Every finding on record at Regent Park Care Center

Based on record review and interviews, the facility failed to ensure four (#4, #8, #9 and #10) of six residents out of 10 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being.Specifically, the facility failed to ensure Resident #4, Resident #8, Resident #9 and Resident #10's weights were documented accurately, which resulted in the residents experiencing severe weight loss.Resident #4 was admitted to the facility on [DATE]. The resident was identified as having a nutritional problem related to a decreased ability to feed herself due to dementia and visual and cognitive deficits. Interventions included monitoring weights as ordered.Resident #8 was admitted to the facility on [DATE], hospitalized on [DATE] and readmitted to the facility on [DATE]. The resident was identified as having a nutritional problem or potential nutritional problem related to brain disorder, dementia, diplopia (double vision), GERD (gastro esophageal reflux disease - a stomach condition) and congestive heart failure. Interventions included monitoring weights as ordered.Resident #9 was admitted to the facility on [DATE]. The resident was identified to be at nutritional risk due to self-feeding difficulty related to physiological and psychological issues, communication difficulty, depression, altered mental status, history cerebral infarction (stroke), poor vision, need for set-up assistance, ability to use only one hand for self-feeding and need for adaptive equipment with meals. Interventions included monitoring weights as ordered.Resident #10 was admitted to the facility on [DATE]. The resident was identified as having a nutritional problem related to dementia, kidney disease, Alzheimer's disease and high blood pressure. Interventions included monitoring weights as ordered.Resident #4, Resident #8, Resident #9 and Resident #10 were all weighed weekly on the same day of the week, which was the process for all residents in the facility. On 1/26/26, the facility documented a severe weight loss for all four residents over a one-week period of time. The residents' severe weight loss was as follows:On 1/19/26 Resident #4 weighed 100.4 pounds (lbs). On 1/26/26 the resident weighed 87.8 lbs, which indicated the resident had lost 12.6 lbs, or 12.6 percent (%), in one week, which was considered severe.On 1/19/26 Resident #8 weighed 115.2 lbs. On 1/26/26 the resident weighed 95.2 lbs, which indicated the resident had lost 20 lbs, or 17.4%, in one week, which was considered severe. On 1/19/26 Resident #9 weighed 103.8 lbs On 1/26/26 the resident weighed 89.2 lbs, which indicated the resident had lost 14.6 lbs, or 14.1%, in one week, which was considered severe.On 1/19/26 Resident #10 weighed 128.2 lbs. On 1/26/26 the resident weighed 111.8 lbs, which indicated the resident had lost 16.4 lbs, or 12.8%, in one week, which was considered severe.The weights obtained on 1/26/26 for the four residents were measured again and found to be accurate. The facility investigated and concluded there was an issue with the accuracy of the previously documented weights for Resident #4, Resident #8, Resident #9 and Resident #10.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 3/3/26 to 3/4/26, resulting in the deficiency being cited as past noncompliance with a correction date of 2/19/26.I. Situation of harmResident #4, Resident #8, Resident #9 and Resident #10 were all weighed weekly on the same day of the week, which was the process for all residents in the facility. On 1/26/26, the facility documented a severe weight loss for all four residents over a one-week period of time. The residents'severe weight loss was as follows:On 1/19/26 Resident #4 weighed 100.4 pounds (lbs). On 1/26/26 the resident weighed 87.8 lbs, which indicated the resident had lost 12.6 lbs, or 12.6%, in one week, which was considered severe.On 1/19/26 Resident #8 weighed 115.2 lbs. On 1/26/26 the resident weighed 95.2 lbs, which indicated the resident had lost 20 lbs, or 17.4%, in one week, which was considered severe.On 1/19/26 Resident #9 weighed 103.8 lbs. On 1/26/26 the resident weighed 89.2 lbs, which indicated the resident had lost 14.6 lbs, or 14.1%, in one week, which was considered severe.On 1/19/26 Resident #10 weighed 128.2 lbs. On 1/26/26 the resident weighed 111.8 lbs, which indicated the resident had lost 16.4 lbs, or 12.8%, in one week, which was considered severe.The weights obtained on 1/26/26 for the four residents were measured again and found to be accurate. The facility investigated and concluded there was an issue with the accuracy of the previously documented weights for Resident #4, Resident #8, Resident #9 and Resident #10.II. Facility plan of correctionThe corrective action plan the facility implemented in response to the discovery of Resident #4, Resident #8, Resident #9 and Resident #10's severe weight loss on 1/26/26 was provided by the registered nurse (RN) quality mentor on 3/4/26 at 5:44 p.m. The corrective action plan documented the following:A. Identification of concern was on 1/29/26 for residents with significant weight changes.B. Corrective action for affected residents included the following:-Reviewed weights for identified residents, reweights completed by the assistant director of nursing (ADON) on 1/30/26.-Notified provider and registered dietitian (RD) of the identified residents on 1/29/26.-Chief operating officer (CEO) notified the corporate team of the concerning weights on 1/29/26.-Checked the last calibration of the weight scale and discussed facility order weights to complete calibration or a company coming to the facility on 1/30/26.C. Identification of other residents having the potential to be affected:-All residents had the potential for deficient practice.D. Address Measures or Systemic Changes to Ensure the Deficient Practice will not Recur:-Education provided to the IDT (interdisciplinary team) on weight management process completed by the registered nurse (RN) quality mentor on 1/29/26 and included the following:Each resident would be weighed upon admission and weekly or per physician orders. The nursing management team would review triggered weight changes daily (Monday through Friday) in the clinical morning meeting. Any concerning weights would be addressed with the RD. Weekly IDT meetings would complete a weight meeting and review any residents with weight concerns. Residents reviewed would be written on the weight log and progress note entered into the electronic medical record (EMR). The RD would review abnormal weights and review high risk residents monthly and all residents quarterly. The team would implement interventions as needed and the resident's care plan will reflect resident weight concerns and interventions. E. Plan to Monitor for Sustained Compliance-The DON or designee planned to audit abnormal weights weekly for 12 weeks, and the audit was to be written on the weekly weight log. Any abnormal weights would be addressed with the RD. -The DON or designee planned to report findings from the audits to the QAPI (quality assurance and performance improvement) committee monthly for 90 days. The QAPI committee would identify any trends and take corrective action as needed. -The first at-risk weight meeting occurred 2/19/26 with IDT and the RD. The RN quality mentor attended the meeting and provided the additional education to the staff.-Additional supplements were ordered for the facility 2/19/26.-Entering supplement orders in EMR education was provided to the nursing team by the RN quality mentor on 2/19/26. F. The facility documented the date of compliance was 2/19/26.III. Facility policy and procedureThe Weight Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 3/4/26 at 3:06 p.m. It read in pertinent part, Residents are monitored for weight changes on a regular basis. Results are reviewed and analyzed by the facility for interventions as appropriate. Residents identified with weight change will be assessed by the IDT, and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability. Weigh all residents upon admission, then weekly or as indicated by physician orders. Document results in the medical record. Residents with weight variance (loss or gain) are reweighed. Significant/severe weight variance is defined as 5% in one month, 7.5% in three months, or 10% in six months. The director of nursing (DON) or designee will analyze results for trends and patterns in residents identified with weight changes and report findings to the QAPI (quality assurance performance improvement) committee for review and recommendations.IV. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, macular degeneration (eye disease causing vision loss), dementia and urinary tract infection.The 2/23/26 minimum data set (MDS) assessment identified Resident #4 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The MDS assessment revealed the resident was dependent on staff for eating, hygiene, dressing and showering and she required substantial assistance with transferring. The MDS nutrition assessment revealed Resident #4 was 67 inches tall and weighed 88 lbs, was on a mechanically altered diet and the resident had a weight loss of 5% or more in the past month or 10% or more in the past six months.B. Record reviewThe nutrition care plan, initiated 5/28/21, revealed Resident #4 had a nutrition problem related to decreased ability to feed self due to dementia and visual and cognitive deficits. The interventions included one-to-one assistance at meals (initiated 3/13/21), dysphagia (difficulty swallowing) diet (initiated 8/9/23), monitoring, documenting and reporting any signs or symptoms of dysphagia, pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appearing concerned during meals (initiated 3/13/21), resident offered ice cream with lunch and dinner (initiated 8/9/23), monitoring weights as ordered (initiated 3/13/21), providing and serving supplements as ordered (initiated 11/6/24), fortified foods (revised 2/20/26), RD evaluation and making diet change recommendations as needed, obtaining and monitoring lab and diagnostic work as ordered (initiated 3/13/21). Resident #4's weights were documented in the resident's EMR as follows:-On 9/2/25, the resident weighed 102.9 lbs;-On 10/6/25, the resident weighed 102.8 lbs;-On 11/3/25, the resident weighed 101.8 lbs;-On 12/1/25, the resident weighed 102.1 lbs;-On 12/30/25, the resident weighed 101.0 lbs;-On 1/5/26, the resident weighed 100.8 lbs;-On 1/12/26, the resident weighed 100.8 lbs;-On 1/19/26, the resident weighed 100.4 lbs; and,-On 1/26/26, the resident weighed 87.8 lbs.-The resident lost 14 lbs, or 13.8% from 11/3/25 to 1/26/26, a period of three months, which was considered severe.-The resident lost 13.2 lbs, or 13.1% from 12/30/25 to 1/26/26, a period of one month, which was considered severe.-The resident lost 12.6 lbs, or 12.6% from 1/19/26 to 1/26/26, a period of one week, which was considered severe.A review of Resident #4's February 2026 CPO revealed the following physician's order:Supplemental shake with every meal three times per day, ordered on 2/19/26.A progress update was provided via email from the RD on 3/4/26 at 6:13 p.m. The RD note documented that prior to the recorded weight loss noted on 1/26/26, Resident #4 was on four ounce (oz) house shakes three times per day with great acceptance and fortified foods with meals. The note documented that through discussion with IDT after the resident's weight loss was identified, Med Pass 2.0 (additional supplement drink) was ordered twice daily, eight oz to provide more calories and protein for the resident. The RD note documented Resident #4 was receiving 420 kcal (calories) and 22 grams (gm) protein more than before. The fortified foods with meals were also continued. The RD documented a full nutritional evaluation was completed on 2/13/26 and the IDT reviewed the resident weekly.V. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE], hospitalized on [DATE] and readmitted to the facility on [DATE]. According to the March 2026 CPO, diagnoses included congestive heart failure, dementia, cerebral (brain) cysts, traumatic brain compression and epilepsy.The 2/25/26 MDS assessment identified Resident #8 had a severe cognitive impairment with a BIMS score of four out of 15. The MDS assessment revealed the resident required moderate assistance with eating and upper body dressing, substantial assistance with transfers and was dependent on staff for hygiene, showering and lower body dressing. The MDS nutrition assessment revealed Resident #8 was 64 inches tall and weighed 95 lbs.-The MDS assessment did not document a significant weight loss for Resident #8.B. Record reviewThe nutrition care plan, initiated 3/1/26, revealed Resident #8 had a nutritional problem or potential nutritional problem related to brain disorder, dementia, diplopia, GERD and congestive heart failure. Interventions included monitoring weights as ordered, monitoring signs and symptoms of dysphagia, monitoring intake and record every meal, monitoring, recording and reporting to physician signs and symptoms of malnutrition, including emaciation, muscle wasting, significant weight loss and RD to evaluate and making diet change recommendations as needed.Resident #8's weights were documented in the resident's EMR as follows:-On 9/2/25, the resident weighed 119.4 lbs;-On 10/6/25, the resident weighed 117.5 lbs;-On 11/3/25, the resident weighed 117.0 lbs;-On 12/1/25, the resident weighed 116.2 lbs;-On 12/30/25, the resident weighed 115.6 lbs;-On 1/5/26, the resident weighed 115.4 lbs;-On 1/12/26, the resident weighed 115.6 lbs;-On 1/19/26, the resident weighed 115.2 lbs; and,-On 1/26/26, the resident weighed 95.2 lbs.-The resident lost 21.8 lbs, or 18.6% from 11/3/25 to 1/26/26, a period of three months, which was considered severe.-The resident lost 20.4 lbs, or 17.6% from 12/30/25 to 1/26/26, a period of one month, which was considered severe.-The resident lost 20 lbs, 17.4% from 1/19/26 to 1/26/26, a period of one week, which was considered severe.A progress update was provided via email from the RD on 3/4/26 at 6:13 p.m. The RD email documented that Resident #8 was transferred to the hospital on 1/28/26 for brain surgery and returned to the facility on 2/19/26. The note documented the IDT discussed Resident #8's weight and return to the facility at the following meeting on 2/26/26. The note documented that Resident #8's appetite had improved and she was consuming most of her meals since her return to the facility. The RD note documented the IDT agreed to start snacks twice daily for added calories and protein due to her weight being in the underweight range and her weight loss. It documented fortified foods and nutritional shakes were not appropriate for the resident at the time due to lactose intolerance. The RD documented a full nutritional evaluation was completed 2/26/26.VI. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included dysphagia, hemiplegia (paralysis on one side of the body), chronic kidney disease and low back pain.The 1/29/26 MDS assessment identified Resident #9 had severe cognitive impairment with a BIMS score of five out of 15. The MDS assessment revealed the resident was dependent on staff for eating, hygiene and dressing and she required substantial assistance with showering and transferring. The MDS nutrition assessment revealed Resident #9 was 64 inches tall and weighed 89 lbs, was on a mechanically altered diet. -The MDS assessment did not document the resident had a significant weight loss in the past month.B. Record reviewThe nutrition care plan, initiated 6/10/21, revealed Resident #9 was at nutritional risk due to self-feeding difficulty related to physiological and psychological issues, communication difficulty, depression, altered mental status, history cerebral infarction (stroke), poor vision, need for set-up assistance, ability to use only one hand for self-feeding and need for adaptive equipment with meals. Interventions included adaptive equipment as ordered (revised 5/16/23), cuing and assistance with meals (revised 5/16/23), encouraging fluid intake between meals, offering snacks (revised 5/16/23), inviting the resident to activities that promote additional intake (initiated 6/10/21), monitoring and documenting signs and symptoms of dysphagia (initiated 6/10/21), monitoring, recording and reporting to physician signs and symptoms of malnutrition including emaciation, muscle wasting, significant weight loss (initiated 10/9/24), mechanical soft regular diet (revised 12/12/25), RD evaluation with diet change recommendations as needed (initiated 6/10/21). The care plan included potential nutritional problems specific to CVA (stroke), revised on 10/28/24, with additional interventions of explaining and reinforcing the importance of the diet ordered, monitoring weights as ordered, obtaining food preference determination and offering food alternatives of equal nutritional value.Resident #9's weights were documented in the resident's EMR as follows:-On 9/2/25, the resident weighed 107.1 lbs;-On 10/6/25, the resident weighed 106.4 lbs;-On 11/3/25, the resident weighed 107.1 lbs;-On 12/1/25, the resident weighed 105.8 lbs;-On 12/30/25, the resident weighed 104.2 lbs;-On 1/5/26, the resident weighed 104.0 lbs;-On 1/12/26, the resident weighed 103.8 lbs;-On 1/19/26, the resident weighed 103.8 lbs; and,-On 1/26/26, the resident weighed 89.2 lbs.-The resident lost 17.9 lbs, or 16.7% from 11/3/25 to 1/26/26, a period of three months, which was considered severe.-The resident lost 15 lbs, or 14.4% from 12/30/25 to 1/26/26, a period of one month, which was considered severe.-The resident lost 14.6 lbs, or 14.1% from 1/19/26 to 1/26/26, a period of one week, which was considered severe.A weight change progress note documented by the RD, dated 2/14/26, revealed Resident #9 had a significant weight change. It documented the resident was in the severe underweight range for her age. The note documented there were inaccurate weights prior to 1/26/26 and the facility and physician were aware and an action plan was in place. A review of Resident #9's February 2026 CPO revealed the following physician order:Give nutritional shake with each meal, ordered on 2/19/26.A progress note was provided via email from the RD on 3/4/26 at 6:13 p.m. The RD note documented prior to the resident's recorded weight loss (on 1/26/26), Resident #9 was receiving fortified cereal with breakfast and house shakes (supplement drink) four oz three times a day with good acceptance. It documented after weight loss was identified, fortified foods were increased to be with all meals. The RD note documented the IDT began discussion about possible introduction of the medication Remeron (antidepressant used for appetite stimulation), to increase the resident's appetite, however, it had not started at this time. The RD note documented Resident #9 was evaluated by the RD on 2/14/26 and her nutrition was discussed at the weekly IDT meetings.VII. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included dysphagia, cerebral infarction, hemiplegia, dementia and chronic kidney disease.The 12/2/25 MDS assessment identified Resident #10 had severe cognitive impairment with a BIMS score of three out of 15. The MDS assessment revealed the resident required supervision for eating, moderate assistance with transferring, substantial assistance for dressing and was dependent on staff for hygiene/bathing. The MDS nutrition assessment revealed Resident #10 was 65 inches tall and weighed 129 lbs and was on a mechanically altered diet.-The MDS assessment was completed prior to Resident #10's documented significant weight loss on 1/26/26 and did not indicate the resident had a significant weight loss.B. Record reviewThe nutrition care plan, initiated 5/23/25, revealed Resident #10 had nutritional problems related to dementia, kidney disease, Alzheimer's disease and high blood pressure. It documented Resident #10 had a significant weight loss on 1/26/26. Interventions included monitoring weights as ordered (initiated 5/23/25), monitoring, documenting and reporting as needed signs and symptoms of dysphagia (initiated 5/23/25), providing and serving supplements as ordered and monitoring acceptance (revised 7/23/25), monitoring intake and recording every meal, regular mechanical soft, nectar thick diet, fortified foods (revised 2/20/26), monitoring, recording and reporting to physician signs and symptoms of malnutrition, muscle wasting, significant weight loss (initiated 5/23/25), and RD evaluation and making diet change recommendations as needed (initiated 5/23/25).Resident #10's weights were documented in the EMR as follows:-On 9/2/25, the resident weighed 132.6 lbs;-On 10/6/25, the resident weighed 131.2 lbs;-On 11/3/25, the resident weighed 130.1 lbs;-On 12/1/25, the resident weighed 129.4 lbs;-On 12/30/25, the resident weighed 128.8 lbs;-On 1/5/26, the resident weighed 128.6 lbs;-On 1/12/26, the resident weighed 128.6 lbs;-On 1/19/26, the resident weighed 128.2 lbs; and,-On 1/26/26, the resident weighed 111.8 lbs.-The resident lost 18.3 lbs, or 14.1% from 11/3/25 to 1/26/26, a period of three months, which was considered severe.-The resident lost 17 lbs., or 13.2% from 12/30/25 to 1/26/26, a period of one month, which was considered severe.-The resident lost 16.4 lbs, or 12.8% from 1/19/26 to 1/26/26, a period of one week, which was considered severe.A weight change progress note documented by the RD, dated 2/14/26 at 10:18 a.m., revealed Resident #10 had significant weight change. It documented the resident was in the underweight range for her age. The note documented there were inaccurate weights prior to 1/26/26 and the facility and physician were aware and an action plan was in place. A review of Resident #10's February 2026 CPO revealed the following physician order:House shake once per day, ordered on 2/19/26.A progress note was provided via email from the R) on 3/4/26 at 6:13 p.m. The RD note documented prior to Resident #10's weight loss, the resident was consuming 50% to100% of meals with no supplements ordered. It documented after the weight loss was identified, the RD recommended fortified foods with meals and started house shake four oz every day for added calories and protein. It documented the IDT agreed to increase shakes to twice daily with breakfast and lunch for more calories and protein. The note documented Resident #10 continued to consume 50% to100% of meals. It documented the RD evaluated Resident #10 on 2/14/26 and Resident #10's nutrition status continued to be discussed weekly at the IDT meetings.VIII. Additional staff interviewsLPN #1 was interviewed on 3/4/26 at 9:00 a.m. LPN #1 said Resident #4 was taking a supplement with every meal. LPN #1 said the supplement was recently changed to include more protein content. LPN #1 said residents had a physician's order when supplements were needed.Certified nurse aide (CNA) #2 was interviewed on 3/4/26 at 9:30 a.m. CNA #2 said Resident #4's meal intake was good, especially at breakfast. CNA #2 said Resident #4 was dependent on staff to provide meal assistance.The DON and the RN quality mentor were interviewed together on 3/4/26 at 9:35 a.m. The DON said residents' weights were being reviewed weekly at IDT meetings since the beginning of February 2026. The RN quality mentor said the facility was unsure of the accuracy of Resident #4, Resident #8, Resident #9 and Resident #10's weights prior to 1/26/26. The RN quality mentor said there were many weights that were significantly different from what they had been trending prior to 1/26/26. The RN quality mentor said the facility came to the conclusion that the weights were not being recorded accurately prior to 1/26/26. The RN quality mentor said an action plan was created to address the discrepancies (see corrective action above). The DON said there was a change in physician coverage which began at the beginning of February 2026, and the new primary care physician (PCP) was notified of the residents' weight discrepancies when this change occurred. The DON said the CNAs collected the residents' weights and gave them to the previous DON. Both the DON and the RN quality mentor said they thought the scale was accurate, but were confirming through calibration. The DON said she could only speculate, but she thought someone was intentionally putting in weights that were inaccurate prior to 1/26/26. The DON said there were no obvious signs previously of residents with significant weight loss. The DON said the CNAs did not look in the residents' EMRs to see what the residents' previous weights had been. The assistant director of nursing (ADON) was interviewed on 3/4/26 at 10:19 a.m. The ADON said all residents' weights were done by the CNAs on Mondays. She said the CNAs would provide a sheet with all of the weights to the previous DON. The ADON said the previous DON would sit down together with the ADON to talk about residents weights and the previous DON would recite the weight amounts of residents to the ADON, who then entered the weights into the residents' EMRs. The ADON said after the previous DON left the facility, the ADON began entering the weights directly from the CNAs report sheet and found there were significant discrepancies in several residents' weights on 1/26/26, and all of the weight discrepancies were much lower than the residents' previous weights. The ADON said she asked the staff to reweigh the residents and their weights did not change. The ADON said she notified the physician of the weight discrepancies. The ADON said there had been no significant clinical changes with the residents' whose weights were significantly lower than the previous weights. The ADON said there were no issues with the scale and other residents' weights were trending appropriately. The ADON said she came to the conclusion that it was possible she was provided with the wrong weights to enter into the Resident #4, Resident #8, Resident #9 and Resident #10's EMRs by the previous DON. The ADON said she had asked the previous DON if she should enter the weights and the previous DON said it was faster for her to verbally report the weights to the ADON as she entered them. The ADON said after the residents' weight discrepancies were identified, the facility met with the corporate representative and their dietitian to develop any needed interventions for the residents who were found to have weight discrepancies between 1/19/26 and 1/26/26.CNA #1 was interviewed on 3/4/26 at 12:30 p.m. CNA #1 said residents' weights were always done on all residents weekly on Mondays, and they had been done this way for the past eight years. CNA #1 said she did not look at residents' EMRs to see what their previous weights had been when she collected new weights. CNA #1 said the CNAs had records of how to weigh each resident, such as with or without the foot pedals on a wheelchair. CNA #1 said the list of weights was provided to the ADON and the DON every week to be entered into the residents' EMRs. The RD was interviewed on 3/4/26 at 1:36 p.m. The RD said she was informed when the new NHA arrived at the facility that there were residents who had significant weight discrepancies. She said she was told that inaccurate weights had been reported. The RD said the facility informed her they were obtaining accurate weights and an action plan was in place to address the issue. The RD said when she was at the facility on 2/13/26, she reviewed and updated each of the residents' plans who had documented discrepancies. The RD said the PCP was aware of all of the discrepancies and the PCP had seen and evaluated each resident's condition after the discrepancies were found. The RD said if a resident had inaccurate weights documented and the resident weighed significantly less than what was documented, the facility might not have proper nutritional interventions in place, which could result in further weight loss and malnutrition. The PCP was interviewed on 3/4/26 at 1:59 p.m. The PCP said he was notified of residents' weight discrepancies. The PCP said there had been a change in leadership. He said after this change, staff weighed residents and some residents' weights were significantly different than previous weights. The PCP said it could have been purposeful mis-documentation from the prior administration. The PCP said he reviewed all of the residents with weight discrepancies. The PCP said he doubted there was a significant weight loss during that time for any of the residents. The PCP said the facility was obtaining reliable weights at the time of the interview and would let him know of significant changes. The NHA, the RN quality mentor and the regional operations manager were interviewed together on 3/4/26 at 4:45 p.m. The NHA said on the first day working at the facility, the NHA asked about weight loss and the previous DON said there was no significant weight loss at the facility. The NHA said the facility was not having at-risk meetings for nutrition and weight management when the NHA arrived at the facility. The NHA said after the previous DON was terminated on 1/26/26, the ADON notified the NHA of weight discrepancies on 1/26/26. The NHA said the PCP was notified on 1/26/26 of these weight discrepancies. The RN quality mentor said the PCP saw and evaluated Resident #4 on 2/10/26, Resident #8 on 1/26/26, Resident #9 on 2/4/26 and Resident #10 on 2/10/26. The NHA said a few of the residents were started on Remeron medication for appetite stimulation. The NHA said after the PCP had evaluated all of the residents, the RD began reviewing the residents weekly and the first at-risk nutrition meeting was on 2/19/26. The NHA said the facility had had these meetings weekly since they began on 2/19/26. The RN quality mentor said it was unknown when Resident #4, Resident #8, Resident #9 and Resident #10 had lost weight. The NHA said the plan moving forward was to audit residents' weights, address weight concerns and bring any issues to the at-risk nutritional meetings. The NHA said the current DON was going to print the previous week's resident weights for the CNAs reference when they obtained the residents' next weights. The NHA said the audit process would continue for at least 12 weeks.

Based on record review and interviews, the facility failed to protect one (#2) of three residents reviewed for misappropriation of property out of 10 sample residents.Specifically, the facility failed to ensure Resident #2's recliner lift chair, purchased with funds from the resident' personal funds account, was delivered to and was kept in Resident #2's room.Findings include:I. Facility policy and procedureThe Abuse policy, revised 9/4/25, was provided by the nursing home administrator (NHA) on 3/4/26 at 3:06 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Misappropriation of resident property is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Misappropriation includes, but is not limited to theft, fraud and financial exploitation.II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included Parkinson's disease (a neurologic disease of the brain), cerebral infarction (stroke), hemiplegia (one-sided paralysis) and heart disease.The 2/21/26 minimum data set (MDS) assessment revealed Resident #4 had severely impaired cognitive skills for daily decision making. The MDS assessment revealed the resident required set-up assistance with eating, substantial assistance with transferring, and was dependent on staff for hygiene, dressing and showering.B. Observations and staff interviewsOn 3/3/26 at 4:10 p.m. a brown recliner chair which had scuff marks on it and an indentation on the seat, was observed in Resident #2's room within a few feet of his bed. Certified nurse aide (CNA) #4 said the resident had had the same brown recliner chair since she began working at the facility in May 2025. On 3/3/26 at 4:30 p.m. a blue recliner lift chair in room #E3 that had no scuff marks or an indentation in the seat was observed with the director of nursing (DON). The DON said she thought the recliner was likely the recliner that was ordered for Resident #2 in November 2025.On 3/4/26 at 9:00 a.m. a blue recliner lift chair was observed in Resident #2's room next to his bed. The previous brown recliner chair was no longer present at the resident's bedside.C. Record reviewA financial statement, withdrawal receipt and furniture invoice for the use of Resident #2's personal funds were provided by the business office manager on 3/3/26 at 3:30 p.m. The financial statement contained a withdrawal entry from Resident #2's personal funds account in the amount of $1,200.00 and was identified as personal needs items.The withdrawal receipt, which contained two authorized staff signatures, identified $1,200.00 was removed from Resident #2's personal funds account on 11/19/25. The invoice from the furniture store, dated 11/19/25, identified Resident #2 as the purchaser of a LazyBoy lift chair. The invoice total was $1,200.00.III. Staff interviewsCNA #1 was interviewed on 3/3/26 at 1:30 p.m. CNA #1 said Resident #2 was not able to respond to questions.The business office manager was interviewed on 3/3/26 at 4:20 p.m. The business office manager said she ordered a recliner lift chair for Resident #2 in November 2025. The business office manager said she did not know if the resident had the ability to make daily decisions. She said she was told by the previous NHA that Resident #2's personal fund resources were too high and the resident needed to spend down the balance in the account. The business office manager said the NHA told her to order a recliner chair for the resident. The business office manager said she ordered the chair. The business office manager said she did not know what the chair looked like and she never saw the chair after it arrived at the facility from the furniture store.The DON and the NHA were interviewed together on 3/3/26 at 4:35 p.m. The DON said there were no other new recliners besides the blue recliner chair (see observations above) in the facility and she was pretty certain the recliner in room #E3 was Resident #2's recliner. The NHA said when a resident needed to spend down funds in their personal funds account, the facility should ask permission from the resident or the resident's representative to discover what the resident's needs were. The NHA said the social services director (SSD) should establish the decision making ability of the resident, and if a resident was incapable of making decisions, the SSD should take the lead to help establish a guardian for the resident. The NHA said it would be difficult to know what the resident wanted to order if the resident did not have decision making capacity and also had no representative.The NHA was interviewed again on 3/3/26 at 5:00 p.m. The NHA said she was not aware that Resident #2's recliner lift chair was in a different resident's room. The NHA said this represented misappropriation of property. The NHA said she was going to open an investigation for the misappropriation of Resident #2's property. The NHA said the facility was going to do an audit for all residents' property and ensure inventory lists of residents' belongings were accurate. The NHA said she was not certain if Resident #2 had wanted the new recliner chair. The NHA said the maintenance director (MTD) told the NHA that the recliner chair found in room #E3 matched the invoice for Resident #2's recliner lift chair. The NHA said Resident #2's recliner lift chair was found in another resident's room.The SSD was interviewed on 3/4/26 at 8:15 a.m.The SSD said she had no previous involvement with purchases when residents needed to use their personal funds accounts. The SSD said she knew the blue recliner lift chair had arrived and that it was designated for Resident #2. The SSD said she did not know the funds to purchase the chair came from Resident #2's personal funds account. The SSD said she did not know where the recliner chair went after it arrived from the store. The SSD said she was aware that Resident #2 had a severe cognitive impairment and she wanted to establish a guardian for him. The SSD said the previous NHA had told her not to worry about it. The SSD said the brown recliner chair in Resident #2's room was old. The SSD said Resident #2's new blue recliner chair had been in room #E3 for several months, as she had sat in the chair to visit with the resident in room #E3.The assistant director of nursing (ADON) was interviewed on 3/4/26 at 10:10 a.m. The ADON said she was present when the blue recliner lift chair arrived and was told it was for Resident #2. The ADON said the previous NHA said she was going to take care of it and tell the furniture store delivery representatives where to place the chair. The ADON said she later saw a new blue recliner lift chair in another resident's room. The ADON said she knew now that the chair should have stayed in Resident #2's room.The regional operations manager was interviewed on 3/4/26 at 11:20 a.m. The regional operations manager said the facility was refunding Resident #2's personal funds account for the recliner lift chair purchase, as it appeared upon review that Resident #2 did not usually use the recliner chair in his room and the facility did not know if the resident wanted the new recliner chair when it was ordered in November 2025.The social services quality mentor was interviewed on 3/4/26 at 11:31 a.m. The social services quality mentor said Resident #2 did not have conservatorship for financial and guardianship for medical needs. She said the facility was contacting the county probate court to establish this representation. The social services quality mentor said this should have been done a long time ago. She said the facility was auditing other residents for legal authority needs.The regional operations manager and the business office manager were interviewed together on 3/4/26 at 12:17 p.m. The regional operations manager said the facility's previous administration did not have coordination to manage spend downs for residents' personal funds. He said the previous NHA and the previous DON together managed this. The regional operations manager said the facility now planned to meet with residents and their representatives to determine needs and use guardianship if residents were not capable of making decisions. He said the SSD would assist with coordinating the purchase orders placed and tracking to ensure residents received their purchased items and the items were delivered to the correct residents. He said there was no documentation for the delivery of Resident #2's recliner lift chair to the facility.The NHA and the registered nurse (RN) quality mentor were interviewed together on 3/4/26 at 4:45 p.m. The NHA said the social services quality mentor was auditing to ensure there were not other residents who were missing personal property. The RN quality mentor said she provided additional education to the interdisciplinary team (IDT) about residents' personal funds spend downs and the business office manager was auditing to confirm all resident's personal funds had been used appropriately.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards in one of one medication storage rooms. Specifically, the facility failed to: -Maintain the emergency medication kit with medications that had not expired; and, -Ensure the emergency medication kit did not have two different expiration dates on individual packages which were prepared by the pharmacy. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy, revised February 2023, was provided by the director of nursing (DON) on 11/6/24 at 3:35 p.m. The policy read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The medication label includes at a minimum the medication name, prescribed dose, strength, expiration date, when applicable, resident's name, route of administration and appropriate instructions and precautions. II. Observations and interview On 11/5/24 at 9:06 a.m. the medication storage room was observed with registered nurse (RN) #1. The emergency medication kit had a yellow label on the outside of the kit which revealed there were medications within the kit that expired in October 2024. The kit contained approximately 100 individually packaged medications that had been prepared by the pharmacy. The following items were found in the emergency kit: -Two individual pill packages of ciprofloxacin (an antibiotic medication) 250 milligrams (mg) with an expiration date on the label of 3/31/23. A second expiration date of September 2024 was also printed on the label. -Three packages of levofloxacin an antibiotic medication) 250 mg all revealed an expiration date on the labels of October 2024. There were no additional expiration dates on the packages. RN #1 said the medications were expired and she did not know which expiration date was accurate for the medication labeled with two expiration dates. She said expired medications could be less effective if they were given to residents. Additional findings found in the emergency medication kit included the following: -Two packages of ciprofloxacin 500 mg with two expiration dates on the label of 10/1/24 and March 2025. -One package of levofloxacin 500 mg with two expiration dates of October 2024 and 9/6/25. -Three packages of albuterol sulfate inhalation solution (medication used to treat respiratory conditions) 0.083%, 2.5 mg with one expiration date on the label of 8/22/24 and an expiration date on the package of January 2025. -Seven packages of metoprolol (a blood pressure medication) 25 mg with two expiration dates on the label of 10/1/24 and March 2026. -One package of Cefuroxime (an antibiotic medication) 500 mg with two expiration dates on the label of 10/1/24 and March 2025. -One package of cephalexin (an antibiotic medication) 250 mg with two expiration dates on the label of 8/22/24 and December 2024. -Ten packages of clindamycin (an antibiotic medication) 150 mg with two expiration dates on the label of 4/26/24 and August 2025. RN #1 said the package labels were confusing because there were two expiration dates on the labels. She said she was not certain if the medications had expired or not because one of the expiration dates was in the past and the other expiration date was dated in the future. III. Staff interviews The pharmacist (PH) was interviewed on 11/5/24 at 9:40 a.m. The PH said the pharmacy department had a list of all medications in the facility's emergency medication kit and a member of the pharmacy team checked the kit monthly for medications that were due to expire. The PH said the pharmacy department was not onsite at the facility during the month of October 2024 to review the expiration dates in the emergency medication kit. The PH said the three levofloxacin 250 mg medication packages and the two ciprofloxacin 250 mg medication packages were expired and had been overlooked when they last checked the kit in September 2024. The PH said the pharmacy and the facility were responsible for checking expiration dates of medications within the emergency kit. The PH said the accurate expiration date was the later of the two dates on each of the packages. She said the earlier expiration date on the packages reflected an automatically generated date when the labels were created. The PH said the two expiration dates on one medication label could create confusion for the nursing staff when they checked expiration dates. She said she would relabel the medications with one expiration date to eliminate any confusion. The DON was interviewed on 11/5/24 at 10:30 am. The DON said it was confusing to have two different expiration dates on the emergency medication kit medication packages and she did not know which expiration date was correct. The DON was interviewed again on 11/7/24 at 9:57 a.m. The DON said the pharmacy had the responsibility of reviewing emergency medication kit expiration dates once per month. The DON said nursing staff should check the expiration dates on medications that were removed from the kit for use or if nursing staff added any replacement medications to the kit received from the pharmacy. IV. Facility follow up On 11/5/24 at 1:20 p.m. the DON provided an example of new emergency medication kit labels made by the PH which contained only one expiration date. The DON said all of the labels on the emergency kit medications had been corrected to one expiration date (during the survey). On 11/7/24 at 9:57 a.m., the DON said the pharmacy was going to begin removing medications from the emergency kit one month prior to the expiration date.

Based on record review and interviews, the facility failed the to report alleged violations of misappropriation of property to the proper authorities, including the police and the State Survey and Certification Agency, in accordance with state law for one (#97) of three residents reviewed for missing property out of 19 sample residents. Specifically, the facility failed to report an allegation of misappropriation of property to the State Agency, adult protective services or the local police when Resident #97 reported he was missing $750.00 from his wallet. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 11/7/24 at 8:39 a.m. The policy revealed the facility did not condone resident abuse and should take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends or any other individuals. Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Misappropriation included, but was not limited to, theft, fraud and financial exploitation. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting could be completed verbally or in writing. Immediately was defined as within two hours of an allegation involving abuse or resulting in serious bodily injury or within 24 hours of an allegation that did not involve abuse or result in serious bodily injury. Notification was also made to the following persons and agencies within the time frames defined by regulation or statute: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, adult protective services (where state law provides jurisdiction in long-term care), law enforcement officials (for all abuse allegations), the resident's attending physician and the medical director (when necessary). In addition to an investigation by the police department, the facility would conduct an internal investigation. While the investigation was ongoing, the alleged assailant would have interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation would include interviewing any staff members, residents or family members who may have knowledge of the incident. Results of all investigations would be reported to the administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency, within 5 (five) working days of the incident, and if the alleged violation was verified, appropriate corrective action would be taken. II. Resident #97 A. Resident status Resident #97, age greater than 65, was admitted on [DATE] and discharged home on 10/23/23. According to the October 2023 computerized physician orders (CPO), diagnoses included motorcycle injury in a traffic accident, traumatic subdural hemorrhage (brain injury), fracture of thoracic vertebra, multiple right side rib fractures, fracture of the neck, atrial fibrillation and quadriplegia. The 8/11/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interview Resident #97 was interviewed by phone on 11/4/24 at 11:39 a.m. Resident #97 said he had $750.00 in a wallet that was placed in a drawer in his room during his stay at the facility. He said he did not carry the wallet with him. He said someone would have had to go into the drawer to retrieve the money from his wallet. He said he did not have a lock box in his room. He said he knew he should not have kept that much money in his room at the facility, however, he said he had needed the money to pay some bills. He said a friend came to help him pay his bills after he was discharged from the facility and that was when he discovered the money was missing. Resident #97 said after he discovered the money was missing from his wallet, he called the facility to report it. C. Record review The Acknowledgement Form Admission Packet signed by Resident #97 on 8/7/23 revealed the facility could not guarantee the safety of personal property and the facility was not responsible for the loss of personal property except as required by applicable federal and state law. If a resident would like insurance protection covering the loss of property, it was the resident's responsibility to obtain such insurance. It was the right of each resident to manage his or her own financial affairs. If the resident was unable to manage their personal affairs or if a resident did not want to manage their personal affairs themselves, the facility had a resident trust fund account that the facility would manage in accordance with federal and state laws. If the resident chose to participate in this program, the monies would be kept in an interest bearing account that was separate from the facility's funds, and the resident would receive quarterly statements of the account. A care plan for discharge, initiated on 5/24/23, revealed the resident was planning to discharge to another state where he independently lived alone. The plan did not reveal the resident had mentioned any missing monies. A review of Resident #97's personal property inventory sheet, dated 8/7/23, did not reveal the resident had $750.00 dollars when he was admitted to the facility. The resident initialed the sheet. The resident's discharge summary, dated 10/23/23 at 10:27 a.m., did not reveal the resident had discussed any missing monies with staff members. The summary revealed the resident said he had no questions or concerns at the time of his discharge from the facility. The multidisciplinary care conference, dated 10/18/23 at 1:10 p.m., revealed a discussion took place regarding Resident #97's overall progress with skilled therapy services and discharge planning. There was no documentation that the resident had reported any missing money. A complaint/concerns report, dated 10/25/23 at 10:15 a.m., revealed the resident called the facility that morning (10/25/23) and said the facility stole $750.00 dollars from him. The report documented that the resident said he was discharged to his home in another state and he wanted to talk with the NHA today (10/25/23). The Misappropriation of Property Occurrence/Abuse form was provided by the NHA on 11/6/24 at 5:49 p.m. The form revealed the first known date and time of Resident #97's allegation of missing $750.00 was 10/25/23 at 10:00 a.m. The form further revealed the resident was discharged on [DATE]. The Misappropriation of Property Occurrence/Abuse form included interviews of residents and staff. None of the residents who were interviewed reported any concerns of missing money or property. None of the staff members who were interviewed reported any knowledge of Resident #97 having $750.00 in his wallet during his stay at the facility. Review of the State Survey Agency database on 11/4/24 failed to show evidence the facility had reported the alleged misappropriation of property involving Resident #97 to the State Agency as required. D. Staff interview The NHA was interviewed on 11/6/24 at 4:07 p.m. The NHA said on 10/25/23 at 10:15 a.m., Resident #97 called the facility and said someone had stolen $750.00 dollars from him. The NHA said the resident said he had the money when he arrived at the facility. The NHA said 10/25/23 was the first time she was made aware of the missing money. The NHA said Resident #97 told her that he did not know the $750.00 dollars was missing until he arrived at his home after being discharged from the facility. The NHA said the resident's belongings inventory sheet did not reveal he had $750.00 dollars when he entered the facility. The NHA said during care conferences and during the discharge meetings, Resident #97 never said he was missing any money. The NHA said neither she nor any of her staff had seen the money the resident referred to. She said she did a thorough misappropriation of property investigation and none of the interviewed staff had ever seen the resident's money and none of the interviewed residents had any missing items. The NHA said Resident #97 did not have a roommate during his stay at the facility. The NHA said upon admission, Resident #97 was offered a lock box for his room, however the resident refused. The NHA said the resident was offered the use of a trust account to put any money he had into the fund and the resident refused. The NHA said she called the previous facility that the resident resided at and was informed that they had no record of the $750.00 dollars and the resident did not have a trust account with that facility. The NHA said, to her knowledge, the money did not exist because she was unable to find anyone who had seen the money. The NHA said while Resident #97 resided in the facility, the resident never said he had missing money. The NHA said she was not able to prove that Resident #97 did or did not have the money at the facility. The NHA said the facility completed an investigation after Resident #97 called and reported the missing money, however, she said she did not report the incident to the State Agency occurrence reporting portal because it did not meet the reporting criteria.

Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#19) of two residents reviewed for use of psychotropic medication out of 21 sample residents. Specifically, the facility failed to for Resident #19: -Ensure staff identified triggers for the the resident's anxiety disorder; -Develop a resident-centered plan of care for generalized anxiety disorder; -Ensure staff monitored and document the resident for her response to antidepressant medication and its effectiveness; and, -Ensure staff monitor and document the resident for adverse reactions to dual antidepressant therapy. Findings include: I. Facility policy The Psychopharmacological policy, dated 3/10/23, was received on 6/21/23 from the nursing home administrator (NHA), which read in pertinent part: The licensed nurse or designee will document any known targeted behaviors and potential interventions on the Kardex (an abbreviated care directive). This will help to assure certified nursing assistants receive communication related to the initial plan of care. The admission record is reviewed within 72-hours of a resident's admission by the interdisciplinary team to assure admission orders and applicable policy and procedures have been initiated. This review will include the use of psychopharmacological drugs, appropriate diagnosis. -The interdisciplinary team will proceed to care planning for the use of psychopharmacological drugs, and the Care Plan for psychopharmacological medications will be implemented. -The care plan will include the resident's focus and target behaviors for the medication. Realistic and measurable goals will be utilized and approaches will include alternatives to psychopharmacological drug use. -The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate. Consideration should be given to potential underlying causes of the behavior symptoms to assure appropriate treatment. Monitoring: Licensed nurses and additional staff will monitor and document any targeted behaviors that occur. These behaviors will be documented on one or more of the following: Point of Care, Progress Notes, or on a Risk Management Incident Report. II. Resident status Resident #38, age 72, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included hypertension, dementia, anxiety and chronic obstructive pulmonary disease. The 5/17/23 minimum data set (MDS) assessment revealed the resident had cognitive impairment with a score of 12 out of 15 on the brief interview for mental status (BIMS) assessment. The resident required assistance from one staff member for bed mobility, walking in the room and corridor, locomotion on and off the unit, dressing, personal hygiene, required extensive assistance from one staff member for toileting and was independent with eating. The resident's behavior assessment documented no behavioral symptoms or behaviors. III. Resident interview and observation Resident #38 was interviewed on 6/21/23 at 9:17 a.m. The resident was sitting on the edge of her bed and was leaning forwards with her face down on the bed. She said she bent over to think and calm herself. Resident #19 said she had bad anxiety. She said that since she had been admitted to the facility she had not had anxiety relief and said that when she felt anxious she would forget to breathe. She said she felt staff did not understand that she needed extra time and explanations because her anxiety could worsen and made her uncomfortable. The resident said that her anxiety increased when it was noisy in her room, when she did not know what was going on during the day, when she felt lonely and when she had the feeling that she had shortness of breath. She said she had to self-adjust the flow rate on her oxygen concentrator when her anxiety worsened. The resident said no staff had asked her if her anxiety was better or worse, she did not know what medications she was taking for her anxiety and did not know that she was taking two antidepressant medications. The resident said she felt unhappy that medications had been changed and that a medication that had worked well for her anxiety (Alprazolam) was stopped and she did not know why and wished to take it again. III. Record review A review of the June 2023 computerized physician orders (CPO) revealed the resident was prescribed the following antidepressant psychotropic medications: -Paxil, 30 mg once a day, prescribed for generalized anxiety disorder with a start date of 5/11/23; -Doxepin 50 mg once a day, prescribed generalized anxiety disorder with a start date of 5/11/23. The physician progress note dated 5/12/23 recorded the resident had dementia with anxiety and chronic history of memory issues. -The physician note did not include information regarding the treatment plan for the status of the resident's anxiety. The resident's care plan dated 6/20/23 (during the survey) revealed the resident was prescribed antidepressant medication (Paxil) for generalized anxiety disorder. -The resident-centered care plan omitted the use of the second antidepressant, Doxepin. The resident's care plan focus area for use of antidepressant medications included: Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included: -Administer antidepressant medications as ordered by physician; -Monitor/document side effects and effectiveness every shift; -Black box warning: monitor closely for worsening and emergence of suicidal thoughts and behaviors; -Monitor/document/report prn adverse reactions to antidepressant therapy: -Change in behavior/mood/cognition; -Hallucinations/delusions; -Social isolation; -Suicidal thoughts; and, -Withdrawal. -The CPO failed to include orders to monitor the resident for side effects, effectiveness and/or adverse reactions to antidepressant therapy. The care plan failed to identify goals or interventions specific to the management of the resident's anxiety disorder to include identifying, recognizing the onset, presence of anxiety. It failed to include the history of her anxiety, and factors which precipitate or exacerbate anxiety. On 6/21/23 at 10:05 a.m., the director of nursing (DON) provided a Behavior/Interventions Monthly Flow Record paper copy of monitoring behavior for the use of Paxil. The pre-printed form, flow record directed the nurse to document resident statements of feeling anxious. -The flow record did not include resident centered goals or interventions to monitor triggers for anxiety. The flow record documented the following anxiety episodes: 6/4/23 two episodes. The resident was provided an activity and the nurse document that was effective. 6/8/23 two episodes. The resident was effectively redirected. 6/11/23 one episode. The resident was provided fluids, which was effective. 6/16/23 two episodes. The resident was provided food and fluids, which was effective. 6/18/23 one episode. The resident was provided food, which was effective. -The flow record did not correlate with the resident's statement on 6/21/23 that her anxiety had not been relieved since her admission to the facility. The DON was unable to locate care plan documentation that included monitoring for antidepressant effectiveness or that focused on the resident's need for anxiety management. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/21/23 at 9:30 a.m. The CNA said she knew the resident had anxiety and noticed sometimes it was difficult for the resident to breathe at times. The CNA said that she had assisted the resident with placing her oxygen tubing and was not aware if the resident had self-adjusted the oxygen flow rate. The CNA acknowledged she was unaware what specifically caused the resident anxiety but she noticed the resident needed her oxygen when the humidity in the building was high. Registered nurse (RN) #1 was interviewed on 6/21/23 at 9:38 a.m. She said tracking and monitoring was documented in the resident's electronic health record specifically on the medication administration record. The RN was unable to locate tracking or monitoring physician orders or documentation specific monitoring for the resident's anxiety or antidepressant therapy. The RN said the tracking information might be in the director of nurses (DON) office. The assistant director of nursing (ADON) and the DON were interviewed together on 6/21/23 at 9:55 a.m. They said the nursing staff monitored residents prescribed psychotropic medications and documented the monitoring in the resident's electronic health record specifically on the medication administration record. The ADON and DON were unable to locate antidepressant medication monitoring for the resident. The DON said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted , the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring.

Based on record review and interviews the facility failed to ensure residents had the right to formulate advance directives for four (#1, #2, #3, and #4) out of six sample residents. Specifically, the facility failed to ensure: -The medical orders for scope and treatment (MOST) forms were completed accurately and thoroughly for Residents #1, #2, #3 and #4; and, -The legal paperwork for the resident's power of attorney was in the record for Resident #4. Findings include: I. Professional reference The Colorado Advance Directives Consortium, Guidance for Health Care Professionals website, dated [DATE], retrieved on [DATE] from http://www.coloradoadvancedirectives.com/wp-content/uploads/[DATE]-MOST-Booklet-REV-2015.pdf read in pertinent part, If the individual resides in a nursing facility, the facility staff are responsible for keeping the MOST form updated. Staff should complete MOST forms for all current residents before the next scheduled quarterly care plan meeting and review the form automatically before each resident's quarterly assessment. For current residents, complete or review at quarterly conference(s). For section A of the form, cardiopulmonary resuscitation (CPR), selecting 'Yes CPR' requires choosing 'Full Treatment' in section B. The form must be dated. A revised MOST form automatically supersedes all previously completed MOST forms. The MOST form must be completed by a healthcare professional with sufficient expertise to discuss medical conditions, treatments, risks and benefits with the individual. This professional should be competent and comfortable with conducting this kind of conversation. The form must be signed by a physician (MD or DO), advanced practice nurse, or physician's assistant and the individual, assuming the individual has decisional capacity. II. Resident #1 A. Resident status Resident #1, age 96, was admitted to the facility on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The [DATE] minimum data set (MDS) assessment coded the resident as severely impaired cognitive status. A brief interview for mental status (BIMS) was not conducted as he was unable to answer the questions. B. Record review The [DATE] computerized progress note showed the resident was alert and oriented to himself only. The resident was unable to make his needs and concerns known. The resident's speech was poor and he was unable to verbalize answers to the nurses questions. The resident required one person assistance for transfers, mobility, incontinence care, and personal hygiene. Review of Resident #1's MOST form for advance directives, dated [DATE], revealed the form was not signed by the resident, rather his son signed the form. The medical record failed to show legal paperwork in the resident's record to allow someone other than the resident to sign the form. C. Interview The assistant director of nursing (ADON) was interviewed on [DATE] at 4:00 p.m. The ADON reviewed the record and confirmed there was no legal paperwork in the record indicating the son could sign the form. She said the legal paperwork needed to be in the medical record. III. Resident #2 A. Resident status Resident # 2, age 79, was admitted to the facility [DATE]. According to the February 2022 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment showed the resident scored seven out of 15 with severely impaired cognition. The resident required extensive total assistance for transfers, mobility, incontinence care, repositioning, and personal hygiene. B. Record review According to the resident's care team initial assessment and history dated [DATE], Resident #2 was only oriented to self and family. The resident had memory impairments and lacked decision making abilities. She required extensive total assistance with all her activities of daily living (ADL). The resident's MOST form dated [DATE] showed the medical durable power of attorney (MDPOA) elected for no cardiopulmonary resuscitation (CPR) with selective treatments. The section of the MOST form for the MDPOA signature was blank. The physician's progress notes dated [DATE] scanned into the miscellaneous section of the medical record indicated that the MDPOA elected to change the resident's code status to Full Code with CPR. Progress note also documents that a new MOST form was completed on [DATE], however the new MOST form was not in the resident's medical record and there was no new CPO for the change from DNR to CPR. IV. Resident #4 A. Resident status: Resident #4, aged 92, was admitted to the facility on [DATE]. According to the care plan revised [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment showed the resident was not interviewable and her cognition was severely impaired. The resident required one person assistance for transfers, mobility, incontinence care, feeding, and personal hygiene. B. Record review The resident's MDPOA read the resident's son as the MDPOA, then the next son was listed as the first successor in line if the MDPOA was not available or unable to act due to death, incapacity, or resignation. The daughter was listed as the second successor. The resident's MOST form dated [DATE] showed the daughter, who was listed as number three appointed in the MDPOA, signed the MOST form. The actual primary MDPOA did not sign the MOST form. C. Interview The assistant director of nursing (ADON) was interviewed on [DATE] at 2:13 p.m. The ADON explained that the resident's daughter signed the MOST form instead of the son because she was the only child involved in the resident's care. The ADON was unaware how the verbiage was read on the MDPOA document. She also was unaware that the facility needed to start in the order of representatives that the resident had appointed on the MDPOA for decision making and the daughter was third in the event the current MDPOA was unable to perform duties (see above). The nursing home administrator (NHA) was interviewed on [DATE] at 2:18 p.m. The NHA was unaware of how the verbiage was read in the MDPOA document regarding the order of representatives. She explained that the facility believed that any of the children listed could sign documents and make decisions. V. Additional interviews The social services director (SSD) was interviewed on [DATE] at 12:00 p.m. She said the process for residents who were unable to sign their own MOST form was followed up by the ADON. If the ADON was not available, the SSD was the backup for this process. The ADON or SSD would meet with the resident's representative and have them provide legal paperwork. If they did not have it at the time of admission, they would be advised to bring it in. The MOST form was reviewed with the representative during the admission process and ADON conducted chart audits after the admission was complete. The interdisciplinary team (IDT) reviewed the MOST forms with the family/resident during their quarterly care conference. The ADON was interviewed on [DATE] at 12:15 p.m. The process for new admissions was that the ADON went over the MOST form with the resident or their representative. She would allow them to take the form home and consider their decision, if needed, and follow up with them within three days. Once completed, she filed the MOST form in a binder at the nurses station. The ADON was interviewed a second time on [DATE] at 1:56 p.m. The ADON said that she had done a MOST form audit and tried to audit MOST forms every week for accuracy during the resident's quarterly care conference meeting. VI. Resident #3 A. Resident status Resident #3, age 72, was admitted to the facility on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B.Record review Review of Resident #3's MOST form dated, [DATE], revealed the form was not accurate, as both boxes were checked for CPR and No CPR. C. Interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 1:40 p.m. LPN #1 said the red and green dots on the resident's room indicate that they were DNR or CPR. She said they would look at the MOST form binder if they did not have a dot. When asked what she would do when shown the MOST form with both boxes checked. She said she would choose DNR. She was unaware the MOST form had both CPR and no CPR were both checked. The ADON was interviewed on [DATE] at 1:53 p.m The ADON said she had not caught the double check and would call the family. The ADON said when the medical records were audited for documents, she did not look at the accuracy of the MOST form.

Based on observations, record review and interviews, the facility failed to ensure medical records were kept in a secure and confidential manner and the medical record was complete and accurate in keeping with accepted standards of practice for four (#2, #3, #4 and #5) out of six sample residents. Specifically, the facility failed to: -Laboratory results were in the medical record for Resident #2; -Ensure there was not missing documentation in the resident's record for Resident #4, #5 and #3; and, -Ensure resident's records were not accessible to others not authorized to view that information. Findings include: I. Facility policy The Medical Records policy, revised December 2006, was received from the assistant director of nursing (ADON) on 7/21/22, documented in pertinent part, The location and the storage of medical records were to be in a locked room, filed in the medical records department and maintained by the medical records clerk. Archived medical records were to be clearly identified as archive records and stored appropriately. The facility medical records policy on order of record assembling documented that the resident medical records were to be assembled in a systematic order. II. Resident #2 A. Resident status Resident #2, age 79, was admitted to the facility on [DATE]. According to the care plan initiated 11/21/21 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/3/22 MDS assessment showed the resident scored seven out of 15 with severely impaired cognition. The resident required extensive total assistance for transfers, mobility, incontinence care, repositioning, and personal hygiene. B. Record review The computerized medical record showed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The computerized medical record failed to show to laboratory results. C. Interview The assistant director of nursing (ADON) was interviewed on 7/20/22 at 3:30 p.m. The ADON, who was also the medical records coordinator, said laboratory results were in the miscellaneous section of the medical record and nowhere else. She reviewed the record and confirmed the specific laboratory results were not in the electronic medical record. D. Facility follow up The ADON was interviewed a second time on 7/21/22 at 2:15 p.m. The ADON said she located the laboratory results. The laboratory results were found in a pile of documents stored on the ADON's desk. III. Resident #4 A. Resident status Resident #4, aged 92, was admitted to the facility on [DATE]. According to the care plan revised 4/2/21, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/1/22 MDS assessment showed the resident was not interviewable and her cognition was severely impaired. The resident required one person assistance for transfers, mobility, incontinence care, feeding, and personal hygiene. B. Record review The computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Order date 4/1/2020 code status Do Not Resuscitate (DNR) The resident's medical record did not include the resident's medical orders for scope of treatment (MOST) form or the power of attorney (POA) documents. C. Interview The ADON was interviewed on 7/20/22 at 2:13 p.m. The ADON reviewed the computerized medical record and confirmed the power of attorney documents were not in the medical record. She said that if POA documents were not in the medical record, they were kept in the business office. The ADON went to the business office and returned with POA documents for Resident #4. VI. Resident #5 A. Resident status Resident #5, age 83, was admitted to the facility on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review The computerized physician record showed that on 5/26/22, there was a handwritten physician's note with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the May and June 2022 medication administration records (MAR), there was no evidence the antibiotic was administered. C. Interview The DON was interviewed on 7/21/22 at 10:00 a.m.The DON said the internet went out frequently. She said if the new medication was started when the internet was down then the medication was started on a paper MAR. She said then the paper MAR continued through the duration. She said it was not transferred to the computerized MAR even after the internet was working. She confirmed the May 2022 and the June 2022 MAR had not been scanned and placed in the resident's electronic record. Licensed practical nurse #1 (LPN) was interviewed on 7/21/22 at 11:30 a.m. LPN #1 said that the antibiotic orders were not put in the resident's MAR and verbally communicated the new order to the oncoming nursing staff. She said that antibiotic paper MARS were kept next to the computer. D. Facility follow-up The ADON was interviewed on 7/21/22 at 10:30 a.m. The ADON said she retrieved the May and June 2022 MAR from a pile of papers. She said it was in the pile on her desk awaiting to be scanned. VII. Resident #3 A. Resident status Resident #3, age 72, was admitted to the facility on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The computerized June 2022 MAR failed to show the antibiotic was administered. C. Interview The ADON was interviewed on 7/21/22 at 10:30 a.m. The ADON said she retrieved the June 2022 MAR from a pile of papers. She said it was in the pile on her desk awaiting to be scanned. VIII. Resident records A. Observation On 7/20/22 at 1:15 p.m., it was observed that resident care conferences with residents and their families were being conducted in the director of nursing (DON), the social services director (SSD), and the ADON's office. This office was used as storage for medical records. The office was shared by all three departments. On 7/21/22 at 9:10 a.m., it was observed resident medical records were kept in the DON, the SSD, and the ADON office on top of desks and in boxes on the floor of the office. It was also observed that an office labeled as medical records was adjoining. B. Interviews The DON was interviewed on 7/20/22 at 5:00 p.m. The DON explained that when the facility computers were not functional, nurses used paper documentation for medication administration records (MAR) and progress notes. It was not their process to later upload paper documents to medical records, instead they were kept in the ADON's office in a file with the boxes of records. The ADON managed the medical records and was responsible for scanning documents into the medical records but she was behind on scanning. The DON explained that some records were kept in the ADON office and some kept in the business office.

Based on observations, record review, and staff interviews, the facility failed to ensure residents were as free from accident hazards as possible for one (#3) out of six sample residents. Specifically, the facility failed to ensure Resident #3 had proper assessment, consent, and physician orders for their wanderguard device. Findings include: I. Facility policy The Elopement and Wandering policy, revised 5/9/19, was received from the nursing home administrator (NHA) on 7/21/22, it documented in pertinent part, The process for identifying residents at risk. A wander/elopement assessment was to be completed upon admission and quarterly or as needed. If identified as an elopement risk, the following were to be maintained in the medical record: a physical restraint use consent form obtained from the resident's responsible party and a physician order for the use of the monitoring device. The order was to include checking placement of the device every shift and checking function of device daily. II. Resident #3 A. Resident status Resident #3, age 80, was admitted to the facility on [DATE]. According to the care plan revised 8/3/21 diagnoses included dementia with behavioral disturbances. The 7/13/22 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a score of three out of 15. The resident required set up, supervision, and one person assistance with activities of daily living (ADLs) related to dementia. The resident was independent in mobility and had demonstrated a pattern of wandering which required intervention from the facility. B. Record review According to the resident's care plan initiated 8/3/21, she was identified as an elopement risk/wanderer related to disorientation to place. The care plan revised 10/5/21 indicated that the resident had a wanderguard device on ankle. The wander/elopement risk evaluation dated 5/24/21 documented that the resident was not an elopement or wander risk. The July 2022 medication administration record (MAR) and treatment administration record (TAR) did not show monitoring for the wanderguard device. The July 2022 CPO did not include an order for a wanderguard device. There was no consent form completed with the resident's representative in the resident's medical record for the wanderguard device. According to the resident's care conference notes on 2/3/21, 7/28/21, 11/3/21, 2/16/22 and 4/20/22, there was not a documented conversation between the interdisciplinary team and the resident representative regarding the wanderguard device. C. Observations On 7/21/22, the resident was observed sitting in a chair next to the front exit door, past the first exit door of the facility. She had a wanderguard device on her left wrist. The wanderguard device was programmed to alert staff when the resident went through the first exit door. No staff member was observed at the front desk or nearby outside watching the resident. D. Interview The NHA was interviewed on 7/21/22 at 10:15 a.m. The NHA said the resident had a wanderguard device because it was her preference to sit in between the two exit doors. The wanderguard device was a precautionary measure in case the resident decided to elope. The NHA said the resident had no history of elopement at the facility. The director of nursing (DON) was interviewed on 7/21/22 at 10:45 a.m. The DON said the process for obtaining consent for placement of a wanderguard device was a duty shared by the DON, assistant director of nursing (ADON), and the social services director (SSD). A form showing the resident representative's consent for the wanderguard device would be scanned into the resident's medical record. The facility would conduct a wander/elopement assessment with the resident and the score would reflect their risk. The DON acknowledged the wander/elopement assessment was not accurate.

Based on observations, record review and staff interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis. Specifically, the facility utilized the DON as a night shift medication nurse on a full time basis. The findings included: Interviews During the entrance conference with the nursing home administrator (NHA) on 9/18/18 at 9:30 a.m., the NHA stated that the DON works night shifts as a medication nurse. She said the DON did not like her new position or any of the administrative work. She said the DON preferred to return to a medication nurse duties. The DON was interviewed on 9/18/18 at 6:00 p.m. She said a couple of months ago the facility lost a registered nurse from the night shift, and she needed to go back to the unit as a medication nurse. She said her heart was not in the DON position and her preference was always taking care of her residents. Certified nurse assistant (CNA #1) was interviewed on 9/21/18 at 8:55 a.m. She said we do not have a DON. CNA #2 was interviewed on 9/21/18 at 9:58 a.m. She said the NHA was currently acting as the DON. Registered nurse (RN#1) was interviewed on 9/21/18 at 9:02 a.m. She said the NHA and the minimum data set (MDS) coordinator (MDSC) were filling in the position of the DON. The MDSC was interviewed on 9/21/18 at 9:12 a.m. She said the facility currently did not have a DON. Record review Review of the facility nursing staff schedule for the week 9/16/18 - 9/22/18 revealed the DON was scheduled to work 12 hours shifts and had worked three night shifts.

Based on interview and record review, the facility failed to ensure the services of a director of nursing (DON) for 35 hours a week. The findings include: Record review: A review of the time sheets for the DON from 4/16/17 to 7/8/17 revealed she did not work 35 hours in 7 of ten weeks. Specifically: The week of 4/16/17 to 4/22/17 she worked 21.5 hours. The week of 4/23/17 to 4/29/17 she worked 23 hours. The week of 5/14/17 to 5/20/17 she worked 25 hours. The week of 5/21/17 to 5/27/17 she worked 23 hours. The week of 6/4/17 to 6/10/17 she worked 33.5 hours. The week of 6/11/17 to 6/17/17 she worked 32.5 hours. The week of 6/25/17 to 7/1/17 she worked 31.5 hours. Interview: The nursing home administrator (NHA) was interviewed on 7/11/17 at 1:50 p.m. She confirmed by observation the DON frequently was not able to work for 35 hours in a week. She said the DON had a number of health issues that made it difficult for her to work a full work week, however, she had been unable to promote from within to obtain a full time DON. The NHA said she had attempted to recruit a full time DON from outside the facility as well, but those efforts had also been unsuccessful. The NHA said she had not looked into separating the DON role as allowed by the federal regulations. She said one of her staff might be willing to take on the role part time. She also said the facility ' s corporate office might be able to send a temporary DON to fill in while the facility searched for a more permanent full time candidate.

Based on observations, interviews and record review, the facility failed to ensure that food was stored, prepared and served in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Have a cooling procedure for potentially hazardous foods; -Maintain potentially hazardous foods at a proper temperature; -Store dishware properly; and -Maintain non-food contact surfaces in a state of good repair. The findings included: 1. Cooling Regulatory Reference: According to Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 7/1/13), section 3-603 Cooling, in pertinent part: Cooked potentially hazardous foods (time/temperature control for safety foods) shall be cooled from 135°F (57°C) to 41°F (5°C), or below, in 6 hours, provided that the food is cooled from 135°F (57°C) to 70°F (21°C) within the first 2 hours. Observation and Staff Interview: On 3/22/17 at 1:40 p.m., a pork roast in a roasting pan, with juices, covered by aluminum foil was observed set out on the counter of the kitchen. The roast was brought to the main part of the kitchen from the reach-in freezer area of the kitchen. The roast was then moved to the reach-in refrigerator by cook #2. On 3/22/17 at 2:04 p.m. cook #2 removed the pan with the pork roast from the refrigerator. The cook removed the foil and then began to remove the netting from the roast. The cook said the roast had been put in the oven on a low temperature to cook overnight on 3/21/17. The dietary director (DD) said she removed the roast from the oven in the morning (on 3/22/17) and placed it in the freezer to cool. The DD said she did not know when she removed the roast from the oven or placed it in the freezer to cool. The DD thought the roast was likely placed in the freezer before breakfast. The cook said the roast had been cooked overnight and was cooled to ensure it was tender. A request was made to check the temperature of the roast. On 3/22/17 at 2:07 p.m., the DD and cook #2 checked the temperature of the roast using two different thermometers. One thermometer was a digital thermometer; the other was an analog (dial) thermometer. The digital thermometer showed the temperature of the roast was 82°F. The analog thermometer showed temperatures of 68°F to 72°F depending on placement in the roast. The DD said they did not have a cooling schedule or cooling log to monitor how the roast was cooled and to ensure it was cooled from 135°F to below 70°F within the first two hours. The DD agreed the procedure that was followed was to place a whole roast, which would retain heat well due to composition, tightly covered by foil, in a reach-in freezer to cool. The DD acknowledged this would raise the temperature of the freezer, limiting its ability to hold foods at a proper temperature. The cook said it would be easier to cool the meat by slicing and placing it in a shallow pan so more surface area could be cooled faster. The regional dietary director (RDD) said the facility should have a cooling log and should monitor the roast to ensure it cooled to a proper temperature. The DD and RDD said food was in the danger zone between 135°F and 41°F (temperature range where microorganisms multiple more quickly). The RDD and DD agreed they did not use a system to limit the time the roast was between 135°F and 41°F. The DD acknowledged since being removed from the oven in the morning, the roast had not achieved a safe cooled holding temperature of 41°F or colder. The DD and RDD said they would make a different pork roast for dinner as they could not be sure the current roast was safe to serve due to handling errors. 2. Proper Holding Temperature Regulatory Reference: According to the Colorado Retail Food Establishment Rules and Regulations, section 3-501 Temperature, in pertinent part: The temperature of potentially hazardous foods (time/temperature control for safety foods) shall be 41°F (5°C) or below or 135°F (57°C) or above, at all times, except during necessary periods of preparation or as otherwise provided in this code. Observations: On 3/21/17 at 11:58 a.m., the one-gallon milk container used to serve residents in the dining room was stored on a thin layer of ice. The milk was stored on a thin layer of ice when observed again on 3/21/17 at 5:10 p.m. and on 3/23/17 at 11:27 a.m. Staff Interview: The DD was interviewed on 3/23/17 at 11:28 a.m. The DD used a digital thermometer to check the temperature of the milk. The temperature was 46.5°F. The DD said the milk should be maintained at 41°F or colder. The DD acknowledged the milk was stored on a thin layer of ice. The DD agreed the thin layer of ice would not be effective for cooling the majority of the gallon-size milk container, which was subject to room temperature. 3. Dishware Storage Regulatory Reference: According to Colorado Retail Food Establishment Rules and Regulations, section 4-601 Equipment and Utensil Storage, in pertinent part: Glasses and cups shall be stored inverted. Other stored tableware shall be covered or inverted, wherever practical. Observations: The kitchen was observed on 3/21/17 at 11:15 a.m., 3/22/17 at 1:30 p.m. and on 3/23/17 at 11:28 a.m. At each observation the tableware (dishes and bowls) used to serve residents was stored upright and not inverted on an open wire rack beside the steam table. The plates and bowls were subject to debris wiped from the steamtable and prep table and from sweeping. Bits of debris were noted in some of the bowls on the lower shelf of the two-shelf storage rack. Staff Interview: On 3/23/17 at 11:28 a.m., the DD said she was not aware of the need to invert tableware. The DD agreed there was debris in the bowls. 4. Ceiling repair Regulatory Reference: According to Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 7/1/13) section 1-202 Definitions, in pertinent part, Smooth means: A floor, wall, or ceiling having an even or level surface with no roughness, projections, perforations, pits, or inclusions that render it difficult to clean. - Section 6-2 Walls and Ceilings, included: Walls, wall coverings, and ceilings shall be designed, constructed and installed to be smooth, durable and easily cleanable. Observations: The kitchen was observed on 3/21/17 at 11:15 a.m., 3/22/17 at 1:30 p.m. and on 3/23/17 at 11:28 a.m. At each observation, the ceiling above the prep table, the steam table and storage in the main kitchen, had cracked and peeling paint. Staff Interview: The DD was interviewed on 3/23/17 at 11:28 a.m. The DD said that there had been a water leak in the kitchen some time ago. The ceiling disrepair was from the leak. The DD said the ceiling was awaiting repair from maintenance staff. The DD was unsure how long the ceiling had been in disrepair or when it would be fixed. The DD agreed the peeling, cracked debris was above preparation, service and storage areas, and bits of the peeling and cracked ceiling could fall into clean dishware or food.

Based on observations and interviews, the facility failed maintain mechanical and patient care equipment in safe working order for one of one dish machine and one of one bathtub. Specifically, the facility failed to ensure the dish machine had a working vacuum breaker and failed to ensure the whirlpool tub for resident bathing was functioning for resident use. The findings included: 1. Dish machine Regulatory Reference: According to Title 21 - Food and Drugs, Chapter 1--Food and Drug Administration Department of Health and Human Services Subchapter B--Food for Human Consumption, Part 178 Indirect Food Additives, Section 178.1010 Sanitizing solutions, (last revised on 4/1/16), in pertinent part: -Sanitizing solutions may be safely used on food-processing equipment and utensils, and on other food-contact articles as specified in this section, within the following prescribed conditions . The solutions consist of one of the following, to which may be added components generally recognized as safe and components which are permitted by prior sanction or approval. -An [MEDICATION NAME] solution containing potassium, sodium, or calcium hypochlorite, with or without the [MEDICATION NAME] of potassium, sodium, or calcium. -The solutions identified .will not exceed the following concentrations .not more than 200 parts per million of available halogen determined as available chlorine. Observations: The dish machine, used for cleaning and sanitizing dishware at the facility, was observed on 3/21/17 at 11:23 a.m. during the initial tour. The vacuum breaker on the dish machine, which prevented the backflow of contaminated water into the building's clean water system, had a noticeable coating of mineralization. The pipe immediately under the vacuum breaker was visibly wet. The combination of mineral buildup and wetness suggested the vacuum breaker might not be functioning adequately. The dish machine was observed on 3/22/17 at 1:42 p.m. The dish machine was observed during a wash and rinse cycle. During the fill portion of the rinse cycle, where the dish machine refilled with fresh sanitizer and water, the vacuum breaker leaked water continuously as the water and sanitizer flowed into the machine. A request was made to test the dish machine for sanitizer levels. The dietary aide (DA), in the presence of the dietary director (DD), tested the machine with a litmus strip for chlorine concentration. The strip turned a very dark purple black. The comparison key on the litmus strip container demonstrated the concentration of chlorine was 400 parts per million (ppm) of chlorine. Interviews: The DD was interviewed on 3/22/17 at 1:45 p.m. The DD said that 400 ppm of chlorine was fine. The DD was asked to recheck acceptable concentrations of chlorine for the dish machine. The DD said the facility was aware the dish machine was not functioning properly and had called the service person for repairs. Per the DD, the facility had scheduled repair for the dish machine next week. The maintenance supervisor (MS) was interviewed on 3/22/17 at 1:50 p.m. The MS said he was aware the dish machine was not working. The MS said the facility had contacted an outside vendor to repair the dish machine. The MS observed the dish machine as it completed a rinse cycle. The MS agreed that the one-way function of the vacuum breaker valve was not working as expected because water was being discharged from the vacuum breaker as water flowed into the machine, instead of discharging water only when dirty water from the machine attempted to backflow into the clean water system of the facility. Facility Follow-up: On 3/22/17 at 2:00 p.m., the MS began performing repairs on the dish machine. On 3/22/17 at 3:20 p.m., the nursing home administrator (NHA) said the vendor for the sanitizer and dish machine repairs would be out in the morning to ensure the machine was adequately repaired and working, and that chlorine concentrations were acceptable. Prior to survey exit on 3/23/17, the DD reported the vendor had repaired the dish machine and that it was operating with acceptable sanitation and a functional vacuum breaker. 2. Whirlpool Tub Observations: The resident bathing room was observed during the initial tour on 3/21/17 at 11:46 a.m. The whirlpool tub stored boxed supplies and disused resident supplies (a commode chair). Debris and stains soiled the bottom of the tub. The whirlpool tub continued to be used as storage and remained soiled when observed again on 3/23/17 at 8:15 a.m. Resident Interview: Resident #3 was interviewed on 3/22/17 at 9:09 a.m. The resident said the facility did not have a bathtub available for resident use. Staff Interview: The nursing home administrator (NHA) and maintenance supervisor (MS) were interviewed on 3/22/17 at 3:20 p.m. The NHA said the facility had a resident tub, but it was not working. The MS said the seal on the tub door was degraded and needed replacement; however, it was impossible to replace the seal because the tub was obsolete. According to the MS, one could not obtain a replacement seal and the tub could not function without a working seal.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for each resident that included measureable objectives and timetables to meet medical, nursing, mental and psychosocial needs for four (#54, #24, #25 and #36) of 29 sample residents. Specifically, the facility failed to develop care plans related to: -Diabetes for resident #25; -Pneumonia and respiratory status for resident #36; -Skin condition for resident #54; and -Activities for resident #24. The findings included: 1. Resident #25 - Diabetic Management Resident Status Resident #25, age 89, was admitted on [DATE] and readmitted on [DATE]. According to the 3/17 computerized physician orders [REDACTED]. According to the 2/22/17 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident had a [DIAGNOSES REDACTED]. Record Review According to the 3/17 CPOs, the resident had orders for: -Accuchecks (blood glucose test) before meals and at bedtime, give [MEDICATION NAME]per sliding scale; and -[MEDICATION NAME] 10 units every bedtime. The 3/17 Medication Administration Record [REDACTED]. According to the 4/26/16 care plan, the resident was at risk for alteration in nutrition/hydration related to body mass index greater than 24.9 and [DIAGNOSES REDACTED]. She had additional risk related to dementia, depression, [MEDICAL CONDITIONS] and diabetes. The only intervention related to diabetes was to do blood sugars before meals, at bedtime and as needed with sliding scale insulin coverage. The resident did not have a specific care plan for diabetes that included comprehensive assessed interventions to manage the resident's diabetes. 2. Resident #36 - Respiratory Status Resident status Resident #36, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the 3/17 CPOs, [DIAGNOSES REDACTED]. According to the 1/15/17 minimum data set (MDS) assessment, the resident had severe cognitive impairment and was unable to complete the basic interview for mental status (BIMS) assessment. Record review Review of the resident's record on 3/22/17 revealed the resident was discharged to the hospital on [DATE] and was re-admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident did not have a specific care plan for pneumonia that included comprehensive assessed interventions to manage the resident's respiratory status. Staff Interviews The nursing home administrator/ interim director of nursing was interviewed on 3/23/17 at 11:05 a.m. She said the computer generated a generic care plan and the interdisciplinary team (IDT) would individualize and update the care plans in their morning meeting and as needed. She said this was not up-to-date and agreed that care plans were needed to assist staff on how to provide care. 3. Resident #24 - Individualized Activities Resident Status: Resident #24, age 92, was admitted on [DATE]. According to the 3/17 CPOs, [DIAGNOSES REDACTED]. The 1/17/17 quarterly MDS assessment indicated the resident had short-term and long-term memory problems and was severely impaired for decision-making. The resident was unable to recall the current season, room location, staff names/faces or that she or he was in a nursing home. The resident was totally dependent on staff for all activities of daily living (ADLs), except eating, for which the resident required extensive assistance. Record Review: The 8/3/16 annual activity assessment documented the resident had a religious affiliation and attended church. The resident's interests included pets, bingo, cooking, outings, exercise, music, discussions, socials, and walking. The resident preferred activity in the morning and attended three to five groups weekly. The 1/26/17 quarterly activity assessment documented the resident required assistance and reminding to attend activities. The resident preferred being with people, enjoyed large and small groups, enjoyed family visits, rarely initiated conversations and was unable to make needs known. A review of the plan of care revealed no activity care plan was in place for the resident. Staff Interview: The activity director (AD) was interviewed on 3/23/17 at 10:17 a.m. The AD said the resident attended activities, but needed help to do so. The AD said the resident was usually passive, but would be an active participant in music, where she was known to tap her feet in time with the music. The AD said each resident should have an activity care plan. The AD said activity care plans were important because they helped staff know resident interests and assistance needs. The AD said activity care plans were reviewed with each MDS assessment cycle. The AD reviewed the resident's care plan. The AD said the resident did not have an activity care plan in place. 4. Resident #54 - Skin Condition Resident Status: Resident #54, age 90, was admitted on [DATE]. According to the 3/17 CPOs, [DIAGNOSES REDACTED]. The 1/7/17 admission minimum data set (MDS) assessment demonstrated the resident had severe cognitive impairment as evidenced by brief interview for mental status score of three out of 15. The resident did not have any skin conditions. Observations: The resident was observed on 3/21/17 at 5:17 p.m. There was a raised lump on the resident's right hand that was the approximate size of a large marble. The resident did not know what the lump was or how it came to be on her hand. The lump remained present on the resident's hand when observed on 3/23/17 at 7:13 a.m. Record Review: A review of the plan of care revealed no documentation related to the lump on the resident's right hand. Staff Interviews: Certified nurse aide (CNA) #2 was interviewed on 3/22/17 at 4:20 p.m. The CNA reported working with the resident. The CNA said she had noticed the lump on the resident's hand. The CNA said she believed the lump had been present since admission to the facility. The CNA denied knowing the origin of the lump and what approaches were in place related to the lump. Licensed practical nurse (LPN) #2 was interviewed on 3/23/17 at 9:08 a.m. The LPN said the raised lump on the resident's hand was present on admission. The LPN said she thought the facility would measure the lump and care plan to observe it for changes. The LPN said skin checks were completed weekly for each resident, so a monitoring system should be in place. The resident's clinical record was reviewed with LPN #3 on 3/23/17 at 12:58 p.m. The LPN reviewed the record and said she could not find a care plan related to the lump on the resident's hand. The LPN said a care plan would direct staff on the status of the area and provide guidance on how to monitor the area for changes.

Based on observations, record review and interviews, the facility failed to provide the necessary care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for six (#25, #36, #6, #16, #54, #5) of 29 sample residents. Specifically, the facility failed to: -Perform adequate diabetic/insulin management for resident #25 and #36; -Implement positioning interventions for resident #6; -Conduct and monitor all skin conditions for resident #16 and resident #54; -Perform adequate monitoring and management of dementia care and services for resident #5. The findings included: I. Diabetic/Insulin Management A. Professional References According to Potter, Perry, Stockart & Hall, Fundamentals of Nursing, 8th edition, Elsevier Mosby, St. Louis, Missouri, 2013, pp. 583-586: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation A medication order is required for every medication that you administer to a patient. When preparing medications from bottles or containers, compare the label of the medication container with the MAR three times: (1) before removing the container from the drawer or shelf, (2) as the amount of medication ordered is removed from the container and (3) at the patient's bedside before administering the medication to the patient. If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the prescribing health care provider before administering the medication. Step to take to prevent medication errors: -Prepare medications for one person at a time. -Follow the six rights of medication administration. -Be sure to read labels at least three times comparing Medication administration record (MAR) with label before administering the medication. -Use at least two patient identifiers and review the patient's allergies [REDACTED]. -Do not allow any other activity to interrupt administration of medication to a patient (e.g., phone call, pager, discussion with other staff). -Double-check all calculations and other high-risk medication administration processes (e.g., patient controlled [MEDICATION NAME]) and verify with another nurse. -Do not interpret illegible handwriting; clarify with prescriber. -Question unusually large or small doses. -Document all medications as soon as they are given. According to the American Diabetes Association, [DIAGNOSES REDACTED] (Low Blood Glucose), Living with Diabetes, 7/1/15, www.diabetes.org (March 2017), [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucose (blood sugar) levels, usually less than 70mg/dl (milligrams/deciliter). If left untreated, [DIAGNOSES REDACTED] may lead to a [MEDICAL CONDITION] or unconsciousness (passing out, a coma). B. Facility Policy On 3/23/17 the nursing home administrator (NHA)/interim director of nursing (IDON) provided a copy of the facility policy and procedure, titled Administering Medications, last revised 4/07, which included in pertinent part: Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medications must check the label three times to verify the right medication, right dosage, right time, and right method of administration before giving the medication. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a.) The date and time the medication was administered; b.) The dosage; c.) The route of administration; d.) The injection site (if applicable); e.) Any complaints or symptoms for which the drug was administered; f.) Any results achieved and when those results were observed; and g.) The signature and title of the person administering the drug. C. Resident #25 Resident Status Resident #25, age 89, was admitted on [DATE] and readmitted on [DATE]. According to the 3/17 computerized physician orders [REDACTED]. According to the 2/22/17 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident had a [DIAGNOSES REDACTED]. According to the 4/26/16 care plan, the resident was at risk for alteration in nutrition/hydration related to body mass index (BMI) greater than 24.9 and [DIAGNOSES REDACTED]. Additional risk related to dementia, depression, [MEDICAL CONDITIONS] and diabetes. The only intervention related to diabetes was to do blood sugars before meals, at bedtime and as needed with sliding scale insulin coverage. The resident did not have a specific care plan for diabetes that included comprehensive assessed interventions to manage the resident's diabetes. (Cross reference F279, comprehensive care plans) Record review According to the 3/17 CPO, the resident had the following orders: -[MEDICATION NAME] 100 units/milliliter (ml) 10 units every bedtime, ordered 2/8/17. (No route in which the medication was to be administered was on the order); and -Accuchecks before meals and at bedtime. Give [MEDICATION NAME]100 unit/ml for the following blood sugars: Below 150 - no insulin, 151 - 200 one unit, 201-250 two units, 251-300 three units, 301-350 four units, 351-400 five units, above 400 call the doctor, ordered 2/8/16. (No route in which the medication was to be administered was on the order.) -The resident did not have an order for [REDACTED]. According to the 3/17 MAR, the amount of sliding scale insulin given was not documented. There was no documentation if insulin was held related to a blood sugar less than 150. The MAR allowed for a check mark (indicating the order was complete), the nurse initials and the blood glucose level. The resident was documented as receiving sliding scale insulin on the following dates/times when it should have been held for a blood sugar less than 150: -3/1/17 at 6:30 a.m. blood sugar was 73 and at 11:30 p.m. blood sugar was 138; -3/2/17 at 6:30 a.m. blood sugar was 118; -3/4/17 at 6:30 a.m. blood sugar was 128 and at 4:30 p.m. blood sugar was 137; -3/5/17 at 6:30 a.m. blood sugar was 138 and at 4:30 p.m. it was 147; -3/6/17 at 6:30 a.m. blood sugar was 81; -3/7/17 at 4:30 p.m. blood sugar was 129; -3/10/17 at 6:30 a.m. blood sugar was 109; -3/11/17 at 6:30 a.m. blood sugar was 108; -3/16/17 at 5:30 a.m. blood sugar was 122 and at 4:00 p.m. blood sugar was 128; -3/17/17 at 5:30 a.m. blood sugar was 78; -3/18/17 at 5:30 a.m. blood sugar was 138; -3/19/17 at 5:30 a.m. blood sugar was 136; -3/20/17 at 5:30 a.m. blood sugar was 104; -3/21/17 at 5:30 a.m. blood sugar was 110; -3/22/17 at 5:30 a.m. blood sugar was 75 and -3/23/17 at 11:00 a.m. blood sugar was 148. The resident also had a blood sugar of 405 on 3/3/17 at 6:30 a.m. and 404 on 3/14/17 at 4:00 p.m. that were not documented as being reported to the physician as per order. No blood sugars or insulin administration was documented for bedtime from 3/1/17 through 3/11/17. According to the 2/17 MAR, the amount of sliding scale insulin given was not documented. There was no documentation if insulin was held related to a blood sugar less than 150. The MAR allowed for a check mark, the nurse initials and the blood glucose level. The resident was documented as receiving sliding scale insulin on the following dates/times when it should have been held for a blood sugar less than 150: -2/10/17 at 6:30 a.m. blood sugar was 138; -2/11/17 at 6:60 a.m. blood sugar was 105; -2/13/17 at 6:30 a.m. blood sugar was 118; -2/15/17 at 6:30 a.m. blood sugar was 91; -2/17/17 at 6:30 a.m. blood sugar was 116; -2/19/17 at 6:30 a.m. blood sugar was 123; -2/20/17 at 6:30 a.m. blood sugar was 74; -2/21/17 at 11:30 a.m. blood sugar was 150; -2/22/17 at 6:30 a.m. blood sugar was 54; (no documentation was found indicating that any intervention was provided, that insulin was held or that the physician was notified of a low blood sugar). -2/23/17 at 6:30 a.m. blood sugar was 124; -2/24/17 at 6:30 a.m. blood sugar was 124 and at 11:30 a.m. blood sugar was 139; -2/25/17 at 6:30 a.m. blood sugar was 145 and at 11:30 a.m. blood sugar was 123; -2/26/17 at 6:30 a.m. blood sugar was 80; and -2/28/17 at 6:30 a.m. blood sugar was 132. No blood sugars or insulin administration was documented for bedtime from 2/8/17 through 2/28/17. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/23/17 at 9:22 a.m. She said the check mark on the MAR indicated that the order for the accuchecks and insulin was completed. She said the computer told the nurse how much insulin was needed based on the blood sugar results. She was not aware that the amount of insulin given was not recorded. She agreed that a clarification was needed and that the order should be two separate orders. She said if the insulin was not given related to a low blood sugar it should be documented on the MAR as no units given. The NHA/IDON was interviewed on 3/23/17 at 11:05 a.m. She said the MAR should include how many units were given with a sliding scale order and this had already been corrected in resident #36's record. She said it should also show if no insulin was given related to a blood sugar less than 150. She said she did not believe that the nurses were giving insulin when the sugar was below 150, and thought it just was not being documented accurately. She said that any assessments needed to be filled out correctly and completely with all the information available D. Resident #36 Resident status Resident #36, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the 3/17 CPOs, [DIAGNOSES REDACTED]. According to the 1/15/17 MDS assessment, the resident had severe cognitive impairment and was unable to complete the brief interview for mental status (BIMS). Record review On 3/22/17, review of the resident's record revealed the resident was discharged to the hospital on [DATE]. According to the SBAR (situation, background, assessment, recommendation) completed on 10/31/16 at 9:54 a.m. the resident had nausea, vomiting, diarrhea, clammy skin and an increased heart rate. The resident's blood pressure, pulse, respirations and oxygen saturation were recorded as 85/52, 120, 20 and 93%. It did not specify if the resident was on oxygen or room air. No temperature or blood sugar was recorded. The rest of the assessment was left incomplete. There was no documentation as to what made the resident's symptoms better or worse, how long the symptoms had been occurring, no background was provided and no assessment was documented. There was no documentation that the physician or family was notified of the change of condition. . Staff Interview The NHA/IDON was interviewed on 3/23/17 at 11:05 a.m. She agreed the SBAR for resident #36 was incomplete. II. Lack of interventions to timely address positioning issues Resident #6, age 97, was admitted on [DATE]. The 3/17 MAR revealed [DIAGNOSES REDACTED]. According to the 3/5/17 MDS assessment, the resident's cognition was moderately impaired with a BIMS score of eight out of 15. She required extensive assistance with bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. She had range of motion limitations to both upper extremities. She was not on a restorative nursing program. The resident did not reject care during the review period. Observations On 3/22/17 at 10:10 a.m., the resident leaned towards the left side of her manual wheelchair. There was no cushion or padding between her left arm and the chair. -At 3:12 p.m., the resident participated in an activity inside the television room. She was slouched and leaned on her left side. There was no cushion or device to help the resident sit in an upright position or reduce the pressure on her left arm against the wheelchair. -At 3:46 p.m., resident remained leaning on her left side during activity. Her head extended beyond the left armrest and her left arm was pressed against the inside of the left wheelchair armrest. No assistance to reposition or reduce the pressure on her left side against the wheelchair offered. -At 4:13 p.m., the resident was by the nurse station and CNA #1 offered to help the resident to the television room. She did not attempt to reposition the resident before she propelled the resident. The resident remained positioned on her left side without help from staff or a device to aide in her position. Her head extended past the left wheelchair arm; her left arm inside the wheelchair was pressed against the left armrest. -At 4:36 p.m., the resident remained leaning. The administrative assistant (AA) offered to propel the resident to the dining room. The resident remained on her left side without repositioning or attempt to locate a cushion or pad. On 3/23/17 at 8:14 a.m., the resident was leaning while she ate breakfast. There was no support device or cushion to help with the pressure applied to her left arm. Record Review: A review of care plans revealed there was no care plan related to the resident's positioning issues. There was no information or evidence available on identification, goals, or approaches for staff to address how she leaned in her wheelchair. A review of the 3/8/17 therapy screen form revealed the resident was screened at the request of the resident's family and nursing department. She had poor positioning and body alignment. She leaned in her wheelchair. The form identified the resident would benefit from positioning and a trunk strengthening program. A request for interdisciplinary progress notes from 3/1/17 through 3/23/17 was made on 3/23/17 at 11:10 a.m. The facility did not provide the notes during the survey process. Interviews: CNA #5 was interviewed on 3/22/17 at 3:20 p.m. The CNA said the resident required assistance propelling down the hallway. CNA #2 and CNA #4 were interviewed on 3/23/17 at 8:14 a.m. The CNAs stated the resident always leaned and had a slouched posture. They said she complained of pain to both arms and shoulders. They stated they were unaware of any wedge to help with her positioning. The CNAs said therapy would be responsible for screening to determine appropriate support equipment and if therapy would benefit the resident. The CNAs confirmed the resident leaned as she ate breakfast and did not have any support cushion. LPN #3 was interviewed on 3/23/17 at 8:20 a.m. The LPN confirmed the resident leaned on her left side. She stated she recalled a recent evaluation for therapy to screen the resident but was not sure of the follow-up or status. The LPN confirmed the resident was leaning as she ate breakfast. The physical therapist (PT) was interviewed on 3/23/17 at 10:20 a.m. The PT stated a screen was performed on the resident two weeks ago (3/8/17). He said the resident's daughter requested the therapy screen because of a decline in the resident's positioning. He said he screened and planned on picking her up but did not file the paperwork and she was not receiving therapy. He said the resident had severe scoliosis and her wheelchair would be replaced with a wider one. The PT stated he needed to submit a funding verification form with the business office manager (BOM) and then call the physician to obtain an order for [REDACTED]. The PT stated the benefits of therapy related to the resident would be improvement on positioning and trunk control, strengthening, and activity tolerance. The BOM was interviewed on 3/23/17 at 10:52 a.m. She said the funding verification form was used to determine pay source for therapy. The BOM said when a funding verification form was submitted to her, she could get the form back either the same day or the next day. She stated she was not aware of a funding verification form for the resident. III. Skin Conditions A. Resident #16 Resident #16, age 98, was admitted on [DATE]. The 3/17 CPO revealed [DIAGNOSES REDACTED]. The 2/11/16 order indicated skin assessments performed every Wednesday and as needed. According to the 2/15/17 MDS assessment, the resident's cognition was moderately impaired with a BIMS score of 12 out of 15. The resident required extensive assistance with bed mobility, transfers, ambulation on/off unit, dressing, toileting, and personal hygiene. There were balance concerns moving from seated to standing position, walking, moving on and off toilet, and surface to surface transfers. She was occasionally incontinent of urine and always continent of bowel. The resident did not have a surgical wound, burn, skin tear, or moisture associated skin damage. The resident had no falls since the previous assessment. Observations On 3/22/17 at 3:14 p.m., the resident was in her room asleep. There was some blue to purple bruising observed on her face near the frontal lobe. On 3/23/17 at 9:00 a.m., the resident returned to her room from breakfast. CNA #4 propelled the resident into her room. The resident had a light blue to purple bruise on her frontal lobe. Record Review: A review of the 2/10/16 skin care plan revealed the resident was at risk for impaired skin integrity related to limited mobility without assistance and incontinence. -The goal was the resident's skin would remain intact. She would also remain free from additional skin breakdown. -Interventions included: weekly skin checks; therapy screen as needed for concerns; nurse would document daily on any aspects of wound healing included but not limited to positioning, nutrition, hydration, pain, dressing, lab work; hematoma to left forehead would heal without complication; bruise to left wrist would heal without complication. A review of the skin inspection reports from 3/7/17 through 3/22/17 revealed the resident had skin not intact on 3/8/17 and 3/15/17. A review of the wound healing report from 3/1/17 through 3/22/17 revealed a bruised left eye and bruised left forearm. There was no mention of the bruise located on her left frontal lobe. A review of the departmental notes from 3/1/17 through 3/23/17 failed to show any monitoring to the resident's left frontal lobe skin condition. Interviews LPN #2 was interviewed on 3/21/17 at 4:40 p.m. She stated the resident fell on [DATE] and the fall resulted in an injury. The LPN said the resident had bruising on her face and arm due to the fall. CNA #1 was interviewed on 3/22/17 at 3:42 p.m. The CNA said she worked the day the resident was found on the floor. The CNA stated she had some bruising to her face after the fall. LPN #3 was interviewed on 3/23/17 at 10:02 a.m. She said the resident's skin assessment was missed on 3/22/17. She stated the resident's skin assessments were ordered to be performed on Wednesdays and as needed. The LPN confirmed the resident had bruising on the left front lobe. She reviewed the wound healing progress note provided on 3/22/17 and confirmed the left frontal lobe bruising was not being monitored according to the wound progress report. LPN #2 was interviewed again on 3/23/17 at 11:31 a.m. She said when skin issues were identified, they were placed on a skin sheet. She said skin conditions were monitored with a daily progress note. LPN #3 was interviewed again on 3/23/17 at 2:22 p.m. The LPN stated skin conditions needed to be monitored to determine if the resident was healing or condition was worsening. She said she looked into the skin condition of the left frontal lobe and reported the skin condition was marked closed. She could not explain how the record was closed. The LPN stated a skin assessment was performed on 3/23/17. B. Resident #54 Resident Status: Resident #54, age 90, was admitted on [DATE]. According to the 3/17 CPOs, [DIAGNOSES REDACTED]. According to the 1/7/17 admission MDS assessment, the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident did not have any skin conditions. Observations: The resident was observed on 3/21/17 at 5:17 p.m. There was a raised lump on the resident's right hand that was the approximate size of a large marble. The resident did not know what the lump was or how it came to be on her hand. The lump remained present on the resident's hand when observed on 3/23/17 at 7:13 a.m. Record Review: A review of the initial skin assessment revealed no documentation related to the lump on the resident's hand. A review of weekly skin assessments revealed no documentation related to the lump on the resident's hand. A review of nurses' notes from 12/31/17 through 3/22/17 revealed no documentation related to the lump on the resident's hand. A review of the plan of care revealed no documentation related to the lump on the resident's right hand. Staff Interviews: Certified nurse aide (CNA) #2 was interviewed on 3/22/17 at 4:20 p.m. The CNA reported working with the resident. The CNA said she had noticed the lump on the resident's hand. The CNA said she believed the lump had been present since admission to the facility. The CNA denied knowing the origin of the lump. The CNA denied knowing what approaches were in place related to the lump. Licensed practical nurse (LPN) #2 was interviewed on 3/23/17 at 9:08 a.m. The LPN said the raised lump on the resident's hand was present on admission. The LPN reviewed initial nursing and skin assessments. The LPN said the initial assessments did not document the lump. The LPN said she thought the facility would measure the lump and care plan to observe it for changes. The LPN said skin checks were completed weekly for each resident, so a monitoring system should be in place. The resident's clinical record was reviewed with LPN #3 on 3/23/17 at 12:58 p.m. The LPN reviewed the record and said she could not find documentation of the lump on the resident's hand in the initial assessments, the weekly skin assessments or the nurses' notes. The LPN said she would expect to find measurements and a description of the area on the resident's hand so that they could determine if the area had changed. The LPN said there was no care plan related to the raised area on the resident's hand. The LPN said a care plan would direct staff on the status of the area and provide guidance on how to monitor the area for changes. IV. Dementia Care / Management Resident Status: Resident #5, age 87, was admitted on [DATE]. According to the 3/17 CPOs, [DIAGNOSES REDACTED]. According to the 1/23/17 quarterly MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident exhibited verbal and physical behaviors on one to three days of the MDS observation period. The resident's behaviors did not significantly impact the resident or others. The resident did not reject cares during the observation period. Observations: Observations of the resident revealed the resident spent much of her time in bed sleeping. The resident called out occasionally. The resident was observed to be in bed with her eyes closed on 3/21/17 at 2:35 p.m. and 4:59 p.m., and on 3/22/17 at 4:01 p.m. On 3/23/17 at 8:22 a.m., the resident was sitting in her wheelchair. She was being fed breakfast on an over-the-bed table in a staff office. The resident intermittently said, Help! or We got to go! while in the staff office. On 3/23/17 at 9:07 a.m., the resident was in bed. She said, Help me and Can I get up? to no one in particular. At 9:11 a.m., the resident called out Help me and then coughed. The resident made no additional verbalizations prior to the observation concluding at 9:18 a.m. Record Review: A review of the 10/16 CPO showed the resident was receiving [MEDICATION NAME] ([MEDICATION NAME]) (atypical antipsychotic) 2.5 mg half tablet by mouth daily for dementia with behaviors. A review of the 10/16 medication administration record (MAR) revealed the resident was receiving [MEDICATION NAME] 2.5 mg half tablet by mouth once daily for dementia with behaviors. The MAR showed the resident was not exhibiting behaviors on the portion of the MARs where the medication was signed off. The target behaviors for which the [MEDICATION NAME] was being given were repetitive statements of Am I Up? Is it time to get up? Where's Ruthie? The 10/16 MAR offered a location to document the presence or absence of the verbal behaviors for each shift. The 10/16 MAR showed the behavior was present on 85 of 93 shifts. A review of the 11/16 MAR documented the resident's [MEDICATION NAME] was discontinued on 11/1/16. The resident began receiving [MEDICATION NAME] (Quetiapine) 25 mg by mouth once daily each morning for Repetitive statements. The 11/16 MAR documented that the resident exhibited repetitive statements of Am I Up? Is it time to get up? Where's Ruthie? on 86 of 90 shifts. An evening dose of [MEDICATION NAME] 25 mg by mouth for repetitive statements was added to the resident's drug regimen on 11/30/16. A review of the 12/16 MAR documented the resident continued on [MEDICATION NAME] 25 mg by mouth twice daily for repetitive statements. [MEDICATION NAME] (anti-anxiety) 0.25 mg by mouth twice daily was added on 12/23/16 for repetitive statements. The resident exhibited repetitive statements (see above for specifics) on 88 of 93 shifts on the 12/16 MAR. The 1/17 MAR documented the resident continued on [MEDICATION NAME] 25 mg by mouth twice daily for repetitive statements. The resident exhibited repetitive statements (see above for specifics) on 88 of 93 shifts on the 1/17 MAR. The 2/17 MAR documented the resident continued on [MEDICATION NAME] 25 mg by mouth twice daily for dementia with behaviors. The resident exhibited repetitive statements on 72 of 84 shifts documented on the MAR. The 3/17 MAR documented the resident continued on [MEDICATION NAME] 25 mg by mouth twice daily for dementia with behaviors. The resident exhibited repetitive statements on 59 of 67 shifts on the 3/17 MAR. A review of social service progress notes demonstrated: -An 11/15/16 note stated the resident made repetitive statements that could be redirected during an interview conducted that day. The note said nursing had noticed decreased repetitive statements since switching from [MEDICATION NAME] to [MEDICATION NAME]. (The 11/16 behavior tracking on the MAR did not support this. See above.) -A 2/27/17 note stated the resident asked repetitive questions and was unable to stay on task during an interview conducted for a quarterly assessment. The resident continued to make repetitive statements, but nursing felt there was a decrease in frequency. A review of nurses' notes demonstrated: -On 11/2/16, the resident yelled and screamed at staff. Specifics of what the resident communicated were not included in the note. Specific staff approaches, resident response to the specific approaches and possible triggers for the behaviors were not documented. -On 11/21/16, the resident yelled at staff and made repetitive statements consistent with those tracked on the MAR. The resident could not be redirected with one-to-one, snacks, environment change, repositioning, and toileting. The resident was checked for a urinary tract infection. The note did not say what attempts were made to determine an external trigger/cause for the resident's behavior. -Two notes were made on 11/25/16 stating the resident had repeated verbalizations. The resident was not easily redirected and refused interventions. The resident responded with Shut up when they asked her to be quiet. -Two notes were documented on 12/3/16. One said the resident had repeated verbalizations while up in her wheelchair after breakfast. The second note said the resident was aggressive with staff during cares after lunch. The resident was tested for a urinary tract infection. It was negative. There were no other notes evidencing resident behaviors from 10/1/16 through 3/23/17. The care plan, initiated on 10/22/14, identified the resident had a risk for alteration in mood and behaviors related to a [DIAGNOSES REDACTED]. The goal was for the resident's mood/behaviors not to interfere with daily routine and quality of life. Pertinent approaches included: -Educate the resident regarding acceptable alternatives to behaviors. (The resident had severe cognitive impairment, rendering education on behaviors questionable) -If resident refuses care, assure safety, leave and re-approach in five to ten minutes. -Monitor for behaviors of repetitive calling out Is it time to eat? Where's Ruthie? I have to pee! Is it time to get up? What do I do now? Chart accordingly. -Rule out medical complications [REDACTED]. -Remove from common areas during times of unacceptable behaviors. The clinical record did not evidence a process where staff worked systematically to determine causative factors for the resident's behavior (pain, boredom, unmet need) of calling out. Additionally the record showed the resident continued to have make repetitive statements on most shifts. A request to review other documentation or resident behaviors was made. The facility responded these materials were considered as quality assurance. The materials were not provided for review during survey or the post-survey grace period. Staff Interviews: Staff interviews revealed the resident's behavior was repetitive statements. The resident's repetitive statements increased when up in the wheelchair. The resident's behaviors persisted even when medications where changed and increased. The [MEDICATION NAME] was increased on 11/30/16, even though there were only two days with documented behavior episodes. Interviews revealed the facility did not have a system to systematically address behaviors in demented residents before increasing anti-psychotic medications. Certified nurse aide (CNA) #2 was interviewed on 3/22/17 at 4:14 p.m. The CNA said the resident's behaviors were saying the same thing repeatedly at times. The CNA said the resident would be worse when she was up in her wheelchair. The CNA said that sometimes, the resident would hit or attempt to bite staff during cares, but the resident was not typically aggressive. The CNA said the resident usually stopped calling out when laid in bed. The CNA said the resident usually was in bed except for meal times and for bathing. The nursing home administrator (NHA) was interviewed on 3/23/17 at 8:10 a.m. The NHA said the resident would eat in a staff office for meals. The NHA said the resident did not eat in the dining room because her verbalizations disturbed others. CNA #1 was interviewed on 3/23/17 at 8:36 a.m. The CNA said the resident did not really have any behaviors. The CNA said the resident would say things without realizing what she was doing. The CNA said the resident might a

Based on observations, interviews and record review, the facility failed to label and store drugs in accordance with practice standards. Specifically, one of one treatment cart had a broken lock, one (#54) of 30 sample residents had an unsecure medication in the room, and the facility did not remove outdated medications from use in one of one treatment cart. The findings included: 1. Facility Policy The Storage of Medications policy, revised 4/07, included: -Compartments (including but not limited to, drawers cabinets, rooms refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. -Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. 2. Unlocked Treatment Cart Observations: The treatment cart was observed with licensed practical nurse (LPN) #2 on 3/21/17 at 2:38 p.m. The LPN opened the treatment cart without a key, demonstrating the cart was not locked. On 3/21/17 at 4:16 p.m. the treatment cart stored next to the nurses' station was unlocked. There were residents nearby in the sitting room. One resident was in transit to the dining room. Medications were present and could be removed. No staff was in line-of-sight of the unlocked treatment cart. On 3/22/17 at 7:31 a.m., 8:16 a.m. and 8:38 a.m., the treatment cart parked next to the nurses' station was unlocked. There was no staff in line-of-sight of the treatment cart. Residents were nearby in the sitting room and were in transit to and from the dining room during the observations. Staff Interview: LPN #3 was interviewed on 3/22/17 at 8:43 a.m. The LPN said the treatment cart's lock was broken and the cart could not be locked. The LPN agreed that the unlocked treatment cart was unattended. The LPN said unauthorized persons could access the treatment cart because it was unlocked. The LPN said the facility had a new treatment cart on order from the pharmacy. The LPN said she could put the treatment cart in her office because it locked and only nurses had a key to access her office. The nursing home administrator (NHA) was interviewed on 3/22/17 at 9:00 a.m. The NHA, who was a registered nurse, said that the facility had a new treatment cart on order from the pharmacy. The NHA said she tried to keep a staff person at the nurses' station at all times. The NHA agreed that the person seated at the nurses' station could be called away at any moment to assist a resident, thus leaving the treatment cart unlocked and unattended. Facility Follow-up: The facility had replaced the treatment cart with one that locked as of the afternoon of 3/22/17. 3. Resident #54's Unsecured Medication Resident Status: Resident #54, age 89, was admitted on [DATE]. According to the 3/17 computerized physician orders [REDACTED]. According to the 1/7/17 admission minimum data set (MDS) assessment, the resident had severe cognitive impairment as evidenced by a brief interview for mental status score of three out 15. Observations: On 3/21/17 at 5:16 p.m., a tube of Orajel tooth and gum analgesic was observed on the soap holder in the resident's bathroom. The Orajel was observed in the same location on 3/22/17 at 4:21 p.m. Staff Interview: LPN #1 was asked to observe the resident's room on 3/22/17 at 4:25 p.m. The LPN said the Orajel was an over-the-counter medication. The LPN said it should not be out and available in the resident's room. The LPN removed the medication from the room. 4. Outdated Medications Manufacturer Directions: The package insert instructions for Advair diskus included, Advair diskus should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard Advair diskus 1 month after opening the foil pouch or when the counter reads '0' (after all blisters have been used), whichever comes first. Observation and Staff Interviews: The treatment cart was observed with registered nurse (RN) #1 on 3/21/17 at 2:59 p.m. There were two outdated Advair diskus in the treatment cart. The Advair 250/50 diskus for resident #37 had an open date of 2/12/17 (which would have been outdated on 3/15/17). There were 41 doses of the medication remaining. The Advair 250/50 diskus for resident #13 was dated with an open date of 10/29/16 (which would have been outdated on 11/28/16) and had 12 remaining doses. The RN said she was not aware the medication was outdated one month after being removed from the protective foil overwrap. The RN read the side of the Advair box and agreed the manufacturer directed the remaining medication was to be discarded one month after removal from the foil overwrap. LPN #2 approached and requested an interview on 3/21/17 at 5:55 p.m. The LPN said she had not administered the outdated Advair to resident #37 as she had a new, open Advair on the medication cart. The LPN said she knew Advair was outdated one month after opening. The LPN said outdated medications should be removed from the medication and treatment carts to prevent them being given in error. The LPN did not provide any information about resident #13's outdated Advair. Record Review: A review of the 3/17 treatment administration record (TAR) for resident #37 demonstrated the resident had an order for [REDACTED]. A review of the 3/17 TAR for resident #13 demonstrated the resident had an order for [REDACTED].

Based on observations and interviews, the facility failed to follow proper infection control procedures to ensure safe and sanitary conditions were maintained to prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Sanitize resident rooms in a manner to reduce the spread of infections; and -Store contaminated items in a sanitary manner. The findings included: 1. Unsanitary housekeeping practices Observations On 3/23/17 at 8:31 a.m., housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER] on the east hallway. She donned gloves outside the room and located a rag and cleaning disinfectant spray. -At 8:32 a.m., HK #1 entered the restroom of room [ROOM NUMBER]. She sprayed the sink and toilet with the cleaning spray. She placed the spray and rag on the resident dresser. -At 8:33 a.m., HK #1 located the broom from her cart and began to sweep the room. She started from the back of the room to the egress door. -At 8:39 a.m., the HK sprayed the rag with the disinfectant solution. She used the rag to wipe the dresser of bed A. The HK then walked over towards bed B area and began to spray the rag with disinfectant to wipe bed B's over the bed tray table. The HK did not address frequently touched items such as the bedside call light, remote control, or light switches. -At 8:41 a.m., HK #1 disposed of the rag used to clean sides A and B of room [ROOM NUMBER]. She returned to the restroom and sprayed a paper towel with the disinfectant. She used the paper towel to wipe down the paper towel dispenser. -At 8:42 a.m., she used a small brown scrub pad to clean the sink. More disinfectant was sprayed into the sink as she scrubbed the bowl. The HK used the scrub pad on the grab bar beside the light switch and then sprayed the toilet seat and bowl again with disinfectant spray. The HK had a toilet brush she used on the toilet seat and then into the toilet bowl. The HK shook the brush out in the bowl and then placed it back into the designated container. The light switch, restroom call light and toilet handle were not cleaned or sanitized. -At 8:44 a.m., HK #1 went to her cart and located a rag. She returned to the restroom with disinfectant spray and into the rag sprayed the disinfectant and wiped down the top and then bottom of the toilet seat. -At 8:46 a.m., she wiped down the door knobs in the room. -At 8:51 a.m., the HK stated she was finished with room [ROOM NUMBER]. She did not perform hand hygiene after she exited the room. -At 8:53 a.m., the HK entered room [ROOM NUMBER] with disinfectant spray. She sprayed the toilet and sink in the restroom. -At 8:56 a.m., the HK began to sweep the room from the back towards the egress door. There were two spiders and two ants she swept into her pile to go into the trash. -At 8:59 a.m., HK #1 sprayed disinfectant into a dry rag and began to wipe down side A and side B of the room. She did not switch rags between separate sides of the room. She did not clean or sanitize any call light cords, light switches, or remote controls. -At 9:03 a.m., the HK used the toilet brush to scrub the seat then bowl. The toilet brush was the same brush used on the toilet seat and bowl in room [ROOM NUMBER]. The regional housekeeping manager (RHM) observed the cleaning practice of the HK. -At 9:05 a.m., the HK sprayed the rag with the disinfectant to clean the door knobs and grab bar in the restroom. She did not clean or disinfect the call light cords or toilet handle. Interviews: HK #1 was interviewed on 3/23/17 at 9:09 a.m. She said she used disinfectant to kill germs and sanitize rooms. The HK did not know the span of time needed for the disinfectant to properly sanitize surfaces. When the bottle was observed, the HK stated the kill time was ten minutes. The HK stated she sprayed the rags and wiped down surfaces. She confirmed spraying the rag and wiping did not meet the ten minute requirement. The HK acknowledged she missed commonly touched surfaces in the room and used the same rags throughout the room. The HK stated moving forward, she would spray all surfaces with the disinfectant to allow for the proper kill time, sanitize all frequently touched surfaces, and switch rags between sides of the room. The HK also acknowledged the toilet brush should only be used in the toilet bowl and not the seat to prevent infections from spreading. The RHM was interviewed on 3/23/17 at 9:15 a.m. The RHM acknowledged infection control issues during the observation related to the toilet brush and its use around the seat and bowl. The RHM stated the facility would consider keeping rags in sanitizing solution for staff to clean and sanitize surfaces in addition to following the kill time requirements of ten minutes. The RHM stated all frequently touched and horizontal surfaces should be cleaned and sanitized according to the manufacturer recommendations. He stated the HK should also perform hand hygiene when going from room to room to prevent spreading potential infections. 2. Contaminated item storage Observations: room [ROOM NUMBER] west was observed on 3/21/17 at 5:16 p.m. There was a toilet plunger stored directly on the floor next to the toilet. The plunger remained next to the toilet on 3/22/17 at 4:25 p.m. room [ROOM NUMBER] west was observed on 3/22/17 at 9:30 a.m. There were two toilet plungers stored directly on the floor next to the toilet in this four-resident room. The plungers remained next to the toilet on 3/22/17 at 4:27 p.m. room [ROOM NUMBER] west was observed on 3/21/17 at 4:53 p.m. There was a toilet plunger stored directly on the floor next to the toilet. The plunger remained next to the toilet on 3/22/17 at 4:28 p.m. room [ROOM NUMBER] east was observed on 3/22/17 at 9:27 a.m. There was a plunger stored on the floor by the toilet in the bathroom. The plunger remained next to the toilet on 3/22/17 at 3:59 p.m. Interviews: The nursing home administrator (NHA), who was a registered nurse and the building's infection preventionist, observed room [ROOM NUMBER] west on 3/22/17 at 4:44 p.m. and 5:19 p.m. The NHA said the plunger was not bagged. The NHA said the plunger should not be stored in a resident room, but if it were, it should be in a bag or other receptacle to contain germs. The NHA agreed that plungers were not placed in toilets that were clean and functioning properly, thus the plungers were likely to be contaminated with germs and toilet matter. The NHA acknowledged there were multiple rooms with unbagged plungers stored on the floor. According to the NHA, the housekeeping manager had placed plungers in resident rooms due to a misunderstanding.

Based on observations, interviews and record review, the facility failed to provide a resident call system that consistently relayed calls for assistance to facility staff. Specifically, the facility's resident call system did not maintain consistent function resulting in an unpredictable loss of service in resident rooms and bathrooms. The findings included: Observations: Room #7 west was observed on 3/21/17 at 4:53 p.m. The bathroom call light was designed for activation by pressing the button on the wall or by pulling on the cord attached to the call box. The call light would not activate by use of the cord. Room #9 west was observed on 3/22/17 at 10:01 a.m. The bathroom call light did not activate from pull cord or from the button on the wall. Room #11 west was observed on 3/22/17 at 9:59 a.m. The bathroom call light would not activate from the pull cord or from the button on the wall. Room #1 east was observed on 3/21/17 at 3:39 p.m. The bathroom call light would not activate from the pull cord after multiple attempts. The call light was able to activate from the push button; however, the light above the door in the hall way did not illuminate to show staff the resident in the room required assistance. Room #4 east was observed on 3/22/17 at 9:57 a.m. The call light in the bathroom did not have a pull cord for use by residents with range of motion or other limitations that would make pushing a button on the wall for service problematic. Room #6 east was observed on 3/21/17 at 4:11 p.m. The cord on the call light in the bathroom detached from the call light at attempted activation. The bathroom call light did not activate. Maintenance was informed of the call cord and call light malfunction. Room #11 east was observed on 3/22/17 at 9:23 a.m. The call light in the bathroom was missing the pull cord. The call light did not activate when checked. Room #13 east was observed on 3/22/17 at 9:46 a.m. The room call light was pulled out of the wall and would not activate. Family Interview: A family member of a resident at the facility requested an interview on 3/23/17 at 4:26 p.m. The family member reported the call lights at the facility were faulty and not reliable. According to the family member, the resident had become trapped on the toilet because his bathroom call light ceased to work. The family member said the resident reported being on the toilet for eight hours. The family member felt the resident was not a good timekeeper, but believed that the resident had a prolonged stay in the bathroom due to the broken call light. Staff Interviews: Certified nurse aide (CNA) #2 was interviewed on 3/22/17 at 4:34 p.m. The CNA was asked to observe the bathroom call light in room #9 west. The CNA said the call light did not work. The CNA said there was a resident that used the bathroom who was known to self-toilet and make calls for assistance from the bathroom. The CNA said the bathroom call lights should work. The CNA said the call light system was glitchy. The CNA said she reported call light problems to maintenance and maintenance would fix the problem. The CNA said she did not go far if a resident was in the bathroom, in part, because she was not sure the call light would work when the resident finished and needed help. The CNA usually waited outside the bathroom door. The administrative assistant (AA) and transportation staff member were asked to observe room #6 east on 3/22/17 at 4:50 p.m. The AA and transportation staff said the call light in room #6 east was not working properly. The maintenance supervisor (MS) and nursing home administrator (NHA) were interviewed on 3/22/17 at 4:58 p.m. and 5:53 p.m. The MS said he audited the call lights twice weekly, but the system would drop call lights without explanation or predictability. The MS said he was available 24/7 to address call system problems and that he lived near the facility. The MS said he was able to make the system work; however, the fixes were not able to be maintained. The MS said he worked at least five hours every week resetting call lights, the resetting callboard and reprogramming devices for the call system. The NHA said the call light system was approximately five years old. The NHA agreed the resident call system was not reliable because call lights would lose function without explanation. The NHA said the facility did frequent checks on residents because the call light system was not reliable. The NHA said the facility had contacted a vendor to come and service the call light system. The vendor would be in the next day. Record Review: A review of maintenance records showed the call light in room #6 east had been repaired on 3/21/17. (See staff interview with AA above showing the call light was malfunctioning again on 3/22/17 at 4:50 p.m.) A review of call light function audits demonstrated the maintenance staff was checking and repairing the resident call system weekly and as needed. The accompanying logs showed SNF (skilled nursing facility) (call light system) consistently needing reset and rooms reprogrammed as a comment in the audit log for the call light system. Facility Follow-up: A vendor was observed on 3/23/17 at 8:22 a.m. working with the MS on the call light system. At survey exit on 3/23/17 the NHA reported the facility would be getting an entirely new call light system to ensure consistent call light access.

Based on record review and interviews, the facility failed to complete, timely, a significant change comprehensive assessment for one (#57) of three residents reviewed for discharge to the hospital within 30 days of nursing home admission. Specifically, the facility failed to complete and submit a change of condition minimum data set assessment (MDS) within 14 days of returning to the facility after discharge to the hospital and acceptance into hospice care. The findings included: Resident Status: Resident #57, age 88, was admitted on [DATE]. According to the ,[DATE] computerized physician orders [REDACTED]. The [DATE] admission MDS comprehensive assessment demonstrated the resident did not have a life expectancy of six or fewer months. The resident was not receiving hospice services. The resident had received five days (240 minutes) of occupational therapy and five days (260 minutes) of physical therapy. Staff felt the resident was capable of improved independence with activities of daily living (ADLs). The resident was dependent on staff for eating, oral hygiene and toileting. The goal was for the resident to improve to set-up or clean-up only assistance from staff related self-performance of eating, oral hygiene and toileting. A [DATE] discharge MDS assessment demonstrated the resident had an unplanned discharge to an acute care hospital on [DATE]. The resident was expected to return to the facility. Record Review: A review of the [DATE] hospital discharge record revealed the resident was being discharged from the hospital back to the facility. The hospital documentation said the resident had end-stage [MEDICAL CONDITION] and was admitted to hospice care. The [DATE] hospice records documented the resident was admitted to hospice with a primary [DIAGNOSES REDACTED]. The clinical record documented the resident was readmitted to the facility on [DATE] under hospice care. A significant change MDS related to the resident's change in health status was not identified in the clinical record. The mortuary release demonstrated the resident expired on [DATE]. Copies of clinical record were requested in writing on [DATE]. The facility did not provide the requested copies during survey or during the post-survey exit. State MDS Coordinator Interview: The state MDS coordinator was interviewed on [DATE] at 2:06 p.m. The state MDS coordinator said the facility would be expected to complete a significant change MDS for the resident because the resident was discharged from the facility with return anticipated and the resident experienced a change in health status that would necessitate interdisciplinary care planning that comes from the MDS review process. The state MDS coordinator said based upon the date of readmission to the facility and admission to hospice, the facility should have already submitted a change of condition MDS. Staff Interview: Registered nurse (RN) #1, who served as the facility's MDS coordinator, was interviewed on [DATE] at 4:01 p.m. The RN said she should have submitted a change of condition MDS for the resident; however, she had not. The RN said she had completed the significant change MDS on paper but had forgot to enter it into the computer and it had become lost on her desk. Review of the paper MDS section J and section O was requested at that time. The RN did not provide section J or section O for review. The facility did not produce for review the handwritten MDS either during survey or during the post-survey grace period. The nursing home administrator (NHA) was interviewed on [DATE] at 6:34 p.m. The NHA stated she expected RN #1 to submit MDS assessments as required. The NHA said the facility had access to a corporate MDS consultant, so staff was familiar with how and when to do MDS assessments.

Based on record review and staff interviews, the facility failed to update and personalize the care plan for two (#50 and #36) of 29 sample residents. Specifically, the facility failed to: -Update resident #50's care plan after a fall; and -Personalize generic care plans for resident #36 related to socialization and psychosocial well-being. The findings included: 1. Resident #50 Resident #50, age 83, was admitted on [DATE] and readmitted on [DATE], after being discharged to the hospital following a fall resulting in a fracture on 3/5/17. According to the 3/17 computerized physician orders [REDACTED]. According to the 3/15/17 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance of one to two staff for most of her activities of daily living (ADL). According to the 5/4/16 care plan, the resident had a history of [REDACTED]. Goals were: No falls times 90 days, will transfer safely to and from all surfaces with (blank) assist times 90 days; and will have no significant injury related to falls times 90 days. Interventions included: Rule out complications with increased falls such as oxygen saturation, blood sugars or urinary infection; -Notify the physician and family of all falls or injuries; -Periodic medication review; -Ensure safe environment, free of clutter, adequate lighting, and clean spills promptly; -Transfer with assist of (blank); -Ensure appropriate specialty/air mattress settings at (blank) every shift; (resident did not have a specialty/air mattress); -Neuro checks per facility protocol for any suspected head injury; -Attempt to identify a root cause for falls; -Fall assessment on admission, quarterly and with changes or falls; -Ensure appropriate footwear when out of bed; -Call bell in reach; -Provide adequate lighting; -Keep assistive device within reach; -Clean and apply glasses daily as appropriate; ophthalmology referrals as deemed necessary; and -Physical therapy to evaluate and treat as indicated. Record Review According to the 2/4/17 fall risk assessment, the resident scored eight indicating high fall risk. According to the 3/6/17 nurse's note at 7:32 a.m. the nurse was summoned to the resident's room and observed the resident lying on the floor next to her bed. The resident was in obvious distress due to pain in her right arm. The resident stated she went to answer her phone and did not lock her brakes. Her range of motion was within normal limits to all extremities except for her right arm. She rated the pain a ten out of ten. She was alert and oriented times three. Her grips to left hand were strong. Pupils were equal and reactive to light. No bruising, swelling or redness observed. However she was wearing a long sleeve sweater and due to intense pain, assessment of right arm could not be completed. The resident was stabilized and left with a certified nurse aide (CNA) while the nurse called the nursing home administrator (NHA) who was also a registered nurse (RN) and interim director of nursing (IDON). She instructed the nurse to notify the physician. A call was placed to the hospital on-call physician and orders were received to send the resident to the emergency room via ambulance. A call was placed to the resident's daughter, who met the resident at the hospital. All paperwork was sent to the hospital and report was called to the emergency department. A call was received later from the hospital that the resident was being sent to another hospital for a surgery consult because she had a fracture to the right humerus head. The resident was re-admitted to the facility on [DATE]. Another fall risk assessment was completed. The resident continued to have a score of eight indicating she was a high fall risk. Review of the resident's care plan on 3/23/17 revealed that it was not updated with the fall on 3/5/17 with new interventions. 2. Resident #36 Resident #36, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the 3/17 CPO, [DIAGNOSES REDACTED]. According to the 1/15/17 MDS assessment, the resident had severe cognitive impairment and was unable to complete the BIMS assessment. Record Review Socialization care plan The resident's 11/4/16 care plan was reviewed and revealed that it was incomplete/inaccurate for socialization and psychosocial well-being as follows: Alteration in socialization as evidenced by (AEB): (blank) with additional risks related to (blank) -Smoker (the resident did not smoke) -May go out on physician authorized therapeutic visits Goals: Will be accepting of room visits as needed to supplement out of room activity Interventions: -Offer scheduled of activities for the resident to select choices; -Engage resident in group activities; -Provide transport to and assistance for engagement as needed; -Give resident verbal reminders of activity before commencement of activity; -Offer activity programs directed towards specific interests of resident; -Assist resident in planning leisure time activities; -Resident enjoys (blank); -Review smoking policy with resident annually and as needed with concerns; -Report smoking related concerns promptly, intervene as appropriate, reassess smoking privileges at least quarterly and as needed with concerns; and -Offer/assist with smoking cessation as requested or clinically indicated (the resident was not a smoker). Psychosocial Care Plan The resident's 11/4/17 care plan (wrongly dated), revealed the resident was at risk for alteration in psychosocial well-being related to (blank). Resident meets criteria for serious mental illness/developmental or related condition subject to preadmission screening and resident review (PASRR) requirements as evidenced by (blank). Interventions included: Encourage participation in facility life; -Invite to care plan meetings; -Honor right to refuse; -Explain risk/benefits of unconventional choices; -Encourage appropriate decision making (resident had severe cognitive function per MDS); -Allow/encourage the resident to express feelings related to current condition as needed; -Elicit the support of family/friends to assist resident with difficult or complex decision making; -Provide one on one emotional support as needed; -Assess ability to self-administer medications as appropriate; (resident had severe cognitive function per MDS); -Notify physician, family responsible party as needed; -Address interventions from PASRR level II; -Conservator/Guardian appointed: (name and contact information blank); -PASRR level II recommendations related to: (blank); and -Outline PASRR driven services related to: (blank). Staff interview The DON/interim NHA was interviewed on 3/23/17 at 11:05 a.m. She said the computer generated a generic care plan that couldn't be updated so the facility printed a copy of the care plan and placed it in a binder that was updated manually as needed. She said the facility had not had an opportunity to update all of the paper care plans yet. She agreed that the care plans were incomplete.

Based on observations, interviews and record review, the facility failed to ensure residents remained as free from accident hazards as possible. Specifically, the facility failed to ensure one (#16) of three sample residents received thorough investigations and implementation of interventions after two incidents. The findings included: Facility Policy: A review of the 10/15 incident and accident process policy revealed, Unusual occurrence events, incidents and accidents noted by facility staff will be reported to the nurse caring for the resident for completion of the incident report in the electronic health record. Notification of physician and responsible party will be noted on each form .incident reports will be reviewed in daily meeting and assigned for follow-up and investigation. Investigations are done in a systematic manner: Identify hazards and risks; evaluate and analyze hazards and risks; implement interventions to reduce hazards and risks; monitor for effectiveness and modifying interventions when necessary. Interdisciplinary Team will review risk, appropriate interventions and trends at least weekly for those residents with falls and other accident related injuries Follow-up for all incidents and related change of conditions will be noted on the 24hr report for a minimum of 72 hours and documented in the medical record. Resident Status: Resident #16, age 98, was admitted on [DATE]. The 3/17 computerized physician orders [REDACTED]. According to the 2/15/17 minimum data set (MDS) assessment, the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required extensive assistance with bed mobility, transfers, ambulation on/off the unit, dressing, toileting, and personal hygiene. There were balance concerns moving from seated to standing position, walking, moving on and off toilet, and surface to surface transfers. She was occasionally continent of urine and always continent of bowel. The resident did not have a surgical wound, burn, skin tear, or moisture associated skin damage. The resident had no falls since the previous assessment. Stage One Staff Interview: Licensed practical nurse (LPN) #2 was interviewed on 3/21/17 at 4:40 p.m. She stated the resident fell on [DATE] and the fall resulted in injury. The LPN said the resident had bruising on her face and arm due to the fall. Record Review: a. Care plans A review of the resident's 2/10/16 fall care plan revealed the resident was at risk for injury from falls related to history of falls. -The goals were the resident would transfer safely to/from all surfaces and have no significant injury related to falls. -Interventions included: rule out medical complication with increased falls by obtaining oxygen saturations, blood sugar, and urine analysis; notify family and physician of falls or injuries; therapy screen. A review of the 2/10/16 skin care plan revealed the resident was at risk for impaired skin integrity related to limited mobility without assistance and incontinence. -The goal was the resident's skin would remain intact. She would also remain free from additional skin breakdown. -Interventions included: Weekly skin checks; therapy screen as needed for concerns; nurse would document daily on any aspects of wound healing included but not limited to positioning, nutrition, hydration, pain, dressing, lab work; hematoma to left forehead would heal without complication; bruise to left wrist would heal without complication. b. 3/8/17 Incident Report (IR) A review of the 3/8/17 IR revealed the resident suffered a fall with head injury. She was in her room, got up from chair without assistance, and lost her balance. She fell hitting her head. A nurse was coming down the hall and heard the resident yelling. The nurse found her on the floor inside her room. The resident had a hematoma to the left frontal lobe and eye, a red area two centimeters by two centimeters (cm) on left wrist. -Immediate Action taken was physical assessment, vitals, and resident transported to the emergency room . The resident expressed pain. -The IR showed the physician and family were notified. There were no signatures the incident report was reviewed. c. 3/8/17 Situation, Background, Assessment, Request (SBAR) form A review of the 3/8/17 SBAR revealed the resident was found on the floor. She hit her head and left wrist. She rated her pain five out of five. Her status was worse by movement. The nurse's assessment was head trauma. d. 3/8/17 Fall Risk Assessment A review of the 3/8/17 fall risk assessment revealed resident was a high fall risk. There were no comments included on the assessment. e. Departmental Notes A review of the departmental notes from 3/1/17 through 3/23/17 revealed no note summarizing the unwitnessed fall on 3/8/17. There were no notes of a post fall review, an interdisciplinary review or investigation of the event. -The notes discussed bruising to left eye but did not discuss left wrist, left frontal lobe or abrasion of location unknown. -On 3/20/17, the resident's daughter concerned with bruising to right wrist still there from fall, and requested an x-ray, although the resident's left arm was identified in the skin assessment (see below). f. Skin Assessments The facility was asked to provide skin assessment documents from the 3/8/17 incident while on survey. A wound healing progress report from 3/1/17 through 3/22/17 revealed monitoring for bruise to left eye and bruise to left forearm. The facility failed to present any documentation to show skin assessments with measurements of the left frontal lobe and abrasion were monitored or tracked. A wound healing progress report from 3/7/17 through 3/22/17 reported a left eye bruise and bruise to left forearm measured on 3/8/17 and 3/15/17. There was no mention of monitoring the frontal lobe or abrasion, location unknown. g. 3/8/17 Incident Investigation A review of the incident investigation revealed the resident got up from bedside chair she normally did not sit in without assistance. The charge nurse heard the resident calling out and responded. The nurse found the resident on the floor. The family requested the removal of the bedside chair. The staff were informed to not have the resident out of bed more than ten minutes before activities and meals. A therapy fall screen was requested and resident was offered to move closer to the nurse station but declined. h. Therapy Fall Screen There was no fall screen performed after the resident fell on [DATE]. Interviews: A certified nurse aide (CNA) #1 was interviewed on 3/22/17 at 3:42 p.m. The CNA said she worked the day the resident fell and was found on the floor. She said she was not the person to find the resident. The CNA stated the resident had noticeable bruising to her face after the fall. LPN #3 was interviewed on 3/23/17 at 10:02 a.m. She said she was not working on the floor the day of the fall but was at the facility. She said a nurse found the resident and called for an ambulance for transport to the emergency room . The LPN said there was a fall packet for nurses to use after a resident fall. The LPN stated neuros, vitals, pain, fall screen, fall investigation and a nurse's note were a part of the procedure. The LPN stated because they transported the resident to the hospital, not all items were completed timely. The LPN reviewed the incident report and revealed the resident had an identified hematoma to left frontal lobe and left eye, a red area on the left wrist. The LPN confirmed the documentation provided only showed monitoring of a left bruised eye and left forearm bruise and it would be expected to have all areas monitored and measured. She stated there was no information about a left wrist, left frontal lobe, or abrasion. The LPN confirmed the resident had a right wrist x-ray. She said the x-ray returned negative on 3/20/17. The LPN stated it was unknown why the right wrist x-ray was performed when the resident had a red area of the left wrist documented after the fall 3/8/17. She said she would follow-up. The physical therapist (PT) was interviewed on 3/23/17 at 10:34 a.m. The PT stated he was not a part of the resident's fall review. He stated he did not screen the resident's room after she fell . He stated the family did not want her to be screened. LPN #2 was interviewed on 3/23/17 at 11:31 a.m. She said the protocol after a fall was to assess for critical conditions, vitals, neuros, make sure the resident was stable, fill out an incident report, fill out an SBAR, and conduct a pain assessment. She said a fall investigation was started to see how the fall happened, care plan updated, recommend therapy screen, and skin sheet started if skin condition was identified. She said the administrator and family were notified. She stated all these steps were taken to identify and prevent further falls. Facility Follow-up: On 3/23/17 at 2:22 p.m., LPN #3 provided additional documents for review. She stated on 3/20/17, the resident's right wrist was examined with use of an x-ray. The LPN said on 3/20/17, the resident experienced a separate incident from the 3/8/17 fall although there was no documentation available in departmental notes. There was no SBAR, no pain evaluation, and no IR to show the incident had occurred. Also, there was no skin assessment until after the interview for clarification when discrepancies with documentation were identified. The LPN could not explain why the incident report stated the physician and family were notified on 3/23/17 when it was the daughter who brought the issue to the nurse on 3/20/17 and requested an x-ray when she thought it was due to the fall on 3/8/17. -Additionally, a skin inspection report pulled from 3/1/17 through 3/23/17 now revealed a skin assessment from 3/20/17. The 3/20/17 skin assessment was not present on the initial skin inspection report provided on 3/22/17 from the facility. Furthermore, a wound healing progress report from 3/1/17 through 3/23/17 was pulled and the progress report now had hematoma to left temple, bruised forehead, bruise to left forearm, and bruise to right wrist. The bruise to left eye was removed. There were documented measurements of the forehead with no change and hematoma to left temple with no change between 3/8/17 and 3/23/17. LPN #2 was interviewed on 3/23/17 at approximately 2:30 p.m. She reviewed the skin inspection report and wound healing progress reports provided on 3/22/17 and 3/23/17 and confirmed they were different although the span of time had remained the same. The LPN could not explain the discrepancies of the documents. LPN #3 was interviewed again on 3/23/17 at 4:28 p.m. She stated the investigations were not thorough and did not provide sufficient information of an investigation performed with follow-up of a committee to determine how to prevent falls, increase safety, and reduce additional incidents of skin issues. The LPN expressed problems with the electronic health record system could have also contributed to problems with monitoring of skin conditions and incidents of where and when skin conditions originated.

Based on record review and interviews, the facility failed to report and/or investigate allegations of abuse for two of seven sample residents (#2 and #3). Specifically, the facility failed to report to the State agency in the required timeframe, and failed to thoroughly investigate the allegation of resident to resident abuse. Resident #3 was observed days later with physical injuries that required hospitalization , but were not documented until reported by an outside authority. -Cross-reference to F323: Resident #2 and #3 were both noted with behaviors; however, the facility failed to implement interventions to ensure residents were safe. Resident #2 and #3 were in an altercation which was witnessed by staff and new interventions and monitoring were not put into place to ensure residents were not abused. The findings include: A. Facility Policy of Reporting Abuse to Facility Management (in pertinent part): -It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. -Employees, facility consultants and/or attending physician must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. -Failure to report such an incident may results in legal/criminal action being filed against the individual(s) withholding such information. -Revised April 2011 B. Resident #2: Resident #2, age [AGE] years, was admitted on [DATE] [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment dated [DATE] recorded the resident with a BIMS (brief interview for mental status) score of eight, indicating moderate cognitive impairment. Record Review: -There were no progress notes prior to or after the resident to resident abuse occurring on 8/18/15, in the resident's chart. -The resident was care planned to monitor for behaviors due to [DIAGNOSES REDACTED]. No behaviors were documented for the resident at the time of the abuse incident. The care plan was not updated to include the incident with resident #2 that inflicted serious injuries (see documentation below). C. Resident #3: Resident #3, age [AGE] years, was admitted on [DATE] and readmitted from the hospital 9/2/15 with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] recorded the resident with a BIMS score of eight, indicating moderate cognitive impairment. The resident was not documented with behaviors on the MDS. The resident required extensive assist of two people for transferring, and extensive assistance of one person for locomotion on and off the unit. Record Review: -There was no documentation in the resident's record to indicate that the staff observed bruising on the resident's face or chest. The resident had a skin check on 8/19/15, and was scheduled showering during the week; however, nothing was documented until 8/23/15 when the resident was sent to the hospital and questioned about the bruising. -There were no progress notes on 8/18/15 of the incident of abuse. The first documentation in progress notes of abuse occurred on 8/23/15, the day the resident was sent to the hospital. The progress notes on 8/23/15 were late entry comments after the resident discharged . These were: 8/23/15 3:03 p.m.-Wife reported to this nurse that resident told her he got into a fight with another resident. Is that true? He has a bruise under his eye. This nurse informed the wife that I have no knowledge of an incident between this resident and another. Went to assess resident and did not note any bruising to eye or eyes. 8/23/15 3:16 p.m. - CNA reported seeing a bruise to left cheek. This nurse noted resident lying on back in bed with yellow emesis (vomit) to shirt. CNA noted a moon shaped bruise to upper chest, faded blue and outlined yellow. Also a bruise to lower left cheek. Etiology (cause) of bruises unknown. D. Hospital Records of Resident #3 noted in pertinent part: -On arrival at the facility on 8/23/15 the emergency responders noted bruising on the resident, and when they inquired about the bruising the staff was not aware of the presence or cause of bruising. -Hospital Report: admission date of [DATE] at 9:50 a.m. -Contacted nursing home nurse about bruising. Nursing home unable to give report on bruising. Nurse stated, there is no documentation available on this. It was just reported to me. -Hospital Charting 8/23/15 at 9:55 a.m. - Bruising noted on patient chest and under left eye. Asked patient what happened, patient states I was in a fight. When asked with who patient not able to tell. E. Incident of Resident to Resident Abuse, and Investigation (in pertinent part): From 8/18/15 to 8/24/15 the facility did not have documentation or evidence of investigation of resident #3's injuries. -On Monday, August 24, 2015, the facility administrator (NHA) assessed the pictures of resident #3's injuries. The administrator chose to continue investigation as the bruises were yellow in color and that would indicate that these bruises were more than two days old. The NHA's investigation documented: -The Dietary Aide stated that she had witnessed resident #3 hit resident #2, and then resident #2 hit resident #3 in the back on August 18, 2015 at 4:30 p.m. This aide stated they then told the charge nurse. -The charge nurse (RN) stated she went and immediately assessed the situations and both residents. Physical assessments showed no injury to either resident, and neither resident complained of pain. When asked why she did not follow policy on reporting abuse immediately, she stated that she got busy and forgot and she did not feel that the incident was that big of a deal. She stated she knows the policy and should have followed it. -When the occurrence was brought up by the victim (resident #2) to the activities staff member (AA) three days later, the activity staff member failed to report the incident to the abuse coordinator. -A CNA was interviewed who was on duty the week of the incident. He had stated he did have an incident with the lift when transferring resident #3. On August 19, 2015 at 9:15 p.m. he had resident #3 in the sit to stand lift, and (the resident) almost fell out of the lift due to the fact he would not bear weight. The strap on the lift rose up on (the resident's) chest and (the CNA) tightened it to prevent (the resident) from falling. After reviewing the photos and creating a mock situation of the incident with the lift, the facility concluded that this would be consistent with the bruises found on chest. The investigation did not conclude the cause or the date of resident #3's facial bruising. F. Abuse Reporting Failures: -The progress notes for resident #2 did not address a resident to resident altercation, which included hits to both residents. There was no documentation of skin checks or neurological checks for either resident despite the potential for head injuries. -The dietary staff member reported the observed incident to the charge nurse, who did not follow up appropriately with resident assessments, family, administration and police notification or documentation. -Resident #2 informed the AA three days later of the incident, and it was still not reported. -Resident #3 had no documentation of the incident in his chart, and no skin or neurological checks done. -Resident #3 was sent to the emergency room for a change of condition five days after the occurrence. The ambulance staff and the admitting physicians at the hospital immediately noted the bruising to the resident's cheek and chest. The nursing staff was contacted by the hospital. According to the hospital report, the nursing staff at the nursing home stated they were not aware of bruising or how it could have happened which was contradictory of the late entry progress notes for resident #3 (see nursing notes above). -Both the AA and the RN were documented as stating they did not report potential abuse in a timely manner when interviewed by the NHA during the abuse investigation (started six days after the occurrence). -Interviews noted below indicated that the facility continued to have difficulty identifying and appropriately reporting incidents of potential abuse. G. Interviews: On 9/8/15 at 3:15 p.m. the nursing home administrator (NHA) stated that due to the failure to report the recent resident to resident abuse in a timely fashion, the facility was now reporting everything, even if it did not necessarily qualify as potential abuse. The NHA stated that the facility would be having abuse training for the facility staff that week. On 9/8/15 at 3:37 p.m. a local law enforcement officer was interviewed regarding the facility's abuse reporting. The officer stated that the facility was now reporting things to the police that did not qualify as allegations to report. The law enforcement officer stated that due to the reported issues, the facility did not demonstrate an understanding of current guidelines defining abuse and potential abuse. On 9/8/15 at 4:18 p.m. the NHA confirmed that she was confused as to what to report. The NHA said that the person that would be coming to train the staff on abuse reporting would be coming from an outside source. On 9/8/15 at 4:40 p.m. a frequent visitor was interviewed regarding the facility's abuse reporting. The visitor stated that she was not aware of any abuse training for the staff, but that she was aware of the recent concern with the abuse reporting. The visitor stated they understood the facility would be providing training to the staff on abuse reporting soon. On 9/8/15 at 5:28 p.m. a certified nursing aide (CNA) #1 stated that although she had been a CNA for an extended period of time, she had not worked at the facility for very long. The CNA stated that she had been required to watch videos for her orientation, and then had quizzes. The CNA said that the orientation covered abuse, and that she would need to separate the people involved, and report the issue to the charge nurse if abuse occurred. On 9/8/15at 5:35 p.m. CNA #2 stated that she had worked at the facility for over a year. The CNA stated there was monthly training, and that they have trained on abuse before. The CNA stated if there was a concern with a resident or any abuse, they would report it to the nurse. The CNA stated that the facility had a committee that would get together to discuss these concerns, and then they would come up with ways to fix the issues. The CNA said that once the facility staff determined how to resolve a resident or abuse concern, the staff would let the CNAs know. The CNA stated she was familiar with the Elder Abuse Act, but could not recall when she last had abuse training. On 9/8/15 at 6:15 p.m. the NHA confirmed that she had provided abuse training for the facility staff before, but that the staff did not properly report the resident to resident abuse incident between residents #2 and #3 on 8/18/15. On 9/9/15 from 8:30 a.m. to 9:15 a.m. a local law enforcement officer assigned to the investigation of resident #3's bruising was interviewed. The officer stated when he arrived at the facility in response to an emergent call he saw the resident had yellow bruising on the face which were immediately visible. The officer stated that the facility staff stated that they did not know anything about the resident's visible bruising, and could not find any documentation about the bruising. The facility had informed the officer after they began their abuse investigation that they had believed resident #3 had been possibly injured due to a lift that was used on the resident earlier in the week. The officer stated that a recreation investigation of the lift and resident #3 revealed that the lift was not the cause of the bruising or the rib fractures. The officer stated that the bruising to resident #3's chest and face were all consistently yellow and indicated similar days of healing had already begun when the incident was reported. The officer stated that when they began their official abuse investigation the records for residents #2 and #3 had very little documentation. The officer stated that the facility was observed writing in late charting related to the incident. The officer confirmed after the police began their investigation, the facility could not provide resident records in a timely fashion. The officers served a warrant to the facility three days later to formally request the residents' records for review. The officer confirmed that the AA and the RN were both cited for failure to report a potential abuse allegation. On 9/9/15 at 10:15 a.m. housekeeper #1 stated that she did not recall getting any abuse training from the facility. The staff member stated they recalled getting training related to housekeeping duties, but not related to abuse concerns. On 9/9/15 at 10:28 a.m. CNA #3 stated that they had been employed at the facility for a year. The CNA stated they had abuse training when they started, including who to report to. About two weeks ago the facility posted an abuse training that was mandatory on 9/9/15 that she would be attending. On 9/9/15 at 11:15 a.m. a certified occupational therapy assistant (COTA) stated that they had worked at the facility for a number of months, under a therapy contract. The COTA confirmed that they had not had any abuse training until the previous week. The COTA stated the abuse training was in generalized terms, nothing too specific. On 9/9/15 at 11:48 a.m. the AA was interviewed regarding the incident between resident #2 and resident #3. The AA stated that she was notified by the resident on 8/21/15 that he had been in an altercation. The AA had not reported the issue because they did not think the resident was reporting a current issue, and the AA was caring for another resident at the time. On 9/9/15 at 12:00 p.m. resident #2 was interviewed about the altercation with resident #3. Resident #2 stated that resident #3 was trying to get past him in his wheelchair. The resident said that he thought resident #3 got caught on his chair, got mad, and then started swinging at him. Resident #2 stated he then began to swing back at resident #3. Resident #2 confirmed that he hit resident #3 on the face, and resident #3 hit him back on the face. The resident confirmed he was not hurt in the altercation, and did not think resident #3 recalled the situation that had occurred. On 9/9/15 at 1:50 p.m. the RN involved in the investigation was interviewed regarding the abuse incident between residents #2 and #3. The RN confirmed she had abuse training when she was hired, but she felt it consisted of telling her that if she suspected abuse she should report it to the NHA. The RN said that on the Tuesday (8/18/15) when resident #2 and resident #3 got in the fight, a dietary aide came and reported to her that the situation had occurred in the dining room. The RN said that when she went to the residents, the fight was over. The RN said she was informed that resident #3 was trying to get around resident #2 in his wheelchair, but had become stuck. The RN confirmed she did not believe it was abuse because she did not observe any marks on either resident, and neither said they had pain. She stated that she looked them over but did not think it was abuse. The RN said that it was reported that both residents were hitting each other in the face, and that resident #2 had also hit resident #3 in the arm. On 9/9/15 at 3:10 p.m. the NHA stated the facility was having abuse training on 9/9/15 and would discuss the Elder Abuse Justice Act, which she said would be similar to the original abuse training staff were given. The NHA confirmed it was mandatory by law to report abuse or there could be a potential fine or jail time. The NHA revealed that a police officer contacted her about the incident between residents #2 and #3 while she was out of town. The NHA confirmed that the dietary aide had properly reported the fighting, but the RN had failed to report the incident further or initiate appropriate steps to initiate an investigation. The NHA said that she had been informed during the delayed investigation that resident #3 had potentially bruised/fractured his ribs during a problem with a malfunctioning lift. She stated that the facility believed that was the original cause of the chest injury, not the fight; however, she confirmed the staff did not report or document any issue with the lift until after the investigation of abuse.

Based on observations, interviews and record review, the facility failed to keep two of seven sample residents (#2 and #3) free from physical abuse and/or mistreatment. Specifically, the facility failed to: -Take steps to properly care plan and monitor known antagonistic behaviors of two male residents which resulted in injuries -Ensure both residents were properly assessed after an observed incident of aggression, and -Ensure all necessary steps were taken to have appropriate safety measures in place to prevent further incidents of abuse. The facility's failures including lack of interventions and monitoring residents with known aggression resulted in resident #3's injuries from a preventable resident to resident altercation, and an increased risk for resident to resident altercations. Furthermore, the facility did nothing to ensure the residents were safe from abuse after a resident to resident altercation. The findings include: A. Facility Policy for Preventing Resident Abuse (in pertinent part): -Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. -Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: a. Training all staff and practitioners how to resolve conflicts appropriately. b. Informing residents and family members upon the resident's admission to the facility how and to whom to report complaints, grievances, and incidents of abuse. c. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. B. Resident #2: Resident #2, age [AGE] years, was admitted on [DATE] [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment dated [DATE] recorded the resident with a BIMS (brief interview for mental status) score of eight, indicating moderate cognitive impairment. A Physician assessment dated [DATE] revealed the resident was oriented to time, place, person, and situation, with appropriate mood and affect. The assessment documented the resident with moderately impaired short term memory and mildly impaired remote memory, including olfactory hallucinations (smelling things). The assessment documented the resident was a compensated walker, with a Parkinsonian gait. Review of Resident #2's Care Plans revealed (in pertinent part): -gets anxious, repeats self, worries all the time, can be demanding or feels sorry for self. Needs encouragement to attend activities and one-one (one on one) he is more comfortable. -risk for complication related to psychotropic meds. Approaches include: observe for side effects of anti-anxiety, hypnotic, antidepressant, and antipsychotic medications; gradual dose reductions as clinically appropriate; identify specific behaviors warranting all as needed dosing; psych referrals as symptoms warrant; 8/24/15 one staff assigned to resident every shift to observe for aggressive behavior or change of mood x 72 hours. Record Review: A PASRR II (Preadmission Screening and Resident Review) completed on 6/15/15 documented resident #2 does not do well in large groups of people. The assisted living (at which the resident previously resided) has a list of words that they use when (resident #2) becomes agitated that tend to be helpful in redirecting or calming him. This list needs to be passed on to (nursing home). This was not noted in the resident care plan (see above CP). Review of the Medication Administration Record (MAR) for August 2015 revealed the resident was prescribed Risperdal 1mg daily at noon for schizophrenia, Clonazepam 1mg twice per day for anxiety, Trazadone HCL 50mg every night for depressive disorder, and Buspirone HCL 5mg three times a day for anxiety. The MAR required additional documentation of any Outcomes, Behaviors, and Interventions for the use of these medications. No documentation noted resident to resident abuse on 8/18/15. The resident to resident abuse incident was documented as occurring on 8/18/15 according to a facility report to the department of health. Review of all resident progress notes revealed only one progress note documented in the resident's record for August 2015, on 8/24/15. This late entry progress note reported the incident between resident #2 and resident #3 hitting each other. This late entry also documented the observation of the staff member who witnessed the fight and the registered nurse that did not originally document the report. No progress notes had been documented in the resident record since 8/24/15. -There were no progress notes after the 8/24/15 date in Resident #2's chart to indicate any ongoing concerns with resident behaviors or need for redirection or reevaluation in his care. C. Resident #3: Resident #3, age [AGE] years, was admitted on [DATE] and readmitted from the hospital 9/2/15 with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] recorded the resident with a BIMS score of eight, indicating moderate cognitive impairment. The resident was not documented with behaviors on the MDS. The resident required extensive assist of two people for transferring, and extensive assistance of one person for locomotion on and off the unit. A physician assessment dated [DATE] revealed the resident was oriented to time, place, person, and situation, with appropriate mood and affect. The assessment documented the resident with normal insight and normal judgment. The assessment documented the resident was non-weight bearing and used a wheelchair. Record review Review of Resident #3's care plans revealed (in pertinent part): -risk to exhibit alteration in mood and behavior related to [DIAGNOSES REDACTED]. Additional risk related to generalized pain, insomnia and major depression diagnoses. Approaches include: encourage to be involved in activities of choice and assist him to and from activities; monitor interactions with others for appropriateness; meds/labs as ordered; monitor for side effects of anti-depressants and psychotropic every shift; monitor for targeted behaviors and document every shift (social isolation, sad expression, verbal aggression, disruptiveness, yelling at staff and others, hitting staff or other residents). -has a potential for altered cardiac function related to hypertension, edema, and history of deep vein thrombosis. Approach include: report to nurse any unusual bruising or bleeding; remind staff that resident is prone to bruising related to anticoagulant use. A PASRR II, completed on 7/1/14 documented resident #3 had dementia with behaviors, including threatening wife. The PASRR II also noted that when he is irritable, it is best to give him space and allow him time to calm down before approaching him about the problem. His wife is also good at calming and comforting him. The PASRR II also noted he likes to be outside and to sit in the sun. The Medication Administration Record (MAR) for August 2015 revealed the resident was prescribed Coumadin 5mg (an anticoagulant), Celexa 10mg twice daily except Sunday for depression, Zyprexa 7.5mg twice a day for dementia with behaviors, and Trazadone HCL 25mg daily except for Sundays for dementia. The MAR required additional documentation of any Outcomes, Behaviors, and Interventions for the use of these medications. No documentation noted resident to resident abuse on 8/18/15. The MAR for September 2015 revealed the resident was still prescribed Zyprexa, Celexa, and Trazadone for behaviors, and required documentation of observed behaviors. On 9/4/15 the MAR indicated one episode of behaviors. -Review of Resident #3's MAR failed to document any ongoing behaviors or redirection methods needed. The 9/4/15 Medicare Note stated that the resident was getting upset with a female resident and was telling her to 'shut up' and threatened to hit her. The two residents were separated and a behavior sheet was filled out. The resident to resident abuse incident was documented as occurring on 8/18/15 according to a facility report to the department of health. Review of all resident progress notes from 5/27/15 forward revealed no progress notes on 8/18/15. -An 8/22/15 progress note revealed the resident refused oral medications due to not feeling well. -An 8/23/15 progress note indicated the wife had seen a bruise on resident #3's face, but the nurse documented they did not see it. -A second progress note dated 8/23/15 revealed the resident had a change of condition and required transport to the hospital. This note indicated a certified nursing aid (CNA) noted bruising on the resident, where the nurse had assessed for none. -The progress notes on 8/24/15 documented the late investigation of resident to resident abuse that had not been documented on 8/18/15. -There was a readmission progress note dated 9/2/15 and progress notes again on 9/7/15. These readmission progress notes did not document the monitoring of the resident's behaviors with staff and other residents. -The care plan for Resident #3 did not document all methods to redirect the resident during concerns with behaviors, as noted in the PASRR II. The PASRR II also indicated the resident had threatened a female before, but this was not documented as a concern in the care plan. As noted on 9/4/15, the resident again threatened a female resident. D. Resident to Resident Abuse Incident: A report to the state health department revealed the incident was first reported to the nursing home administrator (NHA) on 8/23/15 at 1:17 p.m. -On Monday, August 24, 2015, the facility administrator assessed the pictures of resident #3's injuries. The administrator chose to continue investigation as the bruises were yellow in color and that would indicate that these bruises were more than two days old. The NHA's investigation revealed: -The Dietary Aide stated that she had witnessed resident #3, hit resident #2, and then resident #2, hit resident #3 in the back on August 18, 2015 at 4:30 p.m. This aide stated they then told the charge nurse. -The charge nurse (RN) stated she went and immediately assessed the situations and both residents. Physical assessments showed no injury to either resident: neither resident complained of pain. When asked why she did not follow policy on reporting abuse immediately, she stated that she got busy and forgot and she did not feel that the incident was that big of a deal. She stated she knew the policy and should have followed it. -When the occurrence was brought up by the victim (resident #2) to the activities staff member three days later, the activity staff member failed to report the incident to the abuse coordinator. -A CNA was interviewed who was on duty the week of the incident. He had stated he did have an incident with the lift when transferring resident #3. On August 19, 2015 at 9:15 p.m. he had resident #3 in the sit to stand lift, and he almost fell out of the lift due to the fact he would not bear weight. The strap on the lift rose up on his chest and he tightened it to prevent him from falling. After reviewing the photos and creating a mock situation of the incident with the lift, the facility concluded that this would be consistent with the bruises found on chest. E. Hospital Records of Resident #3's Injuries (in pertinent part): -Pre-hospital Care Report 8/23/15: Dispatched 911for elderly male patient at (nursing home) in respiratory distress. Ecchymosis (bruising) was noted to patient left lower orbit/zygomatic area and to patient chest when inspected. Both sites had same color; yellow/dark areas bilaterally/mid sternal. When staff asked what happened here and attention to the ecchymosis, staff said I don't know, shook their heads, and looked at each other. -Hospital Report: admission date of [DATE] at 9:50 a.m. [AGE] year old male brought in from ER having been found unresponsive with labored respirations and emesis (vomiting) x1 by nurse aide, but not apparently reported to LPN (licensed practical nurse) for another hour, at which time she noted fever, low o2(oxygen) sat (saturation) and administered o2 and APAP (acetaminophen) and arranged transport to ER, and noted was better by time of transfer. (The) transfer note came after the fact and noted that he had some bruising that we had called to ask about, however it had not been previously documented, even though it is days old. -Hospital Facial Observations: Bruising around left eye (black eye, 4-6 days old). Bruising on eye is yellow in color below the eye. Purple in color down the cheek, ends right above his lip 2.5 inches long and 0.5 inches wide. -Hospital Chest Observations: Chest bruising of 4-6 days duration, appearance either side of sternum on ribs 2-4. Chest CT (computerized tomography scan) multiple right lateral rib fractures. Bruising on right side of chest is yellow edges with purple in the middle. Measures 2 (two) inches across and 1(one) inch wide, smaller yellow bruise located under that bruise. Bruise located on the left side of the chest almost 3 (three) inches long and 2 inches wide, yellow, green and purple in color. Contacted nursing home nurse about bruising. Nursing home unable to give report on bruising. Nurse stated, There is no documentation available on this. It was just reported to me. -Hospital Charting 8/23/15 at 9:55 a.m. - bruising noted on patient chest and under left eye. Asked patient what happened, patient states I was in a fight. When asked with who patient not able to tell. F. Interviews: -On 9/8/15 at 6:15 p.m. the NHA confirmed that she had provided abuse training for the facility staff before, but that the staff did not properly report the resident to resident abuse incident between residents #2 and #3 until many days later. -On 9/9/15 from 8:30 a.m. to 9:15 a.m. a local police officer familiar with the abuse reporting concern was interviewed. The officer stated that he investigated the alleged abuse incident between resident #2 and resident #3. The officer stated that during the investigation the activity assistant (AA) and the RN both admitted to failing to follow the facility protocol on handling an abuse investigation. The RN had admitted to only making a visual observation of resident #3 after the abuse incident, and not a full assessment including a neurological check. The officer stated that resident #2 was a familiar individual in the community for a long period of time, and had been known to have potentially aggressive behaviors in the past - On 9/9/15 at 10:19 a.m. housekeeper #2 stated that she had been at the facility for awhile, and recalled getting abuse training when she started. The housekeeper stated that she did not recall getting any updated training on abuse since that time. The housekeeper added that resident #3 was not able to use his left arm, and was pretty quiet. -On 9/9/15 at 10:28 a.m. CNA #3 stated they had been employed at the facility for a year. The CNA stated they had abuse training when they started, including who to report to. About two weeks ago the facility posted an abuse training that was mandatory on 9/9/15 and that she would be attending. The CNA said resident #3 was very quiet and passive, and could not use his left arm at all. The CNA stated resident #3 could get frustrated and upset. If there was a fight between resident #3 and resident #2, then it would have to have been resident #2, that started it. The CNA stated that she was not present for the incident between these residents. The CNA added that resident #2 had been known to have behaviors, or be aggressive, but this aide had not seen this herself. The CNA was not aware of any special care or monitoring that was care planned for resident #2 regarding behaviors. -On 9/9/15 at 10:52 a.m. resident #3 was interviewed. The resident was not able to answer most questions; however, the resident was able to state he had been in a fight and had been hit in the face. -On 9/9/15 at 11:15 a.m. a certified occupational therapy assistant (COTA) stated resident #3 had been seen by therapy recently, and that his left arm was not highly functional. - On 9/9/15 at 11:48 a.m. an activity aide (AA) was interviewed regarding the incident between resident #2 and resident #3. She stated resident #2 told her that someone hit him. The AA stated that when the resident had previously resided in the assisted living side of the building, the resident had shared many stories about growing up and being hit, and presumed it was another story from his past. I let it go off the back of my shoulders, the AA confirmed. The AA said that she then heard later that he had been in an altercation with resident #3 on that Tuesday, not Friday. I should have reported or investigated when I heard the word 'hit' , but I was busy getting a different resident back to his room. The AA said that resident #2 was very friendly, but he could repeat himself a lot. She said the resident tried to remember different things and phrases, and if he could not remember them, he could get frustrated. The staff member stated she had never seen him violent. The AA said that she had seen resident #3 on that Friday in bingo, and the resident was extra vocal during the game, which was unusual. The AA confirmed that although resident #3 usually spoke with one word answers, his answers always seemed to be accurate. Since the incident, the staff member stated the facility had started abuse training again, similar to the original training. -On 9/9/15 at 11:53 a.m. CNA #4 stated she was not present when resident #2 and resident #3 had a fight. The CNA said resident #3 was quiet but could get upset. The CNA said resident #2 was also not known for being abusive. The CNA said that neither of these residents came across as violent. -On 9/9/15 at 12:00 p.m. resident #2 was interviewed about the altercation with resident #3. Resident #2 stated that resident #3 was trying to get past him in his wheelchair. The resident said that he thought resident #3 got caught on his chair, got mad, and then started swinging at him. Resident #2 stated he then began to swing back at resident #3. Resident #2 confirmed that he hit resident #3 on the face, and resident #3 hit him back on the face. Resident #2 said he was worried his glasses were going to be broken. The resident confirmed he was not hurt in the altercation, and did not think resident #3 even recalled the situation that had occurred. Resident #2 said that he did not recall hitting resident #3 anywhere else but on the face, because that was where resident #3 was hitting him. -On 9/9/15 at 1:50 p.m. the RN involved in the investigation was interviewed regarding the abuse incident between residents #2 and #3. The RN said that on the Tuesday when resident #2 and resident #3 got in the fight, a dietary aide came and reported to her that the situation had occurred in the dining room. The RN said that when she went over, the fight was over. The RN said she was informed that it was speculated that resident #3 was trying to get around resident #2 in his wheelchair, but had become stuck. The RN confirmed she did not believe it was abuse because she did not observe any marks on either resident, and neither said they had pain. She stated that she looked them over but did not think it was abuse. The RN said that now she would know it was abuse (after additional training). The RN stated resident #3 had been known to have a temper and get frustrated and hit or kick at people. This was due in part to his [DIAGNOSES REDACTED]. She said that the staff marked behaviors down in his chart when they occurred. The RN said she had never seen resident #2 aggressive, and that he was usually a good resident. The RN said that it was reported to her as observed that both residents were hitting each other in the face, and that resident #2 had also hit resident #3 in the arm. -On 9/9/15 at 3:10 p.m. the NHA stated that the police officer contacted her about the incident between residents #2 and #3 while she was out of town. She said that it took her three days to figure out what was going on. It just took one person to say the right thing. The NHA confirmed that the dietary aide had properly reported the fighting, but it was a failure that the nurse did not report it and she was not aware as to why the nurse did not report appropriately. She was also aware the AA was aware of the incident and did not report appropriately; however, she did not know why the AA did not report. The NHA confirmed that the nursing staff also failed to follow up with neurological testing for the residents involved in the fight, even though they were observed hitting each other in the face. The NHA stated that the staff still seemed to have confusion as to the meaning of intent, and when to report abuse. The NHA said that she would expect there to be a care plan related to the incident for each resident, and that someone should have been observing the two residents after this incident. She said resident #2 was new to the long term side of the facility, having recently come from the assisted living side. Resident #3 had been in the long term facility for a longer period of time. The NHA said that resident #3 had a lot of antipsychotic drug adjustments lately, which had been hard on him. She said resident #2 was fine, but resident #3 was still sick and septic. She confirmed that that resident #3 did not interact much anymore unless he was annoyed and screamed out, and could be easily agitated in a busy environment. The NHA added that after the incident she would want staff to be monitoring both residents more, and that there should be a higher level of documentation for a period of time. The NHA said that it was good to monitor them both for behaviors, which they documented under behavioral monitoring for the specific behaviors of concern. If there are unusual behaviors there is a place to document that as well. She stated that there should have been more progress notes, especially after the incident, at least for one to two months to make sure the residents were stable. The NHA added that having additional documentation after the incident would provide the physician and counseling something they could evaluate and review. She concluded that they would need the documentation to determine if there was a pattern or catalyst that led up to the incident to prevent the same incident in the future.