Every finding on record at Red Cliffs Post Acute

Based on record review and interviews, the facility failed to ensure one (#1) of three residents received treatment and care in accordance with professional standards or practice out of eight sample residents.Specifically, the facility failed to complete a timely assessment after Resident #1 experienced symptoms of a urinary tract infection (UTI) and an acute kidney injury.Findings include:I. Facility policy and procedureThe Change in a resident's condition or status policy, revised February 2021, was provided by the nursing home administrator (NHA) on 7/22/26 at 5:39 p.m. It revealed in pertinent part, A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan; and ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact situation, background, assessment, and recommendation (SBAR) communication form.II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE] and discharged to the local area hospital on 7/10/26. According to the July 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), neuromuscular dysfunction of the bladder, chronic obstructive pulmonary disease (COPD), congestive heart failure, peripheral vascular disease, hypertension, enterocolitis due to clostridium difficile, calculus of the kidney (kidney stones) and muscle weakness.The 6/29/26 minimum data set (MDS) assessment revealed Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #1 was dependent on staff for bathing, toileting, lower body dressing, footwear and personal hygiene. Resident #1 required substantial assistance with upper body dressing and set up assistance to eat. The assessment documented Resident #1 had an indwelling catheter.B. Resident representative interviewResident #1's representative was interviewed on 7/22/26 at 2:11 p.m. She said came to the facility to visit Resident #1 on 7/9/26. She said he did not look like or act like his usual self. She said he was usually very talkative and liked to joke around. She said on 7/9/26 he was quieter and was more in a somber mood. The representative said his face and skin looked very dry and almost scaly. She said she returned to the facility on 7/10/26 at approximately 6:30 p.m. She said he was very sleepy and lethargic. She said he would briefly open his eyes but then would fall back asleep. She said she felt that something was wrong. She said she noticed he had partially empty cups on his bed side table but there was very little urine in his catheter bag. She said she expressed her concerns with licensed practical nurse (LPN) #1. The resident's representative said LPN #1 told her that he had taken a pain pill, which may have been causing his sleepiness and he had a rough night the night before (7/9/26). The representative said LPN #1 told her Resident #1 had some back pain, nausea and vomiting. The representative said she told LPN #1 that Resident #1 had a history of UTIs, fluid retention and sepsis with similar symptoms. She said she was very worried that he had urinary retention and felt he should go to the hospital. The representative said LPN #1 looked at the resident's catheter bag and said he had not had input of fluids today so he would not have an output of fluids. The representative said LPN #1 pushed on his stomach/bladder and said the resident was not retaining fluid. The representative said LPN #1 told her it was after business hours but tomorrow (7/11/26) she could order a urine analysis. The representative said LPN #1 told her there was nothing she could do now. The representative said LPN #1 took his blood pressure and said he was fine. She said LPN #1 said Resident #1 could be treated at the facility, he did not need to go to the hospital and she would contact his physician. The resident's representative said she was still very worried that Resident #1 was very sick and needed to go to hospital. She said she contacted the Resident #1's power of attorney (POA) who called for the paramedics to come to take him to the hospital for an evaluation. She said the paramedics arrived at the facility and said Resident #1 had little response to them and took him to the hospital. The representative said she was later told by the hospital that Resident #1 had a significant amount of fluid in his bladder and he was septic. C. Record reviewReview of the certified nurse aide (CNA) indwelling catheter device task from 6/24/26 through 7/10/26 revealed the following. On 7/7/26 at 5:54p.m., Resident #1's urine output changed from clear to cloudy. Resident #1's urine color was documented as cloudy again on 7/8/26 at 1:11 a.m. and 7/8/26 at 5:19 p.m. On 7/9/26 at 3:10 p.m., 7/10/26 at 4:36 a.m. and 7/10/26 at 5:26 p.m. Resident #1's urine output was documented as amber on 7/9/26 at 5:24 a.m.On 7/9/26, the task documented Resident #1 had decreased urine output, with 450 milliliters (ml) urine output at 5:24 a.m. and 250 ml urine output at 3:10 p.m.On 7/10/26, the task documented Resident #1 continued to have decreased urine output, with 100 ml urine output at 4:36 a.m. and 50 ml urine output at 5:26 p.m.Review of the Resident #1 intake documentation revealed on 7/9/26, Resident #1 ate 0 to 25 % of breakfast at 9:23 a.m., ate 25 to 50% of his lunch at 1:51 p.m. and 50 to 75% of his dinner at 8:13 p.m. Prior to 7/9/26. On 7/10/26, Resident #1 ate 0 to 25% of his breakfast at 9:56 a.m. and refused his lunch and dinner. Review of Resident Resident #1's intake documentation prior to 7/9/26 revealed Resident #1 typically ate 75 to 100% of each meal.-However, the facility did not complete an assessment despite documenting changes in urine and oral intake. Review of Resident #1 CPO revealed the following order: Ondansetron 8 milligram (mg) oral tablet, give one tablet by mouth every eight hours as needed for nausea or vomiting, ordered 6/23/26. Review of Resident #1's medication administration record (MAR) revealed Resident #1 received Ondansetron 8 mg tablet for nausea on 7/10/26 at 3:16 a.m. This was the first administration of this medication. The progress note, dated 7/10/26 at 8:44 p.m. documented at approximately 6:15 p.m. LPN #1 was notified Resident #1 had a change in condition. The progress note documented LPN #1 was notified Resident #1 had not eaten or drank as usual during the day, was observed sleeping frequently and had reduced urine output. The progress note documented Resident #1 was sleeping when LPN #1 entered the room. The progress note documented responded to LPN #1's voice and was oriented times two and told LPN #1 he felt fine. The progress note documented LPN #1 obtained Resident #1's vital signs and at the time, Resident #1's hands were cool and clammy. The progress note documented Resident #1's blood pressure was 103/60 millimeters of mercury (mmHg), pulse was 94 beats per minute (BPM), temperature was 98.1 degrees Fahrenheit and oxygen saturation was 90% on room air. The progress note documented Resident #1 was clinically stable and did not meet the criteria for emergent transport. The progress note documented the nurse explained to Resident #1's friend and representative that the resident's symptoms could be safely treated at the facility because the facility could order labs, urinalysis, intravenous (IV) fluid and antibiotics with increased monitoring at the facility. The progress note documented LPN #1 also offered to contact Resident #1's provider. The progress note documented when LPN #1 attempted to ask Resident #1 if they wanted to go to the hospital or remain in the facility, the friend and Resident #1's representative would not allow Resident #1 to answer. The progress note documented Resident #1's representative refused to listen to LPN #1's attempts to explain treatment options at the facility and did not allow sufficient time for LPN #1 to complete a comprehensive assessment before calling 911. The progress note documented emergency medical services (EMS) arrived to the facility and transported Resident #1 to the local area hospital. The progress note documented Resident #1 did not appear with acute distress during the brief assessment prior to transport by EMS.The hospital note, dated 7/11/26 at 2:59 a.m., revealed Resident #1 had an altered level of consciousness. The hospital note documented Resident #1 appeared to wake up to stimuli but did not stay awake. The hospital note documented Resident #1 experienced low blood pressure while in the emergency room, with documented blood pressures of 82/55 on 7/11/26 at 2:50 a.m., 76/48 at 2:53 a.m. and 83/56 at 2:55 a.m. The hospital note documented Resident #1 had white blood cell count and lactic acid values that were elevated but not critical. The hospital note documented Resident #1's urinalysis was positive for a UTI. The hospital note documented the initial suspected origin for Resident #1's altered mental status was suspected sepsis w/ possible component of medication accumulation in the setting of an acute kidney injury.The hospital note documented Resident #1 was admitted to the intensive care unit (ICU) for monitoring because Resident #1 was at risk for sudden deterioration requiring urgent physician intervention. Review of Resident #1's records revealed no documentation of nursing assessments for a change of condition on 7/9/26 (the onset of nausea and change in urine output or color) or 7/10/26 (continued reduced intake and low urine output with cloudy urine) prior to the progress note documenting the attempted assessment by LPN #1 at 6:15 p.m. III. Staff interviewsCNA #1 was interviewed on 7/22/26 at 1:17 p.m. CNA #1 said she completed education at the facility regarding cleaning and emptying indwelling catheters at least once a year if not more often. CNA #1 said she knew to tell the nurse about any abnormal urine output when emptying a catheter including changes in color, odor and amount. CNA #1 said she typically did not report urine output to the floor nurse unless the output was abnormally low, but she was not sure what amount of urine was considered abnormally low. CNA #2 was interviewed on 7/22/26 at 1:27 p.m. CNA #2 said it was usually the CNA's responsibility to empty indwelling catheters each shift, but sometimes the floor nurse would empty the catheter bag if the CNA was busy. CNA #2 said she usually emptied the urine collection bag multiple times a shift, approximately every six hours. CNA #2 said she did not report all urine outputs to the floor nurse, but she would report any time the urine collection bag appeared empty or with abnormally low urine output; as well as any time the urine appeared cloudy, pink, red or had a foul odor. CNA #2 said she reported low urine output to the floor nurse when the collection bag had less than 100ml when she emptied it but usually did not consider what the total output was for the shift if she emptied the urine collection bag multiple times in a shift.The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 7/22/26 at 3:17 p.m. The DON said she remembered receiving a call from LPN #1 on 7/10/26 in the evening. The DON said LPN #1 told her Resident #1's representative wanted to transfer Resident #1 to the hospital emergently. The DON said LPN #1 told her the vital signs she obtained, and since the Resident #1's pulse was below 100 beats per minute and blood pressure was within normal limits, they did not indicate emergent transport to the hospital. The DON said she provided education to staff to attempt to handle things in house, but they also have to honor any resident's decision if they request to go to the hospital. The ADON said the facility had the ability to send labs, urinalysis, start IV therapies and obtain antibiotics 24 hours a day and the facility was equipped to manage a UTI. The ADON said Resident #1 had a history of chronic back pain and was also on precautions for C. diff, which could cause nausea for up to one month after the acute illness, so reporting back pain nausea alone would not be enough of an indication to complete a change in condition assessment. The DON said based on the documentation of low urine output below 30 ml/hour and cloudy urine, she would want the nurse to complete a head to toe assessment in order to determine if Resident #1 had a true change in condition, and she could not determine why an assessment was not completed without speaking to the staff directly.The DON said CNAs should report changes in color, odor, or urine output to the nurse because there are many reasons that could cause low output and would require a nurse to assess what problem was occurring. The DON said she could not find an assessment for a change in condition prior to the progress note describing the events on 7/10/26.LPN #1 was interviewed on 7/22/26 at 4:47 p.m. LPN #1 said she remembered caring for Resident #1 on 7/9/26 and 7/10/26. LPN #1 said she remembered Resident #1 reported nausea during the middle of the night, but she thought since the resident recently had C. diff in June 2026 and already had an order for nausea medication, it was not a new symptom for Resident #1. LPN #1 said she remembered a young woman, who she was not sure of her relationship to Resident #1, but thought she might be the resident's niece, visited on 7/9/26. LPN #1 said at the time the visitor told LPN #1 Resident #1 wanted to leave, but LPN #1 said she did not remember the visitor reporting Resident #1 having any symptoms that night. LPN #1 said during change of shift report on 7/10/26, LPN #2 reported Resident #1 had vague symptoms of not feeling well during the day, that Resident #1 was tired and did not eat much. LPN #1 said based on the report, she planned to complete a head to toe assessment on Resident #1 as soon as she was finished getting the medication cart from LPN #2. LPN #1 said she did remember whether or not she asked LPN #2 if she completed an assessment to determine if Resident #1 had a changeLPN #1 said before she could complete an assessment, the same visitor from 7/9/26 came to the nurses station. LPN #1 said the visitor was raising her voice, stating Resident #1 appeared ill and demanded Resident #1 go to the hospital. LPN #1 said Resident #1's representative entered the room when LPN #1 was taking Resident #1's vital signs. LPN #1 said she was able to obtain vital signs but when she tried to ask additional assessment questions, the visitor and Resident #1's representative were talking over Resident #1. LPN #1 said based on Resident #1's vital signs, she tried to explain the resident's symptoms could be treated at the facility and did not require emergent transport to the local area hospital, but Resident #1's representative would not listen to her. LPN #1 said she attempted to call Resident #1's physician, but the visitor and Resident #1's representative followed her to the nurses station, continuing to raise their voice and demand Resident #1 be transferred to the hospital, so she could not reach the provider. She said when she tried to complete her assessment again and ask Resident #1 if he wanted to go the hospital, she felt Resident #1 was frustrated and stopped answering questions. LPN #1 said at this time Resident #1's representative called 911. LPN #1 said Resident #1 would not answer questions for EMS, so they honored Resident #1's representative's request to transport to the hospital. LPN #1 said CNAs would typically report changes in urine color or output to her, but she did not remember any CNA telling her about changes to Resident #1's urine output or color on 7/9/26 or 7/10/26. The ADON, the DON, and the NHA were interviewed together on 7/22/26 at 6:07 p.m. The DON said there was not documentation to show what time LPN #2 noticed changes in Resident #1's intake and urine output, and could not determine what time the changes occurred without speaking to LPN #2 directly, but the DON said it was possible LPN #2 was only made aware of the changes occurring in Resident #2 on 7/10/26 toward the end of her shift and communicated to LPN #1 to complete an assessment. The ADON said she was able to review Resident #1's hospital notes after the interview earlier in the day, and read that Resident #1 met criteria for systemic inflammatory response syndrome (SIRS) while at the hospital, but the ADON said the resident responded well to fluids in the hospital and recovered quickly. The ADON and the DON said they believed if Resident #1's representative and visitor allowed LPN #1 to finish her assessment and contact the provider per the facility policy and procedure, they could have managed Resident #1's UTI without transferring him to the hospital. The NHA said they provided education to staff working today and planned to provide additional education to staff regarding reporting changes in urine output and color as well as completion of change in condition assessment. The NHA said they already provided this education to staff earlier in the year as well as remote video education, but they planned to complete a case study to review the events leading to Resident #1's transfer to the hospital.

Based on observations, record review and interviews, the facility failed to ensure two (#5 and #7) of four residents reviewed for accident hazards received adequate supervision out of 11 sample residents.Specifically, the facility failed to put effective person centered interventions in place to prevent repeated falls for Residents #5 and Resident #7.Findings include: I. Professional reference The National Council of Certified Dementia Practitioners (2026). Fall Prevention for Individuals with Dementia: Tips for Caregivers, retrieved 1/5/26 from http://www.nccdp.org/fall-prevention-for-dementia-patients-tips-for-caregivers/ read in pertinent part, Falls are a serious concern for individuals living with dementia and the consequences can be devastating. As cognitive decline progresses, physical abilities often become impaired, leading to an increased risk of falls. For caregivers, managing risks can prevent injuries and preserve the dignity and independence of loved ones. Dementia and falls are closely linked due to the cognitive and physical changes that occur as the disease progresses. As dementia affects memory and judgement, it also impacts coordination, balance, and motor control. In addition, emotional factors such as anxiety can contribute to fall risks. When individuals with dementia are anxious, they may move erratically or resist help, increasing their chances of losing their balance. Medications prescribed for managing dementia or coexisting conditions such as heart disease can sometimes cause side effects like dizziness or drowsiness, which increase fall risk. Preventing falls with individuals with dementia goes beyond minimizing risks and includes improving the overall well-being and quality of life for both patients and caregivers. By understanding the causes of falls, creating a safe environment, and providing proper supervision, caregivers can significantly reduce fall risks.II. Facility policy and procedure The Activities of Daily Living (ADL) policy and procedure, revised April 2025, was received from the nursing home administrator (NHA) on 12/20/25 at 11:40 a.m. It revealed in pertinent part, Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Appropriae care and services are provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with hygiene, mobility, elimination, dining, and communication. The resident's responses to interventions are monitored, evaluated, and revised as appropriate. III. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included stroke, dementia, anxiety, depression, malnutrition, unsteadiness on feet, need for assistance with personal care, bilateral hearing loss, communication deficit, hypertension and knee arthritis. The 10/2/25 minimum data sets (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required maximum assistance from staff, where staff provided more than half of the effort, for toileting, upper and lower body dressing, putting on and removing footwear, oral hygiene, toileting hygiene, sitting and lying in bed, standing and transfers. The resident required moderate assistance, where staff provided less than half of the effort, for bed mobility. The assessment documented the resident was frequently incontinent of bladder and bowel and had no toileting programs during the look-back period. Resident #5 was prescribed anti-anxiety and anti-depressant medication and blood thinning medication. Resident #5 used a manual wheelchair independently, after staff assisted with transfers and wore a wander/elopement risk alarm. The assessment revealed Resident #5 required eyeglasses for adequate vision. B. Resident observation On 12/30/25 at 10:30 a.m. Resident #5 was sleeping on her bed. On Resident #5's bedside table there was an empty cup, a bottle of room temperature iced tea that was almost empty and her eyeglasses. The bedside table was near the head of Resident #5's bed. Resident #5 had a manual wheelchair positioned next to the foot of her bed. There was a white piece of paper on the wall across from the foot of Resident #5's bed that read call don't fall. The font lettering was light yellow and offered minimal contrast with the background. Resident #5's hearing aids sat on a charger across from the foot of Resident #5's bed, out of her reach. Resident #5's wheelchair had no visible name or room identifiers. C. Record review 1. Care plan and assessments Resident #5's fall prevention care plan, initiated 6/25/25, identified Resident #5 was at risk for falls related to altered balance while standing and/or walking, altered mental status, antipsychotic medications and antidepressant medication. Interventions included anticipating and meeting needs (6/25/25), educating and reminding Resident #5 to call for assistance with all transfers 6/25/25, evaluating medications for side effects that may increase fall risk (6/25/25), keeping call light in reach (6/25/25), keeping personal items frequently used within reach 6/25/25), reviewing medication regime as indicated 6/25/25), monitoring for changes in condition affecting risk for falls and notifying physician if observed (6/25/25), checking with resident prior to the end of the shift to see if Resident #5 would like to sit in her chair or not (8/11/25), providing proper-well maintained footwear (non/skid) 7/30/25, hanging sign on wall reminding to use call light for assistance with transfers (7/31/25), relocating to a room closer to the nurses station (8/15/25), ensuring wheelchair brakes are locked when Resident #5 was not in her chair (8/23/25), keeping within supervised view as much as possible (8/23/25), placing non-skid strips on the floor near Resident #5's bed for safe transfers (8/11/25) and moving the bed against the wall to promote independence with safety interventions (9/3/25). The cognitive impairment care plan, initiated 6/26/25, identified Resident #5 had cognitive impairment related to Alzheimer's disease or other dementia. Interventions included anticipating and meeting needs promptly (6/26/25), discussing concerns regarding overall status/health with resident/family as needed (6/26/25), encouraging routine daily decision making (6/26/25), referring to occupational and physical therapy (6/26/25), providing cognitive therapy and reality orientation when appropriate and as needed (6/26/25), providing memory cues as appropriate (6/26/25), and providing resident education including safety measures and/or memory enhancement techniques as needed (6/26/25) and providing noise distraction as indicated to provide a calm environment (6/26/25). The 9/10/25 fall risk assessment completed by a staff LPN revealed Resident #5 had a fall risk score of 30 out of 42, which indicated the resident had a high risk for falling. Resident #5's initial care plan for fall prevention directed staff to identify resident needs. -However, there was no information in the EMR that documented Resident #8 individual needs. -However, there was no documentation Resident #5 understood the education and had the cognitive ability to locate and activate the call light system and when to call for staff assistance. The fall prevention care plan interventions included direction to staff to evaluate Resident #5's medications for side effects that might contribute to an increased fall and a medication review. Pharmacy review documentation was requested from the DON on 12/29/25 and received on 12/30/25 from the DON. The pharmacy review indicated a pharmacy review on 7/25/25 for hypertension management, 9/22/25 for lipid management, and 12/15/25 for routine laboratory monitoring of thyroid medication therapy. The record review revealed no pharmacy reviews specific for the IDT review of medications for fall prevention.2. Progress notes The 7/31/25 interdisciplinary team (IDT) progress note revealed Resident #5 fell on 7/30/25 at 6:05 p.m. The IDT progress note revealed Resident #5 lost her balance and fell while self transferring. The IDT initiated new interventions that included ensuring Resident #5 wore nonskid footwear and hanging a sign in the room to remind Resident #5 to use the call light before transferring. The IDT review included the NHA, director of nursing (DON), nurse manager, and the MDS coordinator. -However, according the the MDS assessment Resident #5 required glasses for adequate vision. The sign observed in Resident #5's room had a sign with yellow font on white paper, making it difficult to read. Observation further revealed Resident #5's glasses were out of her reach on her bedside table. The 8/11/25 IDT progress note revealed Resident #5 fell on 8/11/25 at 6:17 a.m. The IDT progress note revealed Resident #5 fell while self-transferring. The IDT initiated new interventions that included to check on Resident #5 at 5:00 a.m. and 5:00 p.m. and asking Resident #5 wanted to be in her wheelchair or in bed. The IDT review included the NHA, DON and nurse manager. -However, the record review did not reveal discussion with Resident #5 or the responsible party for preferences for waking during the night to ensure the interventions were person centered to the residents desired wake times. The 8/25/25 IDT progress note revealed Resident #5 fell on 8/23/25 at 12:10 p.m. The IDT progress note revealed Resident #5 fell while self-transferring. The IDT initiated new interventions that included to ensure the resident's wheelchair brakes were locked if Resident #5 was not in her wheelchair and to keep Resident #5 in the line of staff as much as possible. The IDT review included the NHA and nurse manager. The 8/28/25 IDT progress note revealed Resident #5 fell six days prior, on 8/22/25 at 8:20 p.m. The IDT progress note revealed Resident #5 fell while self transferring from a garden room/common area chair to her wheelchair. The IDT initiated a new intervention to keep Resident #5 in the line of sight of the staff as much as possible. The IDT review included the NHA and the DON. The 9/3/25 IDT progress note revealed Resident #5 fell on 9/2/25 at 6:20 p.m. The progress note revealed Resident #5 attempted to self transfer back to bed and fell. The IDT initiated a new intervention to move Resident #5's bed against the wall to promote independence with safety interventions. The IDT review included the DON and two nurse managers. The 9/10/25 IDT progress note revealed Resident #5 fell on 9/10/25 at 8:45 p.m. The progress note revealed a staff member found Resident #5 on the floor with the wheelchair seat cushion next to her. The IDT implemented a new intervention for educating Resident #5 and ensuring Resident #5 did not use her pillow as a cushion in her wheelchair. The resident was provided a pressure relieving wheelchair cushion. The IDT review included the NHA, the DON, the director of rehabilitation services (DOR), and two nurse managers. The 10/16/25 IDT progress note revealed Resident #5 fell on [DATE] at 3:00 p.m. The progress note revealed Resident #5 was found on the floor with her wheelchair next to her and was wearing socks without anti slip protection. The progress note revealed Resident #5 told staff she tried to move from the bed to her wheelchair and ended up on the floor. The IDT implemented a new intervention to add an anti-roll back brakes to Resident #5's wheelchair. The IDT review included the NHA, the DON, the DOR and one nurse manager. -The facility failed to ensure the resident was wearing non-slip shoes and was dependent on staff for putting on footwear. The record review revealed the responsible party for Resident #5 provided the footwear without non-slip protection. The record review revealed the responsible party had not been included in the development of fall prevention interventions. Additionally, the record review revealed the responsible party received education about using nonslip footwear after the fall that included socks without protection. The 10/27/25 IDT progress note revealed Resident #5 fell on [DATE] at 1:30 a.m. The progress note revealed Resident #5 self transferred to the toilet and fell. The IDT implemented a new intervention for checking Resident #5 between 1:00 and 2:00 a.m. if she was awake and to highly encourage Resident #5 to use the toilet. The IDT review included the NHA, the DON and one nurse manager. The 11/18/25 6:01 p.m. IDT progress note revealed Resident #5 fell on [DATE] at 10:55 p.m. The progress note revealed Resident #5 told the staff she just slipped. The progress note read that Resident #5's wheelchair had been changed out with another resident's wheelchair the night before during wheelchair cleanings. The IDT implemented a new intervention for ensuring Resident #5's wheelchair had an identification tag attached to prevent future occurrences. The IDT review included the DON and two nurse managers. -However, observations revealed the identification tag was not on the resident's wheelchair (see observations above). The staff member interviewed said she was unsure where the tag would be found on the wheelchair and was unable to locate the tag. The tag was attached to Resident #'5 wheelchair on 12/30/25, during the survey. The 11/24/25 IDT progress note revealed Resident #5 fell on [DATE] at 1:58 a.m. The progress note revealed Resident #5 was found on the floor next to her bed. The progress note revealed Resident #5 told staff she slid from her bed and her walker (wheelchair) was missing. The IDT progress note read the wheelchair had been removed from the room for cleaning. The IDT implemented a new intervention for ensuring Resident #5 was assisted to the toilet prior to taking her wheelchair out of the room for cleaning. The IDT review included the NHA, the DON and two nurse managers. The 12/2/25 IDT progress note revealed Resident #5 fell on [DATE] at 1:30 p.m. The progress note revealed Resident #5 was found on the floor between her bed and her wheelchair. The IDT progress note revealed Resident #5 was wearing cute slippers that provided no anti slip protection. The IDT implemented a new intervention for the family to remove the slippers and replace them with non-slip slippers. The IDT review included the NHA, the DON, the NM and the DOR. The 12/4/25 IDT progress note revealed Resident #5 fell on [DATE] at 10:40 a.m. The progress note revealed Resident #5 told the staff she just wanted to sit in her chair and slipped. The IDT progress note read that Resident #5 continued to try and self transfer despite the best efforts of the facility. The facility anticipated Resident #5 would continue to try and self transfer. Current interventions would continue. No new interventions were recommended. The IDT recommended an evaluation for consideration of a transfer pole to for Resident #5 to use for safe transfers. The IDT review included the NHA, the DON, two NMs, the DOR and the MDS coordinator. -Record review revealed no additional IDT review for the transfer pole recommendation. 3. Provider progress notes The 9/29/25 nurse practitioner's progress note revealed Resident #5 reported she had one fall without injury in the past year. The physician's progress note revealed Resident #5's fall risk was low. -However, Resident #5 had sustained six falls between 7/30/25 and 9/29/25. The 12/3/25 physician's progress note revealed Resident #5 had trouble remembering to call for help and had no recent falls prior to 12/3/25. The physician progress note revealed Resident #7 had anxiety, balance disorder, dementia, fall with hip pain, and frailty syndrome in a geriatric patient. -However, a review of Resident #5's care plan revealed no resident centered interventions for Resident #5 balance disorder. -Review of the resident's EMR did not reveal documentation that the IDT had communicated with the physician and nurse practitioner, or the pharmacist regarding Resident #5's fall history and interventions. IV. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia, bladder cancer, stage four kidney disease, diabetes mellitus hypertension, unsteady on feet, muscle weakness, need for assistance with personal care, macular degeneration, mood disturbance, anxiety and lack of coordination. The 12/8/25 MDS revealed Resident #7 had severe cognitive impairment with a BIMS score of six out of 15. The resident required substantial assistance from staff for toilet hygiene, showering and upper body dressing. The resident was dependent on staff for lower body dressing, putting on and taking off footwear, rolling left to right in bed, sitting and lying in bed. The resident required transfers with a Hoyer lift (mechanical lift used for transfers). The MDS assessment revealed Resident #7 was always incontinent of bowel and bladder and had no toileting programs during the look back period. B. Resident observation On 12/30/25 at 10:15 a.m. Resident #7 was sitting in his wheelchair in the activities room. The wheelchair did not have an anti-rollback locking mechanism. On 12/30/25 at 2:59 p.m. Resident #7's wheelchair was returned to his room and had anti-roll installed. C. Record review 1. Care plan Resident #7's fall prevention care plan, initiated 5/15/25, identified Resident #7 had a high risk for falling due to his fall history, his unsteady gait, and confusion. Interventions included encouraging Resident #7 to participate in activities that promote exercise for strengthening and improvised mobility (5/15/25), keeping call night within reach (5/15/25), reviewing medication regime as indicated (5/15/25), evaluating medications for side effects that may increase the fall risk (5/15/25), installing anti-roll back brakes on his wheelchair (6/19/25), installing gripper strips next to the bed (6/23/25), checking on Resident #7 every two hours to ensure safety (6/23/25), encouraging Resident #7 to use gripper socks with traction (6/23/25), ensuring a urinal is at the bedside within Resident #7's reach and reminding Resident #7 to use the urinal (7/11/25) assisting to bed after dinner to prevent Resident #7 from self-transferring to bed (7/26/25), placing nonslip tape in wheelchair to prevent slipping (7/28/25), educating and reminding Resident #7 to call for assistance with all transfers (8/13/25), obtaining physical and occupational therapy consultations as indicated (8/13/25) ensuring resident comfort in his recliner, putting the recliner remote away, ensuring Resident #7 has his call light in reach, and checking on Resident #7 frequently when in the recliner (11/24/25), reeducating staff to offer Resident #7 to take a nap after meals (11/18/25), offering Resident #7 to lie down after meals as he gets tired and attempts to self transfer to take a nap (11/18/24) and reeducating staff to offer Resident #7 to lay down, use the restroom when he in his wheelchair to prevent Resident #7 from self-transferring after meals (11/21/25). 2. Progress notes The 5/15/25 IDT progress note revealed Resident #7 fell on 5/14/25 at 2:20 p.m. The progress note documented Resident #7 attempted to self-transfer himself to bed after lunch. The IDT recommended a new intervention to offer Resident #7 the opportunity to lay down after meals. The 6/20/25 IDT progress note revealed Resident #7 fell on 6/18/25 at 5:12 p.m. The progress note revealed Resident #7 was observed out of his wheelchair and on his knees after attempting to self transfer to his bed. The IDT recommended anti-roll back brakes be installed on Resident #7's wheelchair. The IDT review included the NHA, DON, and DOR. -However, observations revealed the anti-rollback brakes were not on the resident's wheelchair (see observations above). The 6/23/25 10:39 a.m. progress note revealed Resident #7 fell on 6/23/25 at 3:00 a.m. The progress note revealed Resident #7 told the staff he forgot he could not walk and thought he was going to the store. The IDT recommended a new intervention to apply non-slip strips to the floor next to Resident #7's bed and have staff encourage wearing non-slip socks while in bed. The IDT review included the NHA, DON, one nurse manager, and the DOR. The 7/14/25 12:40 p.m. IDT progress note revealed Resident #7 fell on 7/10/25 at 2:45 p.m. The progress note revealed Resident #7 was found on the floor in his restroom and holding the toilet. The IDT implemented a new intervention to ensure Resident #7 had a urinal at his bedside and to remind Resident #7 to use his urinal. The IDT review included the DON, one nurse manager and the DOR. The 7/28/25 9:51 a.m. IDT progress note revealed Resident #7 fell on 7/25/25 at 5:30 p.m. The progress note did not include information about the fall. The IDT implemented a new intervention to have the therapist install a non slip pad to Resident #7's wheelchair. The IDT review included the NHA and one nurse manager. The 8/13/25 9:58 a.m. IDT progress note revealed Resident #7 fell on 8/12/25 at 5:55 p.m. The progress note revealed Resident #7 was self-transferring into his bed. The IDT implemented a new intervention to have physical therapy and occupational therapy complete evaluations and assessments for possible treatment. The IDT review included the NHA, the DON, the DOR, the MDS coordinator, the social services director and the dietitian. The 11/21/25 IDT progress note revealed Resident #7 fell on [DATE] at 4:00 p.m. The progress note revealed Resident #7 was found on the floor at the end of his bed. The progress note revealed Resident #7 was in his wheelchair prior to the fall and it appeared Resident #7 attempted to walk to the bathroom and fell. The IDT implemented a new intervention to offer Resident #7 toileting after meals and re-educating staff to offer Resident #7 the opportunity to take a nap after his meals. The IDT review included the NHA, DON and one nurse manager. The 11/24/25 IDT progress note revealed Resident #7 fell on 11/20.25 at 8:15 p.m. The progress note read Resident #7 was found on the floor with his head beneath his bed. The IDT implemented a new intervention for reeducating staff to offer Resident #7 the opportunity to lie down after meals. The IDT review included the NHA, DON and two nurse managers. The 11/24/25 IDT progress note revealed Resident #7 fell on [DATE] 1:10 p.m. The progress note revealed Resident #7 was found on the floor in front of his recliner and it appeared Resident #7 used the remote to raise the recliner to a full upward position and fell out of the chair. The IDT implemented new interventions which included ensuring Resident #7 was comfortable in his chair, putting the remote away, ensuring Resident #7 had his call light, and frequently checking on Resident #7 when he was in his recliner. The IDT review included the NHA, the DON and two nurse managers. The progress note revealed physician's orders were obtained for laboratory testing and changes were made to the resident's blood pressure medication. V. Staff interviews Registered nurse (RN) #1 was interviewed on 12/30/25 at 10:30 a.m. in Resident #5's room. RN #1 said she was aware Resident #5 was a high fall risk. RN #1 said she was unsure of what Resident #5's needs were and pointed to the bedside table, the water container and the residents eye glasses. RN #1 said Resident #5 had an empty water container and a small amount of room temperature iced tea. RN #1 said she was unsure if Resident #5 was able to sit up in her bed independently to reach or drink her beverages. RN #1 said Resident #5's hearing aides were not within her reach, and were charging on the ledge against the wall. RN #1 said she was unsure why Resident #5 was not wearing her hearing aids. RN #1 said Resident #1 did not use her call light. RN #1 said Resident #5's roommate kept an eye on Resident #5 and called staff to assist Resident #5 when necessary. RN #1 said the staff left Resident #5's door open and curtain pulled back so they could observe Resident #5 when they walked past her room. RN #1 said she was unsure of an effective fall prevention intervention, except to watch Resident #5 closely. RN #1 said she completed a search of Resident #5's wheelchair and was unable to locate an identification tag. The DON was interviewed on 12/30/25 at 10:40 a.m. The DON said the facility implemented a performance improvement plan (PIP) in August 2025 because she noticed the facility had a high number of resident falls with and without injuries. The DON said one of the action items on the PIP was the establishment of IDT ambassadors that were responsible for auditing residents for fall prevention interventions. The DON said the PIP included a check list for each high risk resident and the applicable interventions. The DON said the ambassador was responsible to use the checklist and ensure the interventions were in place and effective. The DON said Resident #5 had an intervention that included a sign to remind Resident #5 to use the call light for assistance. The DON said she was unsure if Resident #5 was able to push the call light button. She said she would have the push button call light replaced with a touch-pad to activate the call light system. The DON said said Resident #5's interventions included an intervention to ensure staff anticipated and met the resident's needs. The DON said although Resident #5's care plan did not identify resident-specific needs and preferences, the staff communicated tasks and were updated using an application on their personal cell phones. The DON said if staff did not use a cell phone, all staff were required to read the Kardex (staff directive tool) for each resident and they would find resident-specific interventions. Licensed practical nurse (LPN) #1 was interviewed on 12/30/25 at 2:59 p.m in Resident #7's room. LPN #1 said she was familiar with Resident #7. LPN #1 said Resident #7 was dependent on staff for transfers and required the use of a Hoyer lift. LPN #1 said Resident #7 had a history of falls when he tried to get out of bed without assistance. LPN #1 said she was unaware Resident #7 should have an anti-roll back brake on his wheelchair. LPN #1 said she received information about each residents' risk of falling during the shift report and physician's orders. Certified nurse aide (CNA) #1 was interviewed on 12/30/25 at 2:59 p.m. CNA #1 said she did not know Resident #7 required an anti-roll back brake on his wheelchair. CNA #1 said Resident #7 was dependent on staff for transfers to his wheelchair and for wheelchair mobility in the facility. CNA #1 said the CNA tasks for each resident prompted the CNA for review and completion. The NHA and the DON were interviewed together on 12/30/25 at 5:30 p.m. The NHA said the facility had a PIP in place that had been effective in reducing falls at the facility. The NHA said the facility's IDT reviewed every fall and discussed resident status and made recommendations for fall prevention interventions. The NHA said the facility had identified causes for Resident #5's falls and had done everything possible to prevent Resident #5 from falling, although Resident #5 had the right to fall. The DON said she had been very happy with the results of the PIP because the number of falls had reduced at the facility. The DON said because specific fall prevention interventions were not observed during the survey, it was not significant because the absence of the intervention had not caused additional falls. -However, Resident #7 had eight additional falls since the facility recommended implementing anti-rollback brakes. VI. Facility response The Performance Improvement Plan (PIP), dated 8/21/25, was received from the DON on 12/30/25 at 1:10 p.m. The PIP read the facility identified a deficiency with increasing falls with injury or major injury. The PIP included elements for implementing corrective actions for affected residents, identifying and protecting other potentially affected residents, measuring and systemic changes to prevent recurrences, and monitoring to ensure sustained compliance. The PIP included documentation of random audits by a staff member for call lights, personal items in reach, water is within reach and full, residents ability to use the call light, furniture preferences are identified, footwear is identified, and to ensure fall preventions were in place The 9/29/25, 11/20/25, 12/3/25 and 12/17/25 audits for Resident #5 documented Resident #5 kept closing her curtain, but agreed to leave her curtain open when reminded by staff. The audit documented Resident #5 was able to use her call light and her personal items were in reach. The audit included a review of individual fall prevention interventions but were unchecked for status. -The audit did not include an assessment of Resident #5 ability to read reminder signs, reach and move her bedside table, or her ability to press and activate the call light. Additionally, the audit did not include resident specific needs. There was no status documented for the recommended therapy evaluation of a transfer pole and the residents ability to position herself independently in bed when bilateral bedrails were present. The PIP included the 9/8/25 call light response audit for Resident #5 which documented Resident #5 had a call light in reach. The audit revealed there was no signage for reminding Resident #5 to use the call light for staff assistance and a request was initiated to install non-skid tape to Resident #5's floor next to her bed. The PIP revealed the facility had a downward trend in falls from 398 falls in April 2025, 404 falls in May 2025, 439 falls in June 2025, 412 falls in July 2025, 405 falls in August 2025, 402 falls in September 2025 and 197 falls in October 2025. -However, observations revealed the facility failed to consistently implement person-centered effective fall interventions for Resident #5 and Resident #7.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to implement an effective water management plan. Findings include: I. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, last reviewed 1/3/25, was retrieved on 1/21/25 from https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.html It read in pertinent part, Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140 F (degrees Fahrenheit) or 60 C (degrees Celsius). Ensure hot water in circulation does not fall below 120 F (49 C). Recirculate hot water continuously, if possible. Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 F, 25-45 C). Legionella may grow at temperatures as low as 68 F (20 C). Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Ensure disinfectant residual is detectable throughout the potable water system. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. Consider testing for Legionella in accordance with the routine testing module of this toolkit. B. Facility policy and procedure The Legionella Water Management Program policy and procedure, dated July 2024, was provided by the nursing home administrator (NHA) on 1/13/25 at 2:17 p.m. The program did not include documentation of when dead legs and low-flow piping runs were appropriately flushed to prevent the growth and spread of legionella. -However, the CDC recommended that all dead legs and low flow piping runs should be flushed at least weekly to prevent the growth and spread of legionella (see professional reference above). III. Record review The water management maintenance logs were provided by the NHA on 1/13/25 at 2:17 p.m. The maintenance logs documented the facility had obtained water temperature readings in the building on a weekly basis. -There was no documentation available to verify that dead legs and low flow piping runs had been flushed in the last calendar year. On 1/14/25 at 12:52 p.m., the NHA documented that two resident rooms had been unoccupied for seven contiguous days or more in the last 60 days. -The water management plan failed to document when empty resident rooms had low flow piping runs and lead legs flushed. IV. Staff interviews The maintenance director (MTD) was interviewed on 1/15/25 at 10:23 a.m. The MTD said he had recently assumed the MTD role in the past few months. The MTD said the facility tested for legionella annually, which was negative in August 2024. The MTD said he did not know where all the water piping and dead legs in the building were. The MTD said he did not know how often dead legs and low flow piping runs such as sink and toilet p-traps (back drainage) should be flushed to prevent the growth and spread of waterborne bacteria such as legionella. The MTD said the facility did not have documentation to show when resident rooms or infrequently used water fixtures were flushed. The NHA was interviewed on 1/15/25 at 10:44 a.m. The NHA said he was not sure how often dead legs and low flow piping runs should be flushed to prevent the growth of legionella. The NHA said the facility did not have documentation to verify that flushing of dead legs and low-flow piping runs had occurred in the last calendar year.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen and dining room. Specifically, the facility failed to: -Ensure hand hygiene was conducted appropriately after touching potential contaminated surfaces; and, -Ensure hand hygiene was conducted before and after glove use. Findings include: I. Professional reference The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings (2/27/24), was retrieved on 1/23/25 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, read in pertinent part, Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients. According to the CDC, hand washing should occur before preparing or eating food, before touching the eyes, nose or mouth, and after touching potential contaminated surfaces. II. Facility policy and procedure The Food Preparation and Service policy, undated, was provided on nursing home administrator (NHA) on 1/16/25 at 3:22 p.m. The policy read in pertinent part, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Cross contamination can occur when harmful substances, (for example) chemical or disease-causing microorganisms are transferred to food by hands including gloved hands, food contact services, sponges, cloth towels, or utensils that are not adequately cleaned. The Preventing Foodborne Illness policy, revised November 2022, was provided on nursing home administrator (NHA) on 1/16/25 at 3:22 p.m. The policy read in pertinent part, Food and nutrition services employees follow appropriate hygiene and sanitary practices to prevent the spread of foodborne illnesses. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illnesses. Employees will demonstrate knowledge and competency in these practices prior to working with food or servicing food to residents. According to the policy, employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks and/or after engaging in activities that contaminate the hands. The policy identified that gloves are considered single-use items. The gloves must be discarded after completing the task. According to the policy, hands were to be washed after the gloves were removed and before the new gloves were replaced. B. Observations During a continuous observation of the lunch meal service in the dining room on 1/13/25, beginning at 11:45 a.m and ending at 12:52 p.m., the following was observed: At 12:03 p.m. dietary aide (DA) #4 began delivering meal trays to residents in the dining room. DA #4 did not perform hand hygiene before serving three meal trays to residents. At 12:06 p.m. DA #4 touched the outer surface of his face mask with his hand. He did not perform hand hygiene after touching his mask. He proceeded to serve two more meal trays to residents before performing hand hygiene. At 12:15 p.m DA #4 touched the outer surface of his face mask with his hand, delivered a meal tray to a resident in the dining room and placed five meal trays in a mobile food cart before he performed hand hygiene at 12:17 p.m. During a continuous observation of the lunch meal service in the kitchen on 1/15/25, beginning at 11:40 a.m and ending at 12:55 p.m., the following was observed: At 12:01 p.m. DA #1 touched the outer surface of her mask and proceeded to sort meal tickets. She did not change her gloves and wash her hands after she touched her mask. Between 12:07 p.m. and 12:15 p.m DA #1 placed the meal tickets, desert bowls and napkin rolled utensils on each resident meal tray without changing her gloves and performing hand hygiene after touching her mask. At 12:11 p.m. cook (CK) #1 removed her gloves and placed new gloves on her hands without performing hand hygiene. CK #1 separated a pot pie from the disposable cardboard shell with a cooking utensil but touched the rim of the pie crust with her gloved hand. At 12:16 p.m. DA #2 placed gloves on his hands without washing his hands. DA #2 proceeded to place meal tickets, napkins, utensil and dessert bowls on each of the resident meal trays. At 12:43 p.m. DA #2 touched the outer surface of his face mask with the back of his gloved hand, touched four resident meal bowls before removing his gloves and performing hand hygiene. C. Record review The online hand hygiene education certificates for the dietary staff were provided by the NHA on 1/16/25 at 3:22 p.m. The certificates identified DA #1, DA #2, DA #3, DA #4 and DA #5 last completed basic hand hygiene training and handling food safely training in November 2023. The DM completed basic hand hygiene training in November 2023 but evidence of handling food safety training was not provided by the facility. Review of the provided educations did not identify CK #1 received the online basic hand hygiene training or handling food safety training. D. Staff interviews DA #2 was interviewed on 1/16/25 at 2:05 p.m. He said hand hygiene should be completed anytime the hands touch something dirty and between glove changes. CK #1 was interviewed on 1/16/25 at 2:07 p.m. She said hand hygiene should be completed when gloves were changed and after touching any potential surfaces. DA #5 was interviewed on 1/16/25 at 2:07 p.m. He said hand hygiene was completed in between tasks, every time a task was changed and when serving trays. DA #3 was interviewed on 1/16/25 at 2:09 p.m. He said staff should wash their hands after using the restroom, every time they enter the kitchen and before touching resident dishes. He said he was trained to perform hand hygiene with alcohol base hand rub (ABHR) after every third delivery of a meal tray. The DM was interviewed on 1/16/25 at 2:11 p.m. She said her staff has had hand hygiene training but it had not been recent. She said the dietary staff also attended an all staff infection control training that demonstrated proper hand hygiene but the training was not food handling specific. The DM said staff should wash their hands anytime they touch something potentially contaminated and between glove changes. The DM said she trained her to use ABHR after every third tray delivered to the residents. Registered nurse (RN) #2 was interviewed on 1/16/25 at 2:54 p.m. RN #2 identified herself and the facility ' s infection control nurse. She said hand hygiene should be performed before placing gloves on and after removing the gloves, anytime the hands touch potentially contaminated surfaces, or touch a resident. She said staff delivering meal trays should use ABHR between each meal delivery to avoid potential cross-contamination. RN #2 said staff should wash their hands after three uses of ABHR. RN #2 said she had not completed hand hygiene training with the dietary staff. RN #2 was interviewed again on 1/16/25 at 3:45 p.m. RN #2 said she audited the hand hygiene practices in the kitchen with the dietary staff on 1/16/25. She said she identified concerns with hand hygiene and re-educated the dietary on proper hand hygiene procedures. D. Facility follow-up The Clinical Competency Validation for Hand Hygiene audit checklist was provided by the clincal consulant (CC) on 1/16/25 at 4:58 p.m. The review of the competency audit identified hand hygiene practices of five (DM and DA #2, #3, #5 and #6) dietary staff were observed by RN #2 on 1/16/25. According to the audit, there were hand hygiene concerns identified during the observation. RN #2 addressed the identified concerns and provided hand hygiene education to the present dietary staff.

Based on record review and interviews, the facility failed to offer choices to residents for three (#8, #11, and #23) of five residents reviewed for activities of daily living (ADL) out of 32 sample residents. Specifically, the facility failed to ensure Resident #8, Resident #1 and Resident #23 received showers consistently according to their choice of frequency. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, page 1794, retrieved on 1/21/25, Frequent bathing and skin care help promote overall health and wellness. Older adults may find it necessary to bathe only every two or three days, use less soap, and increase the use of skin moisturizers. II. Resident #8 A. Resident status Resident #8, over the age of 65, was admitted on [DATE] and readmitted [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, congestive heart failure (CHF), and rheumatoid arthritis. According to the 11/6/24 minimum data set (MDS) assessment Resident #8 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 9 out of 15. The assessment documented the resident required substantial or maximum assistance with bathing cares. B. Resident interview Resident #8 was interviewed on 1/13/25 at 2:18 p.m. Resident #8 said he wanted two baths every week but usually received one bath per week. Resident #8 said he felt ignored when staff did not assist him to bathe twice weekly. Resident #8 said he was often asked to have a bath in the afternoon which he did not prefer. C. Record review Bathing preference documentation, dated 8/23/23, documented that Resident #8 preferred to receive two baths per week on Monday and Thursday. The facility documented Resident #8 preferred to receive his bath in the morning. Point of care bathing task documentation was reviewed for 30 days between 12/18/24 and 1/15/25. The facility documented Resident #8 was offered six baths in the review period. The facility documented Resident #8 refused one bath on 12/18/24 at 3:21 p.m. because it was too late in the day for him to receive a bath. All six occasions bathing was offered to Resident #8 in the last 30 days of the review period was documented to occur between 1:22 p.m. and 5:59 p.m. -The facility failed to offer morning bathing twice weekly in accordance with Resident #8's bathing preferences. D. Staff interviews Registered nurse (RN) #1 was interviewed on 1/16/25 at 10:07 a.m. RN #1 said residents were bathed according to their preferences. RN #1 said that was typically two or three times per week for each resident. RN #1 said that if a resident refused a bath, then it should be reoffered the same day or the following morning. Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 11:25 a.m. LPN #3 said residents were bathed according to their preferences. LPN #3 said most of the residents preferred two baths each week. LPN #3 said if a resident refused their bath, he would reoffer it a few hours later or later on the same day. LPN #3 said it was important that residents were bathed to keep their skin clean. Certified nursing aide (CNA) #3 was interviewed on 1/16/25 at 11:37 a.m. CNA #3 said residents were usually bathed twice each week or according to their wishes. CNA #3 said if a resident refused a bath it would be reoffered the next day. The director of nursing (DON) was interviewed on 1/16/25 at 2:05 p.m. The DON said residents should be bathed in accordance with their preferences, but the facility tried to offer bathing twice a week to the residents. The DON said bathing preferences of each resident was obtained on admission and any time the resident wished to change their bathing preference. The DON said if a resident refused a bath, it should be reoffered the next day. The DON reviewed Resident #8's bathing preferences and bathing documentation in the electronic medical record (EMR). The DON said Resident #8 should have been offered more baths. The DON said staff should have reoffered a bath to Resident #8 after he refused it on 12/18/24. The DON said facility staff documented not applicable on two occasions which meant those were not his day to receive a bath. 48412 III. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO diagnoses included generalized muscle weakness, need for assistance with personal care, age-related physical debility, dependence on a wheelchair, Parkinson's (neurological disorder) disease without dyskinesia (involuntary movements) and dementia. The 10/16/24 MDS assessment revealed Resident #11 had mild cognitive impairments with a BIMS of nine out of 15. Resident #11 had an impairment to one side of his body affecting one upper extremity and one lower extremity. B. Resident interview Resident #11 was interviewed on 1/14/25 at 9:12 a.m. Resident #11 said he usually got two showers a week but requested three showers a week on Mondays, Wednesdays and Fridays. He said showers were important to him because he sweated a lot. C. Record review Resident #11's functional mobility and ADLs care plan, revised 8/21/23 revealed the resident preferred three showers a week. Resident #11's bathing chart was provided by the corporate consultant (CC) on 1/16/25 at 3:49 p.m. The bathing chart revealed the resident received showers on the following days: 12/18/24, 12/20/24, 12/23/24, 12/27/24, 12/30/24, 1/3/25, 1/8/25, 1/13/25 and 1/15/25. -However, out of 11 opportunities, Resident #11 received nine showers. -Resident #11 preferred to shower three times per week as identified on his comprehensive care plan. CNA #2 was interviewed on 1/16/25 at 2:34 p.m. She said she was unsure what time or day Resident #11 preferred his showers. The DON was interviewed on 1/16/25 at 10:15 a.m. She said all residents had their preferences for bathing completed and the staff needed to follow the preferences. She said Resident #47 preferred three showers a week and was care planned for it and should be given three showers a week. IV. Resident #47 A. Resident status Resident #47, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO diagnoses included need for assistance with personal care, dementia and Alzheimer's disease with late onset. The 1/12/25 MDS assessment revealed Resident #47 had mild cognitive impairments with a BIMS of 11 out of 15. Resident #47 needed set-up assistance or supervision with bed mobility, eating, toileting and personal hygiene. B. Resident interview Resident #47 was interviewed on 1/13/25 at 10:12 a.m. Resident #47 said she often received showers in the evening and wanted to shower in the morning. Resident #47 said she wanted showers in the morning so she could relax in the evenings. C. Record review Resident #47's bathing chart was provided by the CC on 1/16/25 at 3:49 p.m. The bathing chart revealed the resident received the following showers: -On 12/19/24 at 3:29 p.m.; -On 1/7/25 at 10:53 a.m.; -On 1/11/25 at 5:59 p.m.; -On 1/11/25 at 9:22 p.m.; and -On 1/13/25 at 5:04 p.m. -However, out of five showers Resident #47 only received one shower in the morning. D. Staff interviews CNA #2 was interviewed on 1/16/25 at 2:34 p.m. CNA #2 said she believed Resident #47 preferred her showers in the morning. The DON was interviewed on 1/16/25 at 10:15 a.m. The DON said she was unaware that Resident #47 was receiving showers in the afternoon and evenings. She said if the resident preferred morning showers then she needed to be showered in the morning.

Based on record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for four (#15, #36, #58 and #74) of six residents out of 32 sample residents. Specifically, the facility failed to: -Thoroughly explain the arbitration agreement in a form and in a manner the residents and/or resident representatives understood the agreement before signing the arbitration agreement; -Accurately inform residents the arbitration agreement was a binding agreement before the agreement was signed; -Accurately inform residents the agreement waived residents' right to a trial before a judge or jury for all disputes between the resident and the facility. -Accurately inform residents the agreement could be rescinded by written notice within 90 days of the signing of the agreement; and, -Ensure staff reviewing the arbitration agreement with residents understood the components of the agreement. Findings include: I. The arbitration agreement The Voluntary Agreement for Arbitration, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 1:27 p.m. The agreement read in part, Under Colorado law two or more parties may agree in writing for the settlement by binding arbitration of any dispute arising between them, including disputes relating to health care matters. By signing this agreement, you will give up your constitutional right to a jury or court trial as you are agreeing that any dispute between you and the facility will be subject to binding and final arbitration. You, as our resident, have the right to seek legal counsel concerning this agreement, and you have the absolute right to rescind this agreement by written notice within 90 days after the agreement has been signed and executed by both parties. The resident and or legal representative understands, agrees to, and has received a fully executed copy of the voluntary arbitration agreement, and acknowledges that terms have been explained to him/her, or his/her designee, in a manner that he/she understands by an agent of the facility and that he/she has had an opportunity to ask questions. Each party agrees to waive the right to a trial, before a judge or jury, for all disputes, including those at law or equity, subject to arbitration under this voluntary arbitration agreement.In the event that any portion of this voluntary arbitration agreement is determined to be invalid or enforceable, the remainder of this voluntary arbitration agreement will be deemed to continue to be binding upon parties hereto in the same manner as if the valid or enforceable provision were not part of the agreement. The undersigned acknowledged that each of them has read this voluntary arbitration agreement and understands that by signing each has waived his/her right to a trial before a judge or jury and that each of them voluntarily consents to all of the terms of the voluntary agreement. By signing this agreement you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than by a jury or court trial. You have the right to legal counsel and you have the right to rescind this agreement within 90 days from the date of signature by both parties unless the agreement was signed in contemplation of hospitalization in which case you have 90 days after discharge or release from the hospital to rescind the agreement. II. Explanation of arbitration to the residents The admissions coordinator (AC) was interviewed on 1/14/25 at 4:39 p.m. The AC said she completed most of the admissions paperwork with the new admissions to the facility. She said when she was not available, the marketing director (MKD) was her back up and completed the admission paperwork process. The AC said most of the admissions paperwork, including the arbitration agreement, was signed by the resident's power of attorney (POA) but she has had several residents that signed their own paperwork. The AC said she always checked with the facility's clinical team to determine if the resident was capable of signing their own paperwork when a POA was not present or in place. The AC said she was trained to explain to the residents that if there were any challenges between the facility and the resident, the facility would try to settle the concern without involving lawyers. She said the arbitration agreement was optional and they did not have to sign it. She said the agreement was not binding and would assume it was a resident right to change their mind if they signed the agreement but still wanted to go to court. She said she was not aware of a timeline/deadline a resident had to rescind the agreement once it was signed. The AC said she would always offer the residents a copy of the arbitration agreement but usually the residents did not want a copy. III. Resident interview Resident #15 was interviewed on 1/15/25 at 1:11 p.m. Resident #15 said he signed all of his admission paperwork but no one told him about the details of the arbitration agreement. He said he had some forgetfulness but would remember something like that. He said he would want to address any legal concerns he had with the facility with the option to sue if warranted. He said if he signed the agreement, he would want to know the deadline to change his mind. Resident #36 was interviewed on 1/15/25 at approximately 1:20 p.m. Resident #36 said she was not familiar with an arbitration agreement. She said was not aware of signing the agreement or anything regarding settling facility disputes with a third party. Resident #58 was interviewed on 1/15/25 at 1:49 p.m. Resident #58 said he signed all of his own paperwork. He said he was not told what an arbitration agreement was or that signing the agreement would waive his right to go to court. He said he had a lawyer and that would be something we would have wanted to review with his lawyer before signing. Resident #74 was interviewed on 1/16/25 at 9:12 a.m. Resident #74 said she did not know what arbitration was and was not aware that she signed an arbitration agreement. She said she would have wanted someone to explain the agreement to her before signing anything. Resident #54 was interviewed on 1/16/25 at 9:18 a.m. He said he knew what an arbitration agreement was and he had signed the agreement with the facility. He said he probably would not ever feel the need to rescind the agreement but he was not told of a timeline when he could change his mind if he wanted to. IV. Record review Arbitration agreements were reviewed for Resident #15, Resident #36, Resident #58, Resident #74 and Resident #54. Each resident signed their own arbitration agreement. The arbitration agreements were signed by either the AC or the marketing director (MKD) as the facility representatives. Resident #15 was admitted on [DATE]. The arbitration agreement was signed by AC on 11/27/24. The arbitration agreement was signed by Resident #15 on 11/27/24. Resident #36 was admitted on [DATE]. The arbitration agreement was signed by the AC on 10/28/24. The arbitration agreement was signed by Resident #36 on 10/28/24. Resident #58 was admitted on [DATE]. The arbitration agreement was signed by the MKD on 10/25/24. The arbitration agreement was signed by Resident #58 on 10/25/24. Resident #74 was admitted on [DATE]. The arbitration agreement was signed by the AC on 12/17/24. The arbitration agreement was signed by Resident #74 on 12/17/24. Resident #54 was admitted on [DATE]. The arbitration agreement was signed by the MKD on 12/27/24. The arbitration agreement was signed by Resident #54 on 12/27/24. IV. Staff interviews The MKD was interviewed on 1/16/25 at 9:23 a.m. The MKD said he would occasionally review the admissions paperwork including the arbitration agreement with the residents and or their POA's when the AC was not available. He said he would look at the arbitration agreement together with the resident and make sure they understand and were comfortable with signing before signing it was comfortable. He said the arbitration agreement was voluntary and not binding. He said he was not sure of a deadline to rescind the agreement, he would have to read it with them. The NHA was interviewed on 1/16/25 at 9:38 a.m. The NHA said the intent of the agreement was to solve disputes but it did not limit the resident from going to court. He said if a resident signed the agreement, they had 30 days to rescind the agreement but if they did not rescind the agreement, they could still go to court. He said the facility wanted to make sure the residents knew that if they had any concerns, the facility wanted to help resolve the concern. He said the residents can request a copy of the agreement and have it read to them. V. Facility follow-up A plan of improvement, dated 1/16/25, was provided by the NHA on 1/16/25 at 12:12 p.m. According to the plan, arbitration agreement education was provided to the AC and the MKD on 1/16/25. The documented education identified the AC and the MKD were trained to ensure the signing party understood they had 30 days to take back their arbitration. According to the provided education, the residents signed away their right to go to court and will use an unbiased party as the arbitrator. The plan of improvement identified the facility would add documentation in the residents' charts that the resident/POA had the right to revise the agreement within 30 days of signing it. -However, the arbitration agreement the facility had in place, documented the residents had 90 days to rescind the agreement. According to the plan of improvement, an audit was conducted to ensure residents/POA who signed the arbitration agreement in the last 30 days understood the agreement. The plan identified the notification to six of the facility's residents or their representatives who signed the arbitration agreement. -The plan of improvement did not include Resident#15, Resident #36, Resident #58, and Resident #74

Based on observations, record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#53) of four residents reviewed for mood and behavior out of 32 sample residents. Specifically, the facility failed to effectively implement person-centered approaches for dementia care to prevent resident-to-resident altercations. Cross-reference: F600 failure to prevent resident abuse. Findings include: I. Facility policy and procedure The Dementia Clinical Protocol policy and procedure, revised November 2018 was provided by the nursing home administrator (NHA) on 1/16/25 at 3:29 p.m. The policy read in part, For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. II. Resident status Resident #53, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included chronic obstructive pulmonary disease, alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, single episode, severe without psychotic features, and insomnia. The 12/13/24 minimum data assessment (MDS) assessment identified Resident #23 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment indicated Resident #53 did not have physical or verbal behavioral symptoms other behaviors directed by others. The resident's functional ability on admission identified the resident was independent or needed some supervision with his ADLs. According to the MDS assessment, he did not use a mobility device for ambulation. III. Incident of physical abuse of Resident #34 by Resident #53 The 12/31/24 investigation report for abuse was provided by the NHA on 1/15/25 at 3:15 p.m. p.m. The investigation report identified Resident #53 pushed Resident #34 on 12/28/24 because he did not shut the shared bedroom door and Resident #53 did not want his dog to get out of the room. The facility was not aware of the incident until Resident #34 reported the incident to a staff member on 12/30/24. The investigation for abuse determined physical abuse was substantiated because of the intentionality of the incident. IV. Resident interviews Resident #53 was interviewed on 1/13/25 at 2:45 p.m. Resident #53 said he had a lot of problems with his former roommate (Resident #34) and referred to him as a derogatory name. According to the resident, he and his roommate had a lot of verbal fights, cursing at each other. Resident #34 was interviewed on 1/14/25 at 4:09 p.m. Resident #34 said his roommate yelled and cursed at him on two different occasions prior to the 12/28/24 incident of physical abuse. He said he reported yelling and cursing to the maintenance director when he worked on his television remote (12/24/24). -The facility failed to document and observe potential triggers, outward frustration or verbal aggression toward other residents or roommates and intervene as necessary as identified by Resident #53's behavior care plan (see below). V. Record review The behavior care plan, revised 12/23/24, identified Resident #53 exhibited or was at risk for behavioral symptoms (for example) striking out, grabbing others, combative, verbally, or physically abusive, inappropriate disrobing, smears/throws food/feces/objects) due to: anxiety, dementia, depression, history of alcohol abuse, history of substance abuse, insomnia and major depression. Interventions, dated 11/17/24, read in pertinent part, directed staff to anticipate Resident #53's needs and meet the needs promptly; encourage the resident to verbalize his feelings; maintain a calm, slow, and understandable approach; manage environmental factors to optimize comfort; observe and document changes in behavior, including frequency of occurrence and potential triggers with outward frustration or verbal aggression toward other residents or roommates; observe the resident's mood and response to medication; observe whether the behavior endangers the resident and/or others and intervene if necessary, removing others from the surrounding area; and, reduce stimulation such as noise, crowding, other physically aggressive residents to the extent possible. The psychosocial unsettled relationships care plan, initiated 1/13/25 (during survey), indicated Resident #53 had an unsettled relationship with friends, other residents, and roommates. He could become irritated and exhibited verbal or physical behaviors with increased confusion and frustration without processing the situation. Interventions, dated 1/13/25, directed staff to assess Resident #53 for mood and/or behavioral problems; assist the resident with psychosocial needs, to include preferences with placement of roommates who had similar likes/interests; assist the resident in identifying the origin of the complaint or concern; monitor Resident #53's behavior and determine appropriate interventions for each situation; encourage the resident to verbalize feelings of anger, anxiety, or sadness in an acceptable manner; provide understanding and validation of his preference of routine; establish a therapeutic relationship; redirect and offer solutions with the resident when he was frustrated; encourage Resident #53 to share how staff could assist or correct a situation; praise efforts in the use of effective coping strategies and provide reassurance and active empathetic listening. -The facility did not implement new interventions to address Resident #53's mood and behavior until 1/13/25, two weeks after physical abuse was reported and substantiated and provided a new roommate. The December 2024 treatment administration record (TAR) directed staff to monitor Resident #53's targeted behaviors of aggression. According to the December 2024 TAR, the resident exhibited easily altered aggression on 12/29/24, 12/30/24, and 12/31/24. The TAR did not identify behaviors on the 12/21/24 and 12/24/24 (see interview below) or behaviors on 12/28/24 when the physical altercation occurred. Review of progress notes did not identify what the behavior was on 12/30/24 and 12/31/24 as a targeted aggressive behavior on the December 2024 TAR as directed by Resident #53's behavior care plan. The 12/29/24 medication administration note identified Resident #53's roommate exited the bedroom without shutting the bedroom door behind him. Resident #53 was alone in his room and got up out of bed and said loud enough for the nurse to hear in the hallway that he was going to initiate a physically aggressive act towards his roommate because the roommate did not shut the bedroom door. The note documented a manager on call was notified of the Resident #53's behavior. According to the note, staff would make sure the door was closed at all times to prevent an altercation. -The facility failed to address the physically aggressive threat other than to document they would make sure the door was shut. -The staff did not approach the Resident #43 to understand Resident #53 feelings and concerns as identified in his behavior care plan. -Resident #53 was not provided another room to separate him from the situation that was triggering his aggression as identified in his behavior care plan. The review of the December 2024 progress notes for Resident #53 revealed the 12/29/24 medication administration note was the only note in December 2024 that identify concerns or behaviors related to Resident #53's roommate. VI. Staff interview The maintenance director (MTD) was interviewed on 1/15/25 at 10:35 p.m. The MTD said when he was looking at the televisions (12/24/24), Resident #34 told him there was tension between him and his roommate. He said Resident #34 said his roommate would curse and yell at him. The MTD said he was not sure he mentioned Resident #34's concerns to someone else. The MTD said he thought the Resident #34's concerns were something that may have already been reported. The MTD said he probably should have made sure someone else knew about the report of cursing and tension towards Resident #34 from Resident #53. The NHA was interviewed on 1/15/25 at 3:18 p.m. The NHA identified the resident had a pattern of altercations with a roommate. He said he was moved to Resident #34's room after an altercation with his former roommate in November 2024. He said there was argument between the two roommates and Resident #53 threatened his roommate at the time. The NHA said he was not aware of the threatening words made by Resident #53 as documented on 12/29/24. He said the interdisciplinary team tried to review progress notes to identify potential concerns but the note was not identified as a concern. The NHA said behavior tracking was documented in TARs and a note documented a behavior would usually just be completed when there was a significant change from a resident's baseline behavior. The director of nursing (DON) was interviewed on 1/15/25 at 4:54 p.m. The DON said the threatening remarks on 12/29/24 were loud enough for the nurse in the hallway to hear him but Resident #34 was not in the room at the time. The DON said Resident #53 was already on behavior tracking so his behaviors should have been monitored. The social service director (SSD) was interviewed on 1/16/25 at 3:07 p.m. The SSD said she helped the facility with dementia care training with the certified nurse aides (CNA). She said she helped the CNAs understand and familiarize themselves with person centered care planned interventions. The SSD said Resident #53 had vascular dementia which could contribute to aggressive behaviors. She said Resident #53 was reclusive. His personal space and visits with his dog was very important to him. The SSD said he could make his needs known and it was important for staff to meet him where he was at, meaning identifying his behavior needs. She said staff attempted to pair him with an appropriate roommate. She said his new roommate (after the 12/28/24 incident) spent most of his time on his side of the shared room in bed. She said moving Resident #53 to another room was the safest option after the 12/28/24 physical aggression. The SSD said to help prevent Resident #53's aggressive behaviors, staff should watch for restlessness and changes in his normal behavior. She said if they observe any concerns in his behavior, staff should ask him if there was something bothering him so the concern could be addressed. The SSD said arguing with his roommate would be an opportunity to use dementia care inventions. She said staff should have watched Resident #53's watch body language and interactions. She said it would have been important to keep an eye on the interactions between Resident #53 and Resident #34. The SSD said she was not made aware of the augments between the roommates or Resident #53's threat of physical aggression until 1/15/25. She said it was important to involve social services when their behavioral concerns with residents because she focuses on residents' psychosocial wellness and could help deescalate potential altercations and provide additional support needs. The SSD said additional dementia care resources could have been family support. She said she could have requested family involvement and encouraged them to come to visit. The SSD said she would continue to provide dementia care education and remind staff to report any changes staff see with Resident #53.

Based on observations, record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for two (#3 and #44) residents of 32 sample residents. Specifically, the facility failed to: -Have staff members identify themselves when entering Resident #3's room, who was blind; and, -Assist Resident #44 to use the restroom in a dignified manner. Findings include: I. Failure of staff to identify themselves appropriately to Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included low vision of the right and left eye, macular degeneration and generalized anxiety disorder. The 12/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15 . Resident #44 required set-up or clean-up assistance with eating and oral hygiene and was dependent on staff for all other cares. B. Resident interview Resident #3 was interviewed on 1/13/25 at 3:18 p.m. Resident #3 said that she had very low vision but was essentially blind. Resident #3 said she felt afraid when staff members entered her room without announcing who they were. Resident #3 explained that her experience when staff did not announce who they were was limited to hearing the door open and then hearing footsteps approaching her. Resident #3 said sometimes she guarded her body when she heard footsteps approaching her because she did not know if someone was coming into the room to touch her body, or not. C. Observations During a continuous observation of the 300 hall on 1/15/25, beginning at 1:09 p.m. and ending at 2:53 p.m., the following was observed: At 1:27 p.m., an unidentified laundry aide was knocked on Resident #3's door. The laundry aide entered the resident's room without announcing his name or title. At 1:42 p.m., Resident #3 illuminated her call button, indicating that she requested assistance. Certified nursing aide (CNA) #5 knocked on Resident #3's door and said the resident's name and walked inside without announcing her name or title. D. Record Review The psychosocial and behavioral plan of care, initiated on 11/24/24 and revised on 11/27/24, documented that Resident #3 was exhibiting or at risk for behavioral symptoms, poor coping mechanisms, or willingness to use inappropriate behaviors in response to her anxiety. The documented goals included Resident #3 would accept supportive strategies and demonstrate adequate control of emotions which would not result in injury to self or others, that Resident #3 would respond to early interventions influencing the alterability of her behaviors, and that Resident #3 would be compliant with nursing care. Interventions included to establish a rapport with Resident #3, to announce your name and title when entering her room, and to announce what you are providing her in her room. The plan of care documented Resident #3 had a deep past history of mistrust with caregivers, family and loved ones. II. Failure to provide Resident #44 restroom assistance in a dignified manner A. Resident status Resident #44, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included pelvic and perineal pain, dementia, cognitive communication deficit and wheelchair dependence. The 10/21/24 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of eight out of 15. The MDS assessment indicated Resident #44 had no rejections of care. Resident #44 required moderate assistance with eating, and substantial or maximum assistance with all other activities of daily living (ADL). B. Observation and resident interview During a continuous observation on the 100 hall on 1/14/25, beginning at 3:01 p.m. and ending at 4:43 p.m., The following was observed: At 4:07 p.m., the light outside of room [ROOM NUMBER] illuminated, indicating a request for assistance. A voice was heard coming from room [ROOM NUMBER] which loudly proclaimed I need to urinate really badly. At 4:11 p.m., Resident #44 self-propelled herself in her wheelchair to exit her room. Resident #44 then proceeded to self-propell herself to the nurses station, where she observed her nurse on the phone taking a medical report. Resident #44 then self-propelled herself into the rehabilitation room. At 4:12 p.m., a loud voice was heard in the rehabilitation room which said I need to urinate really badly. A second voice was heard in response, Okay, just go back to your room, turn your call light on and your CNA (certified nurse aide) will help you. Resident #44 was interviewed on 1/14/25 at 4:14 p.m. Resident #44 said that she had been instructed to return to her room, turn on her call light, and wait for assistance. Resident #44 also said that she needed to urinate very badly. Resident #44 had a furrowed brow. At 4:17 p.m., Resident #44 was offered and assisted to use the restroom by a staff member. C. Record review The functional mobility plan of care, initiated on 10/16/24 and revised on 10/31/24, documented that Resident #44 was dependent on one staff member to assist with toileting needs, and that Resident #44 required moderate assistance with the stand-pivot transfer with assist rails. III. Staff interviews Registered nurse (RN) #1 was interviewed on 1/16/25 at 10:07 a.m. RN #1 said that it was not okay to turn away a resident who was asking you for help. RN #1 said that she would help the resident right away. RN #1 said it was not helpful for staff or residents to send the resident back to their room. RN #1 said residents should be assisted when they asked for help. RN #1 said that staff knew to say who they were when entering Resident #3's room. RN #1 said residents should have their preferences honored. Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 11:25 a.m. LPN #3 said that if a resident requested assistance, it would not be okay to send the resident back to their room. LPN #3 said he would assist the resident right away because he personally empathized with how uncomfortable that feeling was and residents need help right away when they have the need to void. LPN #3 said it was not respectful to send a resident back to their room. LPN #3 said when he worked on the 300 hall he knew to always introduce himself when entering Resident #3's room. LPN #3 said Resident #3 was known to get scared and upset, so it was extra important to be calm and respectful with her. The director of nursing (DON) was interviewed on 1/16/25 at 2:05 p.m. The DON said it was not acceptable for staff members to tell a resident to return to their room and wait when they request assistance. The DON said the staff member should have either assisted the resident or found someone else who could assist the resident. The DON said it was not acceptable to enter Resident #3's room without announcing who you were, and that was written on her plan of care. The DON said Resident #3's plan of care should be followed.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for one (#39) of five residents reviewed for personal funds accounts out of 32 sample residents. Specifically, the facility failed to notify Resident #39, who was Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person. Findings include: I. Facility policy and procedure The Accounting and Records of Resident Funds, revised 2001, was provided by the nursing home administrator (NHA) on 1/16/25 at 12:57 p.m. It read in pertinent part, A representative of the business office informs the resident if the balance in his or her personal funds account reaches $200 (two-hundred dollars) less than the resident's resource limit and that if the amount in the account reaches the resource limit for one person, the resident may lose eligibility for Medicaid. II. Record review A. Resident #39 A review of the facility's current trust account balance revealed that Resident #39 had $1,960.86 in his account as of 1/15/25, which was $39.14 away from exceeding the allotted limit for Medicaid-funded residents. -There was no documentation indicating the facility notified Resident #39 or his legal representative when his personal funds account reached $200 less than the eligibility resource limit until 1/15/25 (during the survey). III. Staff interviews The NHA and business office manager (BOM) were interviewed together on 1/15/25 at 2:33 p.m. The BOM said she notified Resident #39 his account was close to the allotted limit for Medicaid. The BOM said she did not have documentation indicating the resident was notified his account was close to the allotted limit for Medicaid prior to 1/15/25. The NHA said the facility would work with the BOM to implement a performance improvement plan (PIP) to prevent this from happening again. The BOM said Resident #39, or any other resident, with funds over the limit was at risk of losing their Medicaid. IV. Facility follow-up The NHA provided a PIP for Medicaid allowable limit on 1/15/25 at 3:16 p.m. which read in pertinent part, It was identified during the annual survey on 1/15/25 that there was no documentation of notification to resident or resident guardian or power of attorney (POA) of Medicaid allowable limit almost being reached for two residents. We have created a binder to ensure that going forward there will be proof that the notification was sent out. When the notification is sent out, the date and document will be put into the binder with resident's name. This will be audited weekly to ensure compliance. The binder will be updated weekly, updated yearly with the correct personal needs account amount on the authorization sheet and added to the binder. There will be a monitoring lof updated weekly, and brought to quality assurance and performance improvement (QAPI) monthly for three months to ensure compliance.

Based on interviews and record review, the facility failed to ensure one (#34) of three residents reviewed were free from abuse out of 32 sample residents. Specifically, the facility failed to ensure Resident #34 was free from physical abuse by Resident #53. Findings include: I. Facility policy and procedure The Abuse policy, dated September 2022, was provided by the nursing home administrator (NHA) on 1/16/25 at 12:57 p.m. The policy identified in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. All findings of all investigations are documented and reported. II. Incident of physical abuse of Resident #34 by Resident #53 A. Incident on 12/28/24 The 12/31/24 investigation report for abuse was provided by the NHA on 1/15/25 at 3:15 p.m. p.m. The investigation report documented pushing was the nature of the suspected physical abuse. The report identified Resident #34 informed the staff that his roommate (Resident #53) made contact with his chest on 12/28/24 when Resident #34 forgot to close the bedroom door. The report indicated both residents were assessed without injury on 12/31/24 and offered emotional support. The facility issued a room move to separate Resident #34 and Resident #53. The facility interviewed both residents on 1/2/25. According to the documented interviews, Resident #53 said he was upset with Resident #34 because he let Resident #53's dog out of the room when he did not shut the door. Resident #34 said he returned to his room after smoking. He was walking to his side of the shared room when Resident #53 put his hands on Resident #34's chest. Resident #34 said he was startled, was backed up to the wall and put his hand out in front of him to get Resident #53 away from him. Resident #34 said he did not tell anyone because he was trying to make efforts to get along. Resident #34 said he decided to report the incident because he felt Resident #53 would otherwise get away with the bad treatment towards Resident #34. The investigation report indicated five other residents and five staff members were interviewed on 1/3/25 without concerns of abuse. The investigation for abuse determined physical abuse was substantiated because of the intentionality of the incident. B. Resident #34 - victim 1. Resident status Resident #34, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included chronic ischemic heart disease, epilepsy (seizure disorder), history of falling, weakness, depression and encounter for palliative care. The 10/17/24 minimum data set (MDS) assessment identified Resident #34 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out 15. He did not exhibit behaviors or disorganized thinking or inattention. Resident #34 did not have physical and verbal behaviors other behavioral symptoms directed to others. The resident was independent in most of his activities of daily living (ADL) cares and used both a walker and wheelchair for mobility. 2. Resident interview Resident #34 was interviewed on 1/14/25 at 4:09 p.m. He said Resident #53 was a new roommate and would yell at Resident #34 because his remote control for his television would unintentionally change the channels on Resident #53's television. He said he told the maintenance director (MTD) of the remote control malfunction and the MTD said he had a plan and would come back later to try to fix it. Resident #34 said one day he used the remote control, forgetting it was a problem, and changed the channel on his television which inadvertently changed the channel on his roommate's television. Resident #34 said Resident #53 started to yell, scream and curse at him. Resident #34 said he tried to explain to Resident #53 that he did not change the channel on purpose and maintenance was going to try to fix the problem but his roommate continued to yell at him. Resident #34 said the yelling happened a couple of times, both in the evening hours between 6:00 p.m. and 8:00 p.m. Resident #34 said he was surprised no one heard him or came to the room. Resident #34 said he told MTD that Resident #53 would get crazy, curse at him and go ballistic when he yelled at him because he was mad about the television remote control situation. Resident #34 said a few days later, on Saturday (12/28/24) morning between 7:30 a.m. and 8:00 a.m., he went outside to smoke. He said when he came back to his room his roommate came up from behind him and shoved him with so much force that Resident #34 almost fell down. He said Resident #53 started yelling at him to close the door. He said he turned around and Resident #53 started to come at him again so he grabbed Resident #53's throat to protect himself. Resident #34 said his roommate then backed away and left the room. He said a couple days later he told the marketing director (MKD) what happened. He said the following day Resident #53 was moved out of his room. He said he later realized that Resident #53 wanted the door shut because his dog spent time with him and he did not want the dog to get out. Resident #34 said the altercations with Resident #53 made him feel bad. Tearfully, he said he had always been a sensitive person and had a hard time forgetting when bad things happened to him. He said it was always something he had difficulty with. Resident #34 said he felt that when he was shoved he was not going to say anything but the more he thought about it, he felt it was abusive and wrong to attack another resident so he decided to report Resident #53. He said he currently felt safe in the facility but at the time of the incident, he did feel a little fearful. He said he could not hear well and did not hear when the resident came from behind him. He said he was startled and then felt fear when he turned around and Resident #53 was coming at him so he put his hands out to stop him. Resident #34 said he had seen Resident #53 outside when he went to smoke but there had not been any more concerns and the television remote control was now fixed. 3. Record review The psychosocial emotional trauma care plan, revised 7/29/24, indicated the resident was at risk for decreased psychosocial wellbeing; adjustment issues; emotional distress; ineffective coping skills; poor impulse control; and, adverse effects on function, mental, physical, social, or spiritual wellbeing related to the history of stressful events or experience. Interventions, dated 4/21/24, directed staff to encourage Resident #34 to express emotions and help him identify triggers that prompted symptoms. The psychosocial well-being care plan, initiated on 1/13/25 (during the survey), indicated Resident #34 was at risk for psychosocial well-being concerns related to diagnosis of depression and his overall health status. Interventions, dated 1/13/25, directed staff to allow Resident #34 to voice feelings and frustrations as needed; assist Resident #34 to communicate with his family and friends through phone calls, video calls, and email; assist Resident #34 with conflict resolution as needed; encourage Resident #34's friends and family to visit; listen to Resident #34 attentively and observe Resident #34 for tearfulness, increased agitation, and decreased participation in care. -Review of Resident #34's progress notes between 12/1/24 and 1/14/25, did not identify altercations, behavior monitoring or concerns between Resident #34 and Resident #53. The progress notes did not identify visits offered to the resident offering emotional support or follow up after the 12/28/24 incident. The January 2025 CPO revealed a physician's order for targeted behavior for sad statements. It directed staff to monitor how often the sad behavior occurred and how he responded to redirection for every day and night shift, ordered on 11/28/24 and discontinued on 12/10/24. -The December 2024 treatment administration record (TAR) did not identify Resident #34's behaviors were monitored between 12/11/24 and 12/31/24. The January 2025 TAR did not identify Resident #34's behaviors were monitored between 1/1/25 and 1/14/25. C. Resident #53 - assailant 1. Resident status Resident #53, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 CPO, diagnoses included chronic obstructive pulmonary disease, alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, single episode, severe without psychotic features and insomnia. The 12/13/24 MDS assessment identified Resident #53 had moderate cognitive impairments with a BIMS score of 10 out of 15. The MDS assessment indicated Resident #53 did not have physical or verbal behavioral symptoms other behaviors directed by others. Resident #53 did not have limitations with upper and lower range of motion. The resident's functional ability identified the resident was independent or needed some supervision with his ADLs. According to the MDS, he did not use a mobility device for ambulation. 2. Resident interview Resident #53 was interviewed on 1/13/25 at 2:45 p.m. Resident #53 said he had a lot of problems with his former roommate (Resident #34) and referred to him as a derogatory name. He said they had a lot of verbal fights, cursing at each other, but he did not hit him (Resident #34) because he did not want to get discharged from the facility. He said he was now in a new room and had not had any problems with his new roommate. 3. Record review The behavior care plan, revised 12/23/24, identified Resident #53 exhibited or was at risk for behavioral symptoms, including striking out, grabbing others, combative, verbally, or physically abusive, inappropriate disrobing, smearing/throwing food/feces/objects) due to: anxiety, dementia, depression, history of alcohol abuse, history of substance abuse, insomnia and major depression. Interventions, dated 11/17/24, directed staff to anticipate Resident #53's needs and meet the needs promptly; encourage the resident to verbalize his feelings; maintain a calm, slow, and understandable approach; manage environmental factors to optimize comfort; observe and document changes in behavior, including frequency of occurrence and potential triggers with outward frustration or verbal aggression toward other residents or roommates; observe the resident's mood and response to medication; observe whether the behavior endangers the resident and/or others and intervene if necessary, removing others from the surrounding area; and, reduce stimulation such as noise, crowding, other physically aggressive residents to the extent possible. The psychosocial unsettled relationships care plan, initiated 1/13/25 (during survey), indicated Resident #53 had an unsettled relationship with friends, other residents, and roommates. He could become irritated and exhibit verbal or physical behaviors with increased confusion and frustration without processing the situation. Interventions, dated 1/13/25, directed staff to assess Resident #53 for mood and/or behavioral problems; assist the resident with psychosocial needs, to include preferences with placement of roommates who had similar likes/interests; assist the resident in identifying the origin of the complaint or concern; monitor Resident #53's behavior and determine appropriate interventions for each situation; encourage the resident to verbalize feelings of anger, anxiety, or sadness in an acceptable manner; provide understanding and validation of his preference of routine; establish a therapeutic relationship; redirect and offer solutions with the resident when he was frustrated; encourage Resident #53 to share how staff could assist or correct a situation; praise efforts in the use of effective coping strategies and provide reassurance and active empathetic listening. A maintenance work order sheet was provided by the NHA on 1/15/25 at 4:56 p.m. The work order sheet revealed a work order was created on 12/21/24 for the shared room of Resident #34 and Resident #53 and set to be completed on 12/24/24. According to the work order notes, the televisions were placed back to back so (the remotes) did not change each other's (television). The December 2024 TAR directed staff to monitor Resident #53's targeted behaviors of aggression. According to the December 2024 TAR, the resident exhibited easily altered aggression on 12/29/24, 12/30/24, and 12/31/24. -The TAR did not identify behaviors on 12/21/24 and 12/24/24 (see interview below) or behaviors on 12/28/24 when the physical altercation occurred. -Review of progress notes did not identify what the behavior was that was documented on 12/30/24 and 12/31/24 as a targeted aggressive behavior on the December 2024 TAR. The 12/29/24 medication administration note identified Resident #53's roommate exited the bedroom without shutting the bedroom door behind him. Resident #53 was alone in his room and got up out of bed and said loud enough for the nurse to hear in the hallway that he was going to initiate a physically aggressive act towards his roommate because the roommate did not shut the bedroom door. The note documented a manager on call was notified of Resident #53's behavior. According to the note, staff would make sure the door was closed at all times to prevent an altercation. -However, according to the investigation report, a physical altercation had already occurred on 12/28/24. -The 12/29/24 medication administration note did not identify the resident's roommate (Resident #34) was asked if he had been threatened by Resident #53 or if there had been any physical or verbal altercations with Resident #53. The review of the December 2024 progress notes for Resident #53 revealed the 12/29/24 medication administration note was the only note in December 2024 that identified concerns or behaviors related to Resident #53's roommate. III. Staff interviews The MTD was interviewed on 1/15/25 at 10:35 p.m. The MTD said a work order was created to look at Resident #34's television. He said he was told that Resident #34's remote control was changing Resident #53's television channels. The MTD said when he was looking at the televisions, he fixed the remote control situation (on 12/24/24). The MTD said Resident #34 told him there was tension between him and his roommate. He said Resident #34 said his roommate cursed and yelled at him. The MTD said he was not sure he mentioned Resident #34's concerns to someone else. The MTD said he thought Resident #34's concerns were something that may have already been reported. The MTD said he probably should have made sure someone else knew about the report of cursing and tension towards Resident #34 from Resident #53. The NHA was interviewed on 1/15/25 at 3:18 p.m. The NHA said any reports of pushing, the use of threatening words and cursing at another resident would warrant immediate follow up with the residents to determine what was going on. The NHA said he was not aware of any verbal altercations between Resident #53 and Resident #34. He said he would want to know if there were reports of a verbal altercation before the situation escalated to a physical altercation. He said cursing at a resident and/or talk of threatening a resident would need to be investigated and reported. The NHA said allegations should be reported to him, as the abuse coordinator, and he needed to know what was going on so actions could be taken. He said he should have been made aware of the verbal altercation reported to the MTD by Resident #34. The NHA said threatening behavior and/or cursing at another resident could cause the resident harm. The NHA said he was notified of the reported 12/28/24 physical altercation between Resident #34 and Resident #53 by the social service director (SSD) on the evening of 12/30/24. He said he reported the allegation and started the investigation on 12/31/24. He said he substantiated the allegation of physical abuse based on intent. He said Resident #53 intentionally pushed Resident #34. He said the residents were separated and Resident #53 was provided a different room on 12/31/24. He said if he would have been made aware of situation sooner, than he would have started an investigation and looked into moving Resident #53 prior to the physical altercation. The NHA said knowing about the concerns between Resident #34 and #53 before 12/30/24 could have potentially decreased Resident #34's discomfort. The NHA said Resident #53 had a history of altercations with another roommate. He said Resident #53 was moved to Resident #34's room after the altercation with his former roommate in November 2024. He said there was an argument between the two roommates and Resident #53 threatened his roommate at the time. The NHA said he was not aware of the threatening words made by Resident #53 as documented on 12/29/24. He said the interdisciplinary team tried to review progress notes to identify potential concerns, but the note was not identified as a concern. The NHA said behavior tracking was documented in TARs and a note documented a behavior would usually just be completed when there was a significant change from a resident's baseline behavior. The NHA said the nurse supervisor should have informed the DON and the NHA when Resident #53's threatening remarks were reported to her so an investigation could have been started. He said the facility's abuse training was ongoing and he would look at additional education needs. The DON and the NHA were interviewed together on 1/15/25 at 4:54 p.m. The DON said the nurse who documented the threatening words spoken on 12/29/24 by Resident #53 notified licensed practical nurse (LPN #1), who was identified as the supervisor on 12/29/24 that the nurse reported her concern to. The DON said LPN #1 did not notify her of the threatening statement. She said the nurses were not trained to report remarks by a resident made to themselves in the privacy of their room. The DON said the threatening statement was made loud enough for the nurse in the hallway to hear him but Resident #34 was not in the room at the time. She said no one followed up with Resident #34 or initiated an investigation to identify if he was being threatened by Resident #53 or if there were concerns between the two roommates. The DON said Resident #53 was already on behavior tracking so his behaviors should have been monitored. The DON said she would report the 12/29/24 incident on the evening of 1/15/25. The DON was interviewed again on 1/16/25 at 1:20 p.m. She said she was in the process of reeducating the staff on abuse and reported Resident #53's 12/29/24 threats of physical aggression. The NHA was interviewed on 1/16/25 at 1:32 p.m. The NHA said there were two opportunities missed to identify and address the situation between Resident #34 and #53 before the physical altercation. He said even a check-in with the residents could have potentially prevented the physical altercation. IV. Facility follow-up A 1/16/25 abuse reporting and investigation training participation sheet was provided by the NHA on 1/16/25 at 12:57 p.m. The participation sheet identified 31 facility staff members received abuse training on 1/16/25.

Based on observations, record review and interviews, the facility failed to ensure services provided to one (#10) of seven residents met professional standards of quality out of 32 sample residents. Specifically, the facility failed to ensure Resident #10's enteric-coated omeprazole was not crushed prior to administration. Findings include: I. Professional reference According to the MayoClinic, Omeprazole oral route (2024) was retrieved on 1/21/25 from https://www.mayoclinic.org/drugs-supplements/omeprazole-oral-route/description/drg-20066836 It read in pertinent part, Do not crush or chew the tablet. Do no crush or open the capsule. Swallow whole. II. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO) diagnoses included gastro-esophageal reflux disease, chronic obstructive pulmonary disease (COPD) and need for assistance with personal care. The 11/25/24 minimum data set (MDS) assessment revealed Resident #10 was unable to participate due to rarely being understood. The staff assessment revealed Resident #10 had short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. B. Observations and interview On 1/15/25 at 9:55 a.m., licensed practical nurse (LPN) #4 was crushing Resident #10's morning medications, which included an Omeprazole Capsule Delayed-Release 20 mg capsule. LPN #4 said the resident's medications needed to be crushed and ready for when the resident woke up. LPN #4 said any medication that was enteric coated, an extended-release or a delayed-release could not be crushed. She said if there was a medication that needed to be crushed but was unable to be crushed she would call the doctor asking for an alternative option. C. Record review On 6/23/21 a physician's order was entered for Resident #10 for Omeprazole Capsule Delayed-Release 20 milligrams (mg) to be administered every morning. III. Staff interviews LPN #5 was interviewed on 1/15/25 at 9:40 a.m. LPN #5 said any medication that was enteric coated, an extended-release or a delayed-release could not be crushed. She said if there was a medication that needed to be crushed, but was unable to be crushed she would call the doctor asking for an alternative option. Registered nurse (RN) #3 was interviewed on 1/15/25 at 9:45 a.m. RN #3 said any medication that was enteric coated, an extended-release or a delayed-release could not be crushed. She said if there was a medication that needed to be crushed, but was unable to be crushed she would call the doctor asking for an alternative option. The director of nursing (DON) and the corporate consultant (CC) were interviewed together on 1/15/25 at 10:30 a.m. The DON said any medication that was enteric coated, an extended-release or a delayed-release could not be crushed. She said if there was a medication that needed to be crushed, but was unable to be crushed she would call the doctor asking for an alternative option. The DON said she was preparing education for the nursing staff regarding crushing medications. IV. Facility follow-up The CC provided education that was provided to the nursing staff on 1/15/25 at 11:00 a.m. (during the survey). The education explained that any medication that was enteric coated, an extended-release or a delayed-release could not be crushed. The facility posted a list of medications from the pharmacy describing which medications were crushable and which medications were not crushable.

Based on record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for one (#8) of five residents out of 32 sample residents. Specifically, the facility failed to: -Implement and update fall care plans in a timely manner for Resident #8; and, -Ensure neurological checks were completed appropriately for Resident #8 following an unwitnessed fall. Findings include: I. Facility policy and procedure The Falls and Fall Risk, Managing policy, revised March 2018, was provided by the corporate consultant (CC) on 12/18/24 at 3:12 p.m. It documented in pertinent part, According to the minimum data set (MDS), a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g. a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff will identify and implement relevant interventions (hip padding or treatment of osteoporosis, as applicable) to try and minimize serious consequences of falling. The Neurological Record Documentation procedure, not dated, was provided by the director of nursing (DON) on 1/16/25 at 4:57 p.m. It documented in pertinent part, that after a fall, resident vital signs must be obtained and neurological assessments must be performed every 15 minutes for one hour following the fall event, then every 30 minutes for two hours after the first hour assessments, then assessments are performed every hour for the following two hours, then assessments were performed every shift thereafter until 72 total hours had passed since the fall even occurred. II. Resident #8 A. Resident status Resident #8, age greater than65, was admitted on [DATE] and readmitted [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, congestive heart failure (CHF) and rheumatoid arthritis. The 11/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. He was independent when eating, required set-up or clean-up assistance with oral hygiene, required moderate assistance with personal hygiene, and required substantial or maximum assistance with showering, toileting hygiene, lower body dressing, and footwear. The assessment documented the resident required substantial or maximum assistance with all acts of mobility. B. Record review The fall plan of care, initiated 8/3/23 and revised 10/29/24, documented Resident #8 had experienced a fall on 10/26/24. The plan of care documented Resident #8's goal was to have no falls with injury through the review date of 2/16/25. Interventions included keeping Resident #8's bed in a low position, ensuring non-slip grips were placed next to the resident's bed and bathroom and assisting the resident to organize belongings for a clutter-free environment. An intervention for the resident to be evaluated and treated by therapy as indicated was documented to have been added to the fall plan of care on 10/29/24. Nursing fall risk assessment, dated 10/26/24, documented Resident #8 was a moderate risk for falling. Interdisciplinary (IDT) -fall progress note, dated 10/29/24, documented Resident #8 experienced an unwitnessed fall on 10/26/24 at 3:00 p.m. when he was attempting to self-transfer to his bed from his wheelchair and slid to the ground. The progress note documented that physical therapy and occupational therapy would evaluate and provide treatment forResident #8 because he fell . The neurological record documentation, dated 10/26/24 to 10/29/24, documented the vital signs obtained and neurological assessments performed by nursing staff after Resident #8 fell on [DATE]. -The flow sheet failed to document neurological assessments performed or vital signs obtained during the day shift on 10/27/24 and 10/28/24. -The facility failed to perform neurological assessments per the facility's protocol (see interview below). A review of Resident #8's January 2025 CPO revealed a physician's order for physical therapy to evaluate and provide treatment to the resident, ordered on 10/29/24. Physical therapy note, dated 10/29/24, documented Resident #8 was evaluated by physical therapy on 10/29/24. -The facility failed to implement the newly identified fall prevention intervention in a timely fashion (see record review above and interviews below). D. Staff interviews The physical therapist (PT) was interviewed on 1/15/25 at 2:19 p.m. The PT said if a resident was referred to PT following a fall, the resident could be seen the same day if the therapy department was notified. The PT said she was not aware of a time the PT could not see a resident the day it was ordered, unless it was ordered near the end of the day. Registered nurse (RN) #1 was interviewed on 1/16/25 at 10:07 a.m. RN #1 said if a resident experienced an unwitnessed fall she would immediately assess the resident for any injuries and start obtaining neurological assessments per the facility schedule printed on the documentation sheet. RN #1 said it was not okay to skip or miss neurological assessments for any reason unless the resident refused. RN #1 said it was important to complete neurological assessments to watch for delayed head injuries. Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 11:25 a.m. LPN #3 said if a resident had an unwitnessed fall, he would make sure the resident was okay and then get a RN to assess the resident. LPN #3 said neurological assessments were then completed by the protocol printed on the documentation form. LPN #3 said it was never acceptable to miss a neurological assessment because nurses had to make sure the resident did not develop a head injury. The DON was interviewed on 1/16/25 at 2:05 p.m. The DON said she considered a fall to be an unplanned descent to the floor. The DON said when a resident experienced an unwitnessed fall, she expected a RN to perform an assessment, ensure the resident did not have injuries and begin neurological assessments. The DON said neurological assessments should be performed according to the printed schedule on the neurological record documentation sheet. The DON said neurological assessments should not be skipped or missed unless the resident was not in the building. The DON said it was important to perform all the neurological assessments according to the printed schedule to ensure residents did not injure their brain. The DON said she reviewed the neurological record documentation for Resident #8. The DON said the facility did not document a neurological assessment or vital signs on day shift of 10/27/24 or 10/28/24 for Resident #8. The DON said after a resident experienced a fall, the facility would review and update the plan of care with new interventions. The DON said the new intervention should closely match the reason for the fall. The DON said that physical therapy could see residents the same day if needed. The DON said it should not have taken three days for Resident #8 to be evaluated by physical therapy.

Based on record review and interviews, the facility failed to ensure catheter care in accordance with professional standards of care for two (#50 and #58) of three residents reviewed for appropriate catheter use and care out of 32 sample residents. Specifically, the facility failed to: -Provide suprapubic catheter care to Resident #50; -Conduct a thorough assessment after Resident #58 completed antibiotics for a urinary tract infection (UTI) to ensure the resident did not display further signs or symptoms of an UTI. Findings include: I. Professional reference According to the National Institutes of Health Library of Medicine: Prevention of Dependent Loops in Urine Drainage Systems in hospitalized Patients, retrieved on 1/22/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC4423413/#F1. It revealed in pertinent part, A dependent loop is formed by excess drainage tubing in a urine drainage system where urine or liquid can accumulate. Dependent loops trap drained urine and are suspected of impeding bladder drainage and increasing the residual volume of retained urine in the bladder. II. Facility policy and procedures The Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing policy, revised June 2014, was provided by the corporate consultant (CC) on 1/15/25 at 11:55 a.m. It documented in pertinent part, Be able to identify and report the clinical signs and symptoms of a urinary tract infection (with or without catheter), including: acute dysuria, fever, pain, swelling or tenderness of testes, suprapubic tenderness, costovertebral angle tenderness, leukocytosis, hematuria, incontinence, increased urgency or frequency, hypotension, confusion and/or functional decline, and/or purulent discharge around the catheter. Perform daily meatal hygiene with soap and water for residents with indwelling catheters. The Catheter Care, Urinary policy, revised August 2022, was provided by the facility on 1/15/25 at 11:55 a.m. The policy directed staff to make sure the catheter tubing and drainage bag were kept off the floor, observe and report complaints of burning, tenderness or pain in the urethral area. The Infections, Clinical Protocol policy, revised March 2018, was provided by the CC on 1/15/25 at 11:55 a.m. The policy documented the nursing staff and the physician would monitor the progress of a resident with an infection until it was resolved with no further significant clinical signs of symptoms. III. Resident #50 A. Resident status Resident #50, age greater than 65, was admitted on [DATE] and readmitted [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included bladder disorder unspecified, other retention of urine and obstructive and reflux uropathy (abnormal urine flow in the urinary system). The 10/24/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. He was dependent on staff for assistance with bathing and toileting hygiene. He required substantial or maximal assistance with dressing, footwear and personal hygiene. B. Resident interviews and observations Resident #50 was observed and interviewed on 1/14/25 at 10:18 a.m. Resident #50 said he was experiencing discomfort at his suprapubic catheter insertion site. Resident #50 said his suprapubic catheter was not being cleaned daily. Resident #50 said he did not think his suprapubic catheter had been changed since October 2024. Resident #50 said he was concerned about his suprapubic catheter. Resident #50 revealed his suprapubic catheter site. The suprapubic catheter site skin appeared to be dark and inflamed, with inflammation extending approximately one centimeter (cm) lateral to the insertion site. A small amount of white drainage was seen where the suprapubic catheter entered the body. Black and brown matter was adhered to approximately one cm of length of the yellow catheter tube. No dressing was observed on the suprapubic catheter at the insertion site. Resident #50's suprapubic catheter site was observed again on 1/15/25 at 11:12 a.m. The suprapubic catheter tubing had black and brown matter adhered to approximately one cm of length of the yellow catheter tube. No dressing was on the suprapubic catheter at the insertion site. Resident #50 was interviewed again on 1/15/25 at 11:14 a.m. Resident #50 said facility staff had not assessed or cleaned his suprapubic catheter yesterday or today. Resident #50 said he had experienced several UTIs in the facility before and he was concerned that these symptoms indicated another UTI was developing. C. Record Review The suprapubic catheter plan of care, initiated 2/7/24 and revised 8/13/24, documented Resident #50 had a suprapubic catheter placed on 1/2/24 by a urologist as a result of multiple traumatic urinary diagnoses. The resident's goal was to be free from catheter-related trauma and complications through the review date. Interventions included performing catheter care every shift and as needed, cleansing the suprapubic catheter daily with normal saline, patting dry and covering with a dry dressing every day and as needed if soiled or dislodged, checking the suprapubic catheter tubing for kinks each shift, monitoring and documenting intake and output each shift, monitoring and document pain or discomfort due to the catheter, and to monitor, record and report signs and symptoms of urinary tract infection such as: pain, burning, blood tinged urine, cloudiness, no urinary output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behaviors, or changes in eating patterns. Point of care documentation of catheter care offered and provided was reviewed for 30 days (12/17/24 and 1/16/25). In 30 days of opportunities, the facility documented catheter care was performed daily on 29 of those 30 days. The facility documented catheter care was performed on 1/14/25 and 1/15/25. -However, black and brown matter was observed to be adhered to the catheter tubing on 1/14/25 and 1/15/25, indicating catheter care had not been performed. -Licensed practical nurse (LPN) #6 and the CC said Resident #50's catheter needed to be cleaned on 1/15/25 (see interviews below). Urinary catheter staff education was provided by the CC on 1/15/25 at 4:48 p.m. The education documented that five staff members received education on 1/15/25 on how to properly clean urinary catheters. The education consisted of a printed facility urinary catheter care policy that was individually signed by the staff members. The education included documentation that perineal hygiene included using a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward. D. Staff interviews LPN #6 was interviewed on 1/15/25 at 11:35 a.m. LPN #6 said she had not observed Resident #50's catheter or performed catheter care for Resident #50 today. (1/15/25) LPN #6 said catheter care should be performed daily and as needed if the tubing was dirty. LPN #6 said she was not aware of any concerns with Resident #50's suprapubic catheter. LPN #6 then entered and observed Resident #50's suprapubic catheter with the resident's permission. LPN #6 said there was black and brown matter on the suprapubic catheter tubing and the tubing needed to be cleaned. LPN #6 said that urine was flowing freely into the drainage bag and the urine color itself had not changed. LPN #6 said she was not concerned with how Resident #50's suprapubic catheter appeared on observation at that time. LPN #6 said she would perform catheter care to remove the black and brown matter that adhered to the tubing. The CC was interviewed on 1/15/25 at 12:08 p.m. The CC said she had an opportunity to look at Resident #50's catheter. The CC said the catheter needed to be cleaned. The CC said that there was no current concern to change the catheter tubing or involve a physician at this time. The CC said education would be provided to all nursing staff on how to clean a urinary catheter. Registered nurse (RN) #1 was interviewed on 1/16/25 at 10:07 a.m. RN #1 said suprapubic catheters should be cleaned every day. RN #1 said if there was visible matter on the suprapubic catheter, it should be scrubbed off because it was an infection risk for the resident. Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 11:25 a.m. LPN #3 said all catheters should be cleaned daily and as needed when the tubing was unclean. LPN #3 said if any matter was visible on the catheter tubing, it must be scrubbed off to prevent infection. The DON was interviewed on 1/16/25 at 2:05 p.m. The DON said that indwelling catheters should be cleansed daily and as needed. The DON said that if a resident had a catheter with white drainage, or if a resident was experiencing pain or discomfort at their catheter site it should be reported to the physician. The DON said she did not have a chance to see Resident #50's catheter on 1/15/25. The DON said black or brown matter adhered to the urinary catheter should be cleansed off of the catheter tube because the adhered matter can contribute to the development of a urinary tract infection. 40467 IV. Resident #58 A. Resident status Resident #58, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included neuromuscular dysfunction of the bladder, unspecified urinary incontinence, other urethral stricture, male, unspecified site, benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. The 12/17/24 MDS assessment documented Resident #58 was cognitively intact with a BIMS score of 14 out of 15. He did not have inattention, disorganized thinking or rejection of care behaviors. The resident required partial to moderate assistance with most of his activity of daily living (ADL) care needs. Resident #58 used a wheelchair for mobility. According to the MDS assessment, the resident used an indwelling catheter B. Resident interview and observation Resident #58 was observed in his room on 1/13/25 at 3:20 p.m. Resident #58 sat in his wheelchair. His indwelling catheter bag laid flat on the floor in front of him. The long catheter tubing was outstretched by more than six inches from his feet. He said he placed the catheter bag on the floor earlier when he was urinating and had not picked it up off the floor. He said he placed the catheter bag on the floor so when he urinated the urine would go straight to the bag and not back up the catheter tube. He said he routinely would lay the catheter bag on the floor when he was sitting in his wheelchair and urinated. Resident #58 said he was prone to urinary track infections and in the past he went to the hospital for sepsis. Resident #58 picked up the catheter bag from the floor and clipped the bag to the wheelchair. A loop was created in the catheter tubing when he clipped the bag. Resident #58 was interviewed on 1/15/25 at 2:01 p.m. He said his catheter was leaking during the night of 1/14/25 and today (1/15/25) he had a burning feeling when he urinated. He said he told the staff and they told him they would keep an eye on it for now. Resident #58 was observed a second time on 1/15/25 at 5:02 p.m. His catheter bag was hooked to the bottom rail of his wheelchair. A section of catheter tubing hung below the catheter bag and about one inch off the floor, creating a dependent loop. Resident #58 was interviewed on 1/16/25 at 1:02 p.m. He said he still had a burning sensation when he urinated and told his nurse. C. Record review The indwelling foley catheter care plan, revised 10/15/24, identified Resident #58 was at risk for complications with urinary system related to his indwelling catheter for wound healing history of obstruction and reflux uropathy bladder with retention. The care plan included the following interventions, dated 9/13/23, providing the resident catheter care and empty his catheter every shift and as needed; notifying the nurse of foul-smelling urine, blood, or discharge; keeping the catheter anchored for security and to prevent trauma; and, notifying the physician of signs and symptoms of a UTI such as mental status changes, foul smelling urine, color change in urine, hematuria, sedimentation, burning with urination and an increased body temperature. The 11/12/24 physician's order directed staff to monitor placement of Resident #58's foley catheter. According to the CPO, staff should make sure the catheter had no kinking or compression that could obstruct urine flow to the gravity bag during catheter care on every day and night shift. -However, observations revealed the resident's catheter tubing had a loop, which could prevent the flow of urine (see observations above). The 1/3/25 nurse progress note documented Resident #58's nurse clamped the catheter drainage tubing for 40 to 45 minutes at two separate times before attempting to collect urine from the catheter after disconnecting drainage tubing. According to the note, the nurse was unable to collect urine at that time and would pass the concern on to the day nurse. The 1/5/25 laboratory note documented a urine culture was collected from the foley port of Resident #58 and sent to the hospital lab for analysis. The 1/8/25 CPO identified the resident had a physician's order for Cephalexin (Keflex) oral tablet antibiotics. The CPO directed staff to give the resident 500 milligrams (mg) twice a day for five days for a UTI with a start date 1/8/25 and competed on 1/13/25. The 1/9/25 72-hour charting note documented Resident #58 started Keflex for a UTI. According to note, the resident denied pain or discomfort and had no adverse reactions during this shift The 1/10/25 72-hour charting note documented Resident #58 continued on Keflex for a UTI. According to note, the resident denied pain or discomfort and had no adverse reactions during this shift The 1/11/25 72-hour charting note documented Resident #58 continued on Keflex for a UTI. According to note, the resident denied pain or discomfort and had no adverse reactions during this shift The 1/12/25 72-hour charting note documented Resident #58 continued on Keflex for a UTI. According to note, the resident denied pain or discomfort and had no adverse reactions during this shift The January 2025 medication administration record (MAR) documented Resident #58 took his last dose of antibiotics for his UTI on the morning of 1/13/25. Review of Resident #58's electronic medical record (EMR) did not identify the resident was placed on 72 hour charting after he completed his prescribed antibiotics on 1/13/25 (see interviews below). The EMR did not identify the resident was assessed for UTI symptoms after he completed the antibiotics on the morning of 1/13/25. D. Staff interview The DON and the CC were interviewed together on 1/16/25 at 1:04 p.m. The DON said Resident #58 has a history of concerns with UTI's and was followed by a urologist. The CC said he was last seen by the urologist on 11/19/24. The DON said Resident #58 recently was treated with antibiotics for a UTI. She said the nurses would complete 72 hour charting to monitor the response to the antibiotics. She said the nurses should complete 72 hour charting after the resident completed the antibiotics for a UTI to make sure the UTI was gone and he no longer had signs and symptoms of an infection. The DON said she reviewed Resident #58 progress notes. She said there were no 72 hour progress notes that identified the nurses were assessing the resident for signs and symptoms of the UTI after he completed the course of antibiotics. She said the nurses were probably asking how he was feeling but did not chart his response or if there were concerns. The DON said she would reeducate the nursing staff to complete 72 charting the completion of antibiotics. The DON said a catheter bag should never be placed on the floor because of the risk of cross-contamination and infection. She said she was not aware that Resident #58 placed the catheter bag on the floor to help with drainage to the catheter bag. The RCR said a loop in the catheter tubing could cause back flow of the urine. The DON said she would review the resident's catheter and look at solutions to these concerns to decrease the risk of infection.

Based on observations, record review and interviews,, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings including the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to: -Ensure the residents knew where the state survey results were located; and, -Ensure the binder was accessible for review by residents and visitors. Findings include: I. Facility policy and procedure The Availability of Survey Results policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 12:57 p.m. It read in pertinent part, The survey binder is located in the main lobby and is available for review by interested persons who wish to review information relative to our company's compliance with federal and state rules, regulations and guidelines governing our company's operations. A representative of management is assigned the responsibility of making weekly inspections of the survey binder to ensure that the binder contains current information, is located in its designated area(s) and is readily accessible without one having to ask staff members for the information. II. Group interview The group interview was conducted on 1/15/25 at 10:30 a.m., with eight residents (#11, #51, #47, #35, #5, #62, #24 and #23), who were identified as alert and oriented by facility and assessment. The residents said they were unaware they could view the federal and state survey results. The residents said they were not aware the results of the surveys had been posted for them to be able to access and read. The residents said they were unaware there was a binder accessible for residents and family members to read past survey results. The residents said they would be interested in reading the results of previous surveys. III. Observations On 1/14/25 at 12:00 p.m., the binder containing the past survey results was unable to be located and there was not a sign posted in the facility indicating where the binder was located. On 1/15/25 at 2:47 p.m., the binder containing the past survey results was unable to be located and there was not a sign posted in the facility indicating where the binder was located On 1/16/25 at 12:20 p.m., the binder containing the past survey results was located on the lowest shelf underneath another binder in the front area near the receptionist's desk. The binder was unlabeled. -The binder was not easily accessible by residents or visitors and there was not a sign that indicated where the binder could be located. IV. Staff interviews The NHA was interviewed on 1/16/25 at 12:25 p.m. The NHA walked to the main lobby and pulled the state survey binder from the bottom shelf and removed it from underneath another binder. He said the residents would not know where the binder was located without asking a staff member. The NHA said he was going to label the binder and ensure it was not on the bottom shelf or underneath other binders.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 13 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically the facility failed to: -Implement an effective plan of care that adequately addressed the risks posed to Resident #1 and other residents in the facility due to Resident #1's excessive alcohol consumption; -Provide adequate supervision for Resident #1, inside and outside the facility, due to the resident's excessive alcohol consumption; and, -Follow physician's orders for Resident #1 to have supervision when the resident was out of the facility. Findings include: I. Facility policy and procedure The Falls Clinical Protocol policy, dated 2001, was provided by the nursing home administrator (NHA) on 10/2/24 at 6:25 p.m. It read in pertinent part, The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and the caregiver or family about the history of falling. The staff and the physician will document in the medical record a history of one or more recent falls. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The Alcoholic Beverage policy, dated 2001, was provided by the NHA on 10/2/24 at 6:25 p.m. It read in pertinent part, A physician's order must be received before any alcoholic beverages may be administered to a resident. Should such an order be received, the nursing supervisor receiving the order must contact the pharmacist. Should there be a medication that would interact with the alcohol, the nurse supervisor must inform the physician of the medications. Record and follow the physician's instructions. Alcoholic beverages must be paid for by the resident, his family, and/or the resident's representative. The nurse supervisor receiving the alcohol beverage must label the bottle. The label must contain the resident's name and room number. The alcoholic beverage must be treated as a medication and stored in the medication room. II. Resident status Resident #1, age greater than age 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included major depressive disorder, history of falling, atherosclerosis (plaque build up) of the native arteries of extremities with intermittent claudication (a symptom of the disease causing pain, cramping or muscle fatigue) and rest pain of the left leg, generalized muscle weakness, other abnormalities of the gait and mobility, and unspecified dementia, moderate without behavioral disturbance psychotic disturbance, mood disturbance and anxiety. The 7/26/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident used a walker for mobility. She was independent in most activities of daily living (ADLs) According to the MDS assessment, the resident had rejection of care behavioral symptoms. III. Resident interview and observation Resident #1 was interviewed on 10/2/24 at 3:15 p.m. Resident #1 said she came to the facility because she had a bad ankle but planned to return home when her ankle improved. She said she did not want to stay long term at the facility. She said she was not told on admission that she could not leave the facility independently or bring in her own alcohol. Resident #1 said the facility should have told her rights at the facility before she was admitted . She said if she knew about the rules she would not have agreed to come. Resident #1 said the facility found her with a couple of beers and a bottle of wine. She said she knew there were about 42 residents at the facility and there were 26 residents who drank or used to drink but she was the one with a bad reputation. She said some residents wanted a beer from her but she had not given them alcohol. She said the residents needed to ask for alcohol from their nurse. Resident #1 said she knew she was not supposed to leave the facility alone. She said she could go out on pass but she had to have someone come with her. She said she liked to go to thrift stores and go to the grocery store. She said she would take a cab to go shopping. She said she was supposed to have someone go with her but staff did not always have the time to go with her. Resient #1 said a lot of the residents needed help so she would visit them and see what she could do to help them. During the interview, Resident #1 did not show any signs of intoxication or being under the influence of alcohol. The resident's room was observed with the resident. There were no observations or odors of alcohol observed in her room. IV. Other resident interview Resident #7 was interviewed on 10/2/24 at 2:15 p.m. Resident #7 said a few of weeks ago Resident #1 offered her a walker bag. She said Resident #1 opened up her walker seat and a pint of whisky fell out on the floor. She said Resident #1 laughed, quickly put it back in her seat, and told Resident #7 that she did not see anything. Resident #7 said she was worried another resident would get into Resident #1's alcohol and would have to go to the hospital because they had a bad reaction with their medications and the alcohol. V. Record review The fall care plan, initiated on 4/22/24 and revised on 8/8/24, revealed Resident #1 was at risk for falls with and without injuries related to her antidepressant medication, alcohol use, antihypertensive medication, and history of falling. The resident's goal was to minimize her risk for falls to the extent possible. An intervention, dated 8/8/24, documented Resident #1 had a tendency to walk to the liquor store or call a taxi cab and bring alcohol into the facility. The intervention directed staff to keep Resident #1 within a supervised view as much as possible. According to the care plan, a request was made with the taxi cab company to speak to staff prior to picking up the resident and taking her shopping. The 5/12/24 medication administration note documented the resident's primary concern was how to get out of the facility on good terms. The resident was informed she needed to be discharged by the physician. The resident said she would speak to the physician because she needed to get some items out of storage. A 5/15/24 physician's order revealed the physician recommended Resident #1 only leave the facility with supervision and only related to housing issues. The psychosocial care plan, initiated 5/27/24, identified the resident preferred spending time away from the facility drinking alcohol. According to the care plan, the resident understood she had a PRN (as needed) order for five ounces of wine that reset every 24 hours. A physician's order dated 6/11/24 identified the resident could have a five ounce (oz) glass of wine per day every 24 hours as needed. The 6/16/24 at 5:28 a.m. nurse note identified the nurse entered the room of Resident #1 on the morning of 6/16/24. The resident was slurring her words and the room smelled of alcohol. The resident confirmed she had been drinking but said it was okay because management allowed her to have four ounces of alcohol. According to the note, there were beer cans under her bed, a brown bag with alcohol in it and multiple open and empty alcohol containers around her bed. Resident #1 refused to allow staff to clean up the area. The nurse notified the night nurse supervisor. A 6/16/24 behavior noted documented Resident #1 was walking around her room without pants or underwear on. The resident said she had been drinking. The alcohol was observed in the resident's room. The resident consented to the removal of two unopened 24 oz beers at 8.1% (percent) alcohol and three empty 11.2 oz containers of [NAME] mixed drinks, including an open but not finished [NAME] drink and a partially finished can of beer. The director of nursing (DON) and the manager on duty were notified. A late entry 6/19/24 social service note read the social services director (SSD) spoke to Resident #1 regarding consuming alcohol, sharing her alcohol, and bringing it to her room. The resident agreed to work with staff to care plan and create a safety plan. The note identified an alcohol anonymous (AA) meeting would be held in the facility starting on 6/19/24. She was encouraged to attend. According to the note, the SSD informed the resident she had the option to discharge and how to safely discharge if the resident wanted to. -Review of Resident #1's electronic medical record (EMR) and staff interviews (see interviews below) did not identify a specific safety plan or discharge plan for Resident #1. -There was no further documentation to indicate the AA meeting had occurred or whether Resident #1 had attended the meeting. A 6/19/24 health status note documented Resident #1 was sitting outside in front of the facility from 7:00 p.m. to 10:00 p.m. Resident #1 was drinking beer and sharing it with another resident. Resident #1 had several bags and boxes stacked on top of her walker. The resident denied drinking but she was very unsteady when she attempted to walk and had an odor of alcohol on her. According to the note, management was notified. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding bringing alcohol into the facility and/or sharing alcohol with other residents. The 6/17/24 at 3:53 p.m. medication administration note identified Resident #1 left the facility without signing out. The 6/17/24 at 10:17 p.m. medication administration note documented the resident returned to the facility at approximately 10:17 p.m. The 6/23/24 behavior note identified Resident #1 returned from the store with bottles of alcohol. The resident was informed that she was not allowed to bring alcohol into the facility or have it in her room. The resident said she was not aware that she could not bring in alcohol into the facility and she was going to save the alcohol for a family member. The resident allowed the staff to lock up the alcohol in the medication room. The medical director and manager on duty were notified. A 6/28/24 medication administration note documented the resident's gabapentin for neuropathy was held because the resident told the nurse she had a lot of alcohol to drink. The 6/29/24 at 5:07 a.m. nurse's note documented Resident #1's gabapentin and antidepressant were held the night of 6/28/24 due to her intoxication. According to the note, the resident said she had not been drinking but she was mumbling in speech. The nurse educated the resident that mixing her medications with alcohol could cause an adverse reaction. The resident told the nurse that she had recently drank alcohol and repeated alot three times. The resident refused for the nurse to remove any other alcohol she had in her room. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding removing the alcohol from the resident's room. The 7/3/24 physician's note documented Resident #1 was buying and bringing in alcohol in the facility. The staff was concerned about her intoxication. The resident had had falls in the facility. According to the note, the resident spoke to the physician again regarding her desire to return home. The physician wrote the resident's thought's were delusional and the resident lacked medical decision making capacity. The note identified the resident did not have a medical power of attorney and would be appropriate to assign a physician proxy (a physician decision maker for unrepresented residents). -The physician's note did not identify a plan related to the resident's alcohol use and fall risk. The 7/10/24 at 6:26 p.m. medication administration note read Resident #1 left the facility at 11:00 a.m. and was asked to return back to the facility for wound care and afternoon medication. According to the note, the resident still had not returned to the facility as of 6:26 p.m. -There was no further followup documentation to the medication administration note. A 7/15/24 physician's order documented Resident #1 could go out on supervised passes for shopping without medications. Another 7/15/24 physician's order documented Resident #1 could have a pass for two hours only at a time for leaving the facility for safety purposes. The 7/15/24 at 12:35 a.m. nurse's progress note documented the nurse was notified by the certified nurse aides (CNA) of a strong smell of alcohol in Resident #1's room and there was a nearly empty bottle of spiced rum by her bed, knocked over on the floor. The resident consented to the disposal of the alcohol. The physician was notified. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding bringing alcohol into the facility. The 7/24/24 medication administration note for two hour passes identified the resident was seen dropped off by the taxi near the back of the facility. The resident did not sign out and staff was unsure how long the resident was gone. The 7/24/24 medication administration note for supervision with passes identified the resident did not have staff supervision when she was out of the facility and returned by the taxi. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding not leaving the facility unsupervised. The 7/26/24 social service note read the SSD spoke with the resident reminding her not to assist other residents with cares, transfers or pushing them in their wheelchairs. The SSD informed the resident of the safety concerns. The 7/31/24 at 6:41 p.m. medication administration note documented Resident #1 went out of the facility without permission and for an undetermined amount of time. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding not leaving the facility unsupervised. The July 2024 quality assurance and performance improvement (QAPI) meeting minutes were provided by the NHA on 10/2/24 at 6:10 p.m. According to the minutes, the IDT discussed the incident trend of Resident #1 and her alcohol consumption. The minutes documented the facility was going to contact the taxi company to limit her taxi rides. The minutes read the facility was going to investigate where she was getting the alcohol from and what they could do about it (see interview below). -The QAPI minutes did not specify when the investigation was to be completed by or identify any interventions to immediately address the safety concerns related to Resident #1's alcohol consumption. A 8/8/24 physician note identified Resident #1 did not arrive at the 8/8/24 scheduled appointment. Resident #1 had requested the appointment for leg pain. The staff at the facility was contacted when the resident missed the appointment. According to the note, the resident frequently went shopping outside of the facility and purchased alcohol for herself and others. Resident #1 tried to transfer other residents. The note read the resident wanted to be helpful but did not remember she should not try to assist other residents. A 8/9/24 at 11:09 a.m. patient safety note identified Resident #1 had a glass of wine and left in a cab on pass. According to note the staff and the DON were aware and staff would monitor the resident upon her return to the facility. An 8/9/24 at 6:11 p.m. alert note documented the resident returned to the facility at 4:30 p.m. The alcohol she returned to the facility with was placed in the medication room and the NHA, the DON, and the nursing staff were made aware. Her medications were placed on hold for safety. Two medication administration notes on 8/9/24 documented Resident #1 had a pass to leave the facility for two hours every shift for safety concerns. According to the notes, the resident went out whenever she wanted and however long she wanted too. A 8/10/24 change of condition evaluation documented Resident #1 hid alcohol and drank throughout the day. The evaluation identified the resident appeared to have fallen (on 8/10/24) after drinking alcohol. According to the evaluation, the resident said she fell out of her chair. A 8/12/24 nurse note documented Resident #1 requested her order for alcohol. The resident was informed she had already had her daily limit of ordered alcohol. Resident #1 said Well I guess I will have to do a delivery. According to the note, the staff would watch for further behaviors. The 8/13/24 behavior note read Resident #1 was seen giving alcohol to another resident on 8/13/24. The resident denied having the alcohol with her after she was observed hiding the alcohol under a tree. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding bringing alcohol into the facility and/or sharing alcohol with other residents. A 8/19/24 at 5:44 p.m. nurse note documented Resident #1 left the facility by herself without anyone. She went to the store and obtained bottles of beer. The alcohol was confiscated by the DON and locked in the medication room. According to the note, the nurse asked the resident why she left the facility and the resident responded because I can and walked away when the nurse was attempting to educate the resident about the importance of not leaving the facility alone. The note identified the resident had a strong odor of alcohol. The resident let go of her walker as she walked down the hallway and began to push another resident (in a wheelchair) down the hallway. The note described the resident as wobbling as she pushed the other resident down the hall. The resident was stopped by the nurse and reminded of the safety concern. The 8/24/24 behavior note identified Resident #1 enter the facility from the outside. She had a staggering gait and smelled of alcohol. The staff found several empty containers of alcohol in the trashcan near where the resident preferred to sit when she was outside. According to the note, the resident had not notified anyone she was leaving the facility. The resident said she had only walked around the building. The resident was informed of the importance of notifying staff when she exited the building for safety. The note documented an empty bottle of wine and an empty bottle of spiced rum were found in her room. The resident was reminded of the importance of not drinking more than she was allowed to. The resident responded she could do whatever she wanted to. The DON was notified of the situation. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding bringing alcohol into the facility. The August 2024 QAPI minutes were provided by the NHA on 10/2/24 at 6:10 p.m. According to the minutes, the IDT questioned the possibility the resident was getting alcohol from potentially two other named residents and spoke with the taxi company. -The QAPI minutes did not identify any additional plans to address safety concerns for Resident #1's use of alcohol. The 9/4/24 behavior note documented Resident #1 was sleeping in her bed during the morning medication pass, with a plastic cup filled halfway with alcohol. The resident woke up to take her medication and asked not to have the cup removed. According to the note, at 9:30 a.m. a CNA observed a bottle of alcohol in the basket of the resident's walker. The bottle was half empty. The medical director and the nurse manager were notified. The resident gave the bottle to the nurse manager on request. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding bringing alcohol into the facility and/or identified a plan to address the alcohol concerns. The 9/11/24 behavior note identified a nurse entered Resident #1's room for a medication pass. The resident was wandering in the room when the nurse noticed five to six empty bottles of alcohol in the middle of the resident's room floor. -There was no further documentation to indicate the facility's management team followed up further with the resident regarding bringing alcohol into the facility and/or identified a plan to address the alcohol concerns. The 9/23/24 behavior note documented Resident #1 continued to assist residents in wheelchairs to their rooms. According to the note, the resident had been educated multiple times not to push residents and she needed to use a walker for safe mobility. VI. Staff interviews The NHA was interviewed on 10/1/24 at 5:10 p.m. The NHA said the facility had had issues with alcohol and residents sneaking out of the facility. He said Resident #1 was providing alcohol to at least one other resident who had since been discharged from the facility. He said Resident #1 would use the back door near the kitchen to exit and enter the facility. He said staff would leave the back door propped open when it should have been locked after the NHA realized the open back door was how Resident #1 was getting back into the facility. The NHA said he was not monitoring to make sure the back door was shut. He said staff had been educated and now the door was kept shut at all times. The NHA said he was not concerned about Resident #1 eloping because she would always return to the facility and she had not expressed wanting to leave the facility. The NHA said Resident #1 was no longer leaving the facility because the back door was now shut. The NHA said the backdoor can not be open from the outside. He said Resident #1 could not enter the facility without someone noticing her. He said she would have to enter the facility from the front door. He said he did not how Resident #1 continued to still get alcohol in the facility. The NHA said the investigation into Resident #1's alcohol use had been an ongoing process. He said he had been trying to find the source of her alcohol supply. He said he had spoken to staff but had not interviewed residents or residents with known alcohol use that Resident #1 spent time with. He said he would expand the investigation to interviewing residents and more staff. The NHA said Resident #1 had physician orders for wine in hopes it would deter her from seeking out additional alcohol but Resident #1 continued to consume other alcohol. He said her use was preventing her from receiving other medications because of the risk of adverse reactions with the alcohol and increased her fall risk. The NHA said Resident #1's behavior was a liability to the facility, increasing the risk of concerns that contributed to the alcohol use. He said social services and a frequent facility visitor (FFV) had met with Resident #1 to offer support and remind her of the need for supervised passes out of the facility. The NHA said Resident #1 did not have a behavior contract in place. He said he had not felt the situation had risen to that level. Licensed practical nurse (LPN) #2 was interviewed on 10/1/24 at 5:44 p.m. LPN #2 said she was concerned about how much alcohol Resident #1 brought into the facility. She said Resident #1 had fallen a couple times because she was intoxicated. LPN #2 said she had found alcohol in Resident's #1's pillow case. She said Resident #1 had snuck out of the facility several times and picked up alcohol. She said Resident #1 would contact a taxi, give them a false name and get picked up by the taxi from the facility. She said, in the last couple of weeks, Resident #1 had been more compliant with getting someone to supervise her out on pass. She said staff tried to monitor the resident during the week but thought she went out on the weekends to pick up the alcohol. LPN #2 said she had concerns for Resident #1's safety related to her fall risk and her medications because of her alcohol use. She said the resident's gait was unstable when she was under the influence of alcohol and her room was frequently cluttered. LPN #2 said the resident was on several medications she should not have with alcohol but she had an order for alcohol and she would not always know if the resident had other alcoholic beverages. She said if Resident #1 stated she drank or showed signs of intoxication, she would hold the medication. LPN #2 said she was also concerned for other residents due to Resident #1's alcohol use. She said was concerned that another resident would go into her room and drink her alcohol. She said there was one resident who lived on the same hallway as Resident #1 who wandered, however she had not seen her go into Resident #1's room. LPN #2 said she was concerned she would share her alcohol with other residents. LPN #2 said she was worried about Resident #1 helping other residents, especially if she was under the influence of alcohol. She said Resident #1 would go into other residents' rooms and answer their call lights. The maintenance service director (MSD) was interviewed on 10/2/24 at approximately 9:30 a.m. The MSD said he had found bottles of alcohol hidden around the facility grounds. The social service director (SSD) was interviewed on 10/2/24 at approximately 10:00 a.m. The SSD said Resident #1 had a history of alcohol use prior to admitting to the facility. She said the staff started noticing Resident #1 bringing in alcohol near the end of May 2024 or the beginning of June 2024. She said the resident said she used alcohol for pain and felt sad and alone. She said a therapist was recommended but the resident said she felt it would be a waste of time. The SSD said an AA meeting was held at the facility about a month ago but she was not sure if she went to the meeting or not. The SSD said Resident #1 was receptive to conversations with her regarding coping skills and activities she enjoyed. The SSD said Resident #1 was starting to get better about asking staff to go out on pass with her before she left the facility. The SSD said the facility did not have a problem with alcohol until Resident #1 admitted to the facility. The SSD said staff reported that the resident had been intoxicated in the facility and bottles of alcohol had been found in her room. She said the staff had reported Resident #1 shared and provided alcohol to another resident who was discharged in mid-September 2024. She said the other resident could have also been providing the alcohol. The SSD said the alcohol in the facility had decreased since the former resident was discharged . The SSD said there were still some alcohol concerns but she had not asked Resident #1 where she was getting the alcohol. The SSD said Resident #1 had dementia and had poor decision making skills. She said she had a deep need to have time out of the facility. The SSD said she was concerned that the resident left the facility unsupervised. Registered nurse (RN) #1 was interviewed on 10/2/24 at 11:58 a.m. RN #1 said her biggest concern in the facility was alcohol. She said she had found six empty bottles of alcohol in Resident #1's room a couple of weeks ago. RN #1 said, on 9/30/24, Resident #1 was found asleep in her room with a cup of wine still in her hand. She said a couple of weeks ago a bottle of alcohol was found in her bed. RN #1 said another resident admitted to the facility so he would not drink but was influenced by Resident #1's alcohol in the facility and started to drink again. She said he was recently discharged from the facility because of the alcohol. RN #1 said shooters of alcohol had been found on the facility grounds. She said nurses would find Resident #1 with other residents drinking outside and have to ask them to come back into the facility. She said she was not sure if Resident #1 was giving alcohol to other residents, but she was concerned that she tried to provide care to other residents. She said she would push other residents wheelchairs. She said one time Resident #1 started to push a resident in a wheelchair down the hall and the other resident's foot dropped and started to drag under the wheelchair. RN #1 said Resident #1 would try to transfer other residents. She said she was worried the resident would fall when she was intoxicated. She said Resident #1 could fall on another resident. RN #1 said, within the last couple of weeks, she saw Resident #1 return to the facility after leaving without supervision. She said the resident would have the taxi drop her by the back of the facility and she would come in by the front door. She said Resident #1 would have alcohol in her room but staff could not remove it unless she consented. LPN #2 was interviewed again on 10/2/24 at 2:46 p.m. LPN #2 said staff tried to keep tabs on Resident #1 but there was no specific monitoring plan or documentation to track. LPN #2 said close monitoring and tracking of the resident would be a good idea. The housekeeping director (HKD) was interviewed on 10/2/24 at 2:57 p.m. The HKD said Resident #1 asked her on 10/2/24 if she could have a little refrigerator placed in her room so she could chill her beer and tequila. The HDK said she did not see the alcohol, but a couple of weeks prior to the interview, she had found empty bottles in the resident's room and had seen the resident with red eyes and slurred speech. CNA #2 was interviewed on 10/2/24 at 4:09 p.m. CNA #2 said she frequently worked with Resident #1. She said she had not seen too many concerns with Resident #1 during the day but at night she would sometimes show signs of intoxication such as sweating, stuttering speech and having to lean on the handrail when walking and standing in the hall. She said she had seen these concerns in the last couple of weeks. She said she was not sure where she was getting the alcohol but she had seen Resident #1 leave the facility and come back with shooters and a case of beer. She said she had seen her outside hiding near the back dumpster. CNA #2 said Resident #1 hid a lot of alcohol under her bed. She said the resident was observed stumbling at night so the CNAs helped her to her room to help prevent her from falling. CNA #2 said she had witnessed Resident #1 giving alcohol to a former resident and had observed her sitting outside drinking. CNA #2 said the staff had been asked to let the supervisors know if they had seen concerns or the resident was acting differently and redirect the resident when possible. She said she was concerned for Resident #1's quality of life and safety due to her alcohol use. She said the resident was not stable when she walked with her when she was under the influence of alcohol because she already had a bad leg and limped. CNA #2 said Resident #1 was not happy she was not supposed to leave the facility independently. She said she felt like the staff kept eyes on her and tried to provide extra supervision. LPN #1 was interviewed on 10/2/24 at 4:26 p.m. LPN #1 said she was the facility's unit manager. LPN #1 said Resident #1 was at risk for falls and when she was under the influence of alcohol, she would have more of a risk for falling. CNA #3 was interviewed on 10/2/24 at approximately 6:05 p.m. CNA #3 said she worked part time at the facility and sometimes had worked as Resident #1's CNA. She said residents could only have alcohol if they had a physician's order for it. LPN #3 was interviewed on 10/2/24 at 7:03 p.m. She said Resident #1 drank a lot and she had seen bottles of alcohol in the resident's room within the last couple of weeks. She said when the resident drank a lot she had slurred speech and was not steady when she walked. LPN #3 said Resident #1 had orders for five oz of wine twice a day and would usually ask for the wine between 2:00 a.m. and 4:00 a.m. She said she would hold some of her medications when the resident drank because it could cause an increase in her fall risk if she was more sedated. LPN #3 said Resident[TRUNCATED]

Based on record review and staff interviews, the facility failed to ensure one (#2) of four residents reviewed for abuse out of 13 sample residents was kept free from abuse. Specifically, the facility failed to: -Protect Resident #2 from verbal abuse from Resident #3 on two separate occasions (9/1/24 and 9/16/24); -Report an allegation of verbal abuse on 9/1/24 and 9/16/24; -Thoroughly investigate an allegation of verbal abuse of Resident #2 from Resident #3; and, -Initiate and implement interventions to prevent future resident to resident verbal altercations between Resident #2 and Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation, Reporting and Investigating policy, dated 2001, was provided by the nursing home administrator (NHA) on 10/2/24 at 11:44 a.m. The policy read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Staff conducting the investigation should as a minimum: -Review the documentation and evidence; -Review the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; -Observe the alleged victim to include his interactions with staff and other residents; -Interview the person(s) reporting the incident; -Interview any witnesses to the incident; -Interview the resident or resident's representative; -Interview any witnesses to the incident; -Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; -Interview the resident's roommate, family members, and visitors; -Interview other residents; and, -Review all events leading up to the alleged incident; and, document the investigation completely and thoroughly. Witness statements should be obtained in writing, signed and dated and the NHA was responsible for determining what actions were needed for the protection of the residents after any allegations of abuse. II. Allegations of verbal abuse/resident to resident altercation between Resident #2 and Resident #3 on 9/1/24 and 9/16/24. A. Allegation of verbal abuse on 9/1/24 The NHA provided the 9/1/24 investigation on 10/1/24 at 5:10 p.m. The investigation was an interview with Resident #2 and Resident #3, conducted by the social services director (SSD). The 9/1/24 interview with Resident #2 documented Resident #2 was asked if he was called derogatory names. Resident #2 said no and said he had three friends at the facility. He said he did not know if Resident #3 knew where his family placed his items but he was looking for his bags and boxes. The SSD documented Resident #2 was pleasantly confused with the questions asked but did not show any fear, concern or outward discomfort in the questions asked regarding Resident #3. Resident #2 said he felt safe. The 9/1/24 interview with Resident #3 documented Resident #3 said Resident #2 defecated on the floor and Resident #3 stepped into it. Resident #3 said Resident #2 also had been in his dresser drawers and got lost on Resident #3's side of the room. Resident #3 said he did not get mad and knew Resident #2 could get confused. Resident #3 said if he (Resident #3) became upset, he would go for a walk. He said he did not know what the nurse was talking about in reference to the allegation. Resident #3 said he did not get mad, verbally talk down to Resident #2 or show outward aggression towards him. Resident #3 said he liked his roommate and would not hurt anyone at the facility. The resident said he felt safe. A 9/1/24 interview with another resident (Resident #6) was provided by the NHA on 10/2/24 at 6:25 p.m. The interview was conducted by the SSD. Resident #6 was asked if she had heard any verbal concerns or seen any aggression with other residents on the hall. She said she did not recall anything or she would have reported it to the SSD. Resident #6 said she felt safe at the facility. -No other documentation was provided by the facility pertaining to the 9/1/24 investigation. -There was no documentation or evidence that an allegation of abuse was reported to the appropriate parties, including the State Agency. -There was no evidence of a thorough investigation to determine if the allegation of verbal abuse was substantiated or unsubstantiated. -Review of Resident #2's electronic medical record (EMR) did not identify Resident #2 was monitored for any changes in behaviors specific to the 9/1/24 incident. -Review of Resident #2's and Resident #3's EMRs or the provided documentation did not identify either resident was offered or encouraged a room change (see interviews below) as an intervention to prevent future altercations or verbal abuse towards Resident #2 from Resident #3. -Review of Resident #2's and Resident #3's comprehensive care plans did not reveal person centered interventions were put into place for either resident after the 9/1/24 verbal abuse allegation. B. Allegation of verbal abuse on 9/16/24 Resident #3's 9/16/24 behavior progress note, documented at 12:10 p.m., revealed Resident #3 had signs and symptoms of alcohol intoxication and his speech was incoherent. According to the progress note, the staff would monitor him for safety and other behaviors. The 9/16/24 behavior progress note, documented at 10:45 p.m., revealed Resident #3 had signs and symptoms of drinking such as a strong odor of alcohol, stumbling in the hall and in his room and slurred speech. According to the progress note, Resident #3 called his roommate a derogatory name again. -Review of the requested and provided documentation revealed there was no evidence an investigation was conducted after a nurse wrote in the 9/16/24 progress note that Resident #3 called Resident #2 a derogatory name. The review of Resident #2's progress notes did not identify anyone spoke to Resident #2 on 9/16/24 or after 9/16/24 to determine how he felt about the incident, if he felt safe and he any frustration or concerns with Resident #3. -Review of Resident #2's EMR did not identify Resident #2 was monitored for any changes in behaviors specific to the 9/16/24 incident or that any person centered interventions were implemented to prevent further incidents of verbal abuse from Resident #3. III. Resident #2 A. Resident status Resident #2, age greater than 65, admitted to the facility on [DATE] and was readmitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance/mood disturbance and anxiety, Parkinson's disease without dyskinesia and major depressive disorder. The 8/9/24 minimum data set (MDS) assessment documented Resident #2 had severe cognitive deficits with a brief interview for mental status (BIMS) score of five out of 15. Resident #2 required partial to moderate assistance with his activities of daily living (ADL) and used a wheelchair for mobility. According the MDS assessment, Resident #2 did not have physical or verbal behavioral symptoms directed at others or rejections of care. B. Resident interview Resident #2 was interviewed on 10/1/24 at 2:40 p.m. Resident #2 said he liked his current roommate but his former roommate (Resident #3) would get drunk and then be mean to him. Resident #2 said he could not recall what Resident #3 would say to him but it would make him mad. Resident #2 was interviewed a second time on 10/2/24 at 12:20 p.m. Resident #2 again said he liked his current roommate and was happy his former roommate was gone. C. Record review The cognitive impairment care plan, initiated 4/25/24, directed staff to anticipate and meet Resident #2's needs promptly. The psychosocial care plan, initiated 7/18/24, identified the following interventions: allowing the resident to have control over situations as much as possible; assessing the resident for mood or behavior issues; and, determining if the resident's mood and behavior endangered the resident and intervening if necessary. The room change care plan, initiated 7/18/24, documented Resident #2 had the potential for an impaired adjustment related to room change due to his dementia. The care plan interventions, directed staff to: -Allow the resident expressions of fear and/or concerns; -Assist the resident in problem-solving methods to assure roommate compatibility; -Encourage the resident to express feelings regarding room change; and, -Monitor the resident for adjustment to his new room. Resident #2's room change care plan goal, revised on 8/20/24, was to verbalize acceptance of his new room/roommate. -Review of Resident #2's room change care plan did not identify new interventions after 8/20/24 or after Resident #2's roommate (Resident #3) made potential verbally abusive remarks towards Resident #2 on 9/1/24 and 9/16/24. -Resident #2's progress notes did not identify monitoring of Resident #2 after an allegation of verbal abuse on 9/1/24 and 9/16/24. IV. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE] and discharged home on 9/18/24. According to the October 2024 CPO, diagnoses included alcohol dependence with alcohol-induced persisting dementia, alcohol use, unspecified with withdrawal delirium and other abnormalities of gait and mobility. The 9/18/24 MDS assessment documented Resident #3 was cognitively intact with a BIMS score of 15 out of 15. The assessment indicated Resident #3 was independent with most of his ADLs. According to the MDS assessment, Resident #3 had verbal behavioral symptoms directed towards others as examples of threatening others, screaming at others, and/or cursing at others. B. Family representative interview Resident #3's family representative was interviewed on 10/2/24 at 6:48 p.m. The family representative said Resident #3 went to the facility for rehabilitation but started drinking again at the facility. She said there was nothing more the facility could do for Resident #3 so she and Resident #3 decided to have him return home. She said she was not informed of other behaviors or concerns other than drinking at the facility. C. Record review The mood care plan, revised 4/11/24, revealed Resident #3 was at risk of emotional distress, ineffective coping skills, and poor impulse control. The interventions directed staff to: -Assess clinical issues that could cause or contribute to his mood pattern; -Encourage the resident to express his feelings/concerns; and, -Observe for signs and symptoms of depression/emotional distress and notify the physician as needed. The alcohol dependence care plan, revised 4/11/24, documented the resident was at risk for cognitive and behavioral changes. Interventions included monitoring for any signs or symptoms of alcohol withdrawal and notifying the physician if observed, monitoring the resident for signs of depression and referring to a psychiatrist and/or psychologist as indicated. -Review of Resident #3's care plan did not identify a behavior care plan addressing verbal aggression towards others. -Review of Resident #3's care plan did not identify new interventions after he made potential verbally abusive remarks towards Resident #2 on 9/1/24 and 9/16/24. The 9/17/24 care conference note documented a care conference was held with Resident #3 and his family representative. According to the note, Resident #3 felt it would be best for him to discharge from the facility so he could step away from triggers and bad habits that negatively affected his sobriety. According to the note, the staff discussed the current concerns of Resident #3's alcohol use relapse. -The care conference note did not identify behaviors, such as potential verbal abuse of his roommate on 9/1/24 and 9/16/24, were discussed with the resident representative. V. Staff interviews A frequent facility visitor (FFV) was interviewed on 10/1/24 at 2:51 p.m. The FFV said the facility informed her that Resident #3 called Resident #2 derogatory names so the facility conducted an investigation and was going to do a room change. The NHA was interviewed on 10/1/24 at 5:10 p.m. The NHA said he was notified by the SSD on 9/1/24 of an incident between Resident #3 and Resident #2. He said a nurse reported to the SSD that Resident #3 called Resident #2 derogatory names on 9/1/24. The NHA said he started a soft file investigation. He said the SSD interviewed both of the residents and there was no indication of psychosocial distress with either resident. He said the interviews with Resident #2 and Resident #3 was the extent of the facility's investigation of the allegation. The NHA said the facility started to discussed moving Resident #3 to a different room but Resident #3 ended up discharging from the facility on 9/18/24. He said the allegation was not reported to the State Agency because neither resident expressed distress. The NHA said he was not aware of any other allegations or altercations between Resident #3 and Resident #2. He said nothing was reported to him regarding Resident #3 calling Resident #2 derogatory names again on or after 9/16/24. The SSD was interviewed on 10/2/24 at approximately 10:00 a.m. The SSD said a certified nursing assistant (CNA) informed her Resident #3 was verbally inappropriate towards Resident #2 after Resident #2 had an accident on the floor. She said Resident #3, under the influence of alcohol, may have stepped in it and responded by not saying nice things to Resident #2. The SSD said she spoke to Resident #3 on 9/1/24, after it was reported to her of the use of derogatory language towards Resident #2. The SSD said Resident #3 told her Resident #2 had defecated on the floor but he was not mad or irritated at Resident #2. The SSD said Resident #2 got confused and would go through Resident #3's drawers but Resident #3 liked Resident #2. The SSD said Resident #3 told her if he felt upset with Resident #2, he would just go for a walk. The SSD said her conversation with Resident #3 was normal and he did not state aggression towards Resident #2. The SSD said she did not recall the name of the CNA who informed her of the incident, but had asked the CNA who reported the concern to fill out a witness statement. She said she had not retrieved the statement back from the CNA but the CNA might have given it to someone else. She said it would be good to have the witness statement so it could be placed in the investigation file. The SSD said a nurse had also told her Resident #3 called Resident #2 a derogatory name and did not feel it was okay that Resident #2 was called the name. The SSD said she did not recall the name of the nurse and the nurse did not fill out a witness statement. She said she was not sure exactly when the nurse reported the name calling to her. The SSD said she spoke to Resident #2 after she heard of the 9/1/24 incident. She said she asked him how he felt about his roommate, if he had concerns about his roommate and if his roommate was ever hurtful to him. The SSD said Resident #2 did not recall Resident #3 calling him names. She said Resident #2 was pleasantly confused. She said sometimes he had good recall and other days he did not. The SSD said Resident #2 showed no changes in behaviors or emotional distress. She said Resident #2 did not show any cause for concern. The SSD said the NHA was the abuse coordinator but she helped with the investigations. She said she did not interview any other residents regarding the incidents between Resident #2 and Resident #3 on 9/1/24 or 9/16/24. The NHA was interviewed again on 10/2/24 at 3:55 p.m. The NHA said the facility had not collected witness statements but the CNA who reported the 9/1/24 incident had been identified as CNA #1 and was going to come to the facility on [DATE] and fill out the witness statement. The NHA said the nurse also reported the derogatory name calling and was also asked to complete a witness statement but she was now stating she did not recall the incident. The NHA said, on 9/16/24, a care conference was held and discharge was discussed for Resident #3. The NHA said Resident #3 did not feel he needed anything more from the facility and did not express distress. The NHA said because Resident #3 was leaving the facility, the facility did not do anything else related to the situation. The NHA said there was no investigation after a nurse documented on 9/16/24 that Resident #2 was called a derogatory name again by Resident #3. He said the nurse was not interviewed and a witness statement was not collected. He said he had no other information other than what was in the progress note. The NHA said he would report the 9/16/24 incident this afternoon (10/2/24) and do an investigation after he was informed Resident #2 felt Resident #3 was mean and was mad about the interactions. He said it was not originally reported because there were no signs of distress. He said the facility should have done more of a follow up investigation after the incident was documented in a progress note on 9/16/24. CNA #2 was interviewed on 10/2/24 at 4:09 p.m. CNA #2 said sometimes Resident #3 was not nice and would get defensive. She said he spoke to others in a negative way. She said she heard Resident #3 call Resident #2 derogatory names and used expletive language. CNA #2 said she reported to the nurse her concerns of Resident #3's derogatory name calling towards Resident #2 on a couple of occasions. She said the last occasion she was aware of occurred over a month ago. She said when Resident #3 called Resident #2 names she would take Resident #2 to a safe space and tell Resident #3 that it was not okay to speak to Resident #2 in that manner. CNA #2 said the staff was trying to figure out what to do regarding the situation, and then Resident #3 left the facility. Licensed practical nurse (LPN) #1 was interviewed on 10/2/24 at 4:26 p.m. LPN #1 said she was the unit manager. She said when there was an allegation of abuse the staff met as a team and tried to determine what happened, how it affected the resident(s) and review the abuse procedure criteria. She said the facility tried to determine if the allegation caused harm and if the residents involved felt afraid. She said other residents in the facility would also be interviewed. She said the staff who may have witnessed the incident, staff who worked on the shift when the incident occurred and, if needed, staff who worked on other shifts would be interviewed. She said all interviews would be documented in a soft file. LPN #1 said the residents involved would be monitored to make sure they were doing okay after the incident. She said the monitoring would be documented in progress notes and if needed on a change of condition form. LPN #1 said calling a resident derogatory names would potentially be verbal abuse.

Based on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchens during meal services. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; -Ensure safe storage of food for resident use; and, -Ensure a clean environment and equipment where food was prepared. Findings include: I. Professional standards The Centers for Disease Control and Prevention (CDC), reviewed 9/3/23, retrieved on 11/7/23 from: https://www.cdc.gov/foodsafety/keep-food-safe.html, under Four Steps to Food Safety read to Wash your hands for at least 20 seconds with soap and warm or cold water before, during, and after preparing food and before eating. According to the Colorado Department of Public Health and Environment (CDPHE) The Colorado Retail Food Establishment Rules and Regulations, January 2019, retrieved on 11/7/23 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. identified in pertinent part: Equipment food-contact surfaces and utensils shall be clean to sight and touch; clean equipment and utensils need to be stored in a self-draining position that allows air drying; a food in an unopened hermetically sealed container (a container that is designed and intended to be secure against the entry of microorganisms) that is commercially processed to achieve and maintain commercial sterility under conditions of non-refrigerated storage and distribution; the day the original container is opened in the food establishment shall be counted as day 1; and, the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. II. Observations and interviews The initial kitchen tour was on 10/23/23 at 9:40 a.m. The following was observed: -A can of black beans dated 10/20/23 was in the day storage room stacked on a can holding shelf ready for use. The can had a large dent on its side. The dietary manager (DM) was notified. She said all cans should be free from dents and should not have been put on the rack. She said she would educate her staff again on the risk of bacteria growth in the canned food if the seal was breached. The DM removed the dented can from the rack. -The refrigerators and the freezer in the kitchen identified multiple missing dates on the temperature log indicating the temperatures were not checked daily for October 2023. -In one of the refrigerators was a large container of pre-made chicken soup. The container cover was not sealed shut. The lid was lifted up on one of the corners. The container lid had a date of 9/22/23 written on the top of it with a marker. The date was over a month past the observation date of 10/23/23. -On a metal rack were plastic bins with kitchenware. One of the bins contained metal lids used for the steam line. The lids were wet and placed on top of each other in a vertical fashion with no air between multiple surfaces. -Next to the metal rack was a stacking plate and bowl wheeled cart where resident dishes were stored. On the top surface of the cart where the bottom dishes touched, there was debris dust and dried food. -The kitchen floor contained dirt, debris and dried and stuck food remains over most of its visible surface and there was a dusty plastic lid in the floor underneath the oven. -There was a metal table with a rack of cutting boards on the table shelf just above the floor. The cutting boards had deep grooves and stains on them. On one of the cutting boards was a long hair wrapped around the edge and bottom surface of the cutting board adhered by a sticky substance. -On the surface of the metal table was a fan without the cover on. The fan blades and spokes on the back were covered in dust. A continuous observation of the lunch meal preparation and service was completed on 10/25/23 between 11:40 a.m. and 1:00 p.m. -At 11:45 a.m. the cutting boards, pre-made chicken soup and the wheeled dish cart were observed. The cutting board continued to have a hair attached to the surface of the board. The dish cart surface had debris when the dishes touched the cart. The pre-made chicken soup lid was sealed and the date was changed from 9/22/23 to 10/22/23. -At 12:01 p.m. the cook dropped a serving utensil on the kitchen floor. The cook picked up the serving utensil and placed the utensil in the sink and returned to the steam line. The cook did not wash her hands after picking up the utensil off the floor. -At 12:39 p.m. dietary aide (DA) #1 stood at the service window preparing for the next meal to be plated. The DA scratched his head and placed his hand on his face as he waited. The DA retrieved the meal from the cook and served the meal to the resident. The DA did not perform hand hygiene before serving the meal and after touching his face. III. Staff interview The dietary manager (DM) was interviewed on 10/25/23 at 1:02 p.m. The DM said staff should be checking the temperature in the refrigerators and the freezers and recording the temperatures on the log to make sure all cold food was stored correctly. She said the staff did not always do it as they should. The DM said residents were served the premade chicken soup as an alternate choice this week. She said she changed the date because she identified she wrote the wrong month on the lid. The DM said it was important to make sure the food was dated correctly and used or thrown out within the appropriate time period so the food would not have bacteria growth and risk getting residents sick. She said the lid should have been closed so it would not be exposed to anything and prevent potential cross-contamination.The DM said she was in the process of getting new cutting boards. She said the old and marked cutting boards would be replaced. She said the cutting boards should have been clean when ready for use and should have hair or sticky substances on them. The DM was interviewed on 10/26/23 at 11:31 a.m. The DM said staff hand hygiene should be done every time staff touches a potentially contaminated surface. She said hand hygiene should have been completed after picking up the utensil from the floor, when the cook left the service line and after the DA touched his face and then served residents. The DM said dishes, including medal lids, should not have been stacked together wet. She said bacteria could grow between the wet surfaces when there was not enough airflow. The DM said she had instructed staff in the past to make sure the dishes were dry before they were put away. The DM said she started as the DM two months ago and the kitchen was in poor condition. She said she had been working on kitchen cleanliness but it was a work in progress. The DM said she would continue to provide training and oversight. The DM said the registered dietitian (RD) would be at the facility on 11/3/23 training staff on diets and the DM would ask her to go over infection control. The DM said the former infection preventionist reviewed hand hygiene with her staff and the assistant director of nursing (ADON) was a good resource that she could go to for infection control questions. The RD was interviewed on 10/26/23 at 12:37 p.m. She said she usually went into the kitchen weekly. The RD said she did monthly sanitation checks and shared her observations with the DM. She said the facility's corporate office sent monthly training in-services as a kitchen review. The RD said the new DM had made a lot of improvements but there were still areas to focus on.

Based on resident, family, and staff interviews; and record review, the facility failed to act promptly upon the grievances of the resident council concerning issues of resident care and lift in the facility that were important to the residents. These failures affected the resident council vice president and other residents who participated in the resident council over the past three months, regarding call lights, staff not being friendly and providing follow-up on grievances. Findings included: I. Facility policy The Resident Concern or Grievance Program policy, revised 12/17/06, was provided by the social services director (SSD) on 10/25/23 at 2:36 p.m. which read: The facility observes the right of each resident, family member, responsible party, and staff member to voice concerns and grievances with respect to treatment or care and refusals to care. Accordingly, a formal system known as the Resident and Family Concern or Grievance Program is in place to review and act upon concerns or grievances expressed. Any resident has the right to voice grievances without discrimination or reprisal. Grievances may include, but are not limited to, management of funds, behaviors of others, lost clothing lost items, violations of rights, care, services provided, and services and products provided by outside agencies or companies. A resident's concern or grievance may be verbal or non-verbal and does not have to be in writing. The program is intended to reflect the facility policy which acknowledges the right of residents to voice concerns and the expectation of prompt effects by the facility to resolve them. This program is supported by the resident council. Any resident, family member, or staff member may generate a resident concern or grievance report in response to a concern or grievance identified as a result of an individual concern or grievance from a resident, family member, and/or staff member. Procedure: 1. The SSD (social services director) is designated for collecting, reviewing, and communication concerns or grievances to the administrator. These shall be completed within one business day. Responses and results will be completed within five business days. It is the policy of the facility to handle any complaints or grievances relating to abuse immediately and according to the facility abuse prohibition and control manual. 2. Concerns or grievances shall be communicated in writing. The SSD may be called upon to assist in writing these and to complete any necessary forms. Resident Rights assures each resident of the right to voice any grievances, complaints, or concerns without reprisal. 3. The facility Concern Report includes the following components: a. Date submitted (date the written concern is received), b. Person receiving complaint (this person fills out the form), c. Complainant name, d. Nature of concern or grievance (encouragement provided to complainant to write in their own words the nature of their concern), e. Investigation findings, f. Follow-up to concern, g. Administrator must sign and date. 4. The SSD will complete an investigation and confer with the administrator. The administrator may or may not be involved in the actual investigation. Responses will be communicated within 72 hours of completion of the investigation. 5. The SSD will complete a follow-up interview within 7 to 10 days to ensure that the approach taken by the facility has resolved the concern. If the concern remains unresolved the SSD will confer with the administrator and department director to develop a revised approach, which is to be implemented immediately upon development (no more than 72 hours following identification that the initial resolution was not satisfactory). The SSD will complete an additional follow-up interview within 7 to 10 business days to ensure that the corrective action taken by the facility has resolved the concern. 6. All information is maintained according to HIPPA (Health Insurance Portability and Accountability Act) guidelines and only those with a legal right to know will be informed of any information relating to concerns or grievances. 7. The SSD will bring all resident concern reports to the quality assurance committee meeting to review with the team to assess for the need for possible further action. II. Resident council interviews A. Resident council president The resident council president (Resident #19) was interviewed on 10/25/23 at 11:12 a.m. She said she did not believe the facility followed up on any grievances filed by the residents or resident council. B. Resident council vice president The resident council vice president (Resident #39) was interviewed on 10/25/23 at 11:12 a.m. He said he felt like the grievances were blown off by the facility. He said he filed a grievance when he had an issue with another resident and never received a follow-up from anyone. He said he wished someone from management provided one-on-one time with the residents to see if something was going on and would assist them with filling out a grievance. He said he did not see a lot of follow-up from grievances provided by the resident council. C. Resident #3's advocate Resident #3's advocate was interviewed on 10/25/23 at 11:12 a.m. She spoke on behalf of the resident. She said it would be helpful if the facility had someone that would help the residents or their families fill out grievances and the staff were not very interactive with the residents. She said when a call light was triggered the nursing staff turned off the call light and said I have one more thing to finish and then I will be back to help you, but it would take upwards of 30 minutes for the staff to return. Resident #3 was not able to speak more than one word at a time and communicated by making gestures. She nodded in agreement with her advocate about the staff who turned off the call lights and said they would return in a moment. D. Frequent visitor A frequent visitor of the facility was interviewed on 10/23/23 at 3:50 p.m. She said call lights and bathing had been grievances in the resident council meetings for the past few months and there was no follow-up provided. She said residents complained that if a bath aide was not working they did not receive a bath. The visitor also said the residents had complained of call lights not being answered for a long time (30-40 minutes). She said the social services director (SSD) would write down the concerns but failed to provide solutions. The frequent visitor said she brought this up to the nursing home administrator (NHA) and how the SSD was an advocate for the residents but she was not doing her job because she seemed overwhelmed and needed help. She said when the director of nursing (DON) worked the call lights were answered timely but when she was not working the call lights went unanswered for a long time. III. Record review Departmental response forms were filled out for resident council grievances on 8/17/23. One was for human resources, five were for dietary and three were for nursing. -Each department did not fill out a response to the grievances and were not signed by the administrator or executive director. Departmental response forms were filled out for resident council grievances on 9/21/23. Three were submitted to dietary, one was submitted to social services, three were submitted to housekeeping and two were submitted to nursing. -All departments responded on the form except nursing. Departmental response forms were filled out for resident council grievances on 10/19/23. One was submitted to social services but the response provided was referred to nursing and no follow-up was provided. The other grievance was sent to nursing and was provided a follow-up. -Resident council minutes failed to document residents' complaints about call lights and bathing. IV. Observations On 10/26/23: At 9:07 a.m. a call light was triggered in room [ROOM NUMBER]. At 9:11 a.m. three certified nurse aides (CNAs) were observed sitting outside at a picnic table on a break together. At 9:15 a.m. the resident's family member opened the resident's door and scanned the hallway as he looked for a staff member. At 9:16 a.m. the three CNAs were still outside on a break. At 9:17 a.m. the resident's family member exited the room with the resident in a wheelchair. The family member took the resident to another hallway and found a CNA. They returned to the resident's room and was assisted with washing her hands so she could eat breakfast. At 9:18 a.m. the management team was in a morning meeting in the office while the three CNAs were outside on break. V. Staff interviews The DON and the assistant director of nursing (ADON) were interviewed on 10/26/23 at 10:13 a.m. The ADON said CNAs were not allowed to take breaks at the same and the ADON provided education to the CNAs that took the break at the same time on 10/25/23 and 10/26/23. The ADON said the facility did not have a call light system that tracked how long call lights were triggered. She said they would watch the panel that showed lights that were turned on and timed how long they were on. After the ADON or DON timed the panels, they provided feedback to the nursing staff. The SSD was interviewed on 10/23/23 at 11:12 a.m. She said she was not solely responsible for grievances and the department the concern was related to was responsible for providing the follow-up. -However, the policy documented the SSD was responsible for ensuring the grievances were sent to the right department and followed up on. The nursing home administrator (NHA) was interviewed on 10/26/23 at 4:26 p.m. He said he was the compliance officer for the facility but grievances initially went to the SSD. He said any staff was able to assist the residents with a grievance. The NHA said when a concern or grievance was received, a copy was made and each department who needed to respond received a copy. The SSD was responsible for making sure grievances were followed up on. The grievance form said a follow up would be provided in seven to 10 days but the NHA felt that was too long and tried to follow up on grievances within three days or less. He said when the grievance was finalized they would follow up with the resident again. He said grievances were given to staff or placed in a locked box outside the SSD's office. He said the SSD checked the locked box and sent the grievances to the correct department but was unsure how the residents would know if the grievances were received after being placed in the locked box. A concerns and grievances committee was formed within the facility that had four people on the committee. He said management provided education to staff on the resident council minutes that certain things needed to be followed up on. If concerns were brought up at the resident council meetings, the activities director (AD) documented the concerns and wrote them out with the residents, made them a copy and placed a copy in a binder. The binder was supposed to be brought to leadership morning meetings to be discussed but it was not being brought. He said the SSD was great at bringing up concerns at the morning meetings but nothing happened to resolve it after the discussion.

Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#44, #13 and #40) of three residents reviewed for dementia care out of 30 sample residents. Specifically, the facility failed to: -Effectively implement a meaningful activity program for Resident #44; -Implement person centered interventions for Resident #13's behaviors; and, -Implement person centered interventions and care plan for Resident #40. Findings include: I. Facility policy The Dementia policy, revised November 2018, was provided by the administrator in training (AIT) on 10/26/23 at 6:20 p.m. The policy read in pertinent part: As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident centered care plan to maximize remaining function and quality of life. Direct Care staff will support the resident and initiate completing activities and tasks of daily living. bathing, dressing, meal times, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. Resident needs will be communicated to direct care staff through care plan Conference during change of shift communication and through written documentation. The IDT will just interventions with the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. The Activity Program policy, revised August 2006, was provided by the activity director (AD) on 10/26/23 at 6:44 p.m. The policy read in pertinent part: Activity programs designed to meet the needs of each resident are available on a daily basis. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Individualized and group activities are provided that: -Reflect The schedules, choices and rights of the residents; -Are offered at hours convenient to the residents, including evenings, holidays and weekends; reflect the cultural and religious interest, hobbies, life experiences, and personal preferences of the residents, and, appeal to men and women as well as those of various age groups residing in the facility. II. Resident #44 A. Resident status Resident #44, age 71, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, neurocognitive disorder with Lewy Bodies, dementia in other diseases classified elsewhere, unspecified severity and other behavioral disturbance, need for assistance with care, lack of coordination, delusional disorders, visual hallucinations and history of falling. The 8/29/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The review for preferences and activities for Resident #44 was not completed to identify the resident's current preferred activities and routine. B. Observations and interviews Resident #44 was interviewed on 10/23/23 at 11:34 a.m. The resident was observed sitting in his room looking down at his lap. The resident did not have music or television on and there were no visible activity supplies observed. The resident said he did not do much of anything. Observations throughout the morning on 10/24/23 identified Resident #44 sitting in his room without purposeful activity or rolling down the hallways. The resident was not engaged in an independent or group activity and had some difficulty navigating down the hall in his wheelchair, frequently getting stuck on handrails or around obstacles. Resident #44 was observed on 10/24/23 at 1:38 p.m. in a room attempting to transfer himself from his chair to his bed. On 10/25/23 at approximately 2:00 p.m. the resident was observed wiping off a handrail. The AIT said the resident liked to dust and help clean. On 10/26/23 at 9:21 a.m. Resident #44 was observed in the activity room folding a basket of laundry. The resident said he was happy to help. Certified nurse aide (CNA) #1 said the resident used to be a janitor. C. Record review The activity visit log identified the following logged visits for Resident #44: -On 9/21/23 the resident received comfort/help to his room. -On 9/25/23 the resident received comfort/snacks. -On 10/02/23 the resident received a snack/health. -On 10/09/23 the resident had a dog visit/comfort. -On 10/23/23 the resident received a snack. The activity participation record between 8/30/23 and 10/26/23 documented the resident engaged in the following: -On 8/30/23 the resident strolled through the hallway. -On 8/31/23 the resident strolled through the hallway. -On 9/2/23 the resident strolled the patio and lobby. -On 9/6/23 the resident strolled through the hallway. -On 9/7/23 the resident strolled through the hallway and was offered a snack. -On 9/13/23 the resident was offered a snack. -On 9/14/23 the resident strolled through the hallway. -On 9/19/23 the resident strolled through the hallway. -On 9/20/23 the resident engaged in and animal visits was offered a snack -On 9/21/23 the resident strolled the hallway, had a conversation with reminisce and was offered a snack. -On 9/22/23 the resident was offered a snack. -On 9/25/23 the resident was offered coffee/treats and a snack. -On 9/26/23 the resident engaged in a snack. -On 9/27/23 the resident was offered a snack. -On 9/28/23 the resident was offered a snack. -On 9/29/23 the resident strolled through the hallway. -On10/2/23 the resident was offered a snack. -On 10/3/23 the resident was offered a snack. -On 10/4/23 the resident was offered a snack. -On10/3/23 the resident had an animal visit. -On 10/5/23 the resident engaged in cleaning and had a pet visit. -On 10/6/23 the resident strolled the hallway, engaged in cleaning, and was offered a snack. -On 10/9/23 the resident strolled the hallway, engaged in conversation with reminisce, colored and rested. -On 10/10/23 the resident engaged in cleaning, strolled the hallway, worked on a puzzle and was offered a snack. -On 10/11/23 the resident strolled the hallway and had an animal visit. -On 10/12/23 the resident engaged in cleaning, strolled the hallway and was offered a snack. -On 10/14/23 the resident strolled through the hallway. -On 10/15/23 the resident engaged in cleaning and strolled through the hallway. -On 10/18/23 the resident was offered a snack. -On 10/19/23 the resident engaged in a music sing-along. -On 10/20/23 the resident engaged in was offered a snack. -On 10/23/23 the resident engaged in conversation and reminisce. -On 10/25/23 the resident was offered a snack. -On 10/26/23 the resident engaged in a music activity. -The participation record identified the resident primarily self-propelled himself down the hallway and received snacks during the two month review. The activity and preferences care plan, initiated on 8/26/22, identified Resident #44 had expressed multiple specific activity interests. The care plan identified how staff could assist him with pursuing his activities and preferences. The activity care plan read: Resident #44 had impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: dementia with [NAME] bodies. While in the facility, Resident #44 states that it is important that he has the opportunity to engage in daily routines that are meaningful relative to his preferences. He enjoys watching NCIS (television show about naval crime investigation), the channel that airs the Battle Against the Bands, and Dancing with the Stars. He expressed an interest in hunting, fishing and gun magazines. He helped start a gun club. His career was in the lumber industry. His favorite activity is building model airplanes and flying his remote control helicopter. His sister is caring for his dog, which he misses very much. His vision is severely impaired. He is interested in listening to [NAME] L'amour books on tape. Background noise makes it difficult for him to hear. He speaks softly and mumbles. He has dementia, needs time to process his thoughts and respond. He displays visual hallucinations and wears glasses to read. His sister and brother live locally. He has two boys that live in (in a nearby town). He used a wheelchair for general mobility. The care plan directed staff to assist and encourage: -Resident #44 participation in activity preferences of watching his favorite television programs, looking at magazines of interest, reading the bible and literature of his faith, looking out the window, listening to [NAME] L'amour books on tape, visiting with his family and engaging in conversation with the staff and offer frequent to checks if he needed or wanted anything. According to the care plan, -It was important for the staff to know which of my personal belongings he preferred to take care of himself. -It was important for him to choose his bedtime and he preferred to go to bed whenever he wanted. -It was important for him to have family involved in discussions about his care. -It was important for him to be able to use the center phone in private. -It was important for me to have reading materials such as hunting, fishing magazines, and listen to [NAME] L'amour on tape. -It was important for him to go outside when the weather is good and enjoy sitting, talking/visiting. -He would like pet visits. The care plan identified he liked to participate in going to the gun club, target shooting and flying model and remote control planes with groups of people. Half of the guys I used to hang out with have moved away. Resident #44 liked to listen to music, look out the window, lay down/rest, pray, look at magazines, think and watch his favorite television programs and movies in his room. He was interested in listening to [NAME] L'amour books on tape from the Colorado Talking Book Library. He was of Lutheran faith and would like to participate in religious services/practices such as reading the bible and other literature of my faith. The care plan outlined how staff could help engage in activities of interest even though he had physical and cognitive impairments. According to the care plan, Resident #44 would benefit from: -Accommodation for hearing loss by limited background noise, placement near speaker/leader, for people to adjust their tone of voice, and repeat the conversation. -Accommodation for cognitive limitations by using decreased environmental clutter, reminders, one-to-one settings, physical prompts, verbal prompts, allow me time to process my thoughts and respond. I have episodes of intermittent delusions, and visual hallucinations. I speak softly and tend to mumble. -Accommodation for physical limitations by observing me for safety when transferring from the wheelchair and back. -Accommodations for visual impairments by using audiobooks/books on tape, someone to read to him, large print materials, and wearing his glasses. D. Staff interview The hospice nurse for Resident #44 was interviewed on 10/25/23 at 11:02 a.m. She said the resident usually roamed the halls and sometimes cleaned. The social service director (SSD) was interviewed on 10/26/23 at 11:12 a.m. She said other residents did not usually interact with Resident #44 unless he was in their way. The director of nursing (DON) was interviewed on 10/26/23 at 2:49 p.m. She said Resident #44 had multiple falls. She said in September 2023 she requested the activity department to provide one-to-one activities for Resident #44 after the resident had two falls. The DON said after the third fall on 10/14/23, the interdisciplinary team (IDT) identified the resident was restless and encouraged more activity interventions. She said she reviewed Resident #44's one-to-one activities and identified the resident was primarily just getting snacks as his one-to-one activity. She said he needed more purposeful activities. She said he always liked to investigate items and wanted to clean. The DON said after the last fall on 10/21/23, she requested staff to provide him with clean clothes. The activity director (AD) was interviewed on 10/26/23 at 5:43 p.m. The AD said Resident #44 did not show interest in group activities and would just go in and out of bingo. She said she did not have activities that were specific or geared for residents with dementia or cognitive loss. She said it was not identified to her that there was a need for dementia activities for residents. The AD said the resident did not have a current activity assessment completed, identifying his interests. She said she had been in the AD position for the past two months. The AD said Resident #44 primarily received snacks as his activity intervention with her department. She said he independently would dust off the handrails in the hall. She said she was asked today (10/26/23) to offer Resident #44 a laundry basket of clothes to fold. III. Resident #13 A. Resident status Resident #13, age 76, with an initial admission on 6/22/23 and was readmitted [DATE]. According to the October 2023 CPO, diagnoses included unspecified fracture of the shaft of the left tibia, Alzheimer's disease, history of falls, chronic pain syndrome, osteoarthritis, generalized muscle weakness unspecified dementia, severe with agitation and other problems related to social environment. The 9/17/23 MDS assessment revealed the resident had severe cognitive impairment, with a BIMS score of six out of 15. The resident had one fall with a major injury and one surgery since her admission. According to the assessment, Resident #13 did not have rejections of care, physical or verbal behaviors or other behavioral symptoms directed towards others. B. Record review The fall risk care plan for Resident #13, 6/22/23 revised on 9/12/23, read Resident #13 was at risk for falls related to cognitive loss, lack of safety awareness, medications, and agitated behaviors that included throwing or breaking things. The care plan read Resident #13 threw liquids on the floor, creating an unsafe environment. The fall care planned interventions initiated on 6/22/23 included providing the resident with opportunities for choice; observe for changes in medical status, pain status, mental status and medication side effects that may contribute to cognitive loss/dementia delirium that can lead to increased fall risk and report to the physician as indicated. Assist the resident to organize belongings for a clutter free environment in the resident room and consistent furniture arrangement. The 7/4/23 cognition care plan read Resident #13 had impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium with impaired decision making. Interventions included staff to observe and evaluate types of changes in cognitive status such as confusion,orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed: and, create a calm, soothing environment by using dim lighting, reducing noise, limiting number of people and reducing clutter. The 7/10/23 behavior care plan read Resident #13 exhibited or had the potential to demonstrate verbal behaviors related to dementia with depressed mood and other problems related to the social environment. -The behavior care plan did not identify the resident had behaviors of throwing items on the floor. The 7/7/23 general progress note read Resident #13 was angry when her dinner tray was delayed and the food was not to her liking. The resident proceeded to throw the meal tray on the floor. Later that evening during her medication administration, the resident knocked her tray table over onto the floor. The resident said she did not get her medications from the facility because she worked at the facility. The resident was de-escalated by staff and then took her medications. The physician was contacted. The 8/13/23 medication administration identified the resident was throwing items around the room, requesting to leave the facility. The 8/14/23 general note read the resident was throwing objects towards the staff, swearing and demanding pain medication every hour. The resident was provided safety and pain management. The physician provided new medication orders. The 9/6/23 at 12:48 a.m. nurse note read the resident requested Tylenol at about 12:10 a.m. however the orders for 325 milligrams (mg) of Tylenol were to be given at 1:00 a.m. The nursing staff entered the resident's room to explain the orders and the resident began to curse loudly. The resident was within her time window and was offered 325 mg to the resident as requested. Resident #13 became angry and showed her copy of medication administration record (MAR). The note read the resident did not appreciate the difference between 325 mg dose and 650 mg dose and all education failed. Resident #13 was yelling and swept all her items from the bedside table onto the floor. Three nurses entered the resident's room and provided printouts of the MAR. The resident yelled in response and said I don't give a damn, get out! The three nurses left and the resident continued to moan and yell behind a closed door. The 9/7/23 at 11:45 a.m. unwitnessed fall report read in part, Resident #13 was found on the floor in her room by a certified nurse aide (CNA). The resident was found on the floor of her room, the floor surrounding the resident had a puddle of water on it and the door to the resident's room was shut. According to the fall report, the resident said she saw water spilled from the floor and got out of bed to clean it up when she slipped and fell . The resident said that she fell back on her left foot. The predisposing environmental, physiological and situation factors to the fall included a wet floor, pain, refusal of care. -The fall report did not include when the resident was last observed and or what her mood or behavior was leading up to the fall. -According to the resident, there was water on the floor that she attempted to clean up. The fall report did not identify how or why the water was on the floor. The 9/12/23 post fall review form was provided by the DON on 10/26/23 at 3:20 p.m. The post fall review form identified during a seven day look period, identified the resident and behaviors occurred daily or more than daily. The fall care plan interventions initiated on 9/12/23 read the resident frequently threw items in her room when she's angry which causes an increase in her fall risk. The care plan instructed staff to conduct frequent checks in rooms to ensure there were no liquids on the floor or tripping hazards due to the resident throwing items when she was angry. -The comprehensive care plan did not identify interventions for her behaviors of throwing items until after she had a 9/7/23 fall. The care plan interventions initiated on 10/26/23 the staff to utilize proactive approaches and response to aggressive behaviors. -However, the intervention using proactive approaches was not personalized for staff to know how to respond to her aggressive behaviors. C. Staff interview The DON was interviewed on 10/26/23 at 3:23 p.m. The DON said the cause of the fall was because the resident threw water on the floor. The DON said when the resident was angry and wanted to have her pain medications all the time even when she was not scheduled for her pain medications. The DON said this resulted in behaviors of throwing things in her room and making messes. The DON said after the 9/7/23 fall, the new intervention was to conduct frequent checks of the resident's room to make sure the floor was clean and dry with no trip hazards. -However, there was no root cause analysis to identify strategies to implement before the resident had behaviors that included getting angry and throwing items. 48412 IV. Resident #40 A. Resident status Resident #40, age 85, was admitted on [DATE]. According to the October 2023 CPO diagnoses included dementia, adult failure to thrive, type two diabetes mellitus with hyperglycemia (high blood sugar) and long-term current use of insulin. According to the 9/12/23 MDS assessment Resident #40 had a mild cognitive impairment with a BIMS assessment score of 10 out of 15. The active discharge planning was not occurring for Resident #40. The assessment documented the resident did not want to speak to someone about returning to the community and a referral was not needed. B. Resident interview Resident #40 was interviewed on 10/23/23 at 10:48 a.m. She said staff told her she was supposed to be discharged home over the previous weekend. She said the staff kept telling her she was stable and ready to be discharged home but it kept getting pushed off and said no one is helping me go home. She wanted to know the facility's plan for her to be discharged home and how soon it was going to happen because her diabetes was stable and she did not need long-term care. C. Record review Resident #40's care plan documented she desired to go back home once she was feeling better (initiated and revised on 6/13/22). -However, the care plan had no interventions or goals documented for this and the resident was staying long term according to the social services director (see interview below). Her care plan documented the resident has impaired or declined cognitive function or impaired thought processes related to dementia (initiated and revised on 6/23/22) The interventions were: -Observe and evaluate types of changes in cognitive status (initiated on 6/23/22); -Monitor medications, especially new/changed/discontinued, for side effects and the resident's response contributing to cognitive loss or dementia (initiated 6/23/22); -Allow the resident to make daily decisions. Use verbal cues, gestures, and demonstration to assist in decision making, if needed (initiate 6/23/22); -Break down tasks to support short-term memory deficits and provide cueing or assistance as needed (initiated 6/23/22); -Provide consistent, trusted caregiver and structured daily routine, when possible (initiated 6/23/22); -Provide an environment that is conducive to the resident's ability to get adequate sleep and maintain the resident's preferred sleep/wake schedule (initiated 6/23/22); -And explain all care, including procedures (one step at a time), and the reason for performing the care before initiating (initiated 6/23/22). -However, the care plan did not document anything about the resident's confusion about being discharged home or personalized interventions to address when she said she wanted to go home. A quarterly social history review was completed on 9/11/23. Resident #40's cognitive pattern, mood, and behavioral status said the resident was alert and oriented and able to make her needs known. Her BIMS score was documented as a 10 out of 15 and the resident was forgetful at times and needed redirection. Her mood during the meeting was calm and pleasant. The review documented the resident would become upset if she felt misunderstood and she enjoyed conversations and being informed of her choices. The discharge assessment documented no discharge plans are in place. The resident was in long-term care. D. Staff interviews The social services director (SSD) was interviewed on 10/23/23 at 11:12 a.m. She said Resident #40 was very confused and had dementia. She said the resident's current and past perceptions were blended and she had always said she was about to be discharged home with her husband. The SSD said Resident #40's power of attorney (POA) explained to the resident that she was admitted to the facility for long-term care and seemed to explain it well to the resident. The SSD said, I think most of it is care planned that Resident #40 will say she is moving out or discharging. She said the facility documented her cognitive function and her decline because of her dementia in the resident's care plan. The DON was interviewed on 10/26/23 at 11:19 a.m. She said Resident #40 was admitted to the facility because her family was not able to take care of her. The DON said she was admitted for long-term care however she was aware the resident said she was to be discharged from the facility. The DON said she did not know how staff were handling the conversation but staff should not have told her she was to be discharged from the facility over the last weekend. The DON said the facility should have documented interventions or guidance for staff in Resident #40's care plan so they knew how to direct the conversation.

Based on observations, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#13) of two residents reviewed for respect and dignity out of 30 sample residents. Specifically, the facility failed to: -Treat Resident #13 with respect and dignity when she requested pain medication after identifying her preferences of no males in her room; and -Communicate Resident #13's preference for no male caregivers. Findings include: I. Facility policy The Resident Rights policy, revised December 2016, was provided by the administrator in training (AIT) on 10/26/23 at 6:20 p.m. The policy read staff should treat all residents with kindness, respect, and dignity. The policy read in pertinent part: Federal and state laws guarantee certain basic rights to all residents in this facility. these rights include the residents right to: -A dignified existence; -Self-determination; and, -Be supported by the facility and exercising his or her rights. II. Resident #13 Resident #13, age 76, with an initial admission on 6/22/23 and was readmitted [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included unspecified fracture of the shaft of the left tibia, Alzheimer's disease, unspecified dementia, severe with agitation, other problems related to social environment, dementia in other diseases, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, history of falls and chronic pain. The 9/17/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment, with a brief interview for mental status (BIMS) score of six out of 15. According to the assessment, the resident did not have inattention or disorganized thinking. She did not have rejections of care. She did not have physical or verbal behaviors or other behavioral symptoms directed towards others. III. Resident interview Resident #13 was interviewed on 10/26/23 at 10:50 a.m. She said she preferred female caregivers instead of male caregivers. She could not remember when she last had a male caregiver in her room. She said she felt safe at the facility but did not have good feelings with men except for her male physician. IV. Record review The medical record identified Resident #13 had a major fall with injury on 9/7/23 resulting in a fractured tibia and required surgery. The record identified the resident expressed a high level of pain after the surgery, when she returned to the facility. The medication administration record, identified Resident #13 was experiencing 10 out 10 pain on 10/5/23 at 2:37 a.m. The 10/5/23 at 2:35 a.m. nurse note read Resident #13 informed the male certified nurse aide (CNA) #8 that she did not want males in her room. The note read a short time later, the resident demanded pain medication. According to the note, the male registered nurse (RN) #1, assigned to her hall, instructed a female CNA #7 to tell Resident #13 that she needed to come to the nursing station to get her medication because the male nurse could not enter her room. Resident #13 came to the nursing station screaming and demanding Tylenol, which she could not have yet. The note read the resident was offered ibuprofen but the resident would not stop screaming and said she had been waiting a half an hour. According to the note, it had been five minutes. A female nurse provided the medication. The psychosocial well-being for mood care plan was initiated 10/25/23. The care plan identified the resident was at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual well-being related to feeling bad about herself or that she was a failure or have let herself or her family down. The psychosocial well-being care plan goal was to minimize risk for mood and behavioral disturbance. The care plan included the following interventions: -Administer medications as ordered and monitor for side effects as indicated. Notify physician if observed. -Assess coping strategies and respect the resident's wishes to the extent possible. -Assess preferences and choices with activities and encourage involvement. -Assist with conflict resolution as needed. -Encourage friends and family support/visits. -Encourage to voice feelings and frustrations as indicated. -Establish rapport using therapeutic communication. -Listen attentively. -Observe for tearfulness, increased agitation, and decreased participation in care. -Provide emotional support. The preferences care plan was initiated 10/25/23. The preferences care plan goal was to honor the residents preferences within facility limits and participate in the development of a person centered care plan to the extent possible. The preferences care plan included the following interventions: -Assist the resident to identify and promote individualized choices. -Encourage to verbalize /communicate personal preferences to staff. -Honor quality of life choices to the extent possible. -Monitor for safety and facility guidelines regarding personal preferences. For the resident and other residents in regards to their rights in the facility. The preference care plan identified the resident had preference on where she ate her meals. -The care plan did not identify Resident #13 did not want male caregivers. The review of the medical record did not identify a follow up on Resident #13's preferences or accommodations made based on the resident's documented preference in regards to no males in her room. V. Staff interview The director of nursing (DON) was interviewed on 10/26/23 at 3:34 p.m. with the assistant director of nursing (ADON). The 10/5/23 note was reviewed with the DON. She said she was not aware of the note or the incident. The DON said she was shocked by the note. The DON said the resident should not have been made to come out of her room in the very early morning hours, especially if she was in pain. The DON said the situation probably made the resident feel horrible. She said the resident was not treated appropriately and it was not okay that the incident occurred. The DON said she would investigate what happened. The DON said the residents have the right to have their preferences honored. She was not aware Resident #13 did not want males in her room, including male caregivers. She said staff did not communicate to her the resident's preferences related to no males in her room. She said she needed to find out why the resident did not want male caregivers in her room. The DON said her preferences should have been communicated and care planned. She did not know if the resident continued to receive male caregivers or not. The DON and the ADON said they were in the process of reviewing all progress notes and orders in the morning meeting to improve oversight of documentation. VI. Staff schedule The review of the staff schedule between 10/5/23 and 10/26/23, identified male staff were frequently assigned the the hall of Resident #13. The staff schedule did not identify a female nurse and CNA would be assigned to Resident #13 when a male nurse or CNA was providing care in the resident's hall.

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of three sample residents. On 10/19/22 Resident #1's insulin orders were discontinued by licensed practical nurse nurse (LPN) #1. The facility failed to have a system in place to confirm and verify the accuracy of the discontinuation of resident medications. Resident #1's insulin orders were discontinued on 10/19/22 by the LPN #1 who thought the orders were a duplicate. This caused the resident to miss (one dose) of 16 units of her Basaglar (long acting insulin) and three units (one dose) of her Novolog (short acting insulin). The resident's blood sugar on 10/21/22 at 7:30 a.m. was 600 milligram/deciliter (mg/dl, with a normal fasting range 70 to 100 mg/dl). The resident was sent to the emergency room for evaluation and treatment, and passed away on 10/21/22 at 11:41 a.m. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/7/22 to 11/10/22, resulting in the deficiency being cited as past noncompliance with a correction date of 10/27/22. I. Facility policy and procedure The Medication Errors policy and procedure, revised 6/1/21, was provided by the nursing home administrator (NHA) on 11/9/22 at 6:11 p.m. It documented the following: Medication error at a (name of the facility) will be investigated and appropriate interventions will be implemented. Staff will report, log, and trend medication errors. A medication error is defined as a discrepancy between what the physician/advanced practice provider ordered and what the patient received. Types of errors include; medication omission; wrong patient, dose, route, rate, or time; incorrect preparation; and/or incorrect administration technique. The NHA stated the facility did not have a policy prior to 10/19/22 for the process to discontinue medications. The NHA stated the facility had implemented a new policy and procedure on 10/27/22. That policy and procedure documented the following: Under no circumstances are resident orders to be discontinued without physician orders. Moving forward all verbal orders will be written on the new physician telephone order form provided. 1. The nurse will take the physician order and write it on the order form and read it back to the physician to ensure orders are clear and concise. 2. (The) nurse will enter (the) order in the computer and place the written order and place it in the queue (of the electronic medical record system). 3. (The) physician order form will be given to the second (2nd) nurse to read and confirm (the) order was entered correctly. 4. (The) physician order will be placed in a folder labeled 24 hour chart checks. 5. (The) night shift (nurse) will conduct 24 hour chart checks to ensure order accuracy. 6. Every nurse on every shift (willO process orders for their shift, no exceptions. 7. Order baskets (are) available at one (1) hall and four (4) hall. II. Immediate Jeopardy for serious harm A. Situation of Immediate Jeopardy Resident #1 insulin orders were discontinued on 10/19/22 by the LPN #1 who thought the orders were a duplicate. This caused the resident to miss (one dose) of 16 units of her Basaglar (long acting insulin) and three units (one dose) of her Novolog (short acting insulin) on 10/20/22. The resident's blood sugar on 10/21/22 at 7:30 a.m. was 600. The resident was sent to the emergency room for evaluation and treatment, and passed away on 10/21/22 at 11:41 a.m. The NHA was notified of the immediate jeopardy on 11/9/22 at 11:40 a.m. Record review and interviews during the complaint investigation confirmed the deficient practice which had been correct and the facility was in substantial compliance at the time of the survey. B. Facility plan to remove the Immediate Jeopardy situation The NHA provided the facility's plan of correction (POC) dated 10/27/22, on 11/8/22 at 11:15 a.m. The POC documented the following: 1. Corrective action- Resident (#1) insulin discontinued. (The) resident (was) sent out to the hospital of choice. 2. Identification of others - All residents have the potential to be affected by this practice. All other residents' on insulin orders were reviewed and confirmed for accuracy by the Medical Director (MD). 3. Systematic measures- Director of nursing (DON) and/or designee provided education to licensed personnel on transcribing and implementing physician orders, medication administration, second (2nd) nurse verification for an new orders or discontinuation of orders, shift to shift report, process for reviewing new orders, identifying change in condition documentation. (The) pharmacy representative to audit for any duplicate orders. 4. Monitoring performance- (The) DON and/or designee will conduct audits 5 (five) times a week of blood glucose (sugar) results and insulin administration for 4 (four) weeks, then weekly for 4 (four) weeks, then monthly for one (1) month, until compliance is sustained. The nursing home administrator (NHA) and/or DON and/or designee will review the results of the audits and reports results in the monthly quality assurance performance improvement (QAPI) Committee meeting monthly for one quarter to ensure compliance is achieved and sustained. Subsequent plans of corrections will be implemented as necessary. 5. Date of compliance- immediately. A review of the training completed by the DON revealed all the nurses in the facility had been trained prior to 10/27/22. C. Removal of Immediate Jeopardy Interview and record review during the complaint investigation revealed corrective actions to identify the resident and other residents having potential to be affected by the deficient practice, systematic changes to prevent its recurrence and monitoring to ensure sustained correction. Therefore, the deficient practice was corrected prior to the onsite investigation and represented past noncompliance at G level, actual harm that is isolated. III. Failure to have a system in place to confirm and verify discontinued medications A. Resident #1 status A. Resident status Resident #1, age 85, was admitted to the facility on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included type 1 diabetes, and long term (current) use of insulin. The 8/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance of one person for bed mobility, transfers and dressing, and total dependence of one person for eating, personal hygiene and eating. The MDS documented the resident received insulin for seven days of the seven day look back period. B. Record review A review of the resident's October 2022 physician orders revealed the following orders: -Basaglar KwikPen Solution Peninjector (long acting insulin) 100 unit/ml (milliliter); inject 16 units subcutaneously one time a day for diabetes, with a start date of 8/19/22, and a discontinue date of 10/19/22. The discontinue note read: duplicate of order: Three (3) units every 12 hours as needed for BG (blood glucose) above 400. -Novolog solution (fast acting insulin) 100 units/ml; inject 3 (three) units subcutaneously in the morning for diabetes, give only if she eats more than 50 percent of breakfast, with a start date of 8/19/22, and a discontinue date of 10/19/22. The discontinue note read: duplicate of order: Three (3) units every 12 hours as needed for BG (blood glucose) above 400. -HumaLog injection (fast acting insulin) solution 100 unit/ml; inject 3 (three) units subcutaneously as needed up to twice daily if blood sugar (is) over 400, with a start date of 9/24/22, and a discontinue date of 10/19/22. The discontinue note read: duplicate of order: Three (3) units every 12 hours as needed for BG (blood glucose) above 400. A review of the resident's nursing progress notes revealed the following progress notes on 10/21/22: 3:57 a.m. Resident c/o (complained of) indigestion. Stated she had a big supper with mac and cheese. CNA (certified nurse aide) confirmed this report stated resident ate 100 percent of her meal. Resident requested ginger ale or seven-up for GI (gastrointestinal) upset. Small amount of Mt. Dew (soda) given, less than 100 cc (cubic centimeter). Approximately 10 minutes later, resident had an emesis which was dark brown and roughly 100 cc (cubic centimeters). Resident a/o (alert and oriented) stated she felt much better. Vital signs taken, resident back to sleep shortly after this no further complaints. 5:09 a.m. Received (a) report from (the) CNA resident with GI (gastrointestinal) upset. BG (blood glucose) taken 393. Reviewed previous day BGs which were all running in the 200 range which is the resident norm. Historically PRN (as needed) insulin not given until BG greater than 400. 5:40 a.m. Received confirmation from (name of Resident #1) (that an) order (was) placed on resident MAR (medication administration record) for HgA1C (diagnostic test to determine the amount of glucose in the blood). Advised (the) resident labs to be drawn in house since hospital personnel (were) unavailable. Resident stated that she did not want to go to the hospital. Remained alert and oriented and stated she felt ok. 6:15 a.m. Report given to oncoming nurse at bedside. Previous emesis retained in the sink for inspection. A variety of open snacks noted on residents bedside table specifically a package of graham crackers with several crackers missing. It is unknown to this author how much or how many of the residents personal snacks were consumed. Resident remains alert and oriented with little changes in vital signs (which) were taken by (name of CNA). Advised resident further physician involvement (was) warranted to evaluate source of GI upset and or additional orders. Resident still stating she did not want to go to the hospital. Oncoming nurse will place (a) call (to the) physician. 9:32 a.m. Resident had dark brown emesis last night and this morning. Her BG (blood glucose) also higher than 600. PCP (primary care physician) and family have been notified. The PCP gave (an) order to send (the) resident to (name of hospital) at 9:30 a.m. 1:00 p.m. The nurse called to check on the resident if there was any update. The daughter who answered informed the nurse that her mom passed away. It was heartbreak for the staff. A review of the residents blood glucose monitoring revealed the following: 10/19/22 8:37 a.m. 150 mg/dl (milligram per deciliter) 12:45 p.m. 138 mg/dl 5:44 p.m. 158 mg/dl 7:50 p.m. 151 mg/dl 10/20/22 7:35 a.m. 208 mg/dl 2:02 p.m. 279 mg/dl 4:58 p.m. 231 mg/dl 7:22 p.m. 268 mg/dl 10/21/22 5:09 a.m. 392 mg/dl 8:33 a.m. 600 mg/dl A review of the hospital documents from Resident #1's hospitalization on [DATE] documented the following: History of present illness: Patient is an [AGE] year old female with a history of insulin-dependent diabetes .presents to the emergency department by EMS (emergency medical services) for evaluation of elevated blood sugars, nausea and vomiting the (sic) been getting progressively worse over the last two days. Patient herself is an extremely poor historian. She states she began feeling very nauseous and had multiple episodes of vomiting over the last 48 hours. Patient states that the nurses noted the emesis was extremely dark sometime yesterday. They attempted to obtain a blood sugar this morning and it was over 400. Patient states that she has not gotten any of her insulin due to her not eating or drinking in the past in the last one to two days. Medical decision making: 11:00 a.m. Patient appears to be extremely ill at this point. Patient appears to be in acute diabetic ketoacidosis. She does have evidence of acute renal insufficiency. She also most likely has an upper GI (gastrointestinal) bleed .Patient is started on insulin drip. 11:41 a.m. Called to the patient's bedside for bradycardia (slow heart rate) and altered mental status .patient is pronounced dead at 11:41 a.m. C. Interviews The county coroner was interviewed on 11/8/22 at 10:30 a.m. He stated an autopsy had been completed with Resident #1, as well as various pathology tests. The coroner said the pathology tests had not been completed as of 11/8/22, and until they were completed he would be unable to determine a cause of death for Resident #1. The coroner said he had completed his own investigation, and had determined that Resident #1's insulin orders had been discontinued on 10/19/22, with the reason of being a duplicate order and no physician order to discontinue any of the insulin medications. He said the resident had several health problems, and was a very sick person, but her insulin medication not being administered could have contributed to her death. Licensed practical nurse (LPN) #1 was interviewed on 11/8/22 at 11:41 a.m. She stated she was the nurse who had discontinued all of Resident #1 insulin medications, but she did not recall doing it. She said the facility had done education with her regarding when and how to discontinue resident medications. She said she was still on administrative leave while the facility investigated the incident, and she was getting additional training when she returned to the facility. The LPN said the facility had implemented a new system for discontinuing medication, which included having two nurses verify the physician orders to ensure the accuracy of the order. The medical director (MD) was interviewed on 11/8/22 at 12:34 p.m. The MD said she was also Resident #1 primary care physician (PCP). The MD said she was not aware Resident #1 insulin orders had been discontinued until several days after Resident #1 had been sent to the hospital. The MD said the facility had made her aware of the resident's change of condition on 10/19/22, 10/20/22 and 10/21/22, but at that time she was not aware the resident's insulin had been discontinued. The MD said the facility had continued to monitor the resident's blood glucose (BG), which was within Resident #1's BG parameters. The MD said although Resident #1 had other medical conditions that also contributed to her death, however it was not good that she had missed her insulin. The MD said she had not been a part of the facility investigation, but she did ask the facility to tell her the result of their investigation and what they determined were the system failures. The MD said the conclusion of the investigation was there was not a system in place to check the accuracy of nurses discontinuing medications. Licensed practical nurse (LPN) #2 was interviewed on 11/9/22 at 9:05 a.m. She said she had been in the facility for about three months, and recently had training regarding discontinuing physician orders. She said prior to 10/27/22, nurses would simply discontinue an order in the resident's medical record, and just create a note which stated the reason the medication was discontinued. She said now when an order comes in for a medication to be discontinued, that order had to be verified by a second nurse working the floor, and then the order was placed into a folder for a third check by the night nurse, to ensure the accuracy of the discontinued order. LPN #3 was interviewed on 11/9/22 at 9:11 a.m. She said she had worked in the facility for about two years, and there had been a recent change to the process of discontinuing orders for residents. The LPN said prior to the medication error with Resident #1, nurses would discontinue orders in resident's medical records by writing a quick note of why the medication was discontinued and there was no system in place to confirm the accuracy of the order being discontinued. She said as of 10/27/22 there was a new process in place. She said now when a nurse gets an order to discontinue a medication, the order is now written out so there is a paper trail to ensure the order is accurately understood by the nurse, and the nurse is to read back the order to the physician to ensure it was transcribed correctly. The nurse then needed to have a second nurse double check the physician order before it was discontinued. The LPN said the final step was placing the order in a folder, which the night nurses reviewed, essentially creating a triple check of each order to ensure the accuracy. The unit manager (UM) was interviewed on 11/9/22 at 9:22 a.m. She said she was the nurse who had discovered Resident #1's insulin medications had been discontinued. She said there was no physician order for any of the insulin medications to be discontinued, and LPN #1 stated the orders were discontinued because they were duplicate orders. The UM said they were not duplicate orders, and should never have been deleted. The UM said the facility had a new process in place which included two nurses checking discontinued medications when they were put into the resident's electronic medical record, and a third check happening on the night shift to ensure the accuracy of all discontinued medications. The director of nursing (DON) was interviewed on 11/9/22 at 9:37 a.m. She said prior to the medication error on 10/19/22, the facility did not have a system in place to ensure the accuracy of discontinued medications. The DON said nurses would discontinue physician orders, and there was no second or triple check system in place, so if orders were transcribed incorrectly, or discontinued incorrectly it could potentially take days before the error was identified and corrected. The pharmacist was interviewed on 11/9/22 at 10:48 a.m. She stated she had been made aware of the situation with Resident #1 yesterday (11/8/22), and had briefly looked over her medical record. The pharmacist stated from her review, all of Resident #1's prescribed insulin had been discontinued. She said she was unable to locate a physician order to discontinue the medications. She said LPN had noted the insulin was discontinued due to being a duplicate order, but the pharmacist said it was not a duplicate order. The pharmacist said the standard practice for discontinuing a medication was to have a nurse check the system was in place, meaning a nurse could not discontinue a physician order without having a second nurse checking the accuracy of the order that was being discontinued. The pharmacist said had that system been in place prior to 10/19/22, this would not have occurred. The pharmacist said since LPN #1 discontinued the medications without a physician order, and therefore the medications were not given, a significant medication error occurred. The nursing home administrator (NHA) was interviewed on 11/9/22 at 11:30 p.m. She said the facility did not have a system in place prior to 10/19/22 to ensure nurses were accurately discontinuing medications. The NHA said the new system, implemented on 10/27/22, now had two nurses verifying physician orders at the time the order was put into the resident's electronic medical record to discontinue medication, along with a third nurse checking for accuracy during night shift.

Based on record review and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for two (#16 and #316) residents out of three residents reviewed for falls and accidents out of 29 sample residents. Systematic facility failures were identified for Resident #16 and Resident #316. The failures resulted in repeat falls resulting in injury and pain. Resident #16 had a history of falls with injury. On 7/14/22 staff identified the resident had a four inch long, deep purple bruise on his left arm. His left arm was swollen and he expressed a worsening of pain. Documentation identified the resident requested to have an x-ray to his arm. The resident did not have the x-ray until 7/26/22, 12 days after his request. The 7/26/22 x-ray determined Resident #16 had a fracture to his left shoulder. The facility did not identify how the resident acquired the injuries. The facility did not conduct a fall investigation on or after 7/14/22. The facility did not conduct a bruise of unknown origin investigation. The resident's nursing staff said the bruising and swelling was due to a possible blood clot, or a residual injury from a fall on 6/12/22. The staff confirmed the injuries were not observed prior to 7/14/22 and the resident had x-rays after the 6/12/22 fall. The physician assessed the resident on 7/14/22 and felt the resident had a possible rotator cuff injury. The physician was informed by the unit manager, Resident #16 was in horrible pain. On 7/15/22, the physician prescribed pain medication and physical therapy. The physician did not provide orders for an x-ray on 7/15/22. The resident was evaluated for physical therapy on 7/19/22, fours days after the order, for transfer training and left shoulder pain. During physical therapy on 7/20/22, the resident expressed he was in pain and refused to have his left arm moved, stating it's broken. The physician provided an order for the x-ray on 7/20/22 but did not receive x-rays until 7/26/22, six days after the order. Additional facility failures for Resident #16 included lack of new fall interventions implemented and care planned after the resident fell on [DATE] and the probable fall on 7/14/22, to prevent the recurrence of future falls. Resident #16 suffered pain and delay in treatment. The facility delayed the resident's treatment when he did not have an x-ray to rule out a significant injury for over two weeks after the resident's request. The x-rays determined there was a significant injury and the resident was provided a sling for arm and shoulder support. The resident also had a delay in treatment after the resident fell on [DATE]. The resident was not provided orders to have therapy services after the 6/12/22 fall. Resident #316 was newly admitted with severe dementia, poor safety awareness and unsteadiness. The facility failed to identify, assess and implement interventions to prevent falls with injury. These failures contributed to the resident experiencing a fall on her first night in the facility, and a total of six falls within three weeks. As a result, the resident suffered large hematomas to her face and right hip, a head injury, severe pain, and two emergency room visits for treatment after falls. Findings include: I. Facility policy The Fall Management policy, last reviewed on 6/15/22 , was provided by the nursing home administrator on 8/3/22 via email. The policy read in pertinent part: Interventions to reduce the risk and minimize injury would be implemented as appropriate .Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented. According to the policy, the purpose was to: -Identify risk for falls and minimize the risk of recurrence of falls. -Evaluate the patient for injury post-fall and provide appropriate and timely care. -Ensure the patient-centered care plan is reviewed and revised according to the resident's fall risk status. The steps for post fall management were outlined in the policy. The policy identified: -If a fall occurred, an assessment will be completed to determine possible injury. -Notify the physician of the fall, report findings and the extent of injury, and obtain orders if indicated. -If the injury is of an emergent nature, the resident will be transported to the hospital. -If the extent of the injuries can not be determined, the nurse will notify emergency medical services (EMS) for evaluation and transport to the hospital. -Any resident who sustained an injury to the head from a fall and or had a non-witnessed fall will be observed for neurological abnormalities by performing neuro check, per policy. The physician will be notified of any abnormal findings. -The resident's representative will be notified of the fall and any follow-up treatment needed. -The staff should document the circumstances of the fall, complete a post-fall assessment, and document resident's fall under risk management, a change of condition, and on the 24 hour report. II. Resident #16 A. Resident status Resident #16, age 70, was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), diagnoses included displaced spiral fracture of the shaft of humerus, left arm, subsequent encounter for fracture with routine healing (onset 7/26/22), [CONDITION(S)] and [CONDITION(S)] (paralysis, muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side, [CONDITION(S)], history of falling, unsteadiness on feet, muscle weakness, abnormalities of the gait and mobility, visual loss, and anxiety. The 4/27/22 minimum data set (MDS) assessment identified the resident was not able to complete the brief interview for mental status (BIMS) assessment. According to the MDS, Resident #16 had moderately impaired cognition, made poor decisions and needed cuing and supervision. He did not exhibit disorganized thinking or inattention. The MDS identified he required extensive assistance of more than two staff for toileting, dressing, bed mobility and transfer. He required one person's physical assistance for personal hygiene. The MDS indicated the resident had a history of falls with injury. B. Resident observation and interview Resident #16 was interviewed on 7/26/22 at 9:18 a.m. He said his shoulder was uncomfortable and was told he would have an x-ray today (7/26/22). He said he recently fell in the bathroom. The resident's left arm was under his blanket as he laid flat in bed. Resident #16 was interviewed on 7/27/22 at 10:18 a.m. The resident was observed in his bed, he wore a sling on left arm. He said he had x-ray yesterday (7/26/22). The resident clearly described how he was injured. He said took himself to the bathroom. He stood up from the toilet, lost his balance and fell into the door. He said he pulled himself up by using a wall mounted bar and went back to his bed. He said he told a certified nurse aide (CNA) what happened. He said he did not know the CNA's name. Resident #16 said the fall in the bathroom was recent. He said the fall in the bathroom was after the fall when he received significant injuries to his face. C. Record review The fall care plan, last revised on 5/20/22, read Resident #16 was at risk for falls related to his history of [CONDITION(S)] ([CONDITION(S)]/stroke), [CONDITION(S)] and recent TBI (traumatic brain injury.) The care plan identified the resident had multiple falls with injury. Review of the care plan revealed the resident had no new interventions related to falls. The most recent intervention initiated on 11/27/19 and revised on 5/20/22, read the resident's last physical therapy (PT) evaluation and treatment was initiated on 4/10/22. The skin care plan, initiated on 2/18/21, identified the resident was at risk for skin breakdown and had a history of falls with injury. The care plan directed staff to observe the resident's skin daily and report abnormalities. The care plan for the resident had new interventions beginning on 7/22/22 directing staff to: -Apply lower and upper extremity protectors. -Observe for verbal and nonverbal signs of pain related to wound or wound treatment and administer medication as ordered. -Conduct weekly wound assessment with measurements and descriptions of the wound status. The 6/12/22 hospital emergency department evaluation read Resident #16 had facial trauma from a fall. The evaluation identified the resident had x-rays and a CT (computer axial tomography) scan. The x-rays showed the resident had multiple facial fractures. The evaluation findings read the resident had no other fracture, dislocation, or other acute bony abnormality. The 6/13/22 e-interact change in condition evaluation identified the resident fell the afternoon on 6/12/22. He did not express discomfort. The resident was sent to the emergency room for testing and x-rays. The evaluation read the resident had laceration sutures to his upper orbital area of his face. According to evaluation, the 6/12/22 x-rays determined the resident had facial fractures. -The evaluation did not identify the resident had fractures to any other part of his body based on the x-ray results. The 6/15/22 nurse practitioner evaluation read the resident was seen on 6/15/22. The evaluation read the resident did not have discomfort. -The evaluation did not indicate the resident expressed pain or concern with his left shoulder and arm. The pain scale between 7/1/22 and 7/12/22 identified Resident #16 reported zero to four out of 10 for pain with one reported pain level of five on 7/7/22. The 7/5/22 physician evaluation performed by the primary care physician (PCP) read the resident was seen on 7/5/22. The evaluation read there was no acute concerns with Resident #16 and he was eating, drinking and sleeping well. According to the evaluation, the resident was not in acute distress, not acutely ill, and not uncomfortable. The 7/5/22 physician note read Resident #16 was sent to the hospital due to facial fractures. The note did not indicate a concern with his left shoulder. The 7/5/22 skin check read the resident's laceration to his left eye was in the healing process. -The skin check did not identify a bruise or contusion to his left arm. The 7/14/22 at 4:05 a.m. general note read a CNA said Resident #16's arm was swollen and bruised. The general note identified the resident requested an x-ray. The resident was assessed (see note below). -There were no additional follow up notes pertaining to the resident's arm or shoulder or if the injuries were a result of a fall. The 7/14/22 at 6:45 a.m. e-interact SBAR (situation, background,assessment, and recommendation) form read Resident #16 had a change in condition. According to the SBAR, the resident had new or worsening [CONDITION(S)], new or worsening pain and a contusion (bruise). The SBAR nursing observations, evaluation, and recommendations read Resident #16's arm was swollen and bruised. There was [CONDITION(S)] present from shoulder to wrist with a 4 (inch) linear, deep purple bruise surrounded by yellow bruising, presumably from fall on 6/13/22. Weak pulse palpable on the left wrist and slightly colder than right. The SBAR read the resident requested an x-ray. The SBAR indicated there was a concern regarding a possible occlusion/blockage. The on call physician was contacted and recommended to alternate heat and ice and then elevate. The SBAR read heat was applied to the resident and his arm elevated. The resident's primary physician was also notified. -The SBAR did not identify if the primary physician offered recommendations and or new interventions. The pain scale beginning on 7/13/22, identified the resident expressed an increase of pain to his left arm. On 7/13/22 he reported a pain level of six. The pain scale on 7/14/22 identified Resident #16 reported a pain level of six. The 7/14/22 at 4:49 p.m. text message between unit manager (UM) #1 and the physician was provided by the UM on 7/27/22 at 11:59 a.m. According to the text message, the UM informed Resident #16's primary care provider/physician (PCP) that Resident #16 had complained of pain since the fall in June 2022. His arm was assessed (on 7/14/22) and his muscle was hard, tight, and painful. Resident #16 had [CONDITION(S)] to his lower arm and had horrible pain with minimal movement. The UM informed PCP that the UM and the director of nursing (DON) assessed the resident and felt he required further assessment. The PCP told the UM she saw Resident #16 on the afternoon of 7/14/22 and provided orders to registered nurse (RN) #1 via text. The PCP indicated the x-rays in the emergency room (prior to 7/14/22), were normal. The PCP identified she felt the resident had a rotator cuff injury. The 7/15/22 CPO read the resident had orders for PT to evaluate. The orders did not indicate the reason for the evaluation. The 7/15/22 CPO identified the resident had a new order for pain medication. The 7/15/22 order directed staff to administer 650 milligrams (mg) acetaminophen tablet, by mouth, three times a day for left upper extremity (pain) for 14 days. The review of the CPO between 7/15/22 and 7/26/22 did not identify the resident had orders to immobilize the left arm/shoulder to provide support when the resident expressed increased pain and exhibited swelling to the arm. -The CPO did not identify an order for an x-ray after the resident requested the x-ray on 7/14/22. The pain scale on 7/17/22 identified Resident #16 reported a pain level of six. The 7/19/22 physical therapy (PT) evaluation, conducted five days after the PT evaluation order and over a month after the resident fell on [DATE], indicated Resident #16 was referred to therapy due to a fall on 6/12/22 and was found on his left side. He complained of shoulder pain and has had a decline in transfers. The x-ray results (following the 6/12/22 fall) identified the resident was negative for a fracture. The PT evaluation revealed the resident was in a good deal of pain. The PT evaluation pain assessment indicated the resident had a pain intensity of eight out 10, located in his upper left arm/shoulder. The evaluation read PT would communicate to staff therapy's findings and determine if further testing of the left shoulder was indicated. The 7/20/22 CPO read Resident #16 had orders for physical therapy due to decline in transfer and shoulder pain. The 7/20/22 PT treatment encounter note read Resident #16 complained of left shoulder pain during treatment and did not want his left arm moved. The note read Resident #16 told PT it's broken! The PT note identified the resident's arm was swollen and painful. The therapist contacted the PCP who reported told PT Resident #16's x-ray was negative. The evaluation suggested if the resident did not have tolerance for range of motion (ROM), he may need to revisit diagnostics. The 7/20/22 handwritten physician orders were provided by the facility on 7/26/22. According to the orders, Resident #16 had an order for an x-ray for left shoulder pain. The 7/20/22 skin check read Resident #16 had a skin injury. -The skin check did not identify what or where the skin injury was. The skin check did not identify the resident had a bruise or the condition of the bruise. The 7/22/22 skin check read the resident had an open area on the middle of his right hand. -The skin check did not identify the resident had a bruise or the condition of the bruise. The appointment log was provided by the facility on 7/28/22. The log identified Resident #16 had an appointment request submitted on 7/25/22. The request read the resident needed an x-ray on his left shoulder STAT (urgent) signed by UM #1. The 7/25/22 request had a line drawn through it. The status of the appointment was left blank. The appointment log identified a second appointment request was made on 7/26/22. The 7/26/22 appointment request was not marked STAT. The status of the appointment was dated 7/27/22, indicating the appointment was completed. The resident appointment log identified the resident had an appointment scheduled for an x-ray, six days after the resident had orders for the x-ray. The 7/26/22 alert note at 12:28 p.m. read the hospital informed the facility that Resident #16 had a spiral fracture to the left humerus. The resident was provided a shoulder immobilizer to keep mobile. According to the alert note, the hospital informed the facility Resident #16 would send results to orthopedics. The hospital indicated the resident probably would not need surgery. The identified Resident #16 would have physical therapy. The 7/26/22 review and 30 day look back of the facility in house and reported investigations after incident occurrence, did not identify the facility conducted an investigation for a fall or a bruise of unknown origin after the resident had a swollen arm with a large four inch purple bruise on the early morning of 7/14/22. D. Staff interview Registered nurse (RN) #1 was interviewed on 7/26/22 at 9:25 a.m. He identified he was Resident #16's regular nurse. He confirmed Resident #16 was scheduled for an x-ray on 7/26/22. The RN said the PCP had already evaluated the resident's arm. RN #1 said the resident's swollen arm and deep purple bruise could have been from the fall on 6/12/22 or because the resident did not often move his left arm due to [CONDITION(S)]/[CONDITION(S)]. He said he was not aware of any falls the resident may have had after 6/12/22. He said the resident was seen by therapy related to his arm. RN #1 was interviewed again on 7/27/22 at 9:23 a.m. The RN said Resident #16's x-ray indicated the resident had a broken shoulder. He said the resident now had a sling. The RN acknowledged the broken shoulder could have occurred on or around 7/14/22. He said the staff originally thought the bruise was from a blood clot and contacted the physician. He said the physician evaluated the resident's arm and ruled out a blood clot. He said he was aware the resident requested an x-ray however the resident often complained of pain. The RN said the facility received orders for an x-ray from the physician. RN #1 said he was not aware of an x-ray appointment delay after the facility received orders. He said the appointment scheduler/facility driver (FD) was responsible for scheduling the x-ray. The RN said he still believed the injuries were caused by the 6/12/22 because no one reported a fall to him. He said it was possible the hospital did not identify the shoulder fracture at that time. The RN said the resident can not use his arm because of a stroke, so it was possible the change was not identified by staff. The RN said he did not observe the deep purple bruise or swelling of the arm prior to 7/14/22. The RN acknowledged the inability to use the arm would not cause a bruise and a fracture. The PCP was interviewed on 7/27/22 at 10:49 a.m. The PCP said she evaluated Resident #16's arm after staff reported to her of his [CONDITION(S)] and bruising. She said the resident has a history of behaviors and would at times not want people in his room. She said she was able to distract the resident's behaviors with conversation and aggressively move his arm. The resident did not express pain at that time (7/14/22). The PCP said she identified the resident's arm was swollen over his bicep. She said based on her assessment, she felt the resident had a bicep tear or rotator cuff injury. She said the resident did not have a blood clot. The PCP ordered the resident pain medication and physical therapy to evaluate him. She did not recall if staff reported to her Resident #16 was having an increase in pain. She said she was not informed the resident requested an x-ray on 7/14/22. The PCP said she asked the resident what happened and he said he did not know. The PCP said the 7/26/22 x-ray results determined the resident had a fracture to his shoulder. The PCP said the fracture would not have been a result of the 6/12/22 fall. She said the resident's prior x-ray after his 6/12/22 fall, identified he had facial injuries but the other bones were normal. The PCP said the shoulder fracture would have been a new occurrence. She said something happened to cause the injuries. The NHA was interviewed on 7/27/22 at 11:10 a.m. The NHA said investigations were conducted when a resident had a bruise of unknown origin. The director of nursing (DON) was interviewed on 7/27/22 at 11:22 a.m. She said she was new to the facility. She said she had limited knowledge of concerns related to Resident #16 on 7/14/22 but was aware he was expressing pain. She said she had UM #1 assess the resident on 7/14/22. His arm was swollen and hard. He had a bruise and pain. She said the PCP was contacted and had already seen the resident on 7/14/22. The physician thought the resident had a rotator cuff injury. The DON said an x-ray was ordered last week (7/20/22) when the physician was informed that the resident's pain and swelling had not improved or resolved. The DON acknowledged the resident did not have an x-ray until 7/26/22, six days after the resident had an order for the x-ray. The DON said it would be the expectation for the resident to have an x-ray on the same day of the orders. The DON confirmed there was a long delay between the time the order was made for an x-ray and the time he had an x-ray. She said she was not sure if the FD was aware of the 7/20/22 orders on 7/20/22. She said the facility was in process of implementing a new appointment system with the nurses and the FD. The nurses would write the appointment request in the appointment book, identify what the appointment was for, and write STAT if it was urgent. The FD should review the book several times a day to identify new changes or add ons to the appointment requests. She said she would educate staff of the new process. The DON identified the resident had not had the 7/20/22 physician ordered x-ray until 7/27/22. The DON said she told the FD on 7/26/22, the resident needed the x-ray now. The DON said because she was new, she was not fully aware of the appointment process before the implementation of the new process. She said she just knew it was unorganized. The UM #1 was interviewed on 7/27/22 at 11:39 a.m. She said she had been in her position for a few weeks. The UM said she was aware Resident #16 had a fall in June 2022 and an x-ray after the 6/12/22 fall. He started reporting pain a couple of weeks ago. She said on 7/14/22 the nurse identified the resident had a swollen arm, and pain. The resident was assessed. His bicep was hard, swollen and had an old green and yellow bruise and a purple bruise in the same area. The UM said she was concerned with the resident's pain level and hardened bicep. She said she texted the PCP, reporting the resident was in horrible pain with minimal movement. She said a couple weeks after 7/14/22, it was reported that the resident was having pain during transfers with PT on 7/20/22. The UM said she was scheduled off work a few days after 7/20/22. She said on 7/25/22 she saw an order on 7/20/22 for the x-ray laying on top of the appointment book and the identified the resident still did not have the x-ray. She said she informed the FD of the appointment. The FD was interviewed on 7/27/22 at 5:16 p.m. The FD identified he was a CNA, the facility driver and appointment scheduler. He said he received physician referrals for appointments. He said he found out what the resident needed the appointment for, identified where he could take the resident for the appointment, contacted the appropriate medical service site, and coordinated his schedule to provide transportation to the appointment and asked the resident if they agreed with the appointment time. The FD said he could not force a resident to go to the appointment. The FD said with the old process, the nurse handed him an order with the appointment that needed to be scheduled. Now, there was an appointment book that he used to schedule the appointments. The FD said he planned on taking Resident #16 to have x-rays on 7/22/22. He attempted to ask the resident on 7/20/22 if he could take the resident to the appointment on 7/22/22 but the resident was having behaviors that day and was not approachable. The resident was in pain and mad. The FD said he planned on re-approaching the resident on 7/22/22 but did not because the resident was yelling at everyone. The FD said Resident #16 had a good rapport with the laundry aide. He said he did not think of asking her to ask the resident he would go to the appointment on 7/22/22. The FD said he may try that approach in the future. The FD said he canceled the 7/22/22 appointment. He said he did not communicate to anyone that he canceled the 7/22/22 appointment except for RN #1 and the CNAs were aware of the resident's behaviors that day and that he was not approachable. The FD said on 7/26/22 the resident was in a good mood and the FD was able to take Resident #16 to the appointment. The resident agreed and had the x-ray on 7/26/22. The FD said no one approached him on Monday 7/25/22 regarding Resident #16's appointment. He had some appointments and had a resident shopping trip scheduled but would have taken the resident if the appointment urgency was expressed or it was communicated that the resident needed to be seen STAT. He said if he knew the appointment was urgent, then he would have coordinated his schedule to make it work. UM #1 was interviewed again on 7/27/22 at 5:25 p.m. She said on 7/25/22 she wrote STAT next to the resident's appointment request but was aware the FD was fully booked on 7/25/22. The UM was asked if she considered to send Resident #16 by ambulance when the x-ray appointment was considered STAT. The UM said she did not consider having the resident go out by an ambulance to the appointment because STAT did not come from the physician. The rehab/therapy service director (RSD) was interviewed on 7/28/22 at 10:32 a.m. The RSD said Resident #16 received therapy services in April 2022 till May 2022. She said the resident did have orders to be seen in June 2022, after the resident fell on [DATE]. She said the resident had x-rays on 6/12/22 in the hospital emergency department, which were negative for a shoulder fracture. She said in July 2022, the resident had new orders to evaluate the resident for transfer training, pain and history of falls. She said she was not aware if the resident was expressing pain prior to 7/14/22 but was aware the resident had pain after 7/14/22. She said the resident was evaluated on 7/19/22. The RSD said during 7/20/22 therapy treatment, the resident complained of pain and reported to PT that he thought his shoulder or arm was broken. The RSD said the physician was contacted with PT's observation and the resident's concern. The NHA was interviewed on 7/28/22 at 7:30 p.m. The NHA said it was a routine intervention for a resident to have a therapy evaluation after a fall. She said she was not sure why the resident did not have an order for therapy after his 6/12/22 fall. The NHA said staff should have been more assertive with the physician of their concerns after they assessed the resident for a change in condition. The NHA said it would be appropriate to send a resident to an x-ray appointment if the FD was not available. The NHA said she would have instructed staff to start an investigation for the bruise of unknown origin if she was aware of staff findings on 7/14/22. E. Facility follow up The DON provided a 7/27/22 staff education on 7/27/22 at 11:22 a.m. The education informed staff of a new process in appointment scheduling. According to the education, the process was discussed a week prior. The process included appointment requests logged in a binder and the requests would include the diagnostic request such as x-rays, CT scans, etc. Nursing staff was responsible for initiating the requests and the scheduler was responsible for reviewing daily. The schedule needed to indicate the appointment had been scheduled and completed on the log. The scheduler would notify the resident and the resident's power of attorney (POA) with the upcoming appointment date and time. According to the education, appointments needed to be scheduled daily, and the scheduler should not wait days to make the appointment. The education read Appointments are very important and are not to be rescheduled for lack of time or transportation. The education informed staff that appointments should only be rescheduled per the resident or physician request. The education identified the facility had both had back up drivers and residents also use a transportation service vendor for appointments. The 7/27/22 education for resident refusal of an ordered treatment was provided by UM #1 on 7/28/22 at 10:18 a.m. According to the education, if a resident refuses an ordered treatment, the refusal, the reason for the refusal, the education to the resident, and the PCP notification must be documented in a progress note in the resident's medical chart. The 7/27/22 education for fall charting was provided by UM #1 on 7/28/22 at 10:18 a.m. According to the education, all falls in the facility must be charted under risk management and a change of condition must be completed. Neurological checks must be initiated for unwitnessed falls with a suspected head injury. The PCP, the POA, and the on-call nurse must be notified of all falls and incidents. III. Resident #316 A. Resident status Resident #316, age 77, was admitted on [DATE]. The July 2022 computerized physicians orders (CPO) included diagnoses of dementia with behavioral disturbance, major depressive disorder, and weakness, and lack of coordination. A minimum data set (MDS) with brief interview for mental status (BIMS) was not performed as the resident was a new admission. B. Record review Resident #316's care plan for falls, initiated 7/8/22, the date of admission, focused on cognitive loss, lack of safety awareness, impaired mobility, and seizures. Interventions implemented to prevent falls included: -Assist resident to organize belongings for a clutter free environment in the resident's room for consistent furniture arrangement -Observe for changes in medical status, pain status, mental status and medication side effects that may contribute to cognitive loss/dementia/[CONDITION(S)] and can lead to increased fall risk, and report to physician as indicated. -Arrange patient's environment to enhance vision and maximize independence -Bed in low position -Gently guide the resident from the environment while speaking in a calm, reassuring voice when needed. -Observe for signs/symptoms of depression and anxiety and promote self-management strategies. -The care plan was not updated or modified after the initiation date of 7/8/22, although the resident experienced repeated falls and injuries. A nursing note on the day of admission, 7/8/22 at 5:55 p.m., showed the resident was admitted to the facility at 4:45 p.m. with goals for physical therapy (PT) and occupational therapy (OT). She was noted to have advanced dementia with inability to understand her reason for admission. She was noted to be confused but oriented to person only and to be unsteady with transferring from surface to surface as well as unsteady with transferring to the toilet, but she was able to stabilize with staff assistance. The resident was noted to be experiencing agitation and restlessness. The resident was noted to have a past medical history of cancer, dementia, [CONDITION(S)], and poor safety awareness. The 7/8/22 admission fall risk assessment, included with the nursing assessment, documented no falls in the last two to six months prior to admission, and no falls in the last month prior to admission/readmission. -The resident's fall risk was otherwise not assessed. 1. Fall #1 A situation, background, assessment, and recommendation (SBAR) note on 7/9/22 at 12:00 a.m., the night of admission, reported the resident's first fall in the facility. The nursing observations section read, CNA alerted me that resident had fallen in her bedroom. Resident was found curled in a ball between the bed and[TRUNCATED]

Based on resident and staff interviews and record review, the facility failed to promote resident dignity and respect. The facility failed to ensure residents were provided timely bathing, meals and call light response. Due to the facility's failure to follow-up with resident concerns for those that required staff assistance with care, it created feelings of frustration, embarrassment, worry, imprisonment, and lack of worth. In addition, the facility failed to ensure residents were treated and spoken to in a dignified manner. Cross-reference F565 grievances of a group Findings include: I. Facility policy The Resident Rights policy, revised 3/1/22, was provided by the nursing home administrator (NHA) on 5/16/22 at 4:38 p.m. via email. The policy read in part: Patients/residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. The (facility) will comply with resident rights under Federal law at 42 U.S.C 48.10 (Resident Rights) and communicate those rights to patients in any language and or by means of communication that ensures understanding. According to the policy, the facility should treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her self-esteem and self-worth. The facility would incorporate the resident goals, preferences, and choices into the residents ' care. The facility shall recognize each individual as well as honor the value of his or her input. The facility will protect and promote the rights of the residents. II. Resident #15 1. Resident status Resident #15, age 68, was admitted on [DATE] and readmitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/10/22 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. According to the 5/4/22 MDS, Resident #15 required extensive physical assistance with two or more staff for toileting and bed mobility. The MDS identified the resident needed one person extensive physical assistance for transferring and dressing. 2. Resident interview Resident #15 was interviewed on 5/10/22 at 6:05 p.m. She said not all staff treated her with respect and dignity. She said she had long waits to have staff answer her call light. She said it was common for her to have a 45 minutes to an hour wait. She said this past Sunday (5/8/22), she only saw two nursing staff working. She said she had been told they had other people to take care of when they answered the light and sometimes they said they were going to come back and then not come back at all. Resident #15 said it made her feel like she was not important to the staff. Resident #15 said a month ago she requested to use the restroom. The certified nursing aide (CNA) started to transfer the resident without a gait belt. The resident told the CNA that she needed a gait belt to transfer so she did not fall. The CNA said she would use the resident's night gown to support her and catch her if she fell . Resident #15 said she refused to transfer without a gait belt. The CNA told the resident she would then have the just lay there and mess herself. Resident #15 said staff also went through her personal belongings when she was at [CONDITION(S)] and had thrown away some of her items. She said a physical therapist (PT) was going through her dresser drawers and questioned why she had a sling in her drawer. The resident said the PT spoke to her in a harsh tone. The resident said she did not report concerns to anyone. She said she would be willing to talk to the NHA. 3. NHA interview Resident #15 reported staff concerns were reported to the NHA on 5/10/22 at 6:53 p.m. The NHA said she would immediately meet with Resident #15. The NHA was interviewed again on 5/10/22 at 7:32 p.m. She said she spoke to Resident #15 and would report her concerns with the State Agency and start an investigation. III. Additional resident interviews Residents expressed how care concerns and the way staff treated and spoke to them created feelings of diminished dignity and respect. All residents were identified by the facility and assessment as interviewable. Resident #17 was interviewed on 5/9/22 at 1:45 p.m. She said sometimes she had to wait over 10 minutes to have a CNA remove her bed pan from under her after use. She said it was very uncomfortable. She says the pan felt like it was going to cut into her skin when she had to wait. She said she was also worried about spilling underneath her. She said she spilled her bed pan recently and made a big mess. She said the facility needed more than one CNA at night because they were too busy to always come to her. She said she had been told she expects too many things. Resident #16 was interviewed on 5/9/22 at 4:40 p.m. He said at night time he had to wait several hours for them to answer his call light. He said he was dependent on staff for incontinent care and catheter care. She said staff told him they were short staff and he was to be patient. He said it was frustrating the way they told him to be patient when he needed assistance. Resident #18 was interviewed on 5/11/22 at 8:25 a.m. He was observed to have his slippered feet in a puddle of a spilled beverage. He said someone saw the spill and went to get something to clean it up. Resident #18 said staff were not usually so quick to respond. He said he was incontinent and would often have to wait over an hour for staff to answer his call light. He said he just had to sit in his soiled brief which was frustrating and uncomfortable. Resident #18 said he had only been at the facility for a couple of weeks but it had lowered his confidence in humanity. He said he had given up on using his call light. He said he did not have skin issues yet but was worried about it. Resident #19 was interviewed on 5/11/22 at 11:22 a.m. She said she transferred from the facility to another facility the week prior to the interview. She said she was concerned about the care at her former facility. She said she would often have to wait over an hour for staff to answer her lights during the day and night. She said it made her angry and she felt very disrespected. She said she had a voice and many of the residents were not able to speak up. She said residents should not be treated that way. Resident #19 said the staff should be able to provide timely care for the residents. IV. Family interview A family member of Resident #14 was interviewed on 5/11/22 at 8:03 p.m. She said Resident #14 was not regularly cleaned. She said the resident voided on the floor and walked into it barefoot. She said he still had feces on his foot three days later. She said Resident #14 was moved to another room. She said during the room move the CNA was very rude to her and Resident #14. He piled the resident's items on the bed near the resident's head and proceeded to move the entire bed down the hall with Resident #14 still in the bed. The CNA bumped into the wall several times when the resident was transported. The family member said Resident #14 could walk and she was not sure why he was transported in such a manner. The family member said she had already reported her concerns to the NHA. V. Resident group interview A resident group interview was conducted on 5/10/22 at 1:45 p.m. with residents (#1, #2, #9, #10, #11, #12) who per facility and assessment were cognitively intact and interviewable. Residents made the following comments during the group interview: -There has been a lot of staff turnover which affects everything. I feel like I am not worth anything. I am not important to them. -Sometimes when I put my call light on I am told that they only have one CNA for two halls and they have to come back later because they have to help someone else. The resident said she needed help too, she was just as important as someone else. -A resident said he feels like he was in jail when food was consistently late and he hardly received a bath/shower. He said it made him very angry. (Cross-reference F565 grievances of a group.) -Another resident said when she was not bathed she felt yucky. She said had worried if other people could smell her. She said when she went out of the facility to see her cousins, she was embarrassed that she was not clean and felt she had an odor. (Cross-reference F565 grievances of a group.) VI. Record review The February 2022 call light audit was provided by the NHA on 5/10/22 at 4:58 p.m. The call audit was conducted on 2/1/22 at 3:20 p.m. The audit identified three resident room call lights were reviewed on the 400 hall. Two of three rooms with call lights on were answered within three to five minutes. The audit revealed the resident in room [ROOM NUMBER] was not always satisfied with the timeliness of call light responses. According to the audit, the resident in 405 was not asked to affirm that his/her request was appropriately handled after staff responded to the resident's call light. The call audit identified room [ROOM NUMBER]'s call light was answered in eight minutes because the staff member was in another resident's room. The call light audit read under the comment section, Based upon call light audit and resident perception; recommending random call light audits. The NHA was identified as the reviewer of the call light audit. No additional call light audits were provided. The staff education was reviewed with the NHA. The NHA provided a statement after the review on the facility's online training program on 5/12/22 at 12:09 p.m. The statement read All staff completed education via (online program.) Their mandatory training is their schedule throughout the year every quarter the human resources department reviews compliance with mandatory trainings and will contact employees to complete their training if applicable. The trainings included a vast array of topics which included resident rights, dignity, and dementia care for all staff. The topics of activities of daily living (ADL) and medication administration are specific to license nursing and CNAs. VII. Staff Interview The NHA was interviewed on 5/10/22 at 4:50 p.m. She said she thought the facility conducted a call light audit but she contacted the former director of nursing (DON) and he did not know where the audits were. The NHA said she could only find one call light audit in February 2022. She said she had asked the interim DON to start the call light audits but she thought she was just to create a plan to start the audits, and they were not completed. The NHA was interviewed on 5/12/22 at 8:56 a.m. She said she was not aware of Resident #15's concerns until it was reported by the surveyor. She said the resident was alert and oriented and was able to relay the same details as was reported to the NHA. The NHA said she assured Resident #15 that it was not alright that she had been treated the way she reported from staff. The NHA said she started an investigation and has a good idea of who the staff were. She said she also met with two nurses that were involved in going through the resident's items. She said the nurses were not aware they could not go through the resident's items or at times throw them away, without discussing the reason or asking for permission from the resident. The NHA said she would do an all-staff education immediately. She said the staff member who spoke to her harshly was no longer at the facility. She said she was passionate about ensuring residents were treated with dignity and respect. She said she was going to implement an all staff inservice on 5/16/22, stressing the importance of dignity. The NHA was interviewed on 5/12/22 at 10:15 a.m. She said the facility was currently conducting new call light audits. The NHA said call lights should be answered within three to five minutes but if the staff was in another resident room, call lights may take up 10 minutes to answer. She said she would continue to remind staff to answer call lights on other halls when available. The NHA said nurses should also be answering call lights. She said all staff should get the routine off answering call lights. The NHA was informed that some residents said they did not feel important when staff does not provide timely call light response. The NHA said slow call light response could cause increased stress on the resident. CNA #5 was interviewed on 5/12/22 at 11:50 p.m. She said when she was trained to make sure to treat residents with respect, allow them to make choices in their care, take time with them, and give them a sense of dignity. She said she can only be in so many places at one time. She said the residents felt the impact when staff was so busy trying to help everyone. CNA #5 said residents expressed frustration when they had to wait for care. She said sometimes they told her oh you have someone else to take care of. CNA #3 was interviewed on 5/12/22 at 12:25 p.m. She said she had completed dignity training. She said staff gave residents privacy, did not use terms of affection, and never spoke to the resident in a condescending tone. She said all staff were supposed to answer call lights but usually she was the only one on the hall to answer the call lights. Residents had to wait sometimes and complained of the long waits. Resident #3 said she told them there was only so much she could do by herself. She said when residents became upset, she tried to spend extra time with them, making sure all their needs are met. CNA #5 was interviewed on 5/12/22 at 12:29 p.m. He said he was one of the few staff members who focused on dignity and respect. He said residents should be provided privacy by taking them to the restroom, calling them by their name, not using terms of affection, or trying to correct them. He said staff should not talk to them like a child. CNA #5 said staff could use more dignity and respect training when working with the residents. The social service director (SSD) was interviewed on 5/12/22 at 1:49 p.m. The SSD said she had only been at the facility for the past month but had dignity training when she was hired. The SSD said treating residents with dignity was one of the most important things staff could do for the residents. She said staff should routinely check on the residents to make sure they were doing okay. The SSD said bathing opportunities, call light and meal timeliness and speaking to the residents appropriately, were all components of a dignified experience. She said residents had reported late meals and not having enough showers. She said she was also aware of a staff night nurse who residents reported had an attitude, was pushy, and a loud voice. The SSD said those concerns were reported to the NHA. VIII. Facility follow up The 5/16/22 all-staff education was provided by the NHA on 5/16/22 via email. The agenda included an exercise of empathy which included a discussion on how difficult it was for residents to transition into the facility. The discussion reminded the staff that they were at the facility to assist the residents. According to the staff education agenda, staff were given examples of dignity to include meal service, call lights, bathing, ADLs and safe transferring.

Based on resident, staff interviews and record review, the facility failed to ensure two (#36 and #6) of five residents reviewed for abuse out of 30 sample residents, were free from physical and verbal abuse. Resident #36 said in an interview on 4/21/21 that he was verbally abused by certified nurse aide (CNA) #4 about a month and a half ago. He said it made him feel not respected and he was shocked and angry. He said that nursing staff were aware but no one had come to talk to him about the issue. Resident #36 said that approximately two months ago he had heard angry yelling in his hallway and as he passed a resident room, he saw CNA #1 standing next to a resident who had his face down on his plate of food. Record review revealed that Resident #36 had a verbal interaction with CNA #4 on 3/7/21. There was no documentation found that the facility followed up on the matter. There was no documentation found regarding Resident #36's observation of the angry yelling involving CNA #1. Resident #6 said in an interview on 4/26/21 that he had been verbally and physically abused by CNA #1 and #6. He said CNA #1 had called him pathetic and had thrown him into bed one night. He said CNA #6 tried to pry open his two fingers that were frozen (contracted) on his left hand and it hurt him. He said that the interactions with both CNAs made him feel undignified, disrespected, and like he was being pushed around. He said he also felt angry and did not know how to defend himself. He said he did not say anything to anyone and did not like talking about it. He said he just wanted to forget about it. There was no documentation found to demonstrate that the facility further investigated the incident with Resident #6 and CNA #6. In addition, CNA #6 was allowed to continue working with residents after the facility was aware of Resident #6's abuse allegation. The facility's failures subjected Resident #36 and #6 to verbal and physical abuse by three CNAs assigned to provide care to vulnerable residents, and the potential for other facility residents to suffer abuse. Cross-reference F609, failure to report alleged allegations of abuse; and F610, failure to thoroughly and timely investigate allegations. Findings include: I. Facility policy and procedures The Abuse Prohibition policy, revised April 2021, was provided by the nursing home administrator (NHA) on 4/22/21 at 2:25 p.m. The policy documented in pertinent part, (The facility) prohibits abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter 'patient') property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The Center will implement an abuse prohibition program through the following: - Screening of potential hires; - Training of employees (both new employees and ongoing training for all employees); - Prevention of occurrences; - Identification of possible incidents or allegations which need investigation; - Investigation of incidents and allegations; - Protection of patients during investigations; and - Reporting of incidents, investigations, and Center response to the results of their investigations. II. Resident #36 A. Resident status Resident #36, less than [AGE] years of age, was admitted on [DATE]. According to the April 2021 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 3/24/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. He had no documented moods or behaviors, and no rejection of care. He was dependent for bathing with no set up or physical help from staff. He was independent with locomotion per electric wheelchair. B. Resident interview Resident #36 was interviewed on 4/21/21 at 10:00 a.m. When discussing abuse, he said that he had a verbal altercation with CNA #4. He said that she had awakened him from a deep sleep and that she had rushed him to go and take a shower. He said this happened over a month ago. He said she was irritated with him and was rushing him to finish his shower and get dressed. He said he was angry and frustrated because of the way he was awakened and how he was being rushed. He said, in standing up for himself, CNA #4 became angry at him and yelled at him. She said she did not have to put up with his f-- s--, and had said s-- of a b--. He said she had cursed at him first and he then cursed back at her. He said it was loud enough that people outside of the shower room could have heard it. The resident said he was not afraid of her and that she was not giving him showers anymore. The resident then said that a couple of months ago he had heard CNA #1 yelling in an angry tone as he wheeled past a room that was on the same hallway that he lived in. He said he saw CNA #1 standing next to a resident who had his face in his food. He said she looked at him as he went by. He said she had yelled so loud it could be heard down the hallway. He said that he had told the director of nursing (DON) about the incident but that no one ever got back to him about it. He said no one had come to talk to him about either of the incidents. C. Record review The resident's mood care plan, initiated 6/26/2020 and revised 11/9/2020, identified the resident exhibited or was at risk for distressed and/or fluctuating mood symptoms such as depression, sadness, anxiety and irritability related to his diagnoses. Interventions included to observe for signs and symptoms of worsening sadness, depression, anxiety and irritability, encourage him to seek staff support for distressed mood, have him refocus on something positive and allow him time for expression of feelings, provide empathy, encouragement and reassurance. A nurse note dated 3/7/21 documented in part that the resident was in the shower room with the bath aide (CNA #4) and was being very aggressive and attempting to swing at the CNA. The aide feared he would get more angry and physical so she asked him to leave to which he responded by calling her a b---, and multiple other insults. The resident was commonly rude to staff. A care plan initiated on 4/15/21 (more than a month later) identified the resident exhibited or had the potential to exhibit physical behaviors related to yelling at staff, using foul language and calling staff names. The interventions included: -Evaluate the nature and circumstances (triggers) of the physical behavior with the resident and/or resident representative, discuss findings with the resident and family members/caregivers and adjust care delivery appropriately. -Resident to seek staff support for distressed mood, explain all care, including procedures (one step at a time) and the reason for performing the care before initiating. -If resident becomes combative or resistive, postpone the care/activity and allow time for him/her to regain composure and provide resident with opportunities for choices during care/activities to provide a sense of control. D. Staff interviews Registered nurse (RN) #1 was interviewed on 4/21/21 at 1:59 p.m. She said that she had not seen any staff yell at residents. She said she had witnessed residents being verbally abusive towards staff by yelling and swearing and that she had heard staff asking residents to please not speak in that manner. She said if a resident continued to be abusive staff should just walk away. The NHA and DON were informed on 4/22/21 at 3:00 p.m. about Resident #36's report of verbal abuse, both directed against him and witnessed by him. They were also informed that the resident said he had reported the verbal abuse (loud yelling) that he had witnessed. The NHA said that staff told him that Resident #36 had made aggressive comments and cursed at them and that he had talked to the resident about his actions. He said the resident became angry at times depending on the situation and then he would calm down. He said he had heard from another staff member that Resident #36 was the one who cursed at CNA #4. The DON said CNA #4 wanted to give the resident a shower and he wanted a different shower time. The DON said Resident #36 had reported to her that he had heard staff raising their voices towards someone who needed help across the hall from him. He told her he went out to the hall to see what the problem was and one of the CNAs told him they were dealing with the issue and that he did not need to be there. She said she did not remember when this happened but that the resident identified the CNA as CNA #1. The NHA said he had not heard anything about CNA #1 yelling at residents and that he talked to Resident #36 on a regular basis. Both the NHA and DON said they had not done an investigation for either of the incidents. The DON said CNA #4 did not work with the resident anymore. She said she had talked to CNA #1 about the yelling allegation but did not document it or do an investigation. The NHA said he would look into this matter right away. On 4/22/21 at 5:00 p.m. the NHA reported that he had suspended CNA #1 and CNA #4 pending the outcome of the abuse investigation to ensure Resident #36 and all other residents were kept safe. CNA #10 was interviewed on 4/26/21 at 2:22 p.m. She said Resident #36 had mentioned to her that a lot of the CNAs got irritated with him but she did not know what that was about. She said she had never seen CNA #6 do anything bad towards a resident. She said that CNA #6 did tell her today that Resident #6 (see abuse allegation below) had hit her with a washcloth. She said if she saw anything like that she would report it right away. Licensed practical nurse (LPN) #2 was interviewed on 4/26/21 at 12:10 p.m. She said if she was aware of any abuse she would first make sure the resident was safe, remove the perpetrator and report it to the DON and NHA right away. She said that she had not witnessed any type of abuse by staff towards residents. She said she had heard residents say before that they do not like a certain staff member and the way they did things. She said if she heard a staff member sounding frustrated, she would encourage them to take a break. She said that Resident #36 had told her about general complaints with staff members like having to wait a long time for his call light to be answered but he had not mentioned abuse to her. She said that Resident #36 could become verbally harsh depending on his mood. E. Facility investigation and follow-up The NHA said he reported Resident #36's allegations of verbal abuse to the State Agency on 4/22/21 during the survey. The facility was aware before 4/22/21 (see interviews above) that the resident had reported a second allegation of verbal abuse by CNA #1. In addition, the facility was aware of the verbal abuse by CNA #4 on 3/7/21. These allegations had not been reported timely to the State Agency (Cross-reference F609, failure to report alleged violations.) An investigation report regarding verbal abuse for Resident #36 and witnessed verbal abuse, dated 4/22/21, was provided by the NHA on 4/26/21. The report documented the allegation was reported to the State Agency on 4/22/21 and to the police (no date or time specified). 1. Staff to resident verbal abuse The investigation revealed Resident #36 was interviewed as well as seven staff and 12 residents. The interviews did not have a documented date or time, or documentation of who conducted the interviews. The investigation documented in part the following: Resident #36's interview revealed CNA #4 entered his room in the afternoon when he was napping. She told him to get up, we ' ve got to take your shower, I ' ve got to go. The resident felt rushed. She said she would take his items to the shower room and come back to get him. When she returned she told him aren ' t you ready yet? When they got to the shower room he may have said something to her but he did not remember and then she responded: I don ' t have to take your f--- s---! He responded to her, F--- you b---! She responded with, get the f--- out of here! and then left the shower room. She then came back and said, I told you to get the f--- out of here! The resident stated he was not fearful, just angry. CNA #4's interview revealed that she entered the resident's room and told him it was time for his bath and that he ignored her. She then took his belongings to the shower room. When she returned she told the resident she was ready and the resident did not respond and she began to leave the room. The resident then said to her, God d--- it, I was sleeping. She said she told him she was sorry and asked him if he would rather not have a bath. He responded by telling her that she was not sorry. He then transferred himself to his chair and followed her to the shower room. He then began to take off his shirt and she went to assist him. He pulled his shirt out of her hands and said, God d--- it, I ' ll do it myself! The CNA then told him to put on his shorts and leave. He then responded to her, You don ' t talk to me that way you f--- b---! The CNA then responded, I ' m sick of your s---, just leave! A nurse interview documented she heard arguing behind the door of the shower room. Then the shower door opened and she heard CNA #4 tell the resident to leave the shower room. The resident said, you f--- b---, I need to wash off. Then CNA #4 said, I f--- told you to leave and left the shower room. CNA #4 then returned to the shower room, the resident was still there and CNA #4 said again, I f--- told you to leave. All 12 resident interviews denied any concerns with staff during their baths. The facility substantiated the verbal abuse towards Resident #36 by CNA #4. 2. Witnessed verbal abuse The investigation (provided by the NHA on 4/27/21 at 10:00 a.m.) revealed Resident #36 was interviewed along with four staff and 10 residents. The interviews did not have a documented date, time or name of the person interviewing. The investigation documented in part the following: Resident #36's interview revealed that he had heard loud yelling when going down the hall. He passed a room and saw a resident asleep on his tray. CNA #1 was standing in the room on the resident's side and looked at Resident #36 as he passed by the door. He did not hear any more yelling. He did not know who the resident was. He said he could not remember the time and that it was approximately a couple of months ago. CNA #1's interview revealed that she had never come across a resident asleep on their tray and that she had never yelled angrily at a resident. One of the 10 residents interviewed said that one morning she told a staff member that she was not ready to eat her breakfast just yet. She said the staff member told her she needed to eat now and she stood up for herself and told the staff member that she could say no and was told again, you have to eat. The resident said the staff person was not yelling, but had an elevated tone. The resident was unable to identify the staff person. A second resident interview revealed that the resident was standing at the end of the bed doing something and the housekeeper asked if he could move. The resident did not respond or move and the housekeeper said, Ok, I just won ' t clean your room today and left the room. He said he felt rushed. The NHA said (on 4/28/21 at 5:06 p.m.) that this investigation was still not completed and that they would be doing more interviews. He said he would provide follow up as it was completed. The NHA and DON were interviewed a second time on 4/27/21 at 7:34 p.m. before the conclusion of the survey. The NHA said that CNA #4 (alleged verbal abuse towards Resident #36) would remain on suspension until things could be sorted out with corporate guidance. He said he felt pretty certain that CNA #4 would be terminated. The NHA provided follow-up on 4/28/21 at 7:36 p.m. The allegation of CNA #4 verbally abusing Resident #36 was substantiated and CNA #4 was terminated. In addition, the nurse that wrote the progress note on 3/7/21 (above) was terminated. The report did not document follow-up on the additional allegations revealed by residents during the investigation, and the investigation was still incomplete. III. Resident #6 A. Resident status Resident #6, age 79, was admitted on [DATE]. According to the April 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 1/21/21 MDS assessment, the resident was cognitively intact with a BIMS of 13 out of 15. He was identified with moods of trouble concentrating on things such as reading the newspaper or watching television. He had no behaviors and did not reject care. He required extensive assistance for transfers, dressing, eating and toileting. He required limited assistance for personal care. He was totally dependent on bathing with one person assistance. He used a wheelchair or walker for ambulation. B. Resident interview Resident #6 was interviewed on 4/26/21 at 10:39 a.m. The resident shook his head and said his weekend was not good. He began to explain that CNA #6 had been rough with him when cutting his fingernails. He said she was also loud and got in his face telling him she had to clip his nails because they were long and dirty. He said she had an attitude that it had to be done right now and her way. He said she tried to pry open his middle fingers on his left hand that were frozen stiff and difficult to open. He said it was painful and he told her to stop and that she did not pay attention to him and continued trying to open his hand. The resident said this was not the first time someone had treated him badly. He said shortly after he moved to the facility there was an incident with CNA #1. He said she had told him he was pathetic and he could not understand why she said that to him. He said that she was assisting him to bed one night and that she was rushing him. He said he moved slower now due to his condition. He said that she had thrown him into bed and that he twisted his neck and his left arm. C. Record review (Cross-reference F610) There was no documentation or investigation found regarding the resident's allegation of verbal abuse by CNA #1. There was no documentation or investigation found regarding the resident's allegation of physical abuse by CNA #6. A care plan initiated 1/27/21 identified the resident stated it was important that he had the opportunity to engage in daily routines that were meaningful to his preferences. Interventions included that he liked his personal activities of daily living organized related to his OCD diagnosis. The resident had a tendency to mumble and speak continuously, one subject after another. He would benefit from accommodation for physical limitations by being transported in his wheelchair. When requested, staff were to assist him with items that he needed his hands for, and his left hand was clenched into a fist (contracture). A nurse note dated 3/14/21 documented in part the resident was found face down in his oatmeal asleep. He was then found at lunch face down on his plate asleep. D. Staff interviews CNA #10 was interviewed on 4/26/21 at 2:22 p.m. She said that Resident #6 did not have any behaviors and was usually very quiet. She said he was slow to do any task and that he did not like any of his personal things moved and liked things placed a certain way. The NHA and DON were informed on 4/26/21 at 11:14 a.m. about Resident #6's report of verbal and physical abuse by CNA #1 and CNA #6 (see resident interview above). The NHA said that he had just talked to the resident yesterday and asked him how he was feeling and if he had seen anyone talking or yelling loudly, and that he did not mention anything about how he felt. The DON said that there was an episode yesterday with Resident #6 and CNA #6 during a bath and that the resident had hit CNA #6 in the face with a washcloth. The DON did not initiate an investigation when she became aware of the situation. The NHA said he would follow up on this right away. On 4/26/21 at 2:20 p.m. the DON provided follow up and said that they had sent CNA #6 home on suspension. She said that she had asked CNA #6 what had happened, and CNA #6 said the resident had hit her in the face with a washcloth during his shower when she was clipping his nails. She said CNA #6 told her that she did try to open his fingers on his left hand because she thought his fingernails may be digging into his left hand. She said the resident said ow, and then she stopped and asked other staff to take over for her. E. Facility investigation and follow-up The NHA said he reported Resident #6's allegations of physical abuse by CNA #6 and physical and verbal abuse by CNA #1 to the State Agency on 4/26/21. (See Resident #6's interview above.) The investigation revealed Resident #6 was interviewed as well as three staff and five residents. The interviews did not have documented dates, times or names of interviewers. The investigation documented in part the following: Resident #6's interview revealed that he was describing different episodes. First he described he was being kept from eating his toast and then that he was rushed in the shower. He said that a staff person had told him he was pathetic, and that it had happened yesterday. He said she went to clean them (his nails) and that they needed to be done a certain way. He said it was not hurting until two fingers, when she pulled them open it hurt, and he told her it hurt a couple of times. He said she let go after he smacked her. He said he did not know why he hit her and that he felt inferior. CNA #6's interview revealed she had bathed the resident and shaved him. She said she was cleaning his fingernails and did his right hand with no problem. She said when she went to move a finger away from his palm on his left hand so she could do his nails he said Ow! She said she immediately let go. She said the resident had grabbed a wet washcloth and smacked her in the eye and called her a f--- b---. She said she got help and had other staff dry and lotion him and take him back to his room. CNA #11's interview revealed she was not there when it happened and that CNA #6 asked for help with the resident. She said CNA #6 told them the resident had hit her with a washcloth. She said the resident was yelling at CNA #6, you're hurting me, you're not listening to me. Registered nurse (RN) #2's interview revealed she went into the shower room and the resident was very angry. She said they were trying to calm him down. She asked the resident what happened and he said that they were not being patient with him and they were rushing him. He said during the time they were drying him and putting lotion on him they were hurting him. She said the staff had stopped and talked with him until he allowed them to resume. She said all the staff were being very gentle with him. She said she did not feel the resident was fearful but angry about being rushed. On 4/27/21 at 7:35 p.m. the NHA said that the investigation regarding allegations of abuse by CNA#1 was still in process and he would provide follow up when it was completed. F. Further observations and interviews Observations on 4/27/21 at 8:35 a.m. revealed that CNA #6 (involved in a physical abuse allegation with Resident #6 on 4/25/21, and suspended on 4/26/21) was back in the facility and working with residents providing baths. On 4/27/21 at 9:00 a.m. the NHA was asked why CNA #6 was back and working with residents. He said that he was not able to substantiate the allegation based on Resident #6's interview. He said the resident was not making sense and confusing his stories. He said other resident and staff interviews revealed no concerns. He said CNA #6 would not be working with Resident #6 anymore. He was asked if CNA #6 had been given education prior to coming back to work and working with residents, and he said he had not started that yet and would get on that right away. The NHA and DON were interviewed a second time on 4/27/21 at 7:34 p.m. before the conclusion of the survey. They were asked about the follow up plan involving CNA #6 since they concluded Resident #6's allegation against her was unsubstantiated. The DON said that CNA #6 had been pulled from the floor this morning to begin additional training and education via computer modules, and then she was sent home. She said CNA #6 would be off of work for a few days while the investigation was resumed. The NHA was asked if there was also a plan to provide supervision and monitoring for CNA #6 before she returned to work at the facility on 4/27/21, and the NHA said he would put one into place. He said that a disciplinary write up would be placed in her employee file. The DON said they would be initiating a new investigation. The NHA said that he was still in the early stages of investigating Resident #6's allegations of abuse regarding CNA #1 and that she was still suspended. He said he still had to interview more staff and residents and contact his corporate office for guidance on how to proceed. He said after hearing of the second allegation against her, CNA #1 had resigned her employment. The NHA acknowledged that if staff were expressing stress and burnout it could be an indication for bigger problems and he wanted to ensure the residents felt safe. The NHA provided follow-up on 4/29/21 at 5:06 p.m. He said that a supervision and monitoring plan had been put into place for CNA #6 and that she would no longer be providing care to Resident #6. He said that she had to report to a licensed nurse when reporting to work. She had to let the nurse know what area of the facility she would be working that day, either giving baths or working on the floor. Random observations of the employee would be conducted while providing resident care and she would be continuing and completing training modules and be cleared by the center executive director (CED) and center nurse executive (CNE) before she returned to work. He said he was not able to substantiate the allegation involving CNA #6 and that the investigation was still in progress regarding the allegation involving CNA #1. On 4/30/21 at 1:00 p.m. the NHA provided the completed investigation regarding the verbal abuse allegation involving CNA #1. The allegation was unsubstantiated. Fifty-two residents were interviewed and one of the 52 residents said that she remembered CNA #1 talked loudly and quickly but she never heard her cursing or calling any resident names. IV. Facility failures 1. The facility was aware of the incident of verbal abuse involving Resident #36 and CNA #4. In addition, they were aware of the witnessed verbal abuse reported by Resident #36 involving CNA #1. This placed the resident and all other residents at risk for abuse. 2. The facility failed to investigate and report to the Stage Agency allegations of verbal abuse reported by Resident #36. (Cross-reference F609 failure to report allegations.) 3. The facility was aware of the incident involving Resident #6 and CNA #6 (on 4/25/21) and failed to investigate it until the following day (4/26/21) when it was reported to them during the survey. 4. CNA #6 was allowed to come back to work the following day after allegations of physical abuse toward Resident #6 were reported on 4/26/21. 5. The facility failures placed Residents #36 and #6 and other residents at risk for verbal and physical abuse.

Based on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#10 and #106) of three residents reviewed for pressure ulcers out of 30 sample residents. The facility failed to ensure Resident #10 did not develop an unstageable (stage 3 or above-see reference below) pressure ulcer to the trunk area on her back, which was acquired in-house. This resident was chair-fast with [CONDITION(S)]. The development of the pressure ulcer caused pain to the resident. The facility failed to consistently monitor and provide adequate and timely wound cares, including routine measurements of the wound. No documentation was found for this wound (which was first observed on 2/22/21) from 2/22/21 through 3/27/21. The facility failed to create a care plan related to actual pressure ulcers and treatment. Furthermore, on 4/27/21, nursing staff was observed using a product which was not ordered for Resident #10's wound care. Additionally, the facility failed to ensure Resident #106 did not develop a stage 2 pressure ulcer to his sacrum and right gluteal area, which was acquired in-house. This resident was bed-bound and was not provided with an air mattress. He was not provided with therapy for five days following his admission. There was also a delay in implementing interventions after his wound had been discovered. Findings include: I. Professional reference A. The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (undated) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Pressure injury prevention points, updated 2016, revealed in part Consider bedfast and chairfast individuals to be at risk for development of pressure injury; Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within eight hours after admission); Use heel offloading devices .on individuals at high risk for heel ulcers. I. Facility policy and procedures The Skin Integrity Management policy, revised 1/31/2020, was provided by the nursing home administrator (NHA) on 4/27/21 at 6:00 p.m. It documented the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds. It documented staff should continually observe and monitor residents for changes and implement revisions to the plan of care as needed. It documented staff should perform skin inspections on a weekly basis, perform wound observations and measurements and complete the Skin Integrity Report upon initial identification of altered skin integrity weekly and with anticipated decline of wound and perform daily monitoring of wounds or dressings for presence of complications or declines and document. The policy documented the facility should develop comprehensive, interdisciplinary plans of care, including prevention and wound treatments, as indicated. They should implement skin/wound care guidelines as applicable, review co-morbid conditions that may affect healing, notify dietician and/or rehabilitation services as indicated, notify the physician to obtain orders, review the care plan weekly and revise as indicated and document daily monitoring of ulcer site (with or without dressing). The policy documented for wounds that do not require a daily dressing change, monitor status of the dressing (intact and clean), status of tissue surrounding the dressing (free of new redness or swelling) and adequate control of wound pain. II. Resident #10 A. Resident status Resident #10, age 91, was admitted on [DATE]. According to the face sheet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/5/21 minimum data set (MDS) assessment documented the resident was cognitively intact for daily decision making with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one for bed mobility and dressing. She required extensive assistance of two for transfers and toileting. She was independent with ambulation once assisted into her wheelchair. She did not reject care. Section M, skin condition, of this MDS documented the resident had a pressure ulcer/injury, a scar over bony prominence. It documented Resident #10 was at risk for developing pressure injuries and that she had one or more unhealed pressure injuries. It documented the resident had one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. B. Observations of Resident #10 and interview Resident #10 was initially interviewed on 4/21/21 at 10:28 a.m. She said she had a sore on her back that she acquired in the facility when she had COVID-19, was very ill and essentially bed-bound and was isolated in her room. She said facility staff did not look at her back very often and that she had some pain in the area of that sore. She said they put some type of a bandage over the wound and she did not know what the wound looked like because she could not see her back. The resident had an air cushion on the seat on her wheelchair, but did not have a cushion for the back on the chair. On 4/22/21 at 8:08 a.m. Resident #10 was sitting in her wheelchair in her room. She was crocheting a red afghan and appeared happy and content with this task. -At 10:25 a.m., the resident was in the same position and continued to be content with her crocheting. - At 1:33 p.m. Resident #10 was in her room, seated in her wheelchair, crocheting her afghan. She said she was still at it because she wanted to make up for lost time when she was quite ill with COVID-19. -At 3:45 p.m., the resident was still in her wheelchair working on her afghan. On 4/26/21 at 8:30 a.m. Resident #10 was seated in her wheelchair in the dining room. She was working on a word puzzle book. -At 11:50 a.m., she was in the dining room doing her word puzzle search and enjoying stuffed peppers that her daughter made for her. -At 1:05 p.m., Resident #10 was in her room, up in her wheelchair working on her afghan. -At 3:45 p.m., the resident was seated in her wheelchair, watching television and crocheting. On 4/27/21 at 8:00 a.m. Resident #10 was eating breakfast in the dining room after working on her word search puzzles earlier that morning. -At 8:30 a.m., the resident remained in the dining room visiting with a staff member. -At 11:50 a.m., the resident was in the dining room, eating the meal her daughter prepared as well as a Wendy's frosty. C. Interview with director of nursing (DON) The DON was interviewed on 4/26/21 at 9:01 a.m. She said the facility did not have a wound nurse, but they were trying to hire one. She said she and the nurse managers had been doing the wound care in the facility. She said the facility had an action plan because of communication problems in the facility with identifying new pressure injuries in a timely manner. She said the floor nurse was providing wound care for Resident #10 and she would check with the nurse to see when her wound could be observed the following day. D. Observations of wound care to right trunk Licensed practical nurse (LPN) #3 was interviewed on 4/27/21 at 10:00 a.m., while making wound care observations for Resident #10. The LPN practiced hand hygiene with soap and water prior to beginning the wound care. LPN #3 placed a clean pad on the resident's bed for a clean surface in which to work from. She cleaned a pair of scissors with alcohol. The resident had not been pre-medicated for pain prior to wound care. Resident #10 said she currently had no pain in the wound area unless she directly laid on the wound. She said she did have quite a bit of pain in the wound area when the injury first occurred. LPN #3 cleansed the wound with [MEDICATION(S)], working in circles from the inside of the wound to the outer areas. She said the pressure injury was an unstageable wound because you could not see the wound bed due to the eschar. She said no exudate (drainage) was observed. She used [MEDICATION(S)] AG with silver for the inner dressing. She did not measure the wound. She did not provide measurements of the wound until specifically asked. She described the wound as 1 centimeter (cm) x 1 cm. She did not give a depth measurement of the wound. She said she did not routinely measure pressure injuries unless specifically requested by the director of nursing (DON). This dressing was covered with an outer [MEDICATION(S)] dressing and dated. She said the wound initially looked like an abrasion, but was located over a bony prominence, so was changed to a stage 2 pressure injury. She said she did not think there was any undermining, but she could not see under the wound bed. She said the scab was directly over the wound. She said she felt the wound was looking good and healing nicely. She said the dressing was changed on the resident's bath days and as needed. She said the dressing usually stayed in place until the resident's next bath day. The LPN said the wound was acquired in-house, but could not remember specifically how long ago. She said the wound started when the resident had COVID-19. She said the resident had lost a lot of weight during COVID-19 and she developed the pressure injury over a bony prominence over her back area of right trunk. She said the resident had been eating more recently and her skin integrity had improved. She said there was no sign of infection or moisture associated with the wound. E. Record review 1. Skin assessments There were no other skin assessments seen in the resident's electronic chart from 2/22/21 until 3/27/21 (see below). No other skin assessments were provided by the facility. The Braden scale for predicting pressure sore risk assessment dated [DATE] did not include a score. It documented the resident's sensory perception was slightly limited and she was occasionally moist. It documented she was chair-fast and her mobility was very limited. It documented her nutrition was very poor. It documented she had a potential problem for friction and shear. The skin check assessment dated [DATE] documented no skin injury was identified. The skin-tear/abrasion/laceration assessment dated [DATE] documented a trunk abrasion measuring 1 cm x 1 cm (centimeter). The skin check assessment dated [DATE] documented no skin injury was identified. The skin-tear/abrasion/laceration assessment dated [DATE] documented the truck wound was first observed on 2/22/21. The wound measured 1 cm x 1 cm. The skin-tear/abrasion/laceration assessment dated [DATE] documented the trunk wound was first observed on 4/22/21 (which was after the date of this assessment) and it was acquired in-house. It measured 0.75 cm long and 0.75 cm wide. It was being left open to air. It documented weight loss was a contributing factor leading to decline. It documented the wound had not changed. The skin check dated 4/17/21 documented moisture associated skin damage, as her groin/peri area was inflamed. -This check did not mention the resident's unstageable pressure injury to her right trunk area. The Skin-Pressure Ulcer assessment dated [DATE] documented the resident had an unstageable pressure injury on her right posterior trunk, which was first observed on 2/22/21. It was acquired in-house. It documented the deepest stage had been stage 2 with no drainage. The wound appearance included 1-24% epithelial tissue. The surrounding tissue was described as healthy. The wound edges were distinct. The wound measured 0.75 cm x 0.75 cm with no depth documented. It documented the facility was using a foam dressing as the secondary dressing. It documented the resident was receiving nutritional treatment and the care plan was updated. It documented the resident was on a turning program, but did not specify how often she should be repositioned. The skin check assessment dated [DATE] documented the resident had skin injury/wounds identified. It documented the resident was at risk for skin breakdown related to decreased mobility, incontinence age and diabetes. It documented the resident had an actual pressure ulcer to her truck, stage 2, on the right side. The injury status was changed from an abrasion to a pressure ulcer on 4/16/21. Interventions included encouraged the resident to consume all fluids of her choice during meals, observe skin for signs/symptoms of skin breakdown, evaluate for any localized skin problems, observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed, utilize (un-named) device to assist resident with turn/positioning to reduce friction/shear, lower extremity protectors, upper extremity protectors, observe for verbal and non-verbal signs of pain related to wound or wound treatment and medication as ordered, obtain dietician consult as needed/ordered, pat (do not rub) skin when drying, obtain skilled PT (physical therapy)/OT (occupational therapy) evaluation to improve functional mobility, pressure redistribution surface to bed as per guideline, pressure redistribution surfaces to chair as per guideline, provide wound treatment as ordered, provide supplements as ordered, weekly skin evaluation by licensed nurse, provide patient and/or healthcare decision maker education regarding risk factors and interventions, provide preventative skin care (i.e. lotions, barrier creams as ordered) and apply barrier cream with each cleansing. 2. Care plan Resident #10's care plans of 3/5/21 were reviewed. There was no care plan related to actual pressure injuries. -There were no care plans related to pressure injuries created after the wound was first identified on 3/29/21. The care plan related to skin breakdown, dated 3/5/21, was reviewed and documented Resident #10 was at risk for skin breakdown due to decreased mobility, incontinence, age and diabetes. Interventions included providing preventative skin care (i.e. lotions and barrier creams) as ordered, observe skin for signs/symptoms of skin breakdown daily with ADL care and report abnormalities, utilize (left blank) device to assist resident with turning/positioning to reduce friction/shear, obtain dietician consult as needed, pressure redistribution surfaces to bed and chair as per guideline, provide wound treatment as ordered and weekly skin assessment by licensed nurse. 3. Computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The April 2021 CPO was reviewed. It documented the following was ordered on 4/16/21, but not started until 4/20/21: Wound right flank. 1. Clean with wound cleanser; 2. Apply [MEDICATION(S)] AG; 3. Change on bath days and prn (as needed). QD (every day) every Tuesday and Friday for wound care. There was no order seen for the use of [MEDICATION(S)] AG with silver for the use with Resident #10's pressure injury as seen during the observation LPN #3 used. There was no order seen in Resident #10's electronic chart related to leaving the wound open to air, as mentioned in the DON's interview of 4/27/21 (see below). 4. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - However, during the 4/27/21 wound care observation at 10:00 a.m. (see above), LPN #3 used [MEDICATION(S)] AG with silver for the dressing, along with [MEDICATION(S)] AG as the outer dressing. F. Additional staff interviews The DON was interviewed again on 4/27/21 at 10:53 a.m. She said Resident #10's wound developed because the resident used to have her bed against the wall and always laid in bed on her right side. She said the wound started developing, grew a bit more and then erupted. She said the facility spoke to the resident about her positioning in bed and the resident agreed to move the bed so she could turn on her other side. The DON said eschar then appeared and the facility's medical director observed the wound with the DON. The DON said they were leaving the wound open to air to let it self-debride. She said the resident was a slow healer due to co-morbid issues. She said the facility did not begin using dressings until 4/16/21 and was prompted when the resident told the DON the area hurt her. The DON said the evening of 4/15/21, someone put a foam dressing on the wound. The eschar had gotten soft and had been pulled off, as it adhered to the dressing. She said the wound had been classified as unstageable because it had eschar and she was now classifying the wound as an unhealing unstageable because you cannot back stage pressure injuries. The DON said that the resident's bed positioning should have been identified and addressed, especially when the resident was quite ill with COVID-19. She said facility staff probably should have encouraged the resident to reposition more often in order to prevent the pressure injury from occurring in-house in the first place. She said, in order to promote wound healing and minimize further wounds, as the resident was still thin following her illness, facility staff should be observing skin condition with all care, repositioning the resident with all care, observing the resident for continued pain, obtaining a dietary consultation and involving therapy as needed. She said the resident had recently a pressure redistribution mattress and chair cushion. She said she would now be requiring weekly evaluations of skin on the resident's entire body in order to detect skin issues in a timely manner. She said the facility would be providing supplements for wound healing, along with high protein snacks. She said the resident's daughter had been bringing food to her mother to try to get her to eat more and gain some weight back. She said a might shake had been ordered prior, but had been discontinued. She was uncertain as to what dates these were. The NHA was interviewed on 4/27/21 at 5:53 p.m. He said the facility had an action plan developed for skin and they conducted an ad hoc QAPI meeting the day prior, after becoming fully aware of the in-house acquired pressure ulcer that Resident #10 sustained. He said he understood it was an issue due to lack of wound measurements for the pressure injuries. He said the facility was aggressively in the process of hiring a wound nurse. He said the assistant director of nursing (ADON) who normally helped with wound care had been out on leave for a family emergency. He said the facility would be willing to pay for a nurse to become wound certified. He said the action plan had identified some issues such as reviewing skin assessments on a daily basis for completeness and accuracy, ensuring proper mattresses and cushions were in place, providing further education with floor nurses on communication issues related to skin care and knowledge into the appropriate use of cushions and surfaces before skin injuries become an issue. He said it was his expectation for the certified nurse aides and bath aides to report skin issues immediately to nurses and for skin assessment audits to be performed at least weekly. III. Resident #106 A. Resident status Resident #106, age 74, was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/10/21 admission MDS, the resident had severe cognitive impairment with a BIMS score of seven out of 15. No mood or behavioral symptoms were documented. He needed extensive assistance with activities of daily living, was dependent for bathing, and used a wheelchair for mobility although ambulation did not occur during the review period. He had range of motion limitations to his upper and lower extremities. He was always incontinent of bowel and bladder. He had no pressure ulcers and had a pressure reduction mattress and wheelchair pad. -The pressure reduction mattress was not an alternating air mattress, see last observation and the director of nursing interview below. The resident was unable to offload his weight on his own. B. Resident interview and observations The resident was interviewed initially on 4/21/21 at 5:06 p.m. He resided on the 100 hall, which was designated for residents on 14-day observation after admission for COVID-19 precautions. He said he had not received a bath or shower, and had not received therapy services. He was lying on his back in bed. (Cross-reference F677 activities of daily living) The resident was interviewed a second time on 4/22/21 at 4:32 p.m. He had been moved to the 300 hall. He said he had a pressure sore on his bottom that had just opened up. He said it was difficult for him to move his body from side to side. Observations of the resident throughout the survey-on 4/21, 4/22, 4/26 and 4/27/21 from approximately 8:30 a.m. to 6:00 p.m. - revealed he was bedbound and was always lying on his back. He had range of motion limitations to his hands and arms. On 4/27/21 at 2:40 p.m. Resident #106's wound was observed with registered nurse (RN) #1. Upon entering the room the resident was lying on his back in bed covered with his sheets. The nurse explained to the resident that she needed to look at his skin. She then uncovered him and with the help of a CNA, helped him turn to his left side and removed his adult brief. There was a large [MEDICATION(S)] dressing covering his entire buttock area. -There was a small open area on his lower right buttock. The RN said it was dime sized and a stage 2 because the skin was broken. There was no depth to the wound; there was no drainage. The surrounding tissue was healthy, pink and blanchable. -RN #1 said his wound was acquired here from the previous mattress that he was on. She said there currently was no treatment order for the wound other than the [MEDICATION(S)] dressing. She said due to his [CONDITION(S)] he could not tolerate position changes and that now that he has the air mattress it will provide rotating air pressure. (The air mattress had just arrived on the afternoon of 4/27/21-see DON interview below.) C. Record review According to the 4/3/21 nursing assessment, the resident had no skin issues, was at risk for developing pressure sores, and was unable to move side to side in bed. Review of Braden Scales for Predicting Pressure Sore Risk assessments revealed the first assessment was dated 4/10/21, seven days after the resident's admission. He scored 16, mild risk, with no sensory perception impairments, skin was often moist, he was chairfast, his mobility was very limited, nutrition was adequate, and friction/shear was not an apparent problem. -On 4/17/21, he scored 10 high risk, with completely limited sensory perception, skin often moist, bedfast, mobility very limited, nutrition adequate, and friction/shear were a problem. -On 4/22/21, he scored 10 high risk, with sensory perception slightly limited, skin constantly moist, chairfast, completely immobile, nutrition probably inadequate, and friction/shear were a problem. According to the resident's skin assessments dated 4/10/21 and 4/17/21, he had no pressure injuries upon admission. According to nursing notes, a stage 2 pressure sore was first discovered on the resident's buttock on 4/22/21 at 3:26 p.m. He had no air mattress yet, but nursing staff had requested one. On 4/26/21 the DON provided a Skin Integrity Report form where she had documented the resident's pressure sore on 4/22 and 4/26/21 as a stage 2, no pain, with epithelial tissue, 1 cm x 1 cm with no depth, no undermining, no drainage, inflamed surrounding tissue, healthy wound edges, no odor, care plan updated on 4/26/21. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] dressing to sacrum and right gluteal area. DX (diagnosis) stage 2 pressure ulcer as needed for pressure ulcer sacrum change dressing as needed and -[MEDICATION(S)] dressing to sacrum and right gluteal area. DX stage 2 pressure ulcer every 72 hours for stage 2 pressure ulcer. His skin integrity care plan, initiated 4/6/21 and revised 4/10/21 and 4/26/21, was not revised regarding the pressure sore until 4/26/21, four days after the pressure sore was discovered, and no interventions to promote healing were added other than physician orders. The care plan focus documented he was at risk for skin breakdown related to [CONDITION(S)] with decreased activity, incontinent of both bowel and bladder and [MEDICATION(S)] dressing to sacrum and right gluteal area. DX stage 2 pressure ulcer (4-22-21). The goal was no skin breakdown for 90 days. Interventions were: -Bed bath 2 times weekly (4/21/21) -Pat (do not rub) skin when drying (4/6/21) -Provide preventative skin care i.e. lotions, barrier creams as ordered (4/6/21) -Apply barrier cream with each cleansing (4/6/21) -During cares assist with turning and repositioning as needed and upon request (4/10/21) -Observe skin for signs/symptoms of skin breakdown (4/6/21) -Observe skin conditions daily with ADL care and report abnormalities (4/6/21) -Obtain dietitian consult as needed/ordered (4/6/21) -Obtain skilled physical/occupational therapy evaluation to improve functional mobility (4/6/21) -Weekly skin check by licensed nurse (4/6/21) Review of the April 2021 treatment administration record (TAR) revealed the resident's wound dressing was not applied until 4/25/21 at 7:52 p.m., three days after the pressure sore was first observed. D. Staff interviews The director of nursing was interviewed on 4/26/21 at 8:30 a.m. and 9:00 a.m. She said she had ordered an air mattress for the resident, but had to order it from a company in Denver and had no estimated time of arrival. She said they had an action plan in place regarding communication, documentation, skin assessments, wound assessments and follow-through regarding pressure injuries. They have no wound nurse, were trying to hire one, and she and the nurse managers were doing wounds now. She said she was going to get an air mattress on the resident's bed. The nurse on duty yesterday was in and out of his room a lot, turning and repositioning him. She acknowledged the resident's wound was first discovered Thursday afternoon (4/22/21) and the nurse documented as if it was new yesterday (4/25/21). The facility failed to prevent Resident #106's inhouse-acquired stage 2 pressure sore from developing by not implementing the appropriate interventions for Resident #106, who required extensive assistance from staff with ADLs and had limited range of motion to his upper and lower extremities. Furthermore, the facility failed to implement timely interventions to promote healing and prevent further skin breakdown.

Based on observations, interviews and record review, the facility failed to ensure three (#106, #14 and #20) of 12 residents reviewed out of 30 sample residents received adequate nutrition/hydration interventions to prevent weight loss and ensure adequate nutritional parameters were met. Resident #106, who was admitted [DATE] with adult failure to thrive and advanced [CONDITION(S)], experienced severe 14.43% weight loss in one month of admission. The facility failed to assess and respond to his nutrition/hydration risk, failed to identify and provide for his dining assistance needs and food preferences and consistently weighed the resident as indicated in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, to facility failed to: -Resident #14, who received hemodialysis, did not have his nutritional needs consistently met, did not have weights obtained consistently to monitor his nutritional status and did not receive the appropriate assistance and oversight for dining; and, -Resident #20 continued to lose weight, her weights were not consistently obtained according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy and procedure The Diet and Nutrition Care Manual, dated 2019 (no month), was provided by the director of nursing (DON) on 4/27/21 at 11:17 a.m. The policy documented in part, The dietary guidelines are a critical tool used by professionals to help Americans make healthy choices in their daily lives with a goal of preventing chronic disease and enjoying a healthy diet . Considerations in menu planning for post-acute and long care settings: Many professionals are concerned that the volume of foods needed to meet the guidelines would be almost impossible for most individuals living in post-acute and long term care settings to consume. Other considerations include customer satisfaction: -Contribute to quality of life, considering food preferences and personal choice; -Provide therapeutic diets and consistency alterations with the most individualized and least restrictive diet possible, as appropriate to encourage intake; -Provide eye-appealing and tasty meals to encourage food intake; -Meet Recommended Dietary Allowances (RDAs) are defined as nutrient intake level that meets the requirement for nearly all people in a specific age group and gender. Adequate intake (AI) is the level of nutrient intake of healthy people assumed to be adequate; -Meet the needs of individuals who sometimes feel the volume of food is overwhelming; -Provide sufficient nutrients for individuals with acute and chronic illnesses who often cannot eat enough food to provide sufficient calories and other nutrients-and therefore; are at risk for unintended weight loss, malnutrition, dehydration and other complications; and, -Meet all state and federal regulations. II. Resident #106 A. Resident status Resident #106, age 74, was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/10/21 admission minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. No mood or behavioral symptoms were documented. He needed extensive assistance with activities of daily living, needed limited physical assistance for eating, and was dependent for bathing. He had range of motion limitations to his upper and lower extremities. He was always incontinent of bowel and bladder. He had no swallowing disorders, was 66 inches tall and weighed 185 pounds. B. Observations and resident interviews Observations and interviews during the survey (conducted 4/21, 4/22, 4/26 and 4/27/21) revealed the resident had difficulty with eating due to range of motion limitations and lack of assistance, was at risk for aspiration, and his food choices and requests were not consistently honored. The resident was observed to request a second helping and an alternate meal for two separate meals, and neither of the requests were honored because the facility was out of the requested item or it was not on the menu. (Cross-reference F677-activities of daily living for dependent residents, and F561-choices.) C. Record review The April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a new order for Protein Liquid give 30 ml by mouth two times a day for wound management, initiated on 4/26/21 (during survey and four days after a Stage 2 pressure ulcer was identified-cross-reference F686 pressure ulcers). The resident's documented weights since admission, via mechanical lift, revealed he had a severe 14.43% weight loss within less than a month: 4/3/21-185 lbs.; 4/17/21-140.9 lbs.; and, 4/24/21-158.3 lbs. which resulted in a 14.43% weight loss from the initial weight on 4/3/21. -No weekly weight was documented on 4/10/21. There was no evidence of a reweigh, or communication to the interdisciplinary team, physician or dietary/registered dietitian after the above severe weight loss was documented under the vital signs section of the resident's chart (see nutritional assessment and progress notes below). The 4/7/21 nutritional assessment documented the resident's weight was 185, usual body weight (UBW) was 180 and body mass index (BMI) was 29.9. The goal was to maintain weight, and there were no nutritional problems. The resident was independent with eating and able to make needs known. He was on a regular liberalized diet. No labs were available. Reassessment per protocol was needed. Review of the resident's undated preferences list revealed he disliked eggs, and no likes were documented. Review of interdisciplinary team (IDT) notes revealed no evidence of an IDT discussion about the resident's weight loss. A nutrition progress note dated 4/7/21 by the registered dietitian (RD) documented his nutritional assessment was completed and no concerns were identified. No nutritional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cross-reference F686 failure to prevent pressure ulcers and promote healing.) The nutrition care plan, initiated 4/8/21 and revised 4/26/21, identified nutritional risk related to [CONDITION(S)] and adult failure to thrive. On regular textures, eats independently and weight stable. The goal was to maintain a stabilized weight of plus or minus five percent on current body weight through the 4/30/21 target date. Interventions, all dated 4/8/21, included: -Honor food preferences within meal plan; -Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake; -Provide diet as ordered; -Offer snacks; -Offer alternate food choices of less than 50% consumed at mealtime; and, -Control any pain or nausea before meals. Review of the resident's meal intake records from admission on 4/3/21 through 4/27/21 revealed the following meal intake was documented: Breakfasts: eight blanks or zeros, 10% once, 25% 11 times, 50% twice, 75% twice; Lunches: two blanks or zeros, 20% three times, 25% five times, 50% eight times, 75% twice, 100% three times; and, Dinners: 17 blanks, refused once, 80% five times, 100% once. -There was no documentation that alternate food choices were offered when the resident ate less than 50%. No snack intake records were provided. D. Staff interviews The dietary manager (DM) was interviewed on 4/27/21 at 10:30 a.m. She was notified of the resident's request for seconds of cole slaw at a lunch meal, potatoes and bacon at a breakfast meal, that neither request was honored because those items were unavailable, and of the weights documented (above). The DM said, That's a significant weight loss either way. (The RD) asks for reweighs and sometimes they don't get done. He should be able to get bacon. I'll keep bacon in stock. I was told by the corporation that we follow the menu. We used to serve bacon, sausage, eggs, everything, but now I can't get it in the budget. She said the NHA told her yesterday if residents haven't had significant weight loss and it's not on the menu not to provide it due to budget. If we provide for one then everyone else will want it too. She said now that she knew Resident #106's weights, which I should have looked up yesterday, if he wants bacon and potatoes, I'll write that down. I'm preferencing him for lunch and dinner. Now that I see these weights I think he should be in the dining room. I'm going to suggest to (the DON and NHA) that (Resident #106) comes down here and eats. Regarding seconds being unavailable when Resident #106 requested, the DM said they always made an additional five to 10 servings, so seconds were available and they kept the food on the line 15 to 20 minutes after each meal to make sure. She said, Mostly that's about CNAs not wanting to come and get extras for residents. The NHA was interviewed on 4/27/21 at 4:48 p.m. He said the facility used to serve huge breakfasts every day with choices of eggs to order, sausage, bacon, potatoes, and sometimes pancakes or waffles in addition and it was beautiful, but their food budget had been reduced and they were unable to continue with those menu items. He said he had spoken with the dietary manager and Resident #106 will be getting potatoes and bacon for breakfast. We are going to do everything we can, and encourage him to come into the dining room. The RD should be working with him on this. The RD was interviewed by phone on 4/29/21 at 10:00 a.m., as she was out of state on vacation. She said she had completed Resident #106's nutritional assessment before his weights reflected weight loss, and she did not recall being notified of his weight loss or pressure ulcer. She said there were so many weight discrepancies at the facility it was overwhelming. She said she had a nutrition-at-risk meeting every Monday with the DON where they discussed residents who had experienced weight loss. She said the DM was pretty good at documenting residents' preferences. When residents asked for foods that were unavailable or not on the menu, she said, I don't like responding with a 'no.' I'll offer something similar, and if they're adamant I'll go to the NHA and ask. Sometimes (the DM) will even purchase items on her own. She said that due to budget restrictions, An a la carte kitchen - we can't do that. But the response to residents is very important. We can find ways to brainstorm together. Food preferences should matter. The RD said that on her visits to the facility, she reviewed ADL (activities of daily living) books and reviewed food and fluid intakes, talked with the DM and NHA and observed residents during meals to see if they were getting help at meal times, and looked at adding fortifying meals if needed. She said she would need to reassess Resident #106. -No additional documentation was provided by the facility regarding Resident #106's weight loss before exit on 4/27/21. III. Resident #14 A. Resident status Resident #14, age 60, was admitted on [DATE]. According to the undated face sheet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the minimum data set (MDS) assessment dated [DATE], the resident had moderate cognitive impairment for daily decision making with a brief interview for mental status (BIMS) assessment of eight out of 15. It documented the resident was independent with set-up for eating. It documented he displayed no symptoms of a possible swallowing disorder. It documented the resident was 5'9 and weighed 173 pounds. Nutritional approaches included a therapeutic (renal) diet. It documented the resident was receiving [CONDITION(S)]. B. Resident observations and interviews Resident #14 was initially observed on 4/21/21 at 10:49 a.m. He was sound asleep in his darkened room, turned to the wall. His breakfast tray, which remained untouched, was observed on his bedside table. -At 12:28 a.m., the resident remained asleep and at this time, his lunch tray was observed untouched, on the bedside table. -At 2:52 p.m., the resident was awake, but somewhat resistant to being interviewed. He said he was living in a facility which was not his hometown because he needed [CONDITION(S)]. He said he was hungry and wanted his lunch tray warmed up. The facility did not warm up his meal because it had been left out too long. Resident #14 was observed on 4/22/21 at 8:40 a.m. He was getting ready to go to his [CONDITION(S)] appointment. Licensed practical nurse (LPN) #1 said the resident received [CONDITION(S)] on Tuesday, Thursday and Saturdays mornings from approximately 8:50 a.m. through sometime after lunch. -At 1:33 p.m., the resident was still at the [CONDITION(S)] clinic. An unidentified certified nurse aide (CNA) stated he was expected back at approximately 2:30 p.m. There was no meal tray delivered for this lunch, as the facility was aware the resident was at [CONDITION(S)]. -At 3:29 p.m., the resident had returned from [CONDITION(S)]. He was lying in bed and said he had no issues or concerns at this time. He stated his weight fluctuated quite a bit, partially due to [CONDITION(S)] and partially due to the food served in the facility. He said it was cold quite a bit, but could give no further specifics about food palatability. Resident #14 was observed on 4/26/21 at 8:25 a.m. He was in bed in his darkened room with his eyes closed. -At 11:50 a.m., the resident remained asleep in bed; he had not received his room tray yet. -At 12:13 p.m., the resident's room tray had been delivered. It was on the resident's bedside table, uncovered. The resident remained asleep in bed. -At 1:00 p.m., the resident remained asleep and his uncovered room tray was untouched. -At 3:17 p.m., Resident #14 was now awake and had eaten a small portion (approximately 25%) of his cold room tray. He said the food did not taste good and requested a grilled cheese sandwich and a cookie to tide him over until dinner. Resident #14 was interviewed on 4/26/21 at 3:30 p.m. He said he did eat some of his room tray when he woke up, but only ate about one third of it, as it was cold and unappetizing. He said he asked someone to warm up his tray, but they would not, saying it had been left out too long to be warmed. He said they offered him a cold sandwich earlier, but that did not sound good to him and that was why he asked for a grilled cheese sandwich and a cookie to tide him over until dinner. He said he appreciated someone asking him if he would like anything else. He said he was rarely asked about that. Resident #14 was observed on 4/27/21 at 8:20 a.m. He was in bed, but awake and in his darkened room wearing sunglasses. He said he had them on because he was getting ready to go to [CONDITION(S)]. His covered breakfast tray remained untouched. He said he did not want to talk at this point in time because he was tired. C. Record review 1. Care plan There was no care plan in the resident's chart related to nutrition, despite the fact the resident was receiving [CONDITION(S)] three times per week. 2. Resident weights 10/1/2020: 173.0 11/1/2020: 167.8 12/22/2020: 165.8 (Post [CONDITION(S)]) No weight documented for January 2021 2/4/21: 144.2 (Post [CONDITION(S)]) 3/4/21: 147.4 4/10/21: 181.6 (Post [CONDITION(S)]), 34.2 lbs weight gain from previous weight. -There were no nutrition progress notes/assessments addressing the resident's significant weight changes until 4/22/21, which was identified during the survey. 3. Nutritional assessment The nutritional assessment completed by the registered dietitian (RD) and dated 2/17/21 documented the resident was 5'9 and his BMI (body mass index) was 25.6. He received a liberalized renal diet. It documented CURRENT -resident continues to dine independently and reports a good appetite. Will request peanut butter and jelly sandwiches prior to [CONDITION(S)] and is aware that peanut butter is outside of renal diet recommendations. PREVIOUS - resident dines independently in his room, able to feed self and make needs and wants known. It documented most meal intakes were recorded as 75% or greater. It documented Resident #14 received a Zone protein bar three times per week while at hemodialysis. This assessment documented the resident received a renal diet related to end-stage renal disease and type II diabetes mellitus (which was not on the resident's face sheet). It documented the resident's current weight was stable (+five pounds or 2.8% over target weight for [CONDITION(S)]). It documented no new nutrition problems or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -However, the resident did not have a care plan related to nutrition (see above). In addition, the resident's meal intakes were documented as 75% or greater, however based on observations (see above) his meal intake was less. The RD note, dated 4/22/21 (written during survey), documented Resident #14 was triggering for significant weight gain of 23.2% in 30 days. It documented the weight recorded in the resident's electronic record for 4/10/21 was actually pre-[CONDITION(S)] weight instead of the previously documented post-[CONDITION(S)] weight. It documented the RD visited with the resident and he felt he had been losing weight. He stated he had not received his house supplement for several weeks. It documented the resident continued to request food outside of his renal diet despite renal diet education. -However, the RD note did not address the resident's poor intake (see below). 4. Meal intakes The March 2021 meal intake records documented Resident #14 refused meals four times this month, mostly for breakfast. It documented the facility failed to document Resident #14's meal intakes on nine occasions, mostly occurring at lunch. The April 2021 meal intake records documented Resident #14 refused breakfast twice and his lunch once. It documented the facility failed to document the resident's meal intakes five times for the supper meal. The April 2021 meal intake records revealed the following meal intakes correlating to the above observation dates: 4/21/21 breakfast: 25% 4/21/21 lunch: 75% 4/22/21 breakfast: 100% 4/22/21 lunch: no lunch documented, as resident out of the facility 4/26/21 lunch: 100% was documented, but was not consistent with observation of resident consuming approximately 33% (see above) 4/27/21 breakfast: resident refusal documented D. Staff interviews The dietary manager (DM) was interviewed on 4/21/21 at 2:59 p.m. She said the kitchen could offer the resident a sandwich of his choosing to tide him over until dinner. She said having food left out for approximately three hours after the lunch tray had been dropped off was not acceptable and she was not comfortable in just warming up his lunch tray for him. The director of nursing (DON) was interviewed on 4/26/21 at 3:30 p.m. The DON said she was working on getting only dry weights for this resident due to the significant weight fluctuations in his chart, as the facility staff had been taking both post [CONDITION(S)] weights and pre [CONDITION(S)] weights interchangeably. She said it was impossible to monitor the resident's true weights and address nutritional issues and parameters without accurate weights being taken into consideration. The dietary aide (DA) was interviewed on 4/26/21 at 3:35 p.m. He said normally CNAs drop the meal trays off in the resident's room and they were expected to let the dietary department know if the resident was sleeping. He said the CNA should have left the tray covered when delivered to keep the food as warm as possible. He said the staff refusing to warm up the resident's meal was a weird response. Nurse aide (NA) #2 was interviewed on 4/26/21 at 3:40 p.m. She said the protocol for delivering room trays would be to wake up the sleeping resident to see if they wanted to eat or not. She said she would leave the tray, but would check in again approximately one hour later. She said if the food had not been consumed, she would take the tray back to the kitchen. She said she did not know if all staff members offered the resident something to eat when he woke up. The DM was interviewed on 4/27/21 at 8:45 a.m. She said food could be reheated for up to thirty minutes after being served, but any food left out longer than 30 minutes should be dumped in the garbage. She said it was the CNAs responsibility to deliver and serve resident trays and stay to encourage the residents to eat. She said CNAs should be monitoring how long trays are being left untouched in the resident rooms. She said after she heard about Resident #14's room tray being left uncovered on his bedside table for several hours before he began eating it, she provided education to the nurse managers and said they needed to educate the CNAs about this issue. The registered dietitian (RD) was interviewed on 4/29/21 via telephone for a post survey interview, as she was out of town during the dates from 4/21/21 through 4/27/21. She said she expected to see a nutritional care plan for Resident #14, especially given he was receiving [CONDITION(S)]. She said Resident #14's potassium and phosphorus levels were within normal limits. She said he was not receiving a renal supplement, but was receiving Ensure. She said this resident did not follow his diet very well and liked peanut butter, which is not on his meal plan. She said she heard about the issue of this resident consuming a cold room tray and thought nurses reheated the resident's food for them. She said, once the DM heard about the issue, she provided the resident with a fresh meal. She said this issue may have happened more than once because that was the story she had heard. She said all facility staff, including herself, were responsible for obtaining accurate weights. She said she had no idea why a weight was not documented for Resident #14 during January 2021. She said she felt the DON should be taking lead on this issue because she was always in the building. She said she did her best to compare and request re-weighs when needed, but for some reason, those reweighs did not always get done. She said maybe the resident refused to be reweighed or maybe the scales were off, but it was a very challenging task to attempt to figure out what was actual weight loss, what was due to scale differentials or if weights were obtained from the hospital or physician's office. She said she tried her best to keep on top of everything else going on, such as how the residents are eating and if they are getting adequate assistance with their meals. She said it helped if the interdisciplinary team (IDT) could come together and discuss if it was actual weight loss or not. She said the IDT tried to get together regularly, but she felt there was a lot of back and forth emailing because not all team members can be together at the same time. She said she would email the DON, who responded with what was requested. She said she helped catch a lot of things and did what she could to help evaluate nutritional concerns. She said the DON was in charge of these issues, however. She felt it was more appropriate for the DON to monitor resident weights. She said she had no idea why the resident's weights varied. She said the scale issue was overwhelming and it had been a struggle for her. IV. Resident #20 Resident #20, age 72, admitted on [DATE]. According to the April 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 3/3/21 MDS assessment, the resident was cognitively intact with a BIMS of 11 out of 15. She had moods to include poor appetite or overeating. She was independent with eating not requiring any staff help or oversight. She was 64 inches (five feet four inches tall) and 80 pounds. She was assessed to have weight loss of five percent or more in the last month or 10 percent or more in the last six months and not on a physician-prescribed weight loss regimen. A. Resident interview and observation The resident was interviewed on 4/21/21 at 11:08 a.m. She was lying in bed and was very thin and frail in appearance in her face, shoulders, clavicles and arms. She was edentulous and said that she had dentures but they did not fit her and she had not worn them for about [AGE] years. She said she did fine without them. She said she had lost a lot of weight and thought she weighed 75 pounds. She said the facility had talked to her about her weight loss and what could be done to help her. She said they tried the liquid supplements but she did not like them. She said she liked the chocolate ice cream they brought with her meals but it was always melted by the time it was served to her. She said she did not like to drink her ice cream. She said she would like to gain some weight back and would like to weigh 110 pounds. She said she used to weigh 145 pounds a long time ago. She said she did not like the facility food very much but did like some items. She said they slather gravy and cheese on everything. She said she really liked macaroni and cheese but the facility would not give her any I guess they won't give it to me because I said something about too much cheese. She said she told the facility she loved food from Taco Bell and McDonalds but that she could not get that from them. The resident had a partially eaten cherry pie on her overbed table and a carton of soda stored on the floor next to her bed. On 4/22/21 at 1:00 a.m. the resident still had her lunch tray in front of her. She said she did not like the egg salad sandwich and it was untouched. She also had a tomato slice and some pasta on the plate. She said she tasted both but did not like it. She said no one had checked in with her to see what else she would like to eat. On 4/26/21 at 11:36 a.m. the resident said she had not received scrambled eggs this morning for breakfast. She was served French toast and hot cereal. The resident said she had a few bites of the French toast. On 4/26/21 at 12:28 p.m. the resident's lunch tray was sitting in front of her. She had a sloppy [NAME] sandwich and fried potatoes. She said she did not like the taste of the meal. On 4/27/21 at 2:40 p.m. the resident still had her lunch meal on her tray in front of her. She said she had mashed up chicken inside a bun and it tasted nasty. She said it was dry and she had asked for mustard but never got any. She said she had a side of mashed potatoes and she ate those. She said her ice cream was melted, again when she got it. She had several packets of hot sauce from Taco Bell on her table. She said that one of the CNAs heard about her love of Taco Bell and she brought the sauce in for her and thought that was very nice. She said her favorite thing from there was the burrito supreme and the tacos. B. Record review Progress notes were reviewed from 2/1/21 to 4/28/21 and revealed the resident was documented with significant weight loss. Two entries found on 2/19/21 and 3/17/21 documented the resident was encouraged to eat in the dining room (ate most meals in room) and the resident verbalized she preferred to eat in her room. A 10/19/2020 admission nutritional assessment documented the resident's height was 64 inches and weighed 97 pounds and her body mass index (BMI) was 16.6. Her calculated total daily nutritional needs were: 1355 total calories, 44 grams of protein and 1322 fluids. She was documented as underweight based on her BMI and that the weight loss was unintended. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She had no chewing or swallowing problems noted. Her nutritional plan was to honor her preferences and comfort focused care and that weight loss may be unexpected and unavoidable. She was to be offered snacks and hydration between meals as desired. A care plan initiated 10/22/2020 and revised on 11/5/2020 documented that while in the facility the resident would express by her words, smile, eyes and body language that it was important for her to have the opportunity to engage in daily routines that were meaningful to her. The goal was she would have the opportunity to make decisions/choices. Interventions included she liked to snack between meals and preferred microwave popcorn, Hershey kisses and peppermint patties. The 11/30/2020 nutritional assessment documented that an updated weight was requested and that her overall nutrient intake had improved. The plan was to continue with routine monitoring and to re-evaluate as needed if weight loss occurred, have supportive nutrition care to honor preferences and to provide balanced and healthy menu options. The resident's hospice care plan initiated 1/27/21 with a target date of 6/1/21, documented in pertinent part that the resident would be provided with food and fluids as desired for physical and emotional comfort. The 3/1/21 nutritional assessment documented the resident's BMI had declined to 14 from 16.6 upon admission (see significant weight loss note below). Her food preferences were re-evaluated and weight loss was discussed. The resident said she had a good appetite but did not like some of the foods, including the ground meats. She enjoyed hot sauce on her meats and hot sauce would be provided by the dietary manager. She continued to eat meals in her room. She enjoyed ice cream and was agreeable to try the frozen treat supplement for extra calories and protein. A nutritional care plan initiated 3/1/21with a target date of 6/1/21 identified the resident at risk related to low body weight, weight loss and decreased oral intake. The goal was she would remain comfortable during end of life and food preferences would be honored. Interventions included hot sauce would be provided by dietary, encourage the resident to chew and swallow each bite, provide diet as ordered, offer snacks between meals and provide house supplement frozen treat three times a day as ordered. A faxed note dated 3/4/21 from nursing department to the resident's primary physician requested a written statement to document that due to the resident being on hospice care, her weight loss was expected and unavoidable. The resident was placed in hospice care on 10/16/2020. A nutrition note dated 3/12/21 documented the resident's weight was fluctuating between 79-82 pounds since 1/19/21 with a significant weight loss of 8.7 percent in 90 days. She ate her meals in her room. The resident would be provided with supportive and nutrition care to honor her preferences and to provide balanced and healthy menu options. The goal was comfort during end of life. A nutrition note dated 3/22/21 documented the resident's preferences were reviewed due to her complaint of the meals. The resident said she liked macaroni and cheese on a regular basis and cherry pie, chocolate ice cream and fast food. She was enjoying the hot sauce provided by dietary to flavor her ground beef. The dietary manager was notified of food preferences and they would try and accommodate them within the ability of the facility. The family was notified to bring in fast food if they were able. A physician visit note dated 4/13/21 documented the staff reported the resident was eating and drinking ok overall but she did not like the food she was served. The resident was frail in appearance and she was losing weight. The goals for her were palliative and she was on hospice care. The physician did not recommend[TRUNCATED]

Based on interviews and record review, the facility failed to ensure one (#63) of 28 sample residents received timely treatment and care in accordance with professional standards of practice and facility policy. Specifically, the facility failed to: -Identify Resident #63 was readmitted to the facility from the hospital; -Assess the resident's initial change in condition and provide notification to the physician, when he was identified to be back in the facility; -Complete a full assessment and notify the physician after the resident experienced an unwitnessed head injury, occurring approximately one and one half hours after his return was discovered; -Timely respond to further declines as evidenced by abnormal vital signs identified approximately two and one half hours after his return to the facility was discovered, and neurological changes identified approximately three hours after his return to the facility were discovered; -Secure emergency transport for the resident in accordance with his advance directives, while awaiting a return call from the physician, after the resident was discovered nonresponsive with an unobtainable blood pressure and heart rate of 37 beats per minute, approximately four and one half hours after he was discovered to have returned to the facility. The facility's failures resulted in a delay of transport to the hospital for several hours. The resident expired shortly after transport to the hospital. Findings include: I. Facility policies and procedures A. Discharge and Transfer policy According to the Discharge and Transfer Policy, last revised [DATE], provided by the director of nursing (DON) on [DATE] at 1:43 p.m., while the discharge planning process was an interprofessional care team responsibility, the registered nurse (RN) was ultimately responsible to ensure there was a safe and coordinated discharge and transfer plan in place for the patient and timely admission to the hospital when a transfer was medically appropriate. B. Accidents/Incidents policy The Accidents and Incidents policy, last revised [DATE], provided by the DON on [DATE] at 1:43 p.m., defined an accident as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. This did not include adverse outcomes that were a direct consequence of treatment or care that was provided in accordance with current standards of practice. Section 2 of the policy titled Assessment, Medical Assistance, and Documentation read for patients, the nurse would examine the patient, provide first aid for minor cuts and abrasions, notify the physician or advanced practice provider of the accident/incident to report the physical findings and extent of injuries and obtain orders if indicated. If the injury was of an emergent nature, the patient would be transported to the hospital. II. Resident #63 A. Resident status Resident #63, age 56, was initially admitted to the facility on [DATE] and readmitted on [DATE]. According to the computerized physician orders [REDACTED]. B. Resident code status According to the resident's Colorado medical orders for scope of treatment (MOST) form dated [DATE], the resident selected under Section A for cardiopulmonary resuscitation (CPR) to have no CPR and do not attempt resuscitation if the person had no pulse and was not breathing. Under Section B for medical interventions the resident chose selective treatment with the goal noted to treat medical conditions while avoiding burdensome measures while utilizing intravenous (IV) antibiotics and IV fluids if indicated. Further information read do not intubate, may use noninvasive positive airway pressure, and to transfer to the hospital if indicated, while avoiding intensive care. III. Failure to identify resident readmission A. Record review According to transfer documentation provided by the facility the resident was transferred out of the facility to the hospital for a change of condition on [DATE] at 5:30 a.m. The inpatient documentation from the hospital noted the resident underwent [REDACTED]. The documentation showed the resident was discharged from the hospital and left in stable condition on [DATE] at 5:29 p.m. Transfer documentation or check in time was requested from the facility to identify when the resident was returned to the facility. However, none was located or provided by the facility. Late entry progress notes from the facility charted by RN #2, the nurse assigned to Resident #63's hall, on [DATE] at 2:33 a.m. showed the RN received report from the day shift nurse and was told the resident had not been returned to the facility from the hospital. The charting indicated the RN was first aware the resident was in the facility when she found the resident in his room at 7:50 p.m. on [DATE]. B. Interview RN #2, assigned to Resident #63's hall, was interviewed on [DATE] at 11:40 a.m. The RN said on [DATE], she had arrived at the facility at 6:00 p.m. and received handoff report from the previous day shift nurse. She said the previous shift's nurse had told her that the hospital had called to give the facility a discharge report and that the resident would be returning to the facility, but that he had not returned to the facility yet. RN #2 said she had first become aware the resident was in the facility when she went to the resident's room to pass medications to his roommate. C. Facility failures Record review and staff interview confirmed the night shift nurse was unaware the resident was returned to the facility after being discharged from the hospital. II. Failure to respond to resident's initial change in condition A. Interview RN #2 was interviewed on [DATE] at 11:40 a.m. The RN said she had identified the resident was in the facility when she went to pass medications for his roommate. She said the resident was really out of it and lethargic. She said the resident from her past interactions was usually really chatty and lively, and that he was not the same resident she knew. She said he didn't look right and she suspected he was still stick, so she put the call light on to have the certified nurse aide (CNA) return the resident to bed, and left the resident in his wheelchair. B. Record review Progress notes from RN #2 on [DATE] showed the RN found the resident in his room slumped over in his chair and unable to hold himself up at 7:50 p.m. The RN charting showed the resident was alert and oriented to person, place, and time and able to follow commands. At this time the charting showed she told the resident to have CNAs get him in bed. There were no vital signs recorded for this encounter. C. Facility's response and failure RN #2's interview and record review confirmed the RN identified the resident had a change in condition from baseline as he was lethargic and unable to hold himself up. The RN did not obtain vital signs or notify the physician of the resident's condition despite the RN's suspicion the resident was still sick from his previous hospitalization . III. Failure to respond to declining emergent condition A. Professional standard According to Fundamentals of Nursing, by Potter, Perry, Stockert, and Hall, 9th edition (copyright (YEAR)), page ,[DATE]: Acceptable vital sign ranges for adults are: Temperature: 96.8 to 100.4 degrees fahrenheit Pulse: 60 to 100 beats per minute (BPM), strong and regular Pulse Oximetry: greater than or equal to 95% Respirations: 12 to 20 breaths per minute deep and regular Blood pressure: Systolic (top number) ,[DATE], Diastolic (bottom number) less than 80 [MEDICAL CONDITION] (low blood pressure): 90 systolic or below. B. RN #2 interview RN #2 was interviewed on [DATE] at 11:40 a.m. The RN said she was notified on [DATE] by a CNA to come and check on the resident. She said she checked on the resident and she thought he must have hit his head on the bed rail as he was bleeding. She said she was aware the resident was on blood thinners and started neuro checks on the resident. At this time she said she had the CNAs obtain vital signs on the resident which were normal. The RN said she had the CNAs get vital signs about every hour or so on the resident, and the resident's heart rate and blood pressure kept going lower and lower. She said at midnight she called the doctor and it took them an hour and a half to call her back after several pages. She said by the time the doctor called her back she was unable to obtain a blood pressure on the resident and about three other staff members attempted to as well. She said by the time the paramedics showed up his blood pressure was low and his heart rate was in the 40's beats per minute (BPM). C. Record review 1. Progress notes According to RN #2's progress notes on [DATE] at 9:30 p.m. a CNA called RN #2 to the room because the resident had hit his face on the bed rail and was bleeding. According to her charting she cleaned the resident up and there were no obvious signs of injury. At this time she started every one hour vital signs and neuro checks. Facility response and failure: The resident was suspected of a head injury and was bleeding. There was no documentation the physician was notified or an attempt was made to notify the physician of the incident. At 11:00 p.m. RN #2 charted she gave the resident medications and his blood sugar was 228. She charted she held the resident's [MEDICATION NAME] (high blood pressure medication which also lowers heart rate) and [MEDICATION NAME] (sleep aid) because the resident was hypotensive with a blood pressure of ,[DATE], bradycardic (low heart rate) with a heart rate of 55 BPM, and very lethargic. According to the [DATE] progress notes documented by RN #2 at 12:00 a.m. she was unable to arouse the resident and unable to obtain a blood pressure. The resident's heart rate was taken manually at his [MEDICAL TREATMENT] fistula site and was at 37 BPM. At this time the nurse paged the on-call doctor. At 12:30 a.m. RN #2 documented she had no response from the physician and she paged them again. At 1:00 a.m. RN #2 documented there was no response from the physician and she paged them again. She was still unable to arouse the resident or obtain a blood pressure, and the resident was still bradycardic according to her documentation. At 1:20 a.m. RN #2 paged the physician again. The physician responded to the page at this time and requested the resident be sent to the hospital. Emergency medical services (EMS) was called at 1:21 a.m. and arrived at the facility at 1:30 a.m. According to RN #2's progress notes the resident left the facility with EMS at 2:01 a.m. 2. Neurologic assessment flow sheet (neuro checks) According to the neuro check flow sheet started by RN #2 on [DATE] at 9:00 p.m. after the resident had hit his face, the resident status was as follows: At 9:00 p.m. the resident was noted to be alert with equal hand grasps and his pupils were equal and responded to light. No vital signs were documented at this time. At 10:08 p.m. the resident neurological status was unchanged from previous assessment. Vitals were taken and his blood pressure was noted to be ,[DATE], heart rate 55, temperature 96.6 degrees fahrenheit, and respirations of 24. At 11:00 p.m. the resident's neurologic status was noted to change as he was drowsy, unable to follow commands for hand grasps, and had a sluggish pupil response in both eyes. The nurse noted a weak pulse and inability to obtain blood pressure. The resident's temperature was 96.5 degrees fahrenheit, heart rate 53, and respirations of 20. There was no documentation the physician was notified of the change of mental status or abnormal vital signs. The timing of these findings are a discrepancy to the EMR charting by RN #2 as she documented she was unable to find a blood pressure starting at 12:00 a.m. At 12:00 a.m. RN #2 drew a line through that time section and no neurological status or vitals were recorded. According to RN #2's documentation at 1:10 a.m. the resident's level of consciousness was stuporous with no pupil response or blood pressure. His heart rate was at 47 BPM, and the RN charted at this time EMS was called. D. Hospital documentation The emergency department report was obtained. According to the report the resident's provisional [DIAGNOSES REDACTED]. The resident according to the emergency room physician notes was extremely mottled and likely had an [MEDICAL CONDITIONS] (lack of oxygen to the brain) from poor perfusion. The time of the resident's death was noted to be 4:48 a.m. on [DATE] when respirations ceased. E. Medical director interview The facility's medical director (MD) was interviewed on [DATE] at 10:30 a.m. The MD said a resident with a do not resuscitate status (DNR) does not mean do not treat the resident. She said not always was a resident with an indeterminable blood pressure, [MEDICAL CONDITION] in the 30's, and unresponsive an emergent condition, but if the resident's code status was unknown or with a resident who had elected to have selective treatment on their MOST form, which included send to the hospital, she would consider that an emergent situation. She said she would expect a nurse to wait 10 minutes at most before calling 911 if they were unable to get ahold of a resident's primary care physician. She also said as she was the medical director for the facility if they were unable to get ahold of a resident's primary care physician the nurse should have called her. F. Assistant director of nursing interview The director of nursing (DON) was unavailable for interview on [DATE], the final day of survey. The assistant director of nursing (ADON) was interviewed on [DATE] at 3:10 p.m. The ADON said a resident that was a DNR with a selective treatment choice on the MOST form should be sent to the hospital for a change in condition. She said if the resident was found without a pulse or not breathing and a DNR then they would not treat the resident, but if the resident was still breathing and had a pulse they would treat the resident, as DNR does not mean do not treat. She said an unarousable resident with [MEDICAL CONDITION] and indeterminable blood pressure was an emergent situation and the nurse should activate the emergency response and call 911. She said waiting an hour to call 911 in an emergent situation was too long to wait, and that nurses in the facility can use nursing judgment to call 911 before calling a doctor.

Based on record review, interviews, and observations, the facility failed to implement proper wound prevention interventions to prevent pressure injuries from developing, identify causative factors of a pressure ulcer, and promote wound healing for one (#38) of two residents reviewed for pressure ulcers out of 28 sample residents. Specifically, the facility failed to: -Prevent a pressure ulcer from developing for a resident who had no skin breakdown on admission; -Implement the proper wheelchair cushion for Resident #38 after identifying the resident was at risk due to spending most of his time in the wheelchair; -Prevent worsening and promote healing of the pressure ulcer, once it developed; -Timely and consistently assess the wound; -Follow physician orders [REDACTED]. -Timely implement physician-ordered antibiotics once infection developed; and -Consistently apply the wound vac as ordered. These failures resulted in the resident's pressure ulcer developing, worsening to a Stage III and becoming infected. The worsening of the wound led to decline in the resident's clinical status, and caused the resident severe pain. Findings include: I. Facility policy and procedure The Skin Integrity Management policy, last revised on 11/28/16, provided by the clinical quality specialist (CQS) on 5/9/19 at 1:15 p.m., read in purpose to provide safe and effective care to prevent the occurence of of pressure ulcers, manage treatment, and promote the healing of all wounds. Under section 4 of the policy it read to develop a comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated, implement pressure ulcer prevention for identified risk factors, and to determine the need for support surfaces for both beds and chairs. II. Resident #38 A. Resident status Resident #38, age 67, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, [DIAGNOSES REDACTED]. According to the resident's admission minimum data set assessment (MDS) completed on 11/9/18, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident had no pressure ulcers according to the admission MDS but was identified as at risk for the development of pressure ulcers by clinical assessment and a formal assessment tool. No behaviors or care rejection were documented. No pain was documented. The resident's most recent 3/22/19 MDS assessment revealed he had a stage III pressure ulcer. No behavioral symptoms or rejection of care were documented. He had almost constant pain, level six out of 10, which interfered with his daily activities. B. Admission record review 1. Admission braden assessment The Braden scale assessment for predicting pressure sores completed upon the resident's admission on 11/2/18 indicated the resident was a moderate risk for pressure ulcers with a score of 14. 2. Admission skin check An admission skin check performed by the director of nursing (DON) on 11/2/18 at 10:30 a.m. showed the resident had no skin injuries or wounds upon admission. 3. Care plan The resident's care plan, initiated on 11/15/18 (13 days after admission), identified the resident was at risk for skin breakdown as evidence by incontinence and limited mobility. The goal was the resident would not show signs of skin breakdown through the next review and included the following intervention: -Pressure redistribution surfaces to chair per protocol. The admission MDS assessment, Braden scale, and care plan identified the resident was at risk for pressure ulcer development upon admission to the facility. III. Timeline of events and failures A. Prior to wound identification According to a social services progress note provided by the facility the resident was admitted with his own wheelchair. However, on 12/7/18 the facility was notified the resident's wheelchair was to be returned due to insurance reasons, and the chair was to be picked up the following week on 12/14/19. According to the progress note, the social services director made a referral to ensure the resident was fitted for a new wheelchair prior to that date. Resident #38 was then evaluated by occupational therapy on 12/12/18, with an initial assessment showing the resident was referred for occupational therapy services to address wheelchair positioning as his most recent provider (previous facility) informed the facility they would be repossessing the resident's wheelchair. The plan of treatment included: Patient would maintain or improve wheelchair mobility in new seating system/chair; Patient would tolerate new wheelchair and seating system for greater than 2 hours reporting 0/10 pain and no signs or symptoms of redness or pressure. According to an occupational therapy progress note signed by the occupational therapist (OT) on 12/28/18, the resident received his new wheelchair on 12/25/18. Under the goal, the resident would tolerate the new wheelchair seating system for greater than two hours reporting 0/10 pain and no signs or symptoms of redness or pressure. It was noted by the OT the resident was reporting pain at this time, but that this was the resident's baseline pain level according to the nursing staff. A new goal added to the resident therapy plan of care on 12/28/18 read caregivers would demonstrate proficiency and patient would agree to sidelying a total of one hour between each meal to reduce the risk for skin breakdown and back pain. It was identified the resident was spending the bulk of his day up in the wheelchair and refusing to lay in bed because he could not see and was nervous nobody would come back for him. Occupational therapy progress notes confirmed the resident was identified at risk for skin breakdown due to the resident spending the majority of his time in the wheelchair. B. Identification of initial skin breakdown A nursing progress note dated 1/15/19 at 12:46 a.m. read the resident had multiple open ares to the right gluteal fold, inner thigh, and left gluteal fold. No signs or symptoms of infection were noted. The nurse charted it appeared to be friction related or from sitting in his wheelchair. The area was cleansed and a barrier cream applied. The nurse noted the change in status in the facility's 24-hour report for the wound team to assess the resident. A therapy evaluation was requested for sitting as the nurse wrote the resident may need a wheelchair cushion or change. An occupational therapy progress note signed by the OT on 1/15/19 identified the resident was exhibiting increased skin integrity concerns in his gluteal folds and caregivers required education to promote the resident to lay supine or side lying, but that the resident had a history of [REDACTED]. note. An occupational therapy progress note signed by the OT on 1/16/19 indicated the resident continued to exhibit substantial amounts of time in his wheelchair and continued to require education on lying supine and side lying between meals. The resident's care plan was not updated at this time. C. Progression of skin breakdown An occupational therapy progress note, signed by the OT on 1/24/19, showed the resident was reporting pain when the back of the wheelchair was all the way up and straight at a level of 5 out of 10. When reclined the resident reported pain of 1-2 out of 10, and that the resident continued to have a wound. An interdisciplinary team progress note by the DON on 1/31/19 at 12:00 p.m., in relation to the resident's bilateral ischial wounds, read the pressure associated wounds were because the resident would not lie down during the day and sat up in his wheelchair for 10-12 hours per day, and the resident had now agreed to lie down after meals. The resident began experiencing some pain with the wounds and was placed on a pressure relieving mattress. The resident's care plan was updated on 1/31/19. It read the resident had actual skin breakdown related to incontinence and limited mobility with interventions including: Weekly wound evaluation to include measurements and description of wound status. Weekly skin assessment by licensed nurse. On 2/2/19 a nursing progress note indicated a dressing change was completed using silver opti- foam and the wound appeared red in color and non odorous. No measurements of the wound were documented. On 2/7/19 a nursing progress note indicated a skin check was performed. The only charting showed the acknowledgment of previously identified wounds to gluteal folds. No measurements were documented. Resident wheelchair cushion: Also on 2/7/19 occupational therapy progress notes indicated the resident was discharged from occupational therapy services. The discharge summary showed the resident reported no new pain or had any new pressure related redness other than existing wounds. The summary showed the resident reported comfort with a most recent gel inlaid wheelchair cushion placed on his chair. There was no indication of when this cushion was placed, and the resident was discharged from service with wounds with this particular cushion. On 2/14/19 a nursing progress note showed a skin check was performed. It read the left gluteal fold edges had become well defined with some red drainage at times. No measurements were documented. On 2/15/19 at 10:37 a.m. a nursing progress note showed there was no noted improvement with the wound, but that there were copious amounts of purulent drainage on the wound dressing that had begun to bleed through the dressing. The nurse documented there was a very small new wound just below the existing wound starting to develop and only the top layer of skin was open. A dressing change was performed. The first identified measurements of the wound provided by the facility were during a skin check performed on 2/15/19 at 3:04 p.m by the assistant director of nursing (ADON). The skin check assessment form showed the wound to the resident's left ischial tuberosity was 2x2 cm with 100% necrotic tissue. However, an associated weekly wound assessment also performed by the ADON dated the same day at 3:10 p.m. showed the same left ischial tuberosity wound to be at 0.5 cm x 0.5 cm. There were conflicting measurements between the two assessments despite being performed by the same licensed nurse. However, a progress note by the DON also on 2/15/19 at 3:41 p.m. confirmed the wound measurements to the left ischial tuberosity were 2x2 cm with 100% eschar (dead tissue). The charting indicated the resident was experiencing pain when the wound was cleaned and that the wound was worse that week. The resident's setting to his air mattress was adjusted and the resident had been compliant with lying down after meals to relieve pressure. It was noted that therapy had been working with the resident and was changing wheelchair cushions. However, therapy documentation showed the resident was discharged from occupational therapy services with a gel inlaid wheelchair cushion on 2/7/19. A nursing progress note from 2/19/19 at 6:10 a.m. read the nurse requested the wound team to assess the resident's wound. She wrote the pressure ulcer was unstageable and worsening as areas appeared deeper, red around edges, and black in color. The ordered Opti-Silver dressing was not available so the nurse used an exuderm dressing. The nurse noted the wound was painful to touch during care. On 2/22/19 at 10:02 a.m. a nursing progress note showed the nurse performed a dressing change and the wound had no improvements or drainage and did not indicate it was worsening. No measurements were performed. The weekly skin check assessment and weekly wound assessment were performed by the same nurse on 2/22/19. The weekly skin assessment did not provide wound measurements. The weekly wound assessment showed the same measurements of the previous wound assessment of 0.5 x 0.5 cm. A progress note from the DON on 2/27/19 at 4:23 p.m. read a new order for mechanical debridement (removal of dead tissue) and nutritional protein supplements were ordered. The wound was noted to have 100% eschar tissue. The weekly skin check assessment dated [DATE] provided no wound measurements. The weekly wound assessment reflected the same measurements as the previous assessment with 0.5 x 0.5 cm. A progress note from 3/8/19 at 4:06 p.m. showed the wound was unstageable. The previously ordered santyl was loosening eschar tissue and they would continue with that treatment. The resident had pain at the site and had been accepting of lying down after meals to change position of pressure. The resident's appetite was good. A care conference meeting was done on 3/15/19 at 2:00 p.m. According to the care conference documentation the doctor had reported the wound had gotten worse and she was considering adding a wound vac for better healing. A nursing progress note from 3/19/19 at 5:43 a.m. showed the resident was having increasing pain with wound care as well as when sitting. The nurse reported the wound was continuing to present into deep layers of the skin and was clean and free of signs of infection. On 3/22/19 at 10:48 a.m. the DON charted the wound was with slough (dead tissue usually cream or yellow in color) and debrided. A change in wound orders was requested to calcium alginate rope with [MEDICATION NAME] dressing to be changed daily. The resident was continuing to have pain with dressing changes and was premedicated prior. The wound dressing was reported to be changed at this time. The next available wound measurements provided by the facility were reported on a weekly skin check on 3/29/19 at 6:00 a.m. The wound measured 1.8 cm x 2.4 cm x 2.2 cm with the first reported depth of the wound. The resident was also referred to the wound clinic for evaluation at this time. D. Wound clinic documentation and further wound progression The resident was seen at the wound clinic initially on 4/4/19 at 1:00 p.m. The left ischial wound was classified as a stage III pressure ulcer. The measurements were 1 cm x 2 cm x 4.1 cm. Wound care orders were given as well as a request for seating and mattress evaluation to offload pressure off the wound. Facility response and failure: The facility failed to follow up on the wound clinic's initial request the resident be evaluated for seating and mattress positioning to offload pressure off the wound. A facility nursing progress note dated 4/10/19 at 4:52 p.m. showed the resident wound had increased drainage, green in color with a foul odor. The nurse notified the medical director, and reported she wanted to wait on new orders as the resident was scheduled for the wound clinic the next day. The resident was seen in the wound clinic on 4/11/19 at 9:45 a.m. The wound measurements were 1.5 cm x 1.7 cm x 5 cm. The wound had red and brown exudate (drainage) with a foul odor after cleaning. The documentation from this wound clinic visit did not indicate a request for evaluation of the wheelchair or bed, but a fax requesting the previous wound clinic recommendation from 4/4/19 was sent to the physician (seven days after the initial request). The computerized physician orders [REDACTED]. The facility failed to act timely upon a request for the resident to be evaluated for seating and mattress positioning. The order was placed seven days after the initial request. The resident was seen again at the wound clinic on 4/18/19. No measurements were provided with this visit. an order for [REDACTED]. The order specifically read for new seating cushion. E. Occupational therapy reevaluation The resident was evaluated by occupational therapy on 4/19/19 (15 days after the initial request by the wound clinic). According to the OT's note the assessment identified the resident was currently with a pressure ulcer to his left gluteal fold and his existing wheelchair cushion was designed for low risk residents. The orders were noted to assist with identifying and ordering an appropriate pressure relieving wheelchair cushion. A therapy goal read the patient would be fitted with an appropriate pressure relieving wheelchair cushion to decrease the resident's risk for exacerbation to the existing wound, and decrease the risk for additional skin breakdown, while allowing the patient to be up in the wheelchair for 2-3 hour durations three times daily. The OT was interviewed on 5/9/19 at 1:17 p.m. The OT said if the cushion he was sitting in according to the charting was deemed for low risk residents, then the resident was sitting in the wrong cushion. The OT confirmed the resident already had a wound at the time the wheelchair cushion was implemented and that the resident was not deemed to be low risk for wounds. She said the resident did not like to be in bed and preferred to be up in his chair. According to an occupation therapy progress note signed 5/6/19 by the OT, the resident was fitted with a new wheelchair cushion classified for high risk patients on 5/2/19. The resident was tolerating the cushion without exacerbation to the wound, but the covering of the wound and existence of the wound vac made it difficult to assess for any changes. Facility response and failure: Record review and interview confirmed the facility failed to ensure the resident, who was determined at risk prior to his pressure ulcer developments as well as after the development of his wound, was utilizing the correct wheelchair cushion. The last documentation of the wheelchair cushion showed the resident was using the incorrect wheelchair cushion according to the occupational therapy notes from 2/7/19 to 5/2/19. During that time the resident's skin integrity status declined and his wound failed to improve, and actually worsened. The resident experienced pain due to the wound. F. Further wound progression - wound infection On 4/21/19 at 10:59 a.m. during a dressing change the wound was noted to have red and yellow odorous drainage. The wound measurements were noted to be 3 cm x 2 cm x 5.5 cm. At 3:02 p.m. on the same day nursing progress notes showed the resident was febrile (elevated temperature) with a fever of 101.7 degrees fahrenheit. The physician was notified at 4:40 p.m. and orders were given which included a wound culture. The wound culture and sensitivity results were called to the facility on on 4/22/19 at 7:42 a.m., indicating the resident had a positive wound culture with displayed antibiotic sensitivities. However, the facility did not order antibiotics for the resident until 4/23/19. A [MEDICATION NAME] tablet 250 mg was ordered to be crushed and applied to the wound bed one time a day until 4/25/19. The resident was seen on 4/25/19 at 9:45 a.m. at the wound clinic. Wound measurements were noted to be 1.4 cm x 1.4 cm x 6.5 cm. The wound had a large amount of brown and red exudate. A wound vac was placed on the resident at this time. The resident was prescribed [MEDICATION NAME] 500 mg twice a day for 7 days for a wound infection as well. Another wound culture was performed at this time. The results of the wound culture were reported to the facility on [DATE]. The culture and sensitivity reported the organism identified in the wound, Proteus mirabilis, was resistant to the prescribed [MEDICATION NAME]. The facility on the same day changed the antibiotic to an appropriately sensitive [MEDICATION NAME] 500 mg tablet every 12 hours for 14 days. According to a nursing progress note dated 5/5/19 at 11:43 a.m., the resident was crying out in pain with any repositioning in bed and dressing changes. G. Wound Vac 1. Record review According to a nursing progress note dated 4/26/19 at 11:27 a.m., the resident's wound vac had not been suctioning for over two hours and the dressing had to be changed. 2 Observations The wound had a wound vac in place which made it unavailable to be directly observed. However, the wound vac and dressing were observed on 5/9/19 at 8:30 a.m. with the ADON. The wound vac was observed to be not on and not plugged in, which was confirmed with the ADON. The ADON plugged the wound vac in and turned it on to the prescribed setting. 3. LPN #2 LPN #2 was interviewed on 5/9/19 at 9:14 a.m. The LPN was assigned to the resident's hallway that day, and she said the wound vac must have come unplugged when the resident received a bed bath. However, she was unsure. IV. Decline in overall condition A. Staff interviews CNA #13 was interviewed on 5/8/19 at 2:30 p.m. The CNA said Resident #38 required a lot of assistance from staff. She said up until about a week ago the resident was able to feed himself, but now he was dependent on staff for meals. She said because of the resident's bed sore he had not been participating in a lot of activities and it had been about four days since the resident came out of his room. LPN #2 was interviewed on 5/9/19 at 11:12 a.m. The LPN said the resident in the past requested to stay in his wheelchair most of the time. She said the resident enjoyed sitting up in the chair watching movies. She said the wound started out in the gluteal fold, which she believed to be a pressure area. She said the resident used to be up for meals, but now he spent more time in bed. She also said they used to be able to use a sit to stand lift on the resident to get him out of bed, but now his legs were too stiff. CNA #6 was interviewed on 5/9/19 at 1:44 p.m. The CNA said the resident used to be in his chair most of the time prior to his wound and never complained. She said now all of a sudden the resident's legs were contracted and he was in a lot of pain. She said the resident used to be able to feed himself but now he was dependent on staff for meals. She said he doesn't eat too much anymore but he does like to drink a lot of fluids. The ADON and infection control nurse (ICN) were interviewed on 5/9/19 at 3:10 p.m. as the DON was absent from the facility and unavailable for interview. The ADON said she believed the resident prior to the wound was care planned for a pressure relieving cushion and mattress, and when the wound was identified they added to reposition him from side to side. She said once a wound was identified, therapy was consulted. She said they should be consulted immediately, but it would be up to therapy to determine how quickly the resident was seen. The ADON said a resident determined to be at risk for pressure ulcers, or residents who already had a pressure ulcer, should not have been using a wheelchair cushion determined for low risk residents. She said [DEVICE] should be plugged in and on per the physician order. The ICN said the resident started showing signs of infection on 4/21/19 and that was when the resident's mentation began to decline. The ADON said she felt the facility had provided adequate care to prevent the pressure injury from developing, and she felt the facility had provided adequate care to promote the wound's healing.

Based on observation, family and staff interview and record review, the facility failed to ensure one (#28) of two residents reviewed for pressure ulcers of 35 sample residents did not develop pressure ulcers. Specifically, the facility failed to timely and thoroughly assess and implement interventions including turning and repositioning for a resident at high risk for skin breakdown. As a result resident #28 acquired unstageable pressure ulcers. The findings included: A. Facility Policy The facility's Skin Integrity Management policy, dated 7/1/01 and revised 12/8/14, provided the following, in pertinent part: Purpose: To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. -The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. -Complete risk evaluation . quarterly, and with significant change in condition. -Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. -Perform skin inspection . weekly. Document on treatment administration record (TAR). -Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. -Perform daily monitoring of wounds or dressings for presence of complications or declines and document. -Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. Refer to the Skin Integrity Care Delivery Process. -Implement pressure ulcer prevention for identified risk factors. -Determine the need for support surface for bed and chair. -Determine the need for heel protectors and heel lift devices and utilize . -Implement skin/wound care guidelines as applicable. -Review co-morbid conditions that may affect healing. -Notify dietitian and/or rehabilitation services as indicated. -Review care plan weekly and revise as indicated. -Document daily monitoring of ulcer site, with or without dressing . B. Professional references regarding nutritional interventions for wound healing 1. According to Nutrition in Clinical Practice Volume 25, Number 1, by Joyce K. Stechmiller, PhD, ACNP-BC, FAAN, 2/3/10, pages 51 and 67: -Early identification and treatment of [REDACTED]. -Ensure a qualified professional completes nutrition screening of all patients on admission and after any change in condition. -Refer patient immediately for full nutrition assessment by a registered dietitian if any deficits are identified by screening. 2. According to Nutrition for the Older Adult, by Bernstein and Munoz, 2016: Early identification of malnutrition/undernutrition and correction of nutritional deficits promote healing and improve the individual's quality of life. 3. According to Nutrition in Wound Care Management by Quain and Khardori, 2015: Suboptimal nutrition can alter immune function, collagen synthesis, and wound tensile strength, all of which are essential in the wound healing process. C. Resident #28 Resident #28, age 76, was admitted to the facility on [DATE] and readmitted on [DATE] and 4/10/14. [DIAGNOSES REDACTED]. According to the 10/14/15 minimum data set (MDS) assessment, the resident was cognitively intact, with a brief interview for mental status (BIMS) score of 15 of 15. No behavioral or mood symptoms were noted. -She was totally dependent for two-plus persons for bed mobility. She required extensive one-person assistance for transfers, dressing and toilet use. -She was unable to walk and was self-sufficient once in her power wheelchair. -She had functional limitation to upper and lower extremities on both sides. She was occasionally incontinent of bladder and always continent of bowel. -The resident had no wounds, ulcers or pressure sores. The resident's care plan, initiated 6/20/14 and revised on 1/11/16, identified risk for skin breakdown as evidenced by impaired sensation, nutritional concerns, history of pressure ulcer, limited mobility, advanced MS ([MEDICAL CONDITION]). Hx (history) of reoccurring coccyx PU (pressure ulcers). Unstageable wound to coccyx 1/6/16, recent COC (change of condition) and decline in health status. -Interventions included: Assist resident in repositioning frequently. Resident does not tolerate positions off of her back for any length of time. -Convertible air mattress to bed for pressure reduction, set at 3. -Observe skin condition with ADL (activities of daily living) care daily and report abnormalities. -Obtain dietitian consult as needed/ordered. -Offer/encourage fluids of choice. -Encourage resident to consume all fluids during meals. C. Observations Resident #28 was observed lying on her back during most observations conducted 1/11 through 1/14/16. - Specifically, she was observed lying on her back throughout the morning and afternoon of 1/11/16; on 1/12/16 at 11:15 a.m., 1:35 p.m., 2:30 p.m., 3:30 p.m. and 6 p.m.; on 1/13 at 8:30 a.m., 9:15 a.m., and 10:40 a.m. - On 1/14/16 at 8:15 a.m., the resident was sitting at the dining room table trying to lift a glass of water to drink, but was unable to lift it. When asked if she needed help, she said yes. A staff person was notified and assisted the resident. At 9:30 a.m. the resident was sitting up in her wheelchair in her room, with her back to the door. At 11:00 a.m., she was sitting up in her wheelchair with a family member and another visitor. A wound care observation was conducted on 1/13/16 at 10:25 a.m. with the director of nursing (DON)/wound nurse, who described the resident's wound as follows: 3.5cm length x 3.0cm width, five percent slough, 50 percent deep tissue injury (not hard eschar), 45 percent [MEDICATION NAME] slough. -The DON said there was a new wound above the first wound, which she described as 0.7cm length x 0.5 cm width, deep tissue injury. -Both pressure areas had blancheable surrounding tissue, per the DON's description. The DON was interviewed at 10:34 a.m. on 1/13/16 after the dressing change observation. The DON said the larger wound was bigger and getting better. When asked how the wound occurred, the DON said she thought it was from a combination of the resident's acute illness and norovirus; the residents were confined to their rooms. She said the resident had MS and developed pneumonia and had an overall decline. She said they had recently changed from a small blue turning pillow to a larger Bronco pillow. -The DON explained that she was not wound certified. The floor nurses did daily wound dressing changes and she did them every Wednesday. She said she was the wound team. D. Facility Failures 1. Resident left on bed pan for seven hours on 1/3/16 The resident was interviewed on the morning of 1/11/16. She said she was recovering from pneumonia. She was barely able to lift her hands to her nasal cannula and was unable to adjust it, speaking seemed to be difficult for her, and she was unable to drink from the glass at her bedside without assistance from a staff person. A family member was interviewed at 6:15 p.m. on 1/12/16 and said she was concerned because the resident had skin breakdown, had no sensation to her lower body, and had recently been left on a bedpan for seven hours. A second family member, interviewed at 10 a.m. on 1/13/16, reiterated the concern about the resident being left on the bedpan for seven hours. She said the day shift CNA had discovered a bedpan under the resident at approximately 1 p.m. that day. The resident had evidently been left on the bedpan by night shift, which meant the day CNA did not check, change or reposition the resident and she has a pressure sore. She said the resident was unable to tell her about the time frame then because she was so sick. She said she knew the resident had fragile skin and no sensation to her lower body. They were going to discuss the outcome of the facility's investigation later that day. Review of nurses' notes revealed a note dated 1/3/16 at 1:43 p.m.: Res(ident) found on bed pan at 1315 (1:15 p.m.). Had been on bed pan unknown length of time. Recent illness, weak with malaise. Denies NVD (nausea/vomiting/diarrhea), VSS (vital signs stable). Purple non blanching area to buttock area, with older skin abrasion noted. Dressing applied to lesion. RMS (risk management summary) report made. Review of the RMS Event Summary Report, dated 1/3/16 at 1:15 p.m., revealed the following, in pertinent part: -Resident handling - staff . Bruise, Suspected deep tissue injury . (at 1:15 p.m.) CNA alerted this RN (registered nurse) that resident had been on bed pan in bed for unknown length of time. On inspection, res (resident) had a purple non blanching ring of skin the shape of a bed pan. CNA stated res had refused toileting X3 this am (morning) and had not received report about bed pan from previous shift. Resident couldn't remember when bed pan was placed. -Resident baseline alert and oriented x4, resident with acute illness, lethargy and confusion this day. Also resident with MS and decreased feeling over body. -Resident reported that the CNA asked her throughout the day if she needed bedpan or commode and she told her no. Resident reported that she was sat up and down for both breakfast and lunch. Resident denied any pain from event. -Day nurses and CNAs interviewed. No one placed resident on bedpan, noc (night) CNA reported that she told day CNA in report and it was not her fault if the day CNA didn't hear her . Day CNA denied noc CNA reported this off. -Education to CNAs regarding COC and when this happens then they will also have a change in function as well and more than likely will require more assistance. Also education on acceptable shift report and relaying accurate information that is received by the other employee by an acknowledgement. A Grievance/Concern Form, filed by the resident's family member and completed by the director of nursing (DON) on 1/3/16 reiterated the information above with the following additional comments: This nurse assessed resident coccyx 1/4, 1/5 and 1/6; reddened areas noted that were blancheable on 1/4-5 where bedpan was; on 1/6 there is no red area or injury r/t (related to) the bedpan being left under resident. Interviews with the DON and RN #16 (see below) revealed their interviews with staff confirmed the resident was left on the bedpan on 1/3/16 from about 5:30 a.m. to 5:45 a.m. until about 1:15 p.m., approximately seven hours. The DON said she was monitoring the day shift CNA's care of residents as a result. However, review of both CNAs' records revealed no evidence of monitoring plans. The DON was interviewed on 1/13/16 at 11:10 a.m. about the bed pan incident and the resident's skin condition. The DON stated she received a call from RN #16 on Sunday, 1/3/16, at about 1 p.m. He said they just rolled her over and found a bedpan under her. I asked if he'd found the staff who put it under her and he said not yet. I asked him to interview staff and find out who put her on the bedpan. - RN #16 reported that the resident was not in any pain, had purplish color all the way around where the bedpan had been. He said he notified family, said he faxed the doctor, and said the resident was comfortable. -The DON stated she interviewed CNA #32 on 1/3/16 at 5:30 p.m. The DON asked the CNA if she was told in shift report that someone was on the bedpan, and the CNA responded, No. When asked if she repositioned the resident during her shift, she said she went in several times, offered her the toilet, repositioned the bed, put the resident's knees up, there was a little pillow they put side to side on her. She said you could not see the bedpan. -CNA #33 worked with the resident on night shift. She said she put the resident on the bedpan about 5:40 or 5:45 a.m. When asked if she relayed in shift report, she said she did. -The DON said she felt she did not need to talk to anyone else. She assessed the resident Monday and Tuesday; Tuesday there was an area on her left buttock: red blancheable and now healed. She did not chart because she was working as a CNA at that time. She said she did an education with staff. She said she and another nurse were monitoring CNA #32's resident care. Day shift CNA #32 was interviewed on 1/13/16 at 1:15 p.m. She acknowledged she was one of the CNAs who left the resident on the bedpan on 1/3/16. She said that when she offered changing that day the resident would say no, that she was okay. Later that day, she said she asked another CNA to help her change the resident because I thought it was time, and a bedpan was already under her. My heart just sank. We got the nurse, had him look at it . The nurse assessed it and we just kept checking on her bottom every hour. When she initially was rolled it looked like a bedpan imprint. As that went away it looked purply-red. -When asked how often she turned and repositioned the resident, the CNA said after this incident . every two hours at least. RN #16 was interviewed the afternoon of 1/13/16. He acknowledged that the resident had been left on the bedpan for approximately seven hours, that he had reported it immediately to the DON, family and physician. He said he was still angry that a CNA would leave their shift and leave a resident on a bedpan, and another CNA would not realize it until hours later. 2. Insufficient turning/repositioning to offload pressure Review of CNA care plan documentation revealed the resident was to be turned frequently, have TED hose on in AM and off in PM, and range of motion exercises. -Range of motion exercises were initialed as completed on 1/3/16, including manual stretching for hip abduction/adduction, knee straightening and ankle dorsiflexion daily during morning care. -No food or fluid intake was documented during breakfast or lunch on 1/3/16. No other CNA cares were documented on 1/3/16. There was no documentation of turning/repositioning and no indication in the care plans of how often the resident should be repositioned. 3. Pressure area first observed 1/3 although skin assessment not documented until 1/13/16 Review of nurses' notes, from 1/3 through 1/14/16, revealed no documentation in the medical record that nurses were assessing the resident's skin condition after it was discovered that she had been left on the bed pan. Nurses' notes on 1/3/16 (see above) revealed a purple non blanching area to buttock area, with older skin abrasion noted. Dressing applied to lesion. On 1/6/16 at 5:38 a.m., a nursing note revealed increased redness noted in coccyx, applied ointment. On 1/11/16 at 4:45 p.m., a nursing note by the DON revealed: Late entry for 1/6 wound team eval(uation). Resident assessed to have unstageable wound to coccyx area. 3cm x 3cm 50% slough 50% DTI. Current treatment is comfort per daughter and IDT. Optiform PRN for hx of skin impairment. Resident offered to reposition but cannot tolerate for any length of time without rolling onto back. Denies pain at site. No skin integrity report or TAR notation was documented (as required by policy above) until 1/13/16. The Skin-Pressure Ulcer report, documented by the DON/wound nurse, noted the wound was first observed 1/6/16, was acquired in house, and was an unstageable due to suspected deep tissue injury pressure ulcer to the resident's coccyx. The wound had light serosanguinous drainage with 50-74% eschar, 1-24% slough and 25-49% [MEDICATION NAME] tissue. Surrounding tissue was inflamed. Rehab was not involved and nutrition treatment was not done (see below). 4. No nutritional interventions to add protein and promote healing Review of progress notes revealed no evidence the resident's pressure sore was reported to the registered dietitian (RD). Review of the most recent nutritional assessment, dated 1/13/16 at 10:27 a.m., revealed it was incomplete as follows: -Under skin integrity, the RD noted no pressure ulcers and no resolved or cured pressure ulcers within the last 90 days. -There were no relevant labs. -There was no noted coughing or difficulty swallowing this week. (See physician/nurse practitioner progress notes below.) -Although inadequate protein-energy intake was noted, and the resident had an unstageable pressure ulcer (unidentified in the assessment), no interventions were recommended or ordered to increase protein intake. -The RD noted decreased ability to consume sufficient protein and/or energy, acute illness, bed bound requiring assist for dining, recent lack of interest in food. Coordination of nutrition care was noted as: IDT meeting, coordinate care with hospice care staff/hospice orders and hospice care plan. The nutrition goal was, Resident to consume food and fluids at desired pace and amount to level of comfort. 5. Delayed physician notification - no evidence of physician assessment of resident skin condition According to a nurse's note by the DON dated 1/13/16, Late entry, for 1/12/16. MD notification received regarding PU, MD spoke with this nurse regarding resident health status on 1/11. NP here on 1/8 spoke with her regarding resident status and skin condition, awaiting to see over weekend if status of resident improves. NP reported she would re eval on 1/11. The physician progress notes [REDACTED]. -Still with decline in PO intake with moderate dysphagia. Not hypoxic but wearing cont 02 (oxygen continuously). Cough has improved. No complaints of pain or discomfort. More alert today . Still getting anbx (antibiotics). -Resident reported mild intermittent cough, improving . Overall improvement since Friday - does not remember most of Friday . Hospice referral consultation with assumed care for . MS recently diagnosed with [REDACTED]. still having moderate dysphagia, is refusing swallow study and has decline in appetite and intake she could benefit from hospice. Goals of care are comfort only, spoke with MDPOA and agreed to hospice consult. There was no mention in the physician/NP progress note of the resident's skin condition. E. Interviews The DON, during interview at 11:10 a.m. on 1/13/16, said the resident had multiple comorbidities, pressure ulcer, and nutritional issues. She said they had her on an air mattress and an aquagel wheelchair cushion. She said, This time I feel like (her skin breakdown is) from not getting up because of the norovirus isolation, and she's not eating or drinking. -The DON said the resident had a larger Bronco pillow now for repositioning, as of 1/12/16 at about 6:30 p.m., because she kept observing her on her back and was concerned that she was not being repositioned properly. She said the resident could not tolerate lying on her side. The DON said she thought the resident was admitted with the air mattress that was in place that day, because of her history of skin breakdown. -The DON said the RD was in the building and added, I just did wounds again so I sent her the report and she'll meet up with me about what we need to do. She said the physician was in on Friday and returned on Monday; the resident was admitted to hospice care on 1/12/16. -The nurse tells me (the resident) will drink for her. Sometimes she'll be able to take sips from a straw. The RD and DON were interviewed by phone at 10:45 a.m. on 1/20/16. They were asked about the nutrition assessment above, which was conducted seven days after the resident's unstageable pressure ulcer was identified and which noted no pressure sore and no increased protein recommendations. -The RD said she was not aware of the pressure ulcer until after she had conducted the nutritional assessment. She said she was aware later that day, on the afternoon of 1/13/16. -When asked how soon she preferred to initiate nutritional interventions, she said she wanted to hear weekly soon after wound rounds, and she gave herself a week to get treatment interventions in place. -When asked why additional protein was not added to the resident's nutritional plan, she said the resident's intake was so minimal, she felt that sips of a shake wouldn't have helped. She said she had asked the resident and she did not want supplements, but she had not documented that. The RD and DON said the resident was in the dining room that morning, and that her wound was improving. She was eating dinner in her room with assistance and family members were assisting her to eat. She was unable to hold a cup in her hand, but was able to sip from a straw. The DON acknowledged the documentation issues and said she had no other skin assessments to provide. She said their lack of documentation was directly related to their recent norovirus outbreak and quarantine, and she thought the residents were receiving good care. The DON said that current interventions to facilitate resident #28's wound healing since 1/11/16 were: - Full air mattress (changed from convertible air); - Turning schedule every two hours and documented per family request, to which the resident responded well; - Bronco pillow; - Wound treatment change; - Daily wound observations; and - Ongoing RD assessment. The facility failed to prevent development of pressure sores, appropriately assess, and provide necessary treatment and services for the resident with pressure sores. F. Facility Response On 1/20/16 at 4:40 p.m., the RD provided a requested nutrition assessment that was completed on this date. The assessment noted in pertinent part as follows: -A pressure ulcer was documented as DTI coccyx, small improvement over last week assessment per nursing. RD aware of wound on 1/13 - no nutr(itional) intervention at that time as minimal po and even if she could drink one shake, nutrition needs would not be met. Plan was to address medical and wound care needs first then nutrition. -Meal intakes average less than 50 percent until lunch and dinner yesterday which are recorded as 75% and 100% - coincides with family report of recent improvement in appetite. -Spoke with family and resident on increasing nutrition intake as able to prevent further weight loss and facilitate wound healing. Family bringing in some special food items (i.e. homemade soup) occasionally. -Injury factor 1.1 was noted; -Protein and fluid needs were upgraded; -Increased nutrient needs to facilitate wound healing was noted; -As resident feeling better, house supplement trialed and resident agreeable to 4 ounce day for additional 200 cals (calories), 6 gr prot/day(grams of protein per day). On 1/20/16 at 5:52 p.m., the DON provided a skin assessment conducted that day, which documented the resident's current wound status as follows: -An unstageable coccyx pressure ulcer first observed 1/13/16, measuring 0.7cm length x 0.5cm width, no depth, no drainage. -An unstageble coccyx pressure ulcer first observed 1/6/16, light serosanguinous drainage, measuring 3.5cm length x 3cm width, no depth. -The DON noted on the assessment, A pressure ulcer skin assessment was completed . Spoke with dietitian, supplement requested, mattress changed out this week. Wound bed appearance improved with no deep purple noted, spoke with MD with new orders for Santyl to be started.

Based on record review and family and staff interview, the facility failed to ensure one of four sample residents (#1) received adequate hydration to maintain health status. The resident was hosptalized on [DATE] for bilateral femur fractures and was also diagnosed with [REDACTED]. The findings included: Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] with bilateral femur fractures. Minimum Data Set (MDS): According to her most recent quarterly 3/6/13 MDS, the resident was severely cognitively impaired, had no behavioral symptoms, was totally dependent on two-plus person assistance for bed mobility, transfers, and toilet use. She was dependent on one-person assistance for ambulation, dressing, eating, personal hygiene and bathing. The resident used a wheelchair and was always incontinent of bowel and bladder. The resident had experienced no falls since her prior assessment. She was 66 inches tall and weighed 136 pounds. Care Plan: The resident's care plan did not direct staff to monitor the resident's fluid intake. The resident's care plan, initiated 3/21/12 and revised on 11/6/12, identified "risk for fluid output exceeding intake characterized by fluid volume deficit; dry skin and mucous membranes, poor skin turgor and integrity related to not consuming all fluids provided, history of urinary tract infections (UTIs), [MEDICAL CONDITION]." The goal was to "show no signs of dehydration," and "maintain appropriate fluid volume level." Interventions were: -Follow therapeutic regime for care/history of UTIs. -Give medication as per physician orders [REDACTED]. -Observe effectiveness and side effects of laxatives/enemas after administration. -Observe resident for signs of dehydration (tenting skin, dry mouth, etc). Report to MD (Medical Doctor) if present. -Observe resident for signs of pain. -Obtain lab work as per orders. Notify MD of abnormal values. -Place straw in glass so resident can drink independently if indicated. -Record frequency and amount of diarrhea. -Record frequency, consistency and amount of emesis. The resident fell off the bed on 5/19/13. 1. Hydration -Hydration Needs - Nutrition Therapy Assessment: The resident's most recent nutritional assessment, dated 2/25/13 and completed by the registered dietitian, identified her total fluid needs as 1534-1840 mls (milliliters) per day. -Fluid Intake Documentation revealed the resident was not meeting her estimated total needs to maintain adequate fluid status before or after the fall: Review of the facility's Resident Functional Performance Record, documented by the Certified Nurse Aides (CNAs), revealed the resident's documented fluid intake was less than half her estimated fluid needs, during 15 out of 21 days. Specifically, the resident's daily fluid intake in cc's was documented from 5/1/13 through 5/21/13 (when she was hospitalized ) as follows: 720, 680, 1360, 720, 960, 600, 720, 600, 720, 1080, 840, 480, 360, 720, 600, 1000, 840, 440, 360, 600, and 360. There were no further RD notes or assessments regarding the resident's fluid needs in the medical record. -Nurses' Notes: On 5/21/13 at 5 a.m., "Res lethargic in evening, encouraged fluids & res had (increase) in alertness. Daughter concerned about res pain & dehydration. Will have day nurse follow up w/ doctor today..." On 5/21/13, the nurse documented (time illegible), "Res daughter in to see res (at 3:45 p.m.) today, concerned - updated daughter on res and that awaiting orders from MD - MD office called (at 3:40 p.m. - PCP) spoke (with) res daughter (power of attorney) and also this nurse about res - not taking in fluids well and pain & swelling to L knee & pain to L hip - (PCP) agreed to have res to go (hospital ER) by non emergent transport for evaluation (at 4 p.m.). Res out at (4:20 p.m. with) non emergent ambulance. Daughter out (with res - 4:25 p.m.) called report to (hospital) ER." -Hospital History and Physical: The resident's 5/21/13 hospital record documented in pertinent part under "Diagnostic data: laboratory review - white blood cell count is 17.6 with 87% [DIAGNOSES REDACTED]s, 2% bands, hemoglobin and hematocrit of 10.7 and 32, platelets 199, sodium elevated at 156 (high - normal range 135-145), potassium 3.9, chloride 112, [MEDICATION NAME] 29, BUN 38 (high - normal range 7-18 mg/DL), creatinine 1.0 (within normal range of 0.5-1.2), glucose 328, calcium 9.0, total protein 6.5, [MEDICATION NAME] 2.9, bilirubin 0.5, AST 55, ALT 69, alkaline [MEDICATION NAME] 133." "Assessment: Distal femur fracture, volume depletion (dehydration) with [MEDICAL CONDITION] (high sodium), leukocytosis, [MEDICAL CONDITION], pain control and [MEDICAL CONDITION]." "Plan: We will continue to follow along with this patient. She does appear to be volume depleted. We will rehydrate her with normal saline and monitor her sodium, BUN and creatinine. In addition, she has leukocytosis (elevated white blood cell count - associated with an [MEDICAL CONDITION] response) that appears to be a stress reaction as I do not see any infectious process on her lungs or her urine at this time. Her [MEDICAL CONDITION] is currently 328 on her basic metabolic panel. We will continue checking blood sugars with insulin management and check a hemoglobin A1C to assess whether she has had chronic diabetes or if this is an acute stress reaction. [MEDICAL CONDITION] and pain control via orthopedic surgery and [MEDICAL CONDITION]. After surgical period, we will begin a diet. She will need to stay on her pureed diet that she has been on before and protein shakes." -After the resident's return from the hospice care center, on 5/31/13, she was noted as "NPO." On 6/1/13 she drank 150 ccs and "sips" of fluid, and on 6/2/13 she took in "sips" of fluid. 2. Interviews: Family Interview: The resident's daughter/power of attorney was interviewed by phone the afternoon of 6/6/13 and again at 2:30 p.m. on 6/25/13. She said when she visited resident #1 at the facility after her 5/19/13 fall; she asked the nurse why the resident was unresponsive. She said the nurse told her "she gets dehydrated," and if they gave her water through a straw "she'll pop up." The nurse said they would call the resident's doctor to request intravenous hydration. (Cross-reference F309 care and services.) Staff Interviews: Nurses made the following comments when interviewed about the resident's hydration on 6/12/13 and 6/13/13: -LPN interviewed 3:30 p.m. on 6/12/13: "We had a toothette (swab) with water and her daughter preferred to do it. She would not take any food in. Her daughter said she had applesauce, and they were able to get applesauce in her." -RN interviewed at 10:15 a.m. on 6/13/13: "(Resident #1) is the kind of (resident) you have to give (water to), sit with her and talk with her when you give her fluid. She had supplements TID (three times a day) and she'd take them and want more. But ... you cannot leave the drink with her and expect her to drink. She would drink 100% (with encouragement) - I'd have no problem with that ... Breakfast was her best meal - lunch and dinner were okay." -The director of nursing interviewed at 3 p.m. on 6/13/13: "Everybody receives at least 240 ccs at every meal. That's our standard. We set up the dining room and everyone reports to nurses if they're not drinking. (Resident #1) is one that within a day you could tell if she was dehydrated - she had no reserves at all. I don't expect (staff) to document daily on (residents') intake. The Activities of Daily Living (ADL) sheet is the only documentation (above). We look at Medication administration records (MARS) and ADL sheets and visualize them. The CNAs are sure to tell a nurse if someone's not drinking. ... We don't document the drink pitchers or on the MARs." Physician Interview: -The resident's primary care physician was interviewed at 5:30 p.m. on 6/13/13. He said, "My biggest concern was she was pretty darn ill and uncomfortable, and it took them that long to call me ... With two fractures, she would have been in a lot of pain. That's why she did so poorly ... I didn't even know she fell until I got a call on Tuesday and they wanted an order to administer IV fluids. I asked why. They said because she hadn't eaten well. Why hasn't she eaten? She's in a lot of pain. Why is she in a lot of pain? She had a fall. When?" (the physician was notified on 5/19/13 that the resident was 'lowered to the ground').

Based on record, resident, family and staff interviews, the facility failed to provide timely assessment, treatment, and adequate pain management for one of four sample residents (#1) after a fall with fractures. These failures contributed to inadequately treated pain, and a two-day delay in identifying and treating the resident's bilateral femur fractures. Cross-reference F323, failure to provide supervision and assistance to prevent fall with fractures The findings included: Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] with bilateral femur fractures. Minimum Data Set (MDS): According to her most recent quarterly MDS (3/6/13), the resident was severely cognitively impaired, had no behavioral symptoms and was totally dependent on two-plus person assistance for bed mobility, transfers, and toilet use. She was dependent on one-person assistance for ambulation, dressing, eating, personal hygiene and bathing. The assessment indicated the resident had no pain. The resident used a wheelchair, was always incontinent of bowel and bladder, and had experienced no falls since her prior assessment. The resident was 66 inches tall and weighed 136 pounds. -Review of her previous MDSs revealed the resident's functional status was the same during the annual assessment on 2/25/13 and the quarterly assessment on 8/31/12, in that she was totally dependent on two-plus person assistance for bed mobility. On both assessments, there was no indication of any pain issues. 1. Care plan failures - although the resident had severe cognitive impairment, nursing staff were instructed to monitor pain on a 0-10 level designed for residents who could rate their pain. The resident's care plan was not updated after her fall and fractures (5/19/13). Care Plan: The resident's care plan for "pain/potential for pain related to immobility," initiated 3/17/12 and revised on 11/26/12, stated the goal was "pain will decrease within 1 hour of intervention." Interventions were: -"Monitor pain on scale of 0-10. -Observe for potential side effects of medication such as constipation, decline in function, sedation, or appetite suppression. -Position pillows as needed for comfort. -Administer pain medication as per MD (Medical Doctor) orders and note the effectiveness. Notify MD if pain not reduced. -Give PRN (as needed) meds for breakthrough as per MD orders. -Encourage resident to communicate presence of pain. -Document/report complaints & non-verbal signs of pain. Assist to reposition for comfort. -Implement relaxation and/or distraction techniques to assist with pain control." -Medical record review revealed the resident had been admitted to hospice care at the local hospice care center after her femur fracture surgery on 5/21/13 (see below), and was readmitted to the facility on hospice care on 5/31/13. An undated hospice care plan noted, "Pain visceral due to disease progression. Goal: Obtain agreed upon level of pain relief, report pain is relieved/controlled. Interventions: Assess meds: effectiveness/duplication/interactions/side effects/regimen adherence; clarify description and/or language of pain." 2. Delay in investigation, [DIAGNOSES REDACTED]. Although the resident had a fall at approximately 4:30 a.m. on 5/19/13 (cross-reference F323 fall with injuries when one staff member was providing ADL care), the facility did not investigate and determine the circumstances surrounding the fall until several days later, and the resident did not receive an X-ray until 5/20/13 at 9:35 a.m. a. No investigation until 5/23/13 The physician was notified via fax, not phone call, at 6 a.m. on 5/19/13 that the resident was "lowered to the floor" and had coccyx pain. Review of the facility's investigative report revealed the Certified Nurse Aide (CNA), who was with the resident when she fell , was not interviewed until 5/23/13, after the resident was hospitalized and diagnosed with [REDACTED]. However, during the facility interview conducted 5/23/13, the CNA said she was cleaning the resident and "had her rolled away from her. The bed was in the high position for cares," the resident made a sudden movement and began to slide off the bed, and then fell to the floor. b. No X-ray until 24 hours after fall The radiology mobile diagnostics report, dated 5/20/13 at 9:35 a.m., noted the resident had a portable left hip X-ray because of pain, and documented the following: "The hip joint is in alignment, but there is narrowing of the joint space due to the marked [MEDICAL CONDITION] changes. There is marked [MEDICAL CONDITION] spurring involving acetabular border and femoral head and neck junction. No fracture or dislocation is seen. Pubic rami are intact. -The study is limited as the patient is unable to completely cooperate. There is difficult positioning and slight ght (as written on the report - word/meaning unknown) motion. Consider follow up if unexplained symptoms persist or indicated. -Impression: Marked [MEDICAL CONDITION] of the left hip within limits." c. Inadequate pain control Review of the physician orders [REDACTED]. There were no other pain medications ordered. There was no evidence the resident was given pain medications prior to the portable X-ray being taken (see below - Tylenol or [MEDICATION NAME] given at 7:30 a.m. and then 3:30 p.m.) to alleviate the resident's pain even though the resident was noted above as "unable to completely cooperate," potentially due to pain. Review of physician orders, medication administration records (MARs) and pain assessments revealed the resident had been given: -5/19/13 at 5:40 a.m., pain rating 3-4 (out of 10) to coccyx, 650 mg of Tylenol given with no effectiveness noted. -5/20/13 at 7:30 a.m., pain rating 5-6 to left hip, Tylenol 650 mg given, pain rating still 5-6 at 9 a.m. (approximate time the X-ray was taken). Review of IDT (interdisciplinary) notes revealed the social services director observed the resident in the dining room at approximately 7:20 a.m. sitting upright in her wheelchair at the dining room table. The resident was noted to state to the SSD, "I hurt," and motioned with her hands to her upper abdomen. The SSD noted that she informed the resident's nurse. -5/20/13 at 3:30 p.m., pain rating 7-8 to left hip, [MEDICATION NAME] 600 mg given, effectiveness at 5 p.m. noted as a pain rating of 1-2. -5/20/13 at 7 p.m., for "pain in hip/groin area," no pain level documented, noted as "effective - decreased pain" under "results," but no time noted for the results assessment. The pain assessment on the 5/20/13 day shift noted 5-6 pain, and 0 (zero) pain on night shift. However, 650 mg of [MEDICATION NAME] was documented as administered at 1:30 a.m. (under the 7 p.m. dose indicating it was given on night shift 5/20/13, early morning of 5/21/13). This dose was not documented on the "PRN pain management flow sheet" where medications, pain rating, and effectiveness were to be noted. -5/21/13 at 6:30 a.m., pain rating 5-6 to hips, Tylenol 650 mg given, effectiveness noted at 8 a.m. as pain level 1-2. -5/21/13 at 10:30 a.m., pain rating 7-8 to back and legs, [MEDICATION NAME] 600 mg given, noted at 12 noon as pain level 3-4. -The pain assessment sheet noted the resident's pain was to be assessed pre- and post-medication on a 0-10 scale on night shift and day shift every day. The resident's pain was rated zero 5/1/13 through 5/16/13 (except for two blanks with no documentation on 5/5 and 5/15/13). On 5/16 through 5/18/13, the day shift nurse had documented "100", which was unexplained. On 5/19, the day and night nurses documented zero pain. On 5/20 and 5/21/13, the day shift nurses documented pain at 5-6, and the night nurse on 5/20 documented zero pain. d. Fax, not call, to physician regarding pain after X-ray. Staff reported the resident was yelling in pain and grabbing her left leg (see below): At 11:58 a.m. on 5/20/13, a fax was sent to the resident's physician stating as follows: "(1) Here are the x-ray results. (2) Res only has Tylenol 650 mg po (oral) q (every) 6 hrs prn (as needed). Res is in a lot of pain. Unable to move res without her yelling in pain and grabbing at her left hip. May we please have something stronger for pain for example: increase Tylenol to 1000 mg po q 4 hrs prn not to exceed 4 GM (grams) in 24 hrs. and [MEDICATION NAME] 600 mg po q 6 hrs prn? (3) Would like to try this for 72 hrs to see if pain is controlled then re-evaluate res if further x-rays needed. Would this be OK with you?" Five hours later, at 5:22 p.m. on 5/20/13, a different physician faxed in response, "OK for [MEDICATION NAME] 600 mg q 6 hours prn." The resident's level of pain, documented as "yelling and grabbing," was not documented as such on the pain assessments (see above). e. Resident not sent to hospital until 5/21/13, when per nurses' notes: -5/21/13 at (time illegible), "Res daughter in to see res (at 3:45 p.m.) today, concerned - updated daughter on res and that awaiting orders from MD - MD office called (at 3:40 p.m. - PCP) spoke (with) res daughter (power of attorney) and also this nurse about res - not taking in fluids well and pain & swelling to L knee & pain to L hip - (PCP) agreed to have res to go (hospital ER) by non emergent transport for evaluation (at 4 p.m.). Res out at (4:20 p.m. with) non emergent ambulance. Daughter out (with res - 4:25 p.m.) called report to (hospital) ER." 3. Interviews: Resident: -Resident #4, who had been resident #1's roommate, was interviewed on 6/12/13 at 10:30 a.m. MDS review revealed that on 5/10/13 resident #4 was assessed with [REDACTED]. No behavioral symptoms were noted. Resident #4 said, "My neighbor next door here fell . She kind of lost her balance I think. Staff didn't get to her fast enough. She broke her leg ... They were too rough with the broken bone. I could hear her yell. And she's gone now. She passed away after she moved away. When her leg broke they were too rough with her because she yelled a lot ..." Staff: -The licensed practical nurse (LPN), who provided care for resident #1 during the day shift, was interviewed at 6 p.m. on 6/13/13. She said, "She was in pain - she couldn't really state but she would just say "ow" - it was out of her normal so I took it as pretty bad. It was all the time - you'd touch the blanket and she'd say "ow." Judging from someone with dementia it's hard to evaluate pain. I got the [MEDICATION NAME] order. She had Tylenol which she could only have every six hours. I spoke with management and we came up with [MEDICATION NAME] ... She hurt all over. I looked at her but there was nothing physical on her that I could see." "That Monday (5/21/13), I didn't notice the pain as bad ... When I got the [MEDICATION NAME] order it was working better. I got the order and only gave the [MEDICATION NAME] once, but I'd given Tylenol earlier in the day ... I gave it at 3:30 p.m. and probably went back in two or three times before I went home at 6-6:30 p.m. No it does not look like I charted anything for (assessments)." The LPN said CNAs never reported pain to her and did not report anything unusual. "In the morning they would've told me with changing ... The daughter and I were talking with the doctor at the same time, trying to figure out what to do at that point. The night nurse got the order for the X-ray - that was done on my shift, and it was negative for the hip. I don't know for sure (why they focused just on the hip). The nurse said her leg was in-turned during the night at some point. I'm not sure, I wasn't there ... I got no reports of extreme, excruciating pain." -The director of nursing (DON) was interviewed at 3 p.m. on 6/13/13. She said, "If the CNA had been forthcoming it would have been different. When (the night RN) did the assessment she said nothing indicated anything beyond what they assessed. The resident wanted to get off the floor. Nothing would have indicated she needed further assessment. That being said, she had the same information as the LPN, from the CNA who said she landed on her bottom. I have to depend on my staff to be trustworthy." The DON said the nurses had assumed the CNA was on the same side of the bed the resident fell from, and lowered her to the floor. They had not realized until the CNA demonstrated how the resident fell that she had fallen from the opposite side of the bed, from a heightened position, to the floor. "I was here Monday morning (5/20/13) ... I assessed her, there was no swelling. I told the nurse to get on the phone, tell the doctor we don't have any pain medication, she's in pain. The doctor gave us an [MEDICATION NAME] order. I told the nurses to monitor, give pain meds, if it's not working, call the doctor and let him know." "They'd say her pain was five or six, alternating Tylenol and [MEDICATION NAME] with minimal effect ... "The day after the fall they said she was eating. She'd gotten up for breakfast ... She was up to the dining room for meals, denies pain, discomfort, and the night nurse is the one who got the X-ray order because the CNA said she's in pain. I wondered what happened after the fall ... I just had a question in my head because the leg was flexed inward and the X-ray of the wrong part of the body. I questioned it in my mind but I think it was that fall the fracture occurred from." When asked her expectation about getting a resident out to the hospital after a fall to the floor from a bed in the high position, the DON said, "You call and have an ambulance take them for non-emergent transport. The nurse ... talked to the physician, but then he didn't feel she needed to go to the hospital, that it was an emergent issue ... but if in doubt, call. Depending on the nurse assessment and the situation you're in, you can make the call ... definitely, and I would support that decision." "The accident happened and things just keep piling up. The on-call nurse was not called at all - that was an education piece. Every nurse manager has said that had they known someone fell from a high position we would've said, 'You send them out (to the hospital).' Physician Interview: -The resident's primary care physician was interviewed at 5:30 p.m. on 6/13/13. He said, "My biggest concern was she was pretty darn ill and uncomfortable, and it took them that long to call me ... With two fractures, she would have been in a lot of pain. That's why she did so poorly ... I didn't even know she fell until I got a call on Tuesday and they wanted an order to administer IV fluids. I asked why. They said because she hadn't eaten well. Why hasn't she eaten? She's in a lot of pain. Why is she in a lot of pain? She had a fall. When?" (See above, the fax to the physician noted the resident was lowered to the floor.) Family Interview: -Resident #1's daughter/power of attorney was interviewed by phone on 6/25/13 at 2:30 p.m. She said facility staff had called her on 5/19/13 to tell her resident #1 had a "slight fall" and had been "caught and lowered to the floor. Monday they called and said her regular doctor was not in, but she had been prescribed [MEDICATION NAME]. Mom hardly ever takes Tylenol or anything. "(When I visited on Monday night 5/20/13 around 6:30 or 7 p.m.), I lifted the blanket off her leg and she screamed ... She never was responsive except to scream ... Monday night her left knee was facing her right leg, her left foot was facing to the left. When I asked them to send her to the hospital, they said they did a portable X-ray and it was negative." "On Tuesday her leg was straight. She was still in pain, still screaming ... The nurse said she called the doctor several times today and no response ... Then they got a phone call from the doctor. When they asked if it was okay for an IV (to treat her dehydration), and the doctor said what do you mean pain, is that usual? Then the doctor said I can send someone in to do blood work or transport her to the hospital. I said, 'Please transport her to the hospital.' ... She laid there two-and-a-half days in pain. When they rolled her to her side, she screamed." The family member said when the resident was hospitalized she "had a totally dislocated femur ... They did surgery ... They also found she was severely impacted ... She had pneumonia (diagnosed after surgery), dehydration, and a urinary tract infection ... They asked us about hospice. She made it through a week at the hospice care center and we decided to send her back to (the LTC facility) ... I thought they should treat her like a queen ... I asked, 'Are you going to take care of my Mom this time?' They said, 'Of course.' ... Then her left leg was swollen ... The nurse said her first thought was a blood clot but she didn't know what was causing it. She had a blood clot from her groin to her knee ... They brought her no breakfast or lunch that day. The pull sheet they were using would put weight on her fractured leg." Failures upon 5/31/13 Readmission - Inadequate pain assessment, pain management, inadequate post-surgery assessment, and inadequate transfer/positioning training: Upon return to the facility on [DATE], the resident had undergone surgery on her left lower extremity to repair the fracture. The right lower extremity was noted with a fracture but no surgical repair; the leg was placed in an immobilizer splint. -According to nurses' notes, the resident was readmitted to the facility from the local hospice care center at 11:35 a.m. on 5/31/13 by ambulance. It was noted the resident was "nonverbal upon arrival but does moan & yell out when moved." The resident had admission orders [REDACTED] -Keep immobilizer on R leg for non-displaced R femur fx. -Dressing changes QOD (every other day) or daily PRN to dressing on L femur s/p L/M nailing. -[MEDICATION NAME] 12 mcg/hr patch to be changed every 72 hours for pain. -[MEDICATION NAME] oral sublingual 0.25 ml to 0.5 ml every hour as needed for breakthrough pain. -Tylenol 650 mg suppository every six hours prn for temp greater than 101. -[MEDICATION NAME] rectal suppository 10 mg daily as needed for constipation. -[MEDICATION NAME] 25 mg suppository every six hours prn for nausea/vomiting. -The resident was not documented to receive SL [MEDICATION NAME] for breakthrough pain until 7:20 p.m. on 5/31/13. -On 6/1/13, the resident was noted in nurses' notes to receive a Tylenol suppository for a temp of 99.6, then CNAs were "trained on how to turn resident & position." The time was not documented, and the Tylenol was not documented on the MAR. -At 9 a.m. on 6/1/13, the resident was noted as "medicated with M-S, turning every 2 hr. Family @ bedside." However, review of the pain management flow sheet and MAR, the resident received SL [MEDICATION NAME] at 7:50 a.m., 9:50 a.m., and 12:45 p.m., for pain levels of 2-3, 3, and 3-4 pain respectively. No effectiveness was noted for the 7:50 a.m. medication. After the 9:50 a.m., medication was given, the resident still had a pain level of 3. After the 12:45 p.m., medication, the resident's pain was rated 1. -At 3:17 p.m. on 6/1/13, "Daughter at bedside. Discussed (with) RN use of [MEDICATION NAME]/[MEDICATION NAME] for pain." The nurse did not document if the resident was experiencing breakthrough pain. -At 5 p.m. on 6/1/13, "Frequent position changes. Pain (with movement noted, facial grimaces)." No SL [MEDICATION NAME] was given until 8:45 p.m. for 3-4 pain. However, 3-4 pain did not show grimacing on the faces scale. Specifically, the facility used a pain assessment form that rated pain on a scale of 1-10 for cognitively intact residents: 3-4 indicated moderate pain, 5-6 was moderate/severe, 7-8 was severe/horrible, and 9-10 was excruciating pain. This form was used for residents able to express pain verbally. For residents with dementia, the form contained a "faces" scale where according to the faces pain scale, 3-4 showed a face with a no smile, 5-6 showed a frowning face, 7-8 showed a sad face with grimacing, and 9-10 showed a crying face. The form also contained a pain rating for cognitively impaired residents with descriptions of activity pattern, appetite, breathing, body pattern, facial expression, mood, vocalization, and effectiveness of treatment. It was not clear which of these methods the nurses were utilizing for documentation of resident #1's pain. -At 4 a.m. on 6/2/13, "Repositioning Q2H throughout night. Daughter at bedside. Appears comfortable lying still, pain w/ movement, position changes. Facial grimacing noted at position changes. Administered [MEDICATION NAME] sulfate 0.25 ml x 2 throughout night." However, the only MS dose noted was at 2:45 a.m. on the pain management flow sheet but not the MAR. -At 3:10 p.m. on 6/2/13, "Increased swelling noted to L thigh. Small pink area noted to thigh ... Res experiencing increase in pain. PRN MS administered x2 this shift with minimal relief. (Physician) on call for (PCP) notified." The resident was transferred to the hospital at 2:50 p.m. via ambulance. Although the nurse noted giving SL MS twice during the shift, only one dose was documented at 9:30 a.m. Moreover, nursing staff were not consistently noting they were checking back with the resident for effectiveness of her breakthrough pain medication; results were documented as quickly as ten minutes but as far apart as two hours. -There was no evidence in the medical record that a physical therapy order was requested or conducted to assess and train staff on safe and comfortable repositioning techniques for the resident. -There was no evidence that nursing staff were assessing the resident's legs, after her initial assessment on 5/31/13, until 3:10 p.m. on 6/2/13, when increased swelling was noted to her left thigh. The resident had been admitted with an order for [REDACTED]. The resident, per a transfer/discharge report form, was sent to the hospital that afternoon, diagnosed with [REDACTED]. Specifically: The 6/2/13 hospital emergency room report documented leg pain and left leg swelling. "Arrive by (ambulance), transported from (facility) after increasing lethargy past two days and this am was noted to have significant swelling in the left leg. She had recent history of bilateral femur fractures with nailing of the left femur. The right femur had distal metaphyseal fx and placed in knee immobilizer. Her daughter is here with her and her daughter tells me she was drinking and eating and conversing two days ago, on Friday. Yesterday not responsive. Today left leg swollen ... Reports: poor appetite, poor fluid intake since Friday, other (no BM for a week). Denies diarrhea, indwelling catheter ... Legs left swelling ... Comments: [MEDICAL CONDITION] ([MEDICAL CONDITION] left LE (left extremity) LCF (lateral circumflex femoral) to popliteal ... Patient's family agree to return patient to inpatient hospice care. Hospice nurse here to discuss this with family ... [MEDICAL CONDITION], femur fractures, UTI (urinary tract infection), decreased level of consciousness, mild dehydration ... Transfer to inpatient hospice." Staff Interviews: An LPN interviewed at 3:30 p.m. on 6/12/13, said she took care of resident #1 one night after she came back from hospice. "She was not very responsive. She responded when I did the sternal rub but that was it ... She appeared comfortable, only had pain with movement, so with position changes I treated her with [MEDICATION NAME] twice that night before position changes." -The LPN said that even though they turned her every two hours, they did not medicate her prior to every turn/reposition because "every two hours would have been too much ([MEDICATION NAME]) for her and I knew she had a [MEDICATION NAME]." -Asked if the resident cried out in pain, the LPN said, "Not too bad, more facial grimacing. (Facial grimacing on the "faces" scale indicated pain at a 7-8, which meant severe/horrible pain.) We just put more pillows under her to keep her off her bottom - it was a process, we did it very slowly and gently ... I'd assess her entire body at these position changes - removed her immobilizer, no sign of a blood clot that night ... I'd look for a hot spot, any swelling, any kind of discoloration or redness." A second LPN interviewed at 10:30 a.m. on 6/13/13, said she had taken care of resident #1 after her fractures. "Hospice called with a really vague report to me. The hospice nurse who came didn't even know her name ... I asked her how to do turns - if they were floating her or turning her, and they said we'd have to ask the nurse who would come in later. The doctor came in at 5:30 p.m. (The daughter) was real helpful in telling us how hospice had turned her. Two aides and another nurse were there. (The resident's daughter) told us how they'd been doing it at hospice ... My aides who were here for night shift, I showed them how you float someone by floating and rotating pillows. (The resident) couldn't turn to the sides without being in excruciating pain. She'd scream out if we tried to turn her." Both nurses who conducted the resident's readmission assessment were LPNs. There was no registered nurse signature on the nursing assessment. The director of nursing, interviewed at 3 p.m. on 6/13/13, said, "We couldn't obtain any information (upon the resident's readmission) - all we got was from the family and hospice. The family barred us from the hospital record. We had discharge instructions from hospice ... I called (the PCP) - he wouldn't order anything until he physically came in the building and saw her. They didn't want to give up hospice, so it was all comfort and palliative at that point ... I know the (nursing home administrator) had our medical records person request the hospital H&P (history and physical). The admissions person couldn't get information from (the) hospital. That's when we found out she wasn't coming back to us."

Based on record review and staff interview, the facility failed to provide supervision and follow safety precautions to prevent a fall with injury for one of four sample residents (#1). The resident was assessed to need two-person assistance for bed mobility, and was at risk for falls. However, during one-person assistance, the resident was rolled to her side, fell from her bed to the floor, and sustained bilateral femur fractures. Cross-reference F309, care and services, delayed treatment and inadequate pain management The findings included: Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] with bilateral femur fractures. Minimum Data Set (MDS): According to her most recent quarterly MDS (3/6/13), the resident was severely cognitively impaired, had no behavioral symptoms and was totally dependent on two-plus person assistance for bed mobility, transfers, and toilet use. She was dependent on one-person assistance for ambulation, dressing, eating, personal hygiene and bathing. The resident used a wheelchair, was always incontinent of bowel and bladder, and had experienced no falls since her prior assessment. The resident was 66 inches tall and weighed 136 pounds. -Review of her previous MDSs revealed the resident's functional status was the same during the annual assessment on 2/25/13 and the quarterly assessment on 8/31/12, in that she was totally dependent on two-plus person assistance for bed mobility. 1. Care plan failures - two-plus person assistance for bed mobility not care planned in keeping with MDS findings - resident care planned to ask for assistance although she had severe dementia. The resident's care plan for fall risk, dated 3/12/12 and revised 5/20/13 (revised after fall - see below), identified "risk for falls related to unstable health condition, decreased safety awareness." The goal was for "no significant injury related to a fall." Interventions included: assist resident getting in and out of bed with two staff assistance and mechanical lift; remind resident to use call light prior to ambulating or transfer; encourage resident to communicate needs/ask for assistance; perimeter mattress - hi/lo bed frame; assess for oversize bed frame with scoop mattress; assist by two for transfers. -The last two interventions were added on 5/20/13, but two-plus person assistance for bed mobility was not added. The care plan for "decreased mobility related to cognitive impairment, loss of muscle strength," initiated 3/21/12 with a target date of 3/6/13, identified the goal "resident will move about in bed with assistance of staff." Interventions included, "Encourage resident to position self when in bed/chair as able and tolerated; turn and reposition every 2-3 hrs and PRN (as needed)." -Two-plus person assistance was not included in the care plan until 5/31/13 (upon the resident's return to the facility), when the following intervention was added: "2 assist to turn and reposition frequently, use turning sheet." 2. Failure to adequately investigate and document the circumstances surrounding the resident's fall. There were no nurses' notes regarding resident #1 for approximately six weeks, between 3/6/13 and 5/19/13. -On 5/19/13 at 6 a.m., a "Change of Condition Documentation" fax to the resident's physician noted "Fall ... (5:30 a.m.) Res (resident) was lowered to floor from bed. She scraped her inner left arm on the dresser and came down on her coccyx. c/o (complaints of) pain in her coccyx area. Res was given 650 mg of tylenol as ordered PRN (as needed) for pain. Did not hit head. Will continue to monitor. Please advise." -On 5/19/13 at 1:10 p.m., a nurse noted the resident's family was called and "informed her of earlier incident. Res up in w/c (wheelchair) and out to dining room for meals this shift. VS WNL (vital signs within normal limits). Res(ident) denies any pain/discomfort at this time, no delayed injury notes, will cont. to monitor." -On 5/20/13 at 5 a.m., "Res c/o of hip & groin pain (at 7 p.m.) when being layed to bed after dinner. Noted L (left) inner leg flexed inward. Distal pulses palpated in BLE (both Lower extremities), no noted leg shorter than the other, no bruising or swelling noted. Res c/o no pain when just laying flat in bed but c/o of severe pain when rolled or (illegible) leg moved. B/P (blood pressure) 138/76, p 92 (pulse), T 98.4 (temperature), 02 at 97 on 2L (oxygen), R 20 (respirations), T.O. order (telephone order) from (physician (at 7:25 p.m.) for portable Xray of hip in a.m." -On 5/20/13 at 9 a.m., "IDT (interdisciplinary team) fall team - had fall when being changed by CNA & resident slid off side of bed to floor. Perimeter mattress in place. Assess for oversize mattress & bed frame. Hi low bed frame. c/o pain in coccyx & hip area. Orders for x-rays today. Assess pain." -5/20/13 at 5:45 p.m., "Res daughter notified of new order & of x-ray results - res having (increased) pain, remained in bed, med x2 today, better relief noted (with) ibuprofen. Res (with) low grade temp encouraging fluids." -5/21/13 at 5 a.m., "Daughter at bedside until (11 p.m.). Res remained in bed. c/o L knee, hip & R (right) knee pain when turned for cares. PRN tylenol administered w/ mild relief. New bruising noted to L knee and swelling on L leg. Res lethargic in evening. Encouraged fluids & res had (increased) alertness. Daughter concerned about res pain & dehydration. Will have day nurse follow up (with) doctor today. Turned res frequently throughout night." -5/21/13 at 1 p.m., "Res cont to have pain - res says 'ouch' each place touched - res remains in bed - receiving Tylenol and Ibuprofen alternating for pain/swelling - swelling noted to (illegible) knee - daughter (second daughter's name) called - concerned about res - wants res to be seen by (primary care physician) - call out to (PCP) office." -5/21/13 at (time illegible), "Res daughter in to see res (at 3:45 p.m.) today, concerned - updated daughter on res and that awaiting orders from MD - MD office called (at 3:40 p.m. - PCP) spoke (with) res daughter (power of attorney) and also this nurse about res - not taking in fluids well and pain & swelling to L knee & pain to L hip - (PCP) agreed to have res to go (hospital ER) by non emergent transport for evaluation (at 4 p.m.). Res out at (4:20 p.m. with) non emergent ambulance. Daughter out (with res - 4:25 p.m.) called report to (hospital) ER." -5/21/13 at 5:35 p.m., "Hospital ER called - to get hx (history) on res - hx given - ER doctor plans to get blood work, x-rays and UA (urinalysis) done." -5/22/13 at 5 a.m., "Res remains (in hospital). Res nurse (at hospital) reports res was admitted but unable to give details." --Return to the facility: -5/31/13 at 7 p.m., "Res arrived by ambulance from hospice at (11:35 a.m.). ...Res nonverbal upon arrival but does moan & yell out when moved. Res has surgical incisions x3 L leg CDI (clean/dry/intact). Brace in place and adjusted into correct placement on R leg. Both heels are slightly boggy to touch, small discoloration on R outer heel. Boggy, discolored area on lower R calf where the brace was rubbing. Bruising noted on back of L knee, R hand - top, outer L & R elbow, inner L elbow, L & R side of neck, behind L ear - ear protectors added to NC (nasal cannula). Tenting present in skin & slow to return. Skin pink, warm to touch, pedal pulses equal bilat(really)..." There was no documentation in nurses' notes of the resident's femur fractures or her admission to hospice, other than the above note. The resident's physician was noted to visit on 5/31/13 at 6:30 p.m., but there was no documentation until 6/1/13 (no time noted) to show "CNAs (Certified Nurse Aide) trained on how to turn resident & position." -The care plan (see above) was not updated other than to state two person assistance and "use turning sheet." Further, there was no documentation that a physical therapy evaluation and training was requested or conducted, to ensure staff were trained on how best to reposition the resident to prevent further injury and pain. 3. Resident hospital [DIAGNOSES REDACTED]. The hospital report was not included in the resident's medical record. Copies were acquired from the hospital on [DATE]. -Hospital Record Review: The history and physical hospital report, dated 5/21/13, documented in pertinent part: "Left knee and hip pain ... presents to the emergency room (ER) after a fall last Sunday (2 days ago). It is unclear whether she fell out of her wheelchair or fell out of bed when she was being rolled. She has been nonambulatory for at least a year. She is transferred via Hoyer lift to the wheelchair 3 times a day for meals and activities." "On Sunday, she did have x-rays of the hip that did not show any hip fractures. She continued to have pain especially in the left leg. She presented to the emergency room today and is diagnosed with [REDACTED]. Left thigh appears abnormal with 2+ dorsalis pedis pulses, warm and well perfused ... I am unable to roll the patient presently due to left femur instability ... She does have response when palpated in the right lower extremity. When she is distracted, this appears to resolve. It is very difficult to interpret in this individual ... The left lower leg is in a shortened position. She does have a palpable pulse distally. She has tenderness about the left lower extremity. It is difficult to fully localize but appears to be most about the known fracture region of the left distal thigh..." The radiology report dated 5/21/13 revealed: "Generalized osseous demineralization, osteoarthritis of the right hip ... Multilevel degenerative disc disease. Oblique fracture of the distal diaphysis of the left femur with three centimeters of medical displacement of the distal fragment. There is bayonet apposition of the fracture ends. Degenerative changes of the left knee." The operative report dated 5/21/13 revealed the resident had "left distal femur internal fixation with retrograde intramedullary nail" surgery for [REDACTED]. A subsequent hospital report, dated 6/2/13, documented the resident had "bilateral femur fractures with nailing of the left femur. The right femur had distal metaphyseal fx (fracture) and placed in knee immobilizer." 4. Staff interviews revealed one CNA turned the resident on her side away facing away from her, the resident fell to the floor from a heightened position, and the initial report inaccurately stated resident was lowered to the floor. -The certified nurse aide (CNA), who was providing care for the resident when she fell out of bed, was interviewed at 5 p.m. on 6/12/13. She said, "I was doing last rounds, at 4:30 or 4:40 a.m. I went in and checked her, realized she'd had a BM (bowel movement), turned her on her right side, I was on the left side of the bed facing her back, cleaning her up. Her left leg was over and up to support her on that side. I was cleaning her up, had just gotten done, was putting barrier cream on her bottom - for whatever reason she decided she needed to roll onto her stomach. She ran out of bed and started to go over the edge. I yelled for help, tried to stop her, the bed was up (about waist height). It didn't take very long for her legs to go over the edge of the bed and she went down. I tried to get the bed down when I realized she was falling and I couldn't. Another resident's alarm was going off - that's why nobody heard me, it was poor timing. She fell on the floor, the alarm went off a few seconds after she was on the floor ... (The LPN - licensed practical nurse) was (helping another resident who was at high risk for falls), and calling out to me, 'I'll be right there.' At that time (resident #1) was already on the floor. I did everything I could to keep her from falling. I've never had a resident fall out of bed ... My understanding was that she needed one person assist - it's care planned and also referred in report, when we get report from previous shift. It's also in the red care books. We've been having another aide or another person in the room always (since the fall). Nobody told me before the incident that (resident #1) needed two person assist for bed mobility - there were no fall mats on the floor. I didn't know she was at risk for falls. She needs two-person for hoyer lift use ... When they asked the right questions I was understandably very distraught over what happened ... From now on I'll have another person on the other side." -The licensed practical nurse (LPN) who was working when the resident fell was interviewed at 3:24 p.m. on 6/12/13. She said, "I heard the CNA yelling out for help from (resident #1's) room. On arrival to the room, (the CNA and resident) were both on the ground. (The CNA) was trying to keep her comfortable on the ground. I think she put a pillow under her head - no fall mats ... I saw (resident #1) on the floor in a lot of pain. I immediately got the RN (registered nurse) in the building to come in and assess (the resident). I asked (the CNA) what happened. What she told me was she was doing ADL care and she fell out of bed and she could not catch her. She made a motion with her body like she tried to catch her but couldn't. She said don't worry, she didn't hit her head. The RN assessed her before we got her into the hoyer lift ... (The resident) was in quite a bit of pain - she complained of pain on her bottom. (The CNA) said she landed on her bottom which I later found out wasn't correct. She said she came down hard but she couldn't catch her. She made the motion with her arms as if she was coming toward her - we found out later that didn't happen. We got the hoyer, got her into bed, she seemed to feel better, the RN did a much more detailed assessment, went up and down her legs, her spine, looked everywhere for any kind of swelling, bones out of place, redness, I watched the RN do the assessment ... Nothing looked out of place at all. She was complaining of pain in her bottom, not her legs, so it went right along with what (the CNA) had told us. She complained less of pain than she had when she was on the floor. I went and got her some Tylenol as she had ordered. Then it was shift change, so I passed it on to my day nurse what happened, and we didn't send her to the hospital because I was under the impression she was lowered to the floor and (the CNA) just couldn't catch her. In hindsight finding out what (the CNA) had told administration at her interview, it just doesn't make sense, because if she fell off the other side of the bed there would be no way she could have told us don't worry she didn't hit her head. ... (The CNA) definitely should have had a second person - you never roll someone away from you like that." -A second CNA who had provided care for resident #1 before her fractures was interviewed at 2:30 p.m. on 6/13/13. She said she had only provided care for resident #1 "a couple times." When asked about assistance with bed mobility and transfers, the CNA said, "She was a two-person assist for bed mobility and transfers, for safety." The director of nursing (DON) was interviewed at 3 p.m. on 6/13/13. She said, "You don't roll someone away from you - if they have a bowel movement you call for help." --Staff interviews regarding two-person assistance: -An LPN interviewed at 3:30 p.m. on 6/12/13, said the CNA "definitely should have had a second person - you never roll someone away from you like that. Our facility since then has implemented training or just made it known you are never to roll anyone away from you in bed without another person." -The NHA was interviewed at 6 p.m. on 6/12/13. She said they had not staffed up on the night shift as a result of this incident. She said three CNAs were enough because of census. -During an interview at 8:30 a.m. on 6/13/13, the NHA was asked for a list of residents who needed two-person assistance. Her first response was, "We don't have any. What specifically do you mean?" Transfers, bed mobility, and toileting assistance. "Per the MDS? If they needed two-person assist only once in the lookback period that wouldn't necessarily be accurate." -An RN interviewed at 10:14 a.m. on 6/13/13, said resident #1 was "Two person assist for any kind of care in bed for (resident #1)." The RN said five residents required two-person assistance on the 400 hall "right now." She said she had one CNA and a float who works 100 and 400 hall. "I usually tell them (CNAs) which (residents) need two people." -The nurse manager was interviewed at 4:45 p.m. on 6/13/13. She said she would not necessarily have expected the CNA to have a second person in resident #1's room with her. "I think she realizes she needs to turn the resident toward her. An assessment should be done each time before they turn somebody. They need to be two-person assist if the MDS and care plan say that. I forgot about the whiteboards. They're in the room and the CNA care cards have the information and they should match, as well as the blue folders on the wall (CNA instructions). All three of those should match." The nurse manager said she had not done a whole house assessment to ensure all sets of instructions for all residents matched. 5. Review of the CNA Documentation of Resident #1's ADL Assistance: Although the resident's MDS (above) assessed her as totally dependent on two-plus persons for bed mobility, toilet use, and transfers (via Hoyer lift), the facility failed to ensure the resident's highest assessed level of care needs were provided. Specifically: Review of "Resident Functional Performance Record" documentation by the CNAs for resident #1 during May 2013 revealed: -For Bed Mobility, CNAs noted the resident received two-person assistance during 13 out of 64 shifts. During the other shifts she was noted to receive one-person assistance. -For Toileting, CNAs noted the resident received two-person assistance during 9 out of 64 shifts. During the other shifts she was noted to receive one-person assistance with toileting. -For Transfers, CNAs noted the resident received one-person assistance six times. During June 2013, even after the resident was hospitalized and diagnosed with [REDACTED]. -For Toileting, the resident received one-person assistance during 5 out of 5 shifts. -For Bed Mobility she was always noted to receive two-person assistance, and Transfers did not occur.

Based on observation, resident and staff interview, and record review, the facility failed to ensure that two of 34 sample residents (#63, #66) who were unable to independently carry out activities of daily living, received the necessary services to maintain their grooming and personal hygiene. Specifically, the facility failed to ensure the fingernails of both residents were adequately trimmed and cleaned, and that resident #63 received adequate assistance with dressing. This failure to trim and clean resident #66's fingernails contributed to her multiple hospital emergency room visits where she underwent invasive treatments for intractable nosebleeds. The findings included: I. Resident #66 A. Facility Expectations The facility policy entitled "Care and Services, #CL-676-0008," revised 8/11, provided by the director of nursing (DON), stated in pertinent part: "It is the policy of the center to provide residents with the necessary care and services to maintain his/her highest level of practicable function in an environment that enhances each resident's quality of life in the scope of a long term care center. - Procedure - Action Steps 1. The IDT interacts with residents in a manner that enhances his/her self-esteem and self-worth, i.e. activities related to bathing, grooming, dining, recreational and social opportunities ..." B. Resident Status 1. Record Review Resident #66, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Minimum Data Set (MDS) According to the 2/10/12 admission Minimum Data Set (MDS), the resident had minimal difficulty hearing, used corrective lenses, had no communication deficits, and was severely cognitively impaired (BIMS cognition score of three). The resident required extensive to total assistance with transfers, propelling wheelchair, dressing, eating, toileting, bathing, and personal hygiene, and was incontinent of bladder and bowel. b. Care Plan The resident's 2/3/12 care plan identified frequent epistaxis (nosebleed) requiring emergency room (ER) visits. Interventions included: apply pressure to bridge of nose, and [MEDICATION NAME] sponges. - The care plan included no preventative measures. The care plan further identified self care deficits, and total staff performance of dressing, grooming and "baths and showers per schedule and PRN (as needed). Skin check, shower, shampoo hair, nail cares and lotion PRN." The goal was for the resident to have a neat, clean, well-groomed appearance. c. Medications According to the resident's 3/12 computerized physician orders [REDACTED]. - Aspirin has antiplatelet properties and can increase bleeding risk (Mosby's 2012 Nursing Drug Reference). 2. Observations Initial observation was made of the resident, on 3/13/12 at 9:45 a.m., when she was sitting in a wheelchair in her room. - She was holding a Kleenex in her hand, was dabbing at the inside of her nostrils and the Kleenex came away with two spots of bright red blood on it. She said, "I guess my nose has stopped bleeding." - Her fingernails on both hands had artificial nails attached that were grown out so long their base was near the tips of her fingers. The nails extended at least one-half inch beyond the tips of her fingers. Her nails were painted with a gold-toned nail polish that was peeling and worn off in places. Underneath her nails there was an accumulation of a brownish substance. - When asked about her fingernails, the resident said, "No, no one has cut my finger nails. I think now and then I can use a trim." She then held her nails out, looked at them and said, "They (nails) do need it (to be trimmed) now ... I don't know who I might ask to cut them." At 10:40 a.m. on 3/12/12, observation of the facility's Activities Calendar revealed manicures were scheduled at 1:00 p.m. every Monday and Wednesday of the month. On 3/12/10 (Monday) between 1 and 2 p.m. multiple residents were observed receiving manicures in the small dining/activity room. Resident #66 was observed at 2:10 p.m. and again at 3:55 p.m. on 3/13/12. Her nails had not been trimmed or cleaned. At 8:07 a.m. on 3/14/12, her nails had not been trimmed or cleaned. On 3/14/12 at 11:15 a.m., the resident was observed in her room. Her nail polish and artificial nails had been removed and her fingernails were trimmed and clean. C. Facility Failures in response to resident needs 1. Medical Record Review The facility failed to adequately assess the length of the resident's fingernails and provide her with timely nail care, i.e. removing artificial nails, cutting and trimming and cleaning them. Record review (below) revealed that on several occasions nurses noted that she had blood on her fingers or under her nails, yet they failed to identify that her picking her nose with long fingernails was contributing to her nose bleeds. - On 3/10/12 the ER physician recommended to the nursing staff that they cut her fingernails; the facility did not do so until 3/14/12. This failure to provide timely, adequate nail care contributed to the resident suffering multiple, intractable nosebleeds for which she had to receive invasive treatment in the emergency room three times and had to be treated by a specialist. Specifically: Resident #66's medical record documented the following in chronological order: - 2/3/12 The Nursing Admission Assessment documentation did not address the resident's long artificial fingernails. - 3/3/12 Resident Transfer Form - The resident was transferred to the hospital emergency room for a nosebleed. - 3/4/12 Resident Transfer Form - The resident was transferred to the hospital emergency room for an intractable nosebleed. - 3/5/12 - 4:15 a.m. Interdisciplinary Progress Notes - "Had small amount of bleeding noted to nose. Also had blood on fingers ... " - 3/10/12 Resident Transfer Form - The resident was again transferred to the hospital emergency room for a nosebleed. - 3/10/12 the hospital's Emergency Report noted, "... I did evaluate the nose at which time there did not appear to be any recurrent bleeding. However, shortly thereafter, she did have recurrent bleeding for which the nose was repacked. It was then unpacked and cauterized. The patient was then left without packing for a period of time and again had re-bleeding. The patient was found to be manipulating her nose and this is what seemed to cause recurring nosebleed ... the bleeding was able to be controlled on multiple occasions here only to start bleeding when the patient began wiping or picking her nose ... Security was placed at the bedside and she did have cessation of bleeding while in a monitored setting ... I did discuss with (nurse in the facility) suggestions on preventing nosebleeds in the future ..." - 3/10/12 - 5:05 a.m. Interdisciplinary Progress Notes - "Resident returned (from hospital) ... Spoke with doctor in ER. Resident was sticking fingers into nose. Suggested cutting nails ..." - 3/11/12 - 4:05 a.m. Interdisciplinary Progress Notes - "Resident experienced nose bleed that lasted about 15 minutes. At 6:30 a.m. - "Resident had nose bleed for one hour ..." - 3/13/12 - 12:00 noon Interdisciplinary Progress Notes - "Nose bleed this morning ... " - 3/14/12 - 4:55 a.m. Interdisciplinary Progress Notes - "Resident with nose bleed at 3:10 a.m. Resident with blood under fingernails. Continues to bleed small amounts. Will continue to monitor." And later at 5:28 a.m. - "Resident bleeding with increasingly large clots ... Call placed to MD at 5:45 a.m." At 7:30 a.m. - "MD returned call. Do not send resident to ER at this time ..." - 3/14/12 Report of Consultation - The resident was seen and treated by an otolaryngologist (ear, nose and throat specialist). The physician reported, "Patient with recurrent right epistaxis (nosebleed), ER X3 ... Patient on 81mg. Aspirin. Most often is bleeding in the mornings." The ENT physician performed a "rigid scope" examination of her right nasal cavity and determined that she had a "small persistent bleed posterior (back of) septum and anterior (front) septum excoriated ... Recommendations: ... Please see nosebleed precautions." The Nosebleed Precautions included: "1. Do not blow your nose. Please do not pick your nose or disturb the scab on the inside of your nose. It may take several weeks to heal ... " 2. Staff Interviews A registered nurse (RN) who routinely provided care for the resident was interviewed at 3:51 p.m. on 3/14/12. The RN said, "The CNAs trim (residents') nails. If they are diabetic then the nurses have to do it. She digs in the front of her nose with her fingers, especially her thumb. She told me she gets in there and tries to scratch it ... Yes, it (picking her nose) may contribute to her nose bleeds. In fact, the night nurse talked to the ER doctor and he said to cut her nails and keep her nails clean and keep her from digging ... I believe it was when I talked with her last Saturday (3/10/12)." When asked why the delay in cutting the resident nails, the RN replied, "It was just overlooked. We have all talked about her nails." The director of nurses (DON) was interviewed at 4:08 p.m. on 3/14/12. The DON said, "The bath aides are responsible for grooming ... cutting fingernails and the nurses do the diabetics ... Yes, I did (notice her nails) when I worked Saturday night (3/10/12) because I was her actual provider and I was trying to determine if they were acrylic or her nails. That was at 5:00 a.m. when I was in there helping her with her nosebleed. My primary concern was getting the nose bleed stopped ... No, I have not seen her pick her nose ... No, I was not aware of what the ER doctor recommended (on 3/10/12). I was not made aware of that (that he recommended cutting her fingernails) and I did not see that in her chart ... I would expect for the nurse to follow his (physician's) instructions. I could trim them without an order but either way you should do what needed to be done." Two of the three CNA bath aides were interviewed. The first bath aide was interviewed at 8:26 a.m. on 3/15/12, and said, "My duties? I give baths, shave them and cut their nails. If they are diabetics, we have a list, then we ask the nurses to trim them ... Yes, I have seen her (the resident's) nails; this morning for the first time. The CNA who usually does her nails is on vacation this week ... No I have never cut any acrylic nails." The second bath aide was interviewed at 8:54 a.m. on 3/15/12 and said, "No, I haven't given her a bath. The other CNA does her ... No I have never trimmed them (artificial nails.) I would ask the nurse how to do it." II. Resident #63 Resident #63, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/27/12 MDS documented the resident had a BIMS score of 4, indicating severe cognitive impairment; and required extensive assistance of one person with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Care Plan The 1/27/12 care plan identified "Self care deficit related to loss of muscle strength, weakness and history of repair of left [MEDICAL CONDITION]. Resident history of chronic [MEDICAL CONDITION] related to infection." Goal - "Resident will be odor free, appropriately dressed, groomed, and her needs will be met daily. Resident's chronic [MEDICAL CONDITION] will be resolved with [MEDICATION NAME] treatment monthly." Interventions - "Allow sufficient time for dressing and undressing since the task may be tiring, painful, and difficult. Encourage resident to do as much for herself as able. Ensure and assist with grooming needs, comb hair, wash face, hands, oral hygiene, and shaving as needed. Reinforce success for task accomplished. Administer eye drops/ointment as ordered, apply warm washcloths to eyes as needed, discourage resident from rubbing or touching the infected eye." - The care plan did not address care to trim or clean resident #63's fingernails or to be completely dressed to include her bra. Observation On the morning of 3/14/12 resident #63's fingernails were observed to be long, with black colored matter under her fingernail tips, and she was dressed without a bra. On the evening of 3/14/12 resident #63's fingernails were observed to remain long, with black colored matter under her fingernail tips, and she wore no bra. The activity calendar documented "Manicures" every Monday and Wednesday from 1:00 to 2:00 p.m. Interviews On the morning of 3/13/12 resident #63's daughter was interviewed. She said she had told the caregivers that she wanted her mother completely dressed, to include her bra. She said even after she expressed to the caregivers that she wanted her Mother to be completely dressed each day to include her bra, she still at times had come in and found her mother dressed, but without the bra. On the evening of 3/15/12 the DON was interviewed related to ADL care that the resident should receive from the facility. The DON expressed that her expectation was that the residents should be given the chance to do for themselves what they can do, and the staff should provide all care that the resident does not do or cannot do for themselves, to include being completely dressed and nail care provided. The facility failed to ensure the resident received adequate dressing and personal hygiene assistance.

Based on physician and staff interview and record review, the facility failed to ensure that one of four sample residents (#1) received the necessary care and services to attain or maintain the highest practicable physical and mental well-being. Specifically, the facility failed to adequately assess, monitor and respond to resident #1's change in medical condition in an appropriate and timely manner. This failure resulted in a delay in providing medical care, including hospitalization , which was warranted by the resident's decline in condition. The findings included: Non-interviewable resident #1, a [AGE] year-old male, was originally admitted to the facility on [DATE] and most recently was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the most current re-admission Minimum Data Set ((MDS) dated [DATE], resident #1 had no hearing deficits, had clear speech, was able to understand and make himself understood, had a BIMS score of 10/15 or moderately impaired in cognitive skills for daily living, required assistance with all activities of daily living, used either a walker or wheelchair for mobility with assistance, and was incontinent of both bladder and bowel. A. Record Review Review of the resident's medical record, initiated at 10:00 a.m. on 10/17/11, revealed the following: The Interdisciplinary Progress Notes stated: - 9/18/11 "Noc" (night) - "Res(ident) started to vomit after dinner. Fever 100.1, P(ulse) 110, B/P 98/54, 02 (oxygen) 90% on 3L, unable to verbally respond, SOB (shortness of breath), trying to talk, unable to move jaw to let words out, left sided weakness. On call doctor notified and ordered [MEDICATION NAME] suppository 25 mg and [MEDICATION NAME] suppository 650 mg Q 4 hrs PRN (every four hours as needed). Nurse tried to administer suppository but resident began vomiting and risk of aspiration more important. Doctor also gave order to transport res if no improvement. Res shipped out at 2145 (9:45 p.m.) via non-emergent transport. Daughter notified on voicemail to call facility. No phone calls from daughter yet." - 9/18/11 "Noc" - "Called (hospital) to get update on res and nurse reported no changes but res was admitted to the med-surg floor. Nurse on med-surg floor said his daughter had been in to visit him." Resident #1 received treatment in the hospital for five days and he was readmitted to the facility on [DATE]. Physician Orders physician's orders [REDACTED].#1 to the hospital. Medication Administration Record Review of the September 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Vital Signs Documentation The Weights and Vitals Summary for September 2011 revealed no further vital signs were taken for resident #1 other than the one set documented in the IDT notes on 9/18/11 (see above). Resident #'1's Vital Sign Sheet, where routine vital signs were hand recorded from 7/15/11 to 10/8/11, revealed no additional vital signs were obtained on 9/18/11. - Review of the record revealed no evidence that a requisite interagency transfer form was completed that would communicate resident #1's vital signs, medical condition, mental status, allergies [REDACTED]. - There was no change of condition documentation reported by the nurse in the medical record. The facility had a form titled, "Change of Condition Documentation" that included the following: "I. Objective/Underlying Illness/Symptoms, II. General Appearance, III. Physical Evaluation, Most Recent Lab Results, Pertinent Meds, allergies [REDACTED]." This had not been completed by the nursing staff related to resident #1's decline and change in condition on 9/18/11. Hospital Emergency Report The Emergency Report from the hospital on [DATE] when resident #1 was admitted , stated in pertinent part: "Chief Complain: Altered mental status, fever, left-sided weakness. "History of Present Illness: this [AGE] year-old male is transferred here from (nursing home) where they noted the onset of altered mental status with lethargy along with acute fever. They thought he might have some left-sided weakness as well. The patient is unable to contribute much to his history secondary to both his chronic dementia as well as his acute medical condition. The patient has had some recent admissions to the hospital this summer . . . He suffered from a febrile illness, including pneumonia. "Physical Examination: Temperature is 40.0 (104 degrees Fahrenheit), otherwise vital signs unremarkable with a systolic pressure in the 110's and a pulse of 101. In general the patient is somnolent but can be aroused with verbal stimulation . . . Pertinent positives on examination include some very dry mucous membranes and secretions of the mouth . . . "Diagnostics: . . . Urinalysis is very cloudy with much sediment, positive tor [MEDICATION NAME], leukocyte esterase, white cells, bacteria; was sent for culture . . . "Course in the Emergency Department and Medical Decision Making: He presents with acute febrile illness. I think this likely is of a urologic source based on his urinalysis and the fact that his chest x-ray appears chronically stable . . . "Primary Diagnosis: [REDACTED]. 2. Altered mental status secondary to #1. 3. Chronic [MEDICAL CONDITION]." The hospital Discharge Summary dated 9/23/11 stated in pertinent part: "Discharge Diagnosis: [REDACTED]. 2. Fever with altered mental status secondary to #1 . . . Discharge Medications: [MEDICATION NAME] 75 mg intravenously for an additional 3 days . . . Hospital Course by Problem . . . 5. Co-morbidities and failure to thrive. We discussed with the patient's durable power of attorney for health care, and a hospice consult was obtained, and they will be following him at (facility) after discharge . . ." B. Interviews Resident #1's attending physician was interviewed at 8:55 a.m. on 10/18/11. He stated that on 9/18/11, he was advised by the nurse in the facility that resident #1 was experiencing fever and a change in mental status. The physician related that resident #1 had been hospitalized "five times since May," was "seriously ill and is now on hospice care." The physician also said that it was his expectation that the nursing staff would have appropriately continued to monitor the resident closely, communicate with him the resident's changes/decline in condition and follow his orders. The Licensed Practical Nurse (LPN) who provided care and documented in the IDT notes for resident #1 on 9/18/11 was interviewed at 1:50 p.m. on 10/17/11. The LPN said that she had worked for the facility for six months and that this was her first nursing job. She stated, "To the best of my knowledge, I received report from 5:45 p.m. to 6:30 from two nurses. Then I started med pass on 4 Hall (where resident #1 resided) . . . between 6:30 p.m. and 7:30 p.m. the CNA told me he was vomiting. There was so much going on. I had 44 residents at the time. He was not responding, like he had lock-jaw, so I took his vitals and his pulse was high. I believe he had a temp. I called the doctor and specifically asked for some [MEDICATION NAME] for his vomiting and I talked to the charge nurse and she said to get an order for [REDACTED].#1) the [MEDICATION NAME] and he started to vomit . . . No, I wasn't able to give it to him. We laid him on his side. He's at high risk for aspiration pneumonia." When asked why there was a delay in his care, she replied, "I thought his nausea/vomiting and temp could wait. I did pull the RN (registered nurse) in and she said if he didn't get better to ship him . . . I had the CNA check his vitals again I think. He couldn't open his eyes. I felt that it was non-urgent. I continued to pass meds at that time. I had 44 residents and 42 of them needed meds . . . and I just had so many that needed pain medications . . . I called for non-emergent transport - he (resident #1) was breathing fine. They told me they would send someone right over. I think they came within five minutes. The paramedics came and did an assessment; really they know more than I do. . . I didn't have the time to check him as often as I would have liked . . . I guarantee I did the best I could . . . His condition was so bad. Had I known . . . I feel horrible." At 6:35 p.m. on 10/17/11, the charge nurse (RN) who worked the evening shift on 9/18/11 was interviewed by phone. After being briefed about the incident with resident #1 on 9/18/11 she stated, "I think I remember . . . to be honest I sent him many times to the hospital so I can't remember if this was the time he was de-sating (oxygen dropping) or not. I know I was not involved in his vital signs, usually the nurse taking care of the resident does that." When asked if she participated in making the decision to send him to the hospital with non-emergent transportation, the RN replied, "I didn't make that call . . . If I am involved, I will document (there was no documentation from this RN in the record.) . . . I usually just tell them (the LPNs that she works with) whether to send them or not. I just can't remember this specific night . . . Yes, 44 residents is normal and then I usually have 28-34 on my halls, it depends on the census . . . We always have two nurses, an RN and an LPN . . . We have a lot of meds to give and of course call light action." One of two certified nurse aides (CNAs) who cared for resident #1 on 9/18/11 stated, "Yes, I was on that night. I didn't know he threw up. I was in the dining room feeding residents. I saw a visitor walk by several times so I asked her if I could help her. She said he (resident #1) had been throwing up . . . She said that she had been waiting 45 minutes for somebody to come and help. The lady was very upset, she was crying. I told her I was sorry and that I didn't even know. She told me she'd told a couple of people but nobody came. So I went down to his room. He was still throwing up. I gave him a bucket and some tissues and when he was done, I cleaned him up, put on a new shirt and got help to transfer him back to his bed . . . This was probably about 6:30 or 6:45 p.m. maybe . . . He acted like he was going to throw up again so I told a nurse, I can't remember which one, and she said she would go down (to his room) as soon as she could. . . He wasn't really talking, it was like his teeth were clenched. (The other CNA) was in there too. (The RN) said one of us had to stay with him. She was worried that he would aspirate. We put the head of his bed up. The other nurse (LPN) had an emergency down another hall . . . I had a million call lights and had to help other residents so she (the other CNA) stayed with him . . . Vital signs? No I never took any, I am not sure what the others did . . . No, I wasn't aware that he went to the hospital." The second CNA who provided care for resident on the evening of 9/18/11 was interviewed at 4:10 p.m. on 10/17/11 and said that she had worked for the facility for 2 months and this was her first job as a CNA. The CNA stated, "I got here at 6:00 p.m., not long after that I heard that he (resident #1) was sick and that a family member was upset . . . It had to be at the end of dinner time I imagine. I went to his room. I helped put him to bed and make him comfortable. He had been vomiting and was not feeling well. He was responding but lethargic. The family was gone and the nurse told me to stay with him because she had to go and call the doctor. When she came to put the suppository in she couldn't because he was having a BM (bowel movement) at the time and so we cleaned him up . . . I think I was helping on the floor when they sent him out. I don't remember anything else." C. Policy and Procedures On 10/17/11 at 6:18 p.m. the Director of Nursing submitted the following requested policies and procedure for review. They stated, in pertinent part: 1."Assessment," Policy Number CL -676-005, revised 2/11: "Policy Statement: It is the center's policy to assess each resident upon admission, re-admission, and quarterly or with a significant change of condition." 2."Change in Condition of a Resident," Policy Number CL-676-0011, dated 1/08: "Policy Statement: It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of the resident. Procedure: Action Steps - 1. The Licensed Nurse determines if there has been a change in condition of a resident. 2. The Licensed Nurse notifies, via telephone, the attending physician and the resident's responsible party of the specific nature of the change of condition . . . 3. The Licensed Nurse initiates action to ensure the immediate safety of the resident. 4. The Licensed Nurse confers with the Physician to determine what actions may be necessary to meet the immediate needs of the resident. 5. The Physician provides orders to direct the care of the resident. 6. The Licensed Nurse implements the physician's orders [REDACTED]." 3. "Medical Emergency Transportation," Policy Number CL-676-0016, dated 1/08: "Policy Statement: It is the center's policy to provide for emergency transportation in response to an emergency medical condition according to state and federal law, guidelines and regulations . . . "Procedure: Action Steps - . . . 3. The Licensed Nurse contacts 911 when a resident, staff member or visitor experiences: [MEDICAL CONDITION], acute shortness of breath, acute chest pain or other symptoms suggestive of acute stroke such as sudden focal weakness or difficulty with speech . . .or any other emergency medical condition. 4. The Licensed Nurse documents information related to the emergency on an interagency referral form and in the medical record as indicated. 5. The Licensed Nurse notifies the resident's physician and responsible party . . ." D. Summary In summary the facility failed to: -Adequately continue to monitor and re-assess resident #1's vital signs and mental status. -Provide appropriate care and services during the time of resident #1's decline and change in condition. -Document a time-line record of events that reflected the nurse's decision-making process in the documentation. -Follow physician's orders [REDACTED]. (From approximately 5:30 to 9:45 p.m. when he was sent to the hospital) -Communicate with the receiving facility, with a requisite interagency transfer form, the necessary information about the resident. These failures contributed to a delay in providing medical care that was warranted by the resident's change/decline in condition and his admission to the hospital with a temperature of 104 degrees and a [DIAGNOSES REDACTED].

Based on observation, facility protocol, record review and staff interviews, the facility failed to ensure three (#80, #52 and #7) of 30 sample residents received the care and services necessary to promote healing and prevent the development of pressure ulcers. Specifically: -Resident #80 was admitted with multiple risk factors for pressure ulcer development. These factors were not comprehensively addressed on admission and, in the first month after admission, staff failed to assess, monitor, and intervene to address an "unstageable right heel wound" noted on the resident's care plan the day after admission. This contributed to worsening of the right heel wound, wound pain, and the need for wound debridement. -Resident #52 was admitted with boggy heels. However, the heels were not comprehensively assessed on admission and their presence was not promptly communicated to the physician and therapy to ensure proper and timely interventions. -Resident #7 was admitted with skin breakdown. The facility failed to accurately assess, monitor and timely intervene to prevent further breakdown. Findings include: 1. Resident #80 Resident #80, a [AGE] year old female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. a. Risk factors on admission for pressure ulcer development - facility failures (1) Known risk factors Although the resident was documented on admission documents, including the admission nursing assessment 9/7/10, the minimum data set (MDS), dated [DATE], and the nutritional assessment completed on 9/16/10, with no skin breakdown (excluding left hip incision), she was at risk for skin breakdown based on the following: -The admitting [DIAGNOSES REDACTED]. -The interdisciplinary team (IDT) note, dated 9/7/10, revealed the resident was documented with "Excoriation/redness to bottom and coccyx." -The Norton Plus Pressure Ulcer Scale completed on 9/7/10, revealed the resident had a score of 8. A score of 10 or less was indicative of high risk for pressure ulcer development. -The resident's care plan 9/8/10 identified the resident with "unstageable wound" to right heel. -The admission MDS 9/13/10 documented the resident required total assistance of one for personal hygiene, extensive assistance of one for dressing and eating and extensive assistance of two for bed mobility, transfers and toilet use. She was also coded as incontinent of bowel and bladder and was wheelchair dependent. (2) Facility Failures on Admission According to the admission MDS, the resident had the following skin treatments: pressure relieving device for chair, bed and a turning/repositioning program. However, review of the resident's record (IDT notes 9/10-1/11) revealed no reference to turning and repositioning the resident. The facility opened a care plan (CP) 9/8/10 that identified the resident had impaired skin integrity recent excoriation buttocks/unstageable wound on right heel. Resident has need for continued observation healing process of wound. Interventions included: -Barrier cream to peri area as needed (9/8/10) -Cleanse perineal area well with each incontinence episode (9/8/10) -Follow treatment to right heel per doctor (MD) order and observe healing process, and for signs/symptoms of infection, alert MD as needed (PRN) status changes (9/8/10) -Keep skin clean and dry on nursing rounds and PRN (9/8/10) -Use two-person transfer and use turn sheet to avoid friction/shearing of resident skin (9/8/10) -Weekly skin assessments (9/8/10) The care plan, reviewed at the facility on 1/10/11, revealed inadequate comprehensive assessment and planning regarding incontinence care, pressure/shearing relief and repositioning, given the resident's known risk factors on admission that included immobility and dependence (recent [MEDICAL CONDITION]), incontinence of bowel and bladder and excoriation/redness of buttocks. -There was no plan identified to ensure regular and frequent turning and repositioning. -There was no individualized bowel and bladder program identified to keep the resident clean and dry. b. Facility Failures 9/10 to 10/1/10 (1) Expectations According to the U.S. Department of Health and Human Services, "Clinical Practice Guidelines" Number 3, "Pressure Ulcers in Adults: Prediction and Prevention," and Number 15 "treatment of [REDACTED]. -All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. -Identification of a pressure sore 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. According to the facility's policy, "Skin Care & Pressure Ulcer Management Program," dated 1/10, section 3, "War on Wounds" program, upon discovery of a "skin issue," staff was (in pertinent part) to: -Complete a Pressure Ulcer Documentation Form to document the status of the pressure ulcer. -Assess and document pressure ulcer at least weekly. -Determine the stage of the pressure ulcer. -Measure the pressure ulcer - length X width X depth. -Notify the Registered Dietician (RD) of the wound by completing the Interdisciplinary communication to nutrition services form. (2) Failure to comprehensively assess and monitor and communicate to RD the status of the resident's right heel and buttocks, as expected. a) On 9/7/10, an IDT note stated, in pertinent part, "skin is warm and dry. Excoriation/redness to bottom and coccyx. Skin tear to left elbow, small scab on back below neck and surgical incision to left hip." A notation stated, "No other skin issues at current." The notation of "no other skin issues at current" was crossed out but not initialed or otherwise clarified. The resident's excoriation/redness was not further described and the resident's right heel was not referenced. Moreover, although the 9/8/10 care plan identified an excoriated/redened buttock/unstageable wound (see above), there was no documentation that showed the RD was promptly notified of the resident's "skin issues," as expected per facility policy. The first RD note on the resident's skin issues was 10/12/10, over a month after the skin issues had been identified on the care plan. Finally, there was no documentation in the record that these areas were monitored more vigilantly or daily after that date. Indeed, the next note was a week later, on 9/14/10. b) On 9/14/10, an IDT note stated, in pertinent part, "Skin check showed red/blanchable heels bilaterally." This note failed to document the status of the resident's buttocks and failed to comprehensively describe the status of the resident's heels. The short description given was inconsistent with the care plan statement that the resident's right heel had an unstageable wound. c) On 9/21/10, 9/22/10, 9/23/10, and 9/26/10 IDT notes documented open areas on the resident's buttocks and left achilles, but included no information on the resident's heels. The 9/21/10 note read, in pertinent part, "Resident noted with stage II 1.5 x 7 cm to left inner buttocks, dry, no odor, and no pain. Also noted, left upper Achilles area with .6 x 1.2 cm dry area with top layer of skin removed-stage II. [MEDICATION NAME] applied and heel free floating in bed on pillow. Also has a very small .2 x .2 cm area abrasion to top of 2nd toe left foot ..." The 9/22/10 note stated, in pertinent part, "...Open area to coccyx cleaned and barrier cream applied." There was no reference to the wound on the toe or left achilles. The 9/23/10 note stated, in pertinent part, "Review week #3 status [REDACTED]. The 9/26/10 note stated, in pertinent part, "...Coccyx area cleaned and barrier cream applied. Dressing intact to left heel no signs/symptoms of infection ..." There was no evidence in the IDT notes after 9/14/10 and until 9/30/10 that the resident's heels, in particular her right heel with an "unstageable" wound was being monitored or addressed. d) Pressure Ulcer Records for the resident's #80's right heel wound was provided by the Director of Nursing on 1/11/11 at 10:00 a.m. Although the right heel wound was noted on the care plan 9/8/10, the first entry on the Pressure Ulcer Records was dated 10/1/10, almost three weeks later. This entry read: "Fluid filled blister, [DIAGNOSES REDACTED] around surrounding skin, blister size 2.5 cm long by 3.6 cm wide. Podus boots applied, and air mattress applied." This was the first documentation of the status of the right heel since 9/14/10, and the first documentation of interventions to relieve pressure on the resident's heels. c. Status of Right Heel Ulcer after 10/1/10 - Facility Failures (1) Record review (IDT notes, MDS 12/2/10, Dietary Progress Notes, and physician progress notes [REDACTED]. Although the pressure area began improving in 11/10, it required dressing changes, antibiotics, pain management, and wound clinic intervention involving wound debridement. -On 9/30/10, an IDT note at 5:00 a.m. stated, "Right heel boggy with darkened area under skin, not open. Spongy allevyn dressing applied to cushion and heel floated, MD faxed." -On 10/1/10, an IDT note stated, in pertinent part, "... Resident with fluid filled blister to right heel; left heel-achilles- area from shoes, area improving. Therapy and wound team checked buttocks- with no open areas but some excoriation, air mattress to bed, podus boots to both feet ..." -On 10/1/10, a physical therapy (PT) note documented that the resident was seen to assess new right heel wound. The therapist recommended bilateral podus boots, side lying either side with two pillows with either heel not touching any surface and upgrade in mattress. Foot pedals to be elevated to provide increased support to calf to further off load heels. -On 10/1/10 "PM", an IDT note stated, "Received orders for dressing change to right heel, was cleaned and covered per orders. Left achilles covered with [MEDICATION NAME] per orders, resident's buttocks wound now open." -On 10/4/10, an IDT note stated, in pertinent part, "Faxed update to doctor about left Achilles, right heel, and buttocks treatment. Requested orders air mattress applied to bed 10/1/10 and podus boots bilaterally, requested to relieve pressure when in bed." -On 10/6/10 at 2:00 a.m., an IDT note stated, "Skin check performed. Small, round, red sore noted on buttocks. Resident positioned on side. [MEDICATION NAME] given for pain at night as ordered ... Podus boots on both feet ..." -On 10/7/10 at 10:00 a.m., an IDT note stated, in pertinent part, "Wounds evaluated by wound team again requested order for podus boots bilaterally at all times and to discontinue soft pad to right heel blister." -On 10/7/10, the Pressure Ulcer Record documented the right heel as a fluid filled blister, size 4 cm long by 5 cm wide. -On 10/8/10, an IDT note stated, in pertinent part, "... Right heel blister open to air, popped draining brown color liquid, moderate amount, area cleansed and covered with soft pad for wounds 4 X 4 to pad, wrap with keflex ... Left elbow area redness covered with [MEDICATION NAME]." -On 10/11/10, the Pressure Ulcer Record documented the right heel as: reabsorbed cap remains intact, 100% eschar and the size was 4 cm long by 4.3 cm wide. (Subsequent entries on 10/15/10, 10/22/10 and 10/27/10 documented the right heel wound 100% eschar.) -On 10/12/10, Dietary Progress Notes (DPP) on 10/12/10 documented that the resident had a wound on her right heel, left Achilles and on her coccyx. Her weight was 106.4 pounds. The dietician suggested a multivitamin with minerals and 60 cc Med Pass 2.0 twice a day to facility wound healing. -On 10/13/10, a PT note documented in pertinent part, that the resident's bed position was assessed "...with new bolsters on air mattress and use of podus boots in bed and wheelchair. Patient tends to prefer right lower extremity internally rotated and repositions self into right hip internal rotation despite podus boot with lateral stabilizing bar. Worked with DON and determined recommendations to off load right heel, to use podus boots in wheelchair for proper alignment, take podus boots off in bed and use heel lift pillow that fits between the air mattress bolster to provide uniformed support and off loading regardless of hip position." -On 10/13/10, an IDT note stated, in pertinent part, "Resident went out to physician for examination of foot ulcer. Orders noted " ...podus boots may come off at night." -On 10/15/10, an IDT note stated, in pertinent part, " ...right heel top layer of skin off, under is black and hard, podus boots on when up, heels up when in bed ..." -On 10/28/10, an DPN revealed the request for multivitamin with minerals and Med Pass 2.0, originally sent 10/12/10, was re-sent, indicating a several week delay in these nutritional interventions. -On 11/2/10, an IDT note stated, "To wound clinic. Wound debrided by Nurse Practitioner (NP) re-dressed with santyl, foam pad and Kerlix ..." -On 11/3/10, an IDT note stated, "dressing change to right heel, white exudates on wound bed. Santyl applied as ordered, area around wound edge seems less reddened today." -On 11/5/10, an IDT note stated, in pertinent part, "...podus boots in place; accumax mattress on bed ..." -On 11/8/10, an IDT note stated, in pertinent part, "...Foul smell noted and reported to wound clinic by phone call, wound clinic stated they were seeing her tomorrow." Resident complained of pain when the dressing was removed. -On 11/11/10, an IDT note stated, in pertinent part, "Dressing change done per physician's orders [REDACTED]. No foul odor noted. Edges to wound bed pink, no complaints of pain during dressing change, or any other times. Podus boots re-applied. Antibiotic given for right lower lobe infiltrate ..." -On 11/12/10, an IDT note stated, in pertinent part, "...No- foul odor to wound, edges pink, yellow exudates in part of wound bed ..." -On 11/15/10, an IDT note at 1:30 p.m. stated, "dressing change on right foot, old dressing had brown drainage, small amount. Decubis 2.8 x 3.0, granulated tissue with brown scab on site. Antibiotic cream and dressing re-applied, resident tolerated well, pain medications given at 12:30. Podus boots on all times." -On 11/16/10, an IDT note stated, in pertinent part, "...Skin check done, and open area to right heel only open area, all other skin intact." -On 11/18/10, an IDT note stated, in pertinent part, "...Podus boots in place at all times." -On 11/18/10, a Physician Consultation Note from the Wound Clinic, identified the right heel wound onset date of 9/2/10 and clinic start date of 11/2/10. The wound was measured at 2.3 cm in length, 3.1 cm wide and 0.2 cm deep. The wound order was to clean the wound with normal saline, to peri-wound apply lotion of choice. Apply [MEDICATION NAME] to the wound bed and cover with foam, secure dressing with Kerlix and tape. Continue to use off loading boot. -On 12/1/10, a hand-written addition to the care plan on 12/1/10 stated, "New Stage II coccyx." And the 12/2/10 quarterly MDS coded the resident as having one stage II pressure ulcer, one stage IV pressure ulcer and one unstageable pressure ulcer. (2) Failures in facility's response IDT and therapy notes indicated podus boots were applied beginning 10/1/10. However, this intervention was not added to the skin integrity care plan until 11/18/10, and direction for use, described in the therapy note on 10/13/10, were not included on the plan. Likewise, the directive to administer pain medication PRN for wound discomfort, prior to dressing change and/or treatments was not added to the plan until 11/18/10, even though the IDT documented pain as early as 10/6/10. Finally, addition of the handwritten entry regarding the new stage II coccyx ulcer was not accompanied by a re-evaluation of the resident's toileting program in an effort to keep the resident clean and dry. See above Dietary Progress Notes 10/12/10 and 10/28/10 that indicated a delay in implementing the dietary interventions of multivitamin with minerals and Med Pass 2.0. The 10/12 DPN note for these interventions was resent 10/28/10. d. Status 1/11 Subsequent IDT notes and Physician Consultation Notes as well as the Pressure Ulcer Records revealed the right heel ulcer and the coccyx ulcer continued to improve; the coccyx wound closed 12/30/10, and the Pressure Ulcer Records dated 1/7/11 documented the wound size was 1.4 cm long by 2.7 cm wide, the wound was scabbed. Observations revealed, however, that interventions to promote continued healing were not being implemented properly. See above; according to the 10/13/10 therapy notes, the resident was to use podus boots in wheelchair for proper alignment, take podus boots off in bed and use heel lift pillow that fit between the air mattress bolster to provide uniformed support and off loading. On 1/10/11 at 3:30 p.m., resident #80 was observed lying in bed. A certified nurse aide (CNA) was asked if the resident was wearing her podus boots and the CNA stated that the resident was wearing the boots in bed. On 1/11/11 at 11:00 a.m., a staff member pulled the covers back on the resident's feet while the resident was in bed. The resident was wearing bilateral podus boots and her heels were not floated. At that time, the Director of Nursing (DON) observed that resident #80 was wearing her podus boots and that her heels were not being floated. Staff Interviews On 1/11/11 at 10:22 a.m., the MDS coordinator was interviewed about resident #80's pressure ulcers and interventions to improve healing. -She stated that the resident was to wear podus boots while up in her wheelchair, but the boots were to be removed while in bed, and the heels should be floated. She discussed that all intervention should be on the resident's care plan and acknowledged that there was no direction regarding the use of the podus boots on the care plan, or instructions that the heels should be floated. She discussed that the resident's mattress had been changed twice, although the type of mattress was not on the care plan, or the date it was changed. -She said the resident's coccyx wound was healed and that the left heel wound was caused by the heel rubbing against the resident's shoes, which was resolved in 2-3 weeks. The resident currently had the one stage II pressure ulcer (her right heel). On 1/11/11 at 10:50 a.m., the MDS coordinator and DON were interviewed about expectations in the facility's policy "War on Wounds." They stated that they were not aware of the policy. On 1/12/11 at 10:23 a.m., the Medical Director stated that for a person who scored high on the Norton pressure score scale, he would expect to see frequent skin checks and repositioning interventions on the care plan. 3. Resident #7, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, dated [DATE], resident #7 did not have memory problems, needed extensive assistance of two persons with bed mobility, transfers, and toileting, was coded no pressure ulcers, and no pain. On 9/1/10, the History and Physical (HOSPITAL RECORD) documented in part: right leg some mild [DIAGNOSES REDACTED] and warmth to the right anterior lower leg, patient has about 1 cm stage two pressure ulcers on the lateral middle foot, no exudative drainage noted. The lab results total protein 7.5 and [MEDICATION NAME] 3.2 (slightly low). a. Admission assessments -On 10/18/10, the Nursing Assessment Form, documented on admission that resident #7 had bilateral boggy heels, open sore on left lateral foot, left shin with red area, no buttocks/other breakdown. -On 10/18/10 Pain Evaluation documented, skin wound right foot, documentation resident expressed she had pain almost constant between lower back to below buttocks every day, worse at night. -On 10/18/10, the Nurses Note documented resident has bilateral boggy heels with the right heel had scaly skin, right foot also had open wound and resident was on antibiotic for right foot wound. b. Documentation of further skin breakdown after admission - inconsistent and incomplete assessments Nurses Notes: -On 10/24/10, documented per Nurses Note, continues on antibiotic for wound infection on right heel dressing dry and intact on right heel. Nursing also documented reddened area to right heel and toes. -On 10/31/10, per Nurses Notes, dressing change to right heel, area with exudates yellow color, wound cleanser and border gauze applied. Peri area reddened but improved from previous days. -On 11/2/10, per Nurses Notes, the resident had two sores on her coccyx. (No description of sores documented.) -On 11/21/10 Nurses Note documented in part, wound on right foot near little toe with black eschar, no drainage. -On 11/27/10 per Nurses Note, right heel wound healing slowly. -On 11/28/10, nurses note documented wound dressing on right foot changed small amount of yellowish drainage with small amount of old blood, top wound on same foot open to air no drainage. -On 12/7/10, the Nurses Note documented, in part, resident had redness over several areas of bottom with one slightly open area, encouraged resident to change position in bed more often and get off bottom, resident has red spot on right heel, reminded resident and CNAs (certified nurse aides) to keep heels floated while in bed. -On 12/8/10, the Nurses Note documented, in part, resident's bottom continues to have breakdown-cream applied. Care Plan: The care plan related to skin, dated 10/22/10, revealed further skin breakdown after admission. It read: Problem/Focus- On admission resident had vascular ulcer right lateral foot not stageable, secondary to [MEDICAL CONDITION]. On 10/27/10, ulcer now with eschar removed and presents as stage three ulcer. On 11/10/10, pressure area on ball of right foot at fifth metatarsal, the resident intentionally positions self down in bed to foot board. On 12/10/10 stage two pressure areas, one on right buttocks and one on buttocks crease. Pressure Ulcer Documentation Forms: The forms documented breakdown on the resident's right lateral foot (on admission), sole of right foot (11/8/10), inner buttocks (12/9/10), and crease of buttocks (12/9/10). (1) Right lateral foot. Pressure Ulcer Documentation Forms related to the right lateral foot revealed documentation as follows: Onset date 10/18/10 on admission. -10/22/10, stage= U (unstageable), length (L) 1.0 cm, width (W) 1.3 cm, no odor, wound bed = 100% eschar. -10/27/10, stage= U (unstageable), length (L) 1.0 cm, width (W) 1.0 cm, no odor, wound bed = 40% granulation and 60% slough. -11/5/10, stage= U (unstageable), length (L) 2.0 cm, width (W) 1.5 cm, no odor, wound bed = 100% slough. -11/10/10, stage= U (unstageable), length (L) 1.0 cm, width (W) 1.0 cm, no odor, wound bed = 100% slough. -11/17/10, stage= U (unstageable), length (L) 1.5 cm, width (W) 2.0 cm, no odor, wound bed = 100% slough. -11/24/10, MISSING DOCUMENTATION -12/2/10, stage= U (unstageable), length (L) 1.3 cm, width (W) 0.8 cm, no odor, wound bed = 100% slough. -12/9/10, stage= U (unstageable), length (L) 1.6 cm, width (W) 1.8 cm, no odor, wound bed = 100% slough. -12/16/10, stage= U (unstageable), length (L) 1.9 cm, width (W) 1.7 cm, no odor, wound bed = 50% [MEDICATION NAME] and 50% slough. -12/21/10, stage= U (unstageable), length (L) 1.9 cm, width (W) 1.5 cm, no odor, wound bed = 75% [MEDICATION NAME] and 25% slough. (2) Sole of Right Foot Pressure Ulcer Documentation Form right sole of foot at the 5th metatarsal head. Onset date 11/8/10. -11/10/10, stage= U (unstageable), length (L) 1.1 cm, width (W) 0.7 cm, no odor, wound bed =(MISSING DOCUMENTATION). -11/17/10, stage= U (unstageable), length (L) 2.0 cm, width (W) 2.0 cm, no odor, wound bed =(MISSING DOCUMENTATION). -11/24/10, (MISSING DOCUMENTATION) -12/2/10, stage= U (unstageable), length (L) 1.3 cm, width (W) 0.8 cm, no odor, wound bed =(MISSING DOCUMENTATION). -12/9/10, stage= U (unstageable), length (L) 1.6 cm, width (W) 1.8 cm, no odor, wound bed = scabbed. -12/16/10, stage= U (unstageable), length (L) 1.6 cm, width (W) 1.8 cm, no odor, wound bed = scabbed. -12/21/10, stage= U (unstageable), length (L) 1.9 cm, width (W) 1.9 cm, no odor, wound bed = scabbed. (3) Inner buttocks The Pressure Ulcer Documentation Form documented: Onset date 12/9/10. -12/9/10, stage= 2, length (L) 1.0 cm, width (W) 1.5 cm, no depth, no odor, wound bed = 50% [MEDICATION NAME] and 50% granulation. -12/16/10, stage= 2, length (L) 1.0 cm, width (W) 1.5 cm, no depth, no odor, wound bed = 50% [MEDICATION NAME] and 50% granulation. -12/21/10, stage= 2, length (L) 1.0 cm, width (W) 1.5 cm, no depth, no odor, wound bed = 50% [MEDICATION NAME] and 50% granulation. (4) Crease of buttocks. The Pressure Ulcer Documentation Form documented: Onset date 12/9/10. -12/9/10, stage= (MISSING DOCUMENTATION), Small slit open area unable to measure, depth=MISSING DOCUMENTATION), no odor, wound bed =50% [MEDICATION NAME] and 50% granulation. -12/16/10, stage= 2, length (L) 0.5 cm, width (W) 2.0 cm, depth(MISSING DOCUMENTATION), no odor, wound bed = 50% [MEDICATION NAME] and 50% granulation. -12/21/10, stage= 2, length (L) 0.2 cm, width (W) 2.0 cm, depth(MISSING DOCUMENTATION), no odor, wound bed = 50% [MEDICATION NAME] and 50% granulation. Although both the Nurses Notes and the Pressure Ulcer Documentation recorded further skin breakdown after admission, there were inconsistencies between the Nurses Notes and the Pressure Ulcer Documentation. Specifically: -The Nurses Notes on 11/2/10 documented the resident had two sores on the coccyx. The Pressure Ulcer Documentation form identified the onset date of the coccyx wounds as 12/9/10. -Nurses Notes referenced a right heel wound and a 12/2/10 note documented that the wound team changed the right heel dressing; however, the Pressure Ulcer Documentation was void of right heel documentation. c. Facility Interventions - Orders, Treatments, Care Plan Review of the resident's skin care plan (see above) revealed the following approaches: -On 10/22/10 Barrier cream to peri area as needed, turn and reposition with skin care every nursing round, use two person transfer with turn sheet to avoid friction/shearing of resident skin. Podus boot to right foot, weekly skin assessments. -On 12/22/10 obtain new bed mattress/ low air loss. Treatment Administration Record (TAR): Review of the TAR documented on 11/12/10, podus boot to right leg at all times to protect the skin. On 11/18/10, right lateral foot apply [MEDICATION NAME] to granulation tissue in wound bed and santyl for debridement of eschar at top of wound. Right 5th metatarsal leave open to air and offload pressure to right foot. On 12/10/10 apply [MEDICATION NAME] to right buttock q3 days, stage 2. Apply cream to buttock coccyx crease twice per day. Nutrition Notes: -On 10/21/10, the facility Medical Nutrition Therapy Assessment documented in part as follows: Diet order Regular texture House Consistent Carbohydrate (HCC) 1400 calories per day. The documented goals: resident to tolerate HCC, no added salt small portions diet to provide estimated nutrient needs to promote weight loss. -The medical record failed to disclose any additional nutritional assessments after 11/18/10, relating to the resident's increased nutritional needs to promote wound healing, even though the resident experienced further breakdown after this date. Physician Orders: -11/5/10 Resident requesting [MEDICATION NAME] Cream to her groin area and buttocks. May we have order for this? -11/10/10 May we have an order for [REDACTED]. -11/18/10 wound team to treat vascular wound to right lateral foot, 2nd area on right 5th metatarsal reabsorbing blister leave open to air and off load pressure to right foot. -12/9/10 new open area noted right buttock- stage two 1cm x 1.5 cm, also noted with very small open area in crease of buttocks at coccyx. -12/17/10 wound on right lateral foot is stalled and need to change dressing. Can we use Puracol Plus cover with bordered gauze, change two times a week and as needed. The facility instructions hand written on a sheet of paper, but not documented on the care plan read: -Bed: -Float heels on small blue roll. Remove any foot wear. -Wheelchair: - Wear protective footwear, right foot use podus or full contact boot, left foot shoe. d. Interviews On the evening of 1/11/11, the Director of Nurses (DON), Restorative Nurse Manager (RNM), Registered Dietician (RD), and the Physical Therapist (PT) were interviewed related to care and services provided to resident #7's wounds. -The PT expressed that the resident had been in other nursing facilities prior to her admission at this facility. She had the podus boot on her admission and after physical therapy evaluation, was found to have a contracture of the right ankle that turned inward and could cause pressure to her foot wearing the podus boot. The PT recommendation was to work on stretching the right ankle contracture before wearing the podus boot. The PT said after working with the therapy department, the right ankle did improve. -The DON expressed the staff was floating resident 7's heels while in bed, she was seen by the RD, she had a pressure reducing mattress, and the resident was encouraged to keep her heels floated and to reposition herself to prevent pressure. -The RNM expressed that the resident was on the pressure reducing mattress (the same mattress that all residents have) on admission. The RNM expressed the facility ordered resident #7 an air mattress on 12/9/10. The RNM expressed the company sent the wrong size mattress and the mattresses had to be reordered. The right size special air mattress was delivered on 12/13/10 and placed onto the bed. -The RD expressed that she gets a copy of the skin/wound sheets and that was one way she is kept informed of new or ongoing skin issues. The RD expressed that she did not or would not have ordered a pre-[MEDICATION NAME] for resident #7 just because she already knew that the resident was eating well and often asked for seconds. The RD expressed resident #7 was eating foods with protein, and was not placed on a supplement. 3. Resident #52 (closed record), an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses, per the facility face sheet, of urinary tract infection [MEDICAL CONDITION], contusion of hip, abnormality of gait, abnormal posture, adult failure to thrive, [MEDICAL CONDITION], and personal history of fall. She was admitted for rehabilitation related to adult failure to thrive and treatment of [REDACTED]. Resident #52 was discharged home from the facility on 9/9/10. Based on the recapitulation of stay, the resident had completed therapy and was able to ambulate independently with a walker. a. Record Review Minimum Data Set (MDS): The admission MDS assessment, dated 8/27/10, was coded in section M, Skin Condition, for abrasions and bruises. Section M1 did not identify any pressure ulcers. Skin treatments were noted as pressure-relieving devices for chair and bed, turning/repositioning program, and other preventative or protective skin care (other than to feet). The Resident Assessment Protocol (RAP): The RAP problem area "Pressure Ulcers" was triggered and stated, "Triggered due to decreased bed mobility, admitted with bilateral heels boggy. She has a small .5 x .5cm area opened on left heel. Now wears podus boot to L foot and heel protector boot to R foot at this time. Has pressure-reducing mattress to bed and cushion to WC (wheelchair). Asst to turn