progress note, dated 11/1/24 at 2:45 p.m., documented Resident #167 had sustained a change in condition related to falls, shortness of breath and decreased urine output. Vital signs documented at the time included an oxygen saturation of 83% (percent) on room air. A nursing note dated 11/1/24 at 3:56 p.m., documented that Resident #167's primary care provider (PCP) gave a physician's order for a stat (immediate) D-dimer (blood test to rule out a blood clot), chest x-ray, two liters per minute of oxygen via nasal cannula, to start a peripheral IV and to administer one liter of 0.9% normal saline solution. It was documented to notify the PCP after completion of the orders and to follow up with any presentation of becoming hemodynamically unstable (unstable movement in blood resulting in inadequate blood flow). A nursing note, dated 11/1/24 at 5:45 p.m., documented that the nurse attempted to start an IV twice on Resident #167 and was unsuccessful. -Review of Resident #167's electronic medical record (EMR) failed to reveal documentation that the resident's PCP was notified when the nurse was unable to start the IV in order to administer the physician ordered normal saline solution (see above). A nursing note, dated 11/2/24 at 6:48 a.m., documented a nurse attempted to start an IV and the resident tolerated it well. However, the IV attempt was unsuccessful and the provider was notified. -However, there was no documentation in Resident #167's EMR to indicate what was recommended by the physician when the IV attempts were unsuccessful. C. Staff interviews The RDQC, the director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 1/16/25 at 2:35 p.m. The DON said when a resident experienced a change in condition, the nurse on duty was to notify the physician, the DON and the resident's family or medical power of attorney (POA). She said orders from the physician were to be completed right away unless there was another emergency going on. She said if a nurse was unable to get an IV initiated, the process was to have another nurse attempt, notify the DON and call the RDQC to get someone to come in to place the IV. The RDQC said the facility could also call for emergency medical services (EMS) to put an IV in. Nurse practitioner (NP) #1 was interviewed on 1/16/25 at 1:19 p.m. NP #1 said she would expect to be notified right away if a nurse was unable to carry out a treatment order for a resident. She said this would potentially change the treatment plan for the resident. Registered nurse (RN) #2 was interviewed on 1/21/25 at 10:45 a.m. RN #2 said if a resident was experiencing a change in condition, she would assess the resident, call the provider and call the nursing supervisor. She said if she could not follow a provider's order, she would notify the provider right away. Primary care physician (PCP) #1 was interviewed on 1/22/25 at 11:26 a.m. PCP #1 said she was notified of Resident #167's change in condition on 11/1/24 and ordered a peripheral IV with fluids. She said she was not notified by the nursing staff until 11/2/24 that the nursing staff was unable to place the IV. She said if she had been notified earlier, she may have sent Resident #167 to the emergency room if the resident was agreeable. 37166 III. Resident #64 A. Resident status Resident #64, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included type 2 diabetes, history of stroke and hypertension. The 7/28/24 MDS assessment revealed the resident was moderately cognitively intact with a BIMS score of 10 out of 15. The resident required moderate assistance with activities of daily living (ADL). B. Record review The primary care provider note dated 11/8/24 documented that Resident #64 was assessed by the physician as he had been off. The resident was skipping meals and smoke breaks. The physician placed physician's orders to obtain blood work for the resident. The blood work was completed by the lab on 11/8/24 and was submitted to the physician's office and facility for review via the EMR. -There was no documentation in Resident #64's EMR to indicate that the resident's primary care provider reviewed the resident's lab work and provided feedback to the facility. -There was no documentation in Resident #64's EMR to indicate the facility followed up with the resident's primary care provider when the facility did not receive feedback from the physician regarding the resident's lab work. On 11/10/ 24 Resident #64's condition deteriorated and he was sent to the emergency room for further evaluation. C. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 1/20/25 at 1:30 p.m. LPN #6 said she was working with Resident #64 on 11/8/24. She said the resident stayed in his bed and did not go to his smoke breaks. She said he was offered fluids, but he preferred to drink only coffee. She said she contacted his physician who ordered lab work on 11/8/24. She said when lab work was completed by the lab, the lab automatically populated residents' EMRs for providers and for nurses in the facility. She said nurses acknowledged receipt of lab work by writing a progress note when it was received and what the response from the physician was. The DON was interviewed on 1/20/25 at 3:40 p.m. The DON said any changes in a resident's condition should be documented in a change of condition form. She said when lab work results were received, nursing staff should write a progress note and indicate the response from the provider. She said there was not a nursing note for Resident #64's lab work that was completed on 11/8/24. The NHA was interviewed on 1/20/25 at 3:40 p.m. The NHA said she contacted Resident #64's physician's office (during the survey) and the physician's office confirmed that they received a call from nursing staff on 11/9/24 asking for feedback on the resident's 11/8/24 lab work. The NHA said the physician's office was not able to comment if any feedback was provided to the nursing staff on 11/9/24. She said the nursing staff should have contacted the physician's office again to request feedback when they did not hear back from the physician.

Based on observation, record review, and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for one resident (#1) out of 38 sample residents. Specifically, for Resident #1, the facility failed to: -Assess the resident for the safe use of bed rails, including assessment for risk of entrapment prior to installing the bed rails; -Create and document a personal care plan for the safe use of bed rails; -Obtain consent from the resident and/or the resident's representative before bed rails installation, including informing them of the risks versus benefits of bed rails; -Obtain a physician's order for the bed rails; and, -Conduct quarterly assessments of the bed rails to evaluate their continued need and safety. Findings include: I. Facility policy and procedure The Side Rail policy, revised on 12/19/16 was received from the nursing home administrator (NHA) on 1/22/25 at 4:15 p.m. It read in pertinent part, An assessment of the resident will be made to include a review of the following: device to be used; indication for use; cognitive status; physical status; pertinent history, as applicable; anticipated benefits; a review of how the device impacts the resident's freedom of movement; a review of whether the resident has the potential to become entrapped or harmed; and, risk factors associated with use of the device. The use of side rails as an assistive device will be addressed in the resident care plan. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks and documented within the assessment. If side rail usage is appropriate, the facility will obtain an order for use from the attending physician. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment. II. Resident #1 A. Resident status Resident #1, age 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included generalized idiopathic epilepsy and epileptic syndromes (seizure disorders), cognitive communication deficit, history of traumatic brain injury, sleep apnea, depression and gastro-esophageal reflux disease without esophagitis (GERD). The 12/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required assistance from one person with activities of daily living (ADLs). The assessment documented Resident #1 did not use bed rails. -However, observations revealed the resident had bed rails in place (see below). B. Resident interview and observations Resident #1 was interviewed on 1/13/25 at 9:30 a.m. Resident #1 said she had temporarily moved to a different bedroom because of an issue with the heater. She said she needed bed rails on the bed to help her get up and move around. Resident #1 was lying in her bed and there were no bed rails attached to the bed. Resident #1 was interviewed again on 1/21/25 at 5:30 p.m. The resident was observed in her room in bed. The side rails were present on her bed. She said they were installed last week. C. Record review Review of Resident #1's comprehensive care plan did not reveal documentation regarding the use of a bed rail. Review of Resident #1's electronic medical record (EMR) did not reveal an assessment for the safe use of side rails, a physician's order for the use of the bed rails or a consent for the use of the bed rails. III. Staff interviews The director of nursing (DON) and the NHA were interviewed together on 1/13/25 at 3:00 p.m. They said the resident was moved to a different room while the facility was working on repairing the heater. The NHA was interviewed again on 1/22/25 at 4:45 p.m. The NHA said Resident #1 had been utilizing bedrails She admitted the bedrail assessment should have been completed prior to installing the bed rails.

Based on observations, record review and interviews, the facility failed to ensure the medication administration error was not greater than five percent. Specifically, the facility's medication administration error rate was 8% (percent), or two errors out of 25 opportunities for error. Findings include: I. Manufacturer's recommendations The Novolog medication package insert (February 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.novo-pi.com/novolog.pdf. It revealed in pertinent part, Giving an air shot before injection (after needle application): before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. the dose selector should return to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. The Humalog medication package insert (July 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/020563Orig1s202,205747Orig1s028Lbl.pdf. It revealed in pertinent part, Priming your insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. II. Observations of medication administration for Resident #18 On 1/14/25 at 10:59 a.m., licensed practical nurse (LPN) #1 was observed during medication administration. She checked Resident #18's blood sugar which was 352 milligrams (mg)/deciliter (dl). She took the Novolog pen out of the medication cart and pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared 22 units of the Novolog solution for Resident #18. She said eight units were for her scheduled insulin and 14 units were the sliding scale order, which was verified correct per the physician's order. She turned the dose to 22 units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #18's lower abdomen with an alcohol wipe and injected the medication into her abdomen. -LPN #1 failed to prime the Novolog insulin pen prior to drawing up the 22 units of insulin. III. Observations of medication administration for Resident #46 On 1/14/25 at 11:12 a.m., LPN #1 was observed during medication administration. She checked Resident #46's blood sugar which was 227 mg/dl. She took the Humalog pen out of the medication cart, pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared eight units of Humalog solution for Resident #46. She said four units were for her scheduled insulin and 4 units were the sliding scale order, which was verified as correct per the physician's order. She turned the dose to eight units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #46's right upper arm with an alcohol wipe and injected the medication into her arm. -LPN #1 failed to prime the Humalog insulin pen prior to drawing up the eight units of insulin. IV. Staff interviews Nurse practitioner (NP) #1 was interviewed on 1/16/25 at 2:33 p.m. NP #1 said it was best practice to prime an insulin pen prior to administration so the resident got the full dose of insulin. The director of nursing (DON) and the regional director of quality and compliance (RDQC) were interviewed on 1/16/25 at 2:35 p.m. The DON said insulin pens should be primed with two units of insulin or whatever the specific manufacturer's recommendation was. Cross reference F760: failure to be free from significant medication errors.

Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for two (#18 and #46) of two residents reviewed for medications errors out of 38 sample residents. Specifically, the facility failed to ensure that Resident #18 and Resident #46 were administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Manufacturer recommendations The Novolog medication package insert (February 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.novo-pi.com/novolog.pdf. It revealed in pertinent part, Giving an air shot before injection (after needle application): before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector should return to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. The Humalog medication package insert (July 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/020563Orig1s202,205747Orig1s028Lbl.pdf. It revealed in pertinent part, Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. II. Observations On 1/14/25 at 10:59 a.m., licensed practical nurse (LPN) #1 was observed during medication administration. She checked Resident #18's blood sugar which was 352 milligrams (mg)/deciliter (dl). She took the Novolog pen out of the medication cart and pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared 22 units of the Novolog solution for Resident #18. She said eight units were for her scheduled insulin and 14 units were the sliding scale order, which was verified correct per the physician's order. She turned the dose to 22 units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #18's lower abdomen with an alcohol wipe and injected the medication into her abdomen. -LPN #1 failed to prime the Novolog insulin pen prior to drawing up the 22 units of insulin. On 1/14/25 at 11:12 a.m., LPN #1 was observed during medication administration. She checked Resident #46's blood sugar which was 227 mg/dl. She took the Humalog pen out of the medication cart, pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared eight units of Humalog solution for Resident #46. She said four units were for her scheduled insulin and 4 units were the sliding scale order, which was verified as correct per the physician's order. She turned the dose to eight units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #46's right upper arm with an alcohol wipe and injected the medication into her arm. -LPN #1 failed to prime the Humalog insulin pen prior to drawing up the eight units of insulin. Cross reference F759: failure to ensure the medication rate was under 5%. III. Staff interviews Nurse practitioner (NP) #1 was interviewed on 1/16/25 at 2:33 p.m. NP #1 said it was best practice to prime an insulin pen prior to administration so the resident got the full dose of insulin. The director of nursing (DON) and the regional director of quality and compliance (RDQC) were interviewed on 1/16/25 at 2:35 p.m. The DON said insulin pens should be primed with two units of insulin or whatever the specific manufacturer's recommendation was.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart; and, -Ensure all medications were labeled with resident information. Findings include: A. Professional references The United States Food and Drug Administration (USFDA) (10/31/24) Don't Be Tempted to Use Expired Medicines, was retrieved on 1/23/25 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It documented in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. The National Institutes of Health (NIH) (July 2017) Strengthen Your Resolve: No Unlabeled Containers Anywhere, Ever, was retrieved on 1/23/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC5481289/#:~:text=Discard%20unlabeled%20medications,event%20as%20a%20hazardous%20condition. It documented in pertinent part, Discard unlabeled medications. Don' t assume that you know what is contained in an unlabeled syringe, cup or basin. Discard any unlabeled solution or medication found in the perioperative area or procedural areas and report the event as a hazardous condition. B. Facility policy and procedure The Medication Labeling and Storage policy, revised 2001, was provided by the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes at minimum: medication name, prescribed dose, strength, expiration date, resident's name, route of administration and appropriate instructions and precautions. C. Observations On 1/15/25 at 5:30 p.m. the medication cart and treatment cart on the secure unit were observed with licensed practical nurse (LPN) #3. The following items were found: -One bottle of nitroglycerin lingual spray with an expiration date of June 2023; and, -One container of nitroglycerin sublingual tablets with no label indicated which resident it belonged to. IV. Staff interviews LPN #3 was interviewed on 1/15/25 at 5:30 p.m. LPN #3 said usually the night shift nurse would audit the medication carts for expired medications. She said she was going to let the director of nursing (DON) know about the expired medication and the unlabeled medication. She said she would dispose of the medications properly. The DON and the RDQC were interviewed together on 1/16/25 at 2:35 p.m. The DON said the medications carts and storage rooms were reviewed weekly. She said this was done by herself or a unit manager. She said if a nurse found an expired medication, the nurse should have removed the medication and destroyed it. She said medications that come from the pharmacy come with resident labels.

Based on record review and interviews, the facility failed to take steps to protect the right to be free from abuse and neglect for one resident (#18) of five out of 36 sample residents. The facility failed to keep Resident #18 free from abuse when certified nurse aide (CNA) #4 who delivered medication to Resident #18, held her hand over the resident's mouth in an attempt to force the resident to swallow sedating medication for ongoing behaviors. Through the course of the investigation, the facility failed to prevent another abuse incident for Resident #18 when CNA #4 pulled the resident's wheelchair in a manner that resulted in a fearful response by the resident. Findings include: Record reviews and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation completed 7/10/23 to 7/13/23. The deficiency was cited as past non-compliance with a correction date of 6/5/23. I. Facility policy The Abuse policy, dated May 2023, was provided by the nursing home administrator (NHA) on 7/11/23 at approximately 3:00 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Neglect is the failure of the facility, its employees or service provider to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The following approaches and interventions are designated as part of the facility abuse prevention protocols. Education is provided at staff orientation and training programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Staff is encouraged to talk with supervisors, department heads, social services, or the administrator about residents or situations they find difficult to manage, stressful, or frustrating. Residents at risk for abusive situations are identified and appropriate care plans are developed. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. An employee shall not knowingly attempt to induce another to fail to report an incident or suspected incident of abuse, or fail to report an incident or suspected incident of abuse. An employee who has knowledge or reason to believe that a resident has been a victim of abuse is required to immediately report such incident or suspicion to a member of the administrative staff. II. Resident status Resident #18, age 89, was admitted to the facility on [DATE]. According to the July 2023 computerized physician orders (CPO), pertinent diagnoses included dementia, anxiety, communication deficit, weakness, severe right eye blindness and need for assistance with personal care. The 6/7/23 minimum data set assessment (MDS) revealed Resident #18 was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. She needed extensive assistance from one person for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. She needed supervision and set up help only with eating and limited assistance of one person for locomotion on and off the unit. III. Observations Resident #18 was observed with one-to-one staff supervision in her room on 7/10/23 at 12:00 p.m., 7/12/23 at 10:50 a.m. and on 7/13/23 at 11:30 a.m. She was observed at the nurses station sitting in her wheelchair with one-to-one staff presence on 7/12/23 at 5:00 p.m. IV. Record review Resident #18's behavior care plan was initiated 5/8/23. She had episodes of being physically and verbally aggressive due to her diagnoses of dementia, anxiety and cognitive deficits. She became agitated with staff and would swipe or kick at them, yell and curse at them, be sexually inappropriate and had episodes of hallucinations. The care plan was initiated on 5/8/23 and revised on 6/1/23. Resident interventions included: line of site supervision, initiated 5/23/23, and one-to-one supervision on 5/29/23; assess and anticipate the resident's needs, initiated 5/8/23 and revised 5/30/23; when resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, and if response is aggressive staff to walk away calmly and approach later, initiated 5/8/23 and revised 6/1/23. The 5/29/23 nursing progress note at 10:17 a.m. documented Resident #18 had constant behaviors of wandering, exit-seeking, physical and verbal aggression. Staff had to perform one-to-one supervision as the resident was bothering other residents in the facility, refusing care, and was combative with staff. The 5/29/23 nursing progress note at 10:20 p.m. documented Resident #18 was resting comfortably in bed with her eyes closed and appeared to be sleeping. No new skin tears were noted to her arms. The resident woke and opened her eyes when her blankets were pulled back. V. Facility investigation The NHA provided an abuse investigation dated 5/29/23 that involved facility staff and Resident #18. The investigation included: A. An investigative timeline that documented the initial reported incident on 5/29/23 and follow up actions of interviews, assessments, education and reporting. The investigation and facility wide education was completed on 6/5/23. According to the investigation, the facility concluded CNA #4 delivered medication that was not prescribed to Resident #18 and CNA #4 held her hand over the mouth of the resident in an attempt to force the resident to swallow sedating medication for ongoing behaviors. The investigation revealed a previous incident with an unknown date involving the same CNA (#4) and Resident #18. The incident was revealed after staff interviews were conducted on 5/31/23. The CNA became agitated with resident behaviors and pulled the resident's wheelchair sideways in an aggressive manner. The resident grabbed ahold of the CNA's arm from what appeared to be fear and licensed practical nurse (LPN) #2 insisted the CNA change how they were moving the resident. LPN #2 did not report the incident immediately to the administration. Both incidents were reported on 5/31/23 to the police, family, ombudsman, adult protective services, physician and the Board of Nursing ([NAME]). B. Investigative report The following investigative timeline was provided by the NHA on 7/13/23 at 1:30 p.m. On 5/29/23: -Licensed practical nurse (LPN) #1 called to inform the NHA of resident aide (RA) #1 reporting an incident concerning Resident #18 at 8:15 p.m. -The NHA arrived on site and began interviews at 8:41 p.m. -All staff associated with the event were suspended pending investigation at 9:45 p.m. -The incident was reported to the State Agency. On 5/30/23: -The medical director was notified. -A plan was initiated to conduct education and a facility wide investigation. -Facility wide resident interviews began. -LPN #2 was interviewed at 5:23 p.m. and suspended pending investigation. On 5/31/23: -A police report was completed and adult protection services were notified. -Facility wide education was conducted on 5/31/23. An emergency all staff meeting was scheduled and training conducted was conducted by the chief clinical officer (CCO) on the abuse policy, zero tolerance for any type of abuse, timely reporting of abuse, resident rights and the residents' right to refuse medications, medication administration to only be conducted as ordered, the scope of practice related to certified nurse aides (CNA) and not being allowed to administer medications, with a signed verification of the abuse policy. -Quality assurance and performance improvement (QAPI) was completed on 5/31/23 specifically for this reported incident. -Interviews concluded for all facility residents. -Compliance packets and training for agency staff were compiled to be completed prior to an agency staff member's shift starting. -Compliance packets for new hire staff was initiated with the packets to be completed at the time of new hire orientation. On 6/2/23: -A second all staff meeting with the pharmacist was scheduled. -All pertinent parties were reported to Boards of Nursing for different states where the nursing staff worked. On 6/5/23: -All staff training completed with topics that addressed abuse, neglect, abuse reporting and Beers list (list of harmful medications). -An updated report was made to the police about the investigation findings. The conclusion of the facility investigation was they substantiated abuse occurred to Resident #18 by CNA #4. C. Recorded interviews and action plan The NHA interviewed all staff and residents of the facility. Residents reported behavioral concerns with Resident #18 and staff reported Resident #18's behaviors had been trying on staff. Staff reported a CNA gave Benadryl to Resident #18 and were under the impression it was appropriate to do so. The interviews also revealed a second incident with Resident #18 and CNA #4 that occurred prior to 5/29/23, however the exact date was unclear and was not reported timely to the abuse coordinator. Resident #18 was placed on behavior monitoring and her care plan was updated with a referral for mental health services. CNA #4 was suspended 5/29/23 and LPN #2 was suspended 5/30/23; their employment at the facility terminated, reported to appropriate governing agencies and complaints filed on their licenses. Ambassador visits were implemented for the three months following the incident in which facility management followed up with residents. The ambassador visits were five a day weekly for three months following the incident and residents were asked if they were being forced to be given medication or medication that was not prescribed or subjected to abuse. Resident #18 was put on one-to-one staff supervision. VI. Staff interviews CNA #1 was interviewed on 7/12/23 at 10:50 a.m. She said she had done one-to-one with Resident #18 and the resident disliked crowded areas. She said the resident was more alert some days than others but it just depended on the day. She said some nights Resident #18 did not sleep at all and she tried to read the resident's mood. She could not always tell her mood or what the resident wanted, so she asked the resident twice. CNA #1 said she had both abuse and dementia training from her agency that she worked for and at the facility. She said she knew the CNA should never administer medication to the resident. She said if she saw or heard abuse she reported it to the nurse or nurse on call and then the NHA and if the NHA was not in the building she called the phone number posted on the wall. RA #2 was interviewed on 7/13/23 at 11:20 a.m. She said she covered the one-to-one shift with Resident #18. She said she did go with the resident to the courtyard or to see the ducks as the resident enjoyed those activities. She said sometimes Resident #18 became agitated and she reported the resident behavior if she observed it. She said sometimes if the resident became agitated, giving the resident space helped or she switched the one-to-one coverage with a different staff member. RA #2 said she had abuse and dementia training and did the training during in person orientation and on a paper inservice. She said if she suspected or witnessed abuse she reported the incident to the NHA and if he was not at the facility there was a phone number posted. Registered nurse (RN) #1 was interviewed on 7/13/23 at 12:15 p.m. She said she would never give a resident a medication that was not prescribed. The unit manager (UM) was interviewed on 7/13/23 at 11:44 a.m. She said Resident #18 was on one-to-one staff supervision and was never to be left alone. The UM said she had dementia and abuse training and provided additional training to the RAs who sat one-to-one with Resident #18. She said Resident #18's behaviors had primarily decreased over the last three months with medication adjustments. VII. The NHA and the chief clinical officer (CCO) interview The NHA and CCO were interviewed on 7/12/23 at 10:00 a.m. The NHA said in response to the incident where the CNA #4 put her hand over Resident #18's mouth, they interviewed all the residents and staff in the facility. The NHA said the incident on 5/29/23 was brought to his attention because a CNA reported the incident to a charge nurse on duty. He said he received a phone call at about 8:30 p.m. and the incident occurred before that. He responded and arrived at the facility within 20 minutes and found the resident asleep in her bed. Resident #18 was assessed by nursing and her vital signs were normal, no injuries noted on the skin. The NHA said he then started interviewing staff. He said CNA #4 was not Resident #18's CNA but was assisting with her and he learned the staff were in the nurses station trying to give Resident #18 her medication. He said CNA #4 attempted three times to give Resident #18 Benadryl, with the third attempt being when CNA #4 put her hand over the resident's mouth to assist the resident in swallowing the medication and the nurse did not stay and watch the delivery of the pill to the resident and denied providing CNA #4 with the pill. The NHA said they suspended all involved staff and reported to the Board of Nursing in different states and he informed the rest of his company which staff were reported so they were not able to work shifts at other facilities. Resident #18 was monitored for a couple days with non verbal behavior monitoring and she seemed pleasant. She was placed on one-to-one staff to resident supervision. He said all staff members were educated on timely reporting and types of abuse and dementia, which included anyone who came into the building including agency staff. He said staff were also educated on medications being administered outside scope of practice and a CNA should not be passing medications ever. The NHA said they initiated ambassador visits of five visits a day for the next three months (initiated prior to survey). Facility managers acted as an ambassador to the residents and an ambassador would have multiple residents; they checked to see if any residents were being given medications that were not prescribed. He said the facility identified the incident, investigated, reported to all agencies and put in place a plan of correction that included facility wide education that was fully completed by 6/5/23.

Based on observations, record review and interviews, the facility failed to ensure one resident (#32) had the right to a dignified existence out of 45 sample residents. Specifically, the facility failed to ensure Resident #32 experienced a dignified living experience by ensuring meals were served timely. Resident #32 said he felt frustrated, humiliated, sad and dehumanized by having to wait over 30 minutes for his meals when his tablemates had already been served, because he required staff assistance. The observations conducted during the survey process showed Resident #32 was the last individual to be served his meal in the dining room. He waited 27 minutes to receive his lunch meal on 6/13/22, after his tablemates had already been served. During this observation, the resident was yelling multiple times asking for his meal and became angry when his food did not arrive timely. Findings include: I. Resident #32 status Resident #32, younger than 65, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/9/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required limited assistance of one person for bed mobility, transfers and extensive assistance of one person for dressing, eating, toileting, and personal hygiene. A. Resident interview Resident #32 was interviewed on 6/14/22 at 1:42 p.m. He said he often had to wait 30 minutes or longer for his meal after arriving to the dining room. He said this made him feel frustrated. He said the facility staff told him he had to wait for his meals, since he required staff assistance with eating. He said this made him feel humiliated and dehumanized. He said his table mate would receive his meal prior to him and he was left waiting. He said he preferred to have his meal at the same time as his tablemate, instead of watching his tablemate eat while he waits. He said since he had to wait extended periods of time to receive his meals, which were often cold, it made him feel sad. B. Observations On 6/13/22, during a continuous observation, beginning at 11:33 a.m. and ended at 12:50 p.m., the following was observed: -At 11:58 a.m. Resident #21 entered the dining room. -At 12:05 p.m. Resident #21 received his meal. An unidentified speech language pathologist (SLP) began assisting the resident to eat his meal. -At 12:10 p.m. Resident #29 entered the dining room and the SLP began working with him after he was assisted to the table. Resident #29 was seated at the table next to Resident #21's table. -At 12:20 p.m. Resident #32 entered the dining room and sat at the same table as Resident #21. -At 12:27 p.m. Resident #21 received a second plate of food and Resident #29 received his meal, which was 17 minutes after he sat at the table. -At 12:31 p.m. Resident #32 asked the facility staff where his meal was. He also had not been served a beverage. -At 12:35 p.m. Resident #32 yelled asking the facility staff again where his meal was in an angry tone and an unidentified certified nurse aide (CNA) said it is coming. -At 12:41 p.m. Resident #29 asked the SLP why his tablemates did not have their meals. The SLP said to Resident #29 You are lucky you got your meal first, because you are working with me. She said the other residents had to wait for their meals. -At 12:44 p.m. Resident #32 yelled at the facility staff again that he wanted his lunch in an angry tone. -At 12:47 p.m. Resident #32 received his meal and cup of ice tea. Resident #32 received his meal 27 minutes after his tablemate Resident #21 had been served. On 6/16/22, during a continuous observation, beginning at 7:33 a.m. and ended at 9:00 p.m., the following was observed: -At 8:30 a.m. Resident #32 entered the dining room and sat at a table. -At 9:53 a.m. Resident #32 received his breakfast. C. Record review The facility meals times were provided by the dining account manager (DAM) on 6/13/22 at 10:30 a.m. It documented the following meal times: Breakfast: 7:30 a.m. open window service, room trays, and dining room Lunch: 11:30 a.m. open window service, room trays, and dining room Dinner: 5:00 p.m. open window service, room trays, dining room II. Staff interviews CNA #2 and CNA #3 were interviewed on 6/16/22 at 12:02 p.m. CNA #3 said the residents who preferred to eat in the dining room often had to wait more than 30 minutes to receive their meals. CNA #3 said this often made the residents angry. She said if the residents waited a long time they would often leave the dining room and refuse to eat their meals. CNA #3 said Resident #32 became upset when he had to wait for an extended period of time for his meal. She said he recently started requesting to have staff get him up later, so he did not have to wait as long for his meals. The dining account manager (DAM), regional dining director (RDD) #1, and the RDD #2 were interviewed on 6/16/22 at 12:46 p.m. The DAM said she started working at the facility one and a half months prior to the survey process. She said the dining process when she started was to serve the room trays first and then the residents, who were sitting in the dining room. The DAM said she had been told recently that residents who ate in the dining room were waiting for extended periods of time for their meals. The DAM and the RDD #1 said they would consider rearranging meal service to ensure the residents were served in a timely manner. The director of nursing (DON), nursing home administrator (NHA), and the regional nurse consultant (RNC) #2 were interviewed on 6/16/22 at 1:50 p.m. The NHA said the kitchen served the residents who preferred to eat in their rooms first to ensure proper temperatures were held. He said residents who were seated at the same table in the dining room should be served their meal at the same time, despite receiving any therapy treatment.

Based on record review and interviews, the facility failed to ensure four (#62, #58, #27, and #6) of seven residents reviewed for accidents out of 45 sample residents remained as free from accident hazards as possible. Resident #62 sustained five falls in the facility within a six month period. The facility identified the resident's numerous fall risks (history of falls, cognitive impairment) but failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize her risks and keep her safe from injury. The resident's fourth fall on 4/8/22 resulted in a clavicle fracture, and the fifth fall on 4/14/22 in hematoma and laceration of her forehead. Additionally, the facility failed to: -Ensure effective interventions were evaluated and put into place after Resident #27 had sustained five falls; and, -Ensure an assessment by a registered nurse (RN) was completed and documented in the medical record for Resident #58 and Resident #6 following sustained falls. Findings include: I. Facility policy and procedures The Fall Prevention Program policy was provided on 6/16/22 at 9:10 a.m. by the nursing home administrator (NHA). In pertinent part, it read: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Residents at high risk for falls will be placed on the facility's Fall Prevention Program. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive care plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. When any resident experiences a fall, the facility will: -Assess the resident. -Completed a post fall assessment. -Complete an incident report. -Notify the physician and family. -Review the resident's care plan and update as indicated. -Document all assessments and actions. -Obtain witness statements in the case of injury. II. Resident #62 A. Resident status Resident #62, age 86, was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included non-displaced fracture of the left clavicle. The 5/24/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score (BIMS) of four out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. She had verbal and physical behaviors toward others one to three days during the assessment period. It indicated the resident had one fall since her admission with an injury. 1. Resident status on admission-At risk to fall a. Facility record review revealed the facility knew Resident #62 was at high risk for falls, identifying multiple fall risks on admission. According to the admission report dated 4/30/21, the resident was at risk for falls due to intermittent confusion, and poor vision. She was chair bound, had one to two falls in the last three months, and took several medications daily that increased her risk for falls. The admission assessment indicated Resident #62 required maximum assistance with most activities of daily living (ADLs). b. Facility response to identified risks on admission The baseline care plan was initiated on 5/2/21, and revealed the resident required one person physical assistance with toilet use, personal hygiene, dressing, bed mobility and transfers. Therapy services were initiated. No additional interventions noted on the care plan. The comprehensive care plan for falls was initiated on 5/5/21. The resident was identified at risk for falls due to a history of a stroke. Interventions included to anticipate and meet resident's needs, make sure the call light was within the reach, make sure the resident was wearing non-skid shoes. The intervention to add anti roll backs to the wheelchair was initiated on 7/8/21. On 7/12/21 the care plan was updated with a note that the resident had an actual fall with no injury. Interventions included to encourage resident to ask for assistance, add resident to fall prevention program, determine and address factors of the fall, assist resident to the bathroom as needed, 2. Facility failure to develop and communicate effective interventions based on thorough investigations after falls which occured on 1/30/22, 3/28/22, 4/5/22, 4/8/22, and 4/15/22, to minimize the resident's risks and keep her safe from injury. Record review revealed the facility failed to comprehensively evaluate Resident #62's multiple falls in order to care plan effective, resident-specific interventions to address her known fall risks and to keep her safe from additional falls and injury. a. Fall #1 on 1/30/22 According to the nurses' progress note dated 1/27/22 the resident was experiencing increased confusion and increased urgency to void. On 1/28/22 the resident was diagnosed with a urinary tract infection ([CONDITION(S)]) and was started on antibiotics. A situation, background, assessment, recommendation (SBAR) note dated 1/30/22 revealed the resident had a fall. -There were no additional nursing notes regarding details of the fall. A post fall review evaluation completed by the interdisciplinary team (IDT) on 1/30/22 read: resident was observed on the floor by the door. She was laying in bed at the time of the fall. She was trying to transfer but the wheelchair was out of her reach and when transferring, she fell . She stated she hit her head but didn't hurt anywhere else. Charge nurse assessed the resident and notified the family and physician. The fall was documented as unwitnessed with no injury. Predisposing factors for fall were marked as dementia, unsteady gait, and history of falls. At the time of fall, the resident was wearing socks. Recommended interventions included keeping the bed in a low position, placing a fall mat next to bed, and revise the resident's care plan. -The resident's care plan was not updated with the recommendations and it was unclear if they were implemented. b. Fall #2 on 3/28/22 A SBAR form dated 3/28/22 read resident was observed on the floor in the dining room, she complained of right arm pain and was transported to the emergency room for the evaluation. The section for a registered nurse (RN) assessment read: I think the resident attempted an unassisted transfer. -There were no nurses' progress notes regarding this fall. The interdisciplinary team (IDT) noted dated 3/30/22 revealed the resident sustained a fall on 3/28/22. She was transferred to the emergency room due to pain in her right arm. She returned the same day with no injuries, but a diagnosis of a [CONDITION(S)]. Recommended interventions included checking anti-roll back on the wheelchair for proper functioning and updating the resident's care plan. -There were no additional interventions to address resident's unassisted transfer. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks and circumstances such as unassisted transfers, contributed to the lack of effective interventions to prevent another fall on 4/5/22. c. Fall #3 on 4/5/22 A SBAR form dated 4/5/22 read Patient was sitting in wheelchair in lobby area by back door. East side nurse came to this writer because the patient was on the floor. Upon assessment no injuries noted. -There were no nurses' progress notes regarding this fall. The IDT noted dated 4/5/22 revealed resident sustained unwitnessed fall on 4/5/22. The IDT note was identical to the SBAR form above. Section for recommendations and interventions included recommendation for physical therapy (PT) evaluation, encouraging the resident to sleep in the recliner or bed, and initiating frequent checks to include the location and activity of the resident. -There were no additional interventions to address resident's unassisted transfer. -The resident's care plan was not updated with any new interventions. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks and circumstances such as unassisted transfers, contributed to the lack of effective interventions to prevent another fall two days later on 4/8/22. d. Fall #4 on 4/8/22 According to the SBAR form dated 4/8/22, the resident had a fourth unwitnessed fall on 4/8/22 that resulted in the fracture of the clavicle. Description of an incident read: Unwitnessed fall with possible injury. Resident was observed lying on the floor in the lodge, stating she fell out of her chair. Resident able to move her extremities but complaining of pain 10 out of 10 (with 10 being the worst pain on the scale) to left shoulder. Physician notified, order received to transfer to emergency room for the evaluation. According to the physician note on 4/12/22, the resident sustained left clavicle fracture on 4/8/22 after a fall. Recommendations included to continue to work with physical therapy. In addition to monitoring the resident, encourage her to stay in common areas where she could be observed at all times and not to leave her alone. The IDT note dated 4/8/22 revealed resident sustained unwitnessed fall on 4/8/22. The IDT note was identical to the SBAR form above. Section for recommendations and interventions read resident was already working with PT. Additional recommendations included scheduling a nap time for the resident after lunch. -There were no additional interventions to address resident's consistent unassisted transfers. -The resident's care plan was not updated with new nursing interventions and physicians recommendations. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks (dementia and cognitive impairment) and circumstances such as unassisted transfers, contributed to the resident experiencing an additional fall with injury on 4/15/22. e. Fall #5 on 4/15/22 A SBAR form dated 4/15/22 read Resident was calling for help in the front lobby. Resident was observed lying on the floor on her right side. Resident couldn't recall how she fell . Res (resident) obtained a hematoma to the right side of her forehead 4.5 x 5 centimeters (cm) & a small laceration 0.5cm at the end of her right eyebrow, no active bleeding, steri-strip applied. The IDT note dated 4/15/22 revealed the resident sustained an unwitnessed fall on 4/15/22. The IDT note was identical to the SBAR form above. Section for recommendations and interventions read resident was already working with PT. Additional recommendations included to provide an Ipad for the resident for activities. -There were no additional interventions to address resident's consistent unassisted transfers. -The resident's care plan was not updated with new interventions. -The above review demonstrated that interventions that were recommended after each fall, such as frequent checks, nap in the afternoon, and physician's recommendation not to leave the resident alone were not implemented by nurses and CNAs. In addition, the resident's desire for unassisted self transfer was not addressed in any IDT reviews and no interventions were implemented. 5. Staff interviews The physical therapy (PT) director was interviewed on 6/16/22 at 12:31 p.m. She said Resident #62 was currently enrolled into physical therapy services. She was enrolled on several occasions prior to the most recent enrollment. Specifically, she started working with therapy on 3/30/22 after the fall. At that time, the evaluation determined that the resident did not have any decline in physical functioning. It was identified that she self transferred herself and was unable to remember that it was not safe. As an intervention it was recommended to check the anti-roll lock on her wheelchair to make sure the wheelchair would not roll back if she attempted to stand up. On 4/6/22 the resident was evaluated again after a fall and it was determined that she had very poor sleeping habits and preferred to sleep in her wheelchair instead of the bed or recliner. The therapy recommended establishing a sleeping routine. -However, the intervention was not effective and the resident continued to sleep in her wheelchair. She said the resident was discharged from the therapy with recommendation for the restorative nursing program. The PT director said that on 5/14/22 resident was evaluated again after the fall and fracture of the clavicle. Resident #62 was switched to a Hoyer mechanical lift with transfers. She said she participated in all IDT meetings and discussed all recommended interventions. She said due to the resident's cognitive decline and resident's preferences to sleep in her wheelchair only few options were left. The best one was not to leave the resident alone when she wanted to sleep in her wheelchair. Registered nurse (RN) #1 was interviewed on 6/16/22 at 1:56 p.m. She said the residents were assessed on admission for fall risk. High fall risk residents were placed closer to the nurses' stations and were on frequent checks by nurses and CNAs. She said Resident #62 did not like to sleep in her recliner or bed, she preferred to sleep in her wheelchair. She said since this was her preference, she was allowed to sleep in her wheelchair, and the staff member was present with her when she was in it. RN #2 was interviewed on 6/26/22 at 2:10 p.m. She said the resident was cognitively impaired due to dementia. She said the resident sometimes used the call light and sometimes preferred to yell out loud for help. She said the resident was not able to remember that she should not self transfer and occasionally did so. Resident #62 did not like sleeping in her room and would frequently self-transfer to wheelchair. She said currently the resident was on frequent checks by all staff members and she was not left alone when she was asleep in her wheelchair. CNA #1 was interviewed on 6/16/22 at 2:20 p.m. She said prior to the fall with fracture, the resident was able to ambulate with a walker. She said now she was chair bound and was not able to propel herself independently. She said the resident was maximum assistance with all cares. She said her preferred activity was to spend time with an Ipad and be around people. She said the resident was always left in the presence of other staff members because she liked to sleep in her wheelchair. She said the resident disliked sleeping in bed and reclining, but would eventually fall asleep in bed. The director of nursing (DON) was interviewed on 6/16/22 at 3:10 p.m. She said she believed all falls for Resident #62 were reviewed by IDT and new interventions added to the care plan. She said she did not know why the care plan appeared not updated with therapy and physician's recommendations. She said the resident had not had any falls since 4/15/22 and nurses and CNAs made sure not to leave the resident asleep in her wheelchair. III. Resident #27 A. Resident status Resident #27, age 84, was admitted on [DATE]. According to the June 2022 CPO, the diagnoses included heart failure, diabetes mellitus type two, depression, cognitive communication deficit, vascular dementia, and a history of falling. The 4/18/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15. He required extensive assistance of two people for bed mobility, transfers, dressing, toileting; extensive assistance of one person for personal hygiene; and, supervision of one person for eating. It indicated the resident had fallen prior to admission. B. Record review The cognitive care plan, initiated on 4/21/22, documented the resident had imparied cognitive function thought process related to dementia and he required cues and reminders to complete tasks. The interventions included asking yes or no questions to determine the resident's needs, communicating with family, using the residents preferred name, cueing and reorienting the resident as needed, providing activities, and using segmentation to support short term memory deficits. The activities of daily living (ADL) care plan, initiated on 4/12/22, documented the resident had an ADL self-care deficit related to dementia, fatigue, and impaired balance. The interventions included, in pertinent part, encouraging active participation in tasks, gathering and providing supplies as needed, allowing sufficient time for dressing and undressing, and providing assistance of one staff member for ADLs. The fall risk care plan, initiated on 4/25/22, revealed the resident was at high risk for falls related to confusion, balance problems, and incontinence. The interventions included anticipating the residents needs, placing the resident's call light within reach, tracking the residents behaviors for three days, participating with therapy, providing proper fitting pants, to contact the physician for a medication review, and providing a safe environment for the resident including even floors free from spills, reduced clutter, glare-free light, and a call light within reach. The 4/12/22 fall risk assessment, completed upon the resident's admission to the facility, indicated the resident was at a high risk for falls. 1. Fall incident on 4/29/22 unwitnessed The 4/29/22 nursing progress note documented at 11:32 a.m., Resident #27 was found on the floor at approximately 8:30 a.m. in front of his recliner by a certified nurse aide (CNA) with his brief pulled down by his knees. The resident had no complaints of pain or signs of injury. The 4/29/22 change of condition assessment documented the registered nurse (RN) conducted an assessment of the resident with no injuries noted and initiated neurological checks. The resident's wife and physician were notified of the fall. The 4/29/22 interdisciplinary (IDT) post fall review documented the resident had an unwitnessed fall in his bedroom and did not sustain an injury. The resident had a history of falls, cognitive deficits, and was recently admitted to the facility. The resident was wearing socks at the time of the fall. The resident was unable to use the call light due to cognitive impairment. The intervention included continuing to work with physical therapy, however according to the physical therapy notes, the resident did not have carry over learning skills. It also included providing the resident with proper fitting pants. 2. Fall incident on 5/24/22-unwitnessed The 5/24/22 change of condition assessment documented Resident #27 was found sitting on the floor against his bed. Calling for assistance and waiting for staff assistance were listed as items that could help prevent further falls. It documented the resident had redness to his lower back and appeared to be attempting to toilet himself without calling for assistance. The 5/24/22 IDT post fall review documented the resident had an unwitnessed fall in his bedroom and did not sustain an injury. He was found sitting on the floor next to his bed. The resident had unsteady gait, a history of falls, and vision deficits. The resident was wearing slippers at the time of the fall. The resident was unable to use the call light due to cognition and the resident's room was cluttered and had poor lighting at the time of the fall. The interventions included offering the resident toileting assistance mid way through the night and continuing to work with physical therapy. -However, the fall risk care plan documented that the intervention of ensuring the resident's room was free of clutter was initiated on 4/25/22, a month prior to the unwitnessed fall. The 5/25/22 IDT progress note documented the resident was receiving therapy services, however had poor safety awareness and was unable to use carry over learning. The interventions included offering toileting at night when the resident appeared anxious. -However, the IDT post fall review documented the resident was unable to demonstrate how to use the call light and staff interviews indicated the resident was unable to use the call light due to cognitive impairment (see staff interviews below). 3. Fall incident on 6/3/22-witnessed The 6/3/22 nursing progress note documented at 6:46 a.m., the RN was at the medication cart and heard the resident begin yelling at the end of the hallway. The RN found the resident, who was ambulating without a walker and wearing slipper socks, falling to the floor and landed on his buttocks. It indicated the resident did not sustain an injury. The 6/3/22 change of condition assessment documented the resident sustained a witnessed fall. The resident was ambulating without assistance. The RN assessment indicated the resident had dementia, which caused him to forget to use his walker when ambulating. The 6/8/22 IDT progress note documented the IDT team reviewed the resident's witnessed fall. It indicated the resident had been very restless, not sleeping well, had increased tearfulness and made statements of depression. A medication review was recommended. 4. Fall incident on 6/10/22-unwitnessed The 6/10/22 nursing progress note documented at 10:56 p.m., Resident #27 was found on the floor lying on his back next to a recliner in the common area. The resident sustained a laceration to his right eyebrow and his posterior (back side) left and right hand. Resident #27 agreed to be sent to the hospital to be treated for bleeding from the laceration to the right eyebrow and posterior left and right hand. The resident received first aid at the hospital and returned to the facility. The 6/10/22 IDT post fall review documented the resident had an unsteady gait, history of falls, and a recent room change. The intervention included to begin a three day documentation of behaviors and toileting needs to establish a personalized activating and toileting schedule. 5. Fall incident on 6/12/22-unwitnessed The 6/12/22 change of condition assessment documented the resident was found on the floor in the common area by an RN. The resident was assessed for injury, neurological checks were initiated, and wound care was initiated. The resident was assisted to the recliner via two staff members. It did not document what injury was sustained by the resident. The 6/12/22 IDT post fall review documented the resident had an unwitnessed fall in the common area. The resident was provided first aid, however the documentation in the resident's medical record did not indicate what injuries were sustained by the resident.The resident had an unsteady gait, history of falls, change in medications, cognitive deficits, vision deficits, and a recent room change. The resident was wearing socks at the time of the fall. The intervention included to begin a three day tracking of behaviors and toileting needs to be monitored frequently to establish behaviors and toileting needs. -However, the 6/10/22 IDT post fall review documented the intervention of a three day tracking of behaviors and toileting needs, which was initiated after the resident sustained a fall on 6/10/22. A new intervention was not put into place after the resident sustained a fall on 6/12/22. C. Staff interviews CNA #3 was interviewed on 6/16/22 at 11:15 a.m. She said Resident #27 became increasingly agitated when he moved rooms. She said he was unable to locate his room. She said Resident #27 became agitated when there were a lot of people or noises around him, was easily confused and was not able to understand what the call light was used for and did not use it appropriately. LPN #5 was interviewed on 6/16/22 at 1:25 p.m. She said Resident #27 had severe cognitive impairment, which led to his frequent falls. She said Resident #27 often became overstimulated and agitated with loud noises, which would cause him to become impulsive. She said the resident enjoyed going on walks outside with the activities to calm down when overstimulated. She said the resident was often incontinent of bowel and bladder and was not notified that the resident was placed on a toileting program. The director of nursing (DON), regional clinical director (RNC) #2 and the nursing home administrator (NHA) were interviewed on 6/16/22 at 1:50 p.m. The DON said Resident #27 had frequent falls. She confirmed the resident had five falls since he was admitted to the facility on [DATE]. She said Resident #27 was identified as a fall risk upon admission. She said when the resident became overstimulated, he was impulsive, which led to falls. The DON said the resident was moved to a different room when he was no longer on therapy services. She said the facility moved the resident to the end of the hallway, so there would be less commotion to cause the resident to become agitated. The DON said the resident was unable to use the call light properly due to his cognitive status. IV. Resident #58 A. Resident status Resident #58, age 68, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 CPO, the diagnoses included secondary malignant neoplasm (cancer) of the brain, heart failure and ischemic [CONDITION(S)] (decreased function of the heart). The 5/25/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required limited assistance of one person with transfers and supervision with bed mobility, dressing, eating, toileting and personal hygiene. -Falls were not coded. B. Record review The 5/28/22 situation, background, assessment and recommendation (SBAR) documented that the resident sustained a fall. It did not include any other details of the fall. The 6/2/22 interdisciplinary team (IDT) progress note documented that the resident fell out of his wheelchair during an unassisted transfer. The resident said he forgot to lock the breaks on the wheelchair. The SBAR was completed by LPN #4 and did not include documentation of an RN assessment being completed after the resident sustained the fall. V. Resident #6 A. Resident status Resident #6, younger than 65, was admitted on [DATE]. According to the June 2022 CPO, the diagnoses included [CONDITION(S)] (paralysis) and [CONDITION(S)] (muscle weakness, partial paralysis) following an unspecified [CONDITION(S)] disease (stroke) affecting the left non-dominant side and major depressive disorder. The 3/14/22 MDS assessment revealed the resident had cognitive impairment with a brief interview for mental status score of severe out of 15. She required extensive assistance of one person with bed mobility, transfer, dressing, toileting, and personal hygiene. -Falls were not coded. B. Record review The 2/22/22 SBAR documented that the resident sustained a fall. It did not include any other information. It was completed by LPN #1. The resident's medical record did not include documentation an RN assessment had been completed following the fall. The 2/22/22 change of condition did not include an RN assessment of the resident following the fall. The 6/3/22 incident progress note documented the resident was observed sitting on the floor, leaning on her bed. The resident was unable to say what happened and denied hitting her head. The resident's wheelchair was observed outside the resident's room, moved there by visitors of her roommate. It indicated an RN assessed the resident following the fall, however, the progress note was completed by LPN #2 and there was no documentation of an RN assessment in the resident's medical record. The 6/10/22 SBAR documented the resident was sitting in the lobby of the facility. When other residents started to yell, staff observed the resident scooting out of her chair trying to transfer herself to another chair in the lobby. The resident was unable to transfer herself and scooted out of the wheelchair onto her knees before staff were able to get to her. The SBAR was completed by LPN #3. The resident's medical record did not contain documentation an RN assessment had been completed following the resident's fall. The 6/10/22 IDT progress note documented that the director of nursing was notified of the fall and completed an assessment of the resident, however the note was not completed by the DON and no documentation of the assessment was found in the resident's medical record. VI. Staff interviews The DON and regional nurse consultant (RNC) #2 were interviewed on 6/15/22 at 3:25 p.m. The DON said following a fall, the nurse assigned to the resident should complete an SBAR. She said, on the SBAR, there was a place to include the RN assessment of the resident. She said the RN did not complete the SBAR. She said the RN did not actually document the assessment completed of the resident following a fall. She said the nurse who was assigned to the resident, was able to click a box on the SBAR that indicated the RN had assessed the resident. RNC #2 said RN assessments were not being consistently documented in the resident's medical record at the facility. The DON, NHA and RNC #2 were interviewed on 6/16/22 at 1:52 p.m. The DON said an RN should assess the resident as soon as possible after the resident sustained a fall. She said the assessment should be conducted head to toe of the resident, including range of motion (ROM), and a neurological assessment. She said the RN assessment should be documented in the resident's medical record. She said she was unable to locate RN assessments for Resident #58's fall on 5/28/22 and Resident #6's falls on 2/22/22, 6/3/22 and 6/10/22. She said an LPN was unable to assess the resident because it was not within their scope of practice. She said an RN assessment was important to determine if the resident sustained an injury.

Based on observations, record review and interview, the facility failed to implement appropriate and timely interventions to ensure one (#40) out of 31 sample residents received the necessary care and treatment to prevent the development of a pressure injury to the sacrum and bilateral heels of the resident. Specifically, the facility failed to provide necessary interventions to assist with pressure relief and friction reduction. Interventions were not timely implemented in order to maintain the resident's skin integrity and promote healing although the facility was aware of the resident's compromised skin condition. Wound assessments were not timely and accurately documented. The facility's failures contributed to the resident developing a Stage III pressure ulcer to the sacrum, and an unstageable pressure ulcer to the heel, which caused the resident pain and discomfort. Findings include: I. Facility policy and procedure The Skin Management System policy, last revised (MONTH) (YEAR), read in pertinent part: -Residents receive care to aid in the prevention . of pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. -Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing a Braden Scale for Predicting Pressure Sore Risk User Defined Assessment (UDA) in conjunction with the Nursing Admission Data Collection Set. II. Professional reference The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: - Positioning that places pressure on the pressure injury should be avoided. - The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. - The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. - Signs of deterioration in the wound should be addressed immediately. - The assessment should include location, category/stage, size, tissue type, color; peri wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. -National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (2/17/17). III. Resident #40 A. Resident status Resident #40, age 95, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The resident was on hospice care with Pathways Hospice. According to the most recent minimum data set (MDS) assessment, dated 3/25/19, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident had activities of daily living (ADL) self-care performance deficits related to fatigue and declining condition. He required total assistance of one staff for bed mobility, transfers and ADLs. With the exception of bilateral upper extremities scattered bruising and rash and skin tags to the upper and lower back, the resident did not have any compromised skin issues. B. Resident interview and observations The resident was interviewed on 5/14/19 at 11:04 a.m. He said his bottom hurt. He said he was too weak to get out of bed by himself. He said there were wounds on his heels, which caused a lot of pain and discomfort which was addressed upon request of pain medication. The resident said staff came in to help him out of bed sometimes but not as frequently as expected. He said no one came in to turn and reposition him, but he was able to manage it when he had the strength. He said staff did not offer to reposition him in the chair or lie him down in bed during the day unless he requested. The resident's wounds were not observed because the dressings had already been changed at the time wound observation was requested. The resident had an air mattress in place at the time of the interview. III. Record review Failure to implement appropriate and timely interventions to maintain skin integrity, relieve pressure and friction, and to prevent further skin breakdown. Records showed that the facility was aware of the resident's compromised skin condition of scabbed and reddened bilateral heels and unstageable sacral wound but failed to act on preventing it from worsening. The facility was aware of the Braden score of 14, which indicated moderate risk for skin breakdown but did act to intervene. A. Care plan The care plan initiated on 3/19/19 and revised on 3/29/19 identified the resident had limited physical mobility related to weakness. Pertinent approaches included to provide supportive care, assistance with mobility as needed and to observe, document, and report any signs and symptoms of immobility. B. Braden scale The 3/18/19 Braden scale document identified him with moderately high risk for skin breakdown with a score of 14. C. Head to toe skin checks The CPO orders dated 3/18/19 documented to complete weekly head to toe skin assessment one time a week on the evening shift on Mondays. Although the skin issues related to the onset of pressure ulcers were noted upon admission on 3/18/19, the facility did not address the issue until the 4/23/19 when the initial wound care orders were placed by the physician. -3/18/19: Head to toe skin assessment identified right lateral foot had some scabbed area. There were no measurements taken, no orders were put in place to address the issue, and no interventions were placed. -3/25/19: Head to toe skin assessment showed he had a bilateral foot scab with the left one on the third metatarsal. There were no measurements taken, no orders were put in place to address the issue, and no interventions were placed. -4/1/19: Head to toe skin assessment showed the resident had developed a new stage two pressure ulcer to the coccyx with [MEDICATION NAME] applied. There were no measurements taken, no orders were put in place to address the issue, and the [MEDICATION NAME] on the wound was not ordered by the physician prior to placement. The assessment showed the resident had a right lateral foot scab that measured 0.5 millimeters (mm) by 0.5 mm. -4/8/19: Head to toe skin assessment showed the resident had an existing pressure ulcer to the sacrum with dressing on it and a right lateral foot scab. There were no measurements taken, no orders were put in place to address the issue, and there was no interventions to address it. -4/15/19: Head to toe skin assessment showed the resident had an existing pressure ulcer to the sacrum. There were no measurements taken, no orders were put in place to address the issue, and there was no interventions to address it. -4/22/19 Head to toe skin assessment showed the resident had an existing pressure ulcer but or measurements were done. No other issues were mentioned. There were no location, description, measurements taken, no orders were put in place to address the issue, and there was no interventions to address it. -4/29/19: Head to toe skin assessment showed the resident had a new unstageable pressure ulcer to the coccyx with dressing clean, dry, intact (CDI), new unstageable pressure ulcers to the bottom of left lateral foot on the 5th metatarsal that measured 0.4 mm by 0.6 mm, and the heel, measuring 0.5 mm by 0.3 mm. existing pressure ulcer. -5/6/19: Head to toe skin assessment showed the resident had an existing pressure ulcer to the sacrum with dressing CDI, unstageable pressures to the bottom of the left foot, lateral to the 5th metatarsal and the heel, but no measurements were done. There were no measurements taken, no orders were put in place to address the issue, and there were no interventions to address it. As wound assessments were inconsistent and contradictory, it was difficult to determine the number of pressure ulcers the resident had developed. D. Progress notes There were limited progress notes documented on the resident's fragile skin condition, pressure ulcers, and interventions provided from the date of admission (3/18/19) to 5/14/19. Although the issues were identified earlier, the initial intervention was through SBAR report on 4/1/19 on what her assumptions were on unrelieved pressure. Another SBAR notes on 4/14/19 recommended the application of heel protectors for the resident because sage boots could not be located, boost the resident up in the bed, and place a pillow in front of the bed. No notes regarding the resident's facility acquired pressure ulcers to the coccyx, sacrum, and to the bilateral heels were mentioned. There were no measurements taken, no orders were put in place to address the issue, and no recommendations for interventions were made. E. SBAR communication -4/1/19: SBAR communication identified a stage two pressure ulcer to the coccyx measuring 2.5 mm by 1.8 mm. It said [MEDICATION NAME] was applied. -4/29/19: Identified an unstageable pressure ulcers to the bottom of the resident's left foot, lateral to the 5th metatarsal that measured 0.4 mm by 0.6 mm and another one measured 0.5 mm by 0.3 mm. F. Weekly pressure ulcer record There were lack of records pertaining to the resident's pressure ulcers since admission. The only available records were those of 4/16/19 and 4/23/19 which had identical information stating that the resident had an existing unstageable sacral wound which was acquired in the facility. It measured 2.2 (mm) (length) by 1.9 mm (width) by 0 mm (depth). IV. Staff interviews The wound nurse was interviewed on 5/14/19 at 11:15 a.m. She said she doubled as the assistant director of nursing (ADON). The wound nurse said the resident had a Braden score of 14 on admission, which placed him in the moderately high category for skin breakdown. She said the facility should have placed the resident on pressure injury precautions according to the facility protocol, but for unknown reasons it did not happen. The wound nurse said she found the resident had an unstageable pressure ulcer to the sacrum on 4/1/19 during routine rounds for wound care. She said the facility notified the hospice staff who took care of the resident. The hospice company said they were going to provide an air mattress for the resident and initiate the appropriate treatment so that the wound could heal. She said the facility waited for two weeks but the hospice company did not provide the air mattress. She said the facility ordered one for the resident, and by then, the sacral wound had worsened to stage three. The wound nurse said regardless of the outcome of the air mattress, the responsibility to care for the resident was on their facility. She said the facility had taken great care of the sacral wound ever since and it was now healing well. The wound nurse said the facility had provided special boots to help heal the pressure wounds to the bilateral heels of the resident. She said the resident was on a strict turning and repositioning schedule and another schedule for loading and unloading to help relieve pressure on the heels. The director of nursing (DON) was interviewed on 5/14/19 at 1:10 p.m. The DON said she was familiar with the resident and knew he spent most of his time in bed. The DON also said the resident should be repositioned every two hours or more frequently by the staff since the resident was dependent upon staff for mobility in and out of his bed and wheelchair. She confirmed the resident acquired the pressure injury in the facility. She said if the facility had paid attention to the initial resident assessment and the Braden score of 14, the pressure wound would not have occurred. The DON said they could have done a better job to prevent the wound from happening in the first place. The DON said the facility had put quality audit measures in place where residents with high risk of developing skin issues were monitored. She said those residents were provided with air mattresses and other protective measures such as supplemental protein nutrition, and turning and repositioning every two hours or as needed. She said they were monitoring the resident's skin conditions on a more serious note. She said the facility's skin monitoring milestone comprised of documenting every skin issue that was found through weekly skin assessments and Braden scale scores for all residents to ensure interventions were in place prior to skin breakdown. She said the facility would be conducting multiple staff education to identify residents at risk.

Based on record reviews, interviews and observation, the facility failed to ensure six (#18, #16, #15 #7, #9, #17) out of 25 sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility delayed implementing advanced directives in accordance with Resident #18's documented wishes. Resident #18 expired. Additionally the facility failed to: -Ensure cardiopulmonary resuscitation (CPR) status for Resident #15 clearly reflected the resident's wishes. -Develop and implement appropriate safety and behavioral interventions for Resident #16, which resulted in the barricading himself in his room for an extended period of time. During such time the resident aspirated on chewing tobacco and required transfer to the hospital for admission. -Timely complete neurological checks for Residents #9 and #17. -Complete Resident #7's [DEVICE] ([DEVICE]) dressing changes in accordance with physician orders. Findings include: I. Delay in implementing CPR in accordance with Resident #18's advanced directives A. Facility policy The Death of a Resident policy, revised (MONTH) 2008, was provided by the director of nurses (DON) on [DATE] at 2:25 p.m. It read, in pertinent part, .when a resident is found to be without heartbeat or respirations, the nurse on duty identifies the code status and if the resident is a full code (CPR) must be started, and emergency 911 services activated . The Changes in Condition policy, updated (MONTH) (YEAR), documented in pertinent part, .for life threatening events, call 911 if initial assessment indicates that such action is necessary. B. Resident status Resident #18, age 88, was admitted to the facility on [DATE]. According to the (MONTH) (YEAR) computerized physician's orders [REDACTED]. C. Record review revealed the Resident #18 wanted CPR and had a history of [REDACTED]. The [DATE] physician progress documented the resident's past medical history indicated he was hospitalized from [DATE]-[DATE] for acute on chronic hypoxic [MEDICAL CONDITION]. During the hospital course, Resident #18 experienced [MEDICAL CONDITION] requiring CPR and mandatory minute volume (a mode of mechanical positive air flow). The resident's advanced directive status was full code. The Medical Orders for Scope of Treatment (MOST) form was signed by the resident on [DATE] and by the physician on [DATE]. The MOST for documented the resident wanted CPR and full medical treatment but declined artificial nutrition by tube. The (MONTH) (YEAR) CPO documented an order for [REDACTED].>D. Staff understanding of expectations regarding implementing resident advanced directives revealed inconsistencies Registered nurses (RN) #7 and #5 were interviewed on [DATE] at 3:25 p.m. They said all nurses were trained in cardiopulmonary resuscitation (CPR) upon hire and recertified every two years. They said the MOST form was used to determine the resident's status. There was also a report that was updated by staff or nursing that utilized an asterisk next to the resident's name to signify the resident was a DNR. RNs #7 and #5 said if they were to enter a resident's room and found the resident unresponsive, they would check the resident's pulse and call out for assistance to obtain the resident's COR status; do not resuscitate (DNR) or full code. They would call 911, the crash cart would be retrieved, the resident would be lowered to the ground and CPR was started. RN's #7 and #5 said if the resident was in a common area of the facility and became unresponsive, they would start CPR even if they did not know the status and nursing would alert the RN by either going to the nurse's station, call, or used the intercom. RN #6 was interviewed on [DATE] at 3:29 p.m. She stated if she walked in a room with a resident with no pulse or who was not breathing, she would go check the chart and verify the resident's code status prior to completing CPR. LPN #1 was interviewed on [DATE] at 3:30 p.m. She stated if she walked in a room with a resident with no pulse or who was not breathing, she would check the chart to verify the code status. She said she would then call the RN. She stated the other halls use a star system. She said the nurse report sheet had stars next to the residents who were a do not resuscitate (DNR). She said when she worked that unit, she had not known what the stars were until she asked another nurse. The director of nursing (DON) was interviewed on [DATE] at 4:08 p.m. The DON stated she had recently completed code blue training with all licensed nurses. She stated the nurses were taught to get on the intercom, call a code blue, and send someone to verify the CPR status in the record. The DON was not aware of the star system (see LPN #1 interview above) for denoting code status. E. Record review and staff interview revealed the facility failed to promptly implement CPR in accordance with Resident #18's wishes and facility expectations. Facility staff telephone an on-call member of nursing leadership in order to identify the resident's code status and awaited instructions from the nurse leader before proceeding with CPR, creating a delay in services. 1. Record Review An electronic progress note dated [DATE], written by the former assistant director of nursing (FADON) read, Called by facility RN who reported resident had been found on floor sitting next to his bed and that she was unable to auscultate (hear with a stethoscope) a heartbeat. She was instructed to start CPR and to call EMS (emergency medical services) The physician discharge summary, signed on [DATE], documented Resident #18 expired unexpectedly at facility after experiencing episodes of [MEDICAL CONDITION]. 2. Staff interviews revealed the Resident #18 was discovered unresponsive on [DATE] at 6:20 a.m. but CPR was not started until at ten minutes later, after the FADON was telephoned for review of CPR status at 6:30 a.m. During an interview on [DATE] at 12:17 p.m., RN #3 said on [DATE] between 6:15 a.m. 6:30 a.m. a certified nurse aide informed her that Resident #18 was unresponsive. RN #3 said she found Resident #18 sitting on his buttocks with his face leaning toward the foot of the bed with no color in his face. The resident was warm upon touch. She said the resident was not responsive and she did not detect vital signs. RN #3 said she did not recall going to the resident's chart to identify the CPR status. RN#3 said she called the FADON using her personal cell phone. The FADON told her to perform CPR. RN #3 said RN #5 performed CPR upon her return to the patient. RN #3 confirmed a resident's code status information can be found on the physician orders [REDACTED]. She said, when a code was called in the facility, she will send any available CNA to verify a residents code status. The FADON was interviewed by phone on [DATE] at 4:28 p.m. The FADON said RN #3 called her at home between 6:30 a.m. and 7:00 a.m. on [DATE] to inquire about Resident #18's code status and to receive instructions on how to proceed. The FADON said RN #3 reported, the resident was on the ground. He felt warm. His oxygen was off. The FADON said that after accessing and reviewing the resident's record via the computer, she found the resident was a full code. She then told RN #3 the resident was a full code and to start cardiopulmonary resuscitation. The FADON said she lived ten minutes away from the facility and arrived sometime after 7:00 a.m. Upon her arrival at the facility, the FADON saw the emergency medical staff were performing CPR on Resident #18. She said, RN #3 did not document the event. The FADON said she started the investigation with interviews and an event note related to the incident. The nursing home administrator (NHA) and the DON were interviewed on [DATE] at 5:43 p.m. The NHA said he interviewed staff present on the day Resident #18 expired. His interviews and investigation concluded the following: -RN #5 checked on Resident #18 during the night. RN #5 found the resident sitting on the edge of the bed. -RN #5 checked the oxygen saturation of Resident #18 on [DATE] at 3:00 a.m. and documented a saturation level as 91 percent. (Record review showed RN #5 documented a nursing note dated [DATE] at 3:30 a.m., stating the resident had experienced decreased oxygen saturation to 88% which was improved to 91% with deep breathing and elevating the head of the bed.) -On [DATE] at 6:20 a.m. the certified nurse aide (CNA #21) entered Resident #18's room and found him sitting on the floor near the head of the bed. CNA #21 checked the resident's pulse and no pulse was found. CNA #21 went to get RN #3. RN #3 checked the resident and found no pulse and listened to the lungs and heart. RN #3 called the on-call nurse (FADON). The FADON verified the code status with RN #3 then RN #3 called emergency medical services (EMS), and initiated CPR. The DON also conducted investigation and interviews regarding Resident #18's death. The DON's investigation concluded RN #5 initiated CPR and took turns with RN #3. On [DATE] the DON provided a document with no date and it read in pertinent part, a one-to-one education on performing codes, was conducted with RN #3. F. Facility follow-up The DON provided a copy of an in-service completed on [DATE] (incident occurred on [DATE]). The in-service read, in part, when a resident is found without a pulse, check the code status. If they are a full code begin CPR immediately. Then call 911. Do not stop CPR, continue until EMS arrives and takes over. Then finally when able call the nurse on call. Seven licensed nurses attended the CPR in service. 14 licensed nurses did not attend. II. Failure to clarify conflicting CPR status a. Resident #15 was admitted to the facility on [DATE]. According to the computerized physician's orders [REDACTED]. The initial minimum data set (MDS) assessment dated [DATE] documented that the resident had a score of 15 out of 15 for the brief interview for mental status (BIMS) which indicated no cognitive impairment. The resident required extensive one to two person assistance from staff with acquired daily living skills (ADLS). b. Record Review The physician orders [REDACTED].#15 as of [DATE] was entered that the resident was both a full resuscitate and do not resuscitate (DNR) status in the event he should stop breathing. The resident did have a completed medical orders for scope of treatment (MOST) form which was located in his paper chart and which documented the resident wished CPR should be performed if he were to stop breathing on his own. c. Interview RN #6 was interviewed on [DATE] at 3:29 p.m. She stated if she walked in a room with a resident with no pulse or who was not breathing, she would go check the chart and see what their code status was. III. Failure to develop and implement appropriate safety and behavioral interventions for Resident #16 A. Facility Policies The Changes in Resident Condition policy, dated (MONTH) (YEAR), was provided by the director of nursing (DON) on [DATE]. It read, The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occurred. Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's attending physical, mental, or psychosocial status in either life threatening conditions of clinical complications; or need to alter treatment significantly. The situation, background, assessment, recommendation (SBAR) communication form and progress notes are used to: Assess and document changes in the condition in an efficient and effective manner; Provide assessment information to physician and Provide clear comprehensive communication. The Fall Management policy, dated (MONTH) (YEAR), was provided by the DON on [DATE]. It read, When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. Unless the evidence suggests otherwise, the most logical conclusion is that a fall occurred. B. Resident Status Resident #16, age 61, was admitted to the facility on [DATE] and discharged on [DATE]. According to the computerized (MONTH) (YEAR) physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He was independent with mobility and transfers. C. Record review The care plan initiated on [DATE] and updated on [DATE], included that he was at risk for falls related to psychoactive medication use, leg amputation and impaired mobility and at risk for skin break down. The [DATE] updated section included that the resident had a history of [REDACTED]. Interventions included, staff should observe/document/report any risk for harm to self-including refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness. The resident was assessed as an unsafe smoker and required supervision when he smoked and that he used chewing tobacco independently. However, there were no assessments regarding the safe and independent use of chewing tobacco while lying on the floor, found upon review of the resident's medical record. The care plan did not address the resident crawling around on the floor and barricading himself in the room, as was the resident's normal behavior according to the staff interviews below. There were no interventions established for the staff to initiate to intervene on behalf of the resident since there was no behavioral plan developed. The nursing progress note, dated [DATE] at 12:45 p.m., completed by the certified nurse aide with medication aide authority (CNA-Med) documented that the resident had refused his medications, was blocking the door to his room and would not let staff enter. A situation, background, assessment and recommendation (SBAR) communication form timestamped at 2:00 p.m. was written by the director of nursing (DON). It read, resident checked by this nurse at approximately 8:15 a.m., 9:30 a.m. and lunch time- unable to gain access to room. He refused any meal trays. Frequently yelling out when others tried to check on him. (However, the DON in an interview below reported she arrived to facility in the afternoon after the resident had been transported to the hospital, therefore had not been the nurse that checked on the resident at the times documented.) The resident had responded to staff in a loud, aggressive voice and was physically blocking the door. Once staff were able to gain entry to the resident's room, the resident was found with head facing the door and legs toward the window, was incontinent of urine and there was brown drool and blood noted on his floor. (However, this note did not indicate the time the staff was able to breach the door to provide assistance to the resident and did not document the attempts made to gain access to the resident to check on his safety so it remained unclear how long the resident was on the floor.) The primary care clinician was notified at 6:40 p.m. on [DATE]; staff attempted to contact his agent for healthcare at 6:50 p.m. but were not able to reach them. The nursing progress note, dated [DATE] at 4:32 p.m. was written by registered nurse (RN) # 2. It read the resident had refused to allow anyone to enter his room, he cursed at staff, refused both breakfast and lunch trays and pounded on the door when staff had attempted to check on him. This note did not document the times of the attempts or the condition of the resident during the checks, if the resident was visible to the staff and what his condition was along with the interventions used to help the resident with his behavioral management. The progress note was entered at 6:48 p.m. on [DATE], written by the former assistant director of nursing (FADON). It read, she was told by staff that the resident was found on the floor. He was combative and used aggressive language. She was able to gain access to his room and complete a brief assessment of him. When she entered his room, there was a pool of blood and sputum at the doorway, puddles of urine on the floor and the resident's jeans were soaked with urine. She observed a bright red, slightly bruised area approximately 10 centimeters wide from his left scapula to the flank and a large protrusion on his upper left buttock. She was able to see his face and noted dried tobacco and spit on both cheeks, clear fluid on the left side of his face and it was red. She described an audible gurgling heard from his chest. Staff exited the room for safety with the resident's door left open and called for emergency medical services (EMS). She documented that when EMS entered the room, the resident was lying on the floor, was unresponsive to noxious stimuli, an audible gurgling could still be heard and oxygen saturation was 58 percent per the EMS monitor. A report was given to EMS and the resident was transported to the hospital on a gurney. However, it did not indicate the time the resident was found on the floor of his room and the assessment completed. The emergency department encounter notes, dated [DATE] documented, Resident #16 was found down outside of his room by staff at the facility and it was unclear how long he had been on the floor. He had decreased levels of responsiveness, an oxygen saturation percentage in the low 70s and was given supplemental oxygen. He was diagnosed with [REDACTED]. The hospitalist assessment completed at 7:30 p.m. on [DATE], documented that the resident possibly vomited while lying on the floor and thus aspirated or could have had a primary cardiac event which led to a fall and then aspirated. The Immediate Education, dated [DATE], was provided on [DATE] at 5:00 p.m. by the nursing home administrator (NHA). It read, In the case of a fall where the resident is refusing first aid, assistance off the floor and/or is being combative, a nurse manager needs to be notified. If there is not a nurse manager in the building, call the nurse on call for assistance. If the refusals and combativeness continue, please call 911 and emergency medical services (EMS) and assist with the resident. Ensure that you chart everything and that all time notes are stamped appropriately. An SBAR, an IDT (interdisciplinary team) Post Fall and appropriately/timely progress notes are required for these situations and must be completed prior to you leaving the building. If you were a witness to these types of situations, it is expected that you enter a progress note regarding what you saw. If you have reported a change of condition and feel it has not been addressed appropriately, please notify a nurse manager. The facility failed to establish a behavioral safety plan to reduce the risk of aspiration while being on the floor chewing tobacco in an unsafe manner. An investigative timeline for staff interactions with Resident #16 on [DATE] was provided by the NHA on [DATE] at 5:00 p.m. According to the timeline, staff became aware that the resident was on the floor of his room at 8:15 a.m. The resident refused to allow staff to enter his room by barricading himself against the door. Staff attempted to engage with the resident periodically throughout the day and were refused by the resident. At 2:45 p.m., staff were able to gain entry to his room to assess the resident; subsequently EMS were called and the resident was transported to the hospital. D. Staff interviews Registered nurse (RN) #2 was interviewed on [DATE] at 12:59 p.m. She reviewed her documentation for the incident on [DATE], however, said that she remembered the day and incident well. She said that it was typical for Resident #16 to be on the floor of his room and he would often be found on the floor. She felt that she had a good rapport with the resident but reported he could be combative at times and she recognized when to give him space. When she had found him on the floor in the past, she would leave him there to be respectful of his space and keep checking in on him periodically. RN # 2 felt that leaving him alone was the best way to deal with him and that sometimes after periods of being left alone he would apologize to staff. She said that on [DATE] he was taking longer than normal to process, but did not think it helped that staff had made several attempts to check on him. RN # 2 said she worked the day shift on [DATE] and said that it had been staff on the evening shift that had made the decision to call for EMS; she was not present when EMS arrived. She said that on [DATE], the director of nursing (DON) and NHA were alerted that Resident #16 was found on the floor and was not allowing staff into his room to assess him. She said the DON and NHA did not tell staff to call for EMS and instructed that they should continue to monitor the resident. She stated that shortly after lunch time one of the aides (whose name she could not remember) was able to get their head into the resident's room briefly and was able to see him before the resident slammed the door shut. It was reported by the aide to RN #2 that Resident #16 was disheveled in appearance but did not have blood at that time. She was not aware of interventions developed by the facility on how to assess or work with Resident #16 when he was on the floor and being combative. The director of nursing (DON) was interviewed on [DATE] at 2:24 p.m. She reported that on [DATE], she had been notified by staff of the resident being on the floor of his room for an extended period of time and she arrived at the facility after the resident had been transported to the hospital by emergency medical services (EMS). When she arrived, she helped to facilitate interviews with staff regarding the incident. She said that it was not unusual for the resident to be on the floor of his room or to be verbally aggressive or combative with staff; interventions for the resident had included staff knocking on the door, introduce themselves and wait to be invited in; staff should follow-up as needed if he was agitated. She said that while the resident had been known to spend time on the floor, the extended time frame he had been on the floor that day should have warranted additional steps being taken to intervene. She reported that staff had not notified the former assistant director of nursing (FADON) when the resident was found on the floor until the afternoon, despite that she had been in the building throughout the shift. Since this incident, she said the facility reevaluated their admissions process for residents who struggle with mental health issues and identified additional considerations to determine whether the facility is an appropriate environment. IV. Failure to complete neuro checks A. Facility policy The director of nursing (DON) provided a copy of the Fall Management on [DATE] at approximately 4:00 p.m. It read, in pertinent part, .Neurological checks are completed and documented per instructions . B. Post fall review Resident status Resident #9, age 63, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. He required supervision for locomotion in a manual wheelchair. Record review Neuro checks for the fall on [DATE] were not dated in accordance with the frequency indicated on the form. The interdisciplinary post fall reviews dated [DATE] and [DATE] showed none for medications Resident #9 was being administered that contributed to a fall. When in fact the resident was currently on two psychoactive medications. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 4:50 p.m. She said a date should be included on the neurological record. Neurological checks for the fall on [DATE] were not dated in accordance with the frequency. Neurological checks were to be initiated and continued for 72 hours after an incident or change in condition (C[NAME]): -every 30 minutes for two hours -every hour for four hours -every four hours for 24 hours -every eight hours for the remaining 72 hours or as ordered by a physician. The director of nursing (DON) was interviewed on [DATE] at 5:20 p.m. She said the interdisciplinary post fall reviews dated [DATE] and [DATE] were mischecked. The resident was currently on two psychoactive medications and each report was marked none. Frequency of neurological record a. Resident status Resident #17 age 69, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. Resident discharged [DATE]. b. Record review Neurological checks were to be initiated and continued for 72 hours after an incident or change in condition (C[NAME]): -every 30 minutes for two hours -every hour for four hours -every four hours for 24 hours -every eight hours for the remaining 72 hours or as ordered by a physician. Post fall neurological checks were not dated in accordance with the frequency shown on the document. The resident returned to the facility at 9:00 p.m. on [DATE]. The first entry on the neurological record was [DATE] at 8:00 a.m. Subsequent entries showed: [DATE] midnight and 8:07 p.m., [DATE] 7:30 a.m. and 7:30 p.m. (a 12 hour span of time), [DATE] 3:00 a.m., 11:00 a.m., and 8:00 p.m. (an eight and seven hour span of time), [DATE] every four hours starting at 6:00 a.m. and ending at 2:00 a.m. on [DATE]. The vital signs shown on the Situation, Background, Assessment, Recommendation (SBAR) dated [DATE] at 10:27 a.m. are the same vital signs shown on the neurological record dated [DATE] at 8:00 a.m. c. Family interview Resident #17's wife was interviewed via telephone on [DATE] at 5:57 p.m. She said the resident returned to the facility from the hospital at 9:00 p.m. on [DATE]. d. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 4:50 p.m. She said neurological checks should be initiated at the time of the fall and continued for 72 hours post fall. V. Failure to follow orders related to gastrostomy tube Resident #7 A. Resident #7, age 64 was admitted on [DATE]. According to the computerized physician orders, dated (MONTH) 2019, [DIAGNOSES REDACTED]. According to [DATE] minimum data set (MDS), assessment showed Resident #7 had a cognitive BIMS score of 11 out of 15, and required total assistance with activities of daily living (ADLS) which included incontinence care and the resident had a gastrostomy tube ([DEVICE]). B. Observation On [DATE] at 10:20 a.m., Resident #7, was observed with a dressing on her [DEVICE] insertion site, dated [DATE]. C. Staff interview On [DATE] at 10:29 a.m., licensed practical nurse (LPN #2) was interviewed. She verified the date and she said she would change the dressing. LPN #2 also said the feeding tube site was to be changed once a day. The LPN said she thought the date was supposed to be [DATE]. On [DATE] at 1:34 p.m., Resident #7 g- tube dressing to insertion site was exposed while receiving incontinence care by two certified nurse aides (CNA #2 & CNA #7). Both CNAs verified the date of [DATE] written on the dressing. On [DATE] at 1:50 p.m., LPN #2 observed providing ordered treatment on Resident #7 feeding tube site to include a new dressing. The director of nursing (DON) was interviewed on [DATE] at 5:55 p.m., she said the g- tube site should be changed daily. D. Record review The computerized physician orders, dated [DATE], provided by the DON on [DATE] at 5:54 p.m., included specific orders for the [DEVICE] site. In pertinent part, it read gastric tube site care every day and as needed, apply zinc oxide to site and cover with a drain sponge.

Based on observations, record review, and interviews; the facility failed to ensure the environment for three (#17, #20, and #21) of four out of 25 sample residents remained free of accidents and hazards, and the residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure Resident #17's wheelchair was secured when transported to an outside doctor appointment to prevent tipping over resulting in hospitalization for a closed head injury; -Ensure Resident #21 followed swallowing strategies to prevent choking, which required hospitalization ; and -Ensure fall prevention interventions were in place for Resident #20. Findings include: I. Failed to ensure Resident #17's wheelchair was secured when transported to an outside doctor appointment to prevent tipping over resulting in hospitalization for a closed head injury. A. Facility policies and procedures 1. The Changes in Resident Condition policy, dated (MONTH) 2005, date last revised (MONTH) (YEAR), was provided by the director of nursing (DON) on 2/7/19 at 4:00 p.m. It read, in pertinent part, .prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention .the Situation, Background, Assessment, Recommendation (SBAR) communication form and the progress notes are used to assess and document changes in condition (C[NAME]) in an efficient and effective manner, provide assessment information to the physician, and provide clear comprehensive documentation . 2. The Resident Transport policy, date last revised (MONTH) 2014, was provided by the nursing home administrator (NHA) on 2/7/19 at 12:54 p.m. It read, in pertinent part, .an employee is required to be screened and receive appropriate driver safety education and training annually .In an emergency, the facility calls an ambulance to transport the resident to the appropriate healthcare facility .secure the resident .in the event of an incident or unusual occurrence: stop immediately-if possible pull off the roadway, check for injuries and render aid if needed, immediately call the administrator to report and obtain further instructions . B. Family interview Resident #17's wife was interviewed via telephone on 2/7/19 at 5:57 p.m. She said the resident was out for a doctor's appointment. The resident was not secured on the way to the appointment and he tipped over in the facility van. The wife said after arriving at the physician office, the resident was taken to the hospital. He returned to the facility from the hospital at 9:00 p.m. on 12/7/18. C. Resident #17's status Resident #17, age 69, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 12/7/18 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of one to two persons with activities of daily living including mobility and transfers. He used a walker and wheelchair for mobility. D. Record review The incident report completed by the ADON dated 12/7/18 at 1:30 p.m. was incomplete. The predisposing environmental factor of the wheelchair not being secured and the post incident injury the resident sustained [REDACTED]. The hospital summary dated 12/7/18 at 5:39 p.m. revealed the resident sustained [REDACTED]. E. Facility van driver observation and interviews 1. On 2/7/19 at 8:40 a.m., observed the facility van driver (FVD) #1 properly load a resident in a wheelchair into the facility van. The driver lowered the lift from the rear of the van and pushed the resident onto the lift. The brakes on the wheelchair were locked and a strap secured behind the wheelchair. FVD #1 stood on the back of the lift behind the resident and raised the lift. The FVD unlocked the brakes on the wheelchair, the wheelchair was pushed into the van and the brakes locked on the wheelchair. Two straps in the front and two straps in the back were secured to the frame of the wheelchair. A seatbelt with a shoulder strap was placed on the resident. The driver rechecked all of the straps. At 10:59 a.m. facility van driver (FVD) #1 was interviewed. She said there were three drivers for two facilities.Training consisted of videos and competencies and driving with another driver for two weeks. The time out portion of the securement checklist was completed for each resident transported in the facility van prior to leaving the facility. The checklist reminded the driver to secure the resident in the van prior to driving away. The form confirmed the checklist had been completed and the wheelchair had been secured in the facility van, however, the resident rolled backwards once the driver took off so the resident was not secured properly. 2. FVD #2 was interviewed on 2/7/19 at 12:04 p.m. He said the protocol for an emergency was to pull over, call 911, the NHA and the supervisor. On the day of the incident, he was running late. He loaded the resident into the van. The resident said he felt like he was going to be sick. The driver ran back inside the facility to grab a basin and alerted nursing. Nursing did not come out to assess the resident, as it was deemed non-urgent. The resident said he felt better as time passed. The driver sat in the driver seat and proceeded to pull into traffic. He said the wheelchair had not been secured in the van and the resident fell backwards. The driver pulled around the corner and assisted the resident to an upright position.The driver did not notice any injuries.The resident said he was ok to continue, as he was to meet his wife at the doctor's office.Halfway to the doctor's office, the driver realized he had not followed protocol and called the NHA before he arrived to the doctor's office. Once at the doctor's office, the resident's wife asked how he was and he said his head hurt.The resident touched the back of his head, found a bump and noticed blood.The doctor's office immediately sent the resident to the hospital.The driver said it was approximately a 25 minute trip from the facility to the doctor's office. F. Facility van driver's training and competencies The Safety Responsibilities for Authorized Drivers form was signed by newly hired employees as acknowledgement of reading and understanding the information. It read, in pertinent part, .report all incidents/accidents no matter how minor to the administrator and await instructions . The Authorized Driver Basic Skills Validation and Motor Vehicle Record Questionnaire; which the van driver would complete after finishing training to demonstrate competency was provided for FVD #1 for (YEAR) but not for (YEAR) and no documentation was provided for FVD #2. G. Staff interview The NHA was interviewed on 2/7/19 at 12:32 p.m. He said the emergency protocol had been in place longer than he has been with the facility. The driver was to call 911 in case of an emergency for the resident to be assessed by a trained individual. The NHA said that he received a call from the driver at 2:00 p.m., after the driver arrived at the doctor's office. The NHA instructed the driver he would meet him at the doctor's office. The NHA said the securement checklist was not completed and should have been according to the facility protocol. H. Facility follow-up The driver was placed on suspension while an investigation was conducted. The driver was required to complete the safety driving training program, and education was provided by the NHA. II. Failed to ensure Resident #21 followed swallowing strategies to prevent choking that required hospitalization . A. Resident #21's status Resident #21, age 74, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/12/18 minimum data set (MDS) assessment, the resident was moderately cognitive impaired with a brief interview for mental status score of eight out of 15. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. Required supervision for eating and bathing. B. Record review The care plan dated 1/18/19 read the resident was at risk for choking due to dysphagia. Interventions included alternating small bites and sips, eat slowly and chew each bite thoroughly, teaspoon used for eating, no straws, check mouth for pocketed food and debris. The physician order [REDACTED]. After the choking incident on 8/6/18 the physician order [REDACTED]. The 8/6/18 emergency department's progress notes showed that on 8/5/18 the resident choked in the dining room and was sent to the hospital. The diet texture was changed to mechanical soft. C. Resident interview and observation Resident #21 was interviewed on 2/7/19 at 8:21 a.m. He said he did not remember the choking event. On 2/6/19 at 11:59 a.m., Resident #21 was served lunch which included a large Polish sausage, cheese bread, mashed potatoes and chilled peaches. He did not receive assistance from staff during the meal. The resident used the side of his fork to break off chunks of the sausage and then ate them. The resident was missing his front teeth. He ate approximately 90 percent of his lunch including all of the sausage. D. Staff interviews 1. The speech therapist (ST) was interviewed on 2/6/19 at 5:00 p.m. She said therapy was alerted to residents who needed to be evaluated in a number of ways; staff could fill out a referral to therapy, a note placed on the dry erase board in the therapy office, a verbal order was generated in the resident's chart or during a meeting. She conducted a bedside swallow during the evaluation, trialing various textures. She started with pureed and progressed to regular texture as the resident tolerated to determine the appropriate diet. To upgrade a diet, an evaluation of the current diet was performed and then a trial of the upgraded diet was conducted for three consecutive days. She continued to monitor the resident for a few days after the upgrade to confirm it was appropriate and safe. She said communication was provided to the kitchen manager, director of nursing (DON), assistant director of nursing (ADON), activities, and the registered dietician (RD). The upgraded diet was placed in the binders located at the nursing station and in the small dining room. The care plan was updated with the interventions. She said on 8/5/18 the resident choked in the dining room and was sent to the hospital. He returned at 5:00 p.m. the same day with a new order for a mechanical soft diet. Speech therapy (ST) saw Resident #21 after the choking incident on 8/5/18 and continued to trial and monitor his progress on an altered diet. On 9/18/18 the resident was upgraded to regular texture and discharged from ST on 9/26/18. The resident was provided with handouts that included instructions on safe swallowing strategies and exercises. She provided a copy of the safe swallowing strategies and exercises on 2/7/19 at 10:30 a.m. She stated the interventions of alternated small bites and sips, eating slowly and chewing each bite thoroughly, teaspoon used for eating, no straws, and to check mouth for pocketed food and debris were added to the care plan by another speech therapist. Speech therapy was responsible for assuring the care plan was updated with the proper interventions. 2. Certified nursing assistants (CNAs) #5 and #6 were interviewed on 2/7/19 at 9:37 a.m. They said the resident just needed to be checked on and reminded from time to time to change his clothes. They were not aware of choking precautions to take with the resident while he ate his food. 3. Licensed practical nurse (LPN) #1 was interviewed on 2/7/19 at 9:41 a.m. She said his cognition fluctuated with level of confusion. She said she was not aware of choking precautions to take with the resident while he ate. 4. ST was interviewed on 2/7/19 at 10:30 a.m. She said she received an order for [REDACTED]. She said she would continue to see the resident for approximately another week. E. Facility follow-up Speech therapy to place visual aids of the swallowing strategies and instructions at the table in the dining room due to residents impaired cognition. The resident will stay on therapy caseload for approximately another week. III. Resident #20 A. Resident status Resident #20, age 45, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/14/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required varied assistance completing his activities of daily living. B. Observation On 2/6/19 at 10:17 a.m., Resident #20 was observed laying on bed in his room. One side of his bed was placed against the wall with two bolsters in place while the rails on the other side of his bed was raised. Resident had no fall mat in place. On 2/6/19 at 11:50 a.m., CNA #8 was observed as she did a one person transfer with Resident #20 from bed to wheelchair. She also did not have a gait belt when she did the transfer. C. Record Review The fall care plan, revised 09/26/18 and with a target date of 4/9/19 documented that Resident #20 was at high risk for falls due to [MEDICAL CONDITION] and total lack of safety awareness. The care plan also documented that resident was on an antipsychotic and antidepressant medication, both of which were reported to have an adverse effect to include but not limited to frequent falls. The (MONTH) 2019 computerized physician order [REDACTED].#20 was taking as active with no reported end date. The fall safety plan documented in the kardex for Resident #20 included to have a fall mat in place and also to have a body pillow in place. These interventions were not in place during observations. D. Staff interview On 2/6/19 at 11:22 a.m., RN #1 was interviewed, she said Resident #20 did not have a fall mat and a body pillow and also confirmed resident bed rail were up. She reviewed the resident ' s care plan and said the resident was supposed to have a fall mat and a body pillow. She also revealed that Resident #20 required a two person assist with transfers. On 2/6/19 at 11:55 a.m., CNA #8 was interviewed, she said Resident #20 required two person assist. She said she did a one person transfer from bed to wheelchair because she had no one to assist her. She also said she forgot her gait belt in another resident room. On 2/7/19 at 3:25 p.m. the director of nursing (DON) was interviewed,she said the resident confirmed the resident did not have a fall mat and a body pillow in place as indicated in his care plan. She said she did not conduct and interdisciplinary team review on Resident #20 to determine if the resident will still benefit from having a fall mat or a body pillow until 2/7/19.

Based on record review and interview, the facility failed to ensure care and services to maintain the highest practicable physical well-being were provided to four (#67, #49, #7, #45) out of 34 sample residents. Specifically: -Resident #67, who was admitted post-cancer surgery and known to have actual, frequent pain, failed to receive ordered pain medication in a timely manner as the medications were not available. -Resident #49's breakthrough pain was not acknowledged or treated. -Resident #7 received [MEDICATION NAME] after it was ordered discontinued for oral surgery. -Resident #45's needs were not communicated between the facility and his hospice agency. The findings include: 1. Resident #67 (closed record) According to the face sheet, the resident, a [AGE] year-old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], showed the resident was cognitively intact. He required limited assistance with bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. The resident had frequent pain which made it hard for him to sleep at night and limited his day-to-day activities. Record Review: The 9/18/12 pain care plan showed the resident had actual pain related to recent surgery [MEDICAL CONDITION]. Approaches included: -Positioning/support -Assistive devices/braces -Administer [MEDICATION NAME] as ordered -Observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions -Notify physician if interventions are not consistently effective -Medicate resident for pain prior to treatments and therapy, if indicated. The pain evaluation, dated 9/18/12, showed the resident was on scheduled pain management, as needed (PRN) pain medications, and non-medication intervention for pain. The resident expressed he had frequent pain which made it hard for him to sleep at night and limited his day-to-day activities. The nursing admission assessment documented the resident was admitted to the facility on [DATE] at 4:30 p.m. The hospital Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -[MEDICATION NAME] Patch applied to the right shoulder on 9/16/12 at 10:48 a.m. -[MEDICATION NAME] 20 milligrams per GTUBE every four hours on 9/16/12 at 10:21 a.m., 3:15 p.m., 5:31 p.m. and 10:16 p.m.; and on 9/17/12 at 2:49 a.m., 7:02 a.m., 9:08 a.m. and 1:12 p.m. -[MEDICATION NAME] 2 milligrams on 9/17/12 at 1:24 p.m. The facility admission orders [REDACTED] -[MEDICATION NAME] Patch every 72 hours change on 9/19/12 for pain -[MEDICATION NAME] 20 mg via Gtube every four hours as needed for pain On 12/20/12 at 10:23 a.m., the resident's spouse stated the resident was in pain constantly on admission. "He told the nurses he was in pain. I was also in the hall asking if someone could help my husband. The nurse was great but said they did not have his medications and had to get them from the pharmacy in (another state). I would not leave his side." The September 2012 PRN pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 9/17/12 nurse's note was reviewed. The note documented, "Pt (patient) admitted today; his wife is with him; tube feeding started at 2030 (8:30 p.m.). Wife is very worried about him staying here ..." On 12/20/12 at 10:49 a.m., the registered nurse (RN) who admitted the resident was interviewed. -When asked about the resident's condition upon admission, she said, "He could answer all my questions. He could talk. He did complain of a lot of pain because of everything that had recently happened. He didn't really say much and was very tired. His wife was with him and she answered most of the questions. In the hospital he was having a lot of pain and his wife wanted to make sure we could keep up with his medications to make sure he wasn't in pain." -The RN said she did not administer any of the resident's medications, including the pain medications during her shift because they did not come from the pharmacy. She added, "We get the medication list and once we get it, we transcribe the medications and fax it to pharmacy. If they can send it from back-up, it will come in a couple of hours. If we don't get it faxed before 2:00 p.m., sometimes they don't come until the next morning. If they have a narcotic, our pharmacy can send us an authorization and we can pull them out of the e-kit so we at least have their pain meds." -The RN stated [MEDICATION NAME] ([MEDICATION NAME]) was available in the e-kit, but stated she was never asked specifically for the medication. "When I asked what the biggest issue was, his wife would say his pain, but when I asked what his pain was, he would tell me a 2 to 3 (out of 10)." The RN said she never asked if the resident needed or wanted pain relief because she was not specifically asked for medication. The fax to the pharmacy was obtained and showed the resident's admission orders [REDACTED] The 9/18/12, morning shift nurse's note was reviewed and documented, "...Resident's wife upset upon beginning of shift. States she is not happy and wants to go to a different facility. RN, ADON (assistant director of nursing) talk(ed) with resident and wife, reassuring them and asking what can be done to make things better. RN requests that PA (physician's assistant) see resident and assist with sorting orders and issues out. PA meets with resident at end of shift." The 9/18/12 evening shift nurse's note then documented, "New orders for IV push [MEDICATION NAME] every three hours. Pt wants the [MEDICATION NAME] every 3 hours ...Received [MEDICATION NAME] at 1550 (3:50 p.m.), 1850 (6:50 p.m.), 2200 (10 p.m.)." The narcotic reconciliation record and MAR indicated [REDACTED]. The resident also sought [MEDICATION NAME] for his pain relief during the early morning hours. On 9/18/12, the resident received [MEDICATION NAME] at 3:00 a.m., 7:00 a.m., 11:00 a.m., 3:45 p.m. and 10:45 p.m. The resident received [MEDICATION NAME] at 3:50 p.m., 6:50 p.m. and 10:00 p.m. (see above) On 9/19/12, the resident received [MEDICATION NAME] at 10:00 a.m. and 7:30 p.m. He received [MEDICATION NAME] at 1:00 a.m., 4:00 a.m., 7:00 a.m., 10:00 a.m., 4:45 p.m., 7:50 p.m. and 11:00 p.m. On 9/20/12, the resident received [MEDICATION NAME] at 12:15 p.m. and 11:00 p.m. The resident received [MEDICATION NAME] at 2:30 a.m., 6:00 a.m., 9:15 a.m., 12:15 p.m., 5:00 p.m., 8:00 p.m. and 11:00 a.m. On 9/21/12, the resident received [MEDICATION NAME] at 6:00 a.m. and 12:30 p.m. He received [MEDICATION NAME] at 2:30 a.m., 6:00 a.m., 12:30 p.m., 2:15 p.m., 7:15 p.m. and 11:15 p.m. On 9/22/12, the resident received [MEDICATION NAME] at 10:00 a.m. and 2:00 p.m. He received [MEDICATION NAME] at 1:15 a.m., 4:15 a.m., 9:15 a.m., 1:15 p.m., 4:30 p.m., 7:30 p.m. and 10:30 p.m. On 9/23/12, during the 10:00 p.m. - 6:00 a.m. shift, a nurse's note documented, " ...No MS04 ([MEDICATION NAME] sulfate) available. Res(ident) agitated with fact that MS04 (not) available. Pharmacy faxed 9/22/12 to send more [MEDICATION NAME], pharmacy called on day shift to remind them to send MS04, res states pain level 5-6 on 1-10 scale. Placement for GT (G tube) checked before liq(uid) [MEDICATION NAME] given. . . This nurse explained to res, "Pharmacy was faxed and called about MS04 order, waiting for courier to bring it into facility." Res appears unsatisfied at explanation, resting in bed comfortably." The September 2012, narcotic administration record showed the resident did not receive [MEDICATION NAME] on 9/22/12 from 10:30 p.m. until 6:00 a.m. on 9/23/12, during which time the facility was waiting for delivery from the pharmacy. On 9/23/12, the resident did receive the [MEDICATION NAME] at 1:30 a.m. and 4:55 p.m. At 1:30 a.m., the resident expressed pain at a 5-6 out of 10. After the medication was administered, the pain went to a 1-2 out of 10. At 4:55 p.m., the resident expressed 5 out of 10 pain. After the medication was administered, the pain went to a 1 out of 10. While pain relief was expressed, per the documentation, the resident was agitated and unsatisfied that [MEDICATION NAME] was not available and per documentation above (September 2012 pain medication administration records), pain relief for the resident was short lived. -On 9/19/12, the resident received [MEDICATION NAME] at 7:30 p.m. for 8 out of 10 pain. At 7:50 p.m., he then received [MEDICATION NAME] and his pain level at that time was not documented. -On 9/22/12, the resident received [MEDICATION NAME] at 9:15 a.m. for 5 out of 10 pain. He then received [MEDICATION NAME] at 10:00 a.m. for 5 out of 10 pain. The resident also received [MEDICATION NAME] at 1:15 p.m. for 6 out of 10 pain. He then received [MEDICATION NAME] at 2:00 p.m. for 7 out of 10 pain. Interviews: On 12/20/12 at 11:20 a.m., the director of nursing (DON) stated if pain was expressed upon admission, "We check to see if there is something we can supplement with until the medications arrive; otherwise, we would have to order it stat from the pharmacy. We could also try to call the doctor to try and get a different medication in." On 12/20/12 at 11:33 a.m., the ADON was asked about the multiple issues she had discussed with the resident and his wife on 9/18/12. She said the resident was ordered [MEDICATION NAME] and it was discontinued upon admission. The resident was unaware it had been discontinued and it had to be reordered. The ADON stated medications typically take about an hour to come to the facility after they are ordered from the pharmacy. On 12/20/12 at 3:42 p.m., the DON read the 9/23/12 progress note regarding the facility being out of [MEDICATION NAME]. -She said, "It seems like he wasn't satisfied because the [MEDICATION NAME] was out." The DON acknowledged the resident was reliant on both of [MEDICATION NAME] and [MEDICATION NAME] for pain relief. The DON said the resident went from 10:30 p.m. on 9/22/12 until 6:00 a.m. on 9/23/12 without getting the [MEDICATION NAME]. -She acknowledged the day shift did not document their calling the pharmacy to check on the status of the delivery on 9/22/12. Additionally, there was no evidence the evening shift had attempted to follow-up with the pharmacy or the resident's physician about the [MEDICATION NAME] not being timely delivered. -She said, "The [MEDICATION NAME] arrived at 6:00 a.m. (on 9/23/12) and he received it at 6:00 a.m." Although both the resident's wife and the admitting nurse acknowledged the resident was in pain on his admitted , no documentation was made regarding the resident's pain. On 12/20/12 at 12:40 p.m., the DON said, "We ask about pain on admission. Pain levels should be assessed and noted." According to the pain Medication Administration Record, [REDACTED]. 2. Resident #49 According to the face sheet, the resident a [AGE] year-old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], showed the resident's cognition was moderately impaired. The resident was documented to have occasional pain. Record Review: According to the 2/9/11 pain care plan, the resident had actual pain related to joint pain and musculoskeletal. Approaches included: -Provide non-pharmacological interventions including positioning/support -Exercise program -Stretching exercises -Recreational therapy/activity programming -Administer [MEDICATION NAME] as ordered, see physician orders. -Implement pain management flow sheet -Observe resident for signs and symptoms of pain including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other) every shift. Notify physician if interventions are not consistently effective. According to the December 2012 computerized physician orders, the resident was prescribed the following pain medications: --[MEDICATION NAME]-[MEDICATION NAME] 10 mg-325 mg BID for pain --[MEDICATION NAME] 15 mg QD for pain --[MEDICATION NAME] Patch Q72 hours HS for pain. Remove and discard old patch. Apply new patch and hold for 30 seconds to activate --[MEDICATION NAME] 20 mg QD for pain The resident's pain was also to be monitored every shift. "Ask resident if he is having pain or discomfort or assess resident's non-verbal indicators using the Wong-Baker faces of Pain Scale 1-10 (2/23/11)." According to the 11/1/12 pain evaluation, the resident had pain related to left sided [MEDICAL CONDITION] and shoulder and hip pain. -During the last 5 days, the resident was on a scheduled pain management regimen, received PRN pain medications, and received non-medication intervention for pain. -The resident stated he experienced occasional pain which made it hard for him to sleep at night and limited his day-to-day activities. -The resident said his goal for pain control was for his pain to be at a 1-2 out of 10. Resident Interview: On 12/17/12 at 3:21 p.m., the resident was asked if he had pain, hurting, or burning without relief. The resident said yes, and stated the pain medication did not always help. He added, "I have arthritis real bad in my shoulder and my left hip and leg." The resident's medication administration records (MARs) including the every shift pain assessments were reviewed back to October 2012. The resident's goal for pain control (1-2 out of 10) was documented as exceeded on the following dates: -On 10/22/12, the resident's pain level was documented to be a 4 out of 10. -On 11/1/12, the resident's pain level was documented to be a 6 out of 10. -On 11/2/12, the resident's pain level was documented to be a 3 out of 10. -On 12/14/12, the resident's pain was documented to be a 3 out of 10. -On 12/15/12, the resident's pain was documented to be a 4 out of 10. -On 12/18/12, the resident's pain was documented to be a 4 out of 10. The nurse's notes were reviewed on the above dates and no further documentation was completed regarding the resident's complaints of pain. There was no evidence non-pharmacological interventions to treat the pain were offered or provided or evidence to show the resident's physician was contacted. Interview: On 12/20/12 at 1:22 p.m., a registered nurse (RN) assigned to the 400 hallway where the resident resided stated if a resident expressed breakthrough pain she would call or fax the resident's physician to obtain a PRN (as needed) pain medication. On 12/20/12 at 3:35 p.m., the director of nursing (DON) stated she would expect the nurse to contact the resident's physician to obtain a PRN pain medication. She stated the resident was on scheduled pain medications, but she expected the nurses to chart if there was (no) pain relief. 3. Resident #7 According to the face sheet, the resident, a [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review: The resident's December 2012 computerized physician orders [REDACTED]. According to the bleeding risk care plan, dated 5/9/12, the resident was at risk for bleeding related to the use of anticoagulant therapy and received [MEDICATION NAME]. Approaches included: --Administer meds as ordered --Monitor labs as ordered --Notify MD of abnormal labs for further direction and treatment determination --Observe for bleeding or increased bruising frequently --Provide and encourage use of soft bristle toothbrush --Provide individual and caregiver education as needed The physician's telephone orders were reviewed and an order made by the resident's dentist, dated 11/8/12 documented, "Stop [MEDICATION NAME] 11/26/12 for dental surgery on 11/29/12. Please resume [MEDICATION NAME] on 12/1/12." After reviewing the resident's lab work, the resident's nurse practitioner modified the resident's [MEDICATION NAME] order on 11/27/12. The order documented, "[MEDICATION NAME] cont(inue) to alternate 6 mg with 7 mg every day, rev(iew) PT/INT 1 week." The resident's November 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview: On 12/18/12 at 3:25 p.m., the director of nursing (DON) stated, "The [MEDICATION NAME] was supposed to be on hold and she did get it because the nurse practitioner (NP) responded to a lab result. It was transcribed by the nurse and it caused the [MEDICATION NAME] to be administered." The DON said, the new order should have been clarified to ensure the [MEDICATION NAME] was still held. 4. Resident #45 Resident #45, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was on hospice. The Minimum Data Set (MDS) assessment, dated 7/23/12, revealed he could usually understand others and was usually understood by others. He needed extensive assist with all activities of daily living. The care plan for hospice was dated 10/24/12. The resident was on hospice due to a decrease in clinical status. The goal was for the resident to be comfortable and pain free. Approaches listed were: -Hospice registered nurse (RN) to visit 2-4 times/per month, -Certified nurse aide (CNA) to visit 1-3 times per week and as needed, -Counselor 1 to 4 times per month, -Assess for additional services, -Encourage friends and family to visit, -Hospice RN to visit with facility at each visit. Review of the medical chart, under the hospice tab, revealed that hospice was started on 10/23/12. The sheet that recorded the hospice visits was completed to 12/17/12. There were no other notes except for the initial assessment notes. The charge nurse was interviewed on 12/17/12 at approximately 10:00 a.m. She stated she was not aware of any other separate book or chart for hospice notes. On 12/18/12 at 3:15 p.m., the nursing home administrator (NHA) and the director of nursing (DON) provided documentation from hospice. Although there was a list of when hospice staff visited and who visited, there was no documentation found to show what services were provided during the visit. Moreover, there was no documentation in nursing notes or social services notes related to hospice services. Both the NHA and DON agreed there were no notes from hospice in the medical record regarding what was done for the resident. The DON and NHA further stated the hospice staff did stop and visit with the facility nurses before they left. However, there was no documentation found or provided to show this occurred. The hospice provider was then contacted by the facility, and stated their notes and documentation were located at their office.

Based on observation, interviews and record reviews, the facility failed to ensure that two (#83, #64) of the 45 sample residents who entered the facility without pressure ulcers did not develop pressure ulcers and that upon developing pressure ulcers, the residents were not provided necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Residents #83 and #64 developed pressure ulcers after admission to the facility. The facility failed to ensure the residents' skin breakdown was properly assessed and monitored and that interventions to promote healing were timely implemented. The findings include: 1. Resident #83 Resident #83, [AGE] years old, was admitted to the facility on [DATE]. According to the facility face sheet, his [DIAGNOSES REDACTED]. According to the MDS on admission, dated 4/4/11, the resident was admitted without any pressure ulcers. According to the minimum data set (MDS), dated [DATE], the resident's BIMS (mental status) score was 99 (unable to participate), he has short-term memory problems, and had difficulty making decisions in new situations. He was not coded as having any physical or verbal behaviors, or any other type of behaviors. He required extensive physical assist of one for bed mobility, dressing, personal hygiene, and toilet use. He was at risk for pressure ulcers, and he had one or more unhealed pressure ulcer at a stage I or higher, a stage II and an unstageable ulcer. a. Record Review - development of skin breakdown after admission on coccyx (5/24/11) and left heel (8/23/11). According to the Braden scale, dated 8/31/11, the resident scored 12, indicating he was moderate risk for skin breakdown, although (see below) the resident had a coccyx wound, identified 5/24/11, and a left heel wound, dated 8/23/11. According to the facility's Weekly Pressure Ulcer (WPU) records, a stage II pressure ulcer has a partial thickness loss of skin layers that present clinically as abrasions, blisters or shallow craters. A Stage III pressure ulcer is a full thickness of skin that is lost, exposing the subcutaneous tissue-presents as a deep crater with or without undermining and instructions read - refer to therapy. Coccyx wound: Review of the WPU record for the resident's coccyx ulcer from 5/24/11 through 7/12/11, revealed the wound was documented as a stage II. The wound depth, on all entries, was 0.1 cm with no undermining. Review of the WPU records from 7/20/11 through 8/9/11, revealed the wound was documented as a stage III. The wound depth, on all entries, was documented as 0.1 cm with no undermining. Review of the WPU records from 8/17/11 through 9/20/11, revealed the wound was documented as a stage II. The wound depth, on all entries, was 0.1 cm. Review of the WPU records from 9/27/11 through 10/18/11, revealed the wound was documented as a stage III. The wound depth was documented as 0.1 cm. Left heel: Review of the WPU record, dated 8/23/11, revealed the resident had an unstagable pressure ulcer to his left heel. The ulcer onset date was 8/23/11, it was 2 cm x 2 cm in size, the depth was unknown, there was no exudate, the wound bed was black, the surrounding skin color was normal for skin, and the surrounding skin was macerated. The physician and dietary were notified on 8/23/11. Review of the WPU record, dated 8/29/11, revealed the wound was 2 cm x 1 cm in size, there were no exudates, the wound bed was black, the surrounding skin color was normal for skin, the surrounding skin was macerated. The wound was documented as improving and the physician and dietary were notified. Review of the WPU record, dated 9/6/11, documented the wound was 2.8 cm x 2 cm, there was no exudate, the wound bed was black, the surrounding skin color was pink, the surrounding skin was macerated. The wound had deteriorated and the physician and dietary were notified. Review of the WPU record, dated 9/13/11, revealed the wound was 3.5 cm x 2 cm in size, no other changes noted. Review of the WPU record, dated 9/20/11, documented the wound was 4 cm x 3 cm in size. The noted change was that there was a foul odor, there was no documentation related to the response to treatment i.e. improving, deteriorated. Review of the WPU record, dated 9/27/11, documented the wound was 3 cm x 4 cm, with moderate foul, purulent, odorous exudate, with no other noted changes. The response to treatment was documented as no change. Review of the WPU record, dated 10/4/11, documented the wound was 3.5 cm in diameter with no undermining. There was no other documentation about the wound. The response to the wound was charted as no change. Review of the WPU record, dated 10/11/11, revealed the wound was 3.5 cm in diameter, moderate purulent, odorous exudate, the wound bed was black, the surrounding skin color was normal, and the surrounding skin was macerated. The response to treatment was documented as improved although "no change" was circled. Review of the WPU record, dated 10/18/11, documented the wound was 3.5 cm x 3.2 cm with no other noted changes. The response to treatment was noted as improving. Review of the WPU record, dated 10/24/11, revealed the wound was 3 cm x 4 cm in size, with no other noted changes. The response to treatment was no change. b. Facility response to pressure ulcer development Care Plan: Review of the resident's care plan for pressure ulcers, dated 4/6/11, revealed the box for potential was marked; the box for actual pressure ulcer was left blank. The care plan read in pertinent, under 'refusal of care and treatment,' that the resident refuses to be turned and repositioned, stage 2 to coccyx, dated 5/24/11, stage 2 to left heel, dated 8/23, turn and reposition while in bed frequently for comfort and pressure reduction, complete full body check weekly and document. Weekly head to toe skin checks: According to the weekly head to toe skin checks form for August 2011, the resident had one head to toe assessment, dated 8/16/11. It documented stage III to the coccyx. Skin checks 8/2/11 and 8/9/11 were documented as 'refusals.' According to the weekly head to toe skin check form for September 2011, one refusal was documented on 9/15/11. There were no other entries/documentation for September. According to the weekly head to toe skin check form for October 2011, the resident had two head to toe assessments completed for the month. A head to toe assessment was completed on 10/11/11, and the documentation reflected an ulcer to the coccyx and left heel. The other assessment was completed on 10/25/11 and the documentation reflected that there was a coccyx ulcer. There was no additional documentation for October. Orders: According to the physician telephone order (TO), dated 8/23/11, the treatment to the left heel ulcer was: cleanse, skin prep to peri-wound, TAO (triple antibiotic ointment) to wound bed, cover with 4x4 gauge and wrap with kling. Change every other day. Off-load heals at all times. According to the TO, dated 9/26/11, the treatment to the left heel ulcer was: cleanse heel, skin prep to whole heel, including wound, cut calcium alginate to fit wound bed, cover with two 4x4, wrap with kling, change every other day. According to the TO, dated 10/12/11, the resident had an order for [REDACTED]. c. Failures in facility response to pressure ulcer development (1) Record Review Referral: On 10/26/11, review of the resident's medical record, including nurses' notes, skin section, and consult section revealed no documentation that showed the wound care clinic had been contacted related to the referral on 10/12/11. Care plan: All entries on the WPU records above reflected that the care plan was updated. However, review of the care plan revealed the only intervention with a date different than 4/6/11, was an intervention for 4 ounces of med pass, dated 7/1/11. Weekly skin checks: See above; weekly skin checks were not documented. Although some refusals were documented, that documentation did not include all the expected weekly skin checks. Moreover, the 10/25/11 skin check was not accurate; it did not reflect the resident's heel ulcer. (2) Observations - lack of pressure relief to heels and coccyx. On 10/26/11 at 11:02 a.m., the resident was observed in his room in bed, lying flat on his back, blanket over his head and tucked tight over his feet and revealing toe indentations through the blanket; his feet were visibly being pulled down by the blanket. There was a strong foul odor in the room. On 10/27/11 at 1:35 p.m., the resident was observed in his room in bed, lying flat on his back. He had the blanket pulled up over his face and hanging over the top of his feet. The strong foul odor was worse than on 10/26/11. d. Interviews On 10/27/11 at 2:23 p.m., the ADON was interviewed. She said she was responsible for overseeing the wound care in the building. She said that she, along with the staff development coordinator (SDC), do weekly wound rounds. She indicated that the resident had a stage III on his coccyx that changes all the time and an unstagable ulcer on his left heel. She stated the resident has off loading air boots and has a referral to the wound clinic. She indicated that the resident was on a specialty mattress and often refused cares, including being turned and repositioned. She said he has the right to refuse. On 11/1/11 at 11:24 a.m., a certified nurse aide (CNA) who regularly cared for resident #83 indicated that the resident does not have behaviors when she provides cares to him. The (CNA) said the resident might get a little gruff or try to refuse cares, s/he just offers to buy him a diet Pepsi and he allows him/her to provide cares. e. Observations of pressure ulcers - failure to measure and document condition of ulcers for tracking improvement/deterioration of ulcers. On 10/31/11 at 2:11 p.m., the resident's dressing change to his left heel was observed. The dressing change was completed by the assistant director of nursing/wound care nurse (ADON) and the staff development coordinator (SDC). A physician was present during the dressing change; he debrided the wound but did not participate in the dressing change. -The ADON prepared the dressing change supplies outside of the resident's room. She then entered the resident's room. The resident was lying in his bed, flat on his back. He had boots on both of his feet. The ADON removed the boots and then the dressing from the resident's left heel. -The wound was approximately 3.5-4.0 cm in diameter. The wound had a copious amount of brown drainage and blood. The wound bed was covered in eschar with slough present on the edges. The wound was foul smelling. The ADON cleansed the wound with wound cleanser, the physician assessed and debrided the wound. The ADON applied a new dressing. The ADON indicated that the wound was unstageable. -At 2:35 p.m., the SDC removed the dressing from the coccyx wound. This wound bed was bright red with slough present around the edges. It was approximately 4 cm x 2.5 cm. The SDC provided wound care per order and applied dressing. -Neither the ADON or the SDC were observed to take notes after the dressing change or measure the resident's coccyx and heel ulcers during the dressing change. On 11/1/11 at 11:01 a.m., a request was made of the ADON, in the presence of the corporate clinical consultant, to view the documentation related to the dressing change that had been observed on 10/31/11. The ADON indicated that she had not yet charted on the dressing change. She indicated that she only does her wound charting once a week and does not document at the time of the dressing change. She acknowledged that she probably should have charted on 10/3/11, after resident #83's dressing change. 2. Resident #64 (Cross-reference F325; nutrition) Resident #64, a [AGE] year old male, was re-admitted to the facility on [DATE]. According to the admission face sheet, the resident's [DIAGNOSES REDACTED]. Resident #64 had been admitted and discharged to the hospital from the facility four times prior to his current admission. The dates of the resident's stay were as follows: (1) 1/26/11- 3/14/11; (2) 6/3/11- 6/10/11; (3) 6/16/11- 9/9/11; (4) 9/19/11- 10/2/11; and (5) 10/18/11- 11/1/11 (survey exit). The most recent minimum data set (MDS), dated [DATE], revealed the resident had a stage I or greater pressure ulcer, was at risk for developing pressure ulcers, and had a stage I or higher pressure ulcer that was not healed. It identified that the resident had one stage III pressure ulcer measuring 5.8 centimeters (cm) by 4.5 centimeters with a depth of 1.2 cm. Interventions included pressure reducing device for bed, nutrition or hydration interventions, ulcer care, application of nonsurgical dressings and applications of ointments or medications. According to the 9/16/11 MDS, the resident had a feeding tube to meet 100% nutritional needs. The resident received nothing by mouth. a. Record review - skin condition during initial admission 1/26/11- 3/14/11. Record review revealed the resident had a surgical scar over a bony prominence according to his MDS, dated [DATE]. According to his discharge MDS, dated [DATE], the resident was discharged with no open wounds or pressure ulcers. b. Record review - skin condition during second admission 6/3/11-6/10/11. On review of the admission orders [REDACTED] According to a discharge MDS, dated [DATE], the resident did not have any unhealed pressure ulcers on discharge. c. Record review - skin breakdown following admission 6/16/11-9/9/11 - facility response and failures in facility response. (1) Documentation of skin breakdown following admission Admission documents: -Admission physician's orders, dated 6/16/11, indicated that no wound care was ordered and no wounds were noted. -Admission MDS, dated [DATE], stated that the resident did not have any unhealed stage I or greater pressure ulcers. -A nursing admission assessment, dated 6/16/11 (see following details) had columns dated 6/16/11, 6/23/11, 6/30/11 and 7/7/11, which rated the resident on the Braden scale. On the back of the admission assessment it indicated that the resident had a skin assessment but the specific date was not listed. (Upon interview with the consultant nurse 10/31/11 at approximately 11:00 a.m., she stated that the skin assessments were done on the first date listed on the Braden scale, indicating 6/16/11). The skin assessment on the back of the assessment indicated that the resident had a left hip scar, a "level II ulcer/opening on the scrotum area," red scaring to calf and top of foot and ankle, old scars on right hip and several scabs on his right leg. -Nursing daily skilled summaries, dated 6/16/11-6/27/11, noted the resident has a skin tear on his scrotum. Weekly pressure ulcer (WPU) records: a) WPU record, dated 7/5/11 (approximately three weeks after admission), documented: -The onset of a right heel pressure ulcer, stage II, 1cm x 1.5 cm by 0.1 cm. The assessment was signed by the assistant director of nursing (ADON), a licensed practical nurse (LPN), who was the wound care nurse (WCN) as well. -The onset of a stage II pressure ulcer on the resident's right ischial prominence and stated that it was a pressure area from the right heel due to tone in the resident's legs. (His leg was contracted in a position that resulted in his heel pressing on the back of his thigh/buttocks). It was documented as 3 cm x 2.5 cm x 0.1 cm. The assessment was signed by the WCN. -The onset of a stage II on the resident's coccyx. It stated that the wound was 2 cm x 3 cm x 0.1 cm. The assessment was signed by the WCN. b) WPU record, dated 7/20/11, signed by the WCN identified open areas on the left great toe with the date of onset 7/20/11 measuring 1 cm x 1.5 cm, left second to right side opening measuring 0.2 cm x 0.2 cm, and a left second toe opening measuring 2 cm x 0.5 cm. It stated that the areas were blisters that opened possibly from sheering from the cover on the air mattress. c) WPU record, dated 7/26/11, identified the left great toe with a 0.6 diameter scab, the left second toe with a wound of 1.5 cm by 2.5 cm on left side (previous measurement 2 cm x 0.5 cm) and the right side of second toe healed. The document was marked as wounds improved; however, measurement of left second toe wound had increased. d) WPU records from 8/2/11 and 8/9/11, documented toe wounds but did not measure the wounds. Nurses' notes: -A nurses' note, dated 7/8/11, stated the following: "Skin: 3 new pressure areas, (right) heel 1 x 1.5 irregular open area-was blistered at edges macerated, (treatment) [MEDICATION NAME], (right) ischial area 3 x 2.5 cm 50% slough-(treatment) santyl/[MEDICATION NAME]. Coccyx: 2 x 3 stage II-treatment [MEDICATION NAME] on air mattress, frequent repositioning." -A nurse's note, dated 7/22/11, stated that the interdisciplinary team met to discuss the resident's skin and diet, reporting a weight of 113.4 lbs. (His weight on readmission 6/16/11 was 128 pounds.) It noted the three pressure areas identified on 7/5/11: The coccyx, right heel and right ischial. It also identified an opening on the left great toe measuring 1 cm x 1.5 cm x 0.4 cm and an open blister on his second toe measuring 0.2 cm x 2 cm x 0.5 cm. Skin checks: Head to toe skin checks, dated 7/20 and 7/26, both documented, "skin breakdown to coccyx and right hip." MDS: A discharge MDS, dated [DATE], documented that the resident did have one or more unhealed pressure ulcers stage one or greater on discharge. It further documented that the resident had a stage III ulcer upon discharge. (2) Facility response to skin breakdown Resident #64's care plan for pressure ulcers was initiated on 6/24/11. It stated that the resident had actual and potential risk for pressure ulcers. The plan was updated on 7/5/11 to identify the right heel wound, the right ischial wound, the coccyx wound, the left great toe wound, and the left second toe wound. Multiple interventions were "checked" as in place, although date of implementation was not identified on the plan. These interventions included interventions such as: pressure reduction mattress to bed, pressure reduction cushion to chair, reposition in chair frequently for comfort, turn and reposition while in bed, and measure and stage wound weekly using the pressure ulcer healing assessment form. See above nurses' note; the interdisciplinary team met 7/22/11 to discuss the resident's skin and diet. However, no nutritional changes were implemented. See below: a [DEVICE] was ordered 8/20/11 and initiated 8/29/11, to address the resident's sacral/coccyx wound. (3) Failures in facility response a) Failure to consistent assess and monitor areas of skin breakdown. See WPU, "head to toe" assessments, and nurses' notes above; staff failed to consistently assess, track and monitor the resident's multiple areas of skin breakdown. There was no reference to the resident's scrotal wound after 6/27/11, specifically whether or when it had improved or healed. The skin breakdown on the resident's toes was not mentioned on the "head to toe" assessments, and several of the resident's open areas (see documentation above) were not consistently or accurately measured. b) Failure to timely address wounds to toes. There was no physician's order or dressing change or weekly wound assessments found for the toe wounds until a 7/27/11 treatment order indicated to leave open to air. This was over 20 days after initial documentation of toe wounds. c) Failure to timely address the resident's nutritional needs with skin breakdown. Review of the dietary progress notes revealed no dietary notes following discovery of the resident's skin breakdown 7/5/11, until 7/18/11. In the 7/18/11 note, the dietitian noted "true weight loss" unknown due to varying weights. In the 7/29/11 note, dietary documented that the resident had lost weight and the physician had been called and verbally agreed with increasing the resident's tube feed for weight and wound healing. There were no further dietary progress notes until 8/26/11. The 8/26/11 note discussed changing the resident's tube feeding from 100 cc to 99 cc/hour for reimbursement purposes; there was no discussion of the resident's weight loss or wounds. Cross-reference F325; nutrition, for further details. d) Failure to consistently implement treatment orders On 8/19/11, the treatment administration record (TAR) for August documented an order for [REDACTED]. -The August TAR documented treatment orders to monitor the resident's coccyx, right ischial wound and the placement of a pillow between the right heel and buttocks each shift. However, there were no initials documenting monitoring on the day and evening shifts on 8/26 and 8/28 along with no initials on the day shift for 8/29-8/31/11. Moreover, the TAR also documented administration of the wound vac three times a week on Tuesday, Thursday and Saturday. While the treatment was initialed on 8/20, 8/22 and 8/26/11 for the month, the wet to dry dressing also was initialed as done on 8/20, 8/23, 8/26, 8/29, and 8/31/11. There were no notes on the back of the TAR or in the chart to explain which of the two treatments had been implemented. d. Record review - admission 9/19/11-10/2/11 -Record review of the nursing (re)admission assessment revealed a Braden scale for predicting pressure sore risk. A column, dated 9/19, identified the resident as a 7 (a total score of less than or equal to 9 indicated a severe risk for pressure ulcers). A column, dated 9/26, indicated that the resident was scored 11, which according to the sheet, reflected a high risk for pressure ulcers. Physician's orders, dated 9/19/11, indicated no wound care orders, but on the [DIAGNOSES REDACTED]. e. Record Review - status of skin condition 10/18/11-11/1/11 (1) Assessments and orders on re-admission Discharge orders from the hospital to the facility, dated 10/17/11, stated, "(Patient's) dad very concerned about repositioning needs. Per (physician) and wound care- (patient) to be turned (every) 2 hours. Left to right only, not on back." Review of the most recent physician orders, dated 10/18/11, showed an order for [REDACTED]." There were initials indicating that the wounds had been covered on 10/22, 10/25, 10/26, and 10/27/11. Nursing admission assessment, dated 10/18/11, documented on a picture of a body that there were skin conditions/wounds on the resident's coccyx, right wrist, and left leg above the knee. The extent of the wounds was not documented. A WPU record provided by the ADON, dated 10/18/11 (the date of resident #64's readmission to the facility), indicated that the resident had one stage III on his coccyx, but no other skin issues were noted, even though the nursing admission assessment, as well as the physician orders referenced other areas of breakdown. (2) Discovery of new wounds during survey -10/26/11 at 8:30 a.m. The resident was observed while the WCN and staff development coordinator (SDC) were turning him from left to right side. He had four dressings visible when he was turned; there was a large dressing on his coccyx, a Coban wrapped (a self adherent wrap) around gauze on his right foot, bordered gauze undated on his right knee, and a large, undated bordered gauze on his left hip. See WPU above; the WCN/ADON's weekly wound documentation only had information regarding the wound on the resident's coccyx. When asked about the resident's other wounds that were covered with dressings on the resident's right foot, knee and left hip, she stated that she was not aware of them. She stated that sometimes the facility covered areas prone to breakdown and that the resident did not have any other open areas other than his coccyx. -10/27/11 at 11:49 a.m., the WCN/ADON confirmed she was the wound care nurse (WCN) and that she did all the measurements, treatments, and documentation for complicated wounds and pressure sores. She stated that minor treatments would be performed by the unit nurses. The WCN was asked what the Coban dressing on the resident's foot was for, as Coban would not reduce pressure. She stated that possibly a blood draw had been done on the resident's foot. She stated she had not seen this dressing before. The WCN donned gloves and began assessing the resident by removing the Coban dressing. It revealed a scabbed area on the outer edge of his right foot. When asked to identify what the wound would be called, the WCN stated that she would call it a stage II. The WCN then removed the undated dressing from the resident's right knee, revealing a circular wound that appeared to be the size of a silver dollar, with a wet but well granulated wound bed. She took her gloved thumb and rubbed the wound twice stating that it was likely a scratch. When asked to elaborate as to what it would be documented on the WPU record, she stated that it would be a stage II. The WCN was asked about the dressing on the resident's hip. She rolled the resident to his side and removed the dressing on his left hip. When this was done several areas along a scar on the resident's hip were open and one area began to bleed. With the same hand she had used to rub the knee wound, she rubbed the blood off of the resident's hip and stated that it was just from the tape but because of the location and the three areas on the hip being opened, she stated that she would consider them a stage II if she had to stage them. She again stated that it was the tape and that she would not suggest putting it on the resident. When asked if the wound coverings were ordered, she stated that she would have to ask the floor nurse. After exiting the resident's room, the WCN verified with the unit nurse that there were wound care orders for the resident scheduled for the 2:00 p.m. shift to perform. She stated that she would have the wounds covered. She added that the resident did not have any open areas except for his coccyx when he was admitted . The director of nursing (DON) was approached at this time and informed of the observations above with the WCN. She stated that even if the resident wounds were not documented on the weekly wound sheets done by the WCN, the unit nurses did a weekly head to toe skin assessment on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. They were told by the DON to initiate one immediately. The WCN then documented on the weekly skin assessment that the resident had a right knee and left toe abrasions and previously identified areas on the coccyx and left hip. (3) Action taken following observations 10/27/11 A change of condition was written on 10/27/11 by the WCN which stated: (Resident) has on (left) outer foot by bunion .25 scabbed area, (right) outer knee he has 2 cm x 1 cm partially scabbed abrasion, (left) hip healed flap scar has pin point open area (at) distal end proximal end has .5 superficial open area center or scab has .7 cm scabbed area all areas cleansed, skin prep to all areas, and all covered with [MEDICATION NAME] will (change) (every) three days and prn (as needed). Fax back ASAP (as soon as possible) (fax number) for any other orders. A physician's progress note, dated 10/28/11, stated: "This is a (SIC) evaluation of a [AGE] year old male which is quite frail with multiple medical problems related to a TBI ([MEDICAL CONDITION]) and [MEDICAL CONDITION]. He was recently hospitalized for [REDACTED]. I was asked by the staff to evaluate the patient for wounds that he has developed on his left hip, left foot and right leg. He has a significant sacral decubitus ulcer which is being followed by wound care. The patient recently returned from the hospital. It is felt that the wounds on his left hip are related to excoriation from tape. His hip is taped frequently for padding. The wound on his left foot has eschar and appears to be closed. Unclear duration of that. The nursing staff reports he had a wound on the lateral aspect of his right leg which appeared to be an abrasion which they were leaving open to heal. However they were directed to cover it 24 hours ago. It is now draining clear fluid ... Skin: 1.5 x 1.5 cm superficial, but open sore lateral aspect proximal right leg with a small amount of clear discharge and maceration consistent with a stage II decubitus ulcer ..."Wound right leg: This wound is consistent with a stage II decubitus ulcer. However the history suggests that the wound became more macerated over the last 24 hours and may have originally been a abrasion/early pressure sore." A physician telephone order written 10/30/11 read, "Skin prep to right hip flap old surgery site each shift. Skin prep to bilateral toes every shift per wound team." Another telephone order, dated 10/31/11, stated treatment to right outer knee abrasion: cleanse skin prep to peri-wound-Apply Allereyn (SIC) dressing to area, change every 7-10 days and as needed. [DIAGNOSES REDACTED]." It was signed by the WCN with no indication of a physician or ordering authority. f. Staff Interview Interview with the DON on 10/31/11 at 7:25 a.m., regarding resident #64 and the oversight provided to the WCN as she was a licensed practical nurse. The DON stated that she personally saw resident #64's wounds about once a week and that the resident's physician was coming in to assess the resident. She stated that her expectation was that all residents had a weekly skin assessment performed and that after it was brought to their attention that resident #64 did not have a skin assessment, they did a facility sweep to ensure all residents were up to date on their skin assessments. She stated that the facility had recognized the issue of the skin assessments not being completed about two months ago, but after bringing to their quality assurance (QA) meetings they thought the issue was resolved and moved on to other issues. She stated that she had seen the wounds on resident #64 on 10/27/11, and thought that the knee wound was an abrasion and not a pressure wound. She stated that the wound had not been that bad until the following day due to covering the wound and causing maceration. She stated that the knee wound was caused by friction and therefore was not a pressure wound. When asked if friction and sheer could contribute to a pressure wound, she stated that it could not. She commented that the WCN was accompanied every time she did an assessment by the staff development coordinator (SDC) who was an RN or by the DON, herself, who was a RN. g. Observations The resident was observed on 10/31/11 at 10:52 a.m. being assessed by the medical director, WCN, and clinical consultant. The WCN was showing the medical director the wound on the resident's right knee, and stated that she had seen people, "dig ulcers before," when the medical director asked what had happened to the knee. The medical director stated that it was an accurate assessment that the wound was a stage II. He stated that the resident had a scab on his right foot and that he would not call the left hip area a pressure ulcer. The WCN stated that the resident should have pre

Based on observation, interviews and record review, the facility failed to ensure that one (#8) of 24 sample residents, who entered the facility without pressure ulcers, did not develop pressure ulcers and, when pressure ulcers developed, failed to ensure the resident was provided necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Specifically: Resident #8 developed two pressure ulcers after admission to the facility. The facility failed to ensure the resident's skin breakdown on her right ischium was properly assessed and monitored and interventions ordered to promote healing were implemented. The resident's ischial wound worsened after discovery, and on 12/13/11, the wound was noted to be larger with foul odor. This failed to trigger a change in pressure ulcer management and the wound was observed, on 12/19/11 with copious, foul drainage and with inflamed surrounding tissue. The findings include: 1. Resident #8, age 49, was admitted to the facility on [DATE]. According to the resident's face sheet, her [DIAGNOSES REDACTED]. According to her most recent minimum data set (MDS), dated [DATE], the resident's functional status was documented as totally dependent for bed mobility, transfers, locomotion on and off the unit and toilet use. She was documented as extensive assist for dressing, eating, and hygiene. 2. Pressure Ulcer Development Right Ischium and Right Heel - Facility Response a. Discovery of Wounds A change of condition form, dated 11/29/11, read that two new pressure areas were noted to the right heel and the back of the right thigh (ischium). It stated that a treatment of [REDACTED]. According to the resident's weekly pressure ulcer record, the ischial wound was unstageable, initially being seen on 11/29/11 measuring 4.5 cm x 3.5 cm with scant serosanguineous exudates. The wound bed was documented as black with the surrounding skin being normal and pink. b. Facility Response to Ischial Wound A telephone order (TO), dated 11/29/11, stated to treat the unstageable pressure ulcer to the back of the right thigh (ischium) by applying Santyl to the wound bed and cover with [MEDICATION NAME], changing it every other day and as needed. Another TO dated the same day stated to monitor dressing and surrounding skin daily and chart whether positive or negative and record in nurses' notes if any concerns. 3. Worsening of Pressure Ulcer on Right Ischium a. Wound Documentation On 12/6/11, the weekly pressure ulcer record documented the ischial wound was unstageable at 6.5 cm x 4 cm with scant serosanguineous exudate, the wound bed was black and normal pink tissue noted surrounding the wound. On 12/13/11, the weekly pressure ulcer record documented the wound was 8 cm x 8.5 cm with purulent odor which was noted as foul, along with bright red surrounding tissue. b. Facility Response to Ischial Wound A TO written on 12/6/11, stated to cleanse wound on right posterior thigh (ischium) with wound cleanser, pat dry, apply triple antibiotic ointment (TAO), and cover with large [MEDICATION NAME] every other day and as needed. A TO dated 12/8/11, from the physician stated to change the ischial wound dressing to Santyl cover with [MEDICATION NAME], change daily, and ordered a wound care appointment. 4. Observation of Ischial Wound Observation of the resident, on 12/19/11 at 10:30 a.m., revealed that the resident had a dressing on her right ischium. When the two nurses in the resident's room were asked to elaborate on the type of wound the resident had, they turned the resident and revealed a saturated dressing that was only attached on one out of four sides. The dressing was undated and unsigned; however, the treatment administration record revealed a dressing change on the 6:00 a.m. to 2:00 p.m. shift the previous day. -The brief under the resident was saturated and serosanguineous fluid was puddled on the mattress. The nurse stated that they would have to change the dressing due to the saturation. She removed the dressing and a large black wound was revealed. The wound was approximately 7 cm x 7 cm with a surrounding white tissue and red inflamed area surrounding the white tissue. The wound had a strong, foul odor. -When the nurse was asked about the wound, on 12/19/11 at 10:30 a.m., she stated the wound did not look this bad on the previous shift that she had worked (approximately 48 hours earlier to 12/19/11 at 10:30 a.m.) and that the wound was larger and had a foul odor which it did not have the last time that she had seen it. Observation of wound care, on 12/19/11 at 10:30 a.m., by the two nurses changing the resident's wound dressing revealed the following (cross-reference F441; infection control): -One nurse exited the room to gather the supplies while the other nurse washed her hands. The nurse in the room stated that she would be back and left the room for nine minutes with the resident exposed in her bed, with the door closed. -Both nurses then returned with the supplies, washed their hands and donned gloves. A certified nurse aide (CNA) entered the room and was asked by the nurses to help roll the resident on her left side, exposing the wound on her right ischium. Both nurses were on the right side of the resident's bed, one standing at the resident's shoulders and the other standing at her hip. -The nurse standing at the resident's shoulders was told by the other nurse to roll the resident forward while she pulled the soiled chuck (absorbant pad) and old dressing from underneath the resident. While the nurse was removing the soiled chuck, the CNA on the left side of the bed removed the soiled bed sheet and placed it on the footrest of the resident's wheelchair next to the bed. -The nurse at the resident's hip then placed a clean chuck under the resident, and handed the other nurse a piece of gauze. The nurse at the resident's shoulder sprayed the gauze with wound cleanser, and then wiped the resident's wound three times. -While the nurse at the resident's hip held the resident in place, the other nurse started to apply Santyl (a [MEDICATION NAME] agent) to the [MEDICATION NAME] dressing, but the other nurse stopped her and told her to only apply the Santyl to the wound bed. The nurse at the resident's shoulder took the Santyl and applied it with her gloved finger to the wound bed. She then took scissors and tape from a bag of supplies. She covered the wound with the [MEDICATION NAME] dressing and while the nurse at the resident's hip held the dressing in place, the nurse at the resident's shoulder cut four pieces of tape and covered the dressing. She used the same gloves for the entire dressing, touching the wound, the scissors, the tape and the clean dressing. 5. Facility Failures a. Failure to Perform Dressing Change in a Manner to Prevent Infection See observations above; staff failed to use proper technique to maintain an infection free environment while providing wound care to resident #8. b. Failure to Transcribe Dressing Change Orders Correctly Review of the treatment administration record (TAR) revealed that the orders from 11/29/11 had never been discontinued, and were signed off on 12/12/11-12/15/11. The TAR also revealed that the orders from 12/6/11 had never been discontinued and were signed off through 12/19/11. The TAR further revealed that the order from 12/8/11 had only been written as an FYI (for your information) and the transcription had not related that the treatment was changed from every other day to every day. The TAR revealed that the resident had only received treatment to the ischium on nine out of 13 days. c. Failure to Pursue a Change in Treatment after Worsening of the Wound Identified 12/13/11 Review of the 12/13/11 weekly pressure ulcer record revealed that a box was checked on the record indicating that the physician was notified, but there was no documentation of follow up regarding this call, no order changes, and the wound was not noted as a change of condition. d. Failure to Update Care Plan as Ischial Wound Worsened Review of the 12/13/11 weekly pressure ulcer report indicated that the resident's plan of care was updated, but the plan of care showed no revision for the ischial wound on 12/13/11. Moreover, on 12/16/11, the care plan was noted as reviewed with a statement of, "continue current treatment." e. Failure to Assess and Monitor Wound after 12/13/11 Although an 11/29/11 order read to monitor dressing and surrounding skin daily and chart whether positive or negative and the 12/13/11 weekly pressure ulcer report revealed the ischial wound was larger and had a foul odor, there was no documentation in the nurses' notes regarding the condition of wound on or after this date. For three out of 13 days, there was no documentation on the TAR indicating if the wound was assessed, and for all other days from 12/7/11-12/20/11, including 12/13/11, there was a "+" documented, indicating that there was no problem with the wound or surrounding skin. Moreover, the TAR revealed the resident's ischial wound dressing had been changed 12/19/11, but there was no documentation on the status of the wound in the nurses' notes. 6. Staff Interview The assistant director of nursing (ADON) was interviewed, on 12/19/11 at 11:40 a.m. The ADON said she was aware of resident #8 having an acquired wound on her heel and ischium. She stated that the resident had an appointment at the wound clinic, on 12/30/11, and had been seen by the nurse practitioner and the physician recently. -When asked how the resident obtained the wound on her ischium, the ADON stated that she thought it was the sling used in the Hoyer lift that caused the wound and that they were padding it with towels to decrease the pressure. She further stated that the resident did not often want to shift positions. -She stated that she had seen the wound the previous week during wound rounds (12/13/11) and that it had not appeared to have any drainage or odor at the time (but see documentation above on the 12/13/11 weekly pressure ulcer record). When asked if she thought that the reddened wound could be an indication of infection, she stated that it could be and they would monitor the resident's vitals. -She stated that the nurses had not received any specific training on applying dressing. In a follow-up interview with the ADON, on 12/20/11 at 11:30 a.m., the ADON stated the treatment for [REDACTED]. 7. Action Taken During Survey A TO, dated 12/19/11 at 2:00 p.m., (following the observed wound change above) ordered a culture and sensitivity to be done on the right ischial wound and antibiotics to be started.