Every finding on record at Pueblo Heights Nursing and Rehabilitation

Based on record review, observations and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#1) of three residents reviewed for psychosocial well-being out of seven sample residents.Resident #1 was admitted to the facility on [DATE] with a history of attempted suicide by two self-inflicted gun shots to her head in 2025.When the resident admitted to the facility on [DATE], the hospital discharge orders included a physician's order for suicide precautions at the facility. However, record review revealed the facility failed to implement suicide precautions for Resident #1 and failed to implement a suicidal ideation care plan upon her admission. On 3/4/26 the staff observed Resident #1 throwing things in her room and she told the nurse she wanted to cut herself and die. The nurse practitioner (NP) evaluated Resident #1 and made a recommendation for Resident #1 to be placed on one-to-one supervision for safety and remove any potential threats from Resident #1's room. However, the facility failed to follow the NP's recommendation for one-to-one supervision and remove any potential threats from Resident #1's room (see observations below). On 3/4/26 the facility made a referral to the behavioral health crisis team to have Resident #1 evaluated at the facility.The behavioral health service crisis team evaluated the resident on 3/5/26 and made a safety plan with the resident that included coping skills. However, during the survey, staff were interviewed and were not aware of the safety plan and what interventions should be in place to keep Resident #1 safe from self-harm.On 3/6/26 Resident #1 was found by staff in the morning attempting to wrap cords from her room around her neck. In the evening of the same day, she was observed by the nurse wrapping the telephone and call light system cords around her neck and trying to stab herself in the leg with a pen. However, the facility again failed to implement any person-centered safety measures related to the resident's suicidal attempts.On 3/12/26 Resident #1 continued to make statements of wanting to hurt herself. The resident said she was digging through her nose, with her finger, to scratch her brain to end her life. Resident #1 was evaluated in the facility by a psychologist that day. The psychologist recommended restricting the resident's access to all cords, utensils and sharps. However, observations during the survey revealed Resident #1 continued to have access to pens and cords and the staff were not aware of the recommended safety intervention. The facility failed to update the resident's care plan to include the psychologist's recommendations. Due to Resident #1's ongoing safety concerns and suicide attempt history, the NP evaluated the resident and placed an order for one-to-one supervision again on 3/25/26.However, the NP's order for one-on-one supervision was not initiated. On 3/28/26 Resident #1 was observed by staff to have cutlery and broken glassware from the kitchen in her room and she was throwing plates and cutlery and ripped up personal belongings. On 4/8/26, during the survey, several easily accessible electronic cords were observed in Resident #1's room. Resident #1 was observed unattended sitting in her wheelchair at the nurses' desk. A nearby medication cart had risk items (pens) on the top of the carts and within Resident #1's reach. Specifically, the facility failed to:-Implement physician's orders for safety interventions due to suicide attempts and suicidal ideations for Resident #1; and,-Educate staff on Resident #1's safety interventions. Findings include:I. Findings of Immediate Jeopardy Resident #1 was admitted with a history of two self-inflicted gunshot wounds to her head. Upon admission, the facility failed to assess the resident's risk of suicide. Throughout the resident's admission, she made several statements of wanting to hurt and kill herself. Additionally, the resident was found stabbing herself, scraping her skin off and attempting to wrap a cord around her neck. The NP recommended placing the resident on one-to-one supervision on 3/4/26 and again on 3/25/26, however the facility failed to implement the intervention. The facility failed to develop a person-centered care plan with safety interventions for Resident #1 and educate the staff on the interventions. A. Situation of immediate jeopardyThe facility failed to provide the appropriate level of support and supervision for Resident #1, who had a history of self-harm and had voiced an active threat to harm herself.B. Imposition of immediate jeopardyOn 4/9/26 at 4:50 p.m. the nursing home administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #1 was kept safe after making suicidal ideations.C. Facility plan to remove immediate jeopardyOn 4/10/26 at 8:26 a.m., the NHA provided a plan to remove the immediate jeopardy situation. The plan read: 1. Immediate action On 4/8/26, Resident #1 was placed on 30-minute safety checks by a caregiver until she was discharged to a local acute care center for acute psychiatric care. The staff members that were assigned to complete Resident #1's safety checks were educated by the staff development coordinator on 4/9/26 regarding the resident's risks and recent attempts at suicide utilizing sharp objects, cords and tubing. All cords were secured to the walls leaving nothing loose or free to be unsecured. Resident #1 would not return to the facility. Resident #1's physician and family member were informed of the discharge to the hospital for placement in a mental health facility for ongoing suicide attempts and current attempts to harm herself. The staff assigned to care for Resident #1 were educated by the SSD and the DON on identified resident's specific needs, and the care plan was updated. 2. Identification of others An audit was completed on 4/10/26 by the social services coordinator and the social services consultant to identify if any other resident had current or historical suicidal attempts or thoughts of harming self. From that audit, a total of eight other residents were identified. Of those eight residents, only one resident required the implementation of a safety plan. The residents identified were assessed by the social services director (SSD), the social services consultant, and the director of nursing (DON). Interventions were put into place to keep the identified residents safe. The interventions associated with the one resident's safety plan to ensure the resident's safety included having the resident meet weekly with our psychologist and quarterly with our psychiatrist unless the resident required more frequent visits. If the resident's condition worsened, the plan included for the staff to remain with the resident continuously, notifying the registered nurse (RN)/provider immediately, increasing the resident's observation to one-on-one supervision, removing all potential hazards and initiating emergency psychiatric intervention. 3. Systemic changesOn 4/10/26 the following was completed:The interdisciplinary team (IDT) was educated by the clinical resource team that when an admission referral was received and the admitting resident had current suicidal ideation, the facility must review the referral with the clinical resource team and the medical director to make sure that the facility could meet that resident's specific personal safety needs. The IDT was educated by the clinical resource team on implementing a safety care plan and then updating each care plan to reflect the changes in the residents' needs as applicable. The IDT and all nursing staff were educated by the DON and the SSD on how to review all new admission orders thoroughly, within 72 hours, to ensure all orders have been captured and implemented. The DON educated all nursing staff on following physician's orders, and if they have questions or concerns about any order, they must notify the provider and document the reasons for the concern. All staff were educated by the DON and the SSD on suicidal ideation monitoring and prevention. All staff were educated that if at any time they see or hear of any resident attempting or voicing suicidal or self-harming ideations, they must notify the NHA, the DON and/or the SSD immediately. The staff were educated by the DON and the SSD on timely, appropriate and person-centered interventions for all residents identified with suicidal ideations or thoughts of harming themselves. This will be completed upon admission, quarterly and annually or with changes of condition that identify suicidal ideations. The education will consist of first and foremost making sure the resident is safe and not left alone until the resident can be discharged to a safe environment. Education also includes identifying if the residents have a plan to harm themselves and if they are capable of carrying out that plan, so that the facility can develop a safety plan to meet the residents' specific safety needs. The psychological services group was educated by the NHA that when they identify a resident that is expressing suicidal or self-harm ideations, they must inform the NHA, DON and or the SSD immediately so that an appropriate safety plan can be initiated by the IDT. The NHA, the DON, and the SSD were educated by the clinical resource team on the importance of following up on all recommendations from psychological services and/or physicians/providers. Education was provided to staff regarding when a resident had active suicidal ideations, the nursing staff would be educated on the resident's specific safety plan s and interventions by the DON and/or the SSD via the care plan, Kardex (staff directive tool) and the electronic medical record (EMR) communication dashboard.The nutrition department would be educated by the dietary manager and would utilize meal tickets to communicate specific safety needs related to utensils. Changes in resident mood and behavior would be discussed by the IDT at the facility's daily stand-up meeting. Interventions would be developed and added to residents' care plans, with the involvement of all front-line staff. 4. MonitoringThe SSD/designee will conduct chart audits to ensure that care plan interventions are in place for any residents with mood, behavior or psychosocial indicators. The SSD or designee will conduct bi-weekly audits of interventions that are pertinent to the resident's safety plan. The NHA, the DON and the SSD will monitor to ensure the staff understand the precautions, recommendations, and/or approaches outlined in the resident's safety plan and that they are being implemented. 5. Removal of immediate jeopardyBased on the facility actions taken and described in the plan, the above plan was accepted and the immediate jeopardy was removed on 4/10/26 at 8:26 a.m. However, record review and interviews revealed deficient practice remained at a D level, no actual harm with potential for more than minimal harm.II. Facility policy and procedureThe Suicide Threat policy, revised December 2007, was provided by the NHA on 4/13/26 at 9:51 a.m. The policy read in pertinent part,Staff shall report any resident threats of suicide immediately to the nurse supervisor or charge nurse.The nurse supervisor or charge nurse shall immediately assess the situation and shall notify the charge nurse/supervisor and/or director of nursing of such threats.A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident.After assessing the resident, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction for the physician.All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately.As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains at the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present.Staff shall document details of the situation objectively in the resident's medical record.III. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE] and discharged to the hospital on 4/9/26 (during the survey). According to the April 2026 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI), depression, post-traumaic stress disorder (PTSD), epilepsy (seizure disorder), suicide attempt by gun shot to the head, left-sided paralysis, pulmonary embolism (a blocked artery in the lungs) and frequent falls.The 3/6/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. Resident #1 was not ambulatory and used a manual wheelchair for mobility. Resident #1 required partial or moderate assistance from staff for toileting hygiene, upper body dressing, rolling left to right in her bed, sitting to lying, lying to sitting and transferring from the bed to a chair and to the toilet. The assessment identified Resident #1 had verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others for one to three days during the assessment look-back period.B. Resident interview and observationOn 4/9/26 at 1:25 p.m. Resident #1 was in the hallway outside of her room sitting in her wheelchair between two medication carts. The medication cart had pens on it that were accessible to Resident #1. Resident #1 was interviewed on 4/9/26 at 1:55 p.m. in her room. During the interview, cords for the telephone, call light system, electric bed and the wall-mounted television were observed to be within reach of Resident #1. Resident #1 said that she felt happy at the facility and enjoyed sitting outside. She said she was unhappy because she had to go outside to the same area where other residents went to smoke. Resident #1 said she had made previous attempts to end her life and said she thought about killing herself or asking the physician for assisted suicide. Resident #1 said her thoughts of ending her life were triggered by her need to rely on others for help with her activities of daily living (ADL). Resident #1 said she had asked staff for work to do in the facility and thought she would be helpful to check on residents that could not speak for themselves, but she said she had not heard anything back from staff.C. Record review1. Care planThe [NAME]-Brown Safety Plan (standardized safety tool), created on 1/4/26 and updated on 3/12/26 was provided by the corporate resource nurse on 4/8/26 at 3:25 p.m. The corporate resource nurse said the safety plan was created by the psychiatrist provider. The safety plan included the following pertinent safety steps: Step one warning signs: not feeling supported by your brother, feeling lonely and isolating yourself, an increase in depressed mood, an increase in crying, not feeling safe or happy where you are, and an increase in pain. Step two internal coping strategies: things I can do to take my mind off my problems without contacting another person: music, reading, spending time with a dog, listening to western music, riding an exercise bike in therapy. Step three people and social settings that provide distraction: providing a list of names and telephone numbers, places: being outdoors in the sun 10 to 15 minutes a day. Step four people whom I can ask for help during a crisis: listing of names and contact information. Step five professions or agencies I can contact during a crisis: listing of names and agencies and contact information. Step six making the environment safer (plan for lethal means safety): patient does not have access to guns; patient lives in a 24/7 nursing and rehabilitation facility since 2/27/26, patient likes the staff and facility, patient has some chronic suicide ideations, resident has no plan to kill herself, she gets lonely, is in pain, and would like more support from her family, brother reports family tries to visit patient daily. Staff at the facility report they will restrict access to all cords, utensils, and sharps. They administer medications and check on the patient and give support. They will have the patient see the facility psychiatrist. The patient was encouraged to do a care plan with staff and family at the nursing home.-However, the safety plan was not implemented into Resident #1's comprehensive care plan (see record review below) and staff were not aware of the safety care plan (see interviews below).The cognitive impairment baseline care plan, initiated 2/27/26, revealed Resident #1 was alert, cognitively impaired and forgetful related to a traumatic brain injury. However, there were no interventions identified for this care area.The psychotropic medication baseline care plan, initiated 2/27/26, identified Resident #1 was prescribed a psychotropic medication (Seroquel) and had no adverse effects. The care plan identified the facility nurse completed a medication reconciliation with the resident and/or representative upon admission. The safety risk baseline care plan, initiated 2/27/26, identified Resident #1 had a history of falls three weeks prior to admission. There were no interventions identified for this care area.-Review of Resident #1's baseline care plan, did not reveal any person-centered safety interventions related to the resident's history of suicide attempts or as ordered by the hospital physician upon discharge (see record review below).The comprehensive care plan, initiated 3/3/26, revealed Resident #1 reported she had traumatic incidents in her past. The care plan documented Resident #1 had always dealt with depression and anxiety and had attempted suicide by shooting herself in the head. The care plan documented Resident #1 exhibited increased triggers around discussing suicidal ideations, depression and had increased triggers at night time. Pertinent interventions included avoiding sudden movements, loud voices, or rushed care, crisis services through health solutions, encouraging participation in individualized activities based on the resident's interests, such as art or painting, crafts, gardening, and science, staff was to introduce themselves each time and explain what they were doing for her before care, monitoring the resident's responses to ensure the animal interaction provided comfort and reduced anxiety (initiated 3/5/26), contacting health solutions crisis and providing active listening (initiated 3/23/26).On 4/8/26 at 2:11 p.m. the clinical resource nurse provided a revision to Resident #1's comprehensive care plan. The revisions identified Resident #1 had traumatic incidents in her past. The care plan documented the resident's triggers included major life changes, such as changes in the environment, feeling lonely and feeling unsupported by her brother. Updated interventions included encouraging Resident #1 to utilize internal coping skills, such as music of choice, reading, spending time with animals if available, riding the exercise bike in therapy and following up with the pain management clinic as needed, showering twice a week per preference and going outside daily as weather permitted.The major depressive disorder with psychotic features care plan, initiated 3/3/26, revealed Resident #1 had complex behaviorial and emotional symptoms that included withdrawl, yelling, cursing, depressive statements and chronic expressions of suicidal ideation. The care plan documented the resident had a history of self-harm. The care plan identified that Resident #1 experienced delusional thoughts and believing her children or grandchildren had been kidnapped. The care plan revealed the beliefs lead to intense panic, fear and emotional distress where Resident #1 may become increasingly agitated, verbally escalated and difficult to redirect. Pertinent interventions included offering consistent staff interaction daily at preferred times, providing brief, simple reassurance, coordinating with activities staff for structured but low-stimulation programs, scheduling regular family calls/visits when possible, providing small group activities to reduce overwhelmness, teaching simple grounding exercises, validating feeling without validating delusion (initiated 3/3/26), immediately reporting suicidal ideation statements or behavior changes to the nurse and the mental health provider, mainting a safe environment and removing harmful items if risk increased, conducting frequent emotional status checks and documenting mood and statements and redirecting Resident #1 to another activity or topic when agitation began. The care plan documented Resident #1 was receiving behavioral health services and loved the rodeo and talking about her grandchildren (initiated 3/6/26).2. Progress notes and assessmentsThe 2/27/26 hospital discharge summary revealed the physician's orders for discharge included suicidal precautions, continuing home Seroquel 150 milligrams (mg) nightly and sertraline (antidepressant) 100 mg daily. The resident was discharged to a skilled nursing facility.The 3/3/26 nurse progress note, documented at 6:20 a.m., revealed Resident #1 was frantic during the previous night. The progress note documented Resident #1 was yelling at staff and throwing things in her room. The nurse documented the physician was notified and staff would continue to monitor Resident #1. The 3/3/26 physician progress note, documented at 8:00 a.m., revealed the physician evaluated Resident #1 and documented Resident #1 had a history of a gunshot wound to her head that required a right-sided craniotomy. Resident #1 had left-sided paralysis. The physician documented Resident #1 had no acute distress, had recurrent major depressive disorder with behaviors and was stable with a good affect. The physician gave a new order for trazodone (antidepressant), increased the Seroquel to 150 mg extended release at bedtime and ordered hydroxyzine (antihistamine) every eight hours as needed for 14 days.The 3/4/26 nurse progress note documented at 7:22 a.m. (late entry) the NP was notified that Resident #1 made statements of wanting to cut herself and wanting to die. The note revealed the psychiatrist was notified for a psychiatrist evaluation. The note revealed a certified nurse aide (CNA) and the DON were alerted that Resident #1 needed one-on-one supervision for safety due to Resident #1's history of attempted suicide. -There was no documentation of the psychiatrist's response to the notification.The 3/4/26 nurse progress note, documented at 7:27 a.m., revealed Resident #1 was crying, throwing things in her room, spilling fluids and knocking over her table. The progress note documented Resident #1 said she wanted to die and did not want to live like this anymore. The progress note documented Resident #1 denied having a plan or intent for suicide and told the nurse she did not want to be here anymore. The nurse progress note documented the day shift nurse put in a request for a psychiatrist evaluation as soon as possible and staff would continue to monitor Resident #1.The 3/4/26 nurse progress note, documented at 9:13 a.m., revealed Resident #1 was restless, throwing everything off her table, yelling and removing her clothing.-However, there was no documentation indicating the facility implemented safety interventions. The 3/4/26 IDT risk review note, documented at 10:26 a.m., revealed Resident #1 was being monitored as a new admission. The resident had a small skin blister, discolored skin on her upper extremities and had a small scratch on her right wrist. The IDT recommended interventions to continue with the current plan of care. -There was no documentation the IDT reviewed the status of the resident's psychiatric evaluation and one-to-one care needs for safety. The 3/4/26 behavior note, documented at 11:48 a.m., revealed the MDS nurse sat with Resident #1 for over an hour. The progress note revealed Resident #1 had verbal outbursts concerning her family and was redirectable by the MDS nurse The progress note documented Resident #1 laughed and joked with the staff.The 3/4/26 social services assistant progress note, documented at 1:05 p.m., revealed Resident #1 was found in her room with her pants off and spilled chocolate milk on the floor. The social services assistant documented Resident #1 wanted her pants on and seemed calm. The progress note revealed the resident was tearful and sad about her dog. The social services assistant documented she and the nurse redirected Resident #1. The social services assistant documented Resident #1 talked about her first suicide attempt and how she hated that she was not successful. The progress note revealed the social services assistant assured Resident #1 that she had a higher purpose and she was glad Resident #1 was still here. The social services assistant offered activities, such as science projects, taking the resident outside to the garden and going on walks. The social services assistant documented Resident #1 could be redirected and that redirection usually worked to alter her sad thinking.The 3/4/26 social services assistant progress note, documented at 1:15 p.m., revealed a suicide lethality evaluation was completed with Resident #1. The progress note revealed the social services assistant went over coping mechanisms with Resident #1 to help alter her sad thoughts or when she was in crisis. The progress note revealed Resident #1 used talking to staff, reading, going outside and science projects as coping mechanisms. The progress note revealed a referral was sent to the behavioral health provider on 3/4/26 and a referral was placed for a psychiatric evaluation.The 3/4/26 NP progress note, documented at 1:28 p.m., revealed Resident #1 was evaluated for suicidal statements. The NP documented she made a referral for Resident #1 to behavioral health services as soon as possible and the nurse removed any potential threats from Resident #1's room. The progress note documented the nursing staff would try to get a one-on-one physician's order for frequent monitoring.-However, observations during the survey revealed loose cords remained in the resident's room (see observations above). The 3/4/26 social services assistant progress note, documented at 1:38 p.m., revealed the mobile mental health crisis team was notified to evaluate Resident #1 due to Resident #1 speaking about suicide and suicide attempts. The progress note documented the mental health provider assessed Resident #1 at the facility and there was no immediate reason to admit Resident #1 (the progress note did not indicate where an admission was considered). The progress note documented Resident #1 did not have access to sharp or lethal objects, and the mental health provider completed a safety plan with Resident #1. The progress note revealed the mental health provider went over coping skills such as reading, talking with staff or her brother and going outside or for a walk with staff. The progress note documented the social services assistant received a copy of the safety plan that was provided to Resident #1. The social services assistant documented Resident #1 was considered a low risk for suicide and would be monitored through the day and the night.The 3/5/26 diagnostic assessment revealed the assessment was completed at the facility by a licensed psychologist. The assessment revealed Resident #1 was evaluated on an emergency basis for suicidal ideation and was referred for concerns of depression, tearfulness, anxiety, worry, confusion, delusions, high risk behavior, suicidal ideation and history of suicide attempt. The assessment revealed Resident #1 reported two previous suicide attempts by gunshot to the head and the last attempt at suicide was last summer (2025). The resident had daily thoughts of wishing to be dead. The assessment revealed Resident #1 told the psychologist she had daily suicidal ideations but denied having a plan. Resident #1 told the psychologist if she were to kill herself, it would be by gunshot, hanging herself or stabbing an object into her head. The psychologist recommended to the facility to schedule visits with the resident's grandchildren, keeping her room close to the nurses' station for monitoring, encouraging family to visit, engaging her in activities with others, capitalizing on her strengths in teaching, reaching out to emergency services if intent or plan was vocalized and and utilizing redirection, calming techniques and distraction when agitated. The assessment revealed Resident #1 was included in formulating a treatment plan that included adressing anxiety, behavior-conduct problems, confusion, delusions/hallucinations, hopelessness, marital/family problems, nervous/worried, sleep disturbance, tearfulness, worthlessness, agressive behavior and suicidal thoughts. Additional recommendations by the psychologist included developing and implementing a behavior plan to reduce the resident's affective and/or cognitive symptoms and providing individual therapy to reduce the resident's affective and/or cognitive symptoms. The assessment revealed the psychologist reviewed the plan with the facility's SSD and the facility was monitoring Resident #1 with a plan in place.-However, review of Resident #1's care plan did not reveal person-centered safety interventions (see care plan above) and the staff were not aware of the safety interventions (see staff interviews below).The 3/6/26 SSD progress note, documented at 9:44 a.m., revealed the SSD was notified regarding Resident #1's concerning behaviors of attempting to wrap items around her neck. The SSD documented mental health services were contacted regarding the behavior concerns and crisis services were notified. The 3/6/26 SSD progress note, documented at 11:07 a.m., revealed mental health services spoke with Resident #1 at the facility. The progress note revealed Resident #1 declined any thoughts or attempts of suicide ideation and stated she wanted her family to visit more. The 3/6/26 SSD progress note, documented at 11:10 a.m., revealed mental health services gave Resident #1 a crisis number and the SSD reminded Resident #1 of the safety plan which included communicating with staff about wants and needs regarding her care.The 3/6/26 nurse progress note, documented at 6:03 p.m., revealed Resident #1 had major behaviors during the shift. The progress note revealed that at the beginning of the shift, Resident #1 was wrapping the telephone cord and call light cord around her neck and needed constant supervision. The progress note revealed the crisis center was called and two women came to the facility to speak with Resident #1. The progress note revealed Resident #1 was then calm and cooperative until dinner time. At dinner time, Resident #1 began to have behaviors, where she entered the dining room hollering that she was in prison and tried to pull her hair. The nurse progress note documented Resident #1 then started to stab her leg with a pen from the front lobby. The nurse progress note documented Resident #1 was not redirected and was kicking chairs and cursing. The progress note revealed Resident #1 exhibited unsafe behaviors and the charge nurse was notified to assist with Resident #1. The progress note revealed staff would continue to monitor Resident #1. -However, the 3/4/26 NP progress note documented the nurse had removed all threats from the resident's room (see NP progress note above).The 3/7/26 at 3:31 a.m. nurse progress note (which was documented as a late entry) documented that on 3/6/26 at 6:15 p.m., Resident #1 left the facility by ambulance for a mental health evaluation. The resident was evaluated in the emergency department and did not meet criteria for an emergency M1 hold (an involuntary, 72-hour emergency mental health hold). Resident #1 returned to the facility on 3/7/26 at 3:21 p.m. Resident #1 was diagnosed at the emergency department with a urinary tract infection and had a physician's orders for antibiotics. The note documented the resident's Seroquel was increased to 50 mg in the morning for anxiety. -Review of Resident #1's EMR did not reveal the facility reviewed the resident's care plan after the 3/4/26 incident to ensure the effecti

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, bathrooms and hallways received necessary maintenance repairs. Findings include: I. Observations and resident interviews Observations throughout the survey were conducted on 7/15, 7/16, 7/17 and 7/18/24 and revealed the following: A. Individual resident rooms room [ROOM NUMBER] had a leaking toilet and the tile on the bathroom floor on the corner edge under the sink was coming off the floor. The bathroom smelled like urine and mildew. The towel rack in the bathroom was not labeled. The bathroom was shared with another resident. In room [ROOM NUMBER], the soap dispenser in the bathroom was broken and the resident had hand sanitizer to wash her hands. -The resident said she reported the broken soap dispenser to staff two weeks ago and was waiting for it to be fixed. The resident who resided in room [ROOM NUMBER] said every time it rained, water would come in from the bottom of the double doors in his room that led out to the courtyard. -There was no weatherstripping at the bottom of the doors to prevent water from coming in. room [ROOM NUMBER] was hot and there was no air conditioner in the room. The resident had a fan on but it was still hot. The resident said he was sweating and even with the fan he had on he said he was still hot. The heater vent in room [ROOM NUMBER] was coming off the wall by the window, the wall behind the head of the bed was patched and needed to be painted. One of the individual slats was broken and missing. The blinds in room [ROOM NUMBER] had one of the individual slats that was broken and missing. There was a broken tile as you entered the bathroom in room [ROOM NUMBER]. B. Hallways There was an outlet that was coming off the wall in the west hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. The baseboard was coming off the wall in the east hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. C. Shower rooms Observations of the four shower rooms were completed on 7/16/24. -The big shower room down the east hallway the paint was chipping as you entered the shower. The transition floor piece as you entered the bathroom from the hallway was missing and there was a gap. -The big shower room down the west hallway had three wet towels left on the floor of the shower. II. Facility environmental tour and staff interviews An environmental tour was conducted on 7/18/24 at 10:05 a.m. with the maintenance assistance (MA). Regarding all observations above, the MA said he was going around and fixing/repairing all the items that needed repaired or fixed while on survey. He said he walked the facility every day he was there to look for items that needed to be repaired. He said patching the walls and painting was an ongoing project. He said he saw the areas that needed to be repaired and was working on getting the repairs done. The MA said he was notified of work orders by a work maintenance program that staff had access to. He said the program sent him the work orders. He said he looked at the work orders everyday. He said the staff would also notify him in person on what needed fixing. He said he was working on getting all the repairs completed. He said he focused on one hallway at a time and, depending on how bad some rooms were, he would get to them first. The MA said the maintenance department was the only department who did walk-throughs of the building to determine what needed to be fixed. He said if he ran into any issues he would notify the administrator.

Based on observation, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on two of four hallways. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were implemented and followed for residents with wounds and/or indwelling medical devices; -Ensure residents' laundry was appropriately covered during transportation; and, -Ensure housekeeping used the proper cleaning method to sanitize a residents' rooms. Finding include: I. Failure to implement and follow EBP for residents with wounds and/or indwelling medical devices A. Facility policy and procedure The Enhanced Barrier Precautions policy, revised 12/2022, was received by the nursing home administrator (NHA) on 7/18/24 at 5:16 p.m. It documented in pertinent part, It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms. Prompt recognition of need: Clear signage will be posted on the door or wall outside of the residents' room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Initiation of EBP: an order for EBP will be obtained for residents with any wound and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO). Implementation of EBP: make gowns and gloves available immediately outside of the resident's room. High contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. B. Resident observations and interviews On 7/15/24 at 4:35 p.m. Resident #82 was observed in his room. He had a foley catheter drainage bag hanging on his bed. -There were no signs for EBP hanging outside the resident's room or on the door (see facility policy above). -There was no PPE located outside the resident's room (see facility policy above). Resident #82 was interviewed on 7/15/24 at 4:47 p.m. Resident #82 said staff helped him with many cares since he broke his shoulder and leg. He said they did bed baths, changed his briefs, emptied his foley catheter drainage bag, dressed him and got him up to the wheelchair. He said the staff wore gloves, but not gowns, when providing his care. He said he had had an indwelling catheter for a long time. On 7/18/24 at 8:45 a.m. Resident #84 was observed lying in bed. Licensed practical nurse (LPN) #2 and RN #3 were preparing to perform the resident's wound care. The door to the resident's room had signs indicating the resident was on EBP. -LPN #2 and RN #3 entered the resident's room without donning gowns. RN #3 turned Resident #84 to one side while LPN #2 removed the resident's old wound dressing. LPN #2 cleansed the wound and applied a new dressing to the wound. LPN #2 and RN #3 said they did not know why the resident was on EBP. C. Staff interviews The infection preventionist (IP) and director of nursing (DON) were interviewed on 7/18/24 at 10:00 a.m. The IP said any resident with open wounds or indwelling medical devices, such as a gastrostomy tube (feeding tube), intravenous device (IV), or catheters, would be placed on EBP. He said the residents should have a sign outside their door and a cart with PPE outside their room, which was how the facility chose to identify residents who were on EBP. Certified nurse aide (CNA) #2 was interviewed on 7/18/24 at 11:45 a.m. CNA #2 said residents on EBP were supposed to have a sign outside their door. She said the sign was how she knew that the resident was on EBP and she would put a gown and gloves on before providing resident care. She said if the resident did not have a sign outside their door, she would not put a gown and gloves on unless told otherwise CNA #2 said she had not been told Resident #82 was on EBP. Registered nurse (RN) #1 was interviewed on 7/18/24 at 11:50 a.m. RN #1 said residents were on EBP if they had a MDRO and if they had a wound or indwelling medical device, even if they did not have a MDRO. He said he put a gown and gloves on while providing care for residents on EBP II. Failure to use proper cleaning method when sanitizing residents' rooms A. Facility policy and procedure The 5-step Daily Patient Room Cleaning Guide, undated, was received from the housekeeping director (HSKD) on 7/17/24 at 4:45 p.m. It documented in pertinent part, The purpose is to show housekeeping employees the proper cleaning method to sanitize a patient's room or any area in a healthcare facility. Horizontal surfaces include disinfecting tabletops, headboards, window sills and chairs. Vertical surfaces are not wiped down daily but must be spot cleaned daily. Walls especially by trash cans, light switches and door handles will need special attention. B. Observations Housekeeper (HSK) #1 was observed on 7/16/24 at 12:19 p.m. HSK #1 was cleaning resident rooms on the [NAME] hallway. He cleaned the bedside table and television for bed A in room [ROOM NUMBER], switched out rags and cleaned the bedside table for bed B. He then cleaned the sink and paper towel dispenser. He cleaned the bathroom and swept the bedroom floor. After cleaning in room [ROOM NUMBER], HSK #1 then moved on to room [ROOM NUMBER]. He cleaned the bedside table for bed A. He said he was not going to clean the bedside table for bed B because that resident did not eat in the room much. He cleaned the sink and paper towel dispenser. He cleaned and mopped the bathroom. -HSK #1 swept and mopped the entire bedroom using the same dust mop and damp mop he had just used to sweep and mop the bathroom floor. -HSK #1 failed to clean the high-touch surfaces in the residents' rooms and mop the bedroom floor in room [ROOM NUMBER]. -HSK #1 failed to treat room [ROOM NUMBER] as separate areas when using the damp mop. -HSK #1 failed to clean bed B's bedside table in room [ROOM NUMBER]. HSK #2 was observed on 7/17/24 at 11:04 a.m. cleaning resident rooms on the East hallway. He cleaned the bedside table and television for bed A in room [ROOM NUMBER], switched out rags, and cleaned the bedside table for bed B. He then cleaned the sink and paper towel dispenser. He cleaned the bathroom and swept and mopped the bedroom floor. He then moved on to room [ROOM NUMBER]. He cleaned the bedside table for bed A, switched out rags, and cleaned the bedside table for bed B. He cleaned the sink and paper towel dispenser. He cleaned and mopped the bathroom. -HSK #2 swept and mopped the entire bedroom using the same dust mop and damp mop he had just used to sweep and mop the bathroom floor. -HSK #2 failed to clean the high-touch surfaces in the residents' rooms. -HSK #2 failed to treat rooms #33 and #31 as separate rooms when using the damp mop. C. Staff interview The housekeeping director was interviewed on 7/17/24 at 4:45 p.m. He said when cleaning a resident room with two sides, it should always be treated as two separate rooms. He said high touch surfaces should be cleaned daily. He said high touch surfaces included call lights, door handles, light switches, and phones. III. Failure to ensure residents' laundry was appropriately covered during transportation A. Facility policy and procedure The Infection Prevention and Control Program policy, revised 12/2022, was received by the NHA on 7/15/24 at 10:00 a.m. The policy documented in pertinent part, The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Clean linen shall be delivered to the resident care units on covered linen carts with covers down. B. Observation An unidentified HSK was observed on 7/17/24 at 12:03 p.m. The HSK was dropping personal laundry off to residents' rooms. The laundry transport cart was overflowing with laundry and only the top part of the cart had a white sheet covering it. The bottom of the cart was enclosed with bars, but there were spaces between the bars with exposed laundry. The HSK took the sheet off the top of the laundry transport cart to expose the laundry, took out clothing, and walked into the resident's room to hang it up. She came out, moved the cart to the next room and took clothing out to give to the next resident. The HSK failed to replace the sheet over the remaining clean laundry as she continued delivering the laundry to residents' rooms. C. Staff interview The HSKD was interviewed on 7/17/24 at 4:45 p.m. He said clean linen and residents' laundry should always be covered during transportation.

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 9.68%, or three errors out of 31 opportunities for error. Finding include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. ,d+[DATE], retrieved on [DATE], Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Medication Administration policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 5:21 p.m. The policy read in pertinent part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection, keep medication cart clean, organized and stocked with adequate supplies, identify expiration date. If expired, notify the nurse manager, correct any discrepancies and report to the nurse manager. III. Manufacturer's Guidelines According to the manufacturer's guidelines for insulin lispro (Humalog), retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/,d+[DATE]s172,205747s008lbl.pdf, Humalog is a rapid acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus. Administer Humalog by subcutaneous (under the skin) injection within 15 minutes before a meal or immediately after a meal. According to the Humalog pen insulin lispro injection instructions retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/,d+[DATE]slr046_humalog_lbl.pdf, The needle must be changed and the pen must be primed before each injection to make sure the pen is ready to dose. Performing these steps before each injection is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. According to the manufacturer's guidelines for artificial tears (polyvinyl alcohol 1.4%), retrieved on [DATE] from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=736f9577-d8ff-45c,d+[DATE]-dfdb7193492f, Artificial tears are for use in the eyes as a lubricant to prevent further irritation or to relieve dryness. To avoid contamination, do not touch the tip of the container to any surface. Replace cap after using. IV. Observations and interviews On [DATE] at 3:25 p.m. licensed practical nurse (LPN) #1 was administering medication to Resident #290. Resident #290 had a physician's order for insulin lispro subcutaneous solution pen-injector 200 unit/milliliter; inject three units subcutaneously before meals for diabetes. The insulin should not be given if blood glucose is lower than 150 milligrams/deciliter (mg/dl). After checking the resident's blood sugar, LPN #1 determined that three units of insulin lispro were required. LPN #1 drew up three units in the insulin pen and cleaned the resident's arm with an alcohol swab. -Before she injected the insulin, LPN #1 was stopped from administering the insulin. LPN #1 said she should have primed the insulin pen prior to drawing up the three units. Resident #290 had a physician's order for artificial tears ophthalmic solution 1 %, two drops in both eyes four times a day for dry eyes. LPN #1 took the eye drops from the medication cart and placed them in her pocket. She went to the resident's room, administered an oral medication and insulin. She then returned to her medication cart. Upon prompting, she said she forgot to administer the eye drops. She returned to the resident room and administered the eyedrops. On [DATE] at 9:27 a.m. registered nurse (RN) #1 was preparing medications for Resident #5. The resident had an order for calcium with vitamin D tablet ,d+[DATE] milligrams (mg)-unit. RN #1 said the facility did not have the prescribed dose in stock currently and he would have to contact the transportation coordinator (TC), who ordered the over the counter medications. He did not administer the calcium with vitamin D and made a progress note that it was unavailable. He contacted the TC but did not notify the physician. V. Additional staff interviews LPN #1 was interviewed on [DATE] at 3:30 p.m. She said insulin pens should be primed prior to administering the insulin. She said she did not prime the insulin pen prior to attempting to administer the insulin. LPN #1 said she forgot to administer eye drops to Resident #290. She said she would have noticed the eyedrops were in her pocket at some point in the day. The TC was interviewed on [DATE] at 10:39 a.m. She said she was responsible for tracking over the counter (OTC) medications. She said if a new OTC medication was ordered she would go to a local store and purchase it, then add it to her next supply order. The TC said she was not notified the facility was out of stock of the calcium with vitamin D ,d+[DATE] mg-unit until that day ([DATE]). She said the medication was on backorder and would not be available until [DATE]. The TC said she would pick the medication up at a local store today ([DATE]) to cover until the stock supply came in. The director of nursing (DON) was interviewed on [DATE] at 2:54 p.m. The DON said all medications should be administered according to the physician's orders. She said when an OTC medication was unavailable, the nurse should notify the TC immediately and the physician for clarification. She said it was easy to go to the local store to pick up an OTC medication. The DON said insulin pens should be primed before drawing up a dose of insulin. She said priming the insulin pen was important to ensure the resident received the correct dose of insulin. The DON said nurses should not put medications in their pocket due to infection control concerns.

Based on observations, record review and interviews, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value and were palatable in taste, texture and temperature. Specifically, the facility failed to ensure the resident's food was palatable in taste, texture and temperature. Findings include: I. Facility policy and procedure The Food Preparation Guidelines policy, revised 1/2023, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:20 p.m. It read in pertinent part, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include using spices or herbs to season food in accordance with recipes, serving hot foods/drinks hot and cold foods/drinks cold and addressing resident complaints about foods/drinks. II. Resident interviews Resident #41 was interviewed on 7/15/24 at 9:33 a.m. Resident #41 said the food was bad. She said the vegetables were mushy. She said she tried to eat a low carbohydrate diet but it was difficult with the facility menu. Resident #25 was interviewed on 7/15/24 at 10:26 a.m. Resident #25 said the food was cold. She said the facility served the same thing (burritos) every day. She said she had talked to the dietitian and it did not help. She said the alternative menu consisted of the same food and it did not change. Resident #64 was interviewed on 7/15/24 at 11:20 a.m. Resident #64 said the food tasted terrible. He said the food had no seasoning to it and was tough to chew. Resident #53 was interviewed on 7/15/24 at 11:33 a.m. Resident #53 said the food was bad. He said the food was always too spicy. He said the facility served a lot of potatoes. He said the sandwiches only had one slice of meat on them. Resident #51 was interviewed on 7/15/24 at 4:01 p.m. Resident #51 said sometimes the food was good and other times the food tasted bad. She said she ordered off the alternative menu all the time. She said the alternative menu could stand to be updated by adding new food items because she was tired of the options on the alternative menu. Resident #59 was interviewed on 7/15/24 at 4:27 p.m. Resident #59 said the food was terrible and was always cold. Resident #47 was interviewed on 7/15/24 at 4:53 p.m. Resident #47 said the food was undercooked. He said he had found hair in his food and the bread was moldy. III. Observations On 7/17/24 during a continuous observation of the dinner meal preparation and service in the main kitchen, beginning at 2:20 p.m. and ending at 5:52 p.m., the following was observed: At 3:52 p.m. the cook (CK) poured butter on the grill and began cooking the peppers on the stove to grill them. He said once the peppers were softened he would add the onions. At 3:58 p.m. the CK added the onions. He said he did not add any seasoning to the bell peppers and onions. At 5:52 p.m. the last tray was plated and placed in the insulated meal tray transport box. The insulated box was taken down the east hallway and the meals were served to the residents IV. Test tray On 7/17/24 at 6:06 p.m. a test tray was evaluated by four surveyors immediately after the last resident had been served their room tray for dinner. The regular diet test tray consisted of a sausage and veggie skillet, scalloped potatoes, garden salad with dressing, a roll and mandarin oranges. -The temperature of the ground sausage and peppers was 100.4 degrees Fahrenheit (F). The ground sausage and peppers felt lukewarm when consumed -The temperature of the scalloped potatoes was 119 degrees F. The scalloped potatoes were dry and hard as the potatoes were not cooked all the way through. The potatoes were bland. V. Record review The food committee meeting minute notes were received from the NHA on 7/17/24 at 12:35 p.m. The 2/9/24 food committee meeting minute notes documented one resident wanted less Spanish food and another resident requested more fruit. The residents were informed that due to the cold weather, fresh fruit was hard to get. The outcome documented the residents were overall satisfied with the dining experience. -The 2/9/24 food committee notes did not include how the facility was going to handle the suggestion of offering less Spanish food on the menu. V. Staff interviews The dietary manager (DM) was interviewed on 7/18/24 at 12:03 p.m. The DM said when he was informed that a resident had a concern or issue with the foods being served to them, he would talk to them and find out what they did not like. He said he would offer the resident something else to eat. He said the certified nurse aides (CNA) were responsible for taking the resident's meal orders. He said the CNAs asked the residents if they wanted what was being served on the ticket and, if not, then the CNAs would offer something from the alternative menu. The DM said the kitchen staff received the meal tickets two to three hours before meal service. He said all the residents should have an alternative menu in their room so it was readily available to them. The DM said he had received some food concerns regarding temperatures from the hallway trays. He said residents had complained about the food being delivered to their rooms cold as he only had insulated carts. He said some of the complaints were the residents did not like some of the foods being served. He said he had not heard of any complaints about the food being bland. He said he had a plan in place and was trying to get more residents to come and eat in the dining room. The DM said the food committee met once a month. He said the monthly meeting had been effective but he said he would like to get more residents to attend the meetings. He said he tried to promote the food committee to encourage more residents to attend. He said he was in charge of addressing the food concerns. He said as soon as he heard of a food complaint, he addressed them immediately. He said when he was told about a concern, he would ask the residents and the resident would tell him that everything was fine. He said he told the residents if they had a concern to let him know so he could fix the problem. He said if he did not know what the problem was he could not fix it. He said that he did not get many food concerns. The DM said he had not heard of any concerns about the food being over cooked, vegetables being mushy, food being greasy and the food tasting bad. He said he had temperature logs and he checked them daily to make sure they were correct. He said he checked the temperatures at the beginning of the meals, sometimes in the middle and checked trays randomly. He said he tasted all the food every day to make sure that it was not overcooked or undercooked. He said the food came down to preference and everyone had different preferences. He said he would keep an eye out on how the cooks were preparing the meals and talk to them and educate them. The DM said the trays being transported to the hallways were transported in an insulated box and were not hot boxes. He said he had two insulated boxes and they did not plug in to be kept heated. He said corporate management had bought the insulated boxes. He said he had mentioned getting hot boxes that plugged into the wall to the NHA. The NHA was interviewed on 7/18/24 at 12:42 p.m. The NHA said the room tray carts were not heating carts. He said the carts held the heat for approximately 45 minutes. He said he did not know that there were hot boxes that plugged into the wall to stay warm. He said he would talk to the DM and ask him if he wanted the plugged in hot boxes and he would buy it. He said the room trays should be served to the residents as soon as possible. He said he had a performance plan in place of not meeting food temperatures and making sure the concerns were being met. He said he had a plan to bring all the residents back to the dining room. He said he would love to see more residents eating in the dining room and not in their rooms The NHA said he looked at the grievance binder every day. He said he did not get a lot of food concerns and had not gotten any within the last month.

Based on observation, record review and interviews, the facility failed to provide an ongoing program of activities for one (#62) of one resident reviewed for activity participation out of 46 sample residents. Specifically, the facility failed to regularly provide individualized, purposeful and therapeutic activities for Resident #62, who was a dependent resident. Findings include: I. Facility policy and procedure The Activities policy, revised October 2022, was provided by the nursing home administrator (NHA) on 7/18/24 at 4:30 p.m. It documented in pertinent part, It is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. II. Resident #62 A. Resident status Resident #62, age 74, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), pertinent diagnoses included non-Alzheimer's dementia (memory problems), Parkinson's disease (brain condition that causes uncontrollable movements and coordination problems) and muscle weakness. The 5/14/24 minimum data set (MDS) assessment documented the resident had severely impaired cognitive skills for daily decision making. A staff assessment for mental status revealed he had a memory problem. The MDS assessment documented Resident #62's preferred language was Spanish. He required maximal assistance for transfers and activities of daily living (ADL). The 11/12/23 annual MDS assessment revealed it was very important for the resident to listen to music he liked, be around pets, do his favorite activities, go outside when the weather was good and participate in religious services. A. Observations On 7/15/24 at 3:15 p.m. Resident #62 was sitting in his wheelchair in his room. He had his eyes open and there was no television or music playing. At 4:01 p.m. the resident was assisted to the hallway by an unidentified CNA. The CNA did not provide the resident with any meaningful activities. Resident #62 began sleeping in his wheelchair. On 7/16/24 during a continuous observation, beginning at 2:25 p.m. and ending at 4:38 p.m., the following was observed: At 2:25 p.m. Resident #62 was sitting in his wheelchair with his eyes open and his head facing the floor. He was positioned in the hallway by the dining room with no meaningful activities. Several staff members walked by him without acknowledging him. At 3:29 p.m. two unidentified certified nursing aides (CNA) assisted him into his room. The CNAs provided incontinence care and left him in the room when finished. His wheelchair was facing the window and there was no television or music playing. His head was facing down and his eyes were closed. -There was a British [NAME] puzzle group activity being offered at 2:30 p.m., however, the resident was not invited to attend. -There was an Emoji meaning group activity at 3:00 p.m., however, the resident was not invited to attend. At 4:10 p.m. an unidentified CNA assisted him into the dining room for dinner. On 7/17/24 during a continuous observation, beginning at 1:10 p.m. and ending at 3:19 p.m., the following was observed: At 1:10 p.m. Resident #62 was sitting in his wheelchair in his room with his eyes open. There was no music or television playing. At 2:02 p.m. two unidentified CNAs walked into the resident's room and provided incontinence care to the resident. They left him in the room once they were finished providing care and did not provide him with any meaningful activities. A housekeeper entered the resident's room to clean at 2:21 p.m. -No other staff members entered the room during the continuous observation. -There was a watercolor painting group activity at 2:00 p.m., however, the resident was not invited to attend. -There was a Discovering [NAME] dice game group activity offered at 3:00 p.m., however, the resident was not invited to attend. B. Record review The activities care plan, initiated 5/22/24, identified Resident #62 expressed individual activity interests including independent activities, such as people watching, propelling himself throughout the facility, chewing gum, snacking, dice games, listening to Spanish music, visiting with others (conversations in Spanish) and visiting with family. He liked pets, such as dogs, and would accept one on one visits. Interventions included inviting Resident #62 to group activities, encouraging family involvement, introducing him to residents with similar backgrounds and interests and assisting him to and from activities. Resident #62's one-on-one activity participation records revealed the following: In April 2024 (4/1/24 to 4/30/24) five informal one-on-one visits were documented. -The resident received activities during five out of a possible 30 days. In May 2024 (5/1/24 to 5/31/24) nine informal one-on-one visits were documented. -The resident received activities during nine out of a possible 31 days. In June 2024 (6/1/24 to 6/30/24) three informal one-on-one visits were documented. -The resident received activities during three out of a possible 30 days. In July 2024 (7/1/24 to 7/18/24) there were zero informal one-on-one visits documented. -The resident received activities during zero out of a possible 18 days. A review of the resident's electronic medical record (EMR) from 4/1/24 to 7/18/24 did not reveal any documentation related to the resident refusing to participate in individual or one-on-one activities. An activity assessment completed on 11/9/22 documented the resident enjoyed listening to music, being around animals, doing his favorite activities, going outside when the weather was good and participating in religious activities (Christian Spanish music). III. Staff interviews CNA #2 was interviewed on 7/18/24 at 1:00 p.m. CNA #2 said she never saw Resident #62 participate in activities. She said Resident #62 sat in his wheelchair most of the day in his room or the hallway. Registered nurse (RN) #1 was interviewed on 7/18/24 at 1:10 p.m. RN #1 said Resident #62 did not participate in many group activities. She said he liked to watch people as they walked by and propel himself around the hallways in his wheelchair. The activities director (AD) was interviewed on 7/17/24 at 3:22 p.m. The AD said Resident #62 enjoyed people watching, propelling himself around in his wheelchair, one-on-one discussions and listening to music. She said he was on their one-on-one program, which involved him participating in three one-on-one activities per week. She said the resident was not getting all the one-on-one visits due to a lack of activities staff. The AD said Resident #62 primarily spoke Spanish and the facility did not have a translator to be used in a conversation. She said the staff used pages with words in English and Spanish to communicate with the resident or relied on other staff members who spoke Spanish to translate.

Based on observations, record review and interviews, the facility failed to ensure resident rights were promoted and dignity was maintained for one (#25) of two residents out of 46 sample residents. Specifically, the facility failed to ensure Resident #25 was provided with incontinence supplies. Findings include: I. Facility policy The Promoting/Maintaining Resident Dignity policy, revised 1/2023, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:16 p.m. It documented in pertinent part, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residents quality of life by recognizing each residents' individuality. II. Resident #25 A. Resident status Resident #25, age 77, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation (abnormal heart rhythm), type two diabetes (high blood sugar) and muscle weakness. The 5/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate assistance with transfers and could not ambulate. B. Resident interview Resident #25 was interviewed on 7/15/24 at 10:43 a.m. She said the facility got rid of the reusable incontinence pads a couple months ago. She said the staff put a folded bath blanket under her when she was lying in her bed. She said she sometimes had incontinent episodes and ended up saturated in urine because the bath mat did not absorb liquid. She said the bed would get completely covered in urine when she had a urinary incontinence episode. She said she felt frustrated by this and it upset her. C. Observations On 7/15/24 at 10:43 a.m. Resident #25's room was observed. There was a folded bath blanket over the fitted sheet in her bed. There was not an incontinence pad over the bath blanket. On 7/17/24 at 2:10 p.m. the [NAME] hall shower room. There were no reusable incontinence pads for residents on the linen cart. On 7/17/24 at 4:30 p.m. the central supply room was observed. There were no reusable or disposable incontinence pads in the room. III. Staff interviews The central supply director (CSD) was interviewed on 7/17/24 at 4:30 p.m. The CSD said the facility did not order the reusable incontinence pads anymore. She said the facility ordered the disposable pads only for residents with air mattresses or wounds. Certified nursing aide (CNA) #1 was interviewed on 7/17/24 at 2:10 p.m. CNA #1 said the facility stopped carrying the reusable incontinence pads a while ago. She said staff should check and change residents who were incontinent every two hours or as needed. She said the staff folded bath blankets and put them under some residents instead of the incontinence pads. CNA #1 said the facility had the disposable pads but they were only used for certain residents. CNA #1 said if a resident soiled their mattress she would change the sheets and wipe down the mattress with an incontinence wipe. She said she would only sanitize the mattress if the resident was out of the bed. The director of nursing (DON) was interviewed on 7/18/24 at 12:00 p.m. The DON said the facility had used reusable incontinence pads in the past, but no longer ordered the supply. She said the facility had stopped using them due to skin breakdown and infections. She said one resident had complained to her about no longer using the reusable incontinence pads and she educated the resident as to why the facility had gotten rid of them. She said she had not heard concerns regarding Resident #25. She said the facility used disposable pads only for residents with weeping wounds or air mattresses.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medication was clinically appropriate for one (#5) of one resident out of 46 sample residents. Specifically, the facility failed to ensure Resident #5 was assessed for safe self-administration of medications. Findings include: I. Facility policy and procedure The Resident Self-Administration of Medication policy and procedure, revised 2/2024, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:16 p.m. It documented in pertinent part, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms. II. Resident #5 A. Resident status Resident #5, age 74, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included muscle weakness, hypertension (high blood pressure) and a history of falling. The 6/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She used a wheelchair and could ambulate around the facility with set-up assistance. B. Observations On 7/15/24 at 11:00 a.m. Resident #5 was in her room sleeping. There was a cup of medications on the bedside table with eight pills At 11:30 a.m. Resident #5 woke up and saw the cup of pills on her bedside table. She was observed self-administering the cup of pills. C. Record review According to the July 2024 CPO, Resident #5 was able to self-administer the following medications: Arformoterol nebulizer (inhaler) to be administered two times daily unsupervised self-administration, ordered on 5/1/23. Albuterol Sulfate (inhaler) to be administered every four hours as needed for shortness of breath or wheezing unsupervised self-administration, ordered 5/1/23. -The July 2024 CPO did not reveal a physician's order for the resident to self administer any of her other prescribed medications. The 6/27/23 self-administration assessment documented Resident #5 was able to self-administer Arformoterol nebulizer, Atrovent nebulizer and budesonide nebulizer. -There was no documented assessment for self-administration of any of her other prescribed medications. -Resident #5's comprehensive care plan did not include Resident #5's self-administration of medications. D. Staff interviews Registered nurse (RN) #2 was interviewed on 7/15/24 at 11:40 a.m. RN #2 said Resident #5 was sleeping when she attempted to administer her medications (on 7/15/24) so she left the medications at the resident's bedside. RN #1 was interviewed on 7/17/24 at 4:15 p.m. RN #1 said Resident #5 had a physician's order for the self-administration of an inhaler and nebulizer medication. He said if the resident was able to self-administer medications it should be included in her care plan. RN #1 said Resident #5's self-administration assessment did not include any pill medications and she needed a self-administration of medication assessment completed in order to self-administer pill medications. He said there were residents with dementia who were ambulatory on the unit with Resident #5, so it was a risk to leave a cup of pills at the resident's bedside. The director of nursing (DON) was interviewed on 7/18/24 at 12:00 p.m. The DON said in order for a resident to be able to self-administer medications, a self-administration assessment should be completed by the nurse, a physician's order obtained, education provided by the nurse to the resident and it should be included on the resident's comprehensive care plan. The DON said there were residents with dementia that wandered who lived on the same unit as Resident #5. The DON said Resident #5 had physician's orders and assessments to self-administer inhaler medications and nebulizers. She said Resident #5 did not have a physician's order or a self-administration assessment for any pill medications.

Based on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the resident's environment for one (#289) of one resident reviewed out of 46 sample residents. Specifically, the facility failed to ensure Resident #289's bathroom call light was consistently accessible to him. Findings include: I. Resident #289 status Resident #289, age 74, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), chronic respiratory failure with hypoxia (low oxygen level) and chronic obstructive pulmonary disease (chronic lung disease that makes it hard to breathe and restricts air flow). According to the brief interview for mental status (BIMS) completed 7/11/24, the resident was cognitively intact with a score of 14 out of 15. He required substantial to maximum assistance of two staff members transferring from bed to chair, using the bathroom and turning in bed. According to the 7/13/24 functional assessment, Resident #289 required substantial to maximum assistance of two staff members transferring from bed to chair, using the bathroom and turning in bed. II. Resident interview and observations Resident #289 was interviewed on 7/16/24 at 11:15 a.m. Resident #289 said he had to yell, whistle or bang on the wall for help when he could not reach his call bell cord in the bathroom. He said last night (7/15/24) a staff person got upset with him for yelling, but he said he could not reach the call bell cord in the bathroom and he needed help. During the interview, Resident #289's call bell cord in the bathroom was observed to be wrapped around the grab bar on the right side of the toilet near the floor. Resident #289 said he could not reach his call bell when it was wrapped around the grab bar near the floor. He said his right arm was affected from his stroke and he did not have full range of motion. On 7/17/24 at 1:56 p.m. Resident #289's call bell cord in the bathroom was again observed to be wrapped around the grab bar on the right side of the toilet. The cord had fallen to the bottom of the grab bar. Resident #289 said it was difficult for him to reach his call bell cord with the limited range of motion in his right arm. On 7/18/24 at 10:30 a.m. Resident #289's call bell cord in the bathroom was observed tied to the top of the grab bar on the right side of the toilet. Resident #289 said he was better able to reach the call bell cord where it was placed on the top of the grab bar. III. Record review The baseline care plan, initiated 7/10/24, indicated Resident #289 was alert, oriented and able to follow instructions. The fall prevention intervention on the care plan indicated to keep the call light within reach at all times. The nurse practitioner visit note, dated 7/11/24, indicated the resident had a stroke with right hemiplegia (paralysis on one side of the body) and right upper extremity decreased range of motion. IV. Staff interview The director of nursing (DON) was interviewed on 7/18/24 at 2:54 p.m. The DON said call lights should be placed within the residents' reach. She said the certified nurse aides (CNA) should not leave residents in the bathroom, but instead, stand outside the bathroom door to give them privacy. She said the CNAs should always ensure the call light in the bathroom was within reach of the resident.

Based on record review and interviews, the facility failed to take steps to prevent abuse for one (#23) of two residents reviewed for abuse out of 46 sample residents. Specifically, the facility failed to protect Resident #23 from sexual abuse by Resident #65. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised October 2022, was provided by the nursing home administrator (NHA) on 7/15/24 at 10:00 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. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. The identification, ongoing assessment, care planning of appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 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. Incident of sexual abuse between Resident #23 and Resident #65 on 5/24/24 The facility investigation was provided by the NHA on 7/17/24 at 12:00 p.m. The investigation included a written statement from the certified nurse aide (CNA) #5 who witnessed the incident. It documented on 5/24/24, while walking down the hall, Resident #65 was seen holding Resident #23's head with his left hand while rubbing her chest and stomach with his right hand. Licensed practical nurse (LPN) #3 was immediately notified. LPN #3 was able to get Resident #65 to stop and Resident #23 was taken back to her room. -The written statement was not dated. On 5/30/24 interviews were conducted with four staff members and four residents. None of the staff members or the residents had any concerns regarding abuse. The investigation failed to document if Resident #23 was assessed following the incident. -The investigation failed to document whether the facility substantiated or unsubstantiated the sexual abuse. III. Resident #65 (assailant) A. Resident status Resident #65, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included unspecified dementia and traumatic brain injury. The 6/26/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. He required supervision or touching assistance with showering and bathing . He was independent with all other activities of daily living (ADL). According to the MDS assessment, Resident #65 had no physical behavioral symptoms directed towards others. B. Record review The affections care plan, initiated on 7/4/24 (over one month after the incident with Resident #23), documented Resident #65's affections could be distressing to others at times. Interventions included educating staff and family members regarding the normalcy of affectionate behaviors, discussing any plans to divert behaviors, discouraging or monitoring displays of affection, encouraging open discussion about affections with the resident's family and staff team to clarify preferences for how to handle the situations, offering activity props, directing the resident toward tasks and change seating to discourage behaviors. The personal space care plan, initiated on 5/24/24, documented Resident #65 tended to periodically invade the staff's personal space and could be verbally inappropriate with staff at times. Interventions included anticipating and meeting the resident's needs, providing the opportunity for positive interaction and attention, stopping and talking with the resident when passing by if reasonable, discussing the resident's behavior, explaining/reinforcing why behavior is inappropriate and/or unacceptable to the resident, intervening as necessary to protect the rights and safety of others, approaching and speaking in a calm manner, diverting the resident's attention, removing the resident from situation and taking to an alternate location as needed, offering reminders and cues as needed; redirecting the resident when needed, reminding the resident of healthy boundaries as needed and redirecting to another activity of choice. -Review of Resident #65's electronic medical record (EMR) revealed there were no progress notes related to the resident's sexual abuse incident with Resident #23 on 5/24/24. IV. Resident #23 (victim) A. Resident status Resident #23, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included cerebral palsy and quadriplegia. The 5/13/24 MDS assessment revealed the resident had severe cognitive impairments and was not able to make decisions regarding daily life through staff assessment She was dependent on staff for all ADLs. B. Record review The impaired cognition care plan, initiated on 11/14/23, documented Resident #23 exhibited both short and long term deficits and had difficulty making herself understood and understanding others. Interventions included encouraging the use of one or two word responses and simple phrases, giving verbal cues and reminders when she could not remember, phrasing questions to yes or no responses, allowing ample time to respond using simple words and sentences, and validating thoughts and feelings when confused or anxious. The communication care plan, initiated on 12/6/23, documented Resident #23 had a communication problem related to neurological symptoms. Resident #23 was able to answer yes and no questions. Interventions included anticipating and meeting the resident's needs, communication, allowing adequate time to respond, repeating words as necessary, requesting clarification from the resident to ensure understanding, facing the resident when speaking, making eye contact, turning off the television/radio to reduce environmental noise, asking yes or no questions if appropriate, using simple, brief, consistent words/cues, using alternative communication tools as needed; and monitoring/documenting residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. -Review of Resident #23's EMR revealed there were no progress note related to the incident with Resident #65 on 5/24/24. -Review of Resident #23's EMR did not document if Resident #23 was assessed following the incident. V. Staff interviews Registered nurse (RN) #3 was interviewed on 7/18/24 at 1:59 p.m. RN #3 said she had seen Resident #65 hovering over Resident #23 and getting too close prior to the 5/24/24 incident. She said Resident #23's representative told Resident #65 he was standing too close and to move away from Resident #23 on 5/23/24. She said she did not witness the incident where Resident #65 had touched Resident #23. RN #3 said she wrote a progress note about Resident #65 getting too close to Resident #23. She said that was the first time she had seen Resident #65 getting too close to another resident. She said when she witnessed any inappropriate behaviors she would write progress notes in the resident's EMR. RN #3 said she was not sure if Resident #65 was being monitored on one-to-one, or on safety fifteen-minute checks. She said both residents had always resided on separate hallways. She said Resident #65 walked all over the facility. She said she did not know if Resident #65 had any other sexually inappropriate behaviors towards others. CNA #5 was interviewed on 7/18/24 at 2:09 p.m. CNA #5 said she witnessed the inappropriate touching between Resident #65 towards Resident #23 on 5/24/24. She said the incident took place down the hallway where Resident #23 resided. She said Resident #65 had one hand over Resident #23's head and his other hand was rubbing Resident #23's chest. She said she told the nurse. She said the residents were separated. She said she took Resident #23 to her room and laid her down and the LPN asked Resident #65 to step away. She said Resident #65 argued with the LPN and said that Resident #23 had told him that she liked him. CNA #5 said Resident #65 was placed on a one-to-one caregiver for one to two weeks. She said she did not know if his care plan was updated. She said she was asked by the DON to write a statement on what she saw. CNA #5 said Resident #65 had a couple of occasions where he had gotten too close to Resident #23 before the inappropriate touching occurred. She said she had had to tell Resident #65 to walk away from Resident #23. -However, review of Resident #65's care plan did not indicate the resident had been placed on a one-to-one caregiver following the incident with Resident #23. CNA #5 said she had seen Resident #65 getting close to another female resident who also had cognitive issues. She said she had never seen Resident #65 touch anyone inappropriately. She said Resident #65 needed to be watched closely. The director of nursing (DON) was interviewed on 7/18/24 at 2:21 p.m. The DON said when she heard about the incident, an investigation was completed. She said she gathered witness statements from staff, residents and questionnaires with families. The DON said a progress note should have been documented in the EMR for both residents. She said the RN, or whomever the incident was reported to, should have written a progress note. The DON said the interdisciplinary treatment team (IDT) met the following business day after the incident (5/27/25). She said any time there was an investigation, the IDT met. She said a progress note should have been written to document the IDT met. She said she was responsible for putting in the IDT notes for risk management regarding skin and falls and for inappropriate behaviors. She said the inappropriate behavior between Resident #65 and Resident #23 was her first incident since she had started working at the facility. She said, moving forward, she would make sure that an IDT note was completed. The DON said staff received education about abuse and reporting following the incident. She said the staff were monitoring both residents to ensure they were not sitting close to each other during meal times in the dining room. She said when Resident #23 was up she was by the nurses' station so the staff could keep a close eye on her. She said Resident #65 was placed on-a-one to one caregiver after the incident on 5/24/24. She said Resident #65 was placed on a one-to-one until the investigation was concluded. She said the one-to-one was removed following the investigation because the residents who were interviewed during the investigation did not report feeling unsafe around Resident #65. The DON said she knew Resident #65 had made inappropriate statements to the receptionist but not towards female residents. She said she did not know if this was a one time incident. She said when she had a conversation with Resident #65 about the incident, he said he just wanted to talk to Resident #23. The DON said a care plan should have been implemented for Resident #65's inappropriate behaviors immediately after the incident. She said she needed to fix the process moving forward. LPN #3 was interviewed on 7/18/24 at 2:56 p.m. LPN #3 said she was working when the incident between Resident #65 and Resident #23 happened. She said when she was notified of what had happened, she alerted the charge nurse. She said the charge nurse had contacted the DON and the NHA. She said when the incident happened, she and CNA #5 separated the two residents. LPN #3 said she was informed that Resident #65 was not allowed down Resident #23's hallway after the 5/24/24 incident. She said she was told by the DON that they could not keep Resident #65 from walking down Resident #23's hallway because it was his right. She said Resident #65 walked down Resident #23's hallway several times a day and tried to peek into her bedroom. She said she checked in on Resident #23 all the time. LPN #3 said she was not aware if Resident #65 had been sexually inappropriate towards any other female residents. LPN #3 said she was given a directive from her charge nurse (RN #3) to hold off on writing a progress note in the EMR because they were waiting on CNA #5 to write her statement. She said she would have written a progress note but, because she was given a directive not to, she did not. CNA #6 was interviewed on 7/18/24 at 3:19 p.m. CNA #6 said Resident #65 was allowed to walk wherever he wanted to because it was his right. She said the DON and the NHA told her that it was a residents' right that he could walk anywhere. She said there should be more interventions put into place to keep Resident #65 from coming down Resident #23's hallway. CNA #6 said when Resident #23 was out of her room, she would sit in her wheelchair by the nurse's station. She said when Resident #23 was in her room she made sure that her door was closed so Resident #65 could not go in. She said when she saw Resident #65 coming down the hallway she would get up right away and would watch him to make sure he did not do anything inappropriate. She said sometimes he would stop at Resident #23's door, especially when no one was watching. The NHA was interviewed on 7/18/24 at 4:43 p.m. The NHA said he neither substantiated or unsubstantiated the abuse at the end of the investigation. The NHA said he did not know that Resident #65 had actually touched Resident #23 inappropriately. He said he had two to three days to follow up on the incident. He said he had not wanted to label Resident #65 as a sexual perpetrator. The NHA said he spoke to Resident #65 and he said he touched Resident #23 on the shoulder and held her head. The NHA said Resident #65 reported he was consoling Resident #23. The NHA said he did not stop that kind of touching. He said when talking to Resident #65, he said he would sit with Resident #23 and talk to her. He said Resident #65 said Resident #23 talked to him all the time. The NHA said Resident #65 said Resident #23 liked being consoled and spoken to. He said Resident #65 said he talked to Resident #23 about the weather. The NHA said he did not think that Resident #65 intended to touch Resident #23 inappropriately. He said he reported and investigated the sexual abuse. He said he only had one CNA who witnessed the inappropriate behaviors. He said Resident #65 had not had any other behaviors noted. The NHA said the only reason why he instructed the staff to keep the two residents separated was because Resident #23s representative had requested no contact between the two. He said Resident #65 had the right to walk down any hallway because it was his home too. He said if Resident #65 looked into Resident #23's room it was alright. He said he talked to staff all the time about making sure that care plans were updated and documentation was completed.

Based on observations, record review and interviews, the facility failed to ensure one (#84) of three residents reviewed for pressure injuries out of 46 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Specifically, the facility failed to implement timely interventions to prevent Resident #84 from developing a Stage 2 pressure injury to his coccyx. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from https://www.internationalguideline.com/guideline on 7/22/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy The Pressure Injury Prevention policy, revised March 2024, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:21 p.m. It read in pertinent part, To prevent formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present, Individualized interventions will address specific factors in the resident's risk assessment, skin assessment and any pressure injury assessment (for example, moisture management, impaired mobility, nutritional deficit, staging and wound characteristics), The goal and preferences of the resident and/or authorized representative will be included in the plan of care. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify the physician to obtain orders. Interventions will be documented in the care plan and communicated to all relevant staff, Compliance with interventions will be documented in the medical record. III. Resident #84 A. Resident status Resident #84, age 76, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (low oxygen level), type 2 diabetes mellitus , Parkinson's disease with dyskinesia (uncontrolled involuntary muscle movements) and vascular disorder of the intestine (narrowing or blockage of the arteries that supply blood to the intestines). According to the 6/27/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident was dependent for all activities of daily living (ADL) including transfers and bed mobility and was always incontinent of bowel and bladder. The assessment revealed the resident was at risk for developing pressure ulcers but did not have a pressure ulcer at the time of his admission to the facility. He had a pressure reducing device for his chair and bed, was on a turning and repositioning program and received applications of ointments/medications other than to the feet. The assessment did not indicate the resident had any behaviors of rejecting care. B. Resident representative interview Resident #84's representative was interviewed on 7/15/24 at 4:15 p.m. The representative said the facility staff did not come in every two hours to provide incontinence care or reposition Resident #84. She said she sat with the resident every day. She said the facility staff would only enter the room when she pushed the call light. She said the facility had never provided Resident #84 with an air mattress (pressure redistribution mattress). C. Observations On 7/16/24 at 11:33 a.m. Resident #84 was lying in bed. -There was not an air mattress on the bed. On 7/17/24 1:47 p.m. Resident #84 was lying in bed and the resident representative was at the bedside. -There was not an air mattress on the bed. On 7/18/24 at 8:45 a.m. Resident #84 was observed lying in bed. Licensed practical nurse (LPN) #2 and registered nurse (RN) #3 were preparing to perform the resident's wound care. -There was not an air mattress on the bed. RN #3 turned the resident to one side while LPN #2 removed the bordered gauze covering the wound. LPN #2 cleansed the wound, exposing a pink wound bed with no slough (yellow/white material containing dead cells that accumulate over a wound bed). The wound size was approximately 2 centimeters (cm) wide by 2 cm long. D. Record review The baseline care plan, initiated 6/21/24, documented Resident #84 was incontinent of bowel and bladder and required total assistance from staff for repositioning in bed. -The care plan did not identify that the resident was at risk for developing pressure injuries or document any pressure wound preventative measures that were put in place. According to the admission assessment, completed 6/21/24, Resident #84 had multiple bruises and scabs to his arms and bruises on his abdomen. There was no pressure injury documented on the admission assessment. According to the Braden pressure ulcer risk assessment (a tool utilized to determine pressure ulcer risk), completed on 6/27/24, the resident was at risk for pressure injuries due to very limited mobility, being bedfast and the potential for friction and shear during repositioning. The skin assessment completed on 6/27/24 indicated the resident had no pressure injuries. The nursing progress note dated 7/4/24 documented Resident #84 had an open area to the coccyx with no drainage or redness noted to the area. A treatment order was obtained on 7/4/24 to cleanse the open area to the coccyx and cover with border gauze dressing every other day. The interdisciplinary team (IDT) progress note on 7/5/24 at 8:53 a.m., documented Resident #84 had a small wound on his coccyx. The recommendations included adding an alternating low loss air mattress and the wound care physician was to follow. -Review of Resident #84's electronic medical record (EMR) revealed a risk for pressure ulcer care plan was not initiated until 7/10/24 (20 days after the resident's admission to the facility and six days after the pressure ulcer was initially identified). The risk for pressure ulcer care plan indicated Resident #84 was at risk for pressure ulcers related to immobility, incontinence and cognitive deficits. Interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness, educating the resident, family, and caregivers as to causes of skin breakdown, including positioning requirements, good nutrition and frequent repositioning, encouraging the resident to turn side-to-side, monitoring nutritional status, monitoring and documenting changes in skin status and obtaining and monitoring laboratory/diagnostic work as ordered. -The care plan did not indicate the presence of an active pressure ulcer. It did not include interventions for wound care treatment, using a specialty mattress or frequent repositioning of the resident by staff. The nursing wound assessment dated [DATE] indicated the wound was identified on 7/6/24. Interventions included a pressure redistribution mattress, a wheelchair cushion, vitamin supplements and positioning devices. The assessment documented that the care plan was updated. -However, according to the nurse progress notes, the wound was initially identified on 7/4/24 (see progress notes above). -Additionally, the facility failed to ensure the care plan, which was not implemented until 7/10/24 (six days after the pressure injury was identified), was to include the pressure injury or interventions. -The facility failed to implement the air mattress which was a documented intervention on the wound assessment (see observations above). According to the wound physician's (WP) progress note dated 7/10/24, Resident #84 had an unstageable pressure injury to the coccyx, due to necrosis (death of tissue) with full thickness measuring 1.5 cm wide by 15 cm long by 0.2 cm deep. The physician's treatment order was changed on 7/10/24 to cleanse the area to the coccyx, apply Medi-honey to the wound bed and cover with bordered gauze dressing every day. The nursing wound observation note dated 7/10/24 revealed Resident #84's pressure wound on the coccyx measured 1.5 cm long by 1.5 cm in wide by 0.2 cm in deep and was unstageable. The note documented the care plan was reviewed, the physician was notified of changes, resident education was provided and the resident's representative was updated with changes. It noted that the wound was unresolved and was acquired after admission. -The measurements documented on the wound observation were significantly different from the WP progress note (see WP progress note above). IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 7/18/24 at 1:00 p.m. CNA #3 said when a resident was at risk for developing pressure ulcers, she repositioned the resident every two hours and applied barrier cream to their skin. CNA #3 said she was not aware that Resident #84 had a pressure ulcer. LPN #2 was interviewed on 7/18/24 at 1:04 p.m. LPN #2 said when a new pressure injury was identified, the director of nursing (DON) or the MDS assessment nurse should be notified. She said the DON and the MDS assessment nurse were responsible for initiating the care plan. LPN #2 said the care plan should include interventions, such as incontinence care and repositioning every two hours, or offloading the pressure injury site. LPN #2 said Resident #84 did not have a pressure ulcer when he was admitted to the facility. She said Resident #84 laid in bed most of the time and staff repositioned and provided incontinence care every two hours. She said the resident did not have an air mattress because his family requested the bolstered (with raised sides) mattress for fall prevention. -However, there was no documentation in the EMR indicating the resident's family was offered and declined the air mattress. The DON was interviewed on 7/18/24 at 2:54 p.m. The DON said upon a resident's admission to the facility, a Braden scale was completed to determine each resident's risk for developing pressure ulcers. She said if a resident was at risk, interventions, such as frequent repositioning, alternating air mattress, frequent incontinence care and dietitian involvement, were initiated. The DON said a care plan for Resident #84's risk of developing pressure injuries should have been developed upon his admission to the facility. She said the baseline care plan should have identified that the resident was at risk for pressure ulcers and preventative interventions should have been put into place. The DON said, initially, the resident's family did not allow him to get out of bed due to his pain. She said the staff had not done a good job of repositioning the resident until after he developed the pressure ulcer. The DON said the pressure ulcer was not identified on the resident's comprehensive care plan and it should have been. She said there were no interventions put into place until after Resident #84 developed the pressure injury to his coccyx. The DON said the family wanted a bolstered mattress because they were concerned about the resident falling out of bed and they declined the air mattress. She said the facility should have documented in the resident's EMR and comprehensive care plan that the resident's representative declined the air mattress. She said the facility might be able to get bolsters for an air mattress, however, she said they had not looked into it. The wound physician (WP) was interviewed on 7/18/24 at 4:30 p.m. The WP said he only assessed the wound once and it was covered with slough and was unstageable. He said the wound measured about 15 cm long by 1.5 cm wide by 0.2 cm deep. The WP said he understood from staff that the family had declined using the air mattress.

Based on observations, record review and interviews, the facility failed to ensure one (#290) of nine residents out of 46 sample residents were free from significant medication errors. Specifically, the facility failed to ensure the insulin pen was primed prior to medication administration for Resident #290. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 7/22/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Manufacturer's guidelines According to the Humalog pen insulin lispro injection instructions, retrieved on 7/22/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/20563slr046_humalog_lbl.pdf, The needle must be changed and the pen must be primed before each injection to make sure the pen is ready to dose. Performing these steps before each injection is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. III. Resident #290 status Resident #290, age 75, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus without complications, chronic kidney disease stage three and myocardial infarction (heart attack). According to the 5/29/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required partial to substantial assistance with transfers, dressing and bathing. IV. Observations On 7/16/24 at 3:25 p.m. licensed practical nurse (LPN) #1 was administering medication to Resident #290. The medication ordered was Insulin Lispro Subcutaneous (under the skin) Solution Pen-Injector 200 unit/milliliter, inject three units subcutaneously before meals for diabetes. Hold if blood glucose is lower than 150 milligrams/deciliter (mg/dl). After checking the resident's blood sugar, LPN #1 determined that three units of Insulin Lispro were required. LPN #1 drew up three units in the insulin pen and cleaned the resident's arm with an alcohol swab. Before she injected the insulin, LPN #1 was stopped from administering the insulin. -LPN #1 failed to prime the insulin pen per manufacturer's instructions. LPN #1 said she should have primed the insulin pen prior to drawing up the three units of insulin. LPN #1 proceeded to prime the pen and administer three units of insulin to Resident #290. V. Staff interviews LPN #1 was interviewed on 7/16/24 at 3:30 p.m. LPN #1 said she should have primed the insulin pen prior to drawing up the three units of insulin. LPN #1 said she had recently received training on priming insulin pens. The director of nursing (DON) was interviewed on 7/18/24 at 2:54 p.m. The DON said insulin pens should be primed prior to drawing up the dose of insulin to remove air that may have collected in the insulin cartridge and ensure the correct dose was given.

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 four medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure a vial of Tubersol (used to test for tuberculosis) was discarded 30 days after it was opened; and, -Ensure expired medications were removed from the medication cart. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 7/23/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read 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. II. Manufacturer's guidelines According to the Tubersol package insert, retrieved on 7/23/24 from https://www.fda.gov/media/74866/download, A vial of tubersol which has been opened and in use for 30 days should be discarded. III. Observations On 7/17/24 at 5:14 p.m. the medication cart on the Diamond Way hall was observed with registered nurse (RN) #1. The following items were found: -A bottle of calcium 600 milligrams (mg) with vitamin D5 with an expiration date of June 2024; and, -A bottle of Fluticasone Propionate 50 micrograms (mcg) nasal spray with an expiration date of April 2024. On 7/17/24 at 5:33 p.m. the East medication storage room was observed with RN #3. The following item was found: -A vial of Tubersol solution with an opened date of 6/11/24. -According to the manufacturer's guidelines (see above), the Tubersol should have been discarded on 7/12/24. IV. Staff interviews RN #1 was interviewed on 7/17/24 at 5:14 p.m. RN #1 said the medications in the Diamond Way hall medication cart were expired and he would dispose of them. RN #3 was interviewed on 7/17/24 at 5:33 p.m. RN #3 said the Tubersol should have been discarded 30 days after it was opened. She said she would notify the director of nursing (DON). The DON was interviewed on 7/17/24 at 5:53 p.m. The DON said medications should be discarded when expired. She said the vial of Tubersol should have been discarded 30 days after it was opened.

Based on observations, record review and interviews, the facility failed to ensure one (#13) of one resident reviewed for assistance with activities of daily living (ADL) out of 46 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #13 received assistance with ADLs, in the areas of dressing, personal hygiene and eating, in accordance with her comprehensive care plan. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised 1/2023, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:21 p.m. It revealed in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following ADLs: bathing, dressing, grooming and oral care, transfer and ambulation, toileting, eating, to include meals and snacks, and using speech, language or other functional communication systems. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #13 A. Resident status Resident #13, age 79, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included lumbar spondylosis (abnormal wear on the cartilage and bones in the neck causing pain), chronic obstructive pulmonary disease (COPD) (damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), hypertension, unspecified dementia without behavioral disturbance and muscle weakness. The 5/1/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. She required partial to moderate assistance with dressing, minimal assistance with transferring and set up assistance for eating. The assessment revealed Resident #13 did not have any episodes of rejecting care. B. Resident observations and interviews On 7/15/24 at 10:47 a.m. Resident #13 was lying in bed wearing a hospital gown. Her breakfast was sitting on the overbed table in front of her, not eaten. The fitted sheet under her was off the bottom half of the bed with her legs directly on the mattress and uncovered. At 2:15 p.m. Resident #13 was lying in bed wearing a hospital gown. Her lunch was sitting on the overbed table in front of her, not eaten. The fitted sheet was still off the lower half of the bed with her legs directly on the mattress and uncovered. On 7/16/24 at 8:45 a.m. Resident #13 was lying in bed wearing a hospital gown. Her breakfast plate was on her overbed table in front of her. She was not eating. At 11:23 a.m. Resident #13 was lying in bed wearing a hospital gown. Her breakfast plate had been removed but there was a fork and breakfast food on the floor. At 12:43 p.m. Resident #13 was lying in bed wearing a hospital gown. Her lunch was on the overbed table in front of her with a small amount eaten. There was cake in a bowl by her lunch plate with plastic wrap still covering it. At 2:03 p.m. Resident #13 was lying in bed wearing a hospital gown. The cake was in front of her, with the plastic wrap removed, but none of it was eaten. She said she did not have a fork. There was not a fork observed on her table or on the floor. At 2:53 p.m. Resident #13 was lying in bed on her side facing the wall. She was wearing a hospital gown with her legs uncovered. On 7/17/24 at 9:19 a.m. Resident #13 was in bed wearing a hospital gown. Her breakfast was sitting on the overbed table in front of her. She was eating scrambled eggs with her fingers. There was a package of unopened plastic silverware on her overbed table. At 9:43 a.m. Resident #13 was in bed wearing a hospital gown. Her breakfast plate was on the floor and food was spilled. There was a bowl of dry cereal on the overbed table in front of her and she had no silverware. Her fingernails were observed to be long and had a dark substance under them. Her head was leaning off to the right side of the bed. At 12:56 p.m. an unidentified certified nurse aide (CNA) took lunch into Resident #13's room. The unidentified CNA moved the resident up in bed and raised the head of the bed, Resident #13 was wearing a hospital gown and was not covered with a sheet or blanket. The CNA gave the resident a hand wipe and asked her to clean her hands. The resident wiped her hands minimally and dropped the wipe into her lap. The CNA opened the plastic silverware packet and put the fork in her food. The CNA provided a flat sheet and covered the resident's legs. At 5:30 p.m. Resident #13 was lying flat in bed with beverages on the overbed table in front of her. She was attempting to drink one of the beverages while lying flat in her bed. She was wearing a hospital gown. The gown was rolled up to her chest, her stomach was exposed and her incontinence brief was open. She was not covered with a sheet or blanket. On 7/18/24 at 9:56 a.m. Resident #13 was up in the recliner in her room. She was wearing personal clothing and watching people walk by in the hallway. She said she was comfortable. At 12:34 p.m. Resident #13 was sitting in the recliner in her room. She had slid down to an almost flat position. She was holding her lunch plate in her lap and was eating with her fingers. A package of unopened plastic silverware was on her overbed table. There was a full piece of sausage on her plate that was not cut up for her. C. Record review The ADL care plan, initiated 2/1/24, documented Resident #13 had an ADL self-care performance deficit related to COPD, fracture of the sacrum, compression fractures, lumbar spondylosis and dementia. The resident required extensive assistance of staff for dressing and extensive to total assistance with personal hygiene. It indicated the resident was independent with eating after set up assistance. -However, observations during the survey revealed Resident #13 had difficulty with eating her food unassisted (see observations above). -The care plan did not indicate Resident #13 ate with her fingers, preferred to wear a hospital gown or preferred to stay in bed during the day and for meals. -The care plan did not indicate that the resident refused assistance with ADLs. -Record review did not reveal Resident #13 refused assistance with dressing or getting out of bed. III. Staff interviews CNA #4 was interviewed on 7/18/24 at 12:30 pm. CNA #4 said the goal was to get Resident #13 dressed and in her chair after breakfast if she agreed. CNA #4 said Resident #13 was able to communicate her preferences. She said Resident #13 usually preferred to wear a hospital gown. CNA #4 said the staff encouraged the resident to get dressed. CNA #4 said the resident was agreeable to getting dressed and out of bed today (7/18/24). -However, Resident #13's plan of care did not indicate that the resident preferred to stay in a hospital gown, rather than getting dressed and being provided personal hygiene assistance. It did not indicate that the resident had episodes of refusing care (see record review above). The director of nursing (DON) was interviewed on 7/18/24 at 2:54 p.m. The DON said morning care included getting the resident up out of bed, changing them or taking them to the bathroom, getting them dressed and assisting with personal hygiene. She said if a resident declined assistance with care in the morning, the CNAs should go back later in the day and offer again. The DON said the staff should encourage residents to get out of bed. The DON said Resident #13 did not always get out of bed. The DON said she had recently tried to assist the resident out of bed and she declined. The DON said the care plan for Resident #13 should reflect her preferences.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: -Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations On 2/14/23 at 8:41 a.m., an unknown certified nurse aide (CNA) was observed making coffee. She grabbed the coffee filter basket. She placed it in the trash can and proceeded to dump the old coffee ground in the trash can hitting the side of the trash can to remove the coffee filter and old coffee grounds. She then replaced the new filter and poured coffee into the filter basket and proceeded to brew a new pot of coffee. Observation of meal service was conducted on 2/15/23 at 10:30 a.m. Dietary aide (DA) #1 was observed scratching his head while rolling clean eating utensils in napkins. DA #1 was wearing a thin coat and would constantly lift his sleeves during this task. DA #1 would scratch his head and pick up service wear and roll them in to clean napkins. DA #1 finished wrapping all of the service wear and placed them onto the serving area. He took a dirty tray and other used utensils to the dishwasher and proceeded to rinse them and place them into the dishwasher. He removed the clean dishes and wiped his hands on the side of his pants. He then proceeded to plate the crumb cake into small dishes for the afternoon meal. During this process, DA #1 continued to scratch his head/face and lift his pants. He filled the tray with the deserts and moved them to the serving area. He retrieved another tray and proceeded to tray the remainder of the desserts. He had some crumbs from the desserts on the counter and proceeded to brush the crumbs into his hand and threw the crumbs into the trash touching the outside of the trash can. DA #1 did not perform hand hygiene during this process. The cook (CK) was preparing the special lunch meals. The CK grabbed several handfuls of frozen French fries and dropped them into the fryer with his bare hands. He wiped his hands on the side of his pants and dropped the French fries basket into the grease. He proceeded to grab approximately five breaded chicken and placed them into the deep fryer with his bare hand. He was preparing to make a chef salad. He walked over to the deep fryer and removed the breaded chicken. He dumped the chicken onto a brown board to let them cool down. After the chicken cooled down, he proceeded to grab them with his bare hand and cut the chicken into small pieces. He scooped them into his bare hand and proceeded to place them onto the plate of salad. He wiped his hands on the side of his pants/apron. He placed the salad on top of the counter to allow it to be served to a resident. The CK did not perform hand hygiene during this process. The CK then proceeded to prepare special orders. He reached into the bread bag and removed several slices of bread. He completed making the special meals on the stove top. The CK did not perform hand hygiene during this process. DA #2 was making the garlic bread in the toaster. DA #2 was observed grabbing the bread with his bare hand and placing the slices into the toaster. DA #2 would remove the toast with his bare hand and place it on the counter. He proceeded to hold the bread with his bare hand and used a large brush to put on the melted butter. He would then place the toast onto a tray. DA #2 was observed picking up his pants and proceeded back to toasting the bread. DA #2 completed the task and placed the bread on the serving line. DA #2 did not perform hand hygiene during this process. DA #2 proceeded to start serving the meals. DA #2 would review the meal tickets and place the order on the plate. He was observed to be constantly picking up his pants during the meal service. DA #2 did not perform hand hygiene during this process. C. Staff Interview The dietary manager (DM) was interviewed on 2/15/23 at 2:00 p.m. He said all kitchen staff needed to wash their hands when their hands become contaminated. He said all staff must wash their hands before handling or serving food. He said staff should never touch ready to eat foods with their bare hands. He said they should use serving tongs. Staff should also wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash heir hands between tasks to avoid cross contamination. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 2/13/23 at 8:49 a.m. revealed seven large cutting boards. There were brown, red, blue, yellow, green and two white cutting boards; all cutting boards were heavily scored and stained. On 2/14/23 at 8:54 a.m., DA #2 was cutting toast on the green cutting board. On 2/15/23 at 10:40 a.m. during kitchen observations the CK was observed cutting chicken on the brown cutting board. C. Staff Interview The DM was interviewed on 2/15/23 at 2:00 p.m. The DM was told of the observations of the cutting boards in the kitchen. He confirmed the cutting boards were visibly stained and showed wear. He said he had just recently replaced the cutting boards and could not understand why they were so discolored and scored. He said the deep scratches could be a potential for bacteria to grow.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 18 of 61 resident rooms in four hallways. Specifically, the facility failed to ensure walls, baseboard coves, halls, floors, doors, and floor tiles were repaired, painted and properly maintained. Findings include: I. Initial observations Observations of the resident living environment conducted on 2/15/23 at 10:57 a.m. revealed: room [ROOM NUMBER]: The sink was clogged with dark rust water. The wall in front of the commode had damaged sheetrock from the wheelchair hitting it. The tile around the commode had water stains and the caulking was black. The residents head board was leaning against the wall at the foot of the bed. The transition strip from the entrance door to the hall was missing. room [ROOM NUMBER]: The bathroom door had a large hole approximately four in circumference. room [ROOM NUMBER]: The corner next to the restroom had chipped and peeling sheetrock approximately 10 inches high by three inches wide. The metal strip was exposed. room [ROOM NUMBER]: The heater vent was falling off of the heater unit. room [ROOM NUMBER]: The heater vent was lying on the floor. room [ROOM NUMBER]: The ventilation fan in the restroom was not functioning. The wall next to room [ROOM NUMBER] had four dime sized holes from where the hand sanitizer used to be. room [ROOM NUMBER]: The sink had black caulking and rust colored stains around the lip of the sink. The bathroom was missing the transition strip. room [ROOM NUMBER]: The floors were yellowish in color and sticky. room [ROOM NUMBER]: The restroom did not have a functioning ventilation fan in the restroom. room [ROOM NUMBER]: The floors were yellowish in color and sticky. room [ROOM NUMBER]: The heater vent was lying on the floor. room [ROOM NUMBER]: The tile next to the door was missing a section approximately six inches long by four inches. room [ROOM NUMBER]: The caulking around the commode had black and rust colored stains. The floors were yellowish and sticky. The electrical box outside of room [ROOM NUMBER] was damaged from the wheel chairs hitting it. room [ROOM NUMBER]: The toilet paper holder was missing and the floor were yellowish in color and sticky. room [ROOM NUMBER]: The caulking around the commode had black and rust colored stains. The floors were yellowish in color and sticky. room [ROOM NUMBER]: The door threshold was missing from the entrance door to the hall. room [ROOM NUMBER]: The toilet paper holder was missing. The tile around the commode had a large hole approximately nine inches long by seven inches wide. The caulking around the commode had black and rust colored stains. The metal door frame had water and rust stains approximately six inches high by three inches wide. The entrance door had a chip approximately seven inches long by six inches wide. The baseboard cove next to the west nursing station had damage approximately five feet long. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 2/16/23 at 10:15 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said the facility utilized a computer system to identify environmental issues. He said staff had not been utilizing the facility system correctly and would educate staff again on how to fill out requisition requests for repairs in the facility. The MS said he did not have any repair requisition requests for the above-mentioned items. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards in one of four medication carts and one of two medication storage rooms. Specifically, the facility: -Failed to discard an expired vial of tuberculin; -Failed to date two vials of Levemir insulin when opened; -Failed to date a vial of glargine insulin (Lantus) when opened; -Failed to discard an expired vial of Humalog insulin; -Failed to date a vial of Novolog when opened; -Failed to date an Incruse and Trelegy inhaler when opened; -Failed to date an Advair inhaler when opened; and, -Failed to discard loose pills in the medication cart. Findings include: I. Professional references According to the Incruse Ellipta inhaler website, retrieved [DATE] from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Incruse_Ellipta/pdf/INCRUSE-ELLIPTA-PI-PIL-IFU.PDF, Safely throw away INCRUSE ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads '0' whichever comes first. Write the date you open the tray on the label on the inhaler According to the Tubersol package insert, retrieved [DATE] from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Prescribing information for Advair diskus, retrieved [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Advair_Diskus/pdf/ADVAIR-DISKUS-PI-PIL-IFU.PDF ADVAIR DISKUS should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard ADVAIR DISKUS 1 month after opening the foil pouch or when the counter reads '0'. According to the Levemir website, retrieved [DATE] from https://www.fda.gov/media/74866/download, Throw away all opened Levemir vials after 42 days, even if they still have insulin left in them. According to the Novolog website, retrieved [DATE] from https://www.novo-pi.com/novolog.pdf, Throw away all opened NovoLog vials after 28 days, even if they still have insulin left in them. According to the Lantus website, retrieved [DATE] from https://products.sanofi.us/Lantus/Lantus.pdf, Store in-use (opened) LANTUS vials in a refrigerator from 36 F to 46 F (2 C to 8 C) or at room temperature below 86 F (30 C) for up to 28 days. According to the Humalog website, retrieved [DATE] from https://uspl.lilly.com/humalog/humalog.html#pi, In-use HUMALOG vials, cartridges, and HUMALOG prefilled pens should be stored at room temperature, below 86 F (30 C) and must be used within 28 days or be discarded, even if they still contain HUMALOG. Protect from direct heat and light. According to the Trelegy Ellipta inhaler website, retrieved [DATE] from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Trelegy_Ellipta/pdf/TRELEGY-ELLIPTA-PI-PIL-IFU.PDF, Discard TRELEGY ELLIPTA 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart. II. Observation and interview On [DATE] at 10:00 a.m. the medication cart for the west hall contained: -Two opened vials of Levemir insulin without an open date. -One open vial of Novolog insulin without an open date. -An open vial of Humalog insulin dated [DATE]. -An open vial of glargine insulin (Lantus) without an open date. -An open inhaler of Advair without an open date. -An open inhaler of Incruse without an open date. -An open inhaler of Trelegy without an open date. -Two plastic pouches, one with a handwritten note of Rosuvastatin (cholesterol medication), and one handwritten Sertraline (depression medication). The medication storage room refrigerator on the west hall had an open tuberculin vial dated [DATE]. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 10:00 a.m. She said she had returned to work after being gone and was not aware the identified medications were not dated or expired. She said it was important to make sure the residents received safe and current medications. She said she would discard the identified medications and make sure to date the replaced medications. III. Interviews The director of nursing (DON) was interviewed on [DATE] at 10:52 a.m. She said it was important to date medication when opened to ensure efficacy and safety of the medication. She said the nurse administering the medication should verify if the medications were safe to give. She said the expired vial of tuberculin should have been discarded 30 days after opening. She said nursing staff would be provided more education going forward.

Based on interviews and record review, the facility failed to conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests for five (#44, #12, #69, #20 and #22) of five residents reviewed out of 29 sample residents. Specifically, the facility failed to document in the resident records the results of COVID-19 tests for Residents #44, #12, #69, #20 and #22. Findings include: I. Record review Five residents (#44, #12, #69, #20 and #22) were reviewed for COVID-19 testing results for the previous six months. The medical record/chart did not have the testing results. The facility did not have COVID-19 test results in the medical record for any of the residents residing in the facility. II. Staff interview The nursing home administrator (NHA) was interviewed on 2/15/23 at 10:00 a.m. She said the facility kept track of the testing results, however, they did not have the results in the resident's charts. She said none of the testing results had been included in any resident's medical record/chart. She said going forward the facility would enter the results into the resident's chart to be in compliance.

Based on observations, record review and interviews, the facility failed to ensure two (#47 and #70) of three sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to assess Resident #47 and Resident #70 after a change of condition. Findings include: I. Facility procedure The Change of Condition procedure, dated October 2022, provided by the nursing home administrator (NHA) on 2/15/23 at 12:14 p.m. included, A nursing assessment will assist the physician and the nursing staff to make good sound decisions. A situation, background, assessment and recommendation (SBAR) assessment will be completed on all residents with any of the above changes. Palliative/Hospice Care: Some residents have chosen to have end of life care or palliative care. The physician and/or hospice still need to know when a change in condition occurs so their needs and comfort can be addressed in a timely manner. II. Resident #47 A. Resident status Resident #47, age 80, was admitted on [DATE] and discharged [DATE]. According to the February 2023 computerized physicians orders (CPO), diagnoses included calorie malnutrition, neoplasm (cancer) of breast, and history of falling. The 1/24/23 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. She had no identified behaviors or rejections of care during the assessment period. B. Record review The provider note, dated 12/23/22, included: Reason for appointment: Nursing request to evaluate right hand swelling. History of present illness: Patient seen per nursing request to evaluate right hand swelling .Suspect due to dependency. Encouraged patient to elevate the hand. -The facility did not have evidence of an assessment of the swelling of the right hand. C. Interviews Certified nurse aide (CNA) #1 was interviewed on 2/15/23 at 9:17 a.m. She said if she noticed anything different in the resident's appearance or cognition she would report the change to the nurse right away for the safety of the resident. Licensed practical nurse (LPN) #3 was interviewed on 2/15/23 at 9:17 a.m. She said if an aide reported a change in the resident she would let the nurse practitioner (NP) know. She said an assessment/progress note should be written in the resident's medical record to indicate the change in the resident. Registered nurse (RN) #1 was interviewed on 2/15/23 at 9:23 a.m. She said if she was notified of any change in a resident's status, she would complete an assessment of the identified area, complete a treatment if needed, and ask the resident about the identified area. She said she would complete an SBAR that included notification to the provider and the responsible party. The director of nursing (DON) was interviewed on 2/15/23 at 10:35 a.m. She said if the staff found a change in condition she would want a SBAR to be completed. She said she could not find an SBAR, a progress note, or any type of assessment beyond the NP progress note. She said it was important to assess immediately for the safety and well-being of the resident. III. Resident #70 A. Resident status Resident #70, age 60, was admitted on [DATE] and discharged [DATE]. According to the January 2023 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), sleep apnea, hypertension, right sided heart failure, obstructive sleep apnea, and atrial fibrillation. The 1/10/23 minimum data set (MDS) assessment revealed the resident's cognitive status was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no identified behaviors or rejections of care during the assessment period. B. Record review The progress note, dated 1/11/23 at 7:44 a.m. documented, This a.m. (morning), resident summoned a nurse to the room. Resident with bruising to right rib area, related to post fall. There is a lump under the bruising, and the resident states that it's a rib. Call out to (provider)'s office. VM. (left a voice mail) -The facility did not have evidence of an assessment of the right rib area, or evidence of notifying the provider of a change in condition. C. Interview The DON was interviewed on 2/16/23 at 1:00 p.m. She said when she looked at the progress note, her expectation was for the staff to complete an SBAR, and notification to the provider. She said she could not locate any more information beyond the note. She said she was not in the facility at the time the progress note was written. She said going forward, she would work with the staff to include further education on documentation.

Based on observations, record review and interviews, the facility failed to ensure two (#68 and #15) out of 29 sample residents' environment remained free of accident hazards and the resident received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure timely assessment for use of wander guard for Resident #68; -Ensure the wander guard (elopement device) was monitored appropriately for Resident #68; and, -Implement effective fall interventions for Resident #15. Findings include: I. Resident #68 A. Facility policy and procedure The Elopement & Wandering Residents policy, revised on 1/1/23, was provided by the nursing home administrator (NHA) on 2/16/23 at 10:17 a.m. 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. B. Resident status Resident #68, age 83, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included fracture of left femur (hip), psychotic disorder, hypertension, and heart disease. According to the 2/8/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident had disorganized thinking. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had verbal and physical behaviors directed toward others. MDS revealed no use of wander guard. C. Resident observation On 2/13/23 at 2:35 p.m., the resident was observed sitting in her room in her wheelchair. On 2/14/23 at 9:58 a.m., the resident was sleeping in her wheelchair in the doorway of her room. -At 2:12 p.m., the resident was visiting with a friend in her room. On 2/15/23 at 2:30 p.m., Resident #68 was observed participating in activities in the dining room. -At 4:21 p.m., Resident #68 was lying in bed sleeping. During observations of Resident #68 (see above) she did not wander aimlessly about the facility or was observed exit seeking. D. Record review The care plan, initiated 12/28/22, identified the resident was an elopement risk/wanderer as she could be disoriented to place, has a history of attempts to leave the facility unattended, impaired safety awareness. Interventions include distracting residents from wandering by offering pleasant diversions such as singing, structured activities, food, conversation, television, book. Resident prefers: She likes funny movies, and likes to talk about dogs. Provide structured activities: toileting, offer to take for a walk inside and outside, reorientation strategies including signs, pictures and memory boxes, offer prayer. The wandering assessment dated [DATE] indicated that Resident #68 was a low risk for wandering. Nurse log note dated 1/18/23 at 10:13 a.m., documented in part: Resident #68's power of attorney gave permission to use the wander guard. The February 2023 CPO included residents who had a wander guard safety device. Please verify that device was intact. Start date 1/26/23. The January 2023 medication administration record (MAR) identified that the resident had a wander guard safety device. Please verify that device was intact every shift. Replace if not present every shift for elopement Y for yes if intact N not intact. Wander guard ordered on 1/26/23. The MAR documented the resident's wander guard was not monitored from 1/18/23 to 1/26/23. -Record review revealed no documentation of attempted elopements or wandering aimlessly in the facility. -Record review of nursing notes revealed no attempted elopements or wandering aimlessly in the facility. E. Staff interview Registered nurse (RN) #1 was interviewed on 2/15/23 at 8:57 a.m. She said the resident did have verbal and physical behaviors but she never had any wandering behaviors. She said she was not sure if the resident had a wander guard but she would check. -At 9:13 a.m. RN #1 stated Resident #68 did have a wander guard. Certified nurse aide (CNA) #2 was interviewed on 2/15/23 at 9:45 a.m. She said Resident #68 did not wander. She stated Resident #68 did not have a wander guard. CNA #4 was interviewed on 2/15/23 at 1:37 p.m. She said she was familiar with Residents #68. She said Resident #68 did not wander in the facility and she did not have a wander guard. Licensed practical nurse (LPN) #3 was interviewed on 2/16/23 at 9:39 a.m. She said she was familiar with Resident #68. She said Resident #68 did not have any wandering behaviors that she was aware of. She said when a resident attempted to elope or if they wandered she would document in a progress note or in the behavior tracking identifying the wandering behaviors. The director of nursing (DON) was interviewed on 2/16/23 10:43 a.m. The DON said if a resident was wandering or exit seeking staff would be documenting it in the behavior tracking or progress notes. She said the documentation should identify what the wandering was about and if the resident was exit seeking. She said the assessment should also identify the residents' risk of elopement to ensure the safety of the resident. The DON was told of the observations above and the score on the elopement assessment. She said she would have to search for the elopement assessment which identified Resident #68 was high risk. The social service director (SSD) was interviewed on 2/16/23 at 1:15 p.m. She said staff would communicate residents' wandering behaviors and an interdisciplinary team (IDT) would review them during IDT meetings and decide if wander guard placement was needed. She said an elopement assessment would be completed and it would show if the resident was a high or low risk for elopement. If the resident was high risk, the IDT would discuss placement of a wander guard. The SSD was told of observations above. She said the elopement assessment was a consideration and it did not cover all basis for wander guard placement. She said staff should have been documenting wandering behaviors to ensure the wander guard was needed. At time of exit on 2/16/23, no elopement assessment was provided that indicated the resident was at high risk as indicated by the DON interview. 46849 II. Resident #15 A. Resident status Resident #15, age of 72, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO) diagnoses included paranoia schizophrenia, major depressive disorder, and diabetes. The 11/10/22 minimum data set (MDS) assessment revealed the resident did not participate in the brief interview for mental status (BIMS), instead the staff completed the assessment. The resident was cognitively intact with independent decision making. The resident required one person assistance with transfers, dressing, walking, toilet use, bathing, and personal hygiene. The resident had unsteady balance but did not use any adaptive device (walker, cane) for ambulation. She was not on a toileting program, was frequently incontinent of urine and always incontinent of bowl. The MDS assessment marked that the resident had not had any falls since the last assessment on 8/19/22. B. Resident observations On 2/14/23 at 10:30 a.m., Resident #15 was observed coming out of her room and walking down the hallway. She was unsteady on her feet and teetered back and forth as she walked. She had only one non- skid sock on, the other foot was bare. A certified nursing assistant (CNA) walked past her twice without saying anything. A registered nurse (RN) walked past her, asked her to sit down so he could get her another sock and her walker. After the RN walked away, the resident kept walking towards the end of the hallway. She walked past the social services office and the business office on her way to the front lobby. There were staff in both offices with their doors open but no staff said anything to the resident. At 10:38 a.m., the resident entered the front lobby and sat in a chair next to the nursing home administrator's (NHA) office. The NHA's door was open. A CNA came with another sock for the resident, the RN never returned. At 10:47 a.m., a female staff member taking food orders finally came over to the resident and assisted her to walk to the dining room. On 2/14/23 at 1:34 p.m. the resident was observed in her room standing in front of her closet without her depends on. On the floor, her depends were soiled with an abundance of loose stool and there was a large pile of loose stool on the floor near her depends. The resident pulled the curtain in front of the feces but it was still visible from the hallway. She then walked over to her bed and sat down, pulling the curtain in front of her bed. There was a sound of urinating coming from the resident's bed and a pool of urine appeared on the floor. A bedside commode was observed next to the feces in the resident's room. Continuous observations from 1:34 p.m. to 2:20 p.m. showed staff members walked past her open door nine separate times taking other residents to the activity room which was directly next door. No staff noticed the mess on the resident's floor. At 2:08 p.m. the maintenance supervisor (MS) walked past her door, looked over, and kept walking without saying anything. At 2:15 p.m. a RN walked past the resident's room to go across the hall. He walked past her door twice and never looked over. C. Record review The comprehensive care plan fall focus initiated on 1/27/20 and revised 12/7/22, revealed the resident was a fall risk due to diabetes, incontinence, and use of psychotropic medications. Interventions revised on 7/15/22 were for staff to assess for spills/urine on the resident's floor, assist with changing socks frequently, encourage the resident to wear shoes and/or dry non-skid socks on both feet, and encourage her to sit if she appeared unsteady on her feet. The activities of daily living focus revised on 12/21/22 revealed the resident was independent with ambulation but the activities care plan revised on 2/13/23 revealed the resident required a walker to ambulate throughout the facility and needed assistance with ambulation. The resident also had poor vision and refused to wear glasses. Nursing fall assessment dated [DATE] revealed the resident was a low fall risk with 1-2 falls in the last three months. She was ambulatory without incontinence and her vision was adequate. She was identified as having balance problems and decreased muscular coordination. A nursing fall assessment for 12/21/22 was not located when the resident had fallen (see below). Nursing fall assessment dated [DATE] revealed the resident was a high fall risk. However, it documented she had not had a fall in three months, she was ambulatory without incontinence and her vision was adequate. She also was identified as having balance problems. Interdisciplinary (IDT) progress notes revealed, -On 8/10/22 the IDT reviewed fall from 8/3/22. The resident had an unwitnessed fall in her room. It was determined the cause of the fall was due to an incontinence episode on the floor in her room and she slipped in it. No injury. A bedside commode provided and the care plan was to be reviewed for person centered interventions. - On 12/21/22 the IDT reviewed fall from 12/20/22. The resident had an unwitnessed fall in the dining room. It was determined the cause of fall was due to the resident's poor balance and refusal to wear proper footwear. No injury. Physical therapy screened resident for services -On 2/1/23 the IDT reviewed fall from 2/1/23. The resident had an unwitnessed fall in her room. She was discovered yelling out for help on her floor. The resident was wearing her socks with a pile of papers around her. No injury. The cause of the fall was undermined. Physical therapy to screen the resident. -There were no progress notes located for the 2/14/23 incontinence episode. D. Staff interviews RN #2 was interviewed on 2/16/23 at 11:05 a.m. The RN stated she was aware of the resident's fall history. She said the resident's falls were due to improper footwear and slipping on her own incontinence. She was not aware of the IDT fall interventions and could not locate them in the resident's medical record. The RN said the resident was difficult to redirect but redirection was the most frequent intervention the staff used. The staff were to check on the resident in her room but there was no documentation of checks or room rounds. The housekeeping department was to park their cart outside of her door when they were cleaning that unit so they could make frequent checks as well. The resident had been screened by physical therapy but would refuse to participate when they would come to work with her. CNA #5 was interviewed on 2/16/23 at 11:15 a.m. The CNA stated the resident was very difficult to redirect. The resident had incontinence episodes all over the facility to include outside in the courtyard and in the dining room. She had fallen in her own incontinence in the dining room and in her own room before. The resident refused to wear shoes, liked to only wear one sock, and frequently walked without her walker. The fall interventions were frequent checks when the resident was in her room and to encourage her to wear socks when out of her room. The staff did not document the checks and the CNA could not say how frequent they were, just whenever the staff had an opportunity. The director of nursing (DON) was interviewed on 2/16/23 at 11:20 a.m. She said the resident had a history of recurring falls due to slipping on her own incontinence and refusing to wear proper footwear. The DON did not know how many falls she had in the last six months. The staff tried to do rounding every two hours to toilet her but she often refused. When the staff saw that she was not wearing proper footwear, they were to offer her clean socks. The staff were to do hourly rounding on the resident but there was no documentation of the rounding. The majority of the resident's falls were in her room with incontinence on the floor. She was unable to find the nursing fall assessment for the 12/20/22 fall.

Based on observations, record review and interviews, the facility failed to ensure three (#4, #3, and #6) of four residents reviewed for accidents out of six sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to develop and implement a person-centered care plan that identified Resident #4's fall risk and put effective interventions into place to reduce falls and prevent an injury. Resident #4 was admitted to the facility for long term care on 2/15/22 with a diagnosis of Lennox-gastaut syndrome ([CONDITION(S)]), diabetes mellitus type two, gastro-[CONDITION(S)] reflux disease (GERD), and chronic pain syndrome. On 2/16/22, one day after the resident's admission to the facility, the resident sustained a fall. The facility failed to put effective interventions into place and the resident fell again on 2/19/22 (four days after his admission) and 2/20/22, for which he sustained a left humerus fracture. After the resident sustained a left humerus fracture on 2/20/22, the resident sustained an additional four falls on 3/17/22, 3/26/22, 5/4/22, and 5/30/22. The facility failed to determine the root cause of the resident's continued falls and put effective, person-centered interventions into place. Additionally, the facility failed to: -Conduct a root cause analysis and update the plan of care with effective person-centered approaches for Resident #3 and Resident #6; and, -Ensure a registered nurse (RN) assessment was completed and documented following sustained falls by Resident #4, Resident #3, and Resident #6. I. Facility policy and procedure The Fall Prevention Program policy, dated November 2020, was provided by the nursing home administrator (NHA) on 7/8/22 at 10:48 a.m. It revealed, in pertinent part, 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. A 'fall' is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. Low/Moderate Risk Protocols: -Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: a clear pathway to the bathroom and bedroom doors, bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed, call light and frequently used items are within reach, adequate lighting and wheelchairs and assistive devices are in good repair. Implement routine rounding schedule, monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. Monitor vital signs in accordance with facility policy. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. High Risk Protocols: The resident will be placed on the facility's Fall Prevention Program: indicate fall risk on care plan, place Fall Prevention Indicator (such as star, color coded sticker) on the nameplate to resident's room and place Fall Prevention Indicator on resident's wheelchair. Implement interventions from Low/Moderate Risk Protocols. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status or recent change in functional status. Provide additional interventions as directed by the resident's assessment, including but not limited to: assistive devices, increased frequency of rounds, sitter, if indicated, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education and therapy services referral. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. II. Failure to implement effective person-centered interventions to prevent falls A. Resident #4 1. Resident status Resident #4, under the age of 65, was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), the diagnoses included Lennox-gastuat syndrome ([CONDITION(S)]), diabetes mellitus type two, gastro-[CONDITION(S)] reflux disease (GERD) and chronic pain syndrome. The 5/27/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of one out of 15. He required supervision for transfers, toileting, personal hygiene and limited assistance of one person for dressing. It documented the resident had two or more falls in the last 90 days. 2. Resident observations On 7/6/22 at 3:17 p.m. Resident #4 was lying in bed without a urinal within reach. -At 4:37 p.m. Resident #4 was sitting in his wheelchair in his room. Anti-rollbacks were not observed on the resident's wheelchair and a urinal was not within reach (see interventions documented on the fall risk care plan). On 7/7/22 at 12:06 p.m. Resident #4 was sitting in his wheelchair. The wheelchair did not have anti-rollbacks. 3. Record review The fall risk care plan, initiated on 2/16/22 and revised on 2/23/22, documented the resident was at risk for falls related to seizures, a new environment, weakness and decreased mobility from a recent hospitalization . The interventions included: providing anti-rollbacks to his wheelchair (5/31/22), assisting the resident to the toilet when he was restless (3/26/22), encouraging the resident to have proper footwear when out of bed (2/16/22), encouraging the resident to wait for assistance (3/26/22), ensuring the resident was positioned correctly during meals (3/17/22), placing a fall mat at the bedside (5/4/22), offering assistance to transfer when in the room (add date), offering a urinal to keep at his bedside (3/30/22), reassuring the resident that staff will allow him to complete tasks with supervision (2/20/22) and reminding the resident to use his call light (2/16/22). The cognitive care plan, initiated on 2/17/22, documented the resident had impaired cognition, dementia, or impaired thought process related to difficulty making decisions, impaired decision making, neurological symptoms and seizures. The interventions included: administering medications as ordered, asking yes or no questions in order to determine the residents needs, communicating with the family, identifying staff and explaining care prior to beginning, monitoring changes in cognitive status, keeping the residents routine consistent, presenting one thought at a time, reminiscing with the resident using photos of family, reviewing medications and using task segmentation to support the residents cognitive deficits. The activities of daily living (ADL) care plan, initiated on 2/22/22, documented the resident had an ADL self-care performance deficit related to encephalitis (swelling of the brain), Lennox-gastaut syndrome and weakness. The interventions included, in pertinent part, the resident required limited to extensive assistance with bed mobility, required extensive assistance with personal care, toileting and transfers. The 2/15/22 admission fall risk assessment identified the resident as a low fall risk. a. Fall incident on 2/16/22-unwitnessed The 2/16/22 nursing note documented at 12:37 p.m., Resident #4 was found sitting on the floor by his bed, one day after his admission to the facility. The immediate intervention put into place was to encourage the resident to call for assistance. -It did not give any further details of the resident's fall. The 2/16/22 change of condition assessment documented the resident did not use his call light for assistance when he was found sitting on the floor next to his bed. The 2/16/22 incident report documented the resident sustained an unwitnessed fall without injury. The resident denied hitting his head or any pain and there were no predisposing environmental factors. It indicated the resident had a gait imbalance, was recently admitted to the facility and was ambulating without assistance. The 2/16/22 interdisciplinary team (IDT) review documented the resident sustained an unwitnessed fall without injury. The resident did not use his call light to ask for assistance. The intervention included the staff should offer the resident assistance with transferring and encourage the resident to use his call light. The fall risk baseline care plan, developed on 2/16/22, included interventions such as encouraging the resident to wear proper footwear on when up, encouraging the resident to call for assistance as needed and offering assistance to transfer from the bed or wheelchair when staff were in the room. The 2/16/22 fall risk assessment, completed after the resident sustained the fall, documented the resident continued to be a low risk for falls. -The facility failed to determine the cause of the resident's fall, in order to put effective interventions in place to prevent further falls. b. Fall incident on 2/19/22-unwitnessed The 2/19/22 change of condition assessment documented the resident sustained an unwitnessed fall. It indicated the resident appeared to be unsteady when ambulating. The 2/19/22 incident report documented Resident #4 was found lying on his left side on the floor in the bathroom. The resident reported he had slipped. The resident was assessed and did not sustain any injuries. The 2/19/22 fall risk assessment documented the resident was at high risk for falls. The 2/20/22 IDT review documented the resident sustained an unwitnessed fall in his bathroom without injury on 2/19/22. The resident was attempting to self-toilet. The intervention documented for staff to offer toileting assistance to the resident when they were in the resident's room. c. Fall incident on 2/20/22-unwitnessed with a sustained major injury The 2/20/22 change of condition assessment documented Resident #4 appeared to have pain in his left arm, left shoulder, and was holding his left wrist. The resident had bruising to his mid upper left arm and swelling to his left shoulder, all sustained from an unwitnessed fall. The physician was notified and ordered an x-ray of the left shoulder, left humerus, and left wrist. The 2/20/22 nursing progress note, documented the facility received the radiology report that the resident sustained an acute fracture of the left humeral neck with minimal displacement from an unwitnessed fall. The physician assistant was notified and orders were obtained to stabilize the resident's left shoulder and administer pain medication as needed. The 2/20/22 fall risk assessment documented the resident was a high risk for falls. The 2/21/22 IDT progress note documented the resident was reviewed for an unwitnessed fall with complaints of pain to the left shoulder and arm. The resident had bruises on the left arm. The resident was weak, unsteady and continued to transfer on his own without calling for assistance. The intervention included offering the resident assistance to transfer or use the toilet when staff were in his room. -However, this intervention was also recommended and updated on the care plan for the 2/19/22 fall. A new person-centered fall intervention was not put into place after the resident sustained a fall with major injury on 2/20/22. -The resident's medical record did not include any additional information about the fall, indicating the facility failed to conduct a root cause analysis of the fall. d. Fall incident on 3/17/22-unwitnessed The 3/17/22 change of condition assessment documented the resident sustained an unwitnessed fall in his room. Resident #4's roommate initiated the call light to alert staff that Resident #4 had fallen. The resident was sitting on the side of his bed and reached for his meal that was placed on his bedside table. Upon reaching for the food, the resident slid off the edge of the bed and onto the ground. The 3/18/22 IDT review documented the resident sustained an unwitnessed fall without injury on 3/17/22. The intervention documented was to ensure Resident #4 was positioned correctly at meals. e. Fall incident on 3/26/22-unwitnessed The 3/26/22 change of condition assessment documented the resident sustained an unwitnessed fall in his bathroom. The resident had no complaints of pain. The 3/26/22 incident report documented the resident was found on the floor of his bathroom. The resident had a gait imbalance and was ambulating without assistance. The 3/27/22 IDT progress note documented the resident sustained an unwitnessed fall, while attempting to toilet himself. It indicated the care plan was reviewed and updated. -The intervention included keeping a urinal at the resident's bedside. However, observations during the survey process showed a urinal was not present in the resident's room nor at the bedside (see observations above). f. Fall incident on 5/4/22-unwitnessed The 5/4/22 change of condition assessment documented the resident sustained an unwitnessed fall. When the certified nurse aide (CNA) answered the resident's call light, he was found on the floor next to his bed. The resident reported he slid out of bed. The resident was wearing slip-resistant socks. The 5/4/22 incident report documented the same details of the resident's fall from bed. The 5/4/22 fall risk assessment documented the resident was at high risk for falls. The 5/4/22 IDT progress note documented putting fall mats in place while the resident was in bed. g. Fall incident on 5/30/22-unwitnessed The 5/30/22 change of condition assessment documented the resident was found laying on the floor next to his bed. The resident reported he slid out of his bed while transferring without assistance to use the bathroom. The 5/30/22 incident report documented the resident sustained an unwitnessed fall in his room. The resident reported he was attempting to use the restroom. The resident had a gait imbalance, was ambulating without assistance, and fell during a transfer. The 5/30/22 fall risk assessment documented the resident was a high risk for falls. The 5/31/22 IDT review documented the resident sustained an unwitnessed fall. He was attempting to use the bathroom by himself. The intervention documented was for physical therapy to evaluate for anti-rollbacks for the wheelchair. The care plan documented the resident was to have anti rollbacks to his wheelchair starting on 5/31/22. -However, observations (see above) revealed the resident did not have anti rollbacks in place. -A review of the physical therapy notes revealed the resident received physical therapy for four weeks (6/1/22 to 6/28/22) and was not evaluated for anti-rollbacks for his wheelchair. B. Resident #3 1. Resident status Resident #3, age 86, was admitted on [DATE]. According to the July 2022 CPO, the diagnoses included diabetes mellitus type two, heart failure, hypertension (high blood pressure), dementia, irritable bowel syndrome, and history of falling. The 6/21/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. It documented the resident had two or more falls in the last 90 days. 2. Observations On 7/7/22 at 10:55 a.m. Resident #3 was lying in bed. CNA #1 confirmed there was not a motion sensored night light in Resident #3's room as indicated in the fall risk plan of care (see below). 3. Record review The fall risk care plan, initiated on 1/27/22, documented the resident was at risk for falls related to poor safety awareness, diabetes mellitus, [CONDITION(S)] (a-fib), heart failure, and a history of falls. The interventions included: anticipating and meeting the resident's needs (1/27/22), assisting the resident to transfer to his wheelchair when he is awake or restless (4/23/22), educating staff on encouraging toileting prior to laying down after meals (1/27/22), encouraging the resident to have an assistive device within reach (2/26/22), encouraging the resident to wear non-skid socks (4/23/22), ensuring frequently used items were within reach (1/27/22), providing a motion sensor night light in the resident's room (3/9/22), offering to assist the resident with toileting when staff were in the resident's room (2/11/22), offering the resident extra blankets at night (2/28/22), an evaluation by physical therapy (5/25/22) and placing the residents wheelchair at his bedside (2/16/22). The ADL care plan, initiated on 1/27/22, documented the resident had an ADL self-care performance deficit related to heart failure, a-fib, and cognitive deficits. The interventions included, in pertinent part: the resident required limited to extensive assistance with personal hygiene, required extensive assistance with toileting and transfers. The admission fall risk assessment documented on 1/21/22, identified the resident at a high fall risk. a. Fall incident on 2/10/22-unwitnessed The 2/10/22 nursing progress note documented at 10:32 p.m., Resident #3 was found on the floor. The resident reported he had used the restroom without assistance. The 2/10/22 change of condition assessment documented the resident had an unwitnessed fall. The resident was found on the floor in his room. The resident reported he was attempting to use the restroom. Upon RN assessment there were no injuries noted. The 2/10/22 incident report documented the resident reported he fell in his room after using the restroom. The resident was confused, incontinent and had a gait imbalance. The resident had ambulated without assistance. The 2/10/22 fall risk assessment documented the resident was at high risk for falls. The 2/11/22 IDT progress note documented the resident sustained an unwitnessed fall without injury. The intervention was documented to offer the resident assistance with toileting during rounding. b. Fall incident on 2/26/22-unwitnessed The 2/26/22 change of condition assessment documented the resident was attempting to check the air vent and was found on the floor at 3:45 a.m. -It did not document any immediate interventions put into place to prevent further falls. The 2/26/22 incident report documented the resident was unsteady on his feet and was not using any assistive devices when he fell . The 2/26/22 fall risk assessment documented the resident was at high risk for falls. The 2/26/22 IDT progress note documented the resident sustained an unwitnessed fall without injury. The intervention was documented to encourage the resident to call for assistance and keep an assistive device within reach. -However, the resident's care plan documented the intervention to place the resident's wheelchair at the bedside on 2/16/22, ten days prior to the residents fall on 2/26/22. The 2/28/22 IDT review documented for staff to provide additional blankets to the resident at night. c. Fall incident on 3/8/22-witnessed The 3/8/22 nursing progress note documented at 7:15 p.m., Resident #3 was observed falling in his room. The resident was unable to report why he was out of bed. The resident sustained a superficial scratch to his left shoulder. -It did not document any immediate interventions put into place to prevent further falls. The 3/8/22 incident report documented the resident was standing in his room when staff observed him fall to the ground. The resident was unable to recall what he was doing. The resident was confused, incontinent, had gait imbalance, impaired memory, and weakness. The 3/8/22 fall risk assessment documented the resident was at high risk for falls. The 3/9/22 IDT progress note documented the resident had a fall on 3/8/22. The resident reported he was attempting to use the restroom and did not call for assistance. The resident had recently been discharged from therapy services. The intervention was documented to place a motion sensor night light in the resident's room. -However, during observations (see above) the resident did not have a motion sensor night light in his room. d. Fall incident on 4/23/22-unwitnessed The 4/23/22 nursing progress note documented at 10:22 p.m., Resident #3 was found on the floor next to his bed. -It did not include any other details of the fall. The 4/23/22 incident report documented the resident was found on the ground next to his bed. There was poor lightning in the resident's room at the time of the fall. -It did not include any additional details of the fall or any immediate interventions to prevent further falls. The 4/27/22 IDT review documented the resident was reviewed for a fall on 4/23/22. It indicated the resident was being treated for a urinary tract infection. -No intervention was put into place to prevent Resident #3 from sustaining further falls after he fell on [DATE]. e. Fall incident on 5/20/22-unwitnessed The 5/20/22 nursing progress note documented at 8:35 a.m., Resident #3 sustained a fall and hit the back of his head on his wheelchair. The resident reported pain to the right side of his forehead about one hour after the fall. The physician ordered for the resident to be sent to the emergency room for evaluation. The 5/20/22 incident report documented the resident had attempted to transfer himself to the toilet when he fell to the ground. The resident reported hitting his head when he fell . The 5/25/22 IDT progress note documented the resident was reviewed for a fall on 5/20/22. The resident was attempting to use the restroom when he sustained a fall and hit his head. The intervention documented physical therapy to evaluate the resident. A review of the physical therapy notes revealed the resident was on physical therapy services from 4/21/22-6/22/22. -The resident was already receiving physical therapy as a fall prevention intervention from 5/20/22. f. Fall incident on 6/23/22-unwitnessed The 6/23/22 change of condition assessment documented the resident sustained an unwitnessed fall. The resident had an increased temperature, non productive cough and increased fatigue for one week. -It did not include any further details of the fall. The 6/23/22 incident report documented the resident was found on the floor near his bed. The resident reported pain to his left hand. -It did not include any further details of the fall or any immediate interventions put into place. The 6/24/22 IDT review documented the resident sustained a fall on 6/23/22. The resident was tested for COVID-19, which resulted in a negative. -No interventions were put into place to prevent the resident from sustaining future falls. C. Staff interviews CNA #1 was interviewed on 7/7/22 at 10:55 a.m. She said person-centered fall interventions should be documented on the resident's care plan. She said when management placed a new fall intervention in place, they would notify the floor staff verbally of the new intervention. CNA #1 said Resident #4 had frequently fallen when he was attempting to use the restroom without assistance. She said Resident #4 had a fall mat next to his bed to prevent injuries. CNA #1 said the nursing staff were doing frequent rounding, every 30 minutes, to check on Resident #4, however they had not been doing the frequent rounding for several weeks. CNA #1 said Resident #3 had cognitive impairment and was unable to use his call light appropriately. She said Resident #3 often fell when he was attempting to use the restroom without assistance. The NHA and the director of nursing (DON) were interviewed on 7/7/22 at 4:04 p.m. The NHA said person-centered interventions should be implemented to prevent residents from falling. The DON said the floor staff should put interventions in place to keep the resident safe immediately following a fall. The NHA said the IDT reviewed the fall the next business day and put an intervention into place. She said the minimum data set coordinator (MDSC) was responsible for updating the resident's care plan with new interventions. The DON said Resident #4 had sustained several falls since his admission to the facility. She said he fell several times within the first week he was admitted and one of the falls resulted in a left humerus fracture. The DON said the resident did not use the call light when he needed assistance. She said the facility had not implemented a toileting program after the resident sustained three falls while he was attempting to use the bathroom by himself. She said the facility had not implemented interventions to help prevent the resident from sustaining further falls with major injury. The DON said Resident #3 had sustained several falls since he was admitted to the facility. She said the resident was confused and unable to use the call light appropriately. She said the staff were to offer toileting during rounding. She said the resident did not have a toileting program in place. The NHA said the IDT team had discussed removing the motion sensored night light as they found it was not effective. The DON said the facility had not implemented person-centered interventions to prevent the resident from continued falls. D. Resident #6 1. Resident status Resident #6, age 81, was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 CPO, the diagnoses included [CONDITION(S)] (paralysis of all limbs) and dementia without behavioral disturbance. The 6/8/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required total dependence upon staff for assistance with all activities of daily living (ADLs). It indicated the resident had sustained one fall since the prior assessment period with no injury. 2. Resident interview Resident #6 was interviewed on 7/7/22 at 3:53 p.m. She said she had fallen from the wheelchair a few times. She said the facility staff would take her to her room after she ate her meals in the dining room. She said they would leave her facing the window, sitting in her wheelchair. She said she had asked the facility staff on multiple occasions to put her back to bed after she finished her meals because it was uncomfortable and hurt to sit up in the wheelchair for long periods of time. The resident said she started falling asleep in the wheelchair and would slip out and onto the ground. She said the facility staff always told her she slipped out of the wheelchair on purpose. She said she was barely able to move her arms and thought it was ridiculous that the facility staff thought she was able to purposely move herself out of the wheelchair and onto the ground. She said in the past two months, she had gotten better about not falling asleep in the wheelchair and that was why she had not had a fall recently. She said the facility never evaluated her for a new wheelchair, cushion or any other steps to prevent her from falling out of her wheelchair. 3. Record review The fall risk care plan, initiated on 7/3/19 and revised on 2/14/22, documented the resident was at a moderate risk for falls due to deconditioning, gait/balance problems and a diagnosis of [CONDITION(S)]. It indicated the resident would gain momentum by moving her head and torso and scoot herself out of the wheelchair when she was upset. The interventions included anticipating the resident's needs to decrease unsafe behaviors that may cause injury to herself or others, assisting the resident with safe positioning in the wheelchair, ensuring the resident's call light is within reach and encouraging the resident to use the call light for assistance, using pillows to assist with positioning in bed for comfort and safety, reassuring the resident that her needs will be met, reassuring the resident that staff will assist her to bed if she asks them and when the resident was in her room and sitting in the wheelchair, offer to assist the resident to bed, especially when she is observed to be angry or upset. -These interventions were put into place upon the resident's admission to the facility (7/3/19) until 12/30/2020. The 12/31/21 fall risk assessment documented the resident as a low risk for falls. a. Fall incident on 2/14/22 The 2/14/22 interdisciplinary (IDT) progress note documented a housekeeper observed the resident sliding down from her wheelchair and onto the foot pedals. It indicated a skin assessment, pain assessment and fall risk assessment were completed and the physician was notified. It documented the staff should assist the resident to reposition in her wheelchair as needed as she would scoot herself forward, monitor the resident per protocol and the resident's care plan was reviewed and updated. -However, upon review of the resident's fall risk care plan, it had not been updated with any additional interventions for the fall on 2/14/22. The 2/14/22 incident report documented the resident slid out of her wheelchair and onto the foot pedals. The resident was calling for a nurse and a housekeeper was walking by the resident's room and saw the resident out of her wheelchair. The resident's back was resting against the seat of the wheelchair with her legs extended out in front of her. The resident said she slid out of the wheelchair because she wanted to go to bed after lunch. It indicated the resident did not sustain an injury. -It did not include any additional interventions to prevent further falls from the resident's wheelchair. b. Fall incident on 3/24/22 The 3/24/22 situation, background, assessment and recommendation (SBAR) documented the resident slid out of the wheelchair and onto the floor. It indicated the resident as assessed and did not sustain an injury. It did not include any immediate interventions to prevent further falls from the resident's wheelchair. The 3/25/22 IDT progress note documented the resident was up in her wheelchair, scooted forward and slid out of the wheelchair onto her buttocks. A skin assessment, pain assessment and a fall risk assessment were completed and the physician was notified. The interventions included encouraging the resident not to scoot forward in the wheelchair, assisting the resident to bed when she was restless and monitoring the resident according to the facility protocol. The 3/24/22 incident report documented the resident slid out of the wheelchair, onto the floor and onto her buttocks. It indicated the resident was placed back into bed. It did not include any interventions to prevent further falls from the resident's wheelchair. Upon review, the resident's care plan was updated on 3/25/22 to include if the resident was up in her wheelchair and becoming restless, assist the resident out of her wheelchair and into bed. -However, the same intervention had been in place since 10/24/2020, indicating to assist the resident to bed when she was angry or [TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure two (#4 and #3) of three out of six sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to adequately monitor residents nutritional status and put effective interventions in place to prevent significant weight loss. Resident #4 was admitted to the facility for long term care on 2/15/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When the resident was admitted to the facility he weighed 122 pounds (lbs). The facility failed to adequately monitor Resident #4's nutritional status by implementing effective nutrition interventions to prevent significant weight loss. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #3 was admitted to the facility for long term care on 1/21/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When the resident was admitted to the facility he weighed 156.5 lbs. The facility failed to adequately monitor Resident #3's nutritional status by implementing effective nutrition interventions to prevent significant weight loss. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy and procedure The Weight Assessment and Intervention policy, revised September 2008, was provided by the director of dining (DOD) on 7/7/22 at 2:44 p.m. It revealed, in pertinent part, The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; greater than 5% is severe, 3 months- 7.5% weight loss is significant; greater than 7.5% is severe, 6 months- 10% weight loss is significant; greater than 10% is severe. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding: the resident's target weight range (including rationale if different from ideal body weight); the approximate calorie, protein, and other nutrient needs compared with the resident's current intake; the relationship between current medical condition or clinical situation and recent fluctuations in weight; and whether and to what extent weight stabilization or improvement can be anticipated. Interventions for undesirable weight loss shall be based on careful consideration of the following: resident choice and preferences; nutrition and hydration needs of the resident; functional factors that may inhibit independent eating; Environmental factors that may inhibit appetite or desire to participate in meals; chewing and swallowing abnormalities and the need for diet modifications; medications that may interfere with appetite, chewing, swallowing, or digestion; the use of supplementation and/or feeding tubes; and end of life decisions and advance directives. II. Resident #4 A. Resident status Resident #4, under the age of 65, was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/27/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of one out of 15. He required supervision for transfers, toileting, personal hygiene and limited assistance of one person for dressing. He required setup assistance for meals. It documented the resident had sustained a significant weight loss that was not prescribed by the physician. B. Observations During a continuous observation on 7/7/22 beginning at 11:55 a.m. and ended at 12:30 p.m., Resident #4 was sitting in his room. -At 12:06 p.m. Resident #4 received his lunch of a ham and cheese sandwich and chips. Resident #4 requested a banana. -At 12:13 p.m. an unidentified certified nurse aide (CNA) served Resident #4 a banana. -At 12:27 p.m. an unidentified CNA removed Resident #4's plate from his room. Resident #4 had consumed 100% of his meal. -The facility did not offer the resident additional food, despite consuming all his food (see interview below). C. Record review 1. Nutritional care plan The nutrition care plan initiated on 2/22/22 and revised on 4/18/22, documented the resident had a nutritional problem or potential for nutritional problems related to Lennox-gastaut syndrome, GERD, diabetes, and [CONDITION(S)] (high cholesterol). It indicated the resident had dental concerns, needed a softer diet, consumed small amounts of food and reported being particular about the food he consumed. The interventions included administering medications as ordered, determining the residents food preferences (likes Mexican and hamburgers, does not like chocolate), providing diabetic Med Pass (nutritional supplement) as ordered (discontinued on 3/23/22 related to refusals), referring to the interdisciplinary team as needed, providing meal assistance, observing for signs of dysphagia (swallowing difficulties), obtaining and monitoring lab work and providing the diet as ordered. The activities of daily living (ADL) care plan, initiated on 2/22/22 documented the resident had an ADL self-care performance deficit related to encephalitis (swelling of the brain), Lennox-gastaut syndrome and weakness. The interventions included, in pertinent part, the resident required set-up assistance at meals and needed a lot of encouragement to eat adequately. 2. Resident #4's weights Resident #4's weights were documented in the resident's medical record as follows: -On 2/15/22, the resident weighed 122 lbs. -On 3/6/22, the resident weighed 118 lbs. -On 3/31/22, the resident weighed 113 lbs. -On 4/2/22, the resident weighed 113 lbs. -On 4/14/22, the resident weighed 107 lbs. -On 4/20/22, the resident weighed 107.5 lbs. -On 5/3/22, the resident weighed 108 lbs. -On 5/16/22, the resident weighed 99.5 lbs. -On 6/2/22, the resident weighed 100 lbs. -On 6/15/22, the resident weighed 103 lbs. -On 6/29/22, the resident weighed 103.5 lbs. -The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Nutritional assessments/progress notes The 2/21/22 admission nutrition data collection documented that the resident weighed 122 lbs on 2/15/22 and was five feet four inches tall. His body mass index (BMI) was 20.9 and his usual body weight was 122 lbs. The resident had no recent weight changes. The resident's skin was intact, he had his own teeth, and was able to feed himself independently. The resident was on a pureed textured diet and was consuming 50-75% of his meals. It indicated the resident enjoyed chili beans and Mexican food. The assessment summary documented there were no nutritional concerns at that time. The 3/7/22 registered dietitian (RD) assessment documented the residents' estimated nutrition needs were 1725 calories per day, 53-60 grams of protein per day, and 1 milliliter (ml) of water per calorie per day. It documented the resident had unintended weight loss related to prolonged illnesses as evidenced by weight loss and poor intake. He was on a consistent carbohydrate diet with a mechanical soft texture. The resident had fractured teeth related to recent seizures. The resident was averaging 50% intakes at meals and was on weekly weights related to reported weight loss in the hospital. It indicated the RD attempted to call the family to discuss residents' history and goals of care. The RD recommended adding Med Pass 120 ml (milliliters) twice per day. It documented the nutrition goals were to maintain weight with a goal of gaining 1-2% body weight per week and to maintain skin integrity. The 3/23/22 nutrition note documented that the RD recommended discontinuing the Med Pass as the resident was frequently refusing it when it was offered. The residents' meal intake was good, but often varied. It documented the resident's family brought food into the facility. The RD requested a new weight be obtained from the registered nurse (RN) on duty. -The facility failed to obtain a weight as recommended by the RD for nine days. The facility also failed to monitor weekly weights. The 4/18/22 nutrition note documented that the resident weighed 107 lbs on 4/14/22 and sustained a significant weight loss (15 lbs or 12.3% in two months). The physician was notified of the weight loss. The RD discussed the weight loss with the resident's spouse. It documented that the resident's spouse reported the resident had always been a picky eater and she was bringing food and Ensure (nutritional supplement) into the facility for the resident. The resident's spouse said the resident enjoyed hamburgers and Mexican food, but did not like chocolate. The RD recommended reimplementing the diabetic Med Pass 237 ml once per day. The resident continued on weekly weights and staff were to encourage meal intake. The 4/29/22 nutrition note documented the resident weighed 107.5 lbs. and had gained half a pound in one week. The resident had varying acceptance of the diabetic Med Pass and refused the supplement half of the time. It documented to continue to offer the residents favorite foods to aid in intake. -No further interventions were documented to address the resident's significant weight loss. The 5/4/22 nutrition note documented the resident weighed 108 lbs. The resident's weight had been stable for two weeks and the interdisciplinary team (IDT) and the physician were working to discharge the resident's home due to failure to thrive in the facility. It indicated the resident refused Med Pass and other nutritional interventions. It documented to continue to encourage food and fluids. -However, the only nutrition interventions put into place were to encourage meal intake and diabetic Med Pass. No other nutrition interventions had been recommended or trialed. The 5/4/22 IDT note documented the resident weighed 108 lbs and had sustained a 5 lbs weight loss. It documented the resident did not like the supplements. The facility was considering transferring the resident home, as he was displaying signs of failure to thrive in the facility. -It did not include any nutritional interventions to address the resident's significant weight loss. The 5/11/22 nutrition data collection documented that the resident weighed 108 lbs on 2/15/22 and was 64 inches tall. His BMI was 18.5 and his usual body weight was 108 lbs. It indicated the resident had sustained a significant weight loss, but did not indicate the amount of weight loss or the timeframe. The resident was on a mechanical soft diet and consumed 51-75% of his meals. The assessment summary documented that the resident had a weight loss and multiple interventions have been attempted with no success. It documented the resident was planning to discharge home with his wife soon related to failure to thrive in the facility. -However, the resident's plan of care lacked any documentation of multiple interventions being trialed with the resident, other than Med Pass and providing the resident with foods he enjoyed. The 5/16/22 nutrition note documented the resident weighed 99.5 lbs. The RD reviewed the resident's weight and documented that the resident had sustained further weight loss and decline. It documented the resident continued to accept the diabetic Med Pass half of the time. It documented the RD left a voice message with the physician and resident's spouse to discuss the resident's weight loss. -The RD did not put any immediate interventions into place as the resident continued to sustain significant weight loss. The RD continually documented the resident refused multiple interventions, however failed to document any other interventions that had been attempted with the resident. The facility continually failed to implement a person centered nutritional intervention after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/25/22 nutrition note documented the RD spoke to the resident regarding his weight loss. At the time of the conversation the resident was in his room with his untouched meal in front of him. The RD offered a meal alternative such as a quesadilla, hamburger, or chicken, which the resident refused. The resident said he did not want a milkshake, but would drink a glucerna (diabetic nutrition supplement) occasionally. The resident said he did not like to eat his meals in the dining room. It documented the RD expressed the importance of eating, maintaining/gaining weight for health, strength, and improving the potential to go home. The RD also expressed concern for his health, weight, and tried to reinforce the need for food. The physician was notified of the weight loss and ordered a therapist to assist with the residents' reported depression. -The recommendation included to continue to encourage the resident to eat and drink, however did not document any significant nutritional interventions. The 6/2/22 nutrition note documented the resident weighed 100 lbs. The RD reviewed the resident's weight and documented that the resident gained weight from the previous week (half a pound). It documented the resident appeared to be eating a bit better at meals. It documented to continue encouraging the resident's meal intake to support weight maintenance and weight gain. - No additional nutritional interventions were added to the resident's plan of care. The 6/8/22 IDT progress note documented that the resident was reviewed for recent weight loss. The resident weighed 100 lbs, which was up half a pound in one week. The resident was being followed by the RD and the resident's spouse had been taking the resident out to eat in the community on the weekends. -No additional nutritional interventions were put into place to promote additional weight gain. The 6/15/22 nutrition note documented the resident weighed 103 lbs. The resident's BMI was 17.7, which was still considered underweight, but had gained 3 lbs. The resident's spouse had been taking the resident out to eat in the community and the resident was consuming 75% of most meals in the past week. The diabetic Med Pass was still in place once per day, but the resident had been refusing it frequently. The RD documented that she would address the possibility of adding an appetite stimulant and to continue to encourage the intake of food and fluid. The 6/29/22 nutrition note documented the resident weighed 103.5 lbs. The RD reviewed the resident's weight and noted he had a positive weight gain. The resident's BMI was 17.8, which was still considered underweight. The resident continued on a carbohydrate controlled diet and was accepting 75% of most meals. The resident was accepting the ordered diabetic Med Pass half of the time. It documented to continue to encourage the intake of food and fluid. -The RD did not document any follow up on the potential appetite stimulant documented on 6/15/22. The facility continued to fail to implement person-centered nutritional interventions after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Resident #3 A. Resident status Resident #3, age 86, was admitted on [DATE]. According to the July 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/21/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. He required setup assistance at meals. It documented the resident had sustained a significant weight loss that was not prescribed by the physician. B. Observations During a continuous observation on 7/7/22 beginning at 11:55 a.m. and ended at 12:30 p.m., Resident #3 was observed in his room. -At 12:03 p.m. Resident #3 received his lunch meal of meatloaf, mashed potatoes, chicken noodle soup, and a brownie. -At 12:27 p.m. an unidentified CNA entered Resident #3's room to check if he was done eating. The resident had consumed 100% of his mashed potatoes and meatloaf. The resident was still eating his chicken noodle soup and said he wanted to eat his brownie. -The resident consumed all of his foods and was not served or ordered fortified foods to provide additional calories or protein to promote weight gain (see interview below). C. Record review 1. Nutritional care plan The nutritional care plan, initiated on 1/27/22 and revised on 5/16/22, documented the resident had a potential for nutritional problems related to cognitive deficits, [CONDITION(S)] (a-fib), heart failure and [CONDITION(S)] (high cholesterol). The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -On 4/5/22 the resident was trialed on the restorative dining program. The interventions included administering fiber/probiotic/[MEDICATION(S)] as ordered, administering medications as ordered, providing a carbohydrate controlled and mechanically soft diet, determining the residents likes and dislikes, providing meal assistance as needed, observing the resident for signs or symptoms of dysphagia (swallowing difficulties), observing the resident for signs of malnutrition, obtaining lab work as ordered, offering snacks throughout the day, providing diet as ordered, providing supplements as ordered and for the RD to evaluate and make changes as needed. 2. Resident #3's weights Resident #3's weights were documented in the resident's medical record as follows: -On 1/21/22 at 8:42 p.m., the resident weighed 156.5 lbs. -On 1/21/22 at 8:44 p.m., the resident weighed 156 lbs. -On 1/29/22, the resident weighed 146.4 lbs. -On 2/12/22, the resident weighed 147 lbs. -On 2/24/22, the resident weighed 144.2 lbs. -On 3/7/22, the resident weighed 140 lbs. -On 3/15/22, the resident weighed 139 lbs. -On 3/22/22, the resident weighed 142.8 lbs. -On 3/29/22, the resident weighed 142 lbs. -On 4/2/22, the resident weighed 144 lbs. -On 4/5/22, the resident weighed 144.1 lbs. -On 4/13/22, the resident weighed 139.5 lbs. -On 4/21/22, the resident weighed 140.5 lbs. -On 4/28/22, the resident weighed 140.5 lbs. -On 5/3/22, the resident weighed 139 lbs. -On 5/7/22, the resident weighed 139 lbs. -On 5/16/22, the resident weighed 138 lbs. -On 6/2/22, the resident weighed 136 lbs. -On 6/15/22, the resident weighed 137 lbs. -The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Nutritional assessments/progress notes The 2/1/22 admission nutrition data collection documented that the resident weighed 146.4 lbs and was six feet four inches tall. The resident's BMI was 17.8 and his usual body weight was 146 lbs. The resident did not have any weight changes. The resident's skin was intact, he had natural teeth, and was able to eat independently. The resident was on a no added salt diet and was consuming 75-100% of his meals. It documented the resident did not have any food preferences. It documented there were no nutritional concerns at this time. -However, the resident had sustained a 6.2% (9.6 lbs) weight loss, which was considered severe in one week. The 2/3/22 nutrition note documented that the resident had lost weight since his admission to the facility. The RD documented that she questioned the accuracy of the weight. It documented the RD spoke with the resident's spouse who reported the resident's usual body weight was 137 lbs. It documented the resident could have had weight fluctuations related to heart failure and [CONDITION(S)] and the RD would conduct a nutritional assessment. The 2/3/33 nutrition RD assessment documented the residents' estimated nutrition needs were 1900 calories per day, 66 grams of protein per day, and 1900 ml of fluid per day. The resident was on a consistent carbohydrate diet and ate meals with set-up assistance from staff. His intake was 75-100% at most meals. The resident had a 10 lbs weight loss since admission, with a BMI of 17.9, which was considered underweight. The RD documented the nutritional goals were to maintain the resident's weight within 5% of 137 lbs or a weight gain towards a BMI within normal limits and to maintain skin integrity. The nutrition interventions included: providing a consistent carbohydrate diet with set-up assistance at meals, monitoring for chewing or swallowing difficulty, monitoring weekly weights and encouraging food and fluid intake. -Regardless of the RD's questioning of the inaccurate weight, she did not recommend a reweigh to clarify the resident's weight or implement a person-centered nutrition intervention to address potential significant weight loss. The RD did not provide education to the resident's spouse that the resident's normal weight of 137 lbs was considered underweight and the risks of the resident continuing to be underweight. The 2/16/22 nutrition note documented that the resident had weight loss and the RD reviewed it. The RD continued to question the accuracy of the resident's admission weight, however did not request the resident to be reweighed. It indicated the resident's weight was stable and he was consuming 76-100% of his prescribed carbohydrate consistent mechanical soft diet. The 3/10/22 nutrition note documented that the resident weighed 140 lbs and the RD reviewed the resident's weights. The resident's BMI was 17, which was considered underweight. The resident was consuming 75% of most meals. It documented that the resident's spouse reported that occasionally the resident's gums became sore from his dentures. The resident's spouse said the resident had Ensure at home, but it caused him to have diarrhea. The resident's spouse said she thought it was appropriate for the resident to trial a nutritional supplement. The RD recommended offering diabetic Med Pass 120 ml twice per day and continuing to monitor weekly weights. -The facility continually failed to provide education the resident and resident's spouse on the risks of the resident returning to a weight of 137 lbs as his BMI would classify him as underweight. The 3/16/22 nutrition note documented that the resident weighed 139 lbs and the RD reviewed the resident's weights. The resident lost 1 lbs in one week and was trending towards his usual body weight of 137 lbs. The resident was accepting the diabetic Med Pass. The 3/23/22 nutrition note documented that the resident weighed 142.8 lbs and the RD reviewed the resident's weights. The resident had gained weight the previous week, but his BMI was 17.4 which still classified him as underweight. The resident was accepting 50-100% of the diabetic Med Pass and consumed 75% of his meals. The 4/4/22 IDT progress note documented that the resident had a 16 lbs weight loss in 90 days. It indicated the resident had episodes of diarrhea that may have contributed to his weight loss. The physician ordered medications to prevent further diarrhea. It documented the facility was monitoring, offering and encouraging snacks. -No other nutritional interventions were put in place to address the significant weight loss of 16 lbs in 90 days. The 4/6/22 nutrition note documented that the resident weighed 144.1 lbs. The resident had lost weight since admission due to trending towards his usual body weight of 137 lbs. The resident gained 2 lbs in one week and was accepting the ordered diabetic Med Pass. The resident's BMI was 17.5, which was considered underweight. It documented to continue with the plan of care and encouraging weight gain if possible. The 4/13/22 nutrition progress note documented that the resident weighed 139.5 lbs and the resident was again trending towards his usual body weight of 137 lbs. The resident was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD recommended increasing the diabetic Med Pass to 150 ml twice per day. The RD recommended continuing weekly weights and encouraging food and fluid intake. The 4/13/22 IDT note documented that the resident was reviewed for weight loss. The resident weighed 139.5 lbs, which was close to his reported usual body weight. It indicated the resident was on a restorative dining program and received diabetic Med Pass twice a day. -It did not document any additional nutritional interventions to address the resident's continued significant weight loss and underweight BMI. The 4/26/22 nutrition data collection documented that the resident weighed 140.5 lbs. It indicated the resident had sustained a significant weight loss, but did not indicate the amount of weight lost or the time frame. The resident's weight loss was not prescribed by the physician. It documented there were no nutritional concerns at that time. -However, the assessment documented the resident had no nutritional concerns at the time of the assessment, despite a significant weight change that was not physician prescribed. The 4/29/22 nutrition note documented that the resident weighed 140.5 lbs and the resident's weight had been stable for 45 days. The resident's BMI was still underweight at 17.1, but was still above his usual body weight. It documented to continue the current plan of care. -However, the resident's weight was not stable as he continued to experience a significant weight loss since his admission to the facility. The 5/4/22 nutrition note documented the resident weighed 139 lbs and the resident's weight was stable. The RD recommended increasing the diabetic Med Pass to 150 ml three times a day and to continue weekly weights. The 5/16/22 nutrition note documented the RD had the resident trail Magic Cup (nutritional ice cream supplement) and he accepted it well. The RD recommended discontinuing the Med Pass and adding the Magic Cup to his lunch and dinner meal trays. The resident weighed 138 lbs and was still underweight with a BMI of 16.8. The resident was consuming 75% of his meals with assistance from a restorative dining aide. The 6/2/22 nutrition note documented that the resident weighed 136 lbs (2 lbs weight loss from the previous nutrition note) and had a weight loss over the last 30 days. The resident was still underweight with a BMI of 16.6. The resident consumed 76-100% of his meals and accepted the Magic Cup. The RD recommended reimplementing the diabetic Med Pass 120 ml twice per day and continuing to monitor weekly weights. -The facility failed to implement person centered nutrition interventions to prevent a 12.5% (19.5 lbs) severe weight loss in six months from 1/21/22 to 6/15/22. Also, the facility failed to implement effective nutrition interventions to promote weight gain to a healthy weight and provide education to the resident and resident's spouse regarding health risks of a low body weight. D. Staff interviews The RD was interviewed on 7/7/22 at 1:38 p.m. She said all residents were weighed upon admission and then weekly for four weeks. She said if the resident's weight was stable, then they were then weighed monthly, but weekly weights would continue if their weight was unstable. She said the restorative nurse aides were responsible for obtaining weights as ordered. She said she was responsible for recommending weekly weights versus monthly weights. She said the physician typically would order weekly or daily weights if the weight fluctuations were related to fluids. The RD said Resident #4's significant weight loss had been a concern. She said he had limited responsiveness to the nutrition interventions that were put into place. The RD said she had recommended diabetic Med Pass, spoke with the physician and resident's spouse, gathered the resident's food preferences, and recommended an appetite stimulant (which, according to the resident's medical record, was not followed up on or implemented). The RD said the resident's spouse would bring in food for the resident, but was unsure how often. The RD said she attempted to speak with Resident #4, however he was primarily Spanish speaking and she was unable to effectively communicate with the resident. She said she did not use an interpreter. She said the resident did not respond to the questions she asked him. The RD said it would be beneficial for facility staff to offer additional food when the resident consumed 100% of his meals. The RD said she had not trialed fortified foods or high calorie/ high protein foods. The RD said she had not discussed liberalizing the resident's diet with the physician and the physician did not have any recommendations regarding Resident #4's significant weight loss. The RD said when a resident had a low BMI they were at a risk for malnutrition, developing pressure wounds and would have a difficult time recovering from an illness. The RD said Resident #3's spouse reported his usual body weight at 137 lbs prior to admission. She said when Resident #3 weighed 137 lbs, he was considered underweight and this could lead to other comorbidities. The RD said she had recommended queuing at meals, Med Pass and Magic Cup as nutritional interventions for Resident #3. The RD said she had not tried fortified foods or high calorie/high protein foods as other nutritional interventions for the resident. The RD said she had not discussed liberalizing the resident's diet with the physician. The RD said since the resident had consumed all of his foods for lunch on 7/7/22, fortified foods could have been beneficial to provide additional calories to promote weight gain. The director of dining (DOD) was interviewed on 7/7/22 at 2:02 p.m. He said Resident #4 enjoyed foods that were on the always available menu. The DOD said the resident was depressed, which led to his poor appetite. He said the resident preferred not to eat most meals. He said Resident #4 preferred to eat in his room, so he was unsure of what he ate. He said he would expect the nursing staff to encourage meal alternatives when taking the resident's meal order. The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 7/7/22 at 4:04 p.m. The DON said Resident #4 was afraid to eat when he admitted , because he was unable to purchase the food. The DON said the facility provided reinforcement that the facility was providing the

Based on observations, record reviews, and interviews, the facility failed to provide the necessary care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for five (#63, #17 and #44) of 40 sample residents. Specifically, the facility failed to: -Utilize a systematic, interdisciplinary approach to determine possible causes and effective interventions to resident #63's frequent, loud calling out. This failure contributed to resident #63's inability to attain and maintain his highest practicable level of physical and mental well-being. -Consistently implement resident #63's plan of care. The failure contributed to the resident experiencing unrelieved pain and unnecessary distress and discomfort. -Sufficiently provide diabetic management for resident #17. -Monitor and assess the accuracy of skin assessments for resident #44. The findings included: I. Resident #63 A. Resident Status Resident #63, age 77, was admitted to the facility on [DATE]. The May 2017 computerized physician orders [REDACTED]. The resident admitted to hospice on 2/25/17 due to severe dementia with protein malnutrition; decubitus stage IV pressure injury to the resident's coccyx. According to the 4/20/17 minimum data set (MDS) assessment, the resident had short-term and long-term memory problems. The resident's decision-making was moderately impaired and supervision was required. The resident had disorganized thinking, altered level of consciousness, and inattention during the review period. There was no change in mental status from baseline. The resident was short-tempered and easily annoyed several days during the review. The resident exhibited verbal behavioral symptoms directed towards others. He required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. Total dependence was required for transfers and locomotion on/off the unit. The resident received pain medication scheduled and as needed. He did not receive non-medication interventions for pain. The staff assessment for pain revealed indicators of pain or possible pain were non-verbal sounds such as crying, whining, gasping, moaning, or groaning. He did not reject care. B. Observations Observations revealed the resident exhibited one behavior, yelling out, at times continuously, when sitting in his wheelchair, when repositioned, and when receiving cares. a. 4/27/17 -At 12:34 p.m., resident #88, who lived on the same unit and near resident #63, was interviewed. He said resident #63 yelled and made noise and the resident's noise affected his comfort. -At 1:30 p.m., the resident was seated in his high backed wheelchair, yelling. He continued to yell, grimace, and move around in his chair while an interview was conducted with his roommate/spouse. -At 1:33 p.m., the resident continued to yell out and staff member entered the room and asked the resident if he would like to lie down. The resident loudly said, Yeah! He continued to yell out when the certified nurse aide (CNA) left to get the lift and another staff to assist. -At 1:36 p.m., the resident continued to yell out when the CNA returned with a second staff and a sling was placed under his legs. He made facial grimacing as the sling was placed. No administration of as needed pain medication observed prior to the transfer. -At 1:38 p.m., the resident continued to yell out while lifted out of his wheelchair and transferred into his bed. -At 1:39 p.m., the resident yelled out continuously as staff repositioned him during care while lying in bed. -At 1:42 p.m., the staff exited the room with the lift. The resident stopped yelling out and fell asleep in bed. b. 5/1/17 -At 9:12 a.m., the resident was heard down the east hallway, yelling out. He yelled four times within one minute and then continued to yell out. The resident was found sitting in his wheelchair, grimacing, moving around in his chair. -At 9:18 a.m., the resident continued to yell out. A CNA entered his room; she did not speak to the resident but remained in the resident's room, and closed the door. The resident continued to yell out. -At 9:21 a.m., the resident's door remained closed and the resident continued to yell out loudly enough to be heard in the hallway where registered nurse (RN) #5 stood in front of a medication cart. The RN did not respond to the resident's yelling out. -At 9:26 a.m., the resident continued to yelling out loudly with changes in pitch, loudness, and length of the yell. Then the staff exited the room with a soiled trash bag. -At 12:49 p.m., the resident was in his room seated in his wheelchair, yelling out. He would stop briefly and then begin yelling again. He could be heard in a room across the hall. -At approximately 1:00 p.m., the resident was in bed asleep. At approximately the same time, resident #71, who lived on the same unit and near resident #63 said (resident #63) was always screaming. He said the screaming affected his comfort and wasn't good to hear. c. 5/2/17 -At 11:08 a.m., loud yelling out was heard coming from the shower room on the east hallway, where resident #63 resided. A knock on the door revealed the resident and hospice certified nurse aide (HCNA) were the shower room. The resident's shower ended at approximately 11:25 a.m. The resident called out throughout his bathing task. His tone and pitch changed, length of yells varied. -At 11:30 a.m., the HCNA propelled the resident to his room in the shower chair. He continued to yell out. He was covered by linen towels and gown. -At 11:34 a.m., two staff entered the resident's room with a transfer lift. The resident continued to yell out. -At 11:36 a.m., the resident continued to yell and could be heard down the east hallway. -At 11:43 a.m., the resident was seated in his room in a manual high back chair. The room door open and the resident yelled out loudly and continuously. He exhibited intermittent facial grimacing and moved restlessly in his chair. C. Facility failure to use a systematic, comprehensive approach to address resident #63's behavior of yelling out. 1. Failure to collect detailed information and investigate potential causes to understand and effectively address resident #63's behavior. a. Record review Review of the resident's record revealed no evidence about the resident that might be the cause for his behavior. Specifically, the resident's record lacked information on his past life experiences, preferences, daily routines and specifically, how he communicated physical needs (pain, discomfort, hunger or thirst) and psychological needs (boredom, anxiety and frustration). Review of the resident's care plans addressing communication and behavior revealed no evidence such information was obtained and incorporated into the care plans in order to develop relevant and effective interventions that staff could consistently implement in response to the resident's behavior of yelling out. -The cognitive impairment care plan, initiated on 1/23/17 and revised 2/9/17, read the resident had impairment due to dementia or impaired thought processes related to dementia and [MEDICAL CONDITION]. The goal was the resident would communicate basic needs on a daily basis. Interventions included to ask yes/no questions. -The resident's behavior care plan, initiated on 1/23/17 and revised 4/27/17, revealed the resident had a behavior of yelling out and screaming out obscenities related to his dementia. Instances of his behavior were to be documented in the unmet needs book (behavior tracking). The goal was the resident would have fewer episodes of yelling out. Interventions included: -Allow choices within individual's decision making abilities -Anticipate and meet resident needs -Encourage resident to express his feelings appropriately -Intervene as needed to protect the rights and safety of others Neither care plan above explained to staff how to recognize the resident's expression of physical needs versus psychological needs in order for staff to effectively intervene or how to interpret the resident's calling out as a form of communication. Neither care plan explained what choices were important to the resident and what choices should be offered. Neither care plan identified his past routines in order for staff to anticipate the resident's needs and communicate to him their understanding of his needs. Neither care plan told staff how to encourage the resident to express his feelings appropriately. Review of the facility unmet needs book used to track behaviors, revealed one entry on 4/18/17 of resident #63 having a behavior. There were no additional entries related to yelling, screaming, agitation or anxiety. Therefore, there was no means to evaluate whether the care plan interventions above for behavior were effective or ineffective in promoting the care plan goal of fewer episodes of calling out. Furthermore, none of the observed incidences from 4/27/17 through 5/2/17 were documented on the resident's unmet needs sheet. Review of progress notes from 3/1/17 through 5/4/17 revealed no evidence the interdisciplinary team met to comprehensively evaluate the resident's behavior, review existing interventions, and consider alternative interventions to establish approaches to promote the resident's highest practicable level of well-being. b. Staff interviews Staff interviews confirmed staff lacked an understanding of the cause for resident #63's behavior of yelling out and how to differentiate what need he was trying to express. 1. The HCNA who assisted the resident with his shower on 5/1/17 (see above) was interviewed at 12:50 p.m. The HCNA said she helped the resident with eating, showers, and shaving. She said the resident frequently screamed when she assisted him with cares. She said she was not sure if the resident yelled because he was in pain or he was trying to communicate. She said he was able to answer yes or no but mostly screamed or yelled. She said she was not sure what he was trying to communicate to her when he yelled during cares. 2. CNA #8 was interviewed on 5/2/17 at 11:22 a.m. The CNA said the resident yelled and she did not know what he was trying to communicate. The CNA stated he could be trying to communicate pain. She said the resident's yelling during bathing sounded like he was not happy. She said he was in his most comfortable and peaceful state when he was left alone and able to lie in his bed. 3. CNA #9 was interviewed on 5/2/17 at 12:40 p.m. She said she was familiar with the resident and worked with him routinely. She said based on his yelling, she thought the resident was in a lot of pain and wanted to be left alone. She thought at times, he probably yelled because he was annoyed or aggravated when helped with cares. She said anything that involved moving him or getting out of bed resulted in him yelling out. She said he was seated in his wheelchair and of out of bed for two to three hours a day and most days he yelled the entire time until he was helped back into bed. The CNA did not express an awareness of the need to convey her observations of the resident appearing uncomfortable to the nurse or other staff. 4. CNA #4 was interviewed on 5/3/17 at 11:48 a.m. The CNA said the resident yelled a lot. She said it was hard to tell what he wanted. The CNA stated she had to guess what he wanted. The CNA stated she helped him get in and out of bed. The CNA said she when helped the resident out of bed before lunch, he would yell until he was helped back to bed. 5. The physical therapist (PT) was interviewed on 5/2/17 at 11:26 a.m. He stated he was new to the facility. He stated he was not familiar with the resident but could hear moaning coming from the room. He stated it was possible his moaning could signify potential discomfort or confusion. He stated he did not understand if the cause of the yelling was a medical condition or physical discomfort. 6. RN #5 was interviewed on 5/2/17 at 12:50 p.m. She said she wasn't sure if the resident e trying to express pain or if his yelling was psychological. She said when people approached the resident, he would scream and yell. She said she thought he was in fear sometimes, but could not clearly describe a reason for her conclusion. She said she did not know if his vision was poor, which could contribute to the yelling. She did not know if the resident's yelling was related to the time of day staff got him out of bed. 7. The social services assistant (SSA) and social services manager (SSM) were interviewed on 5/3/17 at 12:49 p.m. -The SSA said if the resident was comfortable, he wouldn't be yelling so much. She said the resident's yelling was related to his anxiety, over-stimulation or was attempt to let someone know he needed something because he could not use call light. The SSA said the resident hollered out when left alone and required assistance. -The SSM said it was difficult to figure out what was going on with the resident. She stated he looked uncomfortable at times. She said she spoke with the hospice social worker who agreed his yelling was a way of communicating a need. The SSM said the frequency of the resident's yelling suggested the resident's needs not being met. None of the staff above said facility staff had met as an interdisciplinary team to assess the resident's frequent calling out. None of the staff above reported they had received training on how to understand the resident's behavior, how to approach the resident to minimize his behavior, and evaluate the cause for the resident's behavior and differentiate the need he might be expressing in order to meet it appropriately. None of the floor staff observations were gathered by the management team to know the resident was most comfortable and in a peaceful state when he was able to lie in his bed. There was no evidence to show the facility captured floor staff interviews to understand his behaviors related to issues poor vision, fear, time of day - The failure to capture information from the floor staff prevented development into the information and incorporation into his care plans above. 2. Failure to adequately evaluate and address pain as a cause for the resident's behavior Record review and staff interviews revealed the facility failed to consistently evaluate the resident's pain, monitor the resident's pain, and implement planned interventions to determine the effectiveness of planned interventions in addressing pain as a potential cause for the resident's behavior. a. Record review Record review revealed resident #63 had orders for scheduled and as needed (PRN) pain medication, and care plans that addressed pain directly and indirectly, as well as a hospice plans of care addressing pain. Medication orders and administration: Review of the May 2017 computerized physician orders [REDACTED].>-The resident currently was ordered 4/21/17 to receive: [MEDICATION NAME] Concentrate ([MEDICATION NAME]) (narcotic pain medication) 5 milligrams (mg) by mouth every six hours for pain; [MEDICATION NAME] Concentrate, give 5 mg by mouth every two hours as needed (PRN) for severe pain; and Tylenol (pain medication), give 650 mg by mouth every six hours as needed for pain related to other chronic pain. (Review of the CPO revealed that prior to 4/21/17, the resident had been receiving [MEDICATION NAME], a different narcotic medication for pain.) -Staff was to observe for pain every shift. If pain was present, the facility was to treat with non-pharmacologic interventions and document in progress notes. Care plans addressing pain management: The facility's pain care plan, initiated on 2/1/17 and revised on 4/12/17, revealed the resident had chronic pain related to disease processes. The goals were the resident's assigned nurse would monitor the resident for adequate pain relief of pain or ability to cope with incomplete relieved pain; resident would not have discomfort; resident will display a decrease in behaviors of inadequate pain control hollering, agitation and irritability. Interventions included: -Pain was aggravated by repositioning during care -Pain alleviated by repositioning and medication -Administer medication prior to treatments and therapy -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain -Notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain -Report and observe changes in usual routine, sleep patterns, and withdrawal or resistance to care; document and observe for probable cause of each pain episode (remove and limit causes) -Observe/record/report to nurse any signs and symptoms of non-verbal pain - changes in breathing, vocalizations, mood/behavior; eyes, facial, and body changes; -Provide non-pharmacological interventions of positioning, exercise program, activity program, music, chaplain support, counseling support through social services. The activity of daily living (ADL) care plan initiated, on 10/31/16 and revised on 1/26/17, had a goal to improve the resident's level of function. In addition to a directive for two staff to provide shower/bath, the care plan indirectly addressed the resident's pain in that it included interventions for staff to ensure pain management prior to ADLs (activities of daily living) and to provide a sponge bath when a full bath or shower could not be tolerated. The hospice care plan, initiated on 2/23/17, revealed the resident received services for support and comfort care as a result of persistent pain, anxiety, and end of life. The goal was the resident's quality of life would be enhanced and suffering relieved through comfort care. Interventions included: consult with hospice about needs prior to the physician contact; respect and honor the resident and family preferences and wishes. -The 3/2/17 hospice plan of care (POC) showed the resident was unable to communicate his pain but demonstrated non-verbal cues of grimacing, moaning/crying, irritability, and restlessness. -The 3/16/17 hospice POC revealed on 3/15/17, the resident's indicators of pain were moaning, restlessness and irritability. Failures in implementation of the above pain management plans: (1) Record review Review of resident #63's Medication Administration Records/Treatment Administration Records (MAR/TAR) and interdisciplinary progress notes for March and April revealed issues with how the resident's pain was assessed and addressed. Specifically: -Staff recorded pain levels on the MAR/TAR from 1 - 8 (with 10 being the worst pain), but there was no documentation how the resident's pain was measured (whether using a numerical pain scale that asked the resident or a pain scale that observed the resident's expression and behaviors). -Interdisciplinary progress notes from 3/1/17 through 5/4/17 revealed staff did not document the use of non-pharmacological interventions prior to the use of medication for pain or document the reason PRN pain medication was administered. -Interdisciplinary progress notes from 3/1/17 through 5/4/17 revealed inconsistent documentation of the justification for the administration of PRN medication and of the pain scale used to assess the resident's pain. Specifically: --On 3/6/17, 3/7/17, and 3/21/17, 3/24/17, 3/25/17, 3/26/17, 3/30/17, 4/3/17, 4/7/17, 4/8/17, 4/9/17, 4/12/17, 4/13/17, 4/17/17, 4/18/17, 4/21/17, 4/22/17, 4/23/17, 4/26/17, 4/27/17, 5/1/17, 5/2/17, narcotic pain medication was administered related to chronic pain. The nurse in each event reported the resident was unable to communicate pain and no pain scale for cognitively impaired was used. --On 3/4/17, 3/5/17, 3/10/17, 3/19/17, 4/1/17, 4/7/17, 4/9/17, 4/15/17, narcotic PRN administered was without justification or signs or symptoms for administration of medication. Physician notes revealed on 3/8/17, the resident had dementia without behaviors and his chronic pai[DIAGNOSES REDACTED] was under control. He received [MEDICATION NAME] and [MEDICATION NAME]. He received an [MEDICATION NAME] for dementia. On 5/3/17, the physician revealed the issue was the resident's pain because he was non-verbal. He instructed the facility to use the pain scale for advanced dementia (PAINAD) when evaluating the resident. There was no evidence the physician was aware of the behaviors the resident exhibited or evaluated the resident for his yelling and whether it contributed to pain, agitation, or cognition. (2) Observations See above observations of resident #63 constantly yelling when a staff entered the resident's room on 5/1/17, beginning at 9:18 a.m. Review of the MAR/TAR revealed no PRN medication was administered the morning of 5/1/17 prior to care. See above observations of resident #63's response to his shower with the HCNA on 5/2/17, beginning at 11:08 a.m. Neither observation nor interview with the HCNA revealed the resident was offered a sponge bath, as care planned when a full shower cannot be tolerated. (3) Staff interviews Staff interviews confirmed inadequate assessment and monitoring of the resident's pain and failure to implement the resident's care plans to manage his pain. RN #5 was interviewed on 5/2/17 at 12:50 p.m. She said she was not able to assess the resident's pain level. She said based on his mental status, he could not provide a pain level on a 1 to 10 scale. She said it was her practice to document in the record that she could not assess the resident's pain due to his mental status. She said she did not use any formal scale to evaluate the resident's pain because he was unable to verbalize pain. The staff development coordinator (SDC) was interviewed on 5/2/17 at 3:58 p.m. The SDC stated she had completed a pain evaluation for the resident today which, per her documentation, revealed the resident had pain frequently, it limited his day to day activities and made it hard to sleep at night. Using a faces pain scale, the resident's worst pain was a level 4. The SDC said she based her evaluation on how she viewed the resident during night shift observations. She said did not speak with day shift aides or nurses for information on the resident's behaviors or observations physical/nonverbal signs of pain and she did not speak with the resident because he had difficulty communicating or speak with his roommate/spouse. Licensed practical nurse (LPN) #1 was interviewed on 5/3/17 at 9:47 a.m. He stated he thought the resident was agitated and did not believe the resident was in pain. He said the resident only yelled when people approached him, assisted him with eating, or with repositioning. He was unable to provide when he administered anti-anxiety medication versus pain medication when the resident was seen yelling out. D. Facility Leadership Interviews The director of nursing (DON) was interviewed on 5/4/17 at 10:33 a.m. The DON stated the issue was trying to determine if resident #63 yelled out because of pain or if it was his method of communication. She said the facility believes it was his way of communication but it is still unknown what he tries to tell people when he is yelling. -The DON stated she did not realize nursing staff reported they were unable to assess the resident's pain level; she said staff will be educated on how to evaluate residents with cognitive impairment. She stated she did not know how staff were evaluating and gathering information to conduct pain evaluations for the resident. -The DON stated she did not know if staff were aware or familiar with his preferences and approaches to intervene when he began to yell. She agreed the resident needs should be met if he was trying to communicate and the facility should take the necessary steps to make him comfortable. The medical director (MD) was interviewed on 5/3/17 at 9:31 a.m. The MD stated the resident was not seen for a pain management program because of his comfort care status on hospice. -The MD stated he looked at the resident's record and was aware of the concerns related to adequately monitoring the resident's pain level. The MD stated he directed facility staff to use the pain scale for advanced dementia (PAINAD) moving forward. He stated changing pain medications without adequately knowing if the resident was in pain could cause the resident agitation and indicated there had not been adequate monitoring after the change in the resident's pain medication from [MEDICATION NAME] to [MEDICATION NAME] for any potential adverse side effects. -The MD acknowledged concerns associated with starting the resident on [MEDICATION NAME] when it was unknown if his yelling out was due to pain, agitation, or dementia diagnosis. He stated there were other medication options beside [MEDICATION NAME]. He stated there was an issue with communication with hospice providers and pain medications could increase toxicity levels. II. Diabetic Management A. Facility Policy and Procedure The Diabetic Management policy, revised 6/08, was provided on 5/3/17 by the director of nursing (DON). The policy included: Blood glucose measurements are taken per the physicians order. Results outside of ordered parameters are communicated to the physician immediately. The Medication Administration policy, last revised 6/08, also provided by the DON, included: Resident medications are administered in an accurate, safe, timely and sanitary manner. Administer medications within sixty minutes of the scheduled time. B. Resident Status Resident #17, age under 55, was admitted on [DATE] and re-admitted on [DATE]. According to the May 2017 CPOs, [DIAGNOSES REDACTED]. According to the 3/23/17 MDS assessment, the resident had no cognitive impairment and was independent with decision making. According to the resident's care plan, initiated 12/11/16 and last revised 3/6/17, the resident was an insulin dependent diabetic. Interventions included: -Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness; -Fasting serum blood sugar (glucose) as ordered by doctor; -Identify areas of non-compliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified road blocks to compliance; -Observe/document/report PRN any signs/symptoms of [MEDICAL CONDITION] (high blood glucose); -Observe/document/report PRN any signs/symptoms of [DIAGNOSES REDACTED] (low blood glucose); and -Observe/document/report PRN compliance with diet and document any problems. C. Record Review 1. Physician Orders According to the May 2017 CPO, the resident had the following orders: -Finger stick blood sugar two times a day. Call physician if blood glucose (BG) is less than 70 or greater than 300; -Give snack for any BG below 70. Notify the physician if BG is below 60, three times a day for low blood sugar (blood sugar was only ordered to be checked twice a day); -[MEDICATION NAME] Insulin inject 60 units subcutaneously two times a day for diabetes; and -[MEDICATION NAME] inject 1.2mg subcutaneously one time a day for diabetes. 2. Medication administration records (MARs) showed BGs outside physician-ordered parameters without evidence of notification According to the March 2017 MAR, the resident had BG results out of parameters on the following dates/times with no documentation that the physician was notified as per order: On 3/3/17 at 4:00 p.m. BG was 451; On 3/4/17 at 7:30 a.m. BG was 314; and On 3/29/17 at 4:00 p.m. BG was 303. According to the April 2017 MAR, the resident had blood glucose (BG) results out of parameter on the following dates/times with no documentation that the physician was notified as per order: On 4/2/17 at 4:00 p.m. BG was 67; On 4/3/17 at 4:00 p.m. BG was 497; On 4/11/17 at 4:00 p.m. BG was 329; On 4/18/17 at 7:30 a.m. BG was 68; On 4/20 at 7:30 a.m. BG was 303 and at 4:00 p.m. BG was 347; On 4/21/17 at 4:00 p.m. BG was 309; On 4/22/17 at 7:30 a.m. BG was 309 and at 4:00 p.m. BG was 315; and On 4/26/17 at 4:00 p.m. BG was 302. -The resident refused to have his blood glucose checked 11 times during the month with no documentation that the physician was notified. 3. Medications given outside physician-ordered time frames According to the March 2017 Location of Administration Report, the resident's [MEDICATION NAME] injection was due to be administered at 9:00 a.m. It was documented the resident received this injection on the following dates/times out of the prescribed time frame: 3/1/17 given at 10:23 a.m.; 3/2/17 given at 10:21 a.m.; 3/14/17 given at 10:40 a.m.; 3/17/17 given at 10:43 a.m.; 3/20/17 given at 10:05 a.m.; 3/21/17 given at 10:17 a.m.; 3/22/17 given at 10:12 a.m.; 3/23/17 given at 10:33 a.m.; 3/24/17 given at 11:04 a.m.; 3/27/17 given at 10:24 a.m.; 3/28/17 given at 10:33 a.m.; 3/29/17 given at 10:10 a.m.; and 3/30/17 given at 10:04 a.m. According to the March 2017 Location of Administration Report, the resident's [MEDICATION NAME]was due to be administered at 9:00 a.m. and 8:00 p.m. It was documented the resident received this injection on the following dates/times out of the prescribed time frame: 3/1/17 given at 10:20 a.m.; 3/2/17 given at 10:19 a.m.; 3/3/17 given at 9:28 p.m.; 3/7/17 given at 9:34 p.m.; 3/8/17 given at 9:36 p.m.; 3/13/17 given at 9:17 p.m.; 3/14/17 given at 10:40 a.m.; 3/17/17 given at 10:43 a.m.; 3/20/17 given at 10:03 a.m.; 3/21/17 given at 10:18 a.m.; 3/22/17 given at 10:10 a.m.; 3/23/17 given at 10:32 a.m.; 3/24/17 given at 11:04 a.m.; 3/27/17 given at 10:23 a.m.; 3/28/17 given at 10:33 a.m.; 3/29/17 given at 10:10 a.m. and 9:26 p.m. and 3/30/17 given at 10:04 a.m. According to the April 2017 Location of Administration Report, the resident's [MEDICATION NAME] injection was due to be administered at 9:00 a.m. It was documented the resident received this injection on the following dates/times out of the prescribed time frame: 4/1/17 given at 10:57 a.m.; 4/10/17 given at 10:23 a.m.; 4/11/17 given at 10:09 a.m.; 4/18/17 given at 10:05 a.m.; 4/19/17 given at 10:11 a.m.; 4/20/17 given at 10:18 a.m.; 4/21/17 given at 10:04 a.m.; 4/22/17 given at 11:20 a.m.; 4/24/17 given at 10:59 a.m.; 4/26/17 given at 10:38 a.m.; 4/27/17 given at 11:14 a.m.; and 4/28/17 given at 10:01 a.m. The resident did not receive/refused this injection on 4/3/17, 4/29/17 and 4/30/17 with no documentation the physician was notified. According to the April 2017 Location of Administration Report, the resident's [MEDICATION NAME]was due to be administered at 9:00 a.m. and 8:00 p.m. It was documented the resident received this injection on the following dates/times out of the prescribed time frame: 4/1/17 given at 10:56 a.m. and 9:23 p.m.; 4/2/17 given at 11:26 a.m.; 4/5/17 given at 9:33 p.m.; 4/10/17 given at 10:22 a.m.; 4/11/17 given at 10:09 a.m.; 4/12/17 given at 9:17 a.m.; 4/14/17 given at 9:18 p.m.; 4/17/17 given at 10:33 a.m.; 4/18/17 given at 10:05 a.m.; 4/19/17 given at 10:10 a.m. and 9:18 p.m.; 4/20/17 given at 10:18 a.m.; 4/21/17 given at 10:02 a.m.; 4/22/17 given at 11:19 a.m.; 4/23/17 given at 9:30 p.m.; 4/24/17 given at 10:58 a.m.; 4/26/17 given at 10:38 a.m. and 9:01 p.m.; 4/27/17 given at 11:13 a.m.; and 4/28/17 given at 10:01 a.m. The resident did not receive/refused this injection on 4/21/17 at 8:00 p.m., 4/29/17 at 9:00 a.m. and 4/30/17 at 9:00 a.m. and 8:00 p.m. with no documentation the physician was notified. D. Staff Interviews LPN #3 was interviewed on 5/3/17 at 9:15 a.m. She said medications should be given an hour before t

Based on observations, record review and interview with residents and staff, the facility failed to identify issues for which quality assessment and assurance (QA) activities were needed in the areas of resident assessment, resident behavior and facility practices, quality of life, and quality of care, and failed to develop and implement effective plans of action to correct identified quality deficiencies affecting facility residents. The facility failed to have a consistent process resulting in F309 as being cited at a G. The findings included: A. Failure to maintain compliance in the area of Resident Behavior and Facility Practices, Resident Assessment, Quality of Life, Quality of Care, Dietary Services, and Infection Control. The facility was cited with 21 deficiencies (cross reference F221, F241, F246, F248, F250, F253, F279, F280, F309, F312, F314, F315, F319, F323, F332, F334, F371, F441, F514) during the recertification and abbreviated survey exiting 10/12/16. One quality of care deficiency was cited at actual harm (F309) for not assessing, monitoring, investigating and managing residents' pain. B. Resident Behavior and Facility Practices *F221 (repeated citation) - failure to ensure resident (#87) use of restraint had corresponding order and was evaluated on a regular basis. C. Resident Assessment F279 - failure to develop care plans that reflected resident #87 ' s current status. F280 - failure to ensure resident #53 was invited and provided a care conference. D. Quality of Life F241 - failure to ensure residents #9 and #74 were treated in a dignified manner. F246 - Failure to use communication devices for resident #9 and not having call light within reach for resident #90. F248 - failure to provide activity program designed to meet resident interests and psychosocial needs for residents #87 and #9. *F250 (repeated citation) - failure to provide ancillary services for residents #41, #99, and #134. *F253 (repeated citation) - failure to prevent odors and maintain clean environment. E. Quality of Care *F309 (repeated citation) - failure to: - ensure pain medications were readily available for resident #139 and by not having them available the resident experienced an increase in pain over two-day period of time; - ensure effective pain management program for residents #139, #134, #90, and #9; - notify the surgeon of the failed hardware for resident #139 which resulted in an increase in her pain level; - provide pin care treatment according to physician orders [REDACTED]. - ensure effective coordination with hospice related to proper wheelchair management and feeding responsibilities for resident #87; and - ensure communication between the [MEDICAL TREATMENT] center and the facility for resident #145. *F312 (repeated citation) - failure to provide timely and consistent toileting assistance for residents #1 and #93. *F314 (repeated citation) - failure to adequately track and monitor pressure ulcers to ensure management of ulcers was effective in promoting healing and in preventing complications for residents #30 and #71. F315 - failure to justify the use and provide assessments and ongoing monitoring of the indwelling catheter for resident #138. F319 - failure to provide behavioral plan for resident #134. *F323 (repeated citation)- failure to conduct a fall follow up for resident #132 and failed to ensure safe transfers with resident #9. *F332 (repeated citation) - failure to prevent less than 5% medication error rate - the medication pass observation error rate was 11.5%, or three errors out of 26 opportunities for error and non-significant medication errors. F334 - failure to offer the influenza vaccine for residents #87 and #41. F. Dietary Services *F371 (repeated citation) - failure to ensure food was prepared and stored in a sanitary manner. G. Infection Control *F441 (repeated citation) - failure to identify the infection control preventionist or institute an effective infection control program. H. Administration F514 - failure to provide and maintain accurate records for residents #134 and #84. *F520 (repeated citation) - failure to prevent the repetitive citations and develop effective quality assurance plans to maintain regulatory compliance. There were 11 out of the 21 cited deficiencies were repeatedly cited from the previous year ' s survey exiting on 12/8/15. (The * indicated areas below were re-cited from the recertification and extended survey.) Indicating the facility's failure to develop effective quality assurance plans to maintain regulatory compliance. The citations were: F221 D; F250 D; F253 E; F309 D; F312 D; F314 D; F323 K; F332 D; F371 F; F441 D; and F520 F. I. F221 During the 12/8/15 recertification and extended survey F221 was cited at a D for isolated failure to perform an interdisciplinary team evaluation to determine alternatives to the use of a seat belt and address the risk of decline, failed to complete a comprehensive assessment prior to initiating the use of a seat belt, failed to ensure a medical symptom requiring the use of a restraint was identified in the order, and failed to periodically remove the seat belt for residents. During the 10/12/16 recertification and abbreviated survey, F221 was cited again and at the same level (D) for use of restraint without a corresponding order and not evaluated on a regular basis. J. F250 During the 12/8/15 recertification and extended survey F250 was cited at a D for isolated failure to assess and develop a plan to address the reasons the resident had been refusing medications. During the 10/12/16 recertification and abbreviated survey, F250 was cited again and at a higher level (E) for not providing ancillary services for residents. K. F253 During the 12/8/15 recertification and extended survey F253 was cited at a E at more than minimal harm at a pattern for failure to assess and develop a plan to address the reasons the resident had been refusing medications. During the 10/12/16 recertification and abbreviated survey, F250 was cited again and at the same level (E) for not providing ancillary services for residents. L. F309 During the 12/8/15 recertification and extended survey F309 was cited at a D for isolated failure to notify the physician and ensure follow up from the physician of abnormal blood glucose results and medication refusals. During the 10/12/16 recertification and abbreviated survey, F309 was cited at a higher level (G) for not providing effective pain management programs for residents, coordinating the communication between hospice and [MEDICAL TREATMENT] center, and provide treatments as ordered by the physician. M. F312 During the 12/8/15 recertification and extended survey F312 was cited at a D for isolated failure to provide the assistance the resident required to maintain good grooming and personal hygiene. During the 10/12/16 recertification and abbreviated survey, F312 was cited again and at the same level (D) for not providing consistent incontinence care to residents. N. F314 During the 12/8/15 recertification and extended survey F314 was cited at a D for isolated failure to provide repositioning assistance for residents at risk for pressure ulcers. During the 10/12/16 recertification and abbreviated survey, F314 was cited again and at the same level (D) for failing to adequately track and monitor pressure ulcers to ensure management of ulcers was effective in promoting healing and in preventing complications for residents. O. F323 During the 12/8/15 recertification and extended survey F323 was cited at a K with immediate jeopardy with pattern for failure to ensure at risk residents received adequate supervision to prevent elopement. During the 10/12/16 recertification and abbreviated survey, F323 was cited again and at a lesser level (D) for failing to conduct a fall follow up and ensure safe transfers with residents. P. F332 During the 12/8/15 recertification and extended survey F332 was cited at a D for isolated failure, the facility medication administration error rate was 11% with a total of three errors out of 27 opportunities for error. During the 10/12/16 recertification and abbreviated survey, F332 was cited again and at the same level (D) for the medication pass observation error rate was 11.5%, or three errors out of 26 opportunities for error and non-significant medication errors. Q. F371 During the 12/8/15 recertification and extended survey, F371 was cited at a F for widespread failure to follow proper hand washing hygiene and ensure cutting boards were free from scratched and scored surfaces and in sanitary condition. During the first revisit 2/14/16 to the 12/8/15 recertification and extended survey, F371 was recited at a F. And, during the 10/12/16 recertification and abbreviated survey, F371 was cited again at the same level (F) for not ensuring food was prepared and stored in a sanitary manner. R. F441 During the 12/8/15 recertification and extended survey F441 was cited at a D for isolated failure to change a soiled toilet brush after direct contact with feces and failed to ensure staff sanitized their hands after the removal of gloves. During the 10/12/16 recertification and abbreviated survey, F441 was cited again at a highter level (F) for not identifying the infection control preventionist or instituting an effective infection control program. S. F520 During the 12/8/15 recertification and extended survey F520 was cited at a F for widespread failure to maintain compliance in the area of Resident Behavior and Practices, Quality of Life, and Quality of Care, Nursing Services, Dietary Services, Pharmacy Services and Administration. During the 10/12/16 recertification and abbreviated survey, F520 was cited again and at a higher level (G) for not maintaining compliance in the areas of Resident Behavior and Facility Practices, Resident Assessment, Quality of Life, Quality of Care, Dietary Services, and Infection Control. T. Staff interviews The nursing home administrator (NHA), interim director of nursing (IDON) #1 and #2, and the clinical regional consultant were interviewed on 10/11/16 at 4:52 p.m. The NHA said the quality assurance/performance improvement (QAPI) meetings were held monthly with the following attendees: NHA, receptionist, IDON, minimum data set (MDS) coordinator, business office manager, maintenance director, dietary manager, health information manager, rehabilitation manager, director of housekeeping/laundry, resident care services manager, central supply, social service director (SSD), activity director, admissions, and staff engagement coordinator. She said certified nursing aides (CNAs) could get information to the meetings through the IDON but did not usually attend the meetings. She said the medical director attended the meetings on a quarterly basis not monthly. She said during the time she did not have an IDON she had the MDS coordinator or another nurse in the facility acting as the IDON during the meetings. She said any staff member could bring a concern to the meeting by giving the information to the department heads. She said concerns addressed during the daily morning meetings were covered during the QAPI meetings. She said she would re-open the performance improvement plans from the previous survey which had been closed because she felt they had met the goals. She said the restraint for resident #87 was addressed in the QAPI meetings but they chose to take him in the bed from the hospital due to the wife begging. She said she did not know what else to do for the resident but could not turn him away. She did not understand they had failed to get a consent, do an assessment of need, or try alternate interventions for the restraint. She said they could not pad his room and allow him to crawl around freely because he scraped his elbow once she was told by the physician to never let it happen again. She did not try elbow pads and other less restrictive interventions before using the bed cage restraint. She said infection control issues were monitored monthly. She did not mention during this interview the facility had not identified an infection control preventionist or have an effective infection control program. She said they had started a new performance improvement plan for the kitchen staff because the dietary manager identified new staff were not washing their hands and were touching the drinking surfaces of cups. She said they had corrected the issues from last year but it had come up again during the meetings. She said she observed the kitchen staff on hand washing in the kitchen. She said the dietary manager and registered dietician were doing the audits on the kitchen staff. She said she thought this had been corrected so she would re-open the performance improvement plan (PIP) regarding choices on being given showers and at the time they choose. She said she would re-educate the staff on documenting bathing in the medical records consistently to include refusal of cares. She said resident #9 was started on speech therapy (ST) services in order to educate the resident on how to use the computer and communication device as of 10/4/16. She said they review restraint use in the facility and they review who was on a restraint, number of restraints in the building, have the assessments, orders, and consents been completed and do they need the device. She said they recently identified ancillary services were not being provided so they started an action plan this week. She said the team addressed pain management programs during the morning meetings but not recently in QAPI meeting. The IDON #1 said she identified two weeks ago the program needed work and had arranged for the meeting with the wound/ostomy care nurse (WOCN) which was to take place later today. She said they discussed whether wounds had been acquired on site or not during the meetings. She said they had done well with managing falls and had improved the number of falls. She will re-open the action plan regarding immediate notification of DON and NHA for interventions, incident reports being completed timely, documentation completed timely, and interventions in place immediately. She said she would have expected the medication pass issues to come to light during the medication pass observation done by the pharmacy consultant. The IDON and NHA stated they conducted QAPI on the entire 12/8/15 recertification and extended survey and that the deficient practice identified in the survey was addressed.

Based on resident observations and interviews, record review, and staff interviews, the facility failed to ensure each resident received and provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for six residents out of 43 sampled resident (#90, #134, #139, #87, #9, and #145). Specifically, the facility failed to: - ensure pain medications were readily available for resident #139 and by not having them available the resident experienced an increase in pain over two-day period of time; - ensure effective pain management program for residents #139, #134, #90, and #9; - notify the surgeon of the failed hardware for resident #139 which resulted in an increase in her pain level; - provide pin care treatment according to physician orders [REDACTED]. - ensure effective coordination with hospice related to proper wheelchair management and feeding responsibilities for resident #87; and - ensure communication between the [MEDICAL TREATMENT] center and the facility for resident #145. Resident #90 yelled out for over an hour in pain while staff ignored her. She experienced an unnecessarily high pain level while yelling out for help. The nurse had been encouraged to check on the resident's pain medication dosing times but instead the nurse continued to ignore the resident. The resident said her pain level was ten out of ten and she was in extreme pain the entire time she yelled out for help. Resident #139 experienced a high pain level when the screws in her leg came out. The staff called the physician who in turn said to monitor and wait until the surgeon visit later in the week. The resident experienced an increase in her pain level during this time but nothing was ordered to help her. She said her pain level during this time was ten out of ten and the staff did nothing while she suffered. She was sent to the hospital two days after discovery of the pins backing out. There was no pain management system put into place during this time, she was provided the same pain management program as she had upon admission when the pins were intact and she was not in as much pain. She said her pain level before the pins came out was five out of ten and easily managed with the pain medications provided at the time. The staff failed to do the pin care as ordered by the physician which could have helped them with early detection of the screws backing out. The findings included: A. Resident #139 Resident status Resident #139, under the age of 65, was admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. According to the 8/1/16 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score was 15 out of 15. She frequently experienced pain but it did not interfere with daily activities or sleep. She required extensive assistance of two persons with bed mobility, transfers, dressing and personal hygiene. Her primary mobility device was the wheelchair (w/c). 1. Pain Resident observation/interview On 10/10/16 (Monday) at 11:03 a.m. the resident said she did not have her pain medication used for breakthrough pain since Friday. She said the nurses were calling the pharmacy but did not get any medication over the weekend. She said the doctor did not send in the prescription to the pharmacy. She said her pain level was ten out of ten and she had not been able to sleep because she could not get her pain under control. She said ten out of ten pain level was not tolerable to her. She felt her pain was out of control. She said elevating her leg did not help with relieving her pain symptoms. She said her leg swells and it causes pressure in her cast which results in her experiencing an increase in pain. She said by taking the pain medications for the breakthrough pain she can tolerate the severe pain she had in the right leg. Staff interviews Registered nurse (RN) #3 was interviewed on 10/10/16 at 11:04 a.m. He said the nurse who worked with the resident on Friday realized the prescription had run out and called the doctor but the doctor had not faxed the prescription to the pharmacy over the weekend. No one had called the on-call doctor or pharmacy over the weekend to obtain an order, so he was going to call the doctor's office after he called the pharmacy. He wanted to find out if the pharmacy had received the prescription from the doctor and was filling it. The resident kept saying to him during the interview that she was in a lot of pain to her right leg. He told her he was sorry and was working on getting her medications as quickly as he could. He said she took a long acting pain medication but understood that it did not help her with the breakthrough pain. He said the way he would re-order medications was to remove the sticker from the medication label and fax to the pharmacy. He said there was a way to re-order medications directly through the electronic Medication Administration Record [REDACTED]. He said he had ordered medications in the past this way but had not received the medications from the pharmacy so he continued to remove the stickers from the labels and affix them to a piece of paper that he faxed to the pharmacy. He said the sticker contained the amount of refills were remaining on a medication. He said the nurses had accessibility to emergency kits containing the pain medication this resident used for breakthrough pain but this was not the issue with this resident's case, the physician had not sent the prescription to the pharmacy until today. He could not say what time the nurse on Friday had requested the physician to re-fill the prescription. He said as soon as the pharmacy received the prescription they would fill it and so it would be in the building shortly. Record review The care plans provided by the facility did not mention her pain issues. The 10/16 electronic Medication Administration Record [REDACTED]. The medication had not been given since Friday morning. The 8/4/16 pain assessment documented the resident had frequent pain to the right leg and pain medications were effective. 2. Notification of surgeon and pin care treatment Resident observation/interview The resident was interviewed on 10/10/16 at 12:45 p.m. She said the staff did not clean the pin sites on the fixator device she had on her right leg a couple of months ago. She said it became infected and she had to be hospitalized . She said the doctor was discussing amputation to the right leg since the infection was serious. She described the wounds around the pin sites as oozing puss and blood. She said her leg was bent in the wrong direction and swollen. She said she did not understand how the nurses could see her every day suffering in severe pain and do nothing to help her. She said the staff made her wait until she saw her surgeon a couple of days later. She said she was in extreme pain and it was the worst thing she had to experience up to the point in her life. Record review The 7/16 electronic medication administration records (eMARs) documented the resident was receiving [MEDICATION NAME] in [MEDICATION NAME] solution 750 milligrams (mg)/150 milliliters (ml)-Infuse 750 mg intravenously every 12 hours related to infection and [MEDICAL CONDITION] reaction due to internal fixation device of right tibia. The resident took the medication approximately every four hours as allowed per physician order [REDACTED]. The resident's average pain level was ten out of ten with some relief from taking the as needed [MEDICATION NAME]. The 7/26/16 physician order [REDACTED]. It does not specify what product to use to provide the pin care. The 7/16 treatment administration record (eTAR) did not contain the pin care treatment order, it was not signed as being completed. The 7/27/16 at 1:33 p.m. skin/wound note documented, Resident is experiencing pain. Client was medicated before skin assessment. Skin was assessed this date. Right outer ankle 12 cm (centimeters) x (by) 4 cm x ukn (unknown). Scant serous drainage. No odor noted. Right inner ankle 7.5 cm x 2.75 cm x ukn. Blood tinged drainage. Stitches are intact. Fixation device in place with six pins, 3 (three) on each side of foot. Lower calf 5 (five) pins, 2 (two) on each side of lower calf, 3 (three) on shin. Blood tinged drainage noted on all pins. Client continues [MEDICATION NAME] per PICC (peripherally inserted central catheter) line. Will continue to monitor until healed. The 7/30/16 at 1:21 p.m. nursing notes documented, Resident has an [DEVICE] to her right lower leg. The screws located at the top of the foot are backing out. She was also bleeding a little more. Dr. (doctor) . on-call was called and reported to about the screws backing out. The on-call told us there wasn't anything they could do about the screws coming out until she went back to orthopedic doctor. We are to monitor and call back if she starts bleeding more. There was no mention of the increase in pain the resident said she experienced. The 7/31/16 at 9:52 a.m. nursing notes documented, Resident cont (continue) on ABO (antibiotics) for infection c/o (complained of) pain to leg concerned about blood at sites explained md (medical doctor) was notified yesterday and stated he said to monitor until follow up with ortho (orthopedist). Resident upset stating she will call 911 cont to redirect and medicate as needed for pain will cont to monitor. The 7/31/16 at 7:52 p.m. nursing notes documented, Resident cont (continue) on ABO (antibiotics) for infection, no adverse effects noted R/T (related to) ABO therapy. C/O (complained of) pain to leg and is concerned about blood at sites reminded her that MD (medical doctor) was notified yesterday and stated he said to monitor until follow up with Ortho (orthopedist). Will cont to monitor for safety and needs. The 8/1/16 at 6:56 p.m. nursing notes documented, Resident [DEVICE] failed. The screws had come out of her foot. The doctor gave the order to send her to hospital for evaluation and treatment. She went by ambulance via stretcher at 9:30 a.m. Received a call around 12:15 p.m. to 12:30 p.m. by a doctor . stating he had spoken with her orthopod (orthopedist) in Denver and he wanted to transfer (the resident) to clinic in Denver and fix the [DEVICE]. Called the hospital ER (emergency room ) at 6:30 p.m. she is now admitted to hospital at this time. The 8/1/16 emergency room note documented, [AGE] year-old female past medical history of [REDACTED]. There was a problem with healing, and surgery again was done at a Denver hospital on July 22 where patient received an external fixation device. Patient has been staying in nursing home since then for rehabilitation. She is currently on IV [MEDICATION NAME] for I am colonized [MEDICAL CONDITION]. Patient says sometime around July 28, she noted her foot suddenly became crooked at the ankle joint. Also, noticed that the external fixation screws were coming out. She alerted the nursing home staff, they told her that she should wait until her appointment which is coming up later this week. However, today, patient says the nursing manager agreed that she should go to the emergency room for evaluation. Patient says she continues to have no sensation in her foot. However, she is having severe pain in the ankle, as well as the mid-lower leg. She denies new trauma to the lower extremity and does not know how this happened .There is obvious deformity at the malleolus joint. Distal foot is medially deviated. Patient unable to flex or extend toes, though she says this is normal since the surgery .There is mild swelling from the mid-tibia down through foot There are external fixation screws that appeared to be dislodged .She did require several doses of pain medication .The differential [DIAGNOSES REDACTED].X-ray obtained, confirms likely hardware malpositioning. Screws appear to be out of tibia. Osseous deformity noted on x-ray . Staff interviews Registered nurse (RN) #3 was interviewed on 10/10/16 at 3:16 p.m. He said he started working as a floor nurse full time on 9/22/16. He worked on the East unit prior and had not worked with the resident during the time she had the fixator and pins. He said if he observed inflammation or changes to the pins then he would contact the physician. If the physician said to monitor until surgeon visit but he saw that the pins were not seated correctly, then he would contact the surgeon to get her leg treated. He said he would use normal saline and a cotton swab to clean around the pin sites and was not sure of a facility policy on it. The interim director of nursing (IDON) #1 was interviewed on 10/12/16 at 9:58 a.m. She said she would expect the nurses to contact the surgeon as the leg worsened. She said she would expect the nurses to document well enough to show a timeline of events. She expected the nurses to follow the physician orders [REDACTED]. RN #5 was interviewed on 10/12/16 at 11:34 a.m. She said she did not work with the resident on the day she went to the hospital but had worked with her earlier in the week. She said the leg was infected and being treated with intravenous antibiotic medications. She said the resident was not compliant with taking the antibiotics routinely in fact she would refuse or not be available to accept the medication. She felt the leg was painful but believed the resident was drug seeking so she was not sure the resident's pain was as bad as what the resident described. She said the leg was not misshapen when she worked with the resident but it did have some redness around the pin sites and some bloody drainage. She said she remembered providing pin care treatments and thought there was an order for [REDACTED]. RN #2 was interviewed on 10/12/16 at 11:42 a.m. She said she worked with the resident the day she sent her to the hospital. She said the leg was swollen and red but she did not remember it being in a different shape or angle. She said she felt the resident had pulled the pins out over the night. She thought it was painful to the resident but no more than she normally complained of pain. She said when she finally got the doctor he did not want anything done. She thought the primary physician would have contacted the surgeon but she did not think to contact the surgeon. She said there was no conversation with the physician about her increase in pain because she did not believe the resident was in any more pain than usual even though the leg looked red and swollen. She said you know she is a drug seeker? She said she would document the resident's status in the progress notes. She was not aware the note did not describe what the leg or pins looked like. She said she could not remember if there were orders for pin care treatment but she would assume there was. She said she would clean the pin sites using whatever product the doctor ordered. B. Resident #134 Resident status Resident #134, under the age of 55, was admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. According to the 9/2/16 minimum data set assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had frequent pain. Resident and Staff observations/interviews The resident was interviewed on 10/4/16 at 2:30 p.m. and 10/5/16 at 11:35 a.m. She said the nurses would not give her pain medications to help with the severe pain she had in her feet. She said the medications they give her for her headaches do not help with the feet pain. She said she took the [MEDICATION NAME] which was ordered for her headaches, but because the doctor would not order other pain medications for her feet, she had to take the [MEDICATION NAME] to get some relief. She said she had told the staff which medications would be beneficial that she used in the past but the doctor would not order them. She said her physician ordered [MEDICATION NAME] for the nerve pain in her feet but it was not effective. She said the [MEDICATION NAME] was used for breakthrough pain on her feet and body but it was completely ineffective. She said the [MEDICATION NAME] had not been offered to her but it would not help her pain because her pain level was much worse than the light coverage of pain relief it offered. She said she would lay down to help with pain relief but it was effective for about an hour at best then she would have to get up and walk to lessen the pain. She said she needed to rest with her feet elevated longer because of the [MEDICAL CONDITION] but could not with the pain. She said her feet were swollen and it made the pain worse. She said she had been trying to tell the nurses and her doctor that her pain was not being managed but no one was listening to her. She said, I keep telling them I can't take the pain. It's more than I can handle. She said her pain level was eight out of ten. She said her pain level would worsen later in the day because of the swelling to her feet. She said she needed her diabetic shoes to protect her feet and they were on order. She said the podiatrist said she needed more surgeries to her feet but she had to get the pain under control before she pursued more surgeries. The resident was observed being measured for diabetic shoes on 10/10/16 at 2:05 p.m. which had been ordered on [DATE]. The resident was observed on 10/10/16 at 2:05 p.m. standing next to the medication cart explaining to the nurse her feet were hurting her badly. The nurse was attempting to medicate her with [MEDICATION NAME] but the resident kept asking for the [MEDICATION NAME]. The nurse asked the resident if she had a headache and the resident said no. The nurse told her she could not give her [MEDICATION NAME] for foot pain because it was ordered for headaches. The resident was getting frustrated because she said the [MEDICATION NAME] was not effective but was a little effective if used in conjunction with the [MEDICATION NAME]. The nurse said the staff was encouraging the resident to not use the [MEDICATION NAME] for other than what it was ordered for but the resident would frequently say she had a headache just to get the medication. She said they did not have any formal non-pharmacological interventions to help the resident with pain. She said at times the resident would lie down but would come back asking for the medication. The nurse gave the resident the [MEDICATION NAME] and did not offer any other non-pharmacological interventions. The nurse told the resident that the doctor would not order anything further for her so she needed to go to her room to rest. Record review The 9/2/16 pain care plan documented the resident had chronic pain related to rod placement in her right foot, back pain, nerve pain, and muscle spasms. Interventions included: - Administer pain medication prior to treatments and therapy, if indicated. - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance to care. - Observe/document for side effects of pain medication. - Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. - Observe/record/report to Nurse any s/sx (signs and symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). - Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. - Provide non-pharmacological interventions: i.e. positioning/support, exercise program, stretching exercises, activity programing, music, meditation, chaplain/religious support, counseling/support via social services, books on tape. - Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o (complained of) pain or discomfort. - The resident is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain. - The resident prefers to have pain controlled by: medication. The 10/5/16 polysubstance abuse care plan documented, the resident had polysubstance abuse with [MEDICATION NAME] and crack cocaine. Interventions included providing the resident with information related to polysubstance abuse and monitor her mood and behaviors. The 8/26/16 pain evaluation form documented, the resident had occasional pain which interfered with her sleeping at night but did not affect her day-to-day activities. There was no documentation on the location of the pain or the non-pharmacological interventions. The 10/16 medication administration records documented the following pertinent medications: [REDACTED] - Order Date: 8/26/16: [MEDICATION NAME] capsule 300 milligrams (mg): Give one capsule by mouth three times a day for nerve pain - Order Date: 8/26/16: [MEDICATION NAME] tablet 200 mg: Give four tablets by mouth every eight hours for pain - Order Date: 8/28/16: [MEDICATION NAME] tablet 325 mg: Give two tablets by mouth every eight hours as needed for elevated temperature and pain, not to exceed three grams in 24 hours - Order Date: 9/11/16 [MEDICATION NAME] tablet 50-325-40 mg: Give one tablet orally every six hours as needed for migraine headaches - Order Date: 9/22/16 [MEDICATION NAME] tablet 50-325-40 mg: Give two tablets by mouth every six hours as needed for migraine headache: Give two tablets for pain level six to ten - Order Date: 8/26/16 [MEDICATION NAME] tablet 10 mg: Give one tablet by mouth every 12 hours as needed for spasms The 9/16 and 10/16 electronic medication administration records (eMARs) revealed the resident usually took the maximum amount of the [MEDICATION NAME] that was prescribed every day. The 9/16/16 podiatrist progress note read the staff had reported the resident wanted more foot treatments in order to obtain more pain medications. He recommended the feet heal further since it was six months from prior foot surgery and obtain diabetic shoes before progressing to more surgeries. The 9/28/16 telephone order read to have the resident measured for the use of diabetic shoes. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 10/10/16 at 1:14 p.m. She said she has worked with the resident for the past couple of weeks. She said not all residents were asked about pain level. The computer prompted nurses to ask residents about pain level if the resident was taking a pain medication routinely or as needed or if the resident had a history of [REDACTED]. The rest of the residents were not asked unless they showed signs of pain or said they were in pain. She said this resident said her pain level was on average around eight to ten out of ten on the pain scale. She said she complained of headaches a lot which was why she was taking [MEDICATION NAME]. She said she coughed and smoked a lot and this was why her headaches were so bad. She said the resident would not lessen her activities so the pain cycle remained. She said the nurses have been working with her on distractions like laying down instead of taking [MEDICATION NAME]. The resident took the maximum amount of the medication she could in a day. She said she has a long history of drug abuse so they tried to distract her into other activities than pain and medications. Other than mentioning the laying down she had no other distraction type of activities to offer the resident. She said the resident was taking the [MEDICATION NAME] for bone pain along with [MEDICATION NAME]. She said the resident told her the medication was effective. She said she had no pain clinic referral. The activity director was interviewed on 10/10/16 at 4:37 p.m. She said the resident was invited to run some of the activities but would not show up. She discussed with the resident that she might want to attend or run the activities after she dealt with her legal and medical issues she had. She said she had no formal program for her because she was independent with her activities. The resident liked going outside to smoke and walk around the building socializing with other residents. She said she was not involved in distracting the resident from thinking about pain but thought it would help the resident if she would participate in activities. The interim director of nursing (IDON) #1 and the nursing home administrator (NHA) were interviewed on 10/12/16 at 10:21 a.m. The IDON said she worked at the facility as the interim director of nursing for the past two weeks but said she worked for the corporate office and used to visit the building in the past. She said the expectation was for nurses to determine a resident's pain level then treat according to the physician's orders [REDACTED]. She felt this should have been documented on the care plan. She agreed the resident's pain intensity would warrant the initiation of a care plan for pain. The NHA said she would expect the nurses to call the physician and notify him about the ineffectiveness of the current pain management plan. She said she would have expected the staff to discuss other alternatives with the physician like a pain clinic visit for the resident. Even though the resident's behaviors included going to doctor appointments frequently. She said she understood the difficult nature it was to care for this resident but wanted the nurses to respond to her needs. C. Resident #87 Facility Policy The facility's Hospice Care policy, dated June 2008, read, in pertinent part: The facility and Hospice agency are responsible for performing each of their respective functions that have been agreed upon and included in the plan of care .Ensure that the plan of care identifies the care and services which the facility and Hospice agency will provide .Ensure that facility staff is aware of their responsibilities in implementing the plan of care, as well as the responsibilities of the Hospice staff. Resident Status Resident #87, age 64, was admitted on [DATE] and readmitted on [DATE]. According to the 10/2016 computerized physician orders, [DIAGNOSES REDACTED]. The resident was admitted to Hospice care on 3/16/16. According to the 9/12/16 minimum data set (MDS) assessment, a brief interview for mental status (BIMS) score was not determined because the resident was not able to be understood. The resident required extensive assistance for all activities of daily living (ADLs). The care plan, initiated 6/30/16 and revised 9/14/16, identified the resident had an ADL self-care performance deficit related to severe cognitive deficits with adverse behaviors and non-ambulatory status. He used a Posey bed restraint throughout the day related to [MEDICAL CONDITION] with poor impulse control. Interventions included being out of bed for each meal and using a gerichair with lap tray for positioning and comfort. A physician order, dated 3/7/16, read, Do not use wheelchair. Patient up in gerichair supervised only. Hospice Plan of Care The Hospice plan of care, initiated 3/15/16, identified the resident had end-stage dementia. According to the care plan, two Hospice nurse aides were scheduled to provide a shower for the resident three times a week, on Mondays, Wednesdays, and Fridays. The care plan did not specify if the aides would feed the resident during each of these visits, or how this information would be communicated to facility staff. The resident ' s meal consumption records for September and October (through 10/5) did not clearly indicate if the resident received breakfast on the Hospice visit dates of 9/2, 9/12, 9/16, 9/26, 10/2, and 10/5. The Hospice plan of care documented a wheelchair would be supplied to the resident. The care plan did not identify there was a physician order [REDACTED]. Daily Hospice Aide Notes documented the resident received a shower, but did not always indicate if the Hospice aides fed him breakfast. A 10/3/16 note read, Pt (patient) was in bed on arrival. CNAs (certified nurse aides) transferred to bathroom and provided a full body shower and shave .CNA then fed patient breakfast. Transferred back to bed after eating. The Notes indicated staff was putting the resident into the wheelchair that Hospice provided rather than in the gerichair that was in his room. Observations On 10/5/16 at 9:35 a.m., two Hospice aides came up to the resident, who was seated in his wheelchair in the sitting room at the end of the hallway. The wheelchair did not have leg rests. The male aide came up behind the wheelchair and started to push him but did not notice that his feet were still on the floor. The resident yelled out. The female aide then bent over and lifted up his legs with her arms while the male aide pushed him to his room. There was a gerichair in the resident's room, but it was not being used for the resident. On 10/5/16 at 11:34 a.m., a facility employee was observed to push the resident down the hallway in his wheelchair, which now had leg rests attached to it. The resident ' s feet were observed to come off of the foot pedals. He briefly lifted his feet but then dropped them to the floor. The employee kept pushing the wheelchair for several inches until she realized his feet were on the ground. She placed his feet back on the foot pedals but they came off again while the being transported to the dining room. Interviews The rehabilitation services manager (RSM) was interviewed on 10/5/16 at 12:37 p.m. She said that when the resident was admitted to Hospice, Hospice provided a wheelchair for the resident's use. Hospice was responsible for training their staff in the proper use of leg rests during wheelchair propulsion. The wheelchair was supposed to be evaluated by Hospice for proper fit. Facility nursing staff had not informed her the wheelchair was not initially evaluated by Hospice, or that his feet were not staying on the foot pedals. Certified nurse aide (CNA) #1 was interviewed on 10/10/16 at 10:44 a.m. She said that when the Hospice aides came to the facility, They don ' t always feed him. Facility nurse aides were not always certain if the Hospice aides gave him breakfast, or who

Based on observations, interviews and record review, the facility failed to ensure that one (resident #169) sample resident, maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and received a therapeutic diet when there is a nutritional problem. Specifically, the facility failed to correctly document resident intakes; follow the approved menu; failed to identify and implement approaches to increase resident food intake and failed to closely monitor the resident's weights after admission and failed to refer the weight loss to physician for medical review for causes. These failures contributed to the resident, who was underweight at admission, experiencing severe weight loss after admission to the facility and impacted healing of the resident's pressure wounds. The findings include: Cross reference to F 314 for observations, interviews and record review of the resident's pressure ulcers on the sacral/coccyx and the left buttock/ischial not healing and worsening respectively concurrent with the resident's unplanned severe weight loss. Professional References: According to the American Family Physician, Unintentional Weight Loss in Older Adults, http://www.aafp.org/afp/,[DATE]/p718.html (,[DATE]). .Unintentional weight loss (i.e., more than a 5 (five) % (percent) reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of [MEDICAL CONDITION] in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . Treatment (for weight loss) should focus on the underlying cause. This often involves a multidisciplinary team, including dentists; dietitians; speech, occupational, or physical therapists; and social service workers. Common strategies to address unintentional weight loss in older adults are dietary changes, environmental modifications, nutritional supplements, flavor enhancers, and appetite stimulants.27 <http://www.aafp.org/afp/,[DATE]/p718.html> Diet modification incorporating patient preferences, softer food consistency to accommodate for chewing or swallowing disabilities, and assisted feeding may lead to weight gain and improved laboratory parameters; however, study results of this approach are mixed.28 <http://www.aafp.org/afp/,[DATE]/p718.html>-30 <http://www.aafp.org/afp/,[DATE]/p718.html> Creating a more leisurely eating environment simulating an in-home dining experience may improve nutrition in nursing home residents.31 <http://www.aafp.org/afp/,[DATE]/p718.html> Nutritional supplements are predominantly available in liquid form, but also come in puddings, bars, and soups. Nutritional supplements should provide extra calories but not replace scheduled meals. Liquid oral supplements allow for rapid gastric emptying and can be given two hours before a meal.29 <http://www.aafp.org/afp/,[DATE]/p718.html> Melissa Berstein and Nancy Munoz, Nutrition for the Older Adult. 2d. ed., Jones & Bartlett Learning' Burlington, MA, 2016, p. 360; Alternate interventions to address underweight status and unintended weight loss, including oral supplements can be considered if initial efforts are not effective. It is important to note that the use of real, wholesome foods often referred to as food first should always be the first intervention. Resident Status: Resident #169, age [AGE] years, was admitted to the facility on [DATE]. According to the ,[DATE] computerized physician's orders [REDACTED]. The [DATE] admission minimum data set (MDS) comprehensive assessment demonstrated the resident was rarely or never understood. The resident had short and long term memory problems and was severely impaired for decision making. The resident was dependent on staff for eating with a goal of being able to perform the task with partial or moderate assistance. Direct care staff felt the resident was capable of increased independence with at least some of the activities of daily living (ADLs). The resident was 70 inches in height and weighed 119 pounds. The resident did not have a swallowing disorder. The resident had not or was not known to have experienced significant weight loss or gain in the six months preceding admission to the facility. The resident was on a mechanically altered diet. The MDS showed the resident was receiving nutritional intervention for two suspected deep tissues injuries, one unstageable and one stage 2 pressure ulcer that were present at admission to the facility. The nutrition care plan, initiated on [DATE] and revised on 11//,[DATE] read the resident had the potential for nutritional problems related to a history of [MEDICAL CONDITION], chronic pain, impaired skin, being underweight and being edentulous. The goal was for the resident to maintain adequate nutritional status within 5% of current weight or two to four pounds through the next review. Planned approaches included: -Administer medications as ordered -Determine resident likes and dislikes -Interdisciplinary referral as needed (dentist, speech, other) -Meal assistance, extensive -Observe and report pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow, refusing to eat and meal concerns -Observe and report to physician emaciation/cachexia, muscle wasting, significant weight loss, -Obtain lab/diagnostic work as ordered and report results to physician -Provide supplements as ordered -Registered dietician (RD) to evaluate and make diet change recommendations as needed -Weigh monthly or as indicated A review of the resident's daily meal card showed the resident could receive all of the food listed on the menu for breakfast, lunch and dinner meals. Additionally, the meal card showed the resident was to receive a 4oz frozen nutritional treat at breakfast, lunch and dinner. Observations: The resident was observed on [DATE] at 6:08 p.m. The resident was in bed. Meal service was observed to be underway in the dining room during the walk to the resident room. At approximately 6:40 p.m. the resident was provided with a room tray. At 6:57 p.m. the resident remained lying in bed. The resident's room tray was out of reach, with the dinner and drinks both covered. RN #8 observed the room tray and said he would have someone come and assist the resident to eat his dinner. The resident was observed on [DATE] at 8:00 a.m. The resident was lying in bed. The resident's breakfast was covered and out of reach on the over-the-bed table. At 8:15 a.m. certified nurse aide (CNA) #4 entered the room. The CNA said the resident had not had breakfast. The breakfast tray contents were one cup of juice, a scoop of eggs with cheese and one slice of toasted bread. No milk or cereal were present on the tray. The resident's tray did not include a frozen nutritional treat. The CNA said she would be helping the resident to eat. The resident had been observed to eat the toast on his own with his hands but needed assistance to use the spoon to get the eggs to his mouth. The resident had consumed all of the drink, the eggs and the toast. At 8:45 a.m., CNA #4 completed breakfast assistance, and without offering seconds or more food, exited the room with the tray. The resident was observed in the dining room eating lunch with his wife on [DATE] from 11:24 a.m. until 11:55 a.m. The resident received meal assistance from the staff development coordinator (SDC). During the meal, the resident was observed to call out when waiting for the SDC to provide the next bite. The resident was observed to eat all of the turkey meal, accepting bites from the SDC and by using his own hands to pick up food. When the SDC cut up the resident's dinner roll, the resident was observed to eat the roll pieces with his hands, and the resident did not call out while self-feeding. The resident was able to hold the beverage cups and take sips on his own. While the resident was observed to attempt use of utensils, his coordination was such that food did not make it into his mouth. The resident was observed to take the applesauce dessert from his wife, which the SDC assisted him to consume. The SDC did not offer the resident seconds on food once the applesauce was consumed. The resident did not receive a frozen nutritional treat with lunch. The resident was observed in the dining room during the evening meal on [DATE] at 5:36 p.m. The resident was drinking on his own and he finished the one cup of beverage he received. Once he finished, he began calling out. The resident was being assisted to eat by a CNA once the meal was served. The resident was observed to supplement bites being offered by the CNA by reaching on his plate and grabbing bites with his hand. The resident ate everything on his plate. When the plate was empty, the resident began to call out. The CNA opened and fed the resident an ice cream cup that was on the table. Once the ice cream was consumed the CNA was heard to say, You have had all the food you need. You are going to be now. No seconds were offered. The resident was observed eating breakfast in bed with the help of CNA #4 on [DATE] beginning at 8:23 a.m. The CNA confirmed the resident's breakfast was to be the scoop of eggs with bits of ground ham mixed in, one cup of juice and the small sweet roll on his plate. The resident did not have milk or cereal on his breakfast tray. Partway through the meal, CNA #4 exited the room and returned with a cup of milk. The CNA said she obtained the milk so she could soften the sweet roll in it because the resident did not have teeth and the roll needed softening. The CNA was observed to cut the roll in to bite-size pieces and then place the bites into the milk before offering them bite to the resident. The resident was observed to eat the roll, the eggs with ham, and the drink the fluids offered with breakfast. The CNA did not offer the resident seconds before exiting the room with the empty meal tray. The resident did not receive a frozen nutritional treat with breakfast. The resident was observed eating lunch in the dining room on [DATE] at 12:27 p.m. The resident was mostly finished with his meal and was being assisted by staff to eat. The resident had been using his hands to eat some of the food on his plate. The resident was observed to consume his wife's pudding, which she offered to him. Family Interview: The resident's wife was interviewed on [DATE] at 10:53 a.m. and [DATE] at 12:34 p.m. The wife said that when the resident called out, it was often because he was hungry. The resident's wife reported the resident had a good appetite and seemed particularly hungry at lunch. The wife said the resident could feed himself soft, bite-size food and could drink on his own. The wife reported that he ate her applesauce at lunch on [DATE] and that at lunch on [DATE], he ate her pudding and her cornbread. The wife said the resident liked hot cereal, particularly with butter and brown sugar and that the resident also liked milk. Physician Interview: The resident's primary physician was interviewed on [DATE] at 6:37 p.m. The physician said he was the resident's primary physician and coordinated care with other physicians seeing the resident. The physician said the resident arrived at the facility with pressure ulcers that were stage 1 or 2. The physician did not verbalize he was aware that the resident's coccyx and left buttocks wounds had each progressed to stage 4 while at the facility. The physician did not indicate he was aware the resident had severe, unplanned weight loss since admission to the facility. Menu Review: The menu extensions for breakfast were reviewed. On [DATE], the planned breakfast menu was to include egg and cheddar bake, ¾ cup oatmeal, 1 slice toast, 4 oz juice, 8 oz milk and 6 oz of coffee or tea. (See above observation of the resident not receiving hot cereal and milk) On [DATE], the planned breakfast menu was ¼ cup scrambled eggs, 1slice bacon (ground sausage for mechanical diets), 1 sweet roll, ¾ cup oatmeal, 4 oz juice, 8 oz milk and 6 oz coffee or tea. (See above observation of resident not receiving oatmeal or other hot cereal on [DATE] breakfast) Record Review: The record review, detailed below, showed the resident was found to be nutritionally at-risk while at the hospital. The facility did not implement enhanced (weekly) monitoring of the resident status until the resident exhibited severe weight loss. Record review demonstrated the resident did not receive a food first approach, but rather had a nutritional supplement ordered. The record review demonstrated facility did not capitalize on the resident's individual strength of being able to self-feed finger foods. The record review showed the facility did not request labs to evaluate the resident's nutrition status even after severe weight loss and physician documentation did not evidence awareness of the resident's severe weight loss. Finally, the record review showed that even though the resident's pressure wounds had worsened, a protein supplement to aid wound healing was not ordered until [DATE]. -The [DATE] hospital history and physical showed the resident was admitted to the hospital after being found .under a tarp in the yard of his home by adult protective services. During the hospital stay, the resident was found to have [MEDICAL CONDITION], mild [DIAGNOSES REDACTED] and severe dehydration/malnutrition. The resident was placed on a regular diet that was supplemented with multivitamin and Ensure. The resident was given intravenous fluids to treat the dehydration and [MEDICAL CONDITION]. The [DATE] Colorado Medical Orders Scope of Treatment form showed the resident wanted CPR (cardiopulmonary resuscitation), full treatment, and would decide at the time about artificial nutrition. The resident weights (in pounds) were: [DATE] - 118 This weight represents a body mass index (BMI) of 16.9 which the National Institutes of Health considers to be underweight. [DATE] - 119 [DATE] - 112 This weight represents a 5.8% loss in one month and a 5.0% loss since admission. This weight represents a BMI of 16.1, which was underweight. [DATE] - 109 This weight represents an 8.4% loss in six weeks and 7.6% since admission to the facility. This weight represents a BMI of 15.6, which was underweight. The resident's diet order communication form dated [DATE] showed the resident had a regular diet with mechanical texture and nectar thick fluids. There was not an order for [REDACTED]. The [DATE] admission nutrition registered dietitian (RD) assessment noted the resident had increased nutrient needs related to wound healing. Although the resident had a body mass index of 16.9, which was considered underweight, the assessment did not note the resident was underweight. The resident was edentulous, but the assessment did not note biting or chewing difficulty. Additionally, the resident was not marked as having unintended weight loss, altered gastrointestinal function, predicted suboptimal intake, malnutrition, inadequate intake, or a similar condition that may have suggested expected weight loss. The assessment did not include any information in the Additional Nutritional [DIAGNOSES REDACTED]. The [DATE] Nutrition Data Collection assessment form showed the resident's usual body weight was unknown. The resident's BMI was listed as 17. The form indicated the resident had weight loss, however it marked as being not significant or severe. The resident was confused and disoriented. The resident had multiple impaired skin areas. The resident was noted to be edentulous, extensive assistance for feeding. The resident's intake was noted to be 50% to 75%. The form indicated no labs were available although the resident was admitted following a multiple day hospitalization . The summary said there was suspected history of weight loss due to the resident's current low body weight. The resident's meal intakes, plus a once daily health shake (Ensure) was believed to be adequate for wound healing. The plan was to follow-up in November to ensure nutrient needs were met. The Diet History/Food Preference List (not dated) said the resident ate three regular-size meals per day. The resident was noted to like toast, eggs, burgers, steak, chicken fried steak, coffee, milk and ice tea. There were no noted food dislikes. The form was completed by the dietary manager with information from the resident's wife. No laboratory assessments were present in the clinical record. A vital sign note in the progress notes dated [DATE] showed the resident had a significant/severe weight loss of 6.2% in 30 days. The accompanying dietician note dated [DATE] showed the dietician switched the resident to a more calorie dense nutritional supplement, which would be offered three times daily. A review of the [DATE], [DATE], [DATE], [DATE] and [DATE] physician's progress notes showed no mention of weight variance. There was nothing to suggest a work-up of the resident's unplanned weight loss. A review of progress notes demonstrated a [DATE] weight note that showed the resident had a further two-pound weight loss. The RD observed the resident at lunch. The resident called out during lunch, but managed to consume 75%. The RD noted the aide assisting the resident reported, he loves to drink, he'll drink anything. The RD offered a nutritional shake to the resident which he consumed. The RD documented considering nutritional shakes with meals and continued weekly monitoring. A review of meal intakes from [DATE] through [DATE] demonstrated: -The staff could record that the resident consumed 0%-25%; 26%-50%; 51%-75%; and 76%-100% of meals. -Meal intakes for at least one meal were missed on 13 days of the review period. -The resident was documented, generally, to consume 76% to 100% of meals. -The resident was documented to have consumed 76%-100% for breakfast on [DATE] and [DATE]. A review of the Medication Administration Record [REDACTED] -From [DATE] through [DATE] the resident had an order for [REDACTED]. -Beginning on [DATE] the resident had an order for [REDACTED]. -Beginning on [DATE], the resident had an order for [REDACTED]. Staff Interviews: Interviews with staff revealed the resident experienced severe weight loss since admission to the facility. Staff were aware the resident was able to self-feed finger foods, but a finger food diet was not ordered. Staff was aware the resident would readily take food by mouth, but extra portions, larger portions and fortified foods were not offered to the resident before initiating an increase in liquid supplements. Interviews revealed that nurse aide staff, who were responsible for measuring and recording food intakes, were not aware of what made 100% meal consumption, thus incorrect information was recorded which influenced decisions. Lastly, the resident did not have a physician evaluation for severe weight loss. CNA #4 was interviewed on [DATE] at 8:37 a.m. The CNA said the resident ate all of his food for breakfast. The CNA said she would record his consumption at 100% for the meal. The CNA said the resident could eat things like toast on his own but needed to be fed when utensils were required. The CNA agreed the she did not offer the resident seconds of anything for breakfast. The CNA denied she was aware of the resident's weight loss. The assistant director of nursing (ADON) was interviewed on [DATE] at 9:14 a.m. The ADON reported working at the facility for approximately one month. Per the ADON, the facility had just initiated an interdisciplinary team (IDT) meeting on Fridays, the first of which was held on [DATE]. The ADON said because the IDT meeting was held on Fridays, the RD did not attend. Per the ADON, the RD worked in the building on Thursdays only. The ADON said he thought RD attendance would be important because the RD would have expertise in nutrition for wound healing. The ADON said the resident had advanced stage pressure wounds to the sacral/coccyx and the left buttock/ischial. The ADON said current wound IDT forms did not take into account resident unplanned weight variance. The SDC was interviewed on [DATE] at 11:55 a.m. The SDC said the resident ate 100% of his lunch and stole his wife's applesauce as well. The SDC said the resident can eat foods on his own when cut up to bite-size pieces. According to the SDC, the resident initially tried fitting the entire dinner roll in his mouth. Once she cut the dinner roll to bite-size pieces, the resident fed himself the bites of the roll with his hands. The SDC said the resident did not seem to be able to manage eating with utensils. The SDC said the resident was able to manage drinking on his own when fluids were in reach. CNA #4 was re-interviewed on [DATE] at 8:41 a.m. The CNA said the resident ate and drank all of his food and that she would be recording his morning meal intake as 100%. The CNA said the only time she would not record 100% when all food provided was eaten was if there was not a reasonable amount of food offered. The CNA said the resident was able to manage finger foods on his own and tried to use a spoon at times. The CNA said the resident could answer yes or no regarding more portions of food, but was not able to request more food. The CNA said she did not offer the resident seconds on breakfast. The CNA said she did not know if the resident was offered snacks between meals. The CNA did not know if the resident had lost weight. RN #5 was interviewed on [DATE] at 8:49 a.m. The RN reported working as agency staff on the unit where the resident resided for about two weeks full-time. The RN said she was familiar with the resident and his care. The RN said she had observed the resident eating and had seen him self-feed with his hands but require assistance when utensil foods. The RN said the resident was able to drink on his own. The RN said the resident recently started on Pro-Stat (protein supplement). The RN said she mixed the Pro-Stat in juice and the resident usually downed it. The RN said the resident was receiving a nutritional shake also. The RN denied being aware of the resident's weight loss. The rehabilitation manger (RM) was interviewed on [DATE] at 10:26 a.m. The RM said the resident was receiving therapy to improve self-performance of activities of daily living (ADLs) from [DATE] through [DATE]. The RM said therapies included occupational, physical and speech. The RM reviewed the therapy notes. The RM said the resident's self-feeding had improved. The resident was able to drink on his own and self-managed finger foods. The resident was not well-able to manage eating with a utensil due to coordination problems. The dietary manager (DM) was interviewed on [DATE] at 11:48 a.m. and 12:36 p.m. The DM reviewed the menu extensions. The DM said the breakfast menu extension's planned calories were from receiving one of each class of menu item. The DM explained that the breakfast menu had an egg item, a meat item, a bread item, a cereal item, juice, milk, and hot beverage included in the calorie count. The DM said he did not know why the resident would not receive hot cereal or milk at breakfast. The DM said currently there was nothing in place for the resident to be offered extra portions, fortified foods or finger foods in order to promote weight retention and gain. The DM was heard to consult with the RD by phone and discuss possible changes to the resident's nutrition plan. The DM said the resident was not on a finger food diet. The DM said the resident's meal card did not recommend bigger or extra portions at meals. The DM said there was nothing on the diet card that suggested not serving the resident the full breakfast meal. The RD was interviewed by telephone on [DATE] at 12:04 p.m. The interview revealed: -The RD said that current dietetic practices were to provide a food first approach to nutrition. Per the dietician, food first meant offering real foods before adding supplements. -The RD said she was at the facility once per week to assess and coordinate resident nutrition care. The RD said she was familiar with the resident's weight loss and had interviewed the staff about the resident before making recommendations. -The RD agreed that the resident had experienced a severe, unplanned weight loss (greater than 7.5% in three months) after admission to the facility on [DATE]. The RD said unplanned severe weight loss was harmful in elders because the loss could cause vitamin deficiency, contributed to skin breakdown, caused weakness, decline in mentation, and depletion of reserves for fighting acute illness. -The RD said when she became aware of the resident's weight loss, she did order new and additional approaches. Specifically, on [DATE] the RD recommended changing from a once daily nutrition shake to MedPlus 60 ml three times daily. -The RD said she had observed the resident at lunch but had not observed a breakfast. The RD said that the resident was eating ,[DATE]% of meals, according to CNA documentation. The RD said she did use intake documentation when considering approaches for resident nutrition. According to the RD, the resident needed to be served and needed to consume all of each planned menu item in order accurately have 100% of the meal consumed. The RD said not receiving milk and not receiving oatmeal at breakfast precluded the resident consuming 100% of the meal. The RD said ¼ cup eggs with some cheese and a slice of bread was small breakfast. -The RD was informed of observations and interviews of the resident self-feeding finger foods, drinking on his own. -The RD said she had decided to increase the resident's liquid supplement because a staff member told her the resident would drink anything. The RD said she felt it was easy to capitalize on the resident's drinking for calorie intake. The RD had not looked at increased portions, fortified foods or snacks rather than a supplement. -The RD said she had not been informed by IDT that the resident was successful self-feeding with finger foods. The RD acknowledged the resident was not on a finger food diet. -The RD was stated she was not aware of a physician evaluation of the resident's severe weight loss. The director of nursing (DON) and the regional nurse consultant (RNC) were interviewed on [DATE] at 3:09 p.m. The DON said she was aware the resident had a weight loss. The DON said she was not aware the resident was not receiving the planned menu at breakfast yet staff was recording the resident consumed the full meal. The DON said she thought staff would benefit from some training on the menu and meal consumption. The DON agreed the resident's chart did not have a laboratory work up since admission. The DON said she would expect the physician to have evaluated the resident for unplanned weight loss.

Based on observations, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that residents received adequate supervision and assistance to prevent accidents. The facility's failures affected 18 (#72, #43, #60, #49, #39, #30, #15, #18, #50, #37, #38, #74, #40, #17, #8, #56, #33, #75) residents reviewed out of 41 sample residents. Specifically: I. Failure to ensure at risk residents received adequate supervision to prevent elopement: Resident #72 was known since admission to exhibit behaviors that put him at risk for serious injury. Specifically, he was documented almost daily as confused, wandering, exit seeking, and as removing safety devices. Staff documented he needed almost constant supervision. Record review revealed the resident eloped from the facility 10/1/15 and was found after falling in the bushes. The resident eloped again 10/11/15 and was found outside crawling on the grass. Observations revealed the resident was not supervised at the level he was documented to need. He was observed to attempt to leave the facility three times. On one attempt, the door did not alarm although the resident was wearing a wander guard. Record review also revealed the facility failed to reassess the resident's elopement risk after the incidents in 10/15 and failed to review, revise, and implement interventions to ensure the resident's safety. Finally, observations and interviews revealed failures in the facility's system to ensure the safety of the 14 additional residents (#30, #15, #18, #50, #37, #39, #38, #74, #40, #17, #8, #56, #33, and #75) with wander guards. Record review, observations and interviews revealed the facility failed to ensure a log of residents with wander guards was maintained, failed to identify when wander guard batteries were activated, failed to monitor wander guard use, and failed to ensure staff understood important properties of the wander guard, such as battery life span and range. The facility's individual and systemic failures in ensuring residents' safety from elopement created a situation of immediate jeopardy (IJ) with the potential for serious harm. II. Failure to implement adequate interventions to prevent falls: Resident #72, who was known to be at high risk for falls, and fell 13 times between his admission (8/26/15) and 11/24/15. Resident #37 who was known to be at high risk for falls fell multiple times between 10/2/15 and 12/3/15. Record review and observations revealed interventions to keep the residents from falling were either not specific, not appropriate, or not implemented and re-evaluated when determined ineffective. III. Failure to protect residents from other accident hazards: A. Safety while smoking Resident #60 who was assessed to require supervision while smoking, was observed smoking unsupervised, outside designated smoking times. In addition, contrary to facility policy for unsupervised smokers, she was observed to have smoking materials in her posession. B. Grooming Items A razor, without a safety cover, was observed in the bathroom shared by residents #43, #49, and #39. The findings include: I. Immediate Jeopardy - Failure to ensure at risk residents received adequate supervision to prevent elopement: A. Immediate Jeopardy 1. Findings Triggering Immediate Jeopardy Resident #72 was known since admission to exhibit behaviors that put him at risk for serious injury. Specifically, he was documented almost daily as confused, wandering, exit seeking, and as removing safety devices. Staff documented he needed almost constant supervision. Record review revealed the resident eloped from the facility 10/1/15 and was found after falling in the bushes. The resident eloped again 10/11/15 and was found outside crawling on the grass. Observations revealed the resident was not supervised at the level he was documented to need. He was observed to attempt to leave the facility three times. On one attempt, the door did not alarm although the resident was wearing a wander guard. Record review also revealed the facility failed to reassess the resident's elopement risk after the incidents in 10/15 and failed to review, revise, and implement interventions to ensure the resident's safety. Finally, observations and interviews revealed failures in the facility's system to ensure the safety of the 14 additional residents (#30, #15, #18, #50, #37, #39, #38, #74, #40, #17, #8, #56, #33, and #75) with wander guards. Record review, observations and interviews revealed the facility failed to ensure a log of residents with wander guards was maintained, failed to identify when wander guard batteries were activated, failed to monitor wander guard use, and failed to ensure staff understood important properties of the wander guard, such as battery life span and range. The facility's individual and systemic failures in ensuring residents' safety from elopement created a situation of immediate jeopardy (IJ) with the potential for serious harm. 2. Notification of Immediate Jeopardy At 5:13 p.m. on 12/2/15 the Nursing Home Administrator (NHA) and the Regional Consultant Registered Nurse (RCRN) were informed that the failure to prevent resident elopement created a situation of immediate jeopardy with the potential for serious harm. 3. Plan to Remove Immediate Jeopardy The facility's third plan to remove immediate jeopardy was submitted on 12/3/15 at 2:27 p.m. The plan read: Action Plan to Abate immediate jeopardy related to Belmont Lodge Health Care Centers failure to keep an at risk resident safe and from eloping from the building. 1. The identified wandering residents wander guard has been checked for placement and functionality on 12/2/15. 2. The Wanderguard system at all identified doors has been checked for functionality on 12/2/15. The maintenance director adjusted the sensor range for the door on the northwest of the facility on 12/2/15. 3. A list of residents assessed to be an elopement risk and have a wanderguard on has been created and placed at each nurses ' station on 12/2/15. The list and the photographic directory will be updated by the IDT team or designee during morning meeting. 4. The maintenance director checked and validated that all exterior gates shut and latched correctly on 12/2/15. 5. All staff currently working at Belmont Lodge will be educated on the elopement management policy to include the wander guard system, the elopement risk assessment that identifies the resident at risk for elopement and the list of residents that have been identified and where the list will be located before they work another shift, Training will be completed by NHA or designee by 12/7/15. Staff will not be allowed to work until training is completed. 6. The nursing staff will be educated on the process of checking for placement and functionality of the wanderguard placed on the resident before they work another shift. The process is to use the identified manufacture testing tool and place it next to the wanderguard on the resident to validate that the device is working correctly before they work another shift. Training will be completed by NHA or designee by 12/7/15. Staff will not be allowed to work until training is completed. 7. The maintenance staff has been educated on the process of checking functionality of the wanderguard system at the door which is to test the function with the manufactures recommended tool once per week to validate that the device is working correctly by 12/2/15. This will be documented in the facility maintenance record starting 12/2/15. 8. Maintenance will be responsible for checking that the testers function properly. 9. All residents were physically checked for a wanderguard on 12/2/15. 10. All residents with wanderguard will be checked every 15 minutes using 15 minute check sheets starting 12/2/15 until all exit doors are secured. All doors were secured on 12/3/15. 11. All residents without a current elopement risk assessment were assessed 12/2/15. 12. It will be the nurse on duty ' s responsibility to check the functionality of each wanderguard and document on the MAR starting 12/2/15. 13. Five more wanderguard testers were ordered on [DATE] to be over-nighted to the facility. 14. Each resident's wanderguard has been checked to determine if specifications for one year or three year by 12/3/15. 15. If the system is not functioning properly, 15 minute checks will be completed on each resident with a wanderguard until the system is functioning again. The nurse on duty will be responsible for completion of the 15 minute checks. 16. In the event of a power outage, the facility generator provides power to the wanderguard doors. If this system is not functioning a staff person will be stationed by each door until the system is functioning again. 17. The maintenance director or designee will conduct elopement drills quarterly to identify that the system is working correctly and that the staff are responding appropriately. The quarterly drills will be reported in the monthly QUAPI and safety meeting. 18. The administrator and or designee will review any elopement incident reports and results of the elopement drills and wanderguard audits to QA weekly for one month then monthly for three months then quarterly as needed to review all outcomes and applicable action plans. 4. Removal of Immediate Jeopardy The facility's plan to abate Immediate Jeopardy was accepted on 12/3/15 at 2:27 p.m. and the immediate jeopardy removed. However, deficient practice remained at an E level, potential for more than minimal harm at a pattern. II. Failure to provide residents adequate supervision to prevent elopement. A. Pertinent Facility policies - expectations 1. The facility policy on Resident Elopement (OPS2 0401.04 Operations, revised August 2012) was provided on 12/2/15 at 5:02 p.m., by the NHA and read in part. The facility strives to provide a safe environment and preventative measures for elopement. Personnel must report and investigate all reports of missing residents. Wander/Elopement Alarm Activation 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm; b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement; c. If no resident is found to be exiting the facility, the employee should i. Exit the facility, walk around the building, and ensure that a resident has not already exited the facility. Important: be sure to search locked rooms and stairwells. ii. Notify the director of nursing and the administrator immediately; and iii. Complete a head count to ensure that all residents are accounted for. Attempted Elopement 2. If an employee observes an attempted elopement, he or she should: a. Be courteous in preventing the departure and in returning the resident to the facility; b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the director of nursing and the administrator that a resident is attempting to leave the premises. 3. Upon return of the resident to the facility, the director of nursing and administrator should e. Make appropriate notations in the resident's medical record (director of nursing); f. Investigate how the resident attempted to elope and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement Committee; and g. Update the resident's care plan with preventative interventions for elopement (director of nursing). 2. On 12/3/15 at 8:45 a.m., the NHA provided a copy of the Elopement Management Policy (revised February, 2010), which read in part. Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate and safety interventions to minimize elopement risk. Signaling devices may be used if available in the facility and determined to be an appropriate intervention. The interdisciplinary Team (IDT) evaluates each resident to identify elopement risk on admission, all quarterly, annually, and with significant change of condition using the Elopement Risk Review .A plan of care is developed and implemented based on this evaluation with ongoing review. Resident Care Specialist (RCS)/ (certified nurse aide/CNA) assignment sheets/care kardexes are updated as appropriate. The care plan should address the contributing risk factors, including but not limited to: a. Ambulation status; b. Mental status; c. Resistance to long term care placement; d. History of elopement; e. Diseases or medications that may cause confusion/disorientation; and f. Indications or [DIAGNOSES REDACTED]. Check the function of the signaling device daily using the tester box. The Licensed Nurse will verify that the signaling device is functioning and document on the TAR (Treatment Administration Record) or on a separate log and maintained by the facility for 12 months. The Licensed Nurse will immediately replace the signaling device if the device fails the function test . It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse or available nursing manager . A four point Plan of Correction will be initiated with each event. Following an elopement/attempt, the IDT will update the resident's Elopement Risk Review. The IDT reviews the resident's Plan of Care, revises, and implements revisions to the Plan of Care and treatment as indicated. Changes in treatment, the resident's elopement risk, and interventions are communicated to direct care staff. The RCS Assignment Sheet/Care Kardex is updated as appropriate. The Director of Nursing/designee will maintain a list of residents with signaling devices and is to ensure a sufficient quantity of signaling devices are available for use in the facility and accessible to staff. The Facility is to develop a consistent method for tracking the expiration of devices and ensure devices are replaced prior to expiration . Director of Maintenance or designee will complete preventive maintenance. Instructions for preventive maintenance for door monitor testing, door range testing, function tester maintenance and elopement drills are located in: a. Testing the WanderGuard System; b. Resident Elopement; and c. Resident Identification System. The director of nursing/designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment and evaluation, and monitoring exit-seeking behavior. B. Resident #72 Resident #72, [AGE] years old, was admitted to the facility on [DATE]. According to the face sheet, his [DIAGNOSES REDACTED]. According to the quarterly minimum data set ((MDS) dated [DATE], resident #72 had a BIMS (cognition) score of 3, which meant he was severely impaired for daily decision making. Per this MDS, resident #72 required limited assistance of one for ambulating with his wheelchair and eating. He required extensive assistance of one for dressing, bathing and personal hygiene. He required extensive assistance of two+ for bed mobility, transfers and toileting. 1. Resident Status - Known behaviors - wandering confusion, impulsive, repeated episodes of exit seeking Record review revealed the facility was aware the resident was at risk to elope, had successfully eloped, repeatedly attempted to elope, and needed almost constant supervision. In addition, he was known to remove his safety devices. Specifically: An Elopement Risk Assessment was completed on 8/27/15 documented resident #72 scored 9. A total score of 12 or higher is at risk for elopement. The resident's care plan, dated 8/27/15, read in pertinent part, Elopement, At Risk related to: New environment, medications causing dementia or disorientation, dementia and current confusion or disorientation. Approaches included: Offer emotional and psychological support, orient resident to environment, document any attempts to elope, provide safe location for wandering behaviors as needed, increase observation of individual during and after visitors. Although the 10/21/15 MDS stated that resident #72 wandered one to three days during the 14 day look-back period, review of nursing daily skilled notes 8/26/15 to 12/1/15 revealed the resident wandered daily and frequently attempted to exit the facility. Nursing Daily Skilled Summary forms revealed: The Nursing Daily Skilled Summary forms 9/18/15 through 12/1/15 read in pertinent part: 12/1/15: .up and around facility per wheelchair, self propels, helmet on for safety, talkative at times, nonsensical, impulsive, attempted going outdoors a few times. 11/29/15: .Not always easy to redirect. Wanders about common and in WC .requires a lot of supervision. 11/28/15 .Confused, not always easily redirected. Wanders about in WC, around common areas and into other's rooms. Monitored for safety whenever possible. Diversional activities attempted, if for only brief periods of time. 11/27/15: .Exit seeking at times. Diversional activities attempted for brief periods of time .Continues to go in other people's rooms and tests the fire exit door. Very difficult to redirect during the evening. Propels WC all over the building, wearing helmet and lap belt. 11/25/15: .Confused at times with decreased safety awareness. A quick release belt on while up in wheelchair, safety helmet placed by staff - resident removes safety devices. Close supervision by staff for impulsive behavior. 11/23/15: .Continues to need constant supervision, confused at times. 11/22/15: .Helmet on for safety, seat belt in place, states he wants to go home, a few attempts, tried doors, redirected and attempted to reorient. 11/21/15: .Decreased safety awareness, impulsive, safety devices placed by staff and removed by resident. Self propels in wheelchair, wanders into other resident's rooms, .Awake from 2200 to 0130, requiring continual monitoring for decreased safety awareness. 11/18/15: Wanders about common area and into other's rooms. Diversional activities attempted for brief periods of time .Confused at times. Very active this evening causing alarms to go off on doors .difficult to redirect 11/17/15: .Sets door alarms off often. 11/16/15: .Redirected from doors several times. 11/15/15: .Monitored for safety whenever possible secondary to poor safety awareness and impulsiveness. 11/12/15: .Resident in wheelchair roaming hallways, tried to open end door setting off alarm. 11/10/15: .Wanders about common areas, rummages through things. Diversional activities for very short periods of time .accepts re-direction occasionally. 11/9/15: .Patient wanting to leave, Got to go home. Exit seeking after dinner. Diversional activities attempted for only very short period of time. 10/31/15: .Going from door to door, setting off alarms for several hours, but did not go out. 10/29/15: .needs constant direction .remains impulsive, non-sensical at times. 10/28/15: .Decreased safety awareness .pull tab alarm in place, wander-guard in place .safety mats at bedside. 9/18/15: .Monitored for safety whenever possible secondary to decreased safety awareness and impulsiveness. 8/28/15: Alert, confused; continues on neuro checks for un-witnessed fall, fall mats at bedside, pull tab alarms in place; care provided at rounds and in response to safety alarms .Monitor for safety whenever possible. Review of facility incident/accident investigations revealed two incident/accident reports documenting resident #72's elopement. -An Incident/Accident report dated 10/1/15 at 4:30 p.m. read, Resident rolled outdoors in WC (wheelchair) across parking lot, walked between sheds to climb over fence to play yard. fell , sitting in bush pile, seen by maintenance staff - walked to WC. No crying or pain. This report stated that [DIAGNOSES REDACTED]. The action the facility took was check doors. The Interdisciplinary Post Fall Review dated 10/2/15 and 10/5/15 read, .Summary of Interdisciplinary Team: Check wander-guard/doors. -An Interdisciplinary Post Fall Review dated 10/14/15 for a fall resident #72 sustained on 10/11/15 at an un-named time read in pertinent part, Un-witnessed fall .bruising on right hip and coccyx area .Summary of Interdisciplinary Team: Resident outside south-east door, crawling on grass, stated going home to (facility name). Intervention Recommendations: Quote to put wander guard on all doors. 15 minute checks. The SBAR Communication Form, dated 10/11/15 read, .Resident alert, walking unsteady as usual - no abrasions. Red at knees from crawling, at 8:30 p.m., noted reddish-purple bruises at coccyx and right hip .Monitor for bruising - ice to right hip area bruise - 15 minute checks by staff continue - skin intact. 2. Facility's response to resident #72's known at risk behaviors In addition to the 8/27/15 Elopement care plan (see above), record review revealed: A telephone order 9/11/15 that read: Wander-guard for safety, check daily for safety and functioning every morning. A December 2015 Treatment Administration Record (TAR) that read Wander-guard per safety, check every day for safety and function. 3. Failure of the facility to respond as required and as expected per facility policy to keep resident #72 safe from elopement. a. Record review Record review revealed that contrary to facility policy, the facility failed to reassess resident #72's elopement risk after the incidents 10/15, failed to thoroughly investigate the incidents to develop an individualized plan of care that identified the resident's on-going at risk behaviors and how to address them to keep the resident safe. Moreover, the record review revealed no plan regarding the resident's supervision needs - and how these needs were to be met by staff. Record review revealed no documentation that one articulated safety intervention (wander guard) was being monitored as ordered and expected per facility policy. Review of resident #72's record revealed: -No reassessment of the resident's Elopement Risk Assessment after the resident was found outside per the Facility Incident Investigation forms dated 10/2/10/5/15 and 10/14/15. Licensed practical nurse (LPN) #2 was interviewed on 12/2/15 at 3:42 p.m. The LPN stated that the nurses who worked the floor were responsible for completing the quarterly assessments, which included the elopement assessments. -No investigation regarding how the resident eloped per the Facility Incident Investigation form and Interdisciplinary Post Fall Reviews dated 10/1/15, 10/2/10/5/15 and 10/14/15.The form dated 10/1/15 failed to include a situation, background, assessment, and recommendation (SBAR) report. The 10/2/10/5/15 form failed to include information such as when the resident was last seen, where he had last been observed, or his behavior prior to elopement, in an attempt to determine what interventions were necessary to prevent reoccurrence. The second incident, too, lacked detailed information about the circumstances of the incident in order that staff might identify a pattern from which to develop effective interventions to keep the resident safe. -No evidence the interdisciplinary team met to coordinate an interdisciplinary approach to managing the resident's behaviors which put him at risk for harm. -No updates to the resident's care plan regarding the elopements and no evidence of individualized, resident specific interventions to keep the resident safe from elopement. Specifically, there was no plan regarding the resident's supervision needs. -No documentation that the functionality of the resident's wander guard was assessed as ordered or that the exits the wander guard was designed to alarm were routinely tested . Specifically: --Review of resident #72's wander guard on his wrist on 12/2/15 at 5:38 p.m. revealed no date when the battery was activated. Interview with the wander guard company representative on 12/10/15 at 2:20 p.m. revealed the wander guard battery life span was 90 days; it was not guaranteed to work after 90 days. --Review of the resident's TAR revealed that although an order for [REDACTED]. Moreover, although the order was entered on the December TAR, review of the December TAR revealed no documentation the wander guard was monitored daily. b. Observations of resident #72 Observations revealed the resident repeatedly tried to exit the facility, was not supervised by staff at the level he was documented to need (see above, documenting the resident's need for almost constant supervision). Specifically, the resident, wearing a wander guard, was observed to attempt to leave the facility three times during survey (12/1/15 x 2 and 12/3/15 x 1). In one instance, the door the resident exited did not alarm and the first individual to respond was not staff, but another resident. 12/1/15: Resident #72 was observed at 11:04 a.m. The resident was sitting in the dining room in his wheelchair, wearing a white safety helmet. He wore a wander guard on his wrist. The resident had a fading bruise under his left eye and scrapes up and down his left shin. Resident #72 kept disengaging his self-release seat belt on his wheelchair. The resident wheeled out of the dining room at 11:07 a.m. without staff assistance. As he left the dining room a staff member re-engaged the resident's seat belt. However, staff was not observed to take steps to ensure the resident was supervised after leaving the dining room, either by following the resident or alerting staff outside the dining room. The resident was returned to the dining room by staff at 11:25 a.m. At 11:29 a.m., resident #72 was overheard stating, I'm ready to leave again. Resident #72 attempted to get out of his wheelchair at 11:31 a.m. by releasing his own tab-alarmed seat belt; however, certified nurse aide (CNA) #12 intervened. From approximately 11:32 to 11:36 a.m., resident #72 kept releasing his wheelchair seat belt, sounding the tab alarm. At 11:36 a.m., resident #72 took his seat belt off again and CNA #12 approached to intervene. At 11:37 a.m., the director of nursing (DON) came to stand over the resident until CNA #15 brought resident #72 his lunch at 11:38 a.m. Resident #72 settled down to eat and remained calm and engaged in eating his meal after his lunch was brought to his table. After quickly eating his lunch, resident #72 again disengaged his seat belt at 11:48 a.m., sounding the alarm. CNA #14 asked the resident to promise not to remove his seat belt. The DON then escorted resident #72 out of the dining room. At 11:55 a.m., resident #72 was observed unsupervised in the northern East Hall. He was propelling quickly down the hall in his wheelchair, then he exited the northern East Hall back door which was alarmed and headed back towards the rear parking lot. The resident's wander guard sounded the door alarm and the social services director (SSD) escorted resident #72 back into the facility. At 1:47 p.m., resident #72 was observed again, attempting to exit the facility via the northwest door. Although resident #72 opened the door, another resident stopped resident #72 before he could exit. The resident's wander guard did not sound the door alarm at this door. 12/2/15: At 9:06 a.m., resident #72 was observed propelling himself down the hall in his wheelchair. When the surveyor informed the resident s/he would see him later, resident #72 stated, I may or may not be here. When asked where he was going, he stated, I don't know .heaven or hell. At 9:08 a.m., resident #72 set off the East Hall door alarm by exit seeking and staff intervened quickly. At 5:38 p.m. CNA #8 stated that resident #72 was asleep in his room. Resident #72 was in his room, but was awake. The surveyor checked this resident's wander guard, which was in place. The wander guard did not appear to have been dated to show when the battery had been activated. 12/3/15: At 12:08 p.m., resident #72's wander guard kept sounding, as per RN #1, the resident kept attempting to remove his wander-guard bracelet. At 1:28 p.m., resident #72 was observed to exit the west front door onto the patio. The door alarm sounded. Another resident was overheard to tell resident #72 that he was not supposed to be outside. Staff then arrived to check on the resident. 12/7/15: At 3:18 p.m., resident #72 was observed propelling down the east hall in his wheelchair towards the dining room. He set off an alarm in the front lobby. RN # 4 was observed to come out of the east hall nurses station, looked down the hall, stated Where did he go?However, the nurse made no effort to follow resident #72 to see where the resident had gone and whether he had left the facility. C. Interviews confirmed the facility's failures in ensuring the safety of resident #72 and other residents that wandered from elopement. 1. Floor Staff Interviews Record review (see above) revealed there was no plan to ensure resident #72 was adequately supervised, notwithstanding his known risk factors. Interviews with floor revealed insufficient staff to provide resident #72 and other residents at risk to elope adequate supervision. Cross reference F353; nurse staffing. CNA #11 was interviewed on 12/7/15 at 10:48 a.m. He/she stated that it was very difficult to track and monitor residents who wandered and that sometimes they had to just get the resident up and dressed and had the resident sit all day at the nurse's station just to keep them safe. He/she said, The residents are just (left) there. I have tried to get (resident #72) to activities, but he doesn't like it. CNA #15 was interviewed on 12/7/15 at 12:44 p.m. and stated that they monitored the residents in the facility who wandered by their wander guards, but they also tried to go into the resident rooms and check on them a lot. CNA #12, who worked days, was interviewed on 12/7/15 at 1:05 p.m. When asked how the facility monitored and tracked those residents who wandered, the CNA stated, It's impossible and so difficult . CNA #14 was interviewed on 12/7/15 at 1:35 p.m. and stated it was difficult to track and monitor their residents who tended to wander. CNA #14 stated they have attempted to take resident #72 to activities, but the resident will only remain for a short time before he takes off again. The CNA stated resident #72 was really the only one we really can't keep track of because he moves so fast. The CNA felt that both halls should have four CNAs on the day shift because east hall had more residents who wandered than on west hall. CNA #10 stated they attempted to monitor resident #72's wandering by trying to check him every 15 minutes, but admitted that this had not been done consistently. The CNA stated resident #72 would be seated at the nurse's station for busy work, but he will not sit still for bingo or any formal activities. RN #3 was interviewed on 12/7/15 at approximately 3:00 p.m. and was asked how she monitored and tracked the residents who tended to wander. She stated, I just go and check on them every hour so I know where they are. Regarding resident #72, she stated, I try to keep extra tabs on him when he is on this ha

Based on record review and staff interviews the facility failed to ensure that allegations of abuse, neglect, or mistreatment of [REDACTED].#1 and #2) of nine residents reviewed for abuse out of nine sampled residents. Specifically, the facility failed to fully investigate allegations of sexual abuse. Staff interviews reviewed numerous reports of inappropriate behaviors by resident #1 since admission. On 11/15/14, resident #2 experienced unwanted touching and alleged sexual advances. The findings include: Cross Reference to F323; Accidents. The facility failed to provide supervision and behavioral management to protect other residents from injury. A. Facility Policy The facility's policy on Abuse, Neglect, Mistreatment, Misappropriation and Injury of Unknown Source Investigation Guide, read in pertinent part: -Document date and time injury was discovered in the resident's medical record -Document date and time of all notifications per facility policy -Interview and/or obtain statements from potential witnesses as determined by the scope of the investigation -Review the resident's medical record for relevant information B. Alleged Allegation of Sexual Abuse According to the facility's incident investigation dated 11/15/14, a certified nurse aide (CNA #4) walked into resident #2's room to get her ready for breakfast at 7:30 a.m. Upon entering the resident's room the CNA witnessed resident #1 pushing himself up off of resident #2. Injuries at that time were undetermined; however the resident reported pain in her back. Resident #1 admitted to touching resident #2; however he denied having intercourse with resident #2. Resident #2 initially was not sure if intercourse occurred and denied touching resident #1.The facility, family, and police were notified of the incident, resident # 2 was discharged to the emergency room (ER) for an evaluation and resident #1 was discharged to the hospital for a psychiatric evaluation. C. Residents #1 and #2 Status a. Resident #1 Resident #1, age 63, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was discharged on [DATE], following the incident (see above) with resident #2. The 14 day minimum data set (MDS) assessment completed on 9/2/14 revealed a brief interview for mental status (BIMS) score of 14/15, which indicated no cognitive impairment. The resident was also noted to be independent with activities of daily living, except for supervision with personal hygiene. Preadmission Screening and Resident Review: On 8/11/14, prior to resident #1 ' s admission, the facility received a letter stating that a Level II PASRR was being conducted and that it had been determined that the resident would require a Pre-Admission Care Plan due to: " has a long history of assaultive and aggressive behaviors " . Additional information included in the level II PASRR documented a very extensive history of aggression and violence that began in 1966. -records indicated a history of elopement attempts, thus " a secure facility will be needed " b. Resident #2 Resident Status Resident #2, age 64, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly MDS completed on 12/4/14 indicated a BIMS score of 7/15 which indicated moderate cognitive impairment. D. Facility Investigation for the Alleged Allegation of Sexual Abuse The facility's incident investigation dated 11/15/14, between residents #1 and #2, revealed the CNA who first entered the room and witnessed resident #1 on top of resident #2 was interviewed. The CNA stated that she had walked in to assist resident #2 for the morning and found resident #1 pushing himself up from "what I would assume to be from a lying position. I then saw resident #2 and saw her gown pulled up to mid chest and she had no underwear on". According to the CNA during the investigation, resident #1 stated to her "she said to make love to her". No other staff interviews had been conducted; however sixteen residents were documented as being interviewed about resident #1. Seven residents stated the concerns with resident #1 included stealing, talking about sex or that they feared him. The investigation revealed that only one staff member was interviewed about the alleged assault, even though numerous staff members were involved and had pertinent information. Interviews (see below) conducted with staff (during survey 12/30/14 to 1/9/15) indicated there were many employees who had knowledge of both resident #1 and #2, and who could have provided potential insight; however they were not interviewed. Resident #1 investigation interview The facility investigation revealed resident #1 was interviewed on 11/15/14. He indicated that "I asked her if she wanted to get up and go to breakfast about 6:30 a.m. She pulled me over to her bed and started kissing on me." Resident #1 stated that he had not done anything and that he had not touched her, except for the kiss, witnessed when the CNA came into the room. He confirmed in the interview that he helped remove her diaper and that he touched the inside of her thighs and vaginal area. He denied having sex with her. He stated that she was touching his penis. He stated "I don't believe in nonconsensual sex. I wouldn't force anybody to have sex." He later stated to the director of nursing (DON) that he used her hand to complete the sexual act. Resident #2 investigation interview The facility investigation revealed resident #2 was interviewed on 11/15/14. She stated "he came in here and I pushed him away and he came back." The resident confirmed that resident #1 had touched her with his hands, but was not sure if intercourse had occurred, but did state that he had tried. She stated she had been asleep when he came in. Facility investigation conclusion: The Facility investigation concluded that they were unable to substantiate the allegation; however the resident admitted to touching the resident and using her hand to complete the sexual act. D. Staff interviews The Customer Service Coordinator (CSC) was interviewed on 1/8/15 at 8:25 a.m. The CSC revealed that the facility had no social service employee at the time of the 11/15/14 incident and had difficulty hiring a new social service employee during the incident in question. According to the CSC, the facility finally hired a social service employee; however they did not start until December 29th. The CSC confirmed that during that time frame, she and the director of nursing (DON) completed the investigations for all incidents that occurred in the facility. The CSC stated that they would complete their documentation in their investigation summaries. When asked if the investigation information was transferred to the necessary medical records, the CSC stated "It depends on the severity of the incident. My goal was always to document in both charts, but during that transition it was difficult to manage it all. "The CSC stated that the incident between residents #1 and #2 was investigated by her. She stated that a CNA (CNA #4) entered resident #2's room and saw resident #1 pushing himself off of her (resident #2) and that his pants were undone. The CSC stated that she interviewed residents #1, #2 and CNA #4, who first entered resident #2's room. The CSC said that " we continued investigating and asked staff if they saw anything more (Flirting, anything). Nobody saw anything before that. " The CSC was interviewed a second time on 1/8/15 at 10:19 a.m., regarding the investigation process with residents #1 and resident #2. The CSC confirmed that only one CNA (CNA #4) was interviewed regarding the incident. She stated that they had not yet received information about the police investigation, or the results of the sex assault nurse examiner (SANE) report from the hospital. CNA #2 was interviewed on 1/9/15 at 11:44 a.m. According to the CNA, the aides were getting the residents up for breakfast and taking them to the dining room. "A female aide came yelling down the hall, after she was trying to get resident #2 up" and witnessed the incident. The CNA (CNA #4) came out to get other staff to help. The CNA said, "I went into the room with the other aide. The one who saw it was too hysterical and left and a nurse came in. (Resident #1) left the room and went into the dining room and started bragging that he had ' bagged her ..." CNA #2 stated that the staff was told to get resident #2 dressed, so the ambulance could take her to the hospital. The CNA stated that it was about 12 o'clock when the ambulance arrived. The CNA stated, " The DON said to keep her (resident #2) there until she could get in and talk to her. (Resident #2) can only talk a bit and she told the DON that he (resident #1) hurt her". According to the CNA, resident #1 was not arrested; however, he was sent out later that day. The CNA reiterated that resident #1 " was going out and telling everyone what he did." "The DON came in within an hour. The staff questioned both residents a number of times before the ambulance came. The police came and took statements ... " The CNA also confirmed that resident #1 " had talked sexually with another woman, but that lady spoke out and he left her alone. He (resident #1) was very much in her personal space. The CNA stated that resident #1 should know right from wrong and that he knew what he was doing; because he bragged about it. He knows how to play with people. It was a big relief knowing he was gone ... ...Sometimes she (resident #2) jumps like she's scared. "The CNA also stated that although resident #1 had been placed on one to one supervision," in all honesty he wasn't. He hated the one to one supervision ... Taking him off the one to one was a bad idea." Although CNA #2 was directly involved in the incident between resident #1 and #2 and had important information to share, CNA #2 was not interviewed during the facility ' s investigative process. A registered nurse (RN #1) was interviewed on 1/9/15 at 1:33 p.m. The RN stated on 11/15/14 at about 7:15 a.m. in the morning a CNA was heard hollering. The RN stated that when they got to the room the aide was at, (does not make sense) resident #1 was observed fixing his clothes. The RN said that the CNA stated that she had seen the resident in the act. The RN said that resident #2 was checked on with the assistance of the DON. The RN stated that "Someone called the police and I shared what I knew. I do know one of the other male residents said (resident #1) had gone into the dining room and bragged. He (resident #1) was put on one to one and then he went out to the hospital. Resident #1 always seemed to be looking for trouble, didn't' seem trustworthy, and was taking people's stuff. He seemed capable of caring for himself, and had been on one to one before. I don't know why he wasn't on one to one at the end. "The RN confirmed that they were not interviewed about the incident by the investigating facility staff members. CNA #3 was interviewed on 1/9/15 at 2:03 p.m. The CNA stated that resident #1 " was very dangerous. I could see the dark side of him. He would try to put his arm around my waist, or even up higher on me ..." The CNA said that after the incident, resident #2 appeared to have "disassociated herself from the situation. She is still suffering. She talked to me and said she was raped, but she won't talk to people now. There were other staff members that should have been interviewed because they saw things and could have gotten more. " CNA #4 was interviewed on 1/9/15 at 2:36 p.m. CNA #4 said, " When I went into the (resident #2 ' s) room, she was laying perpendicular on the bed, with her head near the wall. Her legs were widespread, not just slightly open. I didn't move her or anything until the DON and CSC arrived. I was in there probably 30 minutes before they got there and rubbed her head, because she wanted to get out of there. She was pretty traumatized. When the CSC came in, she asked resident #2 if she remembered the man in her room. Resident #2 shook her head and the CSC asked her if she had invited him in there, as if it was consensual. Resident #2 said no. The CSC asked resident #2 if she wanted a relationship with that man, she said no. She said he hurt her before the CSC came in. Then the DON came in. I told the DON what resident #2 had said, and the DON said to leave the room ... The next day one of the aides went into (in quotes leave as is or change in to) get resident #2 up, and resident #2 asked her ' how much time are they giving the man who raped me? "" ...We told staff for months he needed to get out of here. He was caught on east (wing) masturbating over a female resident. He was found masturbating in front of another resident, punched a male resident, and stole from residents. " " ...he shouldn't be here, but they said they would take care of it and he was getting better. Women were terrified of him ... This CNA, although directly participated in the incident between residents #1 and #2, was not interviewed by facility staff during the investigation. A Licensed Practical Nurse (LPN) was interviewed on 1/9/15 at 3:05 p.m. The LPN stated that resident #1 had been a "problem from the beginning and shouldn't have been here." The LPN stated that the staff had learned that resident #1 had assaulted females at the hospital, too. The LPN stated that resident #1 would tell dirty jokes that were "very complicated and hard to believe they could have been told by someone who didn't know what they were doing " . The LPN was not aware why resident #1 came off one to one supervision. LPN #1 was not interviewed by facility staff during the investigation, although the LPN had insight into the resident' s behaviors. RN #2 was interviewed on 1/9/15 at 3:15 p.m. The RN confirmed that resident #1 should not have been admitted to the facility. The RN stated that the staff "had told administration over and over again that he was a problem and something bad was going to happen." The RN said that the staff knew that documentation was not being done well ... The RN said that she did not know why resident #1 came off one to one supervision, and that resident #2 would ask if the male resident was going to go to jail for raping her. The RN was not interviewed regarding the incident between residents #1 and #2, although the RN had insight into the resident ' s behaviors and condemning quotes from the victim, which indicated she knew she was assaulted. The DON was interviewed on 1/9/15 at 5:45 p.m. The DON confirmed that she had seen the extensive gaps in the resident's medical records after the investigated incidents. The DON stated she was in the process of correcting that with her nursing staff, at that time, in order to do "a better job of documenting on a more regular basis." An interview was conducted with CNA #5 on 1/9/15 at 5:54 p.m. The CNA stated that the night before the incident of 11/15/14, between resident #1 and resident #2, he walked back towards the day room on the east wing and saw resident #1 with resident #2. The CNA stated that they thought it was strange, and that he was able to see resident #1 pull up his pants when he saw the CNA. The CNA confirmed that the administration was told right away, and that resident #1 was removed from the day area. The CNA reiterated that he had seen the backside of resident #1 before he pulled his pants up. This CNA was not interviewed about the incident between residents #1 and #2, although they had made direct comments to administration the day before regarding a similar sexual assault that may have been occurring between the same two residents.

Based on record review, staff, family, and resident interviews, the facility failed to ensure that residents were safe from resident to resident altercations. The facility failed to ensure one of nine sampled residents (#1) received proper supervision and behavioral management to prevent a resident to resident altercation. Specifically, the facility was aware of and documented physical and sexual behaviors exhibited by resident #1 and did not implement adequate supervision. Subsequently a resident to resident altercation occurred specific to unwanted touching and inappropriate sexual behavior. The findings include: Resident #1, age 63, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] following the incident with resident #2. The 14 day minimum data set (MDS) completed on 9/2/14 showed a brief interview for mental status (BIMS) score of 14/15 which indicated no cognitive impairment. The resident was also noted to be independent with activities of daily living, except for supervision with hygiene. PASRR (preadmission Screening and Resident Review) (an assessment to ensure that individuals are not improperly placed in nursing homes): -On 8/11/2014, prior to the resident's admission, the facility received a letter stating that a Level II PASRR was being conducted and that it had been determined that the resident would require a Pre-Admission Care Plan due to: " a long history of assault and aggressive behaviors". Additional information included in the level II PARR documented a very extensive history of aggression and violence. -Records indicated a " a secure facility will be needed " Care Plans (in pertinent part): -The care plan initiated on 8/18/14 noted: Exhibition of behavioral symptoms as evidenced by verbal abuse and physical abuse history. Target identified behavioral issues included going into other resident ' s rooms, masturbating in inappropriate areas and had pushed another resident causing a fall. Facility/staff approaches to the identified behaviors included: Checking for discomfort or pain, allowing choices within individual's decision making abilities, redirection as needed. Additionally the care plan noted a 1:1 sitter was initiated 10/16/14 and then discontinued on 11/5/14. Resident Hospital History and Physical for Admission (in pertinent part): (in pertinent part): -Reported that patient had hit a resident today for what appeared to be no reason. He had also assaulted a peer two days ago. The director of nursing (DON) reported that patient has been cooperative for the most part but was impulsive in acting out and assaulting residents. The DON reported a long-term locked unit would be recommended. -Client has past legal issues of DV (domestic violence) and sexual assault. -Client has a history of aggression and violence towards others. In the past, client has had sexual misconduct issues and sexually assaulted someone while inpatient at (hospital). Psychiatric Therapy Notes (in pertinent part): -10/13/14: has been exhibiting behavior which included masturbating in front of other residents He appears to be in need of a structured secure unit. -10/15/14: Bullying and intimidating other patients and sexually assaulted another patient. Had two other charges while inpatient at (hospital) for sexually assaulting others. Nurse Notes: -10/8/14: resident sitting on sofa with female resident, he was masturbating. He was reaching towards her waist band on her pants. Staff intervened. He did not touch resident. -10/9/14: placed on 15 minute checks after found in female resident's room kissing her. -10/12/14: resident continues to bully other residents.-10/14/14: reported to this nurse that resident #1 urinated outside of female resident's window standing in courtyard. -10/16/14: nurse note indicates resident #1 punched another resident. Writer suggested we call police but DON asked if victim was injured and with no injury said not to call police at this time. The facility noted that they called the POA for resident #1, who they noted as saying " I ' m not surprised". We need to get him out of there before he hurts someone because he is escalating. " -10/16/14: SBAR (situation background assessment recommendation) Communication Form. Aggression toward another resident. Requested 1:1 supervision. Resident pushed another resident down without provocation. -11/15/14: vitals noted. -No other nurse notes in his chart indicating the incident that occurred on 11/15/14. The only documentation of the incident was located in the investigation report. Social Service Progress Note: -11/3/14-Continues to go into other resident's rooms. -11/24/14 -Late entry summary note: an incident occurred 11/15/14. (Resident #1) at the time was separated from the other resident. One to one staff was coordinated. Resident was alert and able to explain clearly his perspective was sent to ER (emergency room ). Resident/Family Education Record: -10/10/14: writer spoke to the resident and reviewed boundaries with others and going into other rooms. Discussed sexual activity, i.e. masturbation in his room. He was found masturbating in common area. Facility Resident to Resident Abuse Investigation for 11/15/2014 included: -Incident occurred on 11/15/2014 at 7:30 a.m. between resident #1 and resident #2. Resident information and interviews: -Resident #2, age 64, was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS completed on 12/4/2014 indicated a BIM score of 7/15 which indicated moderate cognitive impairment. -Interview with resident #2 revealed that " he came in here and I pushed him away and he came back " . The resident confirmed that resident # 1 had touched her with his hands, but was not sure if intercourse had occurred, but did state that he had tried. She stated she had been asleep when he came in. -Interview with resident #1 indicated that " I asked her if she wanted to get up and go to breakfast about 6:30 a.m. She pulled me over to her bed and started kissing on me". Resident #1 stated that he had not done anything and that he had not touched her, except for the kiss. He further he helped remove her diaper and that he touched the inside of her thighs and vaginal area. He denied having sex with her. He stated that she was touching his penis. He later stated to the DON that he used her hand to complete the sexual act. Facility Conclusion: Unable to substantiate assault. Resident # 1 admitted to touching her but denies intercourse. Resident #2 initially wasn't sure if intercourse occurred and denied touching him. Facility Summary: Resident #2 was sent out to the emergency room (ER) for examination the police were contacted and resident #1 has been sent to hospital for psychiatric evaluation. Overview: -CNA walked into the room and saw resident #1 pushing himself up off of resident #2 -Injury: undetermined. Reports pain in back. -Physician and family notified. -Police notified -One staff member interviewed during the investigation process, the CNA that first witnessed the incident. Facility investigation interviews: -An interview with the initial CNA was conducted during the facility investigation. The CNA stated that she had walked in to assist resident #2 for the morning and found resident #1 pushing himself up from "what I would assume to be from a lying position. I then saw resident #2 and saw her gown pulled up to mid chest and she had no underwear on". According to the CNA during the investigation, resident #1 stated to her "she said to make love to her". -No other interviews with additional staff were conducted -End of investigation Resident and Family Interviews: An interview with a family member of resident #1 was conducted on 1/8/2015 at 1:40 p.m. The family member stated that they had warned the facility " that he had these kinds of behaviors and they told me they were used to handling people like this. They knew before he came what he was like. They knew he required on one to one (supervision). An interview was conducted with resident #3 on 1/9/2015 at 9:00 a.m. regarding resident #1's behavior. She stated he had offered to push her to her room and always commented on things he wanted from her. Resident #3 stated she was warned by other residents that she should stay away from him. She stated " that it was good that they got rid of him". An interview was conducted with resident #6 on 1/9/2015 at 9:30 a.m. The resident stated "he had been punched in the jaw" by resident #1. He stated he knew that they finally had to get rid of him after the last woman was (allegedly) assaulted. He stated the facility had been aware of resident #1 ' s behaviors but had not done anything about it. An interview was conducted with resident #7 on 1/9/2015 at 10:00 a.m. regarding resident #1. The resident stated " I knew he was very aggressive, there were a few people that he really was aggressive with, like a resident (named resident #6) (see interview above). Resident #8 was interviewed on 1/9/2015 at 10:18 a.m. regarding resident #1. According to resident #8, was aggressive with a few residents. " I stayed in my room to stay away from him " . An interview was conducted with resident #4 on 1/9/2015 at 11:00 a.m. regarding resident #1. Resident #4 stated resident # 1 liked going in female residents rooms. Resident #4 stated that "they (the facility) finally got rid of him (after the incident on 11/15/14. An interview was conducted with a family member of resident #2 on 1/9/2015 at 12:10 p.m. The family member stated that she was not happy with how resident #2 had been treated. Staff Interviews: An interview on 1/8/2015 at 8:25 a.m. was conducted with the Customer Service Coordinator (CSC). The CSC revealed that the facility had difficulty with hiring a new Social Service employee during the incident in question. The CSC confirmed that during that time frame, she and the Director of Nursing did the investigating of incidents at the facility. The CSC stated that they would do their documentation in their investigation summaries. The CSC stated that she and the DON investigated the incident that occurred between resident #1 and resident #2 on 11/15/2014. The CSC stated that one of the CNAs at the facility had gone to get resident #2 ready around 7:30 a.m. and had seen resident #1 pushing him off of her."She said his pants were undone and resident #2's legs were slightly spread. The CNA had told the CSC that he had zipped up his pants, and she had gone to get a staff member's help. The CSC said that a staff member sat with resident #2 and resident #1 was taken to his room and had one to one supervision. The CSC stated she and a CNA went to talk to resident #2 who was lying in bed with her head towards the wall and looked " disheveled". The CSC stated that the resident did not want resident #1 in her room and did not know who he was. "We asked if he hurt her, and she said her back hurt from his weight on her. She didn't know if they had intercourse". According to the CSC, resident # 1admitted to touching resident # 2 ' s thighs and breasts. He told the CSC it was consensual. The CSC stated that the police came right after that, and began their investigation. Our NHA felt that we couldn't determine if it was consensual or not. The sister had made a comment about him having sexual behaviors, but we weren't really sure what she was sharing. When we sent her (resident #2) out.. We hadn't seen any prior sexual behavior before this incident (see above 10/8/14 note specific to masturbation in a common area). An additional interview with the CSC was conducted on 1/8/2015 at 10:09 a.m. The CSC stated that resident had been placed for a time on one to one supervision due to physical altercations with other residents but not for sexually inappropriate behaviors. On 1/8/2015 at 10:30 a.m. an interview was conducted with the director of nursing (DON). The DON stated that resident #2 had been sent out to the hospital after the incident had occurred, and that a SANE (Sexual Assault Nursing Exam) investigation was completed. According to the DON, the investigation went to the police officers and they did not get feedback from the hospital. She said the SANE exam was supposed to take 4-6 weeks, but she had not yet heard anything about the results. She stated that the police also did not provide feedback about their investigation. An interview was conducted with CNA #2 on 1/9/2015 at 11:44 a.m. The CNA stated that, the aides were getting the residents up for breakfast and taking them to the dining room when "A female aide came yelling down the hall, after she was trying to get resident #2 up and caught (witnessed) the incident and she came out to get other staff to help. "I went into the room with the other aide. A nurse came in and (Resident #1) left the room and went into the dining room and started talking about the incident. The CNA stated that the staff was told to get the resident dressed so the ambulance could take her. "The DON said to keep her there until she could get in and talk to her. Resident #2 can only talk a bit and she told the DON that he hurt her". According to the CNA, resident #1 was not arrested but was sent out later that day. The CNA stated that resident #1 "was going out and telling everyone what he did". "The DON came in within an hour. The staff questioned both residents a number of times before the ambulance came. He should know right from wrong, but he knew what he was doing because he had bragged about it. The CNA stated that resident #2 used to smile a lot, but did not anymore. An interview was conducted with a registered nurse (RN #1) on 1/9/2015 at 1:33 p.m. The RN stated that it was about 7:15 a.m. in the morning when a CNA was heard hollering. The RN stated that when they got to the room the aide was at, resident #1 was observed fixing his clothes. The RN said that the CNA stated that she had seen the resident "in the act". The RN said that resident #2 was checked on with the assistance of the DON. "Someone called the police and I shared what I knew. He was put on one to one and then went out to the hospital. The RN confirmed that they were not interviewed about the incident by the investigating facility staff members. An interview was conducted with CNA #3 on 1/9/2015 at 2:03 p.m. The CNA stated that resident #1 would try to put his arm around my waist, or even up higher on me. "The CNA said that after the incident, resident #2 talked to me and said she was assaulted. An interview was conducted on 1/9/2015 at 2:36 p.m. with CNA #4. " When I went in to (resident #2 ' s) room, she was laying perpendicular on the bed, with her head near the wall. Her legs were widespread, not just slightly open. I didn't move her or anything until the DON and CSC arrived. I was in there probably 30 minutes before they got there " . The CAN stated the resident appeared traumatized. When the CSC came in, she asked resident #2 if she remembered the man in her room, resident #2 shook her head and the CSC asked her if she had invited him in there as if it was consensual and resident #2 said "no". The CSC asked resident #2 if she wanted relationship with that man and she said "no". She said he (resident #1) had hurt her. . I told the DON what resident #2 had said, and the DON said to leave the room. The CNA stated that the personality of resident #2 had changed since the incident, resident # 2 was different, specifically that she used to talk a lot and now she didn ' t talk anymore. The CNA stated prior to this incident, resident #1 had masturbated over a female resident and masturbated in front of another resident. The CNA stated that resident #1 went to the dining room after the incident and told to other residents about the incident. The CNA stated that she had overheard the DON telling resident #1 not to wash up after the incident, but she found him in the bathroom washing up. An interview was conducted with RN #2 on 1/9/2015 at 3:15 p.m. The RN stated that the staff " had told administration over and over again that he was a problem and something bad was going to happen". The RN said that the staff knew that documentation was not being done well, and that the DON had made it clear "that they shouldn't document some (of the) incidents here (at the facility)". The RN stated that the DON had made it clear that not everything was to get documented in the resident records. The RN stated that resident #2 asked if the male resident "was going to go to jail for assaulting her". An interview was conducted with CNA #5 on 1/9/2015 at 5:54 p.m. The CNA stated that the night before the incident of 11/15/2014 between resident #1 and resident #2, he had walked back towards the day room on the east wing and had seen resident #1 with resident #2. The CNA stated that they thought it was strange, and that he was able to see resident #1 pull up his pants when he saw the CNA. The CNA confirmed that the administration was told right away, and that he was removed from the day area.

Based on record review and interviews, the facility failed to ensure one of three residents (#1), who entered the facility without pressure sores, did not develop pressure sores. Specifically: Resident #1 entered the facility with intact skin on [DATE]. He developed a Stage IV pressure sore that became infected and painful and required debridement. Following debridement, the resident's condition continued to decline. Although the resident was enrolled in an all inclusive program with an outside service provider (PACE) that managed the resident's medical orders, treatments, medications and therapies, the facility failed to ensure facility staff properly assessed, monitored, and planned care to address the resident's deteriorating wound, as well as coordinated care with the outside service provider. Findings include: 1. Resident #1, an [AGE] year old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to an acute care hospital on [DATE] and from the hospital to hospice care where he expired on [DATE]. Resident #1's daughter, interviewed on [DATE] at 1 p.m., said the resident was a participant in the PACE program, a program providing long term service and support for Medicare and Medicaid enrollees, since his admission. She said PACE was in charge of all the resident's care orders and medications. According to the facility Director of Nurses (DON) interviewed on [DATE] at 3:30 p.m., she confirmed PACE was in charge of all resident #1's care while he was in the facility, including medical orders, treatments, medications and therapies. 2. Resident Status on Admission - At risk for skin breakdown - Failure in Facility Response a. Risk factors A nurses' note dated [DATE], as a late entry for admission [DATE], recorded "skin on buttocks is intact." However, the Admission Minimum Data Set ((MDS) dated [DATE], identified several risk factors for skin breakdown, including that the resident's functional status was extensive/total assistance, he was cognitively impaired, and he was frequently incontinent of bowel and bladder. b. Failure in Facility Response Notwithstanding the resident's identified risk factors, review of the resident's record revealed no care plan to reduce these risks, specifically, interventions to minimize the risks associated with his inability to turn and reposition, and his frequent incontinence. 3. Resident Status After Admission - Pressure sore development - Failures in Facility Response ,[DATE] - ,[DATE] a. Pressure sore development Resident #1's daughter, interviewed on [DATE] at 1 p.m., said that in [DATE], the facility notified her resident #1 had a small wound on his right buttocks. She said she was told by the facility licensed practical nurse (LPN), that the wound was very small, like a small spider bite. b. Failures in Facility Response Record review revealed no documentation in the nurses' notes in [DATE] regarding the discovery of a wound on the resident's right buttocks or a description of the wound on any date between ,[DATE] - [DATE] by a registered nurse. -A note [DATE] at 3 p.m. documented, "right buttock dressing change this morning," but gave no description of the wound. -Another note on [DATE] at 10:30 a.m. documented a wound nurse came to the facility and gave new orders for treatment (Duoderm to open area and change every three days and as needed until healed), but there was no description of the wound in the note, either by facility staff or PACE staff. -Record review revealed no further nurses' notes regarding the wound until [DATE] (see below). Record review further revealed no care plan to promote healing of the right buttock wound and no regular skin assessments that documented the characteristics of the wound and tracked the status of the wound. Moreover, record review revealed no documentation from the PACE program regarding the wound and wound care, other than that referenced in the nurses' notes on [DATE] (see above). Record review revealed no dietary assessments or interventions upon discovery of the resident's wound or thereafter from ,[DATE] and until [DATE] when the LPN requested vitamin therapy. Record review of the facility treatment records revealed a treatment order, originating [DATE], for "Topical daily for wound healing to right buttock, pat dry, apply Santyl ointment to yellow slough daily and cover as needed with dry dressing." However, there was no corresponding documentation of the wound in the resident's record at the time this order was initiated. 4. Resident Status after Wound Development - Worsening of Wound - Facility Response - Failures in Facility Response Resident #1's daughter, interviewed on [DATE] at 1 p.m., said the facility kept saying resident #1's wound was "okay," but when she met the resident at the wound clinic on [DATE], she could smell the wound and was "horrified" by the condition of the wound. Record review revealed the resident's pressure ulcer deteriorated, became painful and infected. Sharp debridement was performed [DATE]. Thereafter, the wound was documented as a Stage IV pressure ulcer. a. Deterioration and Facility Response Nurses' notes: -[DATE] at 3:15 p.m., the facility LPN recorded that the resident's buttock was two centimeters (cm) and tunneling. -[DATE] at 9:45 a.m., the facility LPN described the appearance of the wound, "surrounding tissue dark red, firm and warm to touch." She requested an order for [REDACTED]. -[DATE] at 11 a.m., the facility LPN noted, "Wound remains red/war and odor noted this a.m., to wound care clinic at 12:30 p.m." New wound care orders were received at 11 p.m. that evening. -[DATE] at 10:30 a.m., the facility LPN noted the resident's wound "continues with odor - red and warm to the touch." -[DATE] at 7 a.m., the facility's LPN recorded that the resident's wound continued to be malodorous, red and warm to touch. "... tissue around black are(a) is red, no signs of pain related to dressing change. Per RN report this morning, Keflex 500 mg four times daily was received from the PACE pharmacy, however, no order was found for this medication, appears that doses have been given." -[DATE] at 9 a.m., the facility LPN received an order for [REDACTED]. -[DATE] at 11:15 a.m., the resident's daughter called the facility and said she was at the wound clinic and was very upset about the condition of the resident's wound. She said the resident was in pain and the wound area was then 10 cm x 8 cm x 4.5 cm deep. A call was made to the PACE physician for a pain medication order. -[DATE] at 1:55 p.m., the LPN received an order for [REDACTED]. -[DATE] at 4 p.m., the LPN found the resident's dressing saturated in blood from the debridement procedure. The wound clinic was called and orders given to continue packing the wound with Dakin's solution. Wound clinic note: A wound clinic procedure note on [DATE] revealed the physician at the wound clinic completed a sharp debridement due to wound deterioration and increase in necrotic tissue. The resident was to be followed weekly at the wound care clinic and was scheduled to see the physician again on [DATE]. PACE note: A progress note by the PACE nurse practitioner on [DATE] stated the resident's wound was 10.1 cm length x 8 cm width x 4 cm deep. Wound type was "State IV pressure ulcer." The wound bed was red and yellow, edges were intact and there was granulation and slough as the wound bed tissue type, with 60% granulation. Slough was described as adherent black and yellow with serosanguinous drainage, slight odor, no undermining, and no tunneling. Pain was recorded as "patient doesn't verbalize but fights." Wound treatment was listed as ? Dakins solution. The note read the wound had worsened but it was due to the debridement for necrotic tissue at the wound care facility. Physician note: A progress note from the resident's physician on [DATE] read: Pressure wound Stage IV, "I saw the patient ,[DATE], a few days after sharp debridement by the surgeon. The surgeon had debrided all necrotic material down to bleeding tissue with final open wound about 15 cm diameter and 5 cm deep, nearly to ischial bone. By ,[DATE], there was a 3x4 cm area of new superficial necrotic tissue inside the wound at 2 o'clock position. Dakin's solution to be use(d) and further follow up with surgeon." b. Failures in Facility Response Record review, during the period of the above decline, revealed a change in treatment orders on ,[DATE] and [DATE] ("Clean wound with NS pat dry and apply Santyl cover with [MEDICATION NAME] daily and as needed" on [DATE], and "Cleanse wound with NS or wound cleanser. Apply moistened two inch Kerlix with ? strength Dakins solution. Pack wound bed followed by dry gauze, ABD pad and secure with [MEDICATION NAME] tape twice weekly and as needed" on [DATE]). However, the facility's assessment and monitoring of the wound, as well as care planned interventions to prevent further deterioration and to promote healing were not evident from review of the resident's record. Specifically: -The nurses' notes above revealed no documentation the resident's wound was comprehensively assessed by a facility registered nurse as it deteriorated. -The facility's skin assessments completed [DATE], [DATE], [DATE] and [DATE] documented "sore on right buttock." No weekly measurements or staging was included on the assessments by licensed nursing staff and the treatment record for ,[DATE] documented only that the wound measured 8 cm x 10.5 cm 4.7 cm; no further characteristics were described. -The resident's record included no interdisciplinary care plan for the management of the resident's wound. -The resident's record revealed no evidence a licensed nurse assessed the resident's pain and pain management plan. Specifically, review of the nurses' notes revealed that beginning on [DATE], the resident's daughter requested stronger pain medication. Although a call was made on [DATE], the resident's pain management remained the same. On [DATE] at 9:30 a.m., a nurses' note documented the resident's daughter again expressed concern that resident #1's pain was not well controlled. At this time, the facility LPN called for a pain medication order change. There was no documentation from [DATE] - [DATE] of a comprehensive pain assessment to evaluate the resident's pain and the effectiveness of his pain management plan. -The resident's record revealed that, other than the request for vitamins on [DATE], no further nutritional interventions were considered until [DATE], when the facility LPN requested an increase in supplements, and order for Healthshakes four times daily and fortified meals to increase calorie intake, On [DATE] after the LPN spoke with the Medical Director, orders were received for [MEDICATION NAME] and pre-[MEDICATION NAME] testing to determine the resident's nutritional status. (Discussions began on [DATE] for placement of a feeding tube.) 5. Resident Status after Debridement - Further Decline and hospitalization Review of social service notes revealed a care conference was held [DATE] and included the resident's family, the PACE wound nurse and physical therapist, and facility staff. -The note read the resident's room was observed with facility and PACE staff and a special cushion was implemented, leg cradles were planned and it was discussed at this time, that "for his wound to heal, less layers in bed is best ..." -The resident's daughter, during an interview on [DATE] at 1 p.m., stated that at this conference, it was apparent to her there was no communication between the facility and PACE in the management of the resident's pressure sore. Review of a progress note by the PACE nurse practitioner on [DATE] documented the resident was in a fetal position and responded to verbal stimuli by opening his eyes. -It read that nursing staff said the resident was turned every two hours onto his back or left side. -It further read that although the facility LPN had reported the resident's wound was beefy, the nurse practitioner, examining the wound at 2 p.m., found the wound was green/gray with scant amount of foul smelling drainage. Review of nurses' notes revealed: -[DATE] at 11 a.m., a dressing change was conducted by the facility LPN. The LPN noted "some odor," but documented no description of the wound. -[DATE] at 2:45 p.m., the LPN described the wound as "continues with yellow green slough from ,[DATE] cm, other area red and beefy, medication for pain prior to dressing change." -[DATE] at 3 p.m., - the last nurses' note relating to the resident's wound - documented the resident returned from the wound clinic. Review of physician orders [REDACTED]. Resident #1's daughter, interviewed on [DATE] at 1 p.m., said that on [DATE], she was told her father had experienced a rapid decline and was taken to the emergency room (ER) for evaluation of low oxygen saturations, down to 74% (normal range ,[DATE]%). She said she went to the ER and when the ER staff pulled back the covers, the smell from the pressure sore was overwhelming. The physician told her the wound tunneling "is far deeper than you can imagine." Review of the [DATE] History and Physical from the acute care hospital included the history of the present illness as "He has progressive [MEDICAL CONDITION]. His x-ray suggests left-sided infiltrate. He has a severe decubitus on his buttocks. He was given [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) in the ER ...He is slightly leukocytotic. He meets criteria [MEDICAL CONDITION]." The physical exam related to skin included, "He has a decubitus on his buttocks - very deep." The physician's impression was "Sepsis, source from the lungs and the decubitus." The physician's plan of care included Intensive Care Unit, critical care bundle, antibiotics and intravenous fluids. Interview with the facility LPN on [DATE] at 11:45 a.m. revealed the resident was transferred from the hospital to hospice where he died on [DATE]. 6. Staff Interview a. DON On [DATE] at 3:30 p.m. the DON was interviewed. -The DON said that PACE was in charge of all of resident #1's care, including medical orders, treatments, medications and therapies. She said the facility had not obtained information related to the treatment of [REDACTED]. She said lack of communication with the resident's provider was an "ongoing problem." She said it was a very awkward situation because the facility was charged with caring for the resident, but they had no say in the resident's treatments, medications, and assessments. -The DON said the facility's Medical Director had called the medical care provider when the wound had deteriorated "but it didn't change anything." She acknowledged the facility staff had not followed-up with the Medical Director after that one call was made. -The DON said that the facility did not do weekly assessments or measurements of the wound and she confirmed they did not have a care plan in place for pressure wound care. She said the facility should have been doing, but had not done, weekly assessments and measurements. b. LPN The LPN who had documented in the nurses' notes (see above) was interviewed on [DATE] at 11:45 a.m. She said that she was primarily responsible for the care of the resident during his stay. She stated, in pertinent part: -The right buttock wound started as a tiny red spot in [DATE]. Toward the end of January and the first week of February, the wound progressed rapidly. -The facility did not have a wound nurse, and no facility Registered Nurse, including the DON, had assessed the wound while the resident was in the facility. -Although she was an LPN, she was responsible for all the communication and daily wound assessments. -She spoke to the resident's daughter almost every day, and tried to help the daughter contact the PACE staff when they would not return her calls, and -She said "I did everything I could, I felt like I was hanging out there all by myself. I needed a unit nurse and a wound nurse, and we didn't have one." c. DON The DON was interviewed again on [DATE] at 11:30 a.m. Her comments included: -No RN routinely assessed the resident's wounds; the primary nurse completing treatments and visual assessments was a LPN. -Currently she had an independent physician come in and look at pressure ulcers weekly, however, this did not include PACE-enrolled residents such as resident #1. -She was planning to hire a wound nurse and a unit manager RN in the near future. When this hiring was completed, all residents' wounds would be assessed weekly.

Based on observations, interviews and record review, the facility failed to provide necessary care and service to attain and/or maintain the highest practicable physical, mental and psychosocial well-being for three (#69, #89 and #7) of 32 sample residents. Specifically, the facility failed to: -Provide adequate and timely emergency care for the treatment of [REDACTED]. -Develop, implement and evaluate specific interventions when an as-needed (PRN) medication was used to manage resident #89's behavior. -Adequately coordinate the care of resident #7. Findings include: 1. Resident #69, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate receptive and expressive communication skills and scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating significant cognitive impairment. She displayed verbal behavioral symptoms, such as yelling and cursing at others at times. She required extensive assistance with her activities of daily living and utilized a wheelchair for mobility. Observation: On 9/9/13 at 9:45 a.m., the resident was sitting in her wheelchair near the medication cart. Her right eye was bruised purple and black and swollen. -The resident said, "Look at my fractured hand." Observations revealed her right hand was swollen more than twice its size from the wrist to the first metacarpal. It was dark purple in color and was hanging down by the side of the wheelchair wheel without any type of support or immobilization. -The resident said she fell "last night" outside in the smoking area but she could not remember the time. She did not recall how it happened and could not describe what she was doing when the injury occurred. -The resident said her hand was "terribly painful" and had been all night. She said she had not been examined by a physician and had not had an x-ray of her injury. On 9/9/13 at 9:48 a.m., the Director of Nursing (DON) was asked if she had observed the resident's injury. -She said she was unaware of any injury and hurried into the hall to see the resident. She asked the resident what happened and examined the hand. She said that the hand should be immobilized and elevated, but did not reposition the resident's hand. -She questioned the unit nurse at 10 a.m. regarding the injury and what had been done for the injury. The unit nurse said that she had called for a stat (as soon as possible) x-ray by a mobile x-ray provider at approximately 6:30 a.m., but the x-ray service had not arrived. On 9/9/13 at 10:12 a.m., the DON said that the resident was being sent to the emergency department and she was trying to find staff to accompany her. She said neurological checks for an unwitnessed fall were completed the prior evening after the injury. Observations of the resident at this time revealed the resident continued to sit in the hall in her wheelchair with her hand hanging down by the wheel of the wheelchair. On 9/9/13 at 10:20 a.m., the resident's room was observed; it contained no support pillows or evidence of ice application materials. On 9/9/13 at 10:30 a.m., the resident was taken to the emergency room by facility staff in the facility van. On 9/9/13 at 5:13 p.m., the x-ray report from the Emergency Department (see below, not available until after survey exit 9/11/13) showed a comminuted fracture (a fracture in which the bone fragments into several pieces) of the third metacarpal with both radial and ulnar displacement (out of normal alignment) of fracture fragments and slight dorsal displacement of the fracture fragment. There was also an acute comminuted displaced [MEDICAL CONDITION] second metacarpal with some impaction (pieces of bone driven firmly into one another) and of fracture fragments and slight ulnar displacement of the main distal fragment. There was "extreme soft tissue swelling particularly over the dorsum of the hand". A CT of the head revealed no facial fractures but indicated swelling of soft tissue over the right eye. It also confirmed the placement of the resident's cerebral shunt in the left occipital area. Record Review: A Change of Condition form was completed at 7:45 p.m. on 9/8/13. -The form stated the resident fell at 6:15 p.m. "with injuries" outside in the smoking area. It stated the wheelchair started rolling and tipped over. Injuries noted were one centimeter bruise on the right eye and the right hand was noted as "painful and tender from bracing for the fall." -First aid and ice packs were applied to the resident's right hand. Vital signs were taken and were within normal limits. Pain level/location/site were indicated for right eye and right hand. -The resident's physician was notified of the injury at 7 p.m. and instructed the nurse to monitor the resident's condition for change. The resident's representative was notified of the injury at 7:15 p.m. The Neurological Record completed after the injury on 9/8/13 showed assessments completed at 6:45 p.m., 7 p.m., 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:00 p.m., 8:15 p.m., 8:30 p.m., 8:45 p.m., 9 p.m., 9:15 p.m. 9:30 p.m., 9:45 p.m., 10 p.m. and 10:30 p.m. Neurological assessments were recorded as refused at 12:30 a.m., and 6:30 a.m. and "out of facility" at 10:30 a.m. The neurological assessment form did not include any evaluations of the condition of the right hand. No nursing progress notes were recorded from the time of the injury at approximately 6:30 p.m. on 9/8/13 until 6 a.m. on 9/9/13. The first progress note after the injury was recorded on 9/9/13 at 6 a.m. by the night nurse who recorded the resident had refused vital sign assessments twice during the shift, and had screamed and cursed at the nurse when evaluations were attempted. She wrote "Noted swelling of right hand, resident denied pain when asked by stating 'leave me ...alone.' No noted distress." -There was no description regarding amount of swelling, progression of swelling, discoloration or appearance included in nursing progress notes. -There was no evidence the physician was notified of the change in the condition of the resident's hand (pain, increased swelling or discoloration). On 9/9/13 at 11 a.m., the day unit nurse recorded that when she went to do the resident's morning blood sugar, she noted the resident's eye was purple, blue and swollen and her right hand was swollen and painful. The resident was complaining of pain in her right hand. The nurse wrote the resident requested a pain pill, but had gone on to breakfast and out to smoke before a pain pill could be given. The note stated a stat x-ray was ordered from a portable x-ray service at 7:25 a.m., but when the x-ray service did not arrive, the resident was sent to the emergency room . The family was notified of the resident's transfer to the emergency room for treatment and stated they would go to the emergency room immediately to meet the resident there. A nursing progress note on 9/9/13 at 5 p.m., stated the resident had returned from the emergency room and had sustained two fractures in her right hand. The plan was for the resident to go to an orthopaedic surgeon the next morning for evaluation of injury. The chart contained no x-ray report, physician progress notes [REDACTED]. The September 2013 Medication Administration record showed no as needed Tylenol 500 mg every six hours (ordered 7/18/13) was given in the month of September, including the evening of the injury. One as needed [MEDICATION NAME] 10-325 milligrams (ordered 7/18/13) was recorded as given on 9/9/13 at 7 a.m. Interviews: The DON was interviewed in 9/9/13 at 11 a.m. -She said that she had not been notified of the resident's injury the previous evening, and staff had not reported the injury to her when she arrived that morning. She said she had not conducted morning rounds that morning. She said that "usually" staff notified her of significant events or injuries. -She said it was her expectation that the resident's hand should have been immobilized and elevated when swelling and bruising were present, and the condition of the hand should have been regularly monitored during the night. -She said the day unit nurse had ordered an x-ray "stat" at 6:30 a.m. and she did not know why the x-ray service had not arrived for the service by 10 a.m. She said that a three hour wait was not an acceptable length of time to wait for an x-ray for a suspected fracture. She said it was within unit nurses' authority to send resident's to the emergency department any time an injury occurred and they did not have to gain permission from her as the DON. The evening unit nurse (registered nurse/RN) on duty 9/8/13 was interviewed on 9/10/13 at 10 a.m. via telephone. -She said that the resident went outside to smoke on the evening of 9/8/13 and no staff was in the smoking area at the time. She said she was summoned by a resident and went out to find the resident on her right side. Her face showed her right eyebrow was swollen. She said the resident's hand was painful and displayed "a little swelling." -She said that the resident was taken to her room where she examined the resident's hand and determined it was tender when range of motion was evaluated. She said "I thought it was ok because I grabbed her hand and flexed it up and down. It was a little sore, but I knew it wasn't fractured because if it was fractured, she wouldn't have had good range of motion." -She said she gave the resident a Tylenol for pain. She said she was unable to reassess the resident's hand during the night because the resident yelled at her when she attempted to go in her room. She said at the time of the injury, she had notified the physician who had ordered the injuries to be monitored for change. She also had notified the resident's representative of the fall and injuries. The day shift unit nurse aide (CNA) was interviewed on 9/9/13 at 10:20 a.m. She said the resident had complained of pain during the early morning, and the resident had showed her the injured hand. She said no ice was present in the room, and the resident didn't have it elevated or immobilized when she was caring for her. The unit nurse (RN) was interviewed on 9/9/13 at 11:15 a.m. She said she had noticed the discoloration and swelling when she went to complete the resident's blood sugar. Due to appearance of the resident's hand, she had obtained a stat order for an x-ray. She said when the portable x-ray did not arrive by 10:30 a.m., the DON told her to send the resident to the emergency room . The DON was interviewed again on 9/11/13 at 2 p.m. She said the resident had sustained two fractures in her hand and was being evaluated at the orthopedic surgeon's office (9/11/13) that morning. -She said that she had discovered that the on-call phone had not been functioning the night of the resident's injury, so she did not know if the evening nurse had tried to call her or not. -She said it was her expectation that a "stat" x-ray be within a reasonable timeframe and that waiting from 7 to 10:30 a.m. with no service was not acceptable. -She further stated it was her expectation the resident's hand condition would have been reassessed during the night by the nurse and that the results of the assessments would have been recorded in the record and reported to the physician. 2. Resident #7, a [AGE] year old female, was admitted on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status Minimum Data Sets (MDS): The quarterly Minimum Data Set ((MDS) dated [DATE] and the annual MDS dated [DATE] scored the resident at an 8 on the Brief Interview of Mental Status (BIMS) indicating moderate cognitive decline. -The resident needed two to three person assistance with bed mobility, transferring, dressing, eating, toilet use, and personal hygiene. -The resident was coded as never rejecting care. Care plans: Care plan review revealed a care plan for pressure ulcers, [MEDICAL CONDITION] and preferences. -The plan for pressure ulcers (10/16/12) identified a problem dated 6/3/13, that read, "frequently refuses to lie down after meals." -the goal was "the resident will have intact skin without signs of skin breakdown through the next 90 days." -The approaches were "reposition in chair frequently, wedge for side to side positioning, and offer to lie down after meals." The plan for [MEDICAL CONDITION] (7/13/13) identified a problem that read, "potential for pain and skin breakdown." -The goal was "skin will be free from skin breakdown." -The interventions were "check lower extremities daily for breakdown, elevate legs as needed, and assess resident's knowledge of condition and treatments, and teach as needed." The plan for individual preferences identified a problem "the resident chooses to be highly involved in daily care decisions regarding suggested or recommended interventions and has specific preferences related to: prefers to sit by the receptionist's desk in front lobby most of the time." -The goal was "the resident will have preferences honored with individual education related to benefits, risks and outcomes of choices and preferences." -The approaches were "provide individual education related to individual preferences related to individual choices and exercises of preferences, document education provided using patient education record, and notify Medical Doctor (MD) of individual's choices and preferences." This was assigned to the licensed nurse discipline. Orders: Review of the resident's medication administration record (MAR) revealed an order dated 9/27/11 that read: "Patient to lie down in bed three times a day (TID) after meals for one hour. Place on her side to reduce pressure on buttocks, patient to lie down after meals for one hour." The MAR for the months of June 2013 and July 2013 had no signatures by staff indicating staff was laying the resident down three times a day after her meals. September was signed on 9/1/13 indicating the resident had been laid down after meals. No other signatures were noted. Observations: On 9/3/13 at 10 a.m., the resident was observed sitting in the front area looking out the large windows in the front of the facility. At 3:30 p.m. she was again sitting in front of the windows with her daughter. On 9/4/13 at 8:00 a.m., the resident was seen at the front desk in her wheelchair, feet dependent, watching what was going on around her. -At 12:30 p.m., the resident was observed leaving the dining room and foot pedaling back to the front area, where she sat until her daughter arrived for bingo at 1:30 p.m. -The resident was still in her chair with her feet dependent at the evening meal. At no time after the noon or evening meal, was a staff member observed approaching the resident to lie down after the noon meal or the evening meal. Staff Interviews: On 9/10/13 at 7 a.m., a Certified Nurse Aide (CNA) who was familiar with the resident was interviewed. She said the only time the resident gives her a hard time is when you are trying to lay her down, then she screams until you get her up. The CNA said, "She hates to be laid down, she refuses it." On 9/10/13 at 8:45 a.m., another CNA who was familiar with the resident was interviewed. She said the resident does not like to be laid down, stating, "She yells when she wants up and she can become combative." On 9/10/13 at 8:50 a.m., another CNA confirmed the resident "likes to stay up front and people watch. She hates to be laid down and will refuse if you ask her." On 9/10/13 at 7:15 a.m., the Licensed Practical Nurse (LPN) said the resident is very cooperative "unless you try to lay her down, then she's been known to become combative and scream." On 9/10/13 at 10:30 a.m., the Director of Nursing (DON) was asked about the resident's order above, to be laid down after meals. -The DON said the resident refuses and cannot be forced to lie down. She said, "It's her choice to stay up if she wants. She screams out and can become aggressive. I know her legs swell, but we can't put foot pedals or prop up her legs; it puts her at a fall risk because she propels herself with her feet not her hands." -The DON said, "We have talked with the provider about her refusal and they don't want to discontinue the order, they want to keep it so we keep offering her the option." -The DON said they did not have documentation of the offers, refusals, or provider notification about the resident's refusals. She said she could not find documentation that the provider noted the resident's refusals either but stated the provider has been notified 'face to face.' Action taken during survey: On 9/10/13 at 3:45 p.m., the resident was in the front lobby area with her daughter when the Physical Therapist (PT) was observed placing foot rests and a leg board for the resident to put her feet up. The PT was overheard explaining to the resident's daughter, "This might help with her legs swelling, it can be adjusted, we will only use this when you are here to watch her and move her around." On 9/11/13 at 8:45 a.m., the PT was interviewed and said the foot pedals would be placed only with family present so they don't create a fall risk. The PT said the resident becomes very anxious if she can't move her feet. The PT said the resident was going to be placed back on restorative care. See care plans above; there was no evidence the care plans above were updated to include the new intervention of foot pedals and their limited use, the new intervention of restorative care, and new approaches to promote the resident's compliance, and note to staff about the resident's frequent refusals. 3. Resident #89, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses, according to the facility admission face sheet, of dementia with behavior disturbance, central hearing loss, chronic pain, constipation and [MEDICAL CONDITION]. According to the annual Minimum Data Set (MDS) assessment, dated 8/4/13, the Brief Interview of Mental Status (BIMS) was not conducted because the resident was rarely/never understood. Staff assessment of mental status indicated the resident experienced short- and long-term memory loss. Staff described cognitive skills for daily decision-making as severely impaired and reported the resident never/rarely made decisions. The assessment noted the resident did not experience signs and symptoms of [MEDICAL CONDITIONS] or impairment of mood. The MDS documented the resident did not display behavior symptoms or reject care. The MDS also documented the resident took anti-psychotic medications on a daily basis and was administered anti-anxiety medications on four of seven days during the assessment period. The 8/4/13 Care Area Assessment Summary (CAA) included cognitive loss/dementia, psychosocial well-being and psychotic drug use as triggered care areas to be addressed in the resident's care plan. The CAA summary did not include concerns related to the resident's behavior symptoms. Record Review: Computerized Physician order [REDACTED]. An Unnecessary Drug Risk/Benefit Statement dated 5/30/12 indicated the physician did not want to make changes to the resident's use of [MEDICATION NAME] and [MEDICATION NAME] indicating the benefits of the medication outweighed any side effects/risks involved. The Nursing Care Plan (NCP) dated 11/2/12 included a goal to support the resident with concerns related to [MEDICAL CONDITION] medication use. The NCP noted the resident was taken off [MEDICATION NAME] Deconate (an anti-psychotic medication) in 2011 and experienced severe anger and striking out. The note also indicated the physician did not want to consider another change to medication. According to the NCP, [MEDICATION NAME] (an anti-anxiety medication) was administered for repetitive health concerns and yelling out. -The goal was to receive medications at the smallest effective dose. The NCP also included a goal related to behavior symptoms indicating the resident engaged in socially disruptive behavior. -Approaches were listed as "use a firm/gentle voice, give simple/clear instructions, ignore verbal outbursts, check for discomfort, allow choices, modify environment, redirect as needed, be alert for triggers, and reassure and allow resident to express feelings." The NCP did not provide information or instructions in order that staff could consistently identify when non-pharmacological interventions had failed and as-needed (PRN) [MEDICATION NAME] should be administered. The Resident Care Cardex Worksheet, used to provide instructions to staff, mentioned the resident experienced anxiety but did not mention interventions to support the resident with an increase in anxiety or behavior. The Psychoactive Medication Consent dated 1/15/13 identified "yelling out and repetitive health concerns" as targeted behaviors for the PRN use of [MEDICATION NAME]. The Psychoactive Medication Consent dated 3/15/13 identified "unredirectable yelling/screaming" as targeted behaviors for use of [MEDICATION NAME] and [MEDICATION NAME] Deconate. The Psychoactive Medication Quarterly Evaluations completed on 5/10/13 and 8/8/13 indicated no changes were noted in the resident's behavior. The 8/8/13 evaluation documented medications should continue as ordered. A nurse's note written on 1/3/13 noted an increase in agitation for the resident. A nurse's note written on 5/31/13 documented an increase in yelling resulting in use of PRN [MEDICATION NAME]. Further review of nurse's notes completed between 10/12 and 9/10/13 did not reveal further documentation of the resident's behavior or of decisions to administer PRN [MEDICATION NAME]. A social services note written on 5/3/13 documented the resident continues to yell out in anxiety whenever she is "gotten out of bed." A review of the Medication Administration Record (MAR) and behavior tracking for anxiety revealed: (1) June -Behaviors (yelling out) were documented on 6/3 (5 times during the day and 5 times in the evening-[MEDICATION NAME] was administered), 6/4 (6 times in the evening-no [MEDICATION NAME] was administered), 6/5 (5 times during the day and 6 times in the evening-[MEDICATION NAME] was administered twice), 6/6 (6 times in the evening-no [MEDICATION NAME] was administered), 6/7 (6 times in the evening-no [MEDICATION NAME] was administered), 6/8 (2 times during the day-no [MEDICATION NAME] was administered), 6/9 (2 times during the day and 2 times in the evening-no [MEDICATION NAME] was administered), 6/10 (5 times in the evening-[MEDICATION NAME] was administered), 6/11 (10 times in the evening-[MEDICATION NAME] was administered). -On 6/12 and 6/14/13, no behaviors were noted; however, the MAR reflected [MEDICATION NAME] was administered. -Behaviors also occurred on 6/16 (5 times during the day-[MEDICATION NAME] was administered), 6/19 (2 times during the day-repetitive health concerns were noted 2 times as well-[MEDICATION NAME] was not administered), 6/20 (5 times in evening-[MEDICATION NAME] was administered), 6/21 (5 times in evening-[MEDICATION NAME] was administered), 6/23 (6 times in evening-no [MEDICATION NAME] was administered), 6/24 (4 times-[MEDICATION NAME] was administered), 6/25 (6 times in the evening-[MEDICATION NAME] was administered), 6/26 (8 times in evening-[MEDICATION NAME] was administered), 6/26 (8 times in the evening-[MEDICATION NAME] was administered) 6/27 (4 times in evening-[MEDICATION NAME] was administered) and 6/28 (10 times in evening-[MEDICATION NAME] was administered). The record did not reflect the severity of behaviors or indicate why [MEDICATION NAME] was administered on some days and not others. (2) July A review of the MAR and behavior tracking for 7/13 revealed the resident did not receive [MEDICATION NAME] during the month. Behaviors occurred on 7/23 (2 times during the day), 7/24 (2 times during the day) and 7/30 (2 times during the day). The record did not indicate a reason why the resident's documented behavior was less frequent. (3) August A comparison of the MAR and behavior tracking for 8/13 revealed behaviors occurred on 8/1(2 times during the day-no [MEDICATION NAME] was administered). On 8/3 no behaviors noted but [MEDICATION NAME] was administered. Behaviors occurred on 8/6 (3 times during the day-no [MEDICATION NAME] was administered), 8/7 (8 times during the day-[MEDICATION NAME] was administered twice), 8/8 (4 times during the day-[MEDICATION NAME] was administered twice), 8/9 (3 times during the day-[MEDICATION NAME] was administered). On 8/10 and 8/11 no behaviors were noted but [MEDICATION NAME] was administered. The record did not reflect the severity of behaviors or indicate why [MEDICATION NAME] was administered on some days and not others. Interviews: A Certified Nurse Aide (CNA) was interviewed on 9/9/13 at 5:20 a.m. The CNA stated he received basic CNA training but did not receive specific information or training or to support the resident with behaviors. The CNA said the resident used to have behaviors every other night but now they occur about once each week. The CNA indicated whenever the resident had a behavior, the staff "just try to figure out what the resident wants and try to deal with it." Another CNA was interviewed on 9/9/13 at 11:35 a.m. The CNA stated she did not receive specific information or training to support the resident with behaviors. The CNA said it helps to talk with the resident and calm her down. The CNA indicated the resident usually yells when a sock has fallen off, she needs or drink of water or needs the bathroom. The CNA stated she was not aware of any incidents where the resident was inconsolable. A Registered Nurse (RN) was interviewed on 9/11/13 at 1:45 p.m. -The RN indicated she first considers pain as a factor whenever the resident had a behavior. Usually the resident only required someone to talk with her to calm her down. The RN said staff has tried aroma therapy to lessen outbursts. She stated PRN medication was used only as a last resort. -The RN said the resident seemed to "act up" at the end of the 28 day period and prior to receiving her shot of [MEDICATION NAME]. The RN said she was not aware of any stated criteria for the resident's use of PRN [MEDICATION NAME] and acknowledged use of the medication may depend upon staff ability to manage the resident's behavior. -The RN stated the NCP should include a description of non-pharmacological interventions to support the resident and should also define at what point PRN [MEDICATION NAME] should be administered. Interventions are not reviewed when [MEDICATION NAME] needs to be administered. The RN stated she had not seen inconsolable behavior exhibited by the resident on her shift. An interview was conducted with the Director of Nursing (DON) on 9/11/13 at 4:03 p.m. -The DON said all of the nurses who work with the resident have tried to decrease the use of PRN [MEDICATION NAME] to manage the resident's behavior. The DON stated there was some concern the [MEDICATION NAME] was contributing to the behavior. The DON said the Interdisciplinary Team planned to discuss the concern at an upcoming [MEDICAL CONDITION] medication review meeting. -The DON said there should be more specific information available to staff to support the resident, including non-pharmacological approaches to use before PRN [MEDICATION NAME] was required. The DON stated she would expect staff to review the reasons PRN [MEDICATION NAME] was used and evaluate the effectiveness of the non-pharmacological interventions in place.

Based on observation, record review, and resident/staff interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being, of one of three out of 19 sample residents (#35). Specifically, the facility failed to ensure the resident's pain was assessed and managed. Resident #35 self reported unmanaged pain and facility records indicated increasing administration of the resident's PRN "as needed" pain medication. The facility and primary care physician (PCP) were aware of the resident reporting unmanaged pain; however, the facility did not comprehensive assess the resident's pain, pursue alternatives, or seek assistance in an attempt to manage the resident's unrelieved pain. Findings include: A. Facility Policy A policy provided by the facility director of nursing (DON) on [DATE] at 1:07 p.m. dated ,[DATE] and titled, "Pain management," stated in pertinent part: 1. Upon admission, residents will be assessed for pain by using the Nursing Admission Assessment form. 2. Residents will be screened for pain by using the monthly summary and the pain evaluation form quarterly, annually and with a significant change and/or new onset of pain. Also review the RADAR Report (an internal report) to identify residents at risk. a. Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. b. These evaluations will be used by the IDT (interdisciplinary team) to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmalogical techniques. 3. Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain, or identified through the RAI (review) process or otherwise will have a full evaluation of the pain conducted using the Pain evaluation form. 5. Each resident identified for pain will have a Pain Management Care Plan. The care plan will have individualized interventions related to that resident's individual control of pain management. The care plan should include both pharmacological and non-pharmacological pain management interventions. RCS (resident care specialists) assignment sheet/Care Kardex updated if appropriate. 6. The licensed nurse will implement a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 7. The licensed nurse will communicate any new onset or change of resident pain or change in resident pain through the 24 hour report process. 8. The IDT will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT team conference. 9. The pain management care plan with interventions will be updated as indicated and discussed at the IDT stand up meetings, as needed. 10. The staff will implement the care plan, monitor the resident, and administer therapeutic interventions for pain, if ordered. 12. The licensed nurse, when administering PRN (as needed) pain medications; will record the drug administration and the following on the MAR (medication administration record): -Pain level using the Wong-Baker Faces ,[DATE] rating scale; -pharmalogical interventions attempted; -Non-pharmalogical interventions attempted; -Follow up observations post intervention to determine the effectiveness of PRN pain interventions. If resident is asleep or resting, document as an observation. B. Resident #35 Resident #35, a [AGE] year old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed that from [DATE] to [DATE], the resident was hospitalized for [REDACTED]. The resident returned to the facility on [DATE], and thereafter, was hospitalized on [DATE] for severe pneumonia. He was re-admitted to the facility on [DATE]. 1. Resident status The resident's most recent minimum data set (MDS) was dated [DATE]. However, it included neither a cognition assessment (brief interview for mental status/BIMS) nor pain assessment. An earlier MDS, dated [DATE], documented the resident was moderately cognitively impaired and could be understood. He responded at that time to questions about pain as follows: He had pain or hurting in the last five days; in the past five days he experienced pain or hurting frequently; and the intensity of his pain was moderate. A physician progress notes [REDACTED]. In an interview with the Director of Nurses (DON) on [DATE] at 8:36 a.m. she stated the resident's daughter wanted resident #35 to be on hospice for support after the resident was diagnosed with [REDACTED]. According to a telephone order and hospice note, dated [DATE], the resident was admitted to hospice care at the facility for [MEDICAL CONDITION]. An [DATE] nurses' note read that hospice called and reported the resident's primary care physician (PCP) wanted all medication orders/changes to be given by him/her until further notice. (The PCP was not a physician with the hospice.) 2. Resident #35's pain management plan on re-admission [DATE] a. Orders Review of the October/November computerized physician orders [REDACTED]. -[MEDICATION NAME] 400 mg orally three times daily for pain, -[MEDICATION NAME] 5 mg orally every four hours "as needed" for pain, and -Tylenol 650 mg orally every six hours "as needed" for pain. b. Care plan Review of the resident's care plan revealed two focus areas relating to pain. (1) One focus, titled "Pain," dated [DATE], stated the resident had actual pain related to skin ulcer (resident had a pressure ulcer on his heel), joint pain, chronic disease process, history of fracture, and neuropathic pain. -Goals included: will have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain, will have function/ADL (activities of daily living) abilities associated with deceased pain, and will verbally express increased satisfaction with pain control. -Approaches included: positioning/support, music, behavioral management, administer [MEDICATION NAME] as ordered, see physician orders, implement pain management flowsheet, notify physician if interventions are not consistently effective, and medicate resident for pain prior to treatments and therapy if indicated. (2) Another focus, titled 'Behavior symptoms,' dated [DATE], stated that the resident had behavioral symptoms as evidenced by physical abuse, and a targeted behavior was being combative with staff. An approach identified was to check for discomfort or pain. 3. Resident status after readmission - Reports of pain - Increased administration of "as needed" [MEDICATION NAME] a. Nurses notes Review of nurses' notes [DATE] - [DATE] revealed documentation the resident reported and/or received pain medication on [DATE], [DATE], [DATE], [DATE], and [DATE]. b. PRN Pain Administration Record (documenting pain on a scale of ,[DATE] with 10 being the worst pain) October: Review of the PRN Pain Administration Record for October revealed elevated pain levels after [DATE], almost daily administration of "as needed" [MEDICATION NAME] that provided relief, but with pain returning to elevated levels that triggered repeat administration of [MEDICATION NAME]. The record revealed: -[DATE] at 12:45 a.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 7:15 p.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] no PRN documentation was noted -[DATE] at 12:00 a.m., pain level of 8 with a follow up of complete pain relief -[DATE] at 4:00 a.m., pain level of 8 with a follow up of complete pain relief -[DATE] at 9:00 a.m., pain level of 8 with a follow up of complete pain relief -[DATE] at 9:00 p.m., pain level of 7 with complete relief noted on follow up PRN Tylenol 650 mg was noted as being given on ,[DATE], ,[DATE], and [DATE]. November: Review of the November PRN Pain Administration Record from [DATE] to [DATE] revealed, as in October, elevated pain levels, almost daily administration of "as needed" [MEDICATION NAME] that provided relief, but with pain returning on eight (out of 13 days) to elevated levels that triggered repeat administration (from two to four times) of [MEDICATION NAME] that at times was not effective in addressing the resident's pain (see below documentation on ,[DATE], ,[DATE], and [DATE]). As in October, the [MEDICATION NAME] was administered for back pain and, in addition, for non verbal pain indicators of pain included groaning and moaning. The record documented in detail: -[DATE] at 1:15 a.m. pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 9:00 a.m. pain level of 8, and a follow up assessment with complete relief of pain -[DATE] pain level of 8, and a follow up assessment with a pain level of 5. -[DATE], no PRN pain medication was documented -[DATE] at 10:00 a.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 9:00 p.m., pain level of 7, and a follow up assessment with complete relief of pain -[DATE] at 7:45 a.m., pain level of 7, and a follow up assessment with complete relief of pain -[DATE] at 12:30 a.m., pain level of 3, and a follow up assessment with complete relief of pain -[DATE] at 8:00 p.m., pain level of 6, and a follow up assessment with complete relief of pain -[DATE] pain level of 7, and a follow up assessment with complete relief of pain -[DATE] at 9:00 a.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 9:00 p.m., pain level of 6, and a follow up assessment with complete relief of pain -[DATE] at 10:30 a.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 7:00 p.m., pain level of 6, and a follow up assessment with complete relief of pain -[DATE], pain level of 8, and a follow up assessment with complete relief of pain -[DATE], pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 8:00 a.m., pain level of 10, and a follow up assessment with remaining level of 5 out of 10 pain -[DATE] at 12:00 p.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 4:00 p.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 8:00 p.m., pain level of 7, and a follow up assessment with complete relief of pain -[DATE] at 12:00 a.m., pain level of 10+, and a follow up assessment with ,[DATE] pain remaining -[DATE] at 4:00 a.m., pain level of 10, and a follow up assessment with 5 out of 10 pain remaining -[DATE] at 9:15 a.m., pain level of 7, and a follow up assessment with complete relief of pain -[DATE] at 1:10 p.m., pain level of 4, and a follow up assessment with complete relief of pain -[DATE] at 12:00 a.m., pain level of 10, and a follow up assessment with 9 out of 10 pain remaining -[DATE] at 8:30 a.m., pain level of 8, and a follow up assessment with complete relief of pain -[DATE] at 1:15 p.m., pain level of 8, and a follow up assessment with complete relief of pain. PRN Tylenol 650 mg was administered according to the November PRN pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 3. Observations and Resident Interview a. [DATE] Observation of the resident on [DATE] at approximately 12:00 p.m. during the lunch meal revealed the resident had consumed less than 50% of his meal. He was slumped over in his wheelchair and had a furrowed brow. A certified nurse aide (CNA) asked him if he was ready to go and he shrugged. He was wheeled from the dining area to his room. -At 1:26 p.m., the resident was in his room, slumped over in his wheelchair. -At 1:27 p.m. a nurse walked in and asked the resident if he wanted to lie down. A CNA came in immediately after with sheets and said to the resident that she would fix his bed so he could lie down. He stated to the nurse that he was, " just not feeling good." He moved slowly and shifted his weight often. b. [DATE] Observations of the resident on [DATE] during the morning meal at approximately 7:30 a.m. revealed that the resident was taken from the dining area two times per his request; both times stating that he was uncomfortable. He initially returned with a blanket wrapped around his shoulders. Approximately ten minutes later the resident again requested to leave the dining area. After leaving he did not return. While present in the dining room, the resident appeared uncomfortable; he repeatedly shifted his weight and lifting his weight from the seat of his wheelchair by pushing down on the armrests of the chair with his elbows. His head was drooped down and his brow was furrowed. -At 9:15 a.m., the resident was observed in his room, speaking with a counselor and getting ready to go outside and smoke. His brow was furrowed. -At 9:30 a.m., the resident was interviewed after he returned from smoking. He said his pain is not under control. He stated that he would like [MEDICATION NAME] but they would not give it to him. He stated that he felt all wound up and even at that moment he felt wound up and in pain. He stated that he did not really know what his medications were and said he would just take whatever they gave him. He stated he needed something at that moment for pain. As he was asked about his pain he rubbed his left side and leg. Throughout the conversation he frequently rubbed the armrests of his chair and gripped them occasionally, rocking back and forth in his seat with his head bent down and his brow furrowed. 4. Facility response to Resident's Increasing Pain a. Nurses' notes A nurses' note on [DATE] note at 8:30 a.m., stated, "Resident extremely anxious and very restless, yelling out attempting to stand up. Call placed to (physician) to request pain meds and something for anxiety." Another note at 10:00 p.m. stated that the resident was given pain medication with minimal effect. A nurses' note on [DATE] note included three entries. -At 7:25 a.m., the note read the resident was frequently calling out and reported, "Pain." (The nursing note included the quotation marks around the word, "Pain.") The note further read, "Call placed to (physician) and awaiting a call back." -At 8:00 a.m., the note read there was no call back (from the physician) and the resident remained anxious and reported pain. PRN [MEDICATION NAME] and routine [MEDICATION NAME] was given. Another call was placed to the physician and the nurse practitioner for the physician was updated on the resident's anxiety and pain. She stated, "Sounds like you're doing a good job. Keep doing what you are doing." -At 12:00 p.m., the note read the resident was yelling out. He reported pain when asked why he was yelling. PRN [MEDICATION NAME] was given. b. Change of Condition Form -On [DATE], staff completed a change of condition form that stated the resident slid from his bed. For pertinent history it stated, "pain unrelieved by current regimen. (Physician) aware: no increase in med." It indicated no medication changes or new orders in the past week. Need increase in pain meds. Pain was noted as 10+ all over related to history of terminal illness and history in rodeo. The change of condition request stated, "Needs more pain med." c. Unit nurse interview [DATE] The resident's unit nurse was interviewed on [DATE] at 9:36 a.m., after the resident was interviewed (see above; resident reported he was in pain). She looked at the resident's PRN Administration Record and stated the resident had been medicated that morning. Review of the PRN Administration Record revealed that he had received a 5 mg PRN [MEDICATION NAME] IR at 7:40 a.m. He had not received any additional pain medication or intervention that morning. She did not indicate that she would assess or address the resident's pain. Rather, she returned to her task of charting for another resident. 5. Failures in facility response In addition to the unit nurse's response above on [DATE] to the report that the resident was in pain, record review and interview revealed other facility failures in addressing the resident's pain. Specifically: a. Failure to have evidence of a comprehensive pain evaluation when the resident had increased reports of elevated pain levels after re-admission. Contrary to facility policy above, record review revealed no documentation that the resident's pain was comprehensively evaluated in October or November as his pain increased, in particular, on the dates above when he required repeat administrations of pain medication and/or when he obtained limited relief from the pain medication. b. Failure to involve IDT in addressing the resident's increasing need for pain medication after his re-admission. Contrary to facility policy above, record review revealed no documentation of discussions by the IDT regarding the resident's pain management plan. While a social service note, dated [DATE] stated, in part, that the family felt the physician group was not helping the resident, there was no documentation social service staff or the IDT followed up with the family, the resident, or the physician group regarding the resident's pain management plan. Moreover, the resident was admitted to hospice for "end of life management." Although the PCP wished to retain control over the resident's pain medications, there was no documentation that staff sought out hospice assistance in managing the resident's pain through nonpharmacologic interventions. Likewise, review of physician progress notes [REDACTED]. The note, dated [DATE], stated the resident complained of nausea but no emesis or abdominal pain. However, there was no documentation that the resident's pain management plan was discussed. c. Failure to re-evaluate care plan interventions to promote resident comfort. See care plan above for "Pain." Contrary to facility policy, there was no evidence this care plan was updated to include specific nonpharmacological interventions that had been found to be effective in promoting the resident's comfort. Although "positioning" was noted, how to best position the resident to minimize his back pain was not identified for staff. Similarly, "music" was noted, but which music was effective was not identified. d. Failure to ensure the resident was evaluated when the pain management plan (see above) was not consistently effective. See above nurses' notes and change of condition form indicating neither a physician evaluation nor a change in the pain management plan following staff requests. Interview with the unit nurse at 7:30 a.m. on [DATE] revealed the resident had been having issues with his pain. She said nursing staff had requested the physician address the pain medications. She stated that they had not gotten a change order. The nurse practitioner (NP) at the physician's office had been reached; however, the NP had ordered that they were doing well and to continue as they were (see above nurses' note [DATE]). The nurse said she did not think the resident's pain was under control. She did not identify any steps that had been or would be taken to ensure the resident's pain was adequately addressed. Interview with the Director of Nurses (DON) on [DATE] at 8:36 a.m. revealed they had attempted to call the physician and the medical director that morning but had not heard back from either physician. She stated that the PCP would be out to see the resident that day, but she thought the PCP would indicate the resident just wanted to be sedated. The DON stated that if the medical director did not respond by 10:00 a.m. the regional medical director would intervene. 6. Physician (PCP) interview The resident's PCP was interviewed on [DATE] at 10:04 a.m. -He stated that the resident had inappropriate drug use, and read a note from ,[DATE], when the resident had over sedated himself. He stated the resident was able to receive pain medication every four hours using short acting narcotics which allowed the facility to closely monitor the medications. The physician stated the only reason he wanted to get hospice involved was because they would take over the resident's medications when he was actively dying; he said he did not believe two providers (PCP and hospice) could manage pain at the same time. -He stated that after examining the resident (today), the resident might be developing left sided pneumonia which they would treat with antibiotics. -He said the resident's expression of pain usually were not really expressions of pain but rather anxiety or frustration. The physician stated that right now, looking at the resident, he was satisfied the resident was not in pain. He acknowledged it was tough to assess the resident's pain and said he had identified the best way to determine the resident's pain was to observe the resident without the resident being aware he was being observed. 7. Facility follow up during and after exit [DATE] a. [DATE] A follow up interview with the DON on [DATE] at 10:15 a.m. after the physician interview (see above) revealed her expectation was that because a resident has pain they treat it to be 10 out of 10 if the resident were to report it. She stated the nurses had been calling the physician; however, until survey, they had not attempted to call the medical director. The DON stated staff can override the physician if their opinion was different. She said they want what is best for the resident. She said there would be reeducation starting [DATE] to educate staff that if they were not getting a good response from the physician, they would call the medical director or regional medical director, and that they had to do the right thing for the resident all the time. An education for licensed nursing staff dated [DATE], and provided by the DON on [DATE] at 11:54 a.m. titled, 'When to call the Medical Director,' included the following information: -If there is an urgent matter that needs to be addressed and the physician has been called twice, fifteen minutes apart, notify the medical director. When leaving a message for the medical director, let him know that this is an urgent matter that needs addressing. If unable to reach the medical director, then call the regional medical director. Notify the director of nurses and administrator at the time the call is placed to the medical director. -If after talking with a physician about a resident and there are symptoms that are not addressed and the physician declines to intervene, call the medical director. Notify the director of nursing and administrator at the time the call is placed to the medical director. -The medical director should be called anytime there is a resident issue that is not moving forward. b. [DATE] On [DATE], the facility sent a response to the initial report at survey exit [DATE] regarding the findings above. The response read: -"A call was placed on [DATE] ([DATE]) to hospice to coordinate pain medications. The hospice physician will not give any medications because the primary doctor is the physician making all medication recommendations. The facility's medical director will be at the facility [DATE] and will evaluate the resident and make recommendations." -A written statement from the physician repeated his position that overmedicating this patient could be disastrous with aspiration or severe fall with injury.

Based on observation, interview and record review, the facility failed to prevent pressure ulcers and ensure residents with existing pressure ulcers did not worsen for two out of four sample residents. Specifically, the facility failed to ensure two of four sample residents (#2 and #4) did not acquire wounds; and that once wounds were acquired, they did not worsen. The findings include: 1. Facility Policy: A policy provided by the director of nursing (DON) on 7/10/13 at approximately 10:00 a.m., revealed in pertinent part: -Unavoidable pressure ulcer: Per CMS guidelines, unavoidable means the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition, and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of this must be clearly documented in the resident's clinical record. -Staging classification: Note: Slough is not found on Stage II ulcers. In addition, a Stage II blister may be intact or open serum filled. A blood blister is considered to be a suspected Deep Tissue Injury (DTI). Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. -Unstageable: When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided. Identify/document as eschar covered area, unable to determine depth and stage, etc. Eschar in the wound bed may be tan, brown or black in color. Unstageable wounds may be covered by yellow, tan, gray, green, or brown slough. -Wounds are tracked as acquired (developed in-house or admitted with) and are assessed and documented on the weekly pressure ulcer record. -The licensed nurse will document daily monitoring of all pressure ulcers on the treatment administration record (TAR). -A physician's orders [REDACTED]. -A nutritional evaluation will be completed within 7 days of admission on all residents identified with skin impairment for nutritional status in a timely manner. -Ongoing monitoring and continuous quality improvement will be achieved by the interdisciplinary team (IDT). -At risk review meetings will be conducted weekly to review/discuss: new admissions; residents identified at risk or with compromise; review facility RADAR report (internal report) to identify residents at high risk or with decline based on most recent MDS (minimum data set); residents with any skin changes; treatment modalities and interventions with resident/family; and recommendations based on IDT evaluation. -The nurse will assure treatments, interventions, care plan, and the appropriate skin documentation records are initiated in a timely manner according to practice guidelines. -The DON/Designee will distribute follow up assignments to the IDT following the at risk review meeting. -The assigned IDT member will ensure communication to other staff of the results of the review and any changes to the plan of care. -A section of the facility Skin Management policy provided by the DON on 7/10/13 at approximately 10:00 a.m. was titled, "Suggested interventions," and was specific regarding interventions for each stage of pressure ulcer. For all stages of pressure ulcers an intervention included, Care planning and RCS (resident care specialist/Certified nursing aide) assignment sheet/care Kardex updated to reflect new problem and interventions. - On 7/9/13, documentation regarding an in-service, was completed on 5/22/13 for licensed nursing staff, was provided. The in-service was on the skin management program policy (see above), specifically, addressing staging, practice guidelines, use of facility forms, and resources and references. All managers were educated on the same policy on 5/30/13. 2. Professional references: A. According to the "National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel, Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline." Washington, DC: National Pressure Ulcer Advisory Panel, 2009: National Pressure Ulcer Advisory Panel Position Paper on Staging Pressure Ulcers (in pertinent part): Pressure ulcers have been defined by the National Pressure Ulcer Advisory Panel (NPUAP) in conjunction with the European Pressure Ulcer Advisory Panel (EPUAP) as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (NPUAP/EPUAP, 2008). One component of pressure ulcer descriptions is to classify them according to the amount of visible tissue loss, called the category, stage or grade of the ulcer. Describing the depth of tissue loss is an important aspect on the level of tissue damage, plans of care are based on the stage or category of the ulcer depth and in the United States, pressure ulcers that reach full thickness, that is, stage III or IV, deep tissue injury or those that are unstageable are considered "never events"; that is, they should never happen. Therefore, accuracy is imperative in making this distinction. Pressure ulcers are assigned a stage or category once the wound being assessed is diagnosed or determined to be a pressure ulcer. The classification system was not designed for use in any other wound type. Assigning a pressure ulcer stage is based on visual inspection to determine the extent of tissue destruction and wound depth. Pressure ulcer staging requires understanding of the anatomy of the skin and underlying tissues. The information to determine the stage of a pressure ulcer is not exclusively held by any profession. Differentiating pressure ulcers from other wound etiologies is within the domain of registered nurses. As per the Scope and Standards of Nursing Practice detailed in the statement from ANA president, Rebecca M. Patton, MSN, RN, CNOR, RNs are expected to assess the patient's skin, stage the wound and implement an individualized plan of care based on the patient needs. Nurses in particular examine the skin and are most likely to be the first professional to examine any [MEDICAL CONDITION]. In the absence of licensed independent practitioners/wound care specialist, the registered nurse needs to identify and stage the pressure ulcer so that early and appropriate care can be rendered. This care involves independently initiated nursing care, such as turning and repositioning. In order to facilitate accurate [DIAGNOSES REDACTED]. 3. Failure to prevent new pressure ulcers and ensure pressure ulcers did not worsen on resident #2. a. Resident #2 Resident #2 was a [AGE] year old female admitted to the facility on [DATE]. According to her face sheet [DIAGNOSES REDACTED]. According to her most recent MDS, dated [DATE], the resident scored a two out of 15 on her brief interview for mental status (BIMS) indicating that she had severe cognitive impairment. Under section M (Skin) the resident had no Unstageable, no Stage II-IV pressure ulcers but did have a stage one pressure ulcer. Skin ulcer treatments identified included: pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, pressure ulcer care, application of nonsurgical dressing, and applications of ointments/medications other than to feet. The MDS care area assessment summary (CAA) indicated pressure ulcers had triggered and were included in care planning: the noted location of the information used to create the skin assessment was nursing notes/Caretracker/therapy notes 5/26/13 - 6/1/13. Documentation revealed the resident rejected evaluation of care one time during the observation period of 5/26/13 - 6/1/13. -Chart review revealed a hospital history and physical, dated 4/23/13, which revealed in pertinent part: Skin: Warm and dry: There is no breakdown anywhere. -A telephone order written 6/21/13 read, No attends on patient while in bed. Please use chux only underneath bottom. No undergarments or clothing at all while in bed (new wound to peri-anal area). Barrier cream/ointment with each incontinence care (Noted as a telephone order from physician). -A telephone order written 6/25/13 read: [MEDICATION NAME] (antifungal) powder to peri-area with each incontinent episode. Nail care to be performed daily (patient scratches peri-area). (Noted as a telephone order from physician). -A doctor's progress note dated 6/26/13 read, Skin-WD (Warm and Dry). No mention was made of skin integrity issues or breakdown. -The most recent dietary note, dated 5/29/13, revealed all dietary supplements previously ordered: mighty shakes three times daily and 206 juice three times daily were recommended to be discontinued as they were overwhelming for the resident resulting in decreased meal intake. It was recommended to instead provide 90 cc of med pass three times daily. (No dietary note or follow up was provided as of 7/10/13). -Review of the resident care plan revealed a pressure ulcer care plan initiated on 5/22/13 that revealed in pertinent part: Actual pressure ulcers related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, nutritional/hydration risks, friction and shear problem, co-morbid conditions, drugs that affect wound healing, impaired diffuse or localized blood flow, and history of healed pressure ulcer. Approaches noted as last reviewed on 6/1/13 included: Apply pressure reduction mattress to bed, apply pressure reduction cushion to chair, reposition in chair frequently for comfort and pressure reduction, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinent episode or per established toileting plan, measure and stage wound weekly using the pressure ulcer healing assessment form, complete a full body check weekly and document, monitor lab values as ordered, IDT referrals, pressure ulcer treatment as ordered, multipodis boots, and positioning wedge. -Review of nursing notes from 6/18/13 through 6/21/13 revealed there was no mention of foot wounds. There were no nursing notes after 6/21/13 through the date of the survey on 7/10/13. -Review of the July 2013 computerized physician's orders [REDACTED]. Recommendations from the registered dietician on 5/29/13 revealed there was no follow up. The July CPO noted that the resident had been enrolled in hospice on 6/1/13 for a [DIAGNOSES REDACTED]. -Review of the resident's care Kardex (A brief summary of activities of daily living (ADL) assistance needs used to inform certified nursing aides (CNAs) with resident specific care) revealed as dated 4/26/13; and only noted preventative care for skin integrity, and indwelling Foley Catheter care. However, the resident had not utilized a Foley catheter since 5/13 (as indicated on TAR). -Review of the resident's turn and reposition detail report from 6/18/13 to 7/9/13 revealed: 6/18/13-The resident was documented as turned and repositioned two times. 6/19/13- The resident was documented as turned and repositioned four times. 6/20/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 6/21/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 6/22/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 6/23/13- The resident was documented as turned and repositioned three times. 6/24/13- The resident was documented as turned and repositioned four times. 6/25/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 6/26/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 6/27/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 6/28/13- The resident was documented as turned and repositioned three times. 6/29/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 6/30/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 7/1/13- The resident was documented as turned and repositioned three times. 7/2/13- The resident was documented as turned and repositioned three times. 7/3/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 7/4/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 7/5/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 7/6/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 7/7/13- The resident was documented as turned and repositioned two times and was documented as not being on a turning and repositioning program. 7/8/13- The resident was documented as turned and repositioned twice. -Weekly pressure ulcer records reviewed revealed the following: -LEFT HEEL WOUND WORSENED -6/17/13- A left heel wound noted as Unstageable with an onset date of 5/20/13 was measured on 6/17/13 as 1.3cm x 1cm. Interventions noted were air bed, wheelchair cushion, specialized wheelchair, positioning wedge and turning every two hours. -6/25/13- Left heel wound noted as 2cm x 1.5cm (no staging noted) with no change in interventions. -7/2/13- Left heel wound noted as 2cm x 1.5cm (no staging noted) with no change in intervention or treatment from 6/25/13. -NEW WOUND ON LEFT GREAT TOE WHICH WORSENED -6/19/13- Left toe wound noted with an onset date of 6/19/13 (no stage noted) measured as 0.5cm x 0.3cm. Noted as using [MEDICATION NAME] and leaving open to air. -6/25/13- Left toe wound noted as Unstageable measured 0.5cm x 0.2cm. No change in intervention or treatment noted. -7/3/13- Left toe wound noted as Unstageable measured 0.5 x 0.1cm. No change in intervention or treatment. (See observation and measurement of wound below). -RIGHT ANKLE NEW WOUND -6/17/13 noted a right ankle wound measuring 0.8 cm x 0.5 cm (no stage was noted). -6/25/13 noted resolved by the unit nurse responsible for taking weekly measurements (A licensed practical nurse (LPN)). -6/25/13 hospice registered nurse (HRN) noted a 1 cm x 0.6 cm wound on right ankle (see below). -HRN documentation provided on 7/10/13 at 10:30 a.m. by the DON and was faxed to the facility on [DATE] at 4:41 p.m. as it was not in the resident chart. -6/17/13 an HRN note read, Telephone call made to family member (name) in response to her call over the weekend to the on call registered nurse (RN). (She) said she just wanted update on the condition of the resident's wounds. She said that the weekend facility nurse told her on Saturday that she has never seen the wounds because, "hospice was taking care of them." Educated family member that facility nurses should be providing wound care daily per doctor's orders. Let her know that hospice monitors wounds and updates treatments regularly. Discussed patient decline including decrease in appetite as normal part of dying process as well as lack of nutrition causing slow wound healing. -A 6/2/13 HRN note read in pertinent part, "She is sensitive to touch and only complains of pain briefly when extremities are lifted during wound care." -A 6/18/13 HRN wound assessment tool identified the right ankle with a stage I pressure ulcer measuring 1.2 cm x 1 cm. -A 6/25/13 HRN wound assessment tool identified the right ankle with a stage I measuring 1cm x 0.6cm. OBSERVATION: -7/9/13 at 12:37 p.m., the resident was observed in her bed with the unit LPN present. The resident was lying flat on her back in her clothes on top of the sheets. Her heels were floated on a pillow, and she had large fuzzy socks on. The LPN stated the resident did not have boots: they were discontinued because her feet were healed. The resident was asked for consent to watch incontinent care when provided and agreed to being observed. The resident was on an air mattress which was set for a resident who weighed 170 pounds. (Per record review and interview with the DON noted below the resident weighed 105.6 pounds on 7/3/13.) -7/9/13 at 12:55 p.m., two CNAs performed incontinent care on the resident. They rolled the resident to face the wall. Every time the CNAs moved the resident's legs or her body the resident would cry out. The resident had areas of scarring and healing tissues on her upper buttocks and coccyx, but did not have any open areas that were visible. The resident had a dressing on her upper coccyx. The CNAs applied a barrier cream and rolled the resident into the covers on a disposable incontinent pad. There was no [MEDICATION NAME] powder residue apparent on the resident, and none was applied at the time. The CNAs placed a wedge under the resident's right side, and placed the resident's feet under the blankets. The resident's heels were not floated and her right heel was resting on the top of her left foot. -7/9/13 at 2:58 p.m., the unit LPN responsible for measuring and treating wounds assessed the resident's wounds. She pointed out wounds on the left outer heel, the left toe and the right ankle. However she could not comment on the stage of any of the wounds because it was not within her scope of practice. -7/10/13 at 10:05 a.m., the DON was asked to confirm the measurements of the wounds on resident #2 as documented by the LPN as improved - but on observation appeared to be larger. Her measurements for the wounds noted above were as follows: -Left outer heel wound 2.6 cm x 2.1 cm and Unstageable (previously measured as 2 cm 1.5 cm). -Left toe measured 0.8 cm x 0.4 cm and Unstageable (previously measured as 0.5 cm x 0.1 cm). -Right ankle measured 0.5 cm x 0.7 cm and Unstageable (previously measured 1cm x 0.6 cm by HRN) but noted as resolved by the LPN (see above). INTERVIEWS -An interview with the wound care LPN on 7/9/13 at 3:10 p.m., revealed because she could not stage wounds in her documentation, she tried to convey what she saw in her notes regarding thickness and edges. The resident was being seen weekly by a RN who was usually the house manager. She stated there was no documentation or cosignature from the RN who was doing the weekly assessments. She indicated that wounds were discussed in morning meeting with the managers; however, she did not attend morning meeting. If the unit RN or the nurse practitioner did not see the wounds, the hospice nurse assessed the wounds weekly. -At 3:36 p.m. on 7/9/13, the DON was asked to provide the documentation for the HRN's wound documentation. She was unable to locate the documentation and stated she had called the hospice and requested copies. -An interview with the wound care LPN and DON at 2:10 p.m., on 7/9/13 after they reviewed resident #2's care plan revealed their expectation was that all IDT was responsible for updating care plans and Kardexs. They stated the Kardex was not correct for resident #2 and did not include wound care interventions. -Interview with physical therapy and the DON on 7/9/13 at 4:00 p.m., revealed the resident had been evaluated for a foot cradle; however, there was not a foot cradle made for her bed. The DON and physical therapy did not have documentation of the trialed intervention or of alternate interventions once they discovered the foot cradle did not work. The DON added that the physician had been asked to see the resident for her wounds on 6/26/13. She did not know why the physician had not addressed the resident's wounds in the assessment (see note above). -Interview with the DON and nursing home administrator (NHA) at 2:29 p.m. on 7/9/13, revealed that the facility was doing rounds checking that interventions were in place and updating care plans in morning meetings as well as updating the care Kardex. She added that resident #2 was the one that they had not gotten to yet. -Interview with the DON and regional vice president (RVP) on 7/10/13 at 8:52 a.m., revealed they were not aware that the resident's bed was set for a heavier person until that day, and they were not aware that her heels were not floated, and they were not aware that her care plan and Kardex were incorrect until yesterday. The RVP reviewed the chart and stated that on 7/3/13 her weight was 105.6 pounds. The DON stated the mattress must have been bumped causing it to be set incorrectly. The RVP stated that when he reviewed the resident's chart and all of her wounds were getting better, based on documentation from the weekly pressure wound measurements taken by the LPN. He addressed the issue of there not being staging of wounds by stating that LPNs could stage wounds. When shown the documentation, he verified that it did not have staging on the weekly measurements for several of the wounds on resident #2. He verified that the facility policy did direct nursing to measure and stage the wound weekly to ensure appropriate care. The DON stated the facility tried everything with resident #2 and that she did not see how they could do anything else to prevent her wounds. She stated that after the failed cradle intervention, there were no new interventions attempted. She could not provide documentation of the resident's current interventions being implemented properly, including turning frequently, use of the wedge in bed, and floating of the heels. 4. Failure to prevent resident #4 from having new worsening wounds a. Resident #4 -Resident #4 was a [AGE] year old female admitted to the facility on [DATE]. According to her face sheet, [DIAGNOSES REDACTED]. -According to her most recent MDS, dated [DATE], the resident scored five out of 15 on her BIMS indicating that she had severe cognitive impairment. She was also noted as having a stage III decubitus measuring 1.5 cm x 1 cm x 0.3 cm. It noted that there were no pressure ulcers on the last MDS and that the wound had yellow slough. -A telephone order dated 6/18/13 revealed in pertinent part, "[MEDICATION NAME] right posterior foot blister cover with dry dressing and wrap with [MEDICATION NAME] daily and as needed till healed." -A telephone order dated 7/5/13 read to avoid patient lying in bed on her right side: this puts pressure on her right lateral foot wound. Continue to float heels. -The resident care Kardex indicated in pertinent part, "preventative skin care and wound care daily" identifying a pressure ulcer on the right pinky toe, noting that it had slough therefore was unstageable at this time and was noted on 6/19/13. -Review of the July CPO revealed an ancillary note to float heels in bed on pillow. It also noted an order to document pain related to wound surrounding skin and dressing status daily. -A physician's note, dated 6/26/13, noted the resident had a diabetic ulcer on the left heel; however it did not mention the right foot or any other wounds. -A resident/family education record, dated 11/20/12, was written regarding the resident refusing to let facility put on pressure relieving boots. (No further education had been done since then and per the resident care plan boots were not recommended). -A care plan, initiated 5/15/13, for pressure ulcers, indicated the actual pressure ulcers were related to moisture/incontinence, decreased activity, impaired mobility, co morbid conditions, history of healed pressure ulcer. Approaches included: apply pressure reduction mattress to bed, apply pressure reduction cushion to chair, reposition in chair, turn and reposition while in bed, provide incontinence care, complete a full body check weekly and document, IDT referrals, continue to float heels, medical director to review, and no shoes at rest, and float left heel. -A change of condition form, dated 6/18/13, documented a blister to the right posterior foot. -A nursing note, dated 7/5/13, revealed in pertinent part, Staff would monitor positioning and the amount of pressure applied by blankets while in bed. (No further nursing notes were available on the right foot through the time of the survey). -A weekly pressure ulcer record, dated 6/18/13, documented a new stage II pressure ulcer on the right posterior foot (also referred to as the right lateral foot in interview below) measuring 3 cm x 3.5 cm. -A weekly pressure ulcer record, dated 6/25/13, recorded the wound as being 1.5cm x 1cm. -A 7/2/13 weekly pressure ulcer record noted the wound was 1.5cm x 0.2 cm. It noted Santyl (a [MEDICATION NAME] agent) was ordered and debridement was evident. -A treatment order was written on 6/26/13 for the right lateral foot to clean with wound cleaner; pat dry. Apply skin prep to peri-wound. Apply a thin layer of Santyl to wound bed; over with collagen (cut to fit wound bed). Apply bordered foam; change daily. Keep area offloaded. -A wound care consultant note, dated 6/26/13, identified the wound as a full thickness pressure ulcer stage III measuring 1.5cm x 1cm. It documented rational for the order in pertinent part: Collagen will provide protein matrix and support angiogenesis to promote granulation tissue proliferation. Enzyme debridement indicated to expedite recovery of a viable wound bed. OBSERVATION -Observation of wound care on 7/10/13 at 7:44 a.m., revealed the nurse removed the soiled bandage and noted it had exudate on it. She stated the wound was a Stage II. Observation of the wound revealed a silver dollar sized wound with white edges, and a deep indentation with yellow slough in the center. The wound was full thickness skin loss. The nurse measured the wound as 1cm x 1cm but due to the difficult angle, and pain expressed by the resident, the nurse was unsure of the accuracy of the measurement. The nurse cleaned the wound applied skin protectant to the peri wound area, applied Santyl to the wound bed, and covered it with a foam dressing. INTERVIEW -The nurse was interviewed following the observation regarding the wound and treatment. She stated the wound was a stage II and it had slough on the wound bed. She was asked about the lack of use of collagen and she stated that it was only that day that she did not use it because the wound consultant had told her to wait until done with the use of the Santly until she used the collagen. She could not produce any evidence of the wound consultant changing her orders. She agreed that if the order was different than what was in the TAR, she should have written a clarification. She added she had attended an in-service recently on wounds and staging. -An interview with the DON on 7/10/13 at 10:30 a.m., revealed it was the expectation of the facility to complete wound orders as written; and if there were any change of treatment ordered, to document in the chart and write a new order. She also stated that if a wound was a Stage III, it could never be reverse staged and called a Stage II, and had slough per their policy and therefore could not be considered a Stage II pressure ulcer. 5. INTERVIEWS REGARDING FACILITY POLICY AND FAILURES FOR WOUND CARE AND ASSESSMENT ON MULTIPLE RESIDENTS -An interview with the DON on 7/9/13 at 2:10 p.m., revealed the facility had identified the nurse assigned wound care documentation duties was not performing them. They had not identified the issue of residents not having documented stages on their weekly pressure ulcer measurements, and they had not identified the issue of current interventions not being implemented as indicated in the resident plan of care. -An interview with NHA and DON on 7/9/13 at 2:29 p.m., revealed the facility had a new person in place to assure assessments and documentation was completed appropriately. The resident care Kardex and care plans were being updated in morning meetings, but they had missed the care plans and care Kardex for residents #2 and #4. They stated their plan of correction was not completed and they still had work to make their wound care documentation complete. -An interview with regional VP on 7/10/13 at 8:52 a.m., revealed the corporation was going to bring in a wound care company that comes to the facility more often. -An interview with medical director on 7/10/13 at 10:29 a.m., revealed he was not aware of the wound care issues in the facility and he was under the impression that the facility was improving. He stated that it was his expectation that the facility had one person responsible for checking on the wounds and that they were documented with the stage and details necessary every week. He stated the facility had not disclosed the issues they were having with wounds, but if they had disclosed their need for help, he would have assisted them in finding a solution.

Based on record review, observation and interview, the facility failed to ensure two of six sample residents (#1 and #3) did not develop pressure sores and that, once pressure sores developed, the resident received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically: -Regarding resident #1, the facility failed to ensure comprehensive management of pressure ulcers, including monitoring and documentation of the resident's pressure ulcers, timely communication of pressure ulcer status, and implementation of planned interventions. The resident developed two stage IV pressure sores, one on the resident's right heel first noted on 11/13/12, and another on the resident's coccyx first noted 3/19/13. -Regarding resident #3, the facility failed to ensure the resident was assisted with repositioning in bed and off-loading while in the wheelchair. The findings include: A. Facility Policy and Procedure for Skin Management The Facility Policy and Procedure for Skin Management, revision date 8/12, revealed, in pertinent part: Unavoidable Pressure Ulcers, "unavoidable" means the resident developed a pressure ulcer even though the facility defined and implemented interventions. All of this must be clearly documented in the resident's clinical record. Stage IV pressure ulcer means full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.) Unstageable is when eschar is present, accurate staging is not possible. Identify/document as eschar covered area, "unable to determine" depth and stage. B. Resident #1 Resident #1, according to the facility face sheet, was admitted on [DATE] with [DIAGNOSES REDACTED]. The primary care physician's (PCP) note, dated 11/15/12, included [DIAGNOSES REDACTED]. 1. Resident Status The Minimum Data Set (MDS) assessments reviewed, from 10/5/12 through 4/6/13, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 on 10/5/12, and a score of 8 on 4/6/13, indicating moderate memory problems. The resident understood others and was understood by others. -On 10/5/12, the resident was totally dependent on one person for bed mobility, and for locomotion on and off the unit. The resident used a wheelchair for mobility. The resident had range of motion functional impairment on both upper and lower extremities. The resident was 64 inches tall and weighed 168 pounds. The resident had risk of pressure ulcers but had no pressure ulcers. -On 4/6/13, the resident required extensive assistance of two persons for bed mobility. The resident weighed 137 pounds. The resident had one Stage IV pressure ulcer and one unstageable pressure ulcer and necrotic tissue. Although this MDS was the first reporting of the pressure ulcers, the MDS did not indicate that the pressure ulcers were not present or were at a lesser stage on a prior assessment. Each MDS indicated the resident had pressure reducing devices for the bed and chair, and was on a turn and reposition program. The resident's Interdisciplinary Care Plan (IDT) identified problems including: (1) ADLs, initially dated 3/28/11, last reviewed 4/18/13. The resident required extensive assistance of one or two staff members for completion of ADL needs. (2) The IDT care plan for pressure ulcers, initial date 9/6/11, included pressure ulcer right outer heel dated 11/13/12, pressure area to coccyx dated 3/19/13. Approaches initiated included: -Apply pressure reduction mattress to bed, initial review date 9/13/11. -Apply pressure reduction cushion to chair, initial review date 12/6/11. -Reposition in chair frequently for comfort and pressure reduction, initial review date 1/12/12. -Turn and reposition while in bed frequently for comfort and pressure reduction, initial review date 4/19/12. -Provide incontinence care after each incontinence episode, initial review date 7/19/12. -Measure and stage wound weekly using pressure ulcer healing assessment form, initial review date 1/17/13. -Complete full body check weekly and document, initial review date 4/4/13. -Up for meals only, no initial review date. -Turn side to side every two hours, no initial review date. (3) The IDT care plan included a care plan for infection, start date 1/14/13 for wound infection right foot, initial review date 1/17/13. 2. Record Review - Development and Deterioration of Two Pressure Ulcers - Facility Failures in Pressure Ulcer Management, Monitoring, Documentation, and Communication. a. Wound Clinic notes revealed the following: -3/20/13 Assessment: Ulceration deep decubitus extending to bone, Stage IV, right heel. Plan: Wound VAC was reapplied. -4/9/13 the patient presents today without the wound VAC machine on the wound. A dry sterile dressing was the only thing that had been applied to the wound. -4/11/13 the patient was sent for evaluation of a sacral decubitus. The patient had been followed in the wound clinic for quite some time for a right lateral calcaneal (heel) ulcer, which had included bone debridement for osteo[DIAGNOSES REDACTED]. The patient was supposed to have a wound VAC on with 3 times weekly changes. The wound care clinic nurses noticed on the last visit that the patient had a foul odor and thought maybe she had a bowel movement while in wound care. They went to change her and found she had a large necrotic sacral decubitus ulcer and brought her in today for evaluation. The wound was approximately 4 centimeters (cm) in the greatest dimension and covered with a black necrotic eschar with exposed underlying tissues. There was undermining of the wound of approximately 1-2 cm in all directions. The right calcaneal wound measures 18 by 12 millimeters (mm) and was about 2.5 cm deep. It was packed with alginate and the wound VAC was not in place. I am quite concerned about the nursing care that this resident is receiving. -4/18/13 Note was made today that the VAC was not functioning properly on the heel. The sacral VAC was working properly. The resident needed to be on antibiotics for foot wound infection. b. Physician's notes revealed the following: -11/15/12 Monthly Assessment: Skin: No rashes, [MEDICAL CONDITION], or masses. -12/10/12 Monthly Assessment: Skin: No rash, [MEDICAL CONDITION] or masses. -1/9/13 Quarterly Assessment: Skin: Unstageable right heel ulcer. Eschar intact with minimal slough. Approximately 2 cm without signs of infection. Plan: Will not debride. Resident has no lower extremity movement. Alternating pressure mattress, chair cushion, foam boots. -2/4/13 Monthly Assessment: X-Ray heel with soft tissue gas and probable early osteo[DIAGNOSES REDACTED]. On antibiotics with some improvement in unstageable decubitus ulcer present since 11/12. Eschar stable with purulent slough. -2/28/13 Post-hospitalization History and Physical. Planned hospitalization [DATE]-[DATE] for debridement of right heel wound into bone level; wound 5 cm by 4 cm deep. Wound VAC ordered. [DIAGNOSES REDACTED]. -3/4/13 Resident now has a wound VAC in place. At risk of having a non-healing wound, infection,[MEDICAL CONDITION], and the further need of amputation. -Progress notes reviewed from 3/15/13 through 4/5/13 with no note regarding the coccyx pressure ulcer recorded in nurses' notes (see below) on 3/19/13. -4/5/13 Monthly Assessment: It is now reported that the resident has an open wound on the coccyx. Resident continues to have right heel wound being treated with a wound VAC. One area at the bottom of wound is tunneling and measures approximately 10 cm deep. The tissue in the tunneling cannot be visualized. Resident now has ulceration on coccyx which is approximately 2-3.5 inches in diameter. The wound bed has white tissue and the edges are beefy red. Purulent drainage from coccyx wound with foul odor. The whole wound measures 5 cm by 3.6 cm. Coccyx pressure ulcer Stage III. At risk for continued malnutrition/wasting syndrome and poor wound healing. -4/9/13 Seen by wound center surgeon. Up for meals only for 30 minutes then turn every 2 hours. Sacral wound unstageable now due to 100% moist eschar. -4/11/13 Resident out to wound clinic today. Per nursing home report resident was sent for coccyx wound and right heel wound. Right heel wound to continue with wound VAC and pack tunneling with black foam. Per wound clinic resident to be direct admit to hospital for surgical debridement of coccyx. -4/17/13 Post-hospitalization History and Physical: Resident had unplanned hospitalized from [DATE]-4/16/13 for debridement of ulceration to coccyx area and second surgical debridement to right heel. On 4/11/13 the resident was at the wound clinic for evaluation of coccyx ulceration and the doctor at the wound clinic directly admitted the resident to (name of hospital) for surgical debridement. c. Nurses' notes revealed the following in pertinent part: -11/1/12 at 4:30 p.m., new therapy orders. -11/1/12 - 1/14/13 revealed no nurses' notes. -1/14/13: Continue with treatment to right foot/heel area, drainage with odor reported. -3/19/13: Wound on coccyx noted on Nursing Daily Skilled Summary. No description or measurements given. -3/20/13: No documentation regarding coccyx wound. -3/21/13: Wound on coccyx noted. No description or measurement. -3/23/13: Interdisciplinary note: Resident also has open area to coccyx identified on 3/19/13. Treatment orders in place. Currently on air mattress. -4/1/13 at 2:45 p.m., Area to coccyx 4 cm by 4.2 cm. New treatment: clean with normal saline, apply calcium alginate, cover with duoderm and [MEDICATION NAME], change every other day. d. Head to Toe Skin Checks revealed the following, in pertinent part: The unstageable eschar on the right lateral heel was not included on weekly skin check documentation between 11/15/12 and 2/7/13. e. Weekly Pressure Ulcer Records revealed, in pertinent part: -No Weekly Pressure Ulcer Records for the heel wound, start date 11/13/12 until 4/16/13, with one additional undated. -4/16/13: Right heel 5 cm by 2.5 cm by 4 cm depth with undermining. -4/25/13: Weekly note, returned from wound care. No measurements were documented. -3/19/13: Coccyx wound 2 cm by 1 cm, superficial wound. Dietary, physician, family notified. No bed type or cushion noted. -3/26/13: Coccyx wound 3 cm by 3 cm, superficial wound. Dietary, physician, family notified on 3/28/13. Deteriorated. Not improved with down after meals, turn side to side treatment in place. Air mattress, wheelchair cushion. Review of the physician orders [REDACTED]. -4/1/13: Coccyx wound 4 cm by 4.2 cm, superficial wound with serous exudates, wound bed yellow, dietary, physician, family notified. Deteriorated. Open area to coccyx deteriorated new treatment with calcium alginate. -4/10/13: Coccyx wound 6 cm by 5.5 cm by 1 cm depth, foul purulent drainage with odor, yellow black wound bed, white pallor, continues to deteriorate new treatment orders per wound clinic. 3. Interviews - Confirmation of Failures in Management, Monitoring, Documentation, and Communication The Nursing Home Administrator and Director of Nursing were not available for interview during this abbreviated survey (4/24/13 - 5/2/13). On 5/1/13 at 11:00 a.m., the unit manager was interviewed. She stated she had been in this position for about one and a half months. She was not familiar with many residents in the West Hall, although she was unit manager for that hall as well. She stated she did not know if there were wound rounds or a wound committee and if there was, she did not attend. She said she attended morning meetings, but wounds were generally not discussed. On 5/1/13 at 11:05 a.m., the Licensed Practical Nurse (LPN) for West Hall stated the facility had a wound committee. The nurses on each hall did their own wound care. She said if she had questions, she asked another nurse familiar with wound care or the Nurse Practitioner (NP), who was in the facility four or five times a week. She said resident #1 went to wound clinic and they did the measurements and were supposed to be sending the notes. However, the clinic did not automatically send them; rather the facility had to request the clinic fax the data. On 5/1/13 at 11:20 a.m., the Medical Director (MD) was interviewed by phone. The MD stated he was also the resident's primary care provider (PCP). -He stated the resident had been on an air mattress for about a year and in the last six months, the resident had declined in nutrition. He felt the wound on the coccyx was unavoidable because of the resident's nutrition status and her other health conditions. He stated he attended a 90 minute monthly meeting as the MD where falls, infections and catheters were discussed. -He stated he saw the resident monthly, however, he had not seen the Stage IV coccyx wound. The wound VAC had always been in place. He stated he found out about the Stage IV coccyx wound (noted 3/19/13) from the doctor at the wound clinic when that doctor wanted to admit the resident to the hospital for surgical debridement (see above physician progress notes [REDACTED]. -He stated he was not notified by the facility of the wound. He thought the facility might have notified one of his partners who took call for him, but his partners had not notified him of the wound. He stated as the MD, and as the PCP, he would have liked to have been notified by the facility before the wound became a Stage IV. -He stated he had not known about the heel wound (noted 11/13/12) until the podiatrist called him to ask about debridement (see above physician progress notes [REDACTED]. He further stated he was not sure if staff would have been trained regarding the wound VAC, or if education had been provided for staff regarding how to identify eschar. (See above wound clinic notes 4/9/13 and 4/11/13 about the wound VAC not being in place.) On 5/1/13 at 12:20 p.m., two LPNs on West Hall were interviewed. They stated the last resident on a wound VAC was about five months ago. They indicated they had training on [DEVICE] and that most of the VACs were about the same, although they could look different. On 5/1/13 at 2:00 p.m., the Assistant Director of Nursing (ADON) was interviewed. She stated there was an inservice provided on pressure relief on 4/10/13. The ADON stated an inservice on the current wound VAC had been provided and she would check on when that was. On 5/1/13 at 2:30 p.m., the LPN on West Hall stated once the wound clinic called to say the wound VAC was not placed properly. She told them it was on correctly when the resident was put on transport. She added that the wound clinic did not send the facility any wound measurements. The facility had to ask for them, so the communication was not the best. On 5/1/13 at 3:20 p.m., the ADON stated she checked on the wound VAC training and there were three night nurses who had not received the training. She agreed that the night shift might have to replace the wound VAC and dressing if it became dislodged. She stated there was an "as needed" nurse who became full-time nights. The ADON checked with her and found the night nurse had wound VAC training at another facility, but not at this facility. On 5/2/13 at 8:50 a.m., the ADON stated the facility usually did an incident investigation for the onset of an unstageable wound. She would check for the investigation. At 11:00 a.m., the ADON stated she could not find any investigations regarding the resident's wounds. (In a fax received after exit 5/2/13, the 11/13/12 heel wound was listed on the facility Incident/Accident Report; however, no facility investigations of the wound onsets were found or provided.) On 5/2/13 at 9:15 a.m., the doctor at the wound clinic was interviewed. She stated she disagreed that the resident's (coccyx) wound was unavoidable. She stated the resident was completely dependent on staff. She stated the nursing staff at the wound clinic smelled a foul odor and found the wound on the coccyx and referred the resident to her. She stated there had been no communication from the facility to the wound clinic about the Stage IV coccyx wound. She stated the resident's PCP had not seen the wound. On 5/2/13 at 10:15 a.m., the nurse practitioner (NP) was interviewed. She stated she was unaware of the resident's coccyx wound until 4/5/13. She identified it as a Stage III at that time. She stated she was unaware the wound had been first documented by nursing staff back on 3/19/13. She would have wanted to know right away of any changes of skin condition. She stated she knew that orders came from the wound clinic, however, they did not get the notes. On 5/2/13 at 11:25 a.m., the Dietary Manager (DM) was interviewed. She stated there was a weekly meeting CMMR (Care Management Risk Review) that included review of skin. This was confirmed by the ADON, on 5/2/13 at 1:10 p.m., who stated that generally, the Director of Nursing (DON), MDS Coordinator, DM, and the Nursing Home Administrator attended these meetings. On 5/2/13 at 12:45 p.m., Occupational Therapy (OT) and Physical Therapy (PT) staff were interviewed. -OT staff stated they would have expected to be asked to do an evaluation of the wheelchair cushion if a resident developed a coccyx ulcer, when interventions were already in place. They said they would have done a re-evaluation of the cushion and assessed for any other interventions. -They said they had not received an order to do so, stating that usually, nursing would initiate a discussion with the provider for an order. They had observed that the resident was only up in the wheelchair and sitting upright for meals, otherwise, remained in bed to keep pressure off the coccyx. -They further stated they had not worked with the resident since December 2012. On 5/2/13 at 1:10 p.m., the ADON stated on the weekly skin assessments, any necrotic spots or eschar should be included. She stated last week the wound clinic notes were requested and were faxed. However, they were in the DON's office and were not located the resident's record. The ADON said she was just reading them now for the first time. She stated she could not locate nurses' notes for the resident between 11/1/12 and 1/14/13. That documentation would have included the discovery of the heel wound and identified signs and symptoms of infection. On 5/2/13 at 2:35 p.m., the LPN from West Hall was interviewed. -She stated she had not done a weekly pressure ulcer record for the resident's heel wound, as she thought the wound was non-pressure. -She stated she did not chart the eschar on the weekly skin care sheets because the skin was not open. -She said she did not chart which doctor had been notified of the skin changes from superficial to deterioration on the coccyx wound; she said it could have been one of the PCP's partners or could have been the NP. On 5/2/13 at 3:00 p.m., the Medical Records staff stated there were no nurses' notes in the clinical record for the resident between 11/1/12 and 1/14/13, although they had thought there might be skilled notes somewhere. However, she had checked with billing and the resident was not billed under skilled services during that time. On 5/2/13 at 3:35 p.m., the LPN from West Hall stated she wrote orders from the doctor for a referral to therapy on 4/18/13. She said she noticed a gap on the wheelchair cushion and the back of the cushion was not back where it should be. The LPN said she had not noticed it sooner and she did not know why there had been no OT follow-up on the cushion. 4. Fax Received after Exit 5/2/13 A fax received from facility after survey exit included: -An Operative Report regarding the resident's hospitalized from [DATE] - 2/26/13 for debridement of her right heel ulcer. The report revealed the procedure date of 2/22/13. Pre and post operative [DIAGNOSES REDACTED]. Indications: It was determined that the patient due to severe contractures had been unable to respond to adequate offloading measures, as these did not fit the extremity adequately. The resident and family member were advised that dead tissue and infection were occurring to the heel and this was even happening to the bone itself. -The facility attributed the coccyx breakdown to eight incontinent loose stools between 3/2/13 and 3/19/13. 5. Observations On 5/1/13 at 8:40 a.m., the resident was observed in the dining room in the wheelchair, leaning to the left. The resident was sitting at an approximate 90 degree angle being fed liquids by staff. When asked about breakfast, the resident had no response. The resident did not respond to the greeting of "good morning." -At 9:30 a.m., the resident was observed in her room in the wheelchair being given medication and liquids by staff. The resident was wearing foam boots. A bariatric air mattress was noted on the bed. On 5/2/13 at approximately 11:10 a.m., the resident was observed in bed positioned on the right side. Splints were in place. The wound VAC dressing was intact. The VAC read 125 mm/Hg (millimeters mercury). The right heel wound dressing was changed. Due to the resident's position, the wound was not able to be observed. 6. Summary Record review and interviews revealed the facility failed to ensure comprehensive management of resident #1's pressure ulcers, including monitoring and documentation of the resident's pressure ulcers, timely communication of pressure ulcer status, and implementation of planned interventions. The resident developed two stage IV pressure sores. C. Resident #3 Resident #3, according to the facility face sheet, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital history and physical in the record, dated 3/26/13, included additional [DIAGNOSES REDACTED]. The history and physical further revealed the resident had swan neck deformity of the fingers and rheumatic arthritic changes in her extremities. 1. Resident Status The resident's most recent MDS, dated [DATE], revealed the resident needed extensive assistance of two persons for bed mobility, total assistance of two persons for transfer, and had impairment of range of motion on both upper and lower extremities. Her BIMS score was 15, indicating no memory problems, and she had risk of pressure ulcers. The resident's IDT care plan revealed an identified problem of: (1) Impaired ability to self-transfer related to weakness; requires use of mechanical life (two person assist required at all times). Approaches included provide mechanical lift for transfers, full body lift. (2) Potential for pressure ulcers related to decreased activity and impaired mobility. Approaches included apply pressure reduction mattress to bed, apply pressure reduction cushion to chair or wheelchair, reposition in chair frequently for comfort and pressure reduction, and turn and reposition frequently while in bed. There was no indication on review of the care plan to show the resident refused care or treatment. Review of the CNA computerized record for, "Turn and Reposition Detail Report" from 4/25/13 through 5/1/13, revealed inconsistent recordings on a "Turning and Repositioning Program." The question was answered, 'no' six times. The number of times the question was charted varied from three to five entries per day. 2. Observations and Resident Interview On 5/1/13 at 9:00 a.m., the resident was observed in her room, sitting in her motorized wheelchair. The resident was noted to have severe deformity to her fingers. She was observed to be sitting on a bed pillow. There was a partially inflated square blue air cushion lying at the foot of her bed. -The resident stated she had been given the cushion but she did not like it. She stated she was not offered a different one. She stated that in the bed and the chair she could change the position of her upper body, but she could not change position with her lower body. She said she had previous hip surgery on one side that failed. -The resident stated staff would come to help her change positions if she asked them and she stated she asked them when she went to bed in the evening. She stated that she was unable to turn herself in bed or lift herself to change her position in the wheelchair. She stated the staff did not come and ask her if she wanted to change positions. She said she asked staff to put her in bed for a couple of hours in the afternoon to help get off her bottom. At 11:00 a.m., the resident was noted in her room in her wheelchair in the same position she was in at 9:00 a.m. 3. Interviews On 5/1/13 at 10:45 a.m., a certified nurse aide (CNA) was interviewed. She stated she had worked these halls and was able to name residents who were on a turn and reposition every two hour schedule. However, she did not name resident #3. On 5/2/13 at approximately 8:20 a.m., the MDS Coordinator was interviewed. She stated that with a resident who had a bed mobility score of 3/3 (extensive assistance of two persons), she would put that resident on an every two hour turn and reposition intervention. That was what the wording, "frequently" meant to her in the care plan. On 5/2/13 at 12:45 p.m., the OT was interviewed. She stated she was not aware the resident was not using the prescribed cushion, rather the resident was using a bed pillow. She said the resident had been educated on the need for the cushion. The OT said she was not aware the resident did not like the cushion and OT was not contacted to evaluate the use of the cushion. On 5/2/13 at 1:10 p.m., the ADON stated that on the care plan, if the intervention was to turn and reposition "frequently", she expected the resident to be turned and repositioned every two hours or more often if needed. When in the wheelchair, she expected the resident to be offloaded every two hours. On 5/2/13 at 3:10 p.m., the ADON and MDS Coordinator stated there must have been some confusion regarding whether the CNAs were charting every two hours or by the shift, in addition to how they were interpreting the Turn and Reposition Program. Both the ADON and the MDS Coordinator were unsure who was responsible to review the CNA notes.

Based on record review, resident, family and staff interviews, the facility failed to ensure one of 43 sample residents (#76) was free from neglect. Specifically: Resident #76 sustained a fall 9/18/11. Staff failed to comprehensively assess the resident after the fall and failed to listen to the resident and her representative when the resident complained of pain. On a day after the resident's fall (9/18/11), but before x-rays were obtained (9/21/11), staff applied a shoe against the resident's protests of pain. X-rays taken 9/21/11, revealed a distal fibula fracture. In addition to the above failures, the facility failed to adequately medicate the resident for pain on 9/18/11, 9/19/11, and 9/20/11 (cross-reference F309), failed to investigate the resident's fall on 9/18/11, either before or after knowledge of the fracture (cross-reference F323), and failed to timely notify the legal representative of the resident's fall (cross-reference F157). The findings include: A. Facility Policy The facility's policy on Abuse and Neglect dated 2/2010, read in pertinent part: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin and misappropriation of property. -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Injuries of unknown origin may occur as a result of neglect. B. Facility Failure to Prevent Neglect 1. Resident #76 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], revealed she was able to understand and was understood and had short-term memory impairment. She needed extensive assist with activities of daily living, was not ambulatory, and needed human assistance for toileting. She was frequently incontinent of bowel and bladder. a. Resident Interview The resident was interviewed on 11/21/11 at 1:30 p.m. The resident stated she was dropped to the floor in the bathroom on 9/18/11. She stated her leg started hurting and no one listened to her. She stated it hurt so bad, but they did not call the doctor or send her to the hospital. She further stated that they did not give her anything for the pain. b. Record Review - Fall 9/18/11 Nurses' notes: -9/18/11 at 12:30 p.m., with assist of certified nurse aide (CNA) resident was being transferred to the toilet when resident lost her balance. CNA slid her to the floor without injury. -9/18/11 at 2:00 p.m., vital signs within normal limits remained alert and oriented. Up for meals appetite good. No complaints of discomfort. -9/18/11 - vital signs within normal limits. Resident adjusting well to the facility. There were no further nurses' notes regarding the resident's fall until 9/21/11. -9/21/11 - Interdisciplinary team meeting documentation, revealed the resident's witnessed fall was reviewed. The resident was assisted to the toilet when she lost her balance and was lowered to the floor. Resident complained of left ankle pain. Orthopedic appointment in progress will review further interventions after the orthopedic visit. -9/21/11 - resident has fracture of left ankle and has a loose cast on it. New pain pill ordered today. -9/24/11 at 2:00 p.m. vitals within normal limits. PRN (as needed) medication given which was effective. Resident vomiting with low grade fever. Physician on call was told resident had no BM (bowel movement) for five days since she started [MEDICATION NAME] (narcotic [MEDICATION NAME]). -9/27/11 - Medicated for left ankle pain with excellent results. Physical Therapy (PT) Notes: On 9/19/11, the therapy department assessed the resident. The assessment read under the subjective section: Resident stated I can't stand to have my shoe on my foot. She was unable to stand due to pain. The note further read that the resident's ankle was not tested due to increased pain. The pain level was a 4 out of 5 scale for left ankle pain. Received E Stim in an effort to decrease the pain. The resident was to be transferred with a hoyer lift due to left ankle pain. PT notes dates 9/19-9/30/11, revealed the resident was unable to stand due to pain in left lower extremity. Pain at 4 out of 5. Touching the ankle increased the pain. PT note dated 9/21/11, documented x-ray positive for fractured distal fibula. Orders for no weight bearing so transfers with a hoyer lift. The resident was seen by the orthopedic doctor. Orders written for an air cast in place. Patient remains in a great deal of pain. Change of Condition and Monthly Summary Forms: -September Weekly/Monthly Summary. Resident has pain in the right ankle is two person transfer and uses a hoyer for transfers. Patient is stable continue care plan. Dated 9/2011. -Change of Condition Form dated 9/21/11. Pain started 9/20/11, with pain to left lower leg- ankle pain acute. However, the notes on the back of the form were dated 10/21/11 at 7:00 p.m. The notes read: Call to nurse practitioner (NP). Resident rated pain at 7 out of 10 and increased with transfers, activity, PT and OT (occupational therapy). Call to NP (nurse practitioner) for stat (immediate) x-ray. Results called to NP and stat ortho consult received. Physician Notes (9/21/11): Under diagnostics, X-ray was taken today (9/21/11), showing an oblique [MEDICAL CONDITION] fibula. To be put in an air cast, this will support the ankle. Weight bearing only for transfers. And no ambulation. Return in two and half to three weeks. 2. Facility Failure to Ensure Resident #76 was Free from Neglect. a. Failure to comprehensively assess and monitor the resident following her fall 9/18/11. See nurses' note above; there was no documentation in the 9/18/11 note regarding the status of the resident's lower extremities following her fall. Specifically, there was no documentation that the resident's range of motion or pain was assessed. Moreover, there was no documentation on the status of her lower extremities after 9/18/11, until 9/21/11, following her ankle x-ray. The regional registered nurse (RRN), the director of Nurses (DON) and two licensed practical nurses (LPN) were interviewed on 11/22/11, at approximately 3:30 p.m. -LPN #1 did not know lowering the resident to the floor was to be considered a fall, so no fall charting occurred. -LPN #2 said he was unaware the resident had fallen 9/18/11, because there was no fall charting. He said he was aware on 9/19/11, that the resident did not feel well and he felt she was having an off day. He said on 9/19/11, there were no complaints of pain. He became aware of the pain on 9/21/11; at that time he contacted the nurse practitioner. The NP ordered an x-ray and the x-ray showed a left distal fibula fracture. An appointment with the orthopedic physician was set for that day. b. Failure to address the resident's pain (1) Record Review Although LPN #2 stated resident #76 did not complain of pain on 9/19/11, record review (see PT notes above for 9/19/11) revealed the resident was unable to stand due to pain and rated her pain 4 out of 5. Further, record review revealed the resident was not medicated for pain in a timely manner. Specifically: -Review of the medication record for September 2010, revealed the resident received two doses of Tylenol 325 mg on 9/21/11, and one dose on 9/24/11. No Tylenol was given 9/18, 9/19, or 9/20/11. -Review of the medication record, revealed there was no date when [MEDICATION NAME] was ordered and no order for the medication in the medical chart. However, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no further pain medication given to the resident from 9/18 - 10/12/11. (2) Resident, Family, and Roommate Interviews See resident interview above on 11/21/11. The resident was interviewed again on 11/22/11, at approximately 2:00 p.m. She stated that she never received medication for the pain. She stated, "if you check the medication record you will see I did not get any pain medication and I hurt so bad." Resident #76's family member #1 was interviewed on 11/23/11, at approximately 2:00 p.m. She stated she visited the resident several times per week and that the resident complained of pain in her leg on 9/19/11. -The family member said she was not clear of staff names or the dates, but she stated the resident complained of pain in her leg and the staff did not believe her. The family member said the resident told her that staff dropped her to the floor. She stated that she (the family member) did ask for pain medication for the resident, but was told they would have to call the doctor. There was no pain medication administered at that time. -The family member said that on 9/21/11, she asked to speak to the Director of Nurses (DON). The person who responded was not the DON. The family member stated the resident was in pain and she wanted an x-ray done. The staff member stated that the leg was not red and she was not concerned. The family member stated she insisted that an x-ray be done. The x-ray revealed a [MEDICAL CONDITION] at the ankle. -The family member stated there was a certified nurse aide (CNA) who the resident indicated was rough with her and this aide was still working in the building. The family member said the resident pointed the CNA out to her in the dining room. Family member #2, a frequent visitor, was interviewed on 10/27/11, at approximately 4:00 p.m. -She stated that the resident complained of pain and told her the same story of falling in the bathroom (staff dropped her to the floor). She further stated that the resident told her that a CNA, before the fracture was identified (9/21/11), insisted on putting shoes on the resident to go to the dining room. The resident stated putting the shoe on caused much pain. However, after the shoe was taken off, it was even more painful. The resident complained to the CNA that she was hurting her. According to the resident, the CNA stated, "Shut up. I have to get this shoe off." -She said she (family member #2) did not witness the incident with the CNA. However, she stated that when the resident was telling the family member about the incident, the resident's roommate verified the incident and stated that the incident was as the resident stated. The family member said there was no reason for the resident to have the shoes on as she was non weight bearing due to the pain. Resident #76's roommate was interviewed on 11/22/11, at approximately 12 noon. She was asked if she remembered the incident with the shoes; specifically, that the CNA told the resident 'shut up, I have to get your shoe off ' when the resident complained that CNA was hurting her. The roommate stated that this was what was said or words to that effect. The roommate stated the CNAs should speak nicer to the resident. The resident's power of attorney #1 stated on 11/23/11 at 12 noon, that he had not been contacted by the facility concerning the resident's leg pain until 9/21/11 (cross-reference F157). He stated there was no information given to him prior to this date. He stated that the resident complained of the nurses not taking care of her. The resident's power of attorney #2, was contacted on 11/23/11 at 9:00 a.m. and stated he was out of town and was informed of the fracture by the family.

Based on record review and interviews, the facility failed to ensure three of 43 sample residents (#76, #111 and #89) received the care and services necessary to attain and/or maintain their highest practicable level of well-being. Specifically: -Resident #76 sustained a fall [DATE]. Staff failed to comprehensively assess the resident after the fall and failed to address the resident's pain. Three days after the fall, x-rays revealed an ankle fracture. -Resident #111 sustained a fall on [DATE]. Neurological assessments were not completed as expected per facility policy. -Resident #89 sustained two falls in ,[DATE]. There was no documentation that the resident was comprehensively assessed. The findings include: 1. Resident #76 Resident #76 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), dated [DATE], revealed she was able to understand and was understood and had short-term memory impairment. She needed extensive assist with activities of daily living, was not ambulatory, and needed human assistance for toileting. She was frequently incontinent of bowel and bladder. a. Resident Interview The resident was interviewed, on [DATE] at 1:30 p.m. The resident stated she was dropped to the floor in the bathroom on [DATE]. She stated her leg started hurting and no one listened to her. She stated it hurt so bad, but they did not call the doctor or send her to the hospital. She further stated that they did not give her anything for the pain. She stated you can look at the record and you will see no pain meds were given to me. b. Record Review - Fall [DATE] Nurses' Notes: -[DATE] at 12:30 p.m., with assist of certified nurse aide (CNA) and a LPN, resident was being transferred to the toilet when resident lost her balance. The CNA and the LPN slid her to the floor with out injury. -[DATE] 2:00 p.m., vital signs within normal limits remained alert and oriented. Up for meals appetite good. No complaints of discomfort. -[DATE] vital signs within normal limits. Resident adjusting well to the facility. There were no further nurses' notes regarding the resident's fall until [DATE]. -[DATE] - Interdisciplinary team meeting documentation revealed the resident's witnessed fall was reviewed. The resident was assisted to the toilet when she lost her balance and was lowered to the floor. The resident complained of left ankle pain. Orthopedic appointment in progress will review further interventions after the orthopedic visit. -[DATE] - Resident has fracture of left ankle and has a loose cast on it. New pain pill ordered today. -[DATE] at 2:00 p.m., vitals within normal limits. PRN (as needed) medication given which was effective. Resident vomiting with low grade fever. Physician on call was told resident had no BM (bowel movement) for five days since she started [MEDICATION NAME] (narcotic [MEDICATION NAME]). -[DATE] Medicated for left ankle pain with excellent results. Physical Therapy (PT) Notes: On [DATE], the therapy department assessed the resident. The assessment read under the subjective section: Resident stated I can't stand to have my shoe on my foot. She was unable to stand due to pain. The note further read that the resident's ankle was not tested due to increased pain. The pain level was a 4 out of 5 scale for left ankle pain. Received E stim in an effort to decrease the pain. The resident was to be transferred with a hoyer lift due to left ankle pain. PT notes, dates ,[DATE]-[DATE], revealed the resident was unable to stand due to pain in left lower extremity. Pain at 4 out of 5. Touching the ankle increased the pain. PT note, dated [DATE], documented x-ray positive for fractured distal fibula. Orders for no weight bearing so transfers with a hoyer lift. The resident was seen by the orthopedic doctor. Orders written for an air cast in place. Patient remains in a great deal of pain. Change of Condition and Monthly Summary Forms: -September Weekly/Monthly Summary. Resident had pain in the right ankle is 2 person transfer and uses a hoyer for transfers. Patient is stable continue care plan. Dated ,[DATE]. -Change of condition Form dated [DATE]. Pain started [DATE] with pain to left lower leg- ankle pain acute. The note on the back of the form is dated [DATE] at 7:00 p.m. Call to nurse practitioner (NP). Resident rated pain at 7 out of 10 and increased with transfers, activity, PT and OT (occupational therapy). Call to NP for stat (immediate) x-ray. Results called to NP and stat ortho consult received. Physician Notes ([DATE]) Under diagnostics, X-ray were taken today ([DATE]) showing an oblique [MEDICAL CONDITION] fibula. To be put in an air cast, this will support the ankle. Weight bearing only for transfers. And no ambulation. Return in two and half to three weeks. 2. Facility Failures a. Failure to comprehensively assess and monitor the resident following her fall [DATE] See nurses' note above; there was no documentation in the [DATE] note regarding the status of the resident's lower extremities following her fall. Specifically, there was no documentation that the resident's range of motion or pain was assessed. Moreover, there was no documentation on the status of her lower extremities after [DATE] until [DATE] following her ankle x-ray. The Regional Registered Nurse (RRN), the Director of Nurses (DON) and two licensed practical nurses (LPN) were interviewed on [DATE] at approximately 3:30 p.m. -LPN #1 did not know lowering the resident to the floor was to be considered a fall, so no fall charting occurred. -LPN #2 said he was unaware the resident had fallen [DATE] because there was no fall charting. He said he was aware on [DATE] that the resident did not feel well and he felt she was having an off day. He said on [DATE] there were no complaints of pain. He became aware of the pain on [DATE]; at that time he contacted the nurse practitioner. The NP ordered an x-ray and the x-ray showed a left distal fibula fracture. An appointment with the orthopedic physician was set for that day. b. Failure to address the resident's pain (1) Record Review Although LPN #2 stated resident #76 did not complain of pain [DATE], record review (see PT notes above for [DATE]) revealed the resident was unable to stand due to pain. Further, record review revealed the resident was not medicated for pain in a timely manner. Specifically: -Review of the medication record for [DATE] revealed the resident received two doses of Tylenol 325 mg on [DATE] and one dose on [DATE]. No Tylenol was given ,[DATE], ,[DATE] or [DATE]. -Review of the medication (MAR) revealed there was no date when [MEDICATION NAME] was ordered and no order for the medication in the medical chart. The MAR indicated [REDACTED]. There was no further pain medications given to the resident from ,[DATE] - [DATE]. (2) Resident, Family, and Roommate Interviews See resident interview above on [DATE]. The resident was interviewed again on [DATE] at approximately 2:00 p.m. She stated that she never received medication for the pain. Resident #76's roommate was interviewed, on [DATE] at approximately 12 noon. She was asked if she remembered the incident with the shoes; specifically, that the CNA told the resident 'shut up, I have to get your shoe off ' when the resident complained that CNA was hurting her. The roommate stated that this was what was said or words to that effect. The roommate stated the CNAs should speak nicer to the resident. Resident #76's family member #1 was interviewed, on [DATE] at approximately 2:00 p.m. She stated she visited the resident several times per week and that the resident complained of pain in her leg on [DATE]. -The family member said she was not clear of staff names or the dates, but she stated the resident complained of pain in her leg and the staff did not believe her. The family member said the resident told her staff dropped her to the floor. She stated that she (the family member) did ask for pain medication for the resident, but was told they would have to call the doctor. There was no pain medication administered at that time. -The family member said that on [DATE], she asked to speak to the Director of Nurses (DON). The person that responded was not the DON. The family member stated the resident was in pain and she wanted an x-ray done. The staff member stated that the leg was not red and she was not concerned. The family member stated she insisted that an x-ray be done. The x-ray revealed a [MEDICAL CONDITION] at the ankle. -The family member stated there was a certified nurse aide (CNA) who the resident indicated was rough with her and this aide was still working in the building. The family member said the resident pointed the CNA out to her in the dining room. Family member #2 who is a frequent visitor was interviewed on [DATE] at approximately 4:00 p.m. -She stated that the resident complained of pain and told her the same story of falling in the bathroom. She said the resident told her that a CNA insisted on putting shoes on the resident to go to the dining room before the resident was diagnosed with [REDACTED]. However, after the shoe was taken off, it was even more painful. The resident complained to the CNA that she was hurting her. The CNA stated, "Shut up I have to get this shoe off." -She stated she (family member #2) did not witness this incident. However, she stated that when the resident was telling the family member about this incident the roommate verified the incident and stated that the incident was as the resident stated. The family member stated there was no reason for the resident to have the shoes on, as she was non-weight bearing due to the pain. The resident's power of attorney #1 stated, on [DATE] at 12 noon, that he had not been contacted by the facility concerning the resident's leg pain until [DATE] (cross-reference F157). He stated there was no information given to him prior to this date. He stated that the resident complained of the nurses not taking care of her. The resident's power of attorney #2 was contacted, on [DATE] at 9:00 a.m., and stated he was out of town when the fall occurred and was informed of the fracture by the family. c. Resident #89, age 94, was admitted to the facility on [DATE] and then re-admitted on [DATE] from the hospital. According to the document titled '[DIAGNOSES REDACTED]. According to the [DATE] Minimum Data Set (MDS), the resident was moderately cognitively impaired. The resident was able to be understood and understood others. The resident required the extensive assistance of one staff member for activities of daily living (ADLs) for transferring, toilet use and ambulation. The resident scored a zero on her BIMS (mental status) interview [DATE], following her admission [DATE]. The resident was unable to recall any objects, names or numbers. a. Status on Readmission -According to the [DATE] computer physician orders [REDACTED]. -According to the physician's telephone orders, dated [DATE], the resident received a physician order [REDACTED]. -On [DATE], the resident was care planned for potentially being at risk for falls. Approaches listed included having the call light within reach, toileting prior to bedtime, observe for potential side effects of medication administered. -On [DATE], a document titled 'occupational therapy evaluation' documented that the resident was a high fall risk. The same document stated that the resident was not cognitively aware for use of a call light system. d. Falls after readmission [DATE] (cross-reference F323) (1) Fall [DATE] According to a document titled 'interdisciplinary post fall review' dated [DATE], the resident was found by a certified nurse aide (CNA) on the floor next to her bed after a non witnessed fall. A nursing assessment at the time revealed no injuries. On [DATE], four new approaches were added to the resident's care plan for falls. These approaches included low bed, skid strips in front of the resident's bed, removing the resident's wheelchair from her bedside and making sure her call light was easily accessible. (2) Fall [DATE] According to a document titled 'interdisciplinary post fall review' dated [DATE], the resident was found on the floor of her room after a non-witnessed fall at approximately 10:50 p.m. The nursing assessment indicated that the resident was not responsive at the time of nursing assessment. According to the documentation labeled 'change of condition' dated [DATE] and timed 10:50 p.m., the resident had a blood pressure of ,[DATE] and a heart rate of 90. The physician was notified at 10:55 p.m. A telephone physician order, dated [DATE] at 10:55 p.m., was received for comfort care. The resident was not sent to the hospital. The resident expired at the facility at 00:52 a.m. (12:52 a.m.) on [DATE]. e. Facility Failures Record review failed to disclose a comprehensive assessment of the resident following her fall on [DATE] and [DATE]. Record review failed to disclose any documentation from the medical provider since the resident's readmission [DATE]. f. Interviews On [DATE] at approximately 2:00 p.m., an interview was held with the facility director of nursing (DON) and the corporate nursing director. The interview revealed: -The DON expected a facility nurse to assess the resident from head to toe, perform vital signs and notify the physician after a resident had a fall. -The DON expected that a nursing note following a resident fall in the permanent medical record. She also stated that she expected to see some provider charting as part of the medical record. -The DON stated that she would expect a change of condition MDS be conducted by the MDS coordinator after a resident had a fall. 3. Resident #111 a. Professional Reference According to the Resident Assessment and Monitoring for Long-term Care, Established Tools and Guidelines for Clinicians, HC Pro publishing, 2006, Barbara Acello, pages 58 and 59: -Standards of long-term care nursing practice require for an unknown or suspected head injury, neuro-checks (neurological checks) for a minimum of 72 hours. -Immediately after a fall, neuro-checks should be done every 15 minutes. If the resident is stable, time between neuro-checks may be increased to every 30 minutes for two hours, every 60 minutes for two hours, every four hours for 24 hours and then once a shift. According to Mosby's Clinical Nursing, 5th Edition, (2002), page 238, neurological assessment includes determination of the patient's baseline status, ability to verbalize, ability to follow commands, orientation to person, time, place and situation, responsiveness to pain, light pressure, pupillary response to light, and use of the Glascow Coma Scale. The Glascow Coma Scale rates responsiveness for three faculties: eye opening, motor response, and verbal response to various stimuli and creates a score for comparative value. Diminishing function on all of these assessments indicates a deterioration of the patient's neurologic condition. b. Facility Policy and Neurological Record Review of the ,[DATE] Fall Management policy revealed for a resident with potential head injury, "2. Complete the Neurological Record per instructions." Review of the "Neurological Record" revealed the following instructions at the top of the page: "Circle check marks & describe in detail any active or changing neurological problems. Chart motor function based on the best of the worst. Frequency: every 20 min(utes) x4, every 1 hour x4 hours, every 4 hours x24 hours, and every 8 hours x for remaining 72 hours or as ordered by physician." c. Resident Failure Resident #111, age 72, was admitted to the facility on [DATE]. According to the admission face sheet, printed [DATE], [DIAGNOSES REDACTED]. According to the [DATE] Minimum Data Set (MDS), the resident was cognitively intact, able to verbalize his needs and understand the communication of others. -He required extensive assistance with bed mobility, locomotion on the unit, dressing, toilet use, and hygiene/bathing. He required limited assistance with transfers. He had no functional limitations to any extremities. He had a personal history of a fall prior to admission. -His balance during transitions from sitting to standing, walking, turning around and facing the opposite direction while walking and moving on and off the toilet showed he was unsteady, and only able to stabilize with human assistance. Record Review: Review of the [DATE] Change of Condition report showed the resident fell , receiving a laceration to the top of the head. There was no description of the size or exact location of the laceration, nor was there any assessment of the resident's level of consciousness immediately after the fall. There was no mention if the fall was witnessed or unwitnessed. Review of the Interdisciplinary Post Fall Review showed the fall occurred, on [DATE] at 6:30 p.m. Whether or not the fall was witnessed was not checked on the form. -The description of the fall showed the resident became unsteady standing at his walker, and fell backwards. The resident reported he was standing with his walker with the Certified Nurse Aide (CNA) present. The CNA was getting the bed ready. -The same writer described the resident fell to the side, hitting the bedside dresser with the top of his head. (Earlier in the same report, the writer said the resident fell backwards, see above). -Conditions that might have contributed to the fall were an unsteady gait, and a history of falls. He was wearing slippers at the time of the fall. The resident's activity at the time of the fall was "unassisted ambulation" and "stand pivot transfer to bed." -The summary of the interdisciplinary team, on [DATE], was the resident stated skid strips were not under his feet, and he felt the floor was slick. The recommendation was the skid strips be extended to the end of the bed, and the staff was re-educated to prepare the bed prior to transfer. According to the "Neurologic Record," assessments were missing between [DATE] at 8:30 p.m. and sometime on the day shift on [DATE]. This was a period of at least 33.5 hours. Expected assessments would have occurred on [DATE] at 12:30 a.m., then once per shift during the day shift (6:00 a.m. to 2:00 p.m.) on [DATE], the evening shift (2:00 p.m. to 10:00 p.m.) on [DATE], and the night shift beginning [DATE] at 10:00 p.m. until [DATE] at 6:00 a.m. Interviews: The resident no longer resided at the facility during the survey, and was not available for interview or observations during the survey. In interview, on [DATE] at 5:30 p.m., the nurse completing the initial investigative reports related to this fall confirmed there was a page of neurologic checks missing. She confirmed there was no evidence the required neurologic assessments were completed per the facility policy.

Based on observation, staff interview and record review, the facility failed to ensure two of ten sample residents (#1 and #3), who entered the facility without pressure sores, did not develop pressure sores unless the residents' condition demonstrated that they were unavoidable. Specifically: -The facility failed to ensure resident #3's wounds were comprehensively assessed, monitored and treated as ordered. The resident developed a coccyx wound from shearing that worsened to a painful Stage IV ulcer. -The facility failed to ensure resident #1 was provided pressure relief as ordered and care planned. The findings included: A. Definitions Stage I identification: Identification of a pressure ulcer while the pressure sore is a Stage I or unblanchable [DIAGNOSES REDACTED] (redness) of intact unbroken skin is critical. When a resident develops a Stage I pressure sore, more vigilant assessments and nursing interventions, such as more frequent turning and repositioning, must be utilized to prevent the Stage I pressure sore from deteriorating into an open wound (Stages II, III, or IV). Residents who have developed a pressure sore are at a higher risk to develop additional pressure sores. According to the U.S. Department of Health and Human Services AHCPR Clinical Practice Guideline for treatment of [REDACTED]." The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines found at website http//www.npuap.org, provide the following definitions: Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages: Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstagable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. B. Professional Standards of Care pertaining to the Pressure Ulcers 1. Prevention and assessment: According to the "Clinical Practice Guidelines, a Quick Reference Guide for Clinicians" for the prevention and treatment of [REDACTED].S. Department of Health and Human Services, pressure ulcers can cause the resident to experience pain and discomfort from tissue damage, wound cleaning, or dressing changes. Thorough resident assessments must be conducted to identify the residents who are at risk to develop pressure sores. All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. Preventive measures include the following: Identify the at-risk residents that need the preventive measures, ensure that the resident's nutritional and water intake is adequate to maintain the skin's tolerance to pressure, and protect the skin from damage from external pressure by utilizing frequent position changes and pressure-relieving devices; e.g., cushions or special mattresses. Pressure ulcers should be assessed for classification or stage, location, size, and condition of the pressure ulcer and surrounding tissue. According to "Clinical Practice Guidelines," "Written repositioning schedules should be developed even when patients are using a pressure-reducing support surface. These surfaces serve only as adjuncts to strategies for positioning and careful monitoring. Reposition the sitting individual so points under pressure are shifted at least every hour." According to "Pressure ulcers in Adults: Prediction and Prevention" by the U. S. Department of Health and Human Services, page 9, under "Mechanical loading and Support Surfaces, "any person at risk for developing pressure ulcers should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals." C. Facility Policies and Procedures The Skin Management policy was received from the Interim Nursing Home Administrator (NHA) on [DATE]. The policy read in pertinent part: "Overview - Residents with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." D. Resident Failures 1. Resident #3 (closed record) a. Resident Status Medical record review revealed [AGE] year-old resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident expired on [DATE]. The most recent Minimum Data Set (MDS), dated [DATE], indicated the resident had severe impairment in the cognitive patterns. The MDS indicated the resident needed extensive assistance of two or more staff members with bed mobility, and transferring, needed extensive assistance of a staff member with dressing and eating and was dependent upon staff for personal hygiene and bathing. The comprehensive care plan, last updated on [DATE], indicated the resident was care planned for potential weight loss, poor safety awareness requiring the use of restraining devices, being at risk for falling, actual pain, incontinence and for a Foley catheter, on oxygen, and being at risk for increased bleeding due to the use of [MEDICATION NAME], and had contractures. The resident was also care planned for pressure ulcers (coccyx) which were not expected to heal. Some of the interventions listed included: -Pressure reduction mattress, -Pressure reduction cushion to chair or wheelchair, -Reposition in chair frequently, -Reposition and turn in bed frequently, -Provide incontinence care after each incontinent episode, -Measure and stage wound weekly using pressure ulcer healing assessment, -Complete a full body check weekly and document, -IDT (interdisciplinary team) referrals (Registered Dietitian, Physical Therapist, Occupational Therapist), -Monitor lab values as ordered, -Pressure Ulcer treatment as ordered, -Foley catheter (no date) change as ordered, -Hospice evaluation (no date), and foam boots when in bed. The resident was assessed as being at a high risk for developing pressure sores with a score of 11 on the Braden scale, dated [DATE]. A score of 12 or less represents high risk. b. Skin breakdown - facility response and facility failures Initial wound on coccyx: Review of the medical record on [DATE], revealed documentation that the resident was found with a pinpoint area stage I pressure ulcer measuring .5 x .5 cm on the buttocks on [DATE]. On [DATE] a.m. at 10:30 a.m., five days later, a physician ordered [MEDICATION NAME] to the pinpoint wounds on buttocks and change every three days and as needed. This was documented as healed on [DATE]. On [DATE], a nurse documented that a healed pressure sore area was reddened with scar tissue on the left hip measuring 1 cm x 1 cm. On that same day ([DATE]) at 10:15 a.m., the physician ordered [MEDICATION NAME] to left hip and change every three days and as needed. The [DIAGNOSES REDACTED]. The bed was documented as being a high flow air mattress. On [DATE] at 2 p.m., the physician ordered: (1) At the next facility lab draw, Do pre-[MEDICATION NAME], total protein, complete blood count (CBC), and a hemoglobin A-1 C. (2) Begin oral vitamin protocol: 1 tablet [MEDICATION NAME]. orally daily, one tablet Vitamin C 500 mg orally daily, one tablet zinc 220 mg orally daily times 14 days. (3) Registered Dietitian to evaluate and treat. The [DIAGNOSES REDACTED]. On [DATE] at 12:30 p.m., the physician ordered NSA (no sugar added) Mighty shake (supplement) one orally two times a day at 10 a.m. and at 3 p.m. The registered dietitian (RD) documented, on [DATE], that the resident had skin issues and gradual weight loss. The documented weight was 106 pounds. The RD also documented that the pre-[MEDICATION NAME] level was down and this could be to mild depletion of visceral protein or from medication. The RD also documented to continue the current interventions (of the mighty shake twice a day) and to continue to monitor the weight, skin issues and the resident's intake. The next dietary note was not written until [DATE], over two months later. (See below.) On [DATE] at 5 p.m. - the physician ordered Give NSA Magic Cup for HS (bedtime) snack per dietary recommendation. Review of the ,[DATE] Medication Administration Record (MAR) and ,[DATE] Treatment Administration Record (TAR), revealed documentation that the [MEDICATION NAME], and the vitamin C were given beginning on ,[DATE] and continued through [DATE], and zinc was given beginning on ,[DATE] and continued through [DATE]. The NSA mighty shake was documented as given twice a day beginning on ,[DATE] through [DATE]. According to documentation on the ,[DATE] MAR, out of 40 times the mighty shake was offered to resident #3, the resident consumed 100% less than half (18) of the time, consumed 60% one time, 50% 14 times, and 0% seven times. The facility could not provide documentation that the Magic cup was given at bedtime as ordered. According to the ,[DATE] MAR and ,[DATE] TAR, documentation indicated the mighty shake was offered at 10 a.m. and 3 p.m. for the entire month; however, the amount taken was documented only 17 times. The facility could not provide documentation that the Magic cup was given at bedtime as ordered. According to the ,[DATE] TAR documentation, the [MEDICATION NAME] dressing was applied to the left hip on ,[DATE], ,[DATE], ,[DATE], ,[DATE]. On [DATE], a nurse documented that the dressing was not needed. According to the ,[DATE] TAR documentation, the buttocks ulcer was healed. Reopening of coccyx wound - deterioration: On [DATE], a nurse documented the resident had a newly discovered skin shearing measuring 6 cm long and 2 cm wide on the left inner buttocks (coccyx wound). On [DATE], the coccyx wound was described as angry red and measured 6 cm X 4 cm. According to the nurse's documentation, the wound was draining serosanguineous fluid with a scant amount of exudate and the resident had pain associated with the wound. A nurse documented on [DATE] at 2 p.m., that the physician was called regarding a stage II coccyx ulcer. There were no documented measurements and/or description of the wound. On [DATE], the physician ordered treatment for [REDACTED]. The physician documented the resident could be up for meals and activity, otherwise in bed. The doctor also instructed staff to turn the resident every two hours. On [DATE] at 2:30 p.m., the physician ordered an indwelling Foley catheter until the coccyx wound healed. However, on [DATE], the catheter was discontinued due to the resident removing it. According to further review of the medical record, the resident was on antibiotics for a urinary tract infection at this time. On [DATE] at 11:45 a.m., the physician ordered Santyl ointment to the coccyx wound twice a day and as needed and cover with the dry gauze until healed. The physician also ordered to reinsert the Foley catheter for seven days. On [DATE], the coccyx wound measured 6 cm x 4 cm and the wound bed was covered 100% with a thick black and greenish yellow eschar. The drainage was described as purulent with a foul odor. There was no documented evidence that the RD or MD were notified of the deteriorating wound. On [DATE], five days later, the physician ordered that the resident may be seen at the hospital wound care clinic regarding the coccyx wound and physical and occupational therapy (PT/OT) to evaluate and treat as needed. The physician also ordered one tablet of [MEDICATION NAME] ,[DATE] mg orally three times a day before meals for pain. There was no documented evidence that the RD was notified of the deteriorating wound. On [DATE], PT documented the resident would be seen three times a week through [DATE]. On [DATE], an antibiotic was ordered for seven days for a urinary tract infection and the Foley catheter was to be discontinued when the antibiotic was completed. On [DATE], the wound was now described as unstagable, measuring 8 cm x 8 cm and tunneling 6 cm with a large amount of purulent drainage with a foul odor. The wound consultant described the wound as "covering both the left and the right buttocks. The left inner buttock has superficial depth and is pale red in color. The right side of the wound extended into the right buttocks and is unstagable with 100% black eschar. The entire wound is 8 cm x 8 cm with a 6 cm tunnel extending into the rectal vault." According to the documentation, the resident was to be seen at the wound clinic on [DATE]. The physician was contacted to change the wound treatment orders. On [DATE] at 3 p.m., the physician ordered to discontinue the pressure ulcer treatment of [REDACTED]. The physician also ordered a consult with hospice. On [DATE] at 6 p.m., a hospice nurse documented the resident had stated the new medication was helping his pain. On [DATE], the wound measurements were documented as 10 cm x 12 cm. On [DATE], over a month after the coccyx wound appeared, the RD documented the resident was recently admitted to hospice with a nonhealing stage IV coccyx wound. The RD documented the resident currently weighed 107.5 pounds and that the current kilocalories/protein intake appeared adequate to meet the resident's estimated needs. The only recommendation made by the RD was to alternate fluid choices and monitor the wound healing process. On [DATE], a hospice physician prescribed [MEDICATION NAME] 0.25 ml twice a day for pain, [MEDICATION NAME] oral solution 0.25 mL every four hours while awake for pain or shortness of breath, and [MEDICATION NAME] 250 mg orally three times a day for seven days for the wound infection. On [DATE], the mighty shake was discontinued. On [DATE] (no time), a Hospice certified nurse aide (CNA) documented urine was bypassing the resident's catheter. The CNA documented the bed was wet and there was no urine in the bag. On [DATE], the resident expired. The weekly "Head to Toe Skin Checks" and the facility's "Weekly Pressure Ulcer Records," from admission to the resident's death on [DATE], were requested from the Director of Nurses (DON) on [DATE] and again on [DATE], before exit from the facility; however, these records were not received as of [DATE]. There was no documentation what interventions were implemented to promote healing of the resident's ulcer. Review of the MARs and TARs from ,[DATE] and ,[DATE] showed the ordered treatments were completed. However, there was no documentation that the resident was turned and repositioned as care planned or on a schedule, or that other pressure relieving interventions were attempted. Finally, there was no documentation how often the resident was toileted or changed in an effort to keep the open area clean and dry. Attempts were made during the investigation on ,[DATE] and [DATE], to interview staff familiar with the resident and the resident's care. All attempts were unsuccessful; staff was either no longer employed at the facility or were agency staff who could not be contacted. 2. Resident #1 Medical chart review revealed [AGE] year-old resident #1 was admitted to the facility on [DATE] from the hospital. [DIAGNOSES REDACTED]. Further medical chart review revealed the admission nursing assessment, dated [DATE], indicated the resident had no pressure ulcers, only a surgical wound on his right ankle. The admission MDS, dated [DATE], indicated the resident was at risk for developing pressure sores and had no pressure sores at that time. a. Multiple areas of skin breakdown after admission The [DATE] MDS indicated the resident had one stage I pressure sore with the onset date of [DATE] (one month after admission) and a stage IV pressure sore that measured 5 cm x 5 cm with a depth of 60.5 cm (documentation unclear). The [DATE] MDS indicated the resident had a stage IV pressure ulcer that measured 5 cm x 5 cm x 8 cm. The most recent MDS, dated [DATE], revealed the resident had a stage IV pressure ulcer that measured 2.5 cm x 2.5 cm x 6 cm. The MDS also indicated that the resident was moderately impaired when scored by the BIMS (brief interview of mental status). The MDS indicated the resident needed extensive assistance with bed mobility, transferring, dressing, eating, toilet use, and personal hygiene and was dependent upon staff for transferring and bathing. A mechanical lift was used. The comprehensive care plan, last updated on [DATE], indicated some of the issues the resident was care planned for included receiving enteral nutrition, unclear speech, impaired vision, cognitive impairment, actual pain due to arthropathy, being on oxygen therapy, actual weight loss, having an indwelling catheter, and being at risk for falls. The resident was also care planned for the potential of developing pressure ulcers, initiated on [DATE], with a Braden score of 13, related to moisture/incontinence, decreased activity, and impaired mobility. The goal was the pressure ulcer will show signs of healing as evidenced by decrease in depth, width and length by at least 1 cm and free of further breakdown through the next 90 days. Interventions listed included: -Apply lateral rotation air mattress to bed, -Apply Roho cushion to chair or wheelchair, -Turn and reposition while in bed frequently for comfort and pressure reduction, -Monitor labs values as ordered, -Encourage resident to comply with positioning, -Provide incontinence care after each incontinent episode, or per established toileting plan, -Referrals with the RD, PT, and OT as needed, and -Measure and stage wound weekly (dated [DATE]). The care plan documented (hand written), on [DATE], a coccyx wound 1 cm x 1 cm with perineal excoriation. On [DATE], the care plan indicated (hand written) the resident was going to the wound clinic with a Stage II coccyx wound and a Stage III on the right ischial. The care plan also contained a hand written entry of a right ischial stage IV pressure ulcer that measured 5 cm x 3.5 cm and a coccyx stage II pressure ulcer that measured 1.5 cm x 0.5 cm x 0.25 cm. The date of [DATE] was crossed through with a line and the date of [DATE] was hand written. On [DATE], the weekly pressure wound documentation from the onset dates of the various pressure wounds was requested from the DON. The DON stated that the former DON had hired a Licensed Practical Nurse (LPN) as the wound nurse in May who also was no longer employed at the facility. The LPN wound nurse kept all the wound documentation in a notebook which the current DON had not yet located. The DON was called again on [DATE] and the documentation requested. None was provided as of [DATE]. Review of the newly hired nurse practitioner (NP)/physician progress reports revealed the following information regarding resident #1's status. -Initial Progress, dated [DATE] The resident had "developed a stage IV on right ischium and a stage II to his coccyx. He was started on wound care, wound healing vitamins and sent to the Wound Care Center. He is having twice-daily wound care. He was debrided by the Wound Care MD, and further teaching/education was done at the Wound Care Center, and at (name of the facility), and the resident still had difficulty staying off his right side. An air mattress was ordered. His penis also had two dime sized areas of break down, thought to be pressure from the Foley. His [MEDICATION NAME] is 2.4 (low - reference range 3XXX,[DATE].0), and he is eating only soup most of the time. . . " -Progress Note, dated [DATE] ". . . Stage II to coccyx worse this a.m.; area deeper and with two black areas to bottom. Reinforced wound care with wound nurse. At risk for worsening decub(itus), infection and need for graft. Stage IV pressure ulcer to right ischium. Due to his low [MEDICATION NAME] (2.4), [MEDICAL CONDITION] and inability to stay off his bottom (despite staff education and assistance), he has developed a stage IV to the right ischium. At risk for worsening decub (itus), infection and osteo ([DIAGNOSES REDACTED]). . . Will have weekend staff meet with the wound nurse to go over the dressing change orders. . . A family member informed me the resident was up for greater than four hours on Saturday and Sunday. . . feels the resident isn't eating well because you can't read the menu. . ." -Progress Note, dated [DATE] " . . on wound healing vitamins, antibiotic, vitamin D, and [MEDICATION NAME], and Tylenol prn (as needed) . . . supra pubic catheter inserted yesterday [DATE]. . ." -Progress Note, dated [DATE] The NP documented the resident had [MEDICAL CONDITION]. -Progress Note, dated [DATE] The NP documented the resident had just returned from PEG (Percutaneous endoscopic gastrostomy) tube placement, tolerating daily showers, and cooperating with turning and care. -Progress Note, dated [DATE] The NP documented the stage II pressure ulcer on the coccyx was resolved. The stage IV to the right ischium was starting to show granulation and measured approximately 6 cm wide in diameter and down at least 4 cm. The wound care has been increased to three times a day. -Progress Note, dated [DATE] The NP documented the resident now had osteo[DIAGNOSES REDACTED] (stage IV to the right ischium). Review of the NP/physician telephone orders indicated on [DATE], the resident was now on hospice and the wound care clinic has been discontinued. Review of the ,[DATE] MARs and TARs indicated the resident was [MEDICATION NAME] (tube feeding) at 80 cc/hr for eight hours scheduled on at bedtime and off at 5 a.m. and receiving fortified pudding three times a day with meals. The [DATE] coccyx wound measurements were documented as 2.5 cm x 2.5 cm x 6 cm. b. Family and Staff Interviews The family member of resident #1 was interviewed on [DATE] at 1:20 p.m. and again on [DATE] at 11:30 a.m. -The family member stated when the resident first arrived at the facility, she had asked the former DON how they were treating the pinpoint opening on his bottom. The family member stated the former DON was not even aware of the resident's pressure ulcer. -The family member stated the resident's pressure ulcer progressed to a 7 cm ulcer and the resident was sent to the wound clinic. The family member stated the wound clinic would call her and tell her the facility needed to change the resident's dressing as ordered. The family member went on to say that you could smell the resident in the hallway; "such a foul odor." -The family member also stated the facility was not taking care of the resident; she would find the resident lying in wet clothing all day. She stated she informed the former DON, who apologized. However, the DON did not take care of the problems. The family member stated that currently, the resident's care was much better and the resident was on hospice. On [DATE] at 11:30 a.m., the floor nurse (LPN) was interviewed as he was completing the coccyx wound care. The LPN stated that the floor nurses now do the wound treatments. Resident #1's wound bed appeared clean with granulation and with no drainage. The LPN stated he had packed the tunneling with the ordered gauze and the wound had improved since he had started at the facility. c. Observations The resident was observed at intervals on [DATE] and [DATE]. On [DATE] at 9 a.m., the resident was observed seated out in a wheelchair in his room. The Hoyer sling was noted still underneath the resident as he was seated in a wheelchair. His feet were off the foot rests. The resident stated he was waiting for his shower. -At approximately 11:45 a.m., the resident was observed lying on his left side in bed receiving wound care. At approximately 12 p.m., the resident was lying on his back. -At 3 p.m., the resident was observed still lying on his back. The call light was observed unavailable, hanging over the call light button on the wall. The suprapubic catheter was attached to a drainage bag which was observed hanging on the bed frame. The resident's water pitcher on the overhead bedside stand was pushed against the wall and out of the resident's reach. The alternating air mattress was observed on the bed; however, all the indicator lights were off. A staff member was asked to check the bed and she stated she would get someone from therapy to do that. -At 3:20 p.m., the maintenance man reported that the bed had been unplugged since the resident had been put to bed (over three hours earlier). The resident was observed still on his back when he told the surveyor at 4:00 p.m. that he wished to get up. The above observations were relayed to the DON and the Nursing Home Administrator (NHA) on [DATE] at approximately 1:00 p.m.

Based on record review and staff interview, the facility failed to ensure one of 6 sample residents (#1) received proper Groshong catheter treatment and care. Specifically, the facility failed to adequately address the resident's catheter care and needs, contributing to the purulent drainage around the left [MEDICATION NAME] Groshong catheter site and the resident's [DATE] hospitalization and possible [MEDICAL CONDITION]-resistant Staph aureus of the catheter site. The findings include: A. Groshong Catheter According to the website of the University of Wisconsin Hospitals and Clinics Authority's Department of Nursing [DATE], (http://www.uwhealth.org/healthfacts/), "The GROSHONG? catheter is a narrow plastic-like hollow tube. It is tunneled under the skin and placed in one of the veins just under the collarbone. The catheter is placed just above the heart." Other pertinent information included in this reference is summarized below: The GROSHONG? catheter has many uses: drawing blood, [MEDICAL CONDITION], IV fluids, blood [MEDICAL CONDITION] and IV nutrition. If a dressing is not used, the site must be cleaned daily with a washcloth and antimicrobial soap. Soap with a [MEDICATION NAME] base is preferred. If a dressing is used, the dressing should be changed at least every three days or sooner if it is loose, wet, soiled, or if any drainage is present. The catheter should be flushed once a week, or after each use. The hub should always be covered before cleaning to protect it from any water contamination. Loop and secure the catheter at all times to prevent pulling, even if a dressing is not used. Some of the problems the article indicated when the physician should be called immediately included: Persistent blood in catheter tubing. Swelling of face, neck, chest, or arm. Drainage, redness, swelling, severe pain, or bleeding at the exit site. Fever and/or chills. Shaking chills right after you flush the catheter. Difficulty flushing the catheter. B. Facility Policy The facility's policy on the care of central catheters was requested from the Director of Nursing (DON) on [DATE]. Copies of pages ,[DATE] from a textbook were received and indicated advantages and disadvantages of the Groshong catheter. The reference read under disadvantages that the end caps needed to be changed weekly and the catheter was to be flushed with enough saline solution to clear the catheter, especially after drawing or administering blood. The reference also indicated that a sterile dressing should be applied and maintained on the insertion site, and that good hygiene and aseptic technique during insertion and care decreased the risk of catheter-related infection. C. Resident Failures Medical record revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the hospital on [DATE] through [DATE]. The hospital discharge [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], revealed resident #1 needed extensive assistance of a staff member in all activities of daily living except toileting in which the resident was dependent upon staff. The resident was coded as always incontinent of bowel and bladder. The comprehensive care plan did not address the care and treatment of [REDACTED]. The admission "Nursing Admission Assessment," dated [DATE], indicated the resident had a "Groshong catheter to L. (left) chest." In addition, in the nurse's notes a nurse had written the discharge report from the hospital, which also contained the information that the resident had a left chest and Groshong catheter. However, despite the facility's awareness of the resident's Groshong catheter, there was no documented evidence that the physician was contacted for care and treatment of [REDACTED]. Review of the ,[DATE] Medication Administration Record (MAR) and the ,[DATE] Treatment Administration Record (TAR) showed no evidence of any completed documented care and treatment for [REDACTED]. On [DATE], upon return from the physician's office and over a month after the resident's admission to the facility, a physician's orders [REDACTED]." There was no physician's clarification on the type of solution to use to flush the catheter. However, there was no documented evidence on review of the ,[DATE] MAR and TAR that the catheter flushes were completed as ordered. Review of the medical record revealed resident #1 was in the hospital from ,[DATE] through [DATE]. Review of the hospital record indicated the reason for the admission was fever, hypoxemia, had a change in mental status. The hospital discharge [DIAGNOSES REDACTED]. The hospital discharge orders, dated [DATE], included to flush the Groshong catheter with 10 ml of normal saline every shift. Review of the ,[DATE] MAR and TAR revealed an IV Medication Sheet that indicated the normal saline (NS) catheter flush was scheduled to be done once on the 6 a.m. to 2 p.m. shift, once on the 2 p.m. to 10 a.m. shift, and once on the 10 p.m. to 6 a.m. shift. According to the documentation on the ,[DATE] IV Medication Sheet/MAR/TAR, the NS catheter flush was completed 14 of the 29 times as ordered. These included: -On ,[DATE] -two times, -On ,[DATE] -three times, -On ,[DATE] -two times, -On ,[DATE] -one times, -On ,[DATE] -two times, -On ,[DATE] -one times, -On ,[DATE] -one times, -On ,[DATE] -one times, -On ,[DATE] -one times, and -On ,[DATE] -none. According to the hospital record, the resident was admitted to the hospital on [DATE] with an infected Groshong site. According to the hospital record, the resident was started on [MEDICATION NAME] and Bactrim. Additionally, the infected Groshong catheter was removed. The Groshong catheter wound culture [MEDICAL CONDITION], so Bactrim was discontinued and IV [MEDICATION NAME] was started. The resident returned to the facility on [DATE], admitted to hospice and expired on [DATE]. D. Interviews A family member was interviewed on [DATE] and on [DATE]. The family member stated the catheter was inserted due to [MEDICAL CONDITION]. The family member stated the resident was hospitalized because the catheter site was red and infected and draining green pus. The family member felt this was due from the facility's failure of adequate care for the catheter. The Director of Nursing (DON) was interviewed on [DATE] at approximately 3:30 p.m. The DON stated she was not hired until the middle of [DATE] and could not comment on the care of the catheter before her arrival. The DON verified per record review that the facility's documented evidence of adequate Groshong catheter care was lacking.