Every finding on record at Rehabilitation and Nursing Center of the Rockies

Based on observations, record review and interviews, the facility failed to ensure services met professional standards of practice for one (#9) of eight residents out of 13 sample residents.Specifically, the facility failed to:-Ensure nurses did not leave medications on Resident #9's bedside table; -Ensure Resident #9 when he was administered his medications to make sure he swallowed them; and; -Ensure nurses did not document in Resident #9's medication administration record (MAR) that the resident's medications were administered/swallowed when they were not.Findings include:I. Facility policy and procedureThe Medication Administration policy, revised December 2024, was provided by the regional nurse consultant (RNC) on 9/22/25 at 2:47 p.m. The policy revealed medications should be administered as prescribed by the attending physician. Medications may not be set up in advance and must be administered within one hour before or after their prescribed time. The staff administering the medication must record such information on the resident's MAR before administering the next resident's medication. Should a drug be withheld, refused, or given other than at the scheduled time it should be appropriately documented on the resident's medication administration record (MAR).The Six Rights of Medication Administration revealed a medication must be administered at the correct, scheduled time. Incorrect timing could affect the drug's therapeutic effectiveness and might lead to drug interactions. The nurse must accurately and completely document the medication administration in the resident's record. This included the drug given, the dose, the time, the route, and any resident reactions. Incomplete or incorrect documentation could lead to clinical errors.II. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included encephalopathy (a medical condition characterized by a general dysfunction of the brain that affects cognitive function, consciousness, and behavior), non-traumatic intracranial hemorrhage (bleeding within the skull, or the brain cavity, which can damage brain tissue), cerebrovascular disease, vascular dementia, spastic hemiplegia (a type of cerebral palsy that affects one side of the body, typically the arm and leg) affecting right dominate side, muscle weakness and low back pain.The 9/2/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required staff supervision or touching assistance for showering, upper body dressing and lower body dressing.B. ObservationsResident #9's room, which was a double occupancy room, was observed on 9/22/25 at 12:33 p.m. A souffle medication cup containing three white tablets and one brownish capsule was observed sitting on the resident's bedside table. At 12:34 p.m. the director of nursing (DON) observed the souffle medication cup containing the four medications. The DON removed the souffle cup from the room and took them to her office to be identified.C. Record reviewA care plan for being at risk for impairment due to cognitive function/dementia or impaired thought processes related to vascular dementia was revised on 6/25/24. The interventions were for staff to give step-by-step instructions one at a time as needed to support the resident's cognitive function. Staff were to keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Staff were to identify themselves with each interaction. Staff were to face the resident when speaking and make eye contact. Staff were to reduce any distractions such as turning off the television, radio and/or close the door. Staff were to use simple direct sentences. Staff were to provide necessary cues. Staff were to stop and return if the resident became agitated.A care plan for alteration of neurological status related to hereditary ataxia (a condition that affects coordination and balance, causing uncoordinated jerky movements) and cerebral vascular disease was revised on 3/16/25. The interventions included for staff to cue and reorientate the resident as needed. Staff were to administer medications as the physician ordered. Staff were to monitor/document for any side effects and the effectiveness of the medications. Staff were to monitor/document/report to the resident's physician as needed any signs or symptoms of tremors, rigidity, dizziness, slurred speech and any changes in the resident's level of consciousness.A physician's order, dated 8/4/25 at 3:43 p.m., revealed to administer Baclofen (muscle relaxant and antispasmodic medication used to treat muscle spasms, stiffness and pain resulting from multiple sclerosis and other spinal cord conditions) 60 milligrams (mg) orally at midnight for spasticity.A physician's order, dated 9/15/25 at 9:35 a.m., revealed to administer two 250 mg capsules of Valerian Root (utilized for overall effect with the depression of central nervous system activity, including drowsiness, muscle relaxation, sedation and a decrease in anxiety) to equate to a total of 500 mg orally two times a day for supplementation.Review of Resident #9's September 2025 MAR revealed the resident was administered Baclofen 60 mg orally at 12:00 a.m. on 9/22/25 and 500 mg of Valerian root at 1:00 a.m. on 9/22/25.Review of Resident #9's electronic medical record (EMR) did not reveal the resident was able to administer medications by himself. III. Staff interviewsThe DON was interviewed on 9/22/25 at 12:41 p.m. The DON said the three white tablets found in the medication cup on Resident #9's bedside table (on 9/22/25) were Baclofen. She said the one brownish capsule was Valerian root. The DON reviewed the resident's September 2025 time-stamped electronic medication administration record (EMAR), which documented the exact time medications were administered to Resident #9. The DON said the Baclofen tablets were documented as being administered by licensed practical nurse (LPN) #3 at 11:00 p.m. on 9/21/25 and the Valerian root capsule was documented as administered by LPN #3 at 3:04 a.m. on 9/22/25. The DON said medications should not be left in a souffle medication cup on residents' bedside tables. The DON said the nurse should stay with the residents and watch them swallow all medications. The DON said the nurse should not document in the residents' MARs that a medication was administered without watching the residents swallow the medications.The DON, the assistant director of nursing (ADON) and the RNC were interviewed together on 9/22/25 at 1:45 p.m. The DON said LPN #3 had received a medication administration in-service on 7/23/25 that included the five/six rights of medication administration. She said the information included within the in-service revealed a nurse was to stay with the resident until the resident swallowed the medications. She said it also revealed that a nurse was to document in the resident's MAR after the resident swallowed the medications. The DON said that a nurse was to correctly document medication administration. The DON said there were no nurse progress notes for 9/21/25 nor 9/22/25 that would reveal that Resident #9 refused the medications. The DON said the resident did not have a self-administration of medications assessment. The DON said it was important for nurses to observe a resident swallow their medications to ensure they were administered the medications according to physician's orders. The DON said nurses should wait until the medications were swallowed to ensure accuracy in documentation. She said the nurses were not taught to leave residents' medications at the bedside. She said if medications were left at a resident's bedside, there was a potential that another resident could take the medications. The DON said medication in-services with the six rights of administration were started for the nurses that were currently working in the facility, on 9/22/25 at 1:00 p.m., (during the survey) after her initial observation of the medications in the cup in Resident #9's room. The DON said the in-services would be ongoing and each nurse would be in-serviced before the start of their next shift. Licensed practical nurse (LPN) #1 was interviewed on 9/23/25 at 12:40 p.m. LPN #1 said she administered medications by giving the medication souffle cup to the resident and watching the resident take/swallow all of their medications before documenting the medications as administered in the resident's MAR. LPN #1 said she did this process, because she did not want to have to go back into the resident's MAR and make corrections if the resident refused medications or was unavailable.The DON, the ADON, the RNC and nursing home administrator (NHA) #2 were interviewed together on 9/23/25 at 1:42 p.m. The DON said she interviewed LPN #3 and the nurse admitted she left the souffle medication cup with the four medications in it on Resident #9's bedside table. The DON said LPN #3 told her that she attempted to wake Resident #9 to administer his medications and eventually sat them down on the resident's bedside table. LPN #3 said she was going to come back later to administer the medications; however, she never came back to the resident's room. The DON said LPN #3 should have encouraged Resident #9 to wake up with a little more effort and stayed with the resident to watch the medications being swallowed. The DON said if the resident never awoke, LPN #3 should have wasted (destroyed) the medications, documented they were not administered and notified the resident's physician that the medications were not administered. The DON said LPN #3 did not know that Resident #9 had not taken/swallowed the medications she left on the bedside table. The DON said LPN #3 was in-serviced over the telephone initially, on 9/22/25, and in- person upon returning for her next shift. The DON said nurses should follow physician's orders. The DON said it was important to observe the residents during medication administration to monitor the residents from any outcomes for taking or not taking their medications. The DON said there was no documentation of Resident #9 having any additional spasticity of his muscles for not receiving the medications. The DON said the facility started alert charting on Resident #9 after it was discovered he had not taken the medications that were left on his bedside table.LPN #2 was interviewed on 9/23/25 at 2:14 p.m. LPN #2 said she waited to document if a medication was administered/swallowed on a resident's MAR, until after she administered the medication. LPN #2 said she waited to document on the resident's MAR until after a medication was administered in case a resident refused the medication or was unavailable to take the medication. LPN #2 said she administered medications by giving the medication cup to the resident and watching the resident swallow the medications. LPN #2 said she watched residents take their medications to ensure the resident actually took them and to ensure no one else took the resident's medications.

Based on observations, record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#5) of eight residents reviewed for medical record accuracy out of 13 sample residents. Specifically, the facility failed to ensure accurate documentation of Resident #5's medication administration for Cardura (medication used to treat high blood pressure).Findings include:I. Facility policy and procedureThe Medication Administration Documentation policy and procedure, revised August 2025, was received from the regional nurse consultant (RNC) on 9/23/25 at 1:17 p.m. It read in pertinent part, It is the policy of this facility that medication administration should be documented as per physician order and to reflect if the resident accepted medication administration All current drugs and dosage schedules must be reported on the resident's medication administration record (MAR). Should a drug be withheld, it should be appropriately documented on the MAR.II. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included chronic congestive heart failure and primary hypertension.The 9/18/25 minimum data set (MDS) assessment revealed Resident #5 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #5 required partial to substantial assistance from staff for most activities of daily living (ADL).B. Record reviewHospital records, dated 7/19/25, revealed Resident #5 was admitted to the hospital on [DATE] and discharged back to the facility on 7/19/25. Resident #5 was discharged from the hospital with an order for Cardura 8 milligram (mg) oral tablets, give 8 mg by mouth at bedtime.Review of Resident #5's September 2025 CPO revealed the following physician's order:Cardura 8 mg oral tablets, give 8 mg by mouth at bedtime related to primary hypertension, ordered 7/19/25 at 1:43 p.m. and discontinued 9/23/25 at 10:09 a.m. (during the survey).A physician's note, dated 7/21/25, revealed Resident #5 was receiving three medications in order to treat his enlarged prostate. The physician noted Resident #5 was also taking Cardura, and the physician was unclear why the resident was taking two alpha blocking medications (a class of medications that block the effects of a hormone on alpha receptors).-However, the physician did not document any hold (an official order from a healthcare provider to temporarily stop or suspend the administration of a prescribed medication for a resident) on Resident #5's Cardura or place a hold order for the medication.Review of Resident #5's MARs, from 7/19/25 through 9/23/25, revealed the following:The July 2025 (from 7/19/25 to 7/31/25) MAR documented Resident #5 received Cardura on 7/22/25, 7/26/25 and 7/29/25. The 10 other administration opportunities from 7/19/25 through 7/31/25 were documented as other/see nurse's notes.-However, Resident #5 was not administered any doses of Cardura during that time (see interviews below).The August 2025 (from 8/1/25 to 8/30/25) MAR documented Resident #5 received Cardura on 8/1/25, 8/5/25, 8/12/25, 8/15/25, 8/19/25, 8/26/25, 8/28/25 and 8/30/25. Resident #5 was out of the facility from 8/7/25 through 8/10/25. The 19 other administration opportunities from 8/2/25 through 8/31/25 were documented as other/see nurse's notes.-However, Resident #5 was not administered any doses of Cardura during that time (see interviews below).The September 2025 (from 9/1/25 to 9/22/25) MAR documented Resident #5 received Cardura on 9/9/25 and 9/16/25. The 20 other administration opportunities from 9/1/25 through 9/22/25 were documented as other/see nurse's notes.-However, Resident #5 was not administered any doses of Cardura during that time (see interviews below).Review of the progress notes revealed the nursing staff documented Resident #5's Cardura was unavailable and the physician was aware almost daily from 7/19/25 through 9/22/25.Review of Resident #5's electronic medical record (EMR) did not reveal any documentation regarding the resident's Cardura being withheld or the reason why it was withheld. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/23/25 at 12:40 p.m. LPN #1 said she administered medications by giving the medication cup to the resident and watching the resident take all of their medications before marking the medications as administered in the resident's MAR. LPN #1 said she administered medications this way because she did not want to have to go back into the resident's MAR and edit it if the resident refused a medication or was unavailable to take their medications. LPN #1 said if a medication was on hold by the physician, it was usually crossed out on the MAR. LPN #1 said if the medication was on hold but was not crossed out on the MAR, she would contact the physician to see why it was not crossed off, mark the medication as held and document in the progress notes that the medication was held and what the reason for holding the medication was. LPN #2 was interviewed on 9/23/25 at 2:14 p.m. LPN #2 said she waited to mark a medication as administered on the MAR until after she administered the medication. LPN #2 said she waited to mark the MAR until after a medication was administered in case a resident refused or was unavailable to take the medication. LPN #2 said if a medication order was on hold, the hold order was placed by the physician and no longer showed up on the MAR. LPN #2 said if she knew a medication order was supposed to be on hold but it was still on the MAR, she would talk to her charge nurse or the director of nursing (DON) to clarify the physician's order. LPN #2 said she did not document anything in this case, as she brought it to the charge nurse or DON and they would follow up and document it.The DON was interviewed on 9/23/25 at 9:51 a.m. The DON said she observed the documentation of other/see nurse's notes documented in Resident #5's MAR for Cardura but said she would need to look into why the medication administrations had been documented that way. The DON said Cardura was used to treat hypertension. The DON and the RNC were interviewed together on 9/23/25 at 10:14 a.m. The DON said she spoke with her charge nurse and Resident #5's nurse practitioner about the resident's Cardura order. The DON said she was told the Cardura was being held as Resident #5 was taking another hypertensive medication of the same medication class and his blood pressures were starting to get low. The DON said the nurse practitioner reviewed Resident #5's EMR that morning (9/23/25) and observed that his blood pressures were stable, so she was going to discontinue the Cardura medication order. The DON said she was not sure why the nursing staff had been documenting that the medication was out of stock in the progress notes. The RNC said she thought the staff may have been contacting the physician and finding out the situation regarding Resident #5's medication being held after documenting the medication was out of stock. The DON said for the doses of Resident #5's Cardura which were documented as administered, the nursing staff may have gotten a dose out of their emergency medication kit . The DON said they likely should have had a hold order for Resident #5's Cardura, but the nurse practitioner was discontinuing it that morning (9/23/25).The DON and the RNC were interviewed together a second time on 9/23/25 at 11:50 a.m. The DON said the facility did not have the Cardura medication in their emergency medication kit. The DON said Resident #5 did not receive any doses of Cardura from 7/19/25 through 9/22/25. The DON said she had called the nurses who had documented in Resident #5's MAR that they had administered the Cardura and they each said they had documented the medication as administered on accident. The RNC said none of the nursing staff had reordered the medication at any point, so she thought the nursing staff knew the medication was being held.The DON said Resident #5 did not have any high blood pressure readings or other outcomes from the medication not being administered. The DON said there was a breakdown in their process. The DON said she had started educating the nursing staff on the subject of medication administration.The DON and the RNC were interviewed together a third time on 9/23/25 at 1:41 p.m. The DON said Resident #5's Cardura medication had never been delivered to the facility and the resident never received any doses of Cardura. The DON said her expectation would have been for the nursing staff to document the medication in the MAR as being held. The RNC said a step in their medication ordering process was missed and Resident #5's physician should have immediately placed the medication on hold. The DON said the nursing staff needed to accurately document what was administered on the MAR when a resident was being monitored for blood pressures so the staff could accurately monitor the resident for any symptoms or outcomes related to their medications.

IV. Resident #4 - The facility failed to initiate a thorough investigation of an injury of unknown origin. A. Resident #4 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included systemic involvement of connective tissue (autoimmune disease), arthritis, edema, and history of stroke. The 6/3/25 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 14 out of 15. The resident required total assistance (fully dependent) from the staff for toileting, dressing, bed mobility (the ability to sit up or roll from side to side while lying), and all transfers. The resident required (two-person) extensive assistance from the staff for bathing and personal hygiene. Resident #4 had impairments to her lower extremities and a limited full range of motion. 2. Resident interview Resident #4 was interviewed on 6/25/25 at 4:00 p.m. She said she sustained an injury in the middle of May 2025 when a male CNA she did not know came into her room to transfer her from the wheelchair to the bed. She said he told her he was going to show her how to transfer without a mechanical device, then lifted her out of her chair and put her on the bed. Resident #4 said he was rough when picking her up, and she asked him to be gentle and that her bones were fragile, but he did not say anything except to put her down on her bed in a rough manner. She said her body twisted, but not her leg, and both she and the CNA heard a popping sound, then the CNA left her room and did not send anyone in to look at her leg. Resident #4 said she experienced constant aching pain in her right leg and right foot but did not want to tell the doctor because she thought it would heal itself, but it kept swelling instead. She said when the staff would come in to take care of her, they would comment to her that her ankle looked swollen, and if they tried to turn her ankle, it was very painful. Resident #4 said a male nurse came to look at it one evening, and she told CNAs about the injury, but could not recall staff names or exactly when she told them. She said that exactly four weeks after her injury, she told her community provider, who sent her to the hospital for Xrays, and the fractures were then discovered. Resident #4 said her transfer status had changed from a sit-to-stand lift to a Hoyer (mechanical lift) lift. She said she did not like the Hoyer lift because it made her feel nervous and unstable when she was lifted. 3. Record review a. The musculoskeletal care plan, revised on 6/20/25, revealed Resident #4 had an alteration in musculoskeletal status related to a right distal tibia and fibula fracture. Interventions, revised 6/20/25, included to keep the call light within reach, provide heat and/or cold applications as tolerated, and monitor for fall risks. b. The activities of daily living (ADL) care plan, revised 6/20/25, revealed Resident #4 had ADL deficits related to generalized weakness, chronic left lower extremity and right upper extremity, pain, osteoarthritis, and right tibia and fibula fracture. Interventions, revised 6/23/25, included providing two-person Hoyer lift assistance with transfers and providing one to two-person assistance with bathing. Interventions, revised 12/27/24, included providing one to two-person assistance with toileting, bed mobility, personal hygiene, and dressing. -The care plan failed to reveal that Resident #4's ADL focus had been updated to show the resident's physical decline in all areas. c. The 3/3/25 MDS assessment revealed the resident required total assistance from the staff for toileting and toilet transfers. The resident required extensive assistance from the staff for dressing, personal hygiene, bed mobility, and chair transfers. Resident #4 did not have any impairments to her lower extremities and had a full range of motion. -Between 3/3/25 and 6/3/25, Resident #4 had a decline in abilities to include dressing, all transfers, bed mobility, and her range of motion in her lower extremities (see 6/3/25 MDS assessment above). d. The June 2025 CPO revealed the following physician orders: Weight-bearing status: non-weight bearing to right ankle - ordered on 6/17/25. Monitor right lower extremity and notify the provider of any concerns related to circulation, motion, or sensation - ordered on 6/18/25. Float right lower extremity with pillows while in bed due to ankle fracture - ordered on 6/20/25. e. The facility-reported incident on 6/17/25 of physical abuse revealed Resident #4 had been sent to the hospital for Xrays on 6/17/25, directly from her community provider, who she saw twice weekly. Included in the facility-reported incident were ten staff member interviews. Out of ten staff members interviewed, one staff member replied they had observed redness and swelling to the resident's ankle as of 6/16/25, and another staff member replied Resident #4 had expressed pain in her ankle as of 6/16/25. There were no staff names mentioned or follow-up questions reported in the incident. f. The community provider notes revealed that on 6/10/25, an Xray was ordered for 6/12/25 (but not completed until 6/17/25) due to Resident #4 complaining of ankle pain after an injury. During the visit on 6/10/25, the nurse observed pain, redness, bruising, swelling, tenderness, and changes in range of motion. g. A review of skin assessments from 5/1/25 to 6/16/25 failed to reveal observations of redness, bruising, or swelling to the right ankle. h. Progress notes were reviewed from 5/1/25 to 6/16/25 and failed to reveal any injury to the resident had been documented. C. Staff interviews 1. CNA #5 was interviewed on 6/26/25 at 10:33 a.m. She said Resident #4 used to complain to her about her foot hurting, but CNA #5 was not aware of the injury and did not ask the resident what had happened. She said she told RN #3 on 6/15/25 when she noticed bruising on Resident #4's mid calf going down her leg to her foot. 2. CNA #6 was interviewed on 6/26/25 at 10:41 a.m. She said Resident #4 used to use a sit-to-stand lift before the injury, but now required total assistance in a Hoyer lift. CNA #6 said on 6/16/25, she noticed redness to Resident #4's ankle, and the resident complained to her about pain and tenderness. She said there was no place in the CNA charting to document new injuries; the CNAs had to report it to the nurse, but she said she had not reported it. 3. RN #3 was interviewed on 6/26/25 at 12:34 p.m. He said a change of condition would constitute any change in a resident's physical or emotional baseline. He said that when a change of condition was determined, as a nurse, he would assess the change, report it to the physician and family, and make a note in the chart. -RN #3 said that a CNA brought it to his attention on the evening shift on 6/15/25 that while laying Resident #4 down, the resident had complained of pain in her ankle, and the CNA had observed swelling and bruising. RN #3 said he looked at the ankle and observed it was swollen and bruised. He said Resident #4 told him she was waiting for the Xrays to be completed by her community provider; therefore, RN #3 said he did not do a skin assessment or a pain assessment, or contact the resident's family or physician because he assumed all parties were aware since the resident was waiting for Xrays. -He said he did not ask the resident how and when the injury occurred. RN #3 said the following day was the weekly meeting between Resident #4's community provider and the facility and RN #3 advised the DON to ask the community provider if an Xray was scheduled, but he said he did not follow up any time later with the DON regarding the Xrays that the resident mentioned. He said before the injury, Resident #4 was able to propel herself in her wheelchair and participate in sit-to-stand lift transfers. 4. LPN #2 was interviewed on 6/26/25 at 12:55 p.m. She said any changes from a resident's normal baseline would be considered a change of condition. She said a swollen ankle would be considered a change of condition, and if reported to her, she would do a full body assessment to see if any other injuries were present, check vital signs, and ask the resident when and how the injury occurred. LPN #2 said it was important to gain as much information as possible to rule out a potential abuse situation, and when an injury occurred during a transfer, it had to be reported to the NHA and the DON to rule out the abuse. She said nursing documentation would include an assessment of the change of condition and a progress note. 5. LPN #1 was interviewed on 6/26/25 at 12:55. She said a swollen ankle would be considered a change of condition, and if a resident was able to answer questions, she would ask when and how it occurred. LPN #1 said it was important to ask these questions to rule out the abuse, and if injury occurred during the transfer, it must be reported to the NHA and the DON as well for investigation of potential abuse. LPN #1 said a full body assessment and vital signs were taken when a resident experienced a change of condition, and all findings should be documented under progress notes and the change of condition form. She said after assessment, the physician and the family must be notified about findings. 6. The assistant director of nursing (ADON) was interviewed on 6/26/25 at 1:08 p.m. She said any unexpected changes in a resident's physical or mental condition was a change of condition, and upon a change of condition, the nurses were expected to complete a full assessment, vital signs when necessary, ask the resident about the origin and timing of the injury, and assess for pain. 7. The MDS coordinator (MDSC) was interviewed on 6/26/25 at 5:25 p.m. She said a change of condition could be exhibited by health status, physical, psychosocial, or behavioral changes. She said she expected that if a CNA observed something that appeared different about a resident, they were to report to the nurse, and then the nurse was expected to do a visual assessment of the resident to determine if further actions needed to be taken. She said if a change of condition had been determined, an assessment was completed, and the resident's provider was notified. She said if the change of condition was determined on the night shift, it needed to be passed on in report to the oncoming nurse the next morning. Based on observations, record review and interviews, the facility failed to investigate thoroughly allegations of staff-to-resident verbal abuse and failed to initiate a thorough investigation of an injury of an unknown origin. The facility failure affected two (#24 and #4) of five residents out of 37 total sample residents. 1. The facility failed to recognize, address, and thoroughly investigate allegations of staff-to-resident abuse. Interview with Resident #24, who was visibly tearful during three interviews, one on 6/23/25, and two on 6/24/25, revealed she felt mentally and verbally abused. On 6/23/25, Resident #24 said she had reported to the social services director (SSD) and other staff in leadership that registered nurse (RN) #2 accused her of medication-seeking behavior and retaliated against her by not administering her medications on time. She also reported to the SSD and other staff in leadership that certified nurse aide (CNA) #4 yelled at her when she provided her care. Resident #24 said that since she made her report to the SSD and other staff in leadership, nurses and CNAs had argued with her and made her feel bad. Resident #24 said no one followed up with her, both RN #2 and CNA #4 continued to work with her, and she had no other option but to cope with it. Interviews with the director of nursing (DON) on 6/23/25 at 4:26 p.m. and the SSD on 6/23/25 at 4:33 p.m. revealed they were aware of the incident involving Resident #24 and RN #2, and followed up with the resident unofficially, removing RN #2 from Resident #24's care for a while. The SSD said the resident told her that RN #2 ignored her on purpose and CNA #4 was brisk and not friendly, and in response, she had informally educated staff on customer service. The facility's failure to recognize Resident #24's report of her interactions with RN #2 and CNA #4 as potential allegations of staff-to-resident abuse and thoroughly investigate them created a situation that was likely to result in serious harm. 2. The facility failed to initiate a thorough investigation of an injury of unknown origin. Interview with Resident #4, who was alert and oriented and required total assistance from staff for all transfers, revealed she sustained right lower extremity injuries in the middle of May 2025 when a CNA picked her up without a mechanical lift device and put her down in bed in a rough manner. She said she experienced constant aching pain and swelling in her right leg and ankle. Record review revealed Resident #4 was seen by a community provider on 6/10/25, and Xrays completed on 6/17/25 revealed right distal tibia and fibula fractures (lower leg bones). The facility reported the incident on 6/17/25 and interviewed ten staff members, two of whom reported observing injury (redness, swelling, pain) as of 6/16/25. Yet, there were no follow-up questions in the report, and a review of skin assessments and progress notes from 5/1/25 to 6/16/25 failed to reveal observations of bruising or swelling or documentation of the resident's pain. In an interview with RN #3 on 6/26/25 at 12:34 p.m., he said he looked at the resident's ankle on 6/15/25 and observed it was swollen and bruised, but when the resident told him that she was waiting for Xrays to be completed, he did not conduct an assessment or contact family or the physician because he assumed all parties were aware of the situation given the order for Xrays. In an interview with licensed practical nurse (LPN) #2 on 6/26/25 at 12:55 p.m., she said it was important to gain as much information as possible when there was a change in condition to rule out a potential abuse situation. And, when it occurred during a transfer, it had to be reported to the the nursing home administrator (NHA) to rule out abuse. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Interview with Resident #24, who was visibly tearful, on 6/23/25, revealed she felt mentally and verbally abused. She said she had reported to the social services director (SSD) and other staff in leadership that registered nurse (RN) #2 accused her of medication-seeking behavior and retaliated against her by not administering her medications on time. She also reported to the SSD and other staff in leadership that certified nurse aide (CNA) #4 yelled at her when she provided her care. She said that since she made her report to the SSD and other staff in leadership, nurses and CNAs had argued with her and made her feel bad. Resident #24 said no one followed up with her, both RN #2 and CNA #4 continued to work with her, and she had no other option but to cope with it. Staffing records documented CNA #4 continued to be scheduled to work with Resident #24, and RN #2 was taken off from Resident #24's hall but was put back on soon after. The DON was interviewed on 6/23/25 at 4:26 p.m., and the SSD was interviewed on 6/23/25 at 4:33 p.m. Their interviews revealed that the DON and the SSD were aware of the incident involving RN #2. The DON said she had followed up with the resident unofficially, and the resident was satisfied with the outcome. She also said she removed RN #2 from Resident #24's care for a while; she was unsure of the length of time. The SSD said the resident told her that RN #2 ignored her on purpose, and CNA #4 was brisk and not friendly, and in response, she had informally educated staff on customer service. The SSD said that the nursing home administrator (NHA), as well as the other managers, knew about both incidents because she said she had discussed them in their morning meeting. On 6/24/25, Resident #24, visibly tearful, said that on the previous day, the NHA came into her room and drilled her on what she had said during her interview on 6/23/25 with the state. She said she found the exchange intimidating, and she had been up since midnight with anxiety and perseverating about the interaction. On 6/24/25 at 5:02 p.m., the NHA was interviewed. He said he was not aware of the verbal abuse situations involving RN #2 and CNA #4. He said he became aware of the situation on 6/23/25 when he spoke to Resident #24. On 6/23/25 at 2:25 p.m. and 6/24/25 at 10:17 a.m. and 3:51 p.m., Resident #24 was visibly tearful. She expressed feelings of harm, including retaliation, intimidation, anxiety, and mental and verbal abuse as a result of her interactions with RN #2, CNA #4, and the NHA. The facility's failure to recognize, address, and thoroughly investigate her allegations of potential abuse by staff was likely to result in serious harm if not immediately corrected. B. Facility plan to remove immediate jeopardy On 6/25/25 at 2:54 p.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: Immediate actions: Resident #24 was interviewed by clinical resource (CR) #1 and the corporate licensed clinical social worker on 6/24/25, at which time they provided psychosocial support and offered additional mental health support. The NHA and RN #2 were suspended on 6/24/25 at 5:30 p.m. and CNA #4 was suspended on 6/23/25 at 5:00 p.m. Education with the NHA, the SSD, and the DON were conducted on 6/25/25 and included how to identify instances and allegations of abuse and to understand the difference between a concern and forms of abuse. Competencies for understanding of education were completed on 6/25/25, and education was given by a clinical nurse resource. Education provided to RN #2 and CNA #4 in regards to understanding the differences of concerns and forms of abuse and how to report appropriately. Education given by the clinical nurse resource to RN #2 on 6/25/25. CNA #4 will not return to work until education and return demonstration is provided in person. Identification of other residents at risk: Starting on 6/25/25, initiate interviews with all residents who can participate in interviews to ensure all allegations of abuse are identified and thoroughly investigated. Any residents who are not interviewable, the facility will reach out to emergency contact or resident representative to discuss concerns. If an interview is unable to be completed, social services will complete an observation to identify any signs of psychosocial distress or change in mood. All interviews or observations to be completed by 6/25/25. Systemic changes: All staff will be educated on the identification of allegations of abuse versus customer service and abuse reporting. Education to include differentiating potential abuse allegations from concerns or customer service-related issues from residents. Staff education to be provided by social services, clinical nurse resource, or a licensed nurse. Education was initiated via video chat on 6/24/25. All education to be completed by 6/26/25. Any employee who cannot complete education in person will be educated prior to their next scheduled shift. Monitoring: The social services or designee will complete audits on five random residents weekly for 12 weeks. The audit will include identification through a resident interview: have any staff members, resident, visitor abused you? Have you observed any other resident being abused? Record review: if yes, abuse coordinator notified per regulations, thorough investigation completed with new intervention implemented to prevent reoccurrence, completion of state occurrence reporting site and police reporting completed. For identified concerns, corrective action completed. The audits will be recorded on an audit form. Discrepancies will be promptly reported to the administrator. Results will be reported monthly to the quality assurance committee. The director of nursing services or designee will interview five employees weekly for comprehension about types of abuse and signs of mental abuse, the difference between customer service concerns and allegations and reporting immediately. Social service resource or clinical nurse resource will complete oversight weekly to review investigations and audit if managers have an understanding between customer service and allegations. C. Removal of immediate jeopardy On 6/25/25 at 3:50 p.m., the interim nursing home administrator (INHA) was notified that the facility's plan to remove the immediate jeopardy was accepted based on the facility's plan and evidence of implementation of the measures outlined in the plan. However, the deficient practice remained at a G level, isolated, actual harm. Interviews conducted on 6/25/25 verified that staff had been educated on identifying abuse and the difference between an allegation and a customer service concern. -CNA #7 was interviewed on 6/25/25 at 3:35 p.m. She said staff had been getting a lot of training on abuse. She said she attended an in-service that day before her shift started. She said it was about abuse and interventions and the proper steps to take when staff saw it or heard it, who to report it to, and who to report it to if the abuse coordinator was not available. -LPN #2 was interviewed on 6/2525 at 3:28 p.m. She said she had been getting a lot of abuse training within the last week. She said she had received training that day on the difference between a complaint and abuse. She said abuse would be yelling at a resident, and a complaint would be if a resident complained when staff forgot to knock when entering their room. The maintenance director (MTD) was interviewed on 6/25/25 at 4:58 p.m. He said they were trained on the difference between abuse allegations and customer service. The MTD said abuse was purposely not answering a call light, and customer service was not being pleasant while providing care. II. Facility abuse policy The Abuse: Prevention of and Prohibition Against Policy and Procedure, revised January 2024, was received from the NHA on 6/24/25 at 2:39 p.m. It read in pertinent part: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental Abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. The facility will engage in training and orienting its new and existing nursing staff on topics which relate to the delivery of care in the post-acute setting. Topics of such training will include, but not be limited to: - Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; - Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. The investigation, and the results of the investigation, will be documented. III. Resident #24 - The facility failed to recognize, address, and thoroughly investigate allegations of potential staff-to-resident abuse. A. Resident #24 1. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included emphysema, major depressive disorder, and anxiety. The 3/21/25 minimum data set (MDS) assessment revealed Resident #24 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment revealed that Resident #24 was independent or needed supervision for the majority of her activities of daily living (ADL). 2. Resident interview and observations on 6/23/25 Resident #24 was interviewed on 6/23/25 at 2:25 p.m. She said she did not feel comfortable in the facility anymore because the staff did not like it when she stood up for herself. -She said she had gone to RN #2 and asked for her medication, and RN #2 did not put her scheduled pain medication and her scheduled antianxiety medication into her medication cup. She said when she asked about it, RN #2 told her that she had already given them to her and argued with her, which caused her to feel like she was being accused of medication seeking. She said RN #2 checked her medication card and saw that she had, in fact, not given her the medications and put them in her cup without apologizing to her. She said that since that incident, she had felt that the staff and facility had been picking on her. -She said nurses and CNAs would argue with her and make her feel bad. She said that she felt like staff were mentally abusing her. She said that CNAs would become really rude. She said CNA #4 yelled at her when she asked where the lid to her water jug was. She said CNA #4 yelled, Because there wasn't any! when she was assisting her roommate. During the interview, Resident #24 was very tearful when she was speaking about RN #2 and CNA #4. A few minutes later, the NHA was observed entering Resident #24's room. 3. Resident interviews on 6/24/25 Resident #24 was interviewed on 6/24/25 at 10:17 a.m. She said she wanted to share that the NHA had come into her room the day before and drilled her on everything that was said during her interview with the state. She said she remembered another thing that CNA #4 had done. She said she asked CNA #4 to change the oxygen tubing because it was all twisted and she could not get any oxygen out of it, but CNA #4 refused to get it for her. Resident #24 was interviewed again on 6/24/25 at 3:51 p.m. She said the NHA did not ask her if she wanted to continue to work with CNA #4, whom she said she felt was abusive. She said she felt like the NHA was out of line to come and drill her. She said she felt like he was intimidating. -She said the SSD did not discuss the incident involving CNA #4 with her but did discuss a new counselor who would be able to spend more time with her. She said she would like someone outside of the facility to talk to because she felt like the people connected to the facility were vindictive, and she felt like she did not have anyone she could talk to. -She said she had told staff that she did not want to work with RN #2 and CNA #4. She said RN #2 was not on her hall for maybe two weeks, but then she was on her hall again. She said she felt like the management did not care, and they are going to do what they are going to do. -She said she felt like the NHA was the only one she could talk to, but after what he did the day before, she was no longer sure she can talk to him. During the interview, Resident #24 became very tearful when she spoke of RN #2, CNA #4, and the NHA. B. Facility response On 6/23/25, around 3:30 p.m., the NHA submitted a paper file stating that Resident #24 had just reported to him a situation of potential abuse, and he wanted to be proactive and show the investigation. 1. Facility investigation The facility investigation revealed that the NHA interviewed Resident #24, and she reported that several months ago, CNA #4 yelled at her without provocation. When asked what triggered the incident, Resident #24 stated that CNA #4 responded to her by yelling at her. Resident #24 expressed that she felt the interaction had been rude. The report read that Resident #24 said she did not report it to anyone because she did not want to bother anyone or cause any trouble. The investigation further revealed that the NHA interviewed CNA #4 about the allegation. CNA #4 reported she rarely provided cares for Resident #24 since she was mostly independent. She said she delivered iced tea to Resident #24's bedside while she was out of the room, and when she returned, Resident #24 questioned why there was not a lid on the tea. CNA #4 stated she told her that the kitchen was temporarily out of lids. Resident #24 then responded by saying, You don't have to yell at me, and then Resident #24 left the room. CNA #4 reported she did not raise her voice. The investigation further revealed that the nurse who conducted Resident #24's victim assessment was RN #2. CNA #4 received training on customer service and nonverbal/verbal communication. The allegation was unsubstantiated due to not having any witnesses. 2. Failure to thoroughly investigate Resident #24's allegations of potential abuse Staffing records documented CNA #4 continued to be scheduled to work with Resident #24, and RN #2 was taken off from Resident #24's hall but was put back on soon after. -The investigation submitted by the NHA did not include any interviews with other residents who received care from CNA #4, nor any feedback from Resident #24 to see if the resolution (see above) was satisfactory. -The investigation the NHA provided did not include concerns that Resident #24 shared about RN #2. -The investigation did not include observations of interactions between Resident #24, as well as other residents cared for by RN #2 and CNA #4, and the two staff members. -The investigation did not include interviews with staff and residents who worked with or were cared for by RN #2 and CNA #4 about their interactions with the RN or CNA. -The investigation did not include documentation from the unofficial investigation by the DON or any grievances or concerns involving Resident #24, RN #2, and CNA #4. C. Staff interviews 1. RN #2 was interviewed on 6/24/25 at 4:26 p.m. She said her relationship with Resident #24 was good. -She said that Resident #24 was upset with her in the past because of the timing of her medications. She said that Resident #24's pain medication was scheduled at 4 p.m., but she wanted it at 3 p.m. S[TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure two (#4 and #207) of eight residents reviewed for accident hazards received adequate supervision out of 37 sample residents. Resident #4 was admitted to the facility for long term care on 4/5/24 with diagnoses of systemic involvement of connective tissue (autoimmune disease), arthritis, edema and history of stroke. Resident #4 was identified as cognitively intact and was able to transfer with a sit-to-stand mechanical lift (a lift device used to enhance a resident's dignity and independence by helping residents who can bear weight and participate to transition from a seated to a standing position). Resident #4 said a male certified nurse aide (CNA) transferred her without utilizing the sit-to-stand mechanical lift in May 2025. She said while the CNA was transferring her, they heard a pop. Resident #4 expressed pain and was observed by staff to have bruising, swelling, and redness to her right leg, ankle and foot. The facility failed to assess Resident #4 for pain and change of condition and failed to ensure treatment and Xrays were provided until 6/17/25. While the resident was visiting her community physician, she reported increased pain. The community physician ordered Xrays and the resident was transferred to the hospital where she was diagnosed with a right distal tibia and fibula fractures (bones of the lower leg). Due to the facility's failures to transfer the resident appropriately, Resident #4 suffered from extended pain and was not assessed for a less painful transfer status. The facility additionally failed to prevent an injury during transfers by not assessing or investigating the injury when first reported to staff. Additionally, the facility failed to implement person-centered fall interventions for Resident #207 tailored to her cognitive deficits. Specifically, the facility failed to ensure Resident #4 was transferred appropriately, which resulted in tibia and fibula fractures in the resident's right leg and ensure Resident #207 had person-centered fall interventions. Findings include I. Facility policy and procedure The Fall Monitoring and Management policy, reviewed April 2025, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:42 p.m. It read in pertinent part, Falls are any unplanned change of position. The licensed nurse is responsible for assessing and evaluating the resident's fall risk on admission, quarterly, and with a significant change in condition. Examples of interventions to minimize risks for injury due to falls include, but are not limited to, fall mat, raised edge mattresses, night lights, non-skid socks, hip protectors, and toileting schedule. II. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included systemic involvement of connective tissue ), arthritis, edema and history of stroke. The 6/3/25 minimum data set (MDS) assessment revealed Resident #4 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required total assistance from staff for toileting, dressing, bed mobility and all transfers. The resident required two-person extensive assistance from staff for bathing and personal hygiene. Resident #4 had impairments to her lower extremities and a limited range of motion. B. Resident interview Resident #4 was interviewed on 6/25/25 at 4:00 p.m. Resident #4 said she sustained an injury in the middle of May 2025 when a male CNA she did not know came into her room to transfer her from the wheelchair to the bed. She said he told her he was going to show her how to transfer without a mechanical lift device, then lifted her out of her chair manually and put her on the bed. Resident #4 said he was rough when picking her up and she asked him to be gentle and that her bones were fragile but he did not say anything to her. She said he put her down on her bed in a rough manner. She said her body twisted but not her right leg and both she and the CNA heard a popping sound, then the CNA left her room and did not send anyone in to look at her leg. Resident #4 said she experienced constant aching pain in her right leg and right foot afterwards but did not want to tell the doctor because she thought it would heal itself, but it kept swelling instead. She said when the staff would come in to take care of her, they would comment to her that her ankle looked swollen and if they tried to turn her ankle, the resident would yell out. Resident #4 said a male nurse came to look at it one evening but did not ask her about pain or assess her. Resident #4 said she had told several CNAs about the injury but she could not recall staff names or exactly when she told them. She said exactly four weeks after her injury, she told her community provider who sent her to the hospital for Xrays and the fracture was then discovered. Cross reference F610: failure to investigate an injury of unknown origin. C. Record review The musculoskeletal care plan, revised 6/20/25, revealed Resident #4 had an alteration in musculoskeletal status related to a right distal tibia and fibula fracture (fractures of the lower leg). Interventions, revised 6/20/25, included to keep the call light within reach, provide heat and/or cold applications as tolerated and monitor for fall risks. The activities of daily living (ADL) care plan, revised 6/5/25, revealed Resident #4 had a deficit in self care. Interventions, revised 6/5/25, included to provide the resident with one to two-person assistance with transfers and stand by assistance with pivot transfers. The fall care plan, revised 12/27/24, revealed Resident #4 was at risk for falls due to a history of urinary tract infections and weakness. Interventions included anticipating the resident's needs, avoiding rearranging furniture in the room, encouraging participation in physical activities and maintaining a clear pathway (initiated 4/7/25). -The fall care plan failed to reveal Resident #4's care plan had been updated to include the recent fracture as a risk factor. Review of Resident #4's June 2025 CPO revealed the following physician's orders: Weight bearing status: non weight bearing to right ankle, ordered 6/17/25. Monitor right lower extremity and notify the provider of any concerns related to circulation, motion, or sensation, ordered 6/18/25. Float right lower extremity with pillows while in bed due to ankle fracture, ordered 6/20/25. The facility incident report, dated 6/17/25, revealed Resident #4 had been sent to the hospital for Xrays on 6/17/25 directly from her community provider, whom she saw twice weekly. The facility report revealed 10 staff members were interviewed. Out of 10 staff members interviewed, one staff member replied they had observed redness and swelling to the resident's ankle as of 6/16/25 and another staff member replied Resident #4 had expressed pain in her ankle as of 6/16/25. -There were no staff names mentioned or follow up questions reported in the incident. The community provider notes, dated 6/10/25, revealed an Xray was ordered for 6/12/25 due to Resident #4 complaining of ankle pain after an injury. During the visit on 6/10/25, the nurse observed pain, redness, bruising, swelling, tenderness and changes in range of motion. Progress notes were reviewed from 5/1/25 to 6/16/25 and failed to reveal any injury to the resident had been documented. D. Staff interviews CNA #5 was interviewed on 6/26/25 at 10:33 a.m. CNA #5 said Resident #4 used to complain to her about her foot hurting CNA #5 said she was not aware of the injury and did not ask the resident what had happened. She said she told RN #3 on 6/15/25 when she noticed bruising on the Resident #4's mid-calf going down her leg to her foot. CNA #6 was interviewed on 6/26/25 at 10:41 a.m. CNA #6 said Resident #4 used to use a sit-to-stand lift prior to the injury but now required total assistance in a Hoyer (mechanical) lift. CNA #6 said on 6/16/25, she noticed redness to Resident #4's ankle and the resident complained to her about pain and tenderness. Registered nurse (RN) #3 was interviewed on 6/26/25 at 12:34 p.m. RN #3 said a CNA brought it to his attention on the evening shift on 6/15/25 that while laying Resident #4 down, she had complained of pain in her ankle and that the CNA observed swelling and bruising. RN #3 said he looked at the ankle and observed it was swollen and bruised. He said Resident #4 told him she was waiting on the Xrays to be completed by her community provider. He said therefore he did not do a skin assessment, a pain assessment or contact the resident's family or physician because he assumed all parties were aware since the resident was waiting for Xrays. He said he did not ask the resident how and when the injury occurred. RN #3 said the following day was the weekly meeting between Resident #4's community provider and the facility and RN #3 advised the director of nursing (DON) to ask the community provider if an Xray was scheduled but he said he did not follow up any time later with the DON regarding the Xray that the resident mentioned. The minimum data set coordinator (MDSC) was interviewed again on 6/26/25 at 6:08 p.m. She provided handwritten notes by the DON from the 6/16/25 meeting with Resident #4's community provider. The MDSC said the notes indicated that Resident #4 had been discussed during the meeting but the community provider had declined to complete Xrays on 6/16/25. The MDSC said at the time RN #3 was notified by the CNA that Resident #4 had complaints of pain in her ankle, RN #3 should have completed skin and pain assessments. She said RN #3 should have offered non-pharmacological interventions for relief of pain, such as elevating Resident #4's feet, offering a cold compress or offering her as needed pain medication. III. Resident #207 A. Resident status Resident #207, age [AGE], was admitted on [DATE]. According to the June 2025 CPO, diagnoses included absence of right leg above the knee, anxiety, repeated falls, lack of coordination, muscle weakness and dementia. The 5/28/25 MDS assessment revealed Resident #207 was severely cognitively impaired with a BIMS score of seven out of 15. The resident required moderate assistance (staff supports trunk or limbs) from staff for toileting, bathing, dressing and transfers. The assessment indicated the resident had falls prior to admission and one fall since admission with injury. B. Resident interview and observation Resident #207 was interviewed on 6/23/25 at 10:34 a.m. Resident #207 said she had fallen the prior day (6/22/25) and hit her head on the bar on the right side of her bed. She said she had been an amputee (right lower leg) since she was [AGE] years old and used a prosthetic leg but she did not have it at the facility currently because it needed to be refitted. Resident #207 said she did not know if the facility was assisting with follow up on the status of her prosthetic. She said she had a sign on her wall to remind her to use her call light before trying to get up on her own. She said she did not always remember to use it and sometimes she chose not to use it. Resident #207 said she was unsure of any additional fall interventions put into place for her falls. Resident #207 was observed during the interview. A call and do not fall sign was on the wall at the foot of her bed. There was not a fall mat in her room. Her side of the room had limited space to move around with her wheelchair pushed up to the middle of the right side of her bed and her bedside table was pushed up to the head of the right side of her bed. Her nightstand was behind the bedside table and her dresser was at the foot of her bed, next to her wheelchair. C. Record review The fall care plan, revised 6/24/25 (during the survey), revealed Resident #207 was at risk for falls related to dementia and weakness. The care plan indicated the resident had an actual fall with injury. Pertinent interventions included ensuring the call light was within reach (initiated 5/23/25), adding colored tape to the call light (initiated 5/28/25), adding a call and do not fall sign (initiated 5/28/25), adding colored tape to the call light in the bathroom (initiated 6/4/25), adding colored tape to the resident's wheelchair brakes (initiated 6/5/25), adding extenders to the wheelchair brakes (initiated 6/5/25) and monitoring the resident's blood sugars in the evening for five days for hypoglycemic determination (initiated 6/24/25). -Review of the resident's care plan did not identify rounds, frequent toileting, adding a fall mat, physician record review, or medication review that the staff identified as effective fall interventions (see staff interviews below). The cognitive care plan, initiated 5/23/25, revealed Resident #207 had impaired cognitive functioning and impaired thought processes related to dementia with anxiety. Interventions included providing psychosocial support and using simple, detective sentences with necessary cueing (initiated 5/23/25). A review of Resident #207's therapy notes, dated 5/25/25 to 6/21/25, revealed the following: An occupational therapy (OT) evaluation, dated 5/25/25, revealed the goals for Resident #207 included to increase safety awareness. The evaluation documented that during the evaluation, Resident #207 demonstrated uncontrolled downward movements and an instance of forgetting to lock her wheelchair brakes, saying to the therapist that's just what I do. A physical therapy (PT) evaluation, dated 5/25/25, revealed the goals for Resident #207 included ensuring she locked her wheelchair brakes to prevent falls. The evaluation documented during the evaluation, Resident #207 demonstrated needing verbal reminders to lock her brakes before transferring and then the resident forgot the instructions and the therapist had to lock the brakes for Resident #207. The evaluation further revealed the resident demonstrated poor spatial awareness (the ability to tell where objects are in space, including one's own body parts. Additionally, it involves being able to tell how far objects are from one's self and from each other) as evidenced by the bruises and scabs Resident #207 presented to the therapist. Resident #207 explained it was due to hitting her hands on doorways when propelling herself in her wheelchair. A speech therapy (ST) evaluation, dated 5/27/25, revealed the goals for Resident #207 included to increase memory skills, executive functioning (a set of mental processes that help individuals plan ahead and meet goals, display self-control, follow multiple-step directions even when interrupted, and stay focused despite distractions, among others) and sequencing (the mental process of creating an order or specific pattern of steps to complete a task). The ST identified in the evaluation that Resident #207 had impaired executive functioning, impaired problem solving and impaired short term memory. A PT treatment note, dated 5/27/25, revealed Resident #207 had been educated on the need to use her call light due to poor safety awareness. The resident demonstrated the need for assistance from the therapist to navigate the bedroom and the hallway in a wheelchair to prevent from hitting objects. A brief cognitive assessment tool (BCAT) was performed on 5/28/25 to determine various areas of cognitive functioning for Resident #207. The results indicated significant deficits in executive functioning, cognitive shifting (the ability to move seamlessly between different mental tasks to adapt to new information and judgement). The assessment also revealed significant deficits in visuospatial awareness and delayed and immediate memory recall. A PT treatment note, dated 5/29/25, revealed Resident #207 had demonstrated forgetfulness when needing to lock her wheelchair brakes and after being reminded, forgot the instruction ten minutes later. Staff were advised by the therapist to conduct frequent checks on Resident #207 due to memory and poor safety awareness. -However, frequent checks were not identified on the resident's care plan (see care plan above). An OT risk assessment, dated 6/3/25, revealed Resident #207 told the therapist that she tended to fall backwards and hit her head, she felt unsteady walking and she did not ambulate without her prosthetic leg. Her prosthetic leg was currently not with her. An OT treatment note, dated 6/5/25, revealed Resident #207 demonstrated poor safety awareness and memory recall as evidenced by the resident's failure to recall the necessity to lock her wheelchair brakes prior to transferring. The therapist provided colored tape to be placed on the brakes in order for the resident to more easily find them. A ST treatment note, dated 6/6/25, revealed Resident #207 had been provided significant education on the execution of the task of safe transferring and was shown how to use the call light in the bathroom.The therapist put colored tape on the cord for easier identification. An OT treatment note, dated 6/17/25, revealed colored tape had been put on Resident #207's wheelchair brakes to increase her attention to the locks before transferring. During treatment, the resident presented as confused and disorientated. An OT treatment note, dated 6/18/25, revealed Resident #207 neglected to lock her wheelchair brakes when distracted by something in her room and demonstrated poor safety awareness and increased risk for falls when attempting to stand up unsupported. A ST treatment note, dated 6/18/25, revealed Resident #207 demonstrated significantly impaired safety awareness and insight. Resident #207 told the therapist that she did not use the call light because she went to the bathroom by herself. Additionally, she told the therapist that she could read the sign on her wall that told her not to get up, but she still got up. -Therapy notes revealed a focus of ensuring Resident #207 could locate, identify, and utilize her wheelchair brakes when transferring, however, all of Resident #207's falls were determined to be due to the resident trying to self transfer and then falling and not due to unsafe transferring with the wheelchair (see progress notes below). Resident #207's progress notes were reviewed from 5/23/25 to 6/24/25. The progress notes revealed the following: A nursing note, dated 5/27/25, revealed Resident #207 had an unwitnessed fall when she attempted to transfer herself from her bed to her wheelchair without calling for assistance. No injuries were noted and interventions were to add a call and do not fall sign and bright colored tape on the resident's call light. An interdisciplinary team (IDT) fall note, dated 5/29/25, revealed the DON and the director of rehabilitation (DOR) put a sign in place, colored tape was applied to the resident's call light and the resident was provided education to use her call light. A nursing note, dated 6/3/25, revealed Resident #207 had an unwitnessed fall when she attempted to transfer herself from her wheelchair to the toilet without calling for assistance. No injuries were noted and interventions were to add colored tape to the bathroom call light. An IDT fall note, dated 6/4/25, revealed colored tape was applied to the resident's bathroom call light. A nursing note, dated 6/4/25, revealed Resident #207 had an unwitnessed fall when she attempted to transfer herself from her wheelchair to her bed without calling for assistance. The resident suffered from a hematoma to her forehead as a result and interventions were to add bright colored tape to the wheelchair brakes. An IDT fall note, dated 6/5/25, revealed colored tape was applied to the resident's wheelchair brakes. A nursing note, dated 6/16/25, revealed Resident #207 had an unwitnessed fall when she attempted to transfer herself from her wheelchair to her bed without calling for assistance. No injuries were noted and the intervention was to add wheelchair brake extenders. An IDT fall note, dated 6/17/25, revealed wheelchair brake extenders were applied to the resident's wheelchair. A nursing note, dated 6/22/25, revealed Resident #207 had an unwitnessed fall when she attempted to transfer herself from her wheelchair to her bed without calling for assistance. No injuries were noted and interventions were to monitor the resident's blood sugars. An IDT fall note, dated 6/23/25, revealed no new interventions were recommended after the resident sustained a fall on 6/22/25. -IDT fall notes dated 6/4/25, 6/5/25, 6/17/25 and 6/23/25 failed to reveal a review of the previous fall interventions for Resident #207 and an assessment of why the interventions failed (see staff interviews). IV. Staff interviews CNA #1 was interviewed on 6/24/25 at 2:44 p.m. CNA #1 said Resident #207 had behaviors of becoming anxious, forgetting she did not have her prosthetic leg on and falling. CNA #1 said the fall interventions were in the CNA documentation and the interventions for Resident #207 were to toilet her every two hours and check on her when staff passed her room. Licensed practical nurse (LPN) #1 was interviewed on 6/24/25 at 3:00 p.m. LPN #1 said Resident #207 was impulsive, did not wait for staff to assist her to the toilet and was confused because she believed her spouse was going to take her home everyday. LPN #1 said the fall interventions were communicated verbally to the staff by the IDT and Resident #207's interventions were to check her blood sugars and check on her when staff passed her room. CNA #3 was interviewed on 6/24/25 at 3:30 p.m. CNA #3 said the fall interventions for Resident #207 were to check on her hourly, remind her of the sign on her wall, answer her call light in less than five minutes and put a fall mat out on her floor in the evening. CNA #3 said the fall interventions were in the care plan. -However, the interventions indicated by CNA #1, LPN #1 and CNA #3 for Resident #207's falls were not included in the care plan (see care plan above). The MDSC was interviewed on 6/26/25 at 2:00 p.m. The MDSC said she was currently the acting DON. The MDSC said the facility's process when a resident fell, was to first notify the nurse if discovered by a CNA, implement 72-hour observations if the resident hit their head when they fell, and call the provider and the responsible party. She said that on the following day, the IDT would meet to discuss the fall, discuss the previous interventions, and assess why the prior interventions failed to prevent further falls. The MDSC said fall interventions were determined based on the fall and the resident. She said typical interventions the facility would utilize were to put a sign up in the resident's room that reminded them to call for assistance, putting colored tape on their call lights, frequent checks, frequent toileting, providing a fall mat, providing night lights if necessary, environmental assessment of the resident's room, review medications, or have the physician review the resident's record. The MDSC said the IDT communicated new fall interventions to the staff by care planning and providing verbal instruction. She said the staff were aware to look for fall interventions in the care plan. She said she was not aware the staff were not looking for interventions in the care plan. The MDSC said the fall interventions for Resident #207 included putting up a sign, using brightly colored tape to draw her attention to her call light and wheelchair brakes and implementing frequent checks. She said she had not set a specific time for the checks nor did the staff document when they had completed them. The MDSC said a root cause analysis was performed by the IDT and it was determined that Resident #207's repeated falls were due to her cognitive and poor safety awareness deficits. The MDSC said she was unsure how the facility determined what fall interventions would be successful for Resident #207 with her cognitive deficits. The DOR, the consulting pharmacist and the regional clinical resource (RCR) were interviewed together on 6/26/25 at 4:44 p.m. The DOR said the therapy department had started working with Resident #207 on 5/22/25 for OT and 5/27/25 for PT and ST. He said therapy had started working with the resident due to her frequent falls. He said he was notified she had not been locking her wheelchair brakes and was trying to self transfer. The DOR said therapy had identified visual, cognitive and safety impairments while working with Resident #207 and the brightly colored tape on her brakes and call lights were to draw her attention to use them. He said the resident told therapy that she did not always use her call light when she needed to be assisted to the bathroom because she wanted to go to the bathroom when she wanted to go. The DOR said the therapy department incorporated the staff in training for new fall interventions for residents. He said he was not sure why the IDT and therapy had chosen fall interventions that required repetition, retention, and memory recall for Resident #207 when her deficits affected her memory, judgement, sequencing and executive functioning. The RCR said the therapy department had been working with Resident #207 on learning through repetition. He said the resident had been successful in locking her brakes with cueing when staff was present, but the resident had difficulty with memory impairments and retention. The pharmacist said Resident #207's medications had been reviewed, including her psychoactive medications, but the decision had been made that it was too soon in her stay to make changes to her psychoactive medications.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and follow up with residents on the outcomes and resolutions of grievances expressed. Findings include: I. Facility policy and procedure The Grievance policy, reviewed June 2025, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:42 p.m. It read in pertinent part, The grievance official or designee responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken in resolution. II. Resident group interview Four residents (#14, #11, #8 and #54) who regularly attended the resident council meetings were interviewed on 6/25/25 at 9:00 a.m. The residents were identified as alert and oriented by the facility and assessment. The group of residents said the facility did not follow up on grievances brought up in the resident council meetings. Resident #14 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting. Resident #14 said he did not know what happened if a resident had an individual grievance and how the facility handled it. Resident #8 said the resident council had been bringing up the issue of call light times and linens not being changed on their beds but the resolutions were never brought back to resident council. Resident #14 said he specifically complained about linens not being changed but he did not know what the resolution had been. The residents said they did not know how to file a grievance or how the staff were to notify them of resolutions. III. Record review A review of the resident council meeting minutes, dated 3/27/25, revealed the residents brought up concerns regarding cigarette butts on the ground in the smoking area, an individual resident left in the bathroom for too long a time and an individual resident had missing clothes. A review of the March 2025 grievances revealed individual grievances had been written for the missing clothes and the long bathroom wait with resolutions of staff education. A group grievance had been written for the cigarette butts outside and the patio was cleaned. -A review of the March 2025 grievances and the resident council meeting minutes failed to reveal the facility had followed up with any of the individual residents or the resident council as a group regarding what had been done to resolve their concerns. A review of the resident council meeting minutes, dated 4/24/25, revealed the residents brought up concerns regarding cigarette butts on the ground in smoking area, cold food, room trays taking too long, an individual resident said she was in the bathroom too long, there needed to be better communication from therapy department regarding resident schedules and the toilets and floors in the resident rooms were not being cleaned well. A review of the April 2025 grievances revealed individual grievances had been written for the call light times, dirty floors and toilets, cold food, room trays taking too long, bathroom wait times, and communication from the therapy department with resolutions of staff education. A group grievance had been written for the cigarette butts outside and a sign was put up to not throw cigarette butts on the ground. A group grievance had been written for the bed linens not being changed on a regular basis and staff were provided education. -A review of the April 2025 grievances and the resident council meeting minutes failed to reveal the facility had followed up with any of the individual residents or the resident council as a group regarding what had been done to resolve their concerns. A review of the resident council meeting minutes, dated 5/29/25, revealed the residents brought up concerns regarding a shortage of linens, dirty linens on the beds, receiving medications late, staff socializing and not helping the residents, long call light times and staff not changing bed linens. A review of the May 2025 grievances revealed individual grievances had been written for the receiving medications late, staff socializing and not helping the residents, and long call light times with resolutions of staff education. A group grievance had been written for dirty linens on the beds and staff not changing bed linens with resolutions of creating sign off sheets for the staff. -A review of the May 2025 grievances and the resident council meeting minutes failed to reveal the facility had followed up with any of the individual residents or the resident council as a group regarding what had been done to resolve their concerns. IV. Staff interviews The activities director (AD) was interviewed on 6/25/25 at 12:17 p.m. She said she helped the residents run the resident council meeting. The AD said the grievance process during the meeting was that the group talked about any grievances. She said she then wrote the concerns up on a grievance form. She said she then provided the grievance to the department manager responsible for the concern. She said the managers were to bring back the group grievance resolutions to the next meeting. The social services director (SSD) was interviewed on 6/25/25 at 12:26 p.m. She said she was the grievance official. She said the grievance process was for the person receiving the grievance to complete a grievance form and provide it to the department manager responsible. She said once an individual grievance or group grievance had been resolved, it was documented at the bottom of the grievance form. She was not able to explain why the group and individual grievances from March 2025 through May 2025 failed to include any documentation at the bottom of a follow up with the resident or family making the complaint. The SSD said the facility needed to improve this process to ensure resident concerns were being addressed timely.

Based on interviews and record review, the facility failed to ensure one (#52) of five residents had the right to choose her own attending physician out of 37 sample residents. Specifically, the facility failed to allow Resident #52 to choose their primary care provider (PCP) when the resident's previous primary care provider stopped seeing residents. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, revised June 2025, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:32 p.m. It read in pertinent part, The resident has the right to choose a personal attending physician (and be informed how to contact him or her), to be fully informed in advance about care and treatment, and, unless adjudicated incompetent or otherwise found incapacitated under state law, participate in planning medical treatment. II. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included chronic kidney disease, stage 3, history of malignant neoplasm of cervix and uterus (cervical cancer), short bowel syndrome (a condition where the small intestine was unable to absorb enough nutrients and fluids from food), severe sepsis with septic shock (life threatening condition occurring when the body's response to an infection damages its own tissues and organs), colostomy (surgical procedure that creates an opening in the abdominal wall allowing the colon to the surface to allow stool to exit the body) agoraphobia with panic disorder (a mental health condition characterized by an intense fear of public spaces or situations where escape might be difficult), depression, bipolar 2 disease, post-traumatic stress disorder, mixed obsessional thoughts and acts. The 5/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had an impairment on one upper extremity and required a walker. She required set-up assistance with eating, oral hygiene, and showering. The MDS assessment revealed it was very important for her to choose what she wore, for her to take care of her personal belongings, for her to choose her bedtime and for her family or close friends to be involved in discussion about her care. B. Resident interview Resident #52 was interviewed on 6/23/25 at 10:36 a.m. Resident #52 said she loved her former PCP. She said her PCP's clinic had closed indefinitely, and she said she had to be seen by the facility's physician. She said she did not have a choice in what physician took over her care, and the facility did not provide any documentation for her to be able to select an attending physician of her choice. C. Record review The 4/15/25 nurse progress note revealed nursing received notification that Resident #52's physician was ending their provider services with the nursing facility, effective at the end of April 2025. The note documented Resident #52 was notified and wished to transfer to the facility's providers. A telephone call was placed to the facility's providers to notify them of the new resident. The social services director (SSD) and the director of nursing (DON) were aware. -However ,the facility was unable to provide documentation to indicate that Resident #52 was informed about the change in her attending physician or that the resident's permission was obtained to assign the facility's physician as her physician. III. Staff interviews The social services director (SSD) was interviewed on 6/26/25 at 4:19 p.m. The SSD said if a resident said they did not like their current physician, the facility told the current physician and then she sent a referral to other providers to see if the other providers would accept the resident. She said anyone on the interdisciplinary team (IDT) was responsible for working with the resident in selecting a physician, but she said typically it was the nursing staff and/or herself. She said the change in physician was documented as a progress note. The SSD said the facility was provided about three days notice that Resident #52's medical group was dissolving and the physicians in that group, including Resident #52's physician, quit quickly after the medical group announced they had ended services. She said there was no option for physicians provided to Resident #52 because there was no other option other than the one physician for the facility. The SSD said if a resident wanted to choose a different physician besides the facility's physician, the facility needed to make sure the physician the resident wanted to choose was credentialed and licensed. She said the facility did not have enough time in April 2025 because the change happened so quickly. The SSD said she should have explained to Resident #52 how the process to choose a different physician that was not contracted with the facility worked, and asked the resident if she was okay with the facility's physician while the facility worked on a contract for a second physician for the resident to choose from. The interim nursing home administrator (INHA) was interviewed on 6/26/25 at 4:49 p.m. The INHA said it was the resident's choice for who they wanted for their physician. He said if a resident wanted a different physician, the choice was based on which physician was contracted with the facility. He said if a resident wanted a physician who was not contracted with the facility, the facility worked to verify that the physician had their credentials and licensing. He said it could take the facility a couple of days to weeks to months to get a contract with a new physician, depending on the physician's communication with the facility's corporate licensing department. The INHA said the SSD was responsible for working with the residents for their choice of physician. The INHA said he did not know how it was documented when a resident changed physicians. He said it was explained when the resident was admitted in the admission packet. He said he was not familiar with Resident #52. The INHA said the facility had one physician currently contracted with the facility.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeeping staff performed appropriate hand hygiene between cleaning resident rooms; -Ensure staff kept clean and soiled laundry separate in the laundry room; -Ensure staff handled plastic drinking cups in a hygienic manner to prevent contamination; and -Provide tracheostomy care for Resident #34 in a sanitary manner; and, -Ensure that Resident #95's urinary catheter drainage bag was cleaned appropriately and stored in a sanitary manner. Findings include: I. Failed to ensure housekeeping staff performed appropriate hand hygiene between cleaning resident rooms A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Hand Hygiene in Healthcare Settings, revised 1/18/21, retrieved from https://www.cdc.gov/handhygiene/providers/index.html on 7/1/25, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers (ABHS) are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. B. Facility policy and procedure The Personal Protective Equipment policy and procedure, revised August 2024, was provided by the nursing home administrator (NHA) on 6/23/25 at 3:36 p.m. It read in pertinent part, Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene between clean and dirty tasks. C. Observations During a continuous observation on 6/23/25, beginning at 10:00 a.m. and ending at 10:15 a.m., housekeeper (HK) #1 was observed leaving room [ROOM NUMBER] with gloves on both of his hands. He proceeded to enter room [ROOM NUMBER] with the same gloves on his hands and started to clean room [ROOM NUMBER]. -HK #1 failed to change gloves and perform hand hygiene after cleaning one resident's room and prior to cleaning another resident's room. II. Failed to ensure staff kept clean and soiled laundry separate in the laundry room A. Professional reference According to the CDC's Guidelines for Environmental Infection Control in Health-Care Facilities, revised 1/8/24, retrieved from https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html?utm_source=chatgpt.com on 7/1/25, A laundry facility should be partitioned into two separate areas; a dirty area for receiving and handling the soiled laundry and a clean area for processing the washed items. B. Laundry room observation and staff interview During a walkthrough tour of the laundry room with the maintenance director (MTD) on 6/26/25 at 10:45 a.m., the following was observed: Black tape was observed on the floor in two areas of the laundry room. The MTD said the black tape on the floor to the right side of the laundry room's two washing machines designated where facility staff placed soiled laundry. There were two plastic bags of soiled laundry and residents' soiled laundry was spilling out of one of the plastic bags. The soiled laundry crossed over the black tape and was in front of the washing machine, on the left side of the black tape. The MTD said the soiled bags of laundry should not have crossed over the black tape and he did not know why staff had put them like that. The MTD said the black tape on the floor to the left side of the two washing machines designated the clean area of the laundry room. He said soiled laundry should not be on the left side of the black tape on the ground. On the left side of the black tape and the two washing machines were two dryers, a folding table, a hanger rack and a laundry storage section. There were two laundry carts with white linen next to the black tape on the left side of the washing machines. Behind the two carts was a sign on the wall that said dirty rags here and a separate cart. The MTD said dirty rags were placed there and rags were visible in the dirty rag cart. The MTD said the facility needed to find a different location for the housekeeping staff to place soiled rags after cleaning residents' rooms and the facility. He said it was important to find a different location because the black tape on the ground designated the clean versus soiled areas of the laundry facility. He said he would work with the staff to ensure soiled and clean laundry remained separated. III. Failed to ensure staff handled plastic drinking cups in a hygienic manner to prevent contamination A. Professional reference The 2022 Food Code by the US Food and Drug Administration, revised 1/18/23, was retrieved on 7/2/25 from https://www.fda.gov/media/164194/download. It read in pertinent part, Food shall only contact surfaces of equipment and utensils that are cleaned and sanitized. Employees shall wash their hands. Except when washing fruits and vegetables, employees may not contact exposed ready-to-eat food with their bare hands and shall use suitable utensils. Food shall only contact surfaces of equipment and utensils that are cleaned. B. Observations During a continuous observation on 6/23/25, beginning at 11:31 a.m. and ending at 12:29 p.m., the following was observed in the main dining room: At 11:42 a.m. an unknown staff member, who was not wearing gloves, was putting ice in plastic drinking cups on a cart next to the ice machine. The unknown staff member grabbed a cup and placed two to three fingers inside the cup. The staff member proceeded to scoop ice into the cup. The staff member repeated placing her fingers inside the plastic cup eight times. At 11:46 a.m., the staff member grabbed seven cups and placed them face down on the cart without ensuring the cart had been sanitized. -The unknown staff member failed to handle the plastic cups in an appropriate manner in order to prevent contamination of lip contact surfaces. IV. Failed to provide tracheostomy care for Resident #34 in a sanitary manner A. Observations On 6/25/26 at 1:36 p.m. registered nurse (RN) #1 was observed performing tracheostomy care for Resident #34. Upon entering Resident #34's room, RN #1 washed her hands and put clean gloves on. With clean gloves on, RN #1 grabbed a movable table by the surface and moved it closer to the resident. Using the same gloves, she gathered clean dressing supplies and dropped them on the surface of the table. -RN #1 failed to sanitize the table surface prior to putting clean dressing supplies on it. RN #1 remove Resident #34's soiled tracheostomy dressing and disposed of it in the trash. She washed her hands and put clean gloves on. With clean gloves on, she cleaned the area around the resident's tracheostomy with gauze and normal saline. Using the same gloves, RN #1 picked up a new gauze dressing, opened the package, dropped the dressing on the surface of the table, picked it up and applied it around the tracheostomy. -RN #1 failed to change her gloves and perform hand hygiene after cleaning the resident's skin around the tracheostomy site and prior to applying a new dressing to the resident's tracheostomy. -RN #1 failed to obtain another dressing after dropping a newly opened clean dressing on the unsanitized surface of the table. RN #1 applied the dressing that fell on the unsanitized table to Resident #34's tracheostomy site. B. Staff interview RN #1 was interviewed at approximately 1:50 p.m RN #1 said she should have changed her gloves after she removed the soiled dressing and before she touched the clean dressing. She said she forgot to change her gloves. She said the surface of the table was not cleaned and she should have cleaned it before putting clean supplies on it. V. Failed to ensure that Resident #95's urinary catheter drainage bag was cleaned appropriately and stored in a sanitary manner A. Observations On 6/23/25 at 1:34 p.m., a urinary catheter drainage bag was observed in Resident #95's room in their bathtub. The drainage bag still contained urine and the catheter tubing and clamp were resting inside the bathtub's soap dish. On 6/24/25 at 3:20 p.m., a urinary catheter drainage bag was observed again in Resident #95's room in their bathtub. The drainage bag still contained urine and the catheter tubing and clamp were resting inside the bathtub's soap dish. B. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 6/24/25 at 3:30 p.m. CNA #3 said urinary catheter drainage bags were not supposed to be kept in residents' bathtubs. CNA #3 said when a resident's urinary catheter drainage bag was not being used, it should be cleaned with vinegar and hung on the railing in the resident's bathroom to dry. The infection preventionist (IP) was interviewed on 6/24/25 at 3:45 p.m. The IP said a urinary catheter drainage bag with urine in it or a catheter bag kept in a bathtub would not be sanitary to use and should be disposed of. She said once a urinary catheter drainage bag was disconnected, the drainage bag should be cleaned with a vinegar and water solution, rinsed and hung up to dry. The IP said using a urinary catheter drainage bag that had not been kept clean or in a sanitary environment could cause infections , including a urinary tract infection. VI. Additional staff interviews The minimum data set coordinator (MDSC) clinical resource (CR) #2 were interviewed together on 6/26/25 at 1:02 p.m. The MDSC said the infection preventionist (IP) and the director of nursing (DON) were not available for an interview. She said she was familiar with infection prevention and infection control. The MDSC said after removing gloves, staff members should always perform hand hygiene before putting clean gloves on. She said the housekeepers should change their gloves between cleaning one resident's room and another resident's room. She said the housekeepers should perform hand hygiene when they changed their gloves, either by washing their hands or using ABHS. The MDSC said she was familiar with the laundry facility's layout and how the room designated the dirty area versus the clean area. The MDSC said when she walked into the laundry room, the black tape on the ground on the right side of the washing machines designated the area where staff placed soiled laundry. The MDSC said the black tape on the ground on the left side of the washing machines designated the area where laundry was clean. The MDSC said she did not know staff placed their soiled rags in the dirty rag cart located in the clean area. The MDSC said staff should not touch the inside of drinking cups. She said it was important for staff not to touch the inside of cups in order to prevent contamination. She said she was not aware when the unknown staff member had filled drinking cups with ice on 6/23/25, that the staff member had touched the inside of the cups (see observation above). CR #2 said when nursing staff provided tracheostomy care and dressing changes, a clean field should be established. CR #2 said the designated surface for holding the dressing supplies should be sanitized before placing any tracheostomy care supplies on top of the surface. CR #2 said hand hygiene should be performed before putting on gloves and a gown. CR #2 said hand hygiene should be performed and gloves should be changed after touching a dirty area and before touching clean tracheostomy supplies. CR #2 and the MDSC said they were not aware of how the tracheostomy care was provided for Resident #34 on 6/24/25 (see observation above). CR #2 and the MDSC both said they would work with nursing staff to ensure a clean field was established when providing tracheostomy care. The MDSC said if a resident had a catheter attached to their leg or their wheelchair, the catheter should be lower than their bladder and it should not be on the floor. The MDSC said she was not aware Resident #95's catheter was in the resident's bathtub and the tip of the catheter was resting on the soap dish. She said Resident #95's catheter should not be in his bathtub or in the bathtub's soap dish. She said a catheter should not be in a bathtub or a soap dish to prevent infection.

Based on record review and interviews, the facility failed to ensure facility resources were administered in a manner that allowed its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. Specifically, the facility failed to: -Provide sufficient leadership to address and or avoid multiple concerns; -Prevent, report and fully investigate allegations of abuse timely to provide immediate protections to residents at risk; -Report and investigate an injury of unknown origin in a timely manner so that an accurate timeline of events could be established and the injury could be effectively treated and monitored; and, -Monitor a resident for worsening symptoms of depression who expressed suicidal ideations. Findings include: I. Abuse and neglect During the extended survey from 6/23/25 to 6/26/25, it was identified that there were concerns over the timely reporting of an allegation of abuse so that the resident could be immediately protected from a repeat incident of abuse. While staff were aware of the situation of potential verbal abuse, and reported it to the director of nursing (DON) and the social services director (SSD), the management and facility leadership did not immediately investigate the allegations so that immediate interventions could be implemented to prevent repeated attempts of abuse. Facility leadership was aware of the concerns brought by staff as it was discussed in the morning meetings. Cross-reference F610: failure to identify and investigate an allegation of abuse in a timely manner. II. Injury of unknown origin During the extended survey from 6/23/25 to 6/26/25, it was identified that there were concerns over the timely reporting of a discovered injury of unknown origin to Resident #4. On 6/15/25 a certified nurse aide (CNA) reported to the nurse that the resident had a swollen ankle. The nurse did not follow the protocol of the facility and did not complete a full skin assessment and did not ask the resident about how the injury occurred. Additionally, the nurse did not report the finding to the management and resident's physician or family. During the survey, Resident #4 said the fracture occurred during transfer when CNA did not use the lift but picked her up and threw her into the bed. She said her and CNA both heard the pop but the CNA did not report it to anyone. The injury was not reported to the facility's leadership until 6/17/25, when the resident was sent to the emergency room directly from her physical therapy session with an outside provider. The investigation and assessment of the injury started late; it was discovered that the resident had two broken bones on her leg that went unnoticed and untreated. According to the hospital records the fracture was at least four weeks old. Cross-reference F610: failure to investigate an injury of unknown origin. Cross-reference F689: failure to prevent an accident. III. Suicidal ideations and depression Resident #23's minimum date set (MDS) assessment in April 2025 revealed the resident felt bad about himself, felt he was a failure, let himself or his family down every day and he had thoughts he would be better off dead or of hurting himself in some way for several days during the assessment look back period. Resident's depression scores continued to increase in the next two consecutive assessments in September 2025 and December 2025 indicating worsening depression. When interviewed, the SSD said she was aware of the resident's assessment scores, however no actions were taken to help the resident. There was no evidence that the resident had seen a psychotherapist since June 2022. IV. Leadership efforts The nursing home administrator (NHA) had the responsibility to lead investigations for allegations of abuse to ensure compliance with identifying potential abuse; responding to an allegation of abuse; preventing ongoing abuse; and reporting abuse to the proper authority, all in a timely manner. During the interviews, the NHA denied the knowledge of the allegations of abuse for Resident #24. -However, management and staff, such as the DON, the SSD and registered nurse (RN) #2 were aware and said the situation was discussed during the morning meetings and the nurse named in the allegations was reassigned to another unit for a short period of time. V. Staff interviews The DON was interviewed on 6/24/25 at 4:05 p.m. The DON said she was aware of the conflict situation that occurred between the nurse and Resident #24. She said she could not recall the details and would comment on it after she reviewed the details. -The DON was not available for further interviews during the survey. The SSD was interviewed on 6/24/25 at 4:30 p.m. She said she was aware of the situation between Resident #24 and the nurse. The SSD said in addition, the resident later reported a CNA #4 for being rude. She said both reported situations were discussed in the morning meetings with managers. She said management was aware of the situation and her role was to continue working with the resident who reported to her no changes since the incident was brought to her attention. The interim nursing home administrator (INHA) was interviewed on 6/26/25 at 6:18 p.m. He said after spending a few days in the facility he realised that some concerns went unaddressed and unnoticed. He said his plan was to focus on currently identified areas of concerns and continue to provide support, assistance and weekly oversight to the facility.

Based on record review and interviews, the facility failed to ensure one (#23) of five residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 37 sample residents. Specifically, the facility failed to identify Resident #23 had a history of suicidal ideation in order to monitor for worsening signs and symptoms of depression or suicidal ideation. Findings include: I. Facility policy and procedure The Suicide Precaution policy and procedure, revised August 2022, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:32 p.m. It read in pertinent part, If a resident verbalizes an intent to attempt suicide or takes any action that could be interpreted as a suicide attempt, document specific behavior and or statements of the resident, notification of physician and family or responsible party, safety interventions and actions taken. II. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included chronic viral hepatitis C, end-stage renal disease, type 1 diabetes mellitus with hyperglycemia, bipolar 2 disorder, depression, unspecified mood disorder, alcohol dependence and tobacco use. The 4/1/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set up assistance with eating, oral hygiene, showering, dressing and personal hygiene. The MDS assessment revealed the resident felt bad about himself, felt he was a failure, let himself or his family down every day (12 to 14 days) and he had thoughts he would be better off dead or of hurting himself in some way for two to six days during the assessment look back period. B. Resident interview Resident #23 was interviewed on 6/23/25 at 2:03 p.m. Resident #23 said had no choices in his daily life. He said he did not like living in the facility. He said his ex-wife placed him in the facility and he had nowhere to go. He said he was unable to take showers when he wanted to because the shower rooms were always full. He said he had dialysis earlier today, 6/23/25, and he was hungry. He said he had to wait another four hours until he could eat again. He said he did not like the shakes the facility provided him; he said he only liked berry flavor. A vanilla nepro shake (a dialysis supplement shake) was observed on his nightstand. Resident #23 said he did not like the dialysis center he went to and he wanted to go to the dialysis center closer to the nursing facility. He said all of this made him frustrated. He said he had told nursing facility staff his frustrations and they said there was nothing they could do for him. C. Record review The psychosocial well-being care plan, initiated 8/9/23 and revised 6/25/24, revealed Resident #23 had potential for a psychosocial well-being problem related to bipolar 2 disease and alcohol dependence, per the pre-admission admission and resident review (PASRR) Level II recommendations. Interventions included specialized services, psychiatric case consultation, individual therapy and activities. The depression care plan, initiated 9/23/23 and revised 6/23/25, revealed Resident #23 was at risk for depression. Interventions included encouraging expression of feelings and monitoring for signs and symptoms of depression, including tearfulness, lack of appetite or overeating and verbalizations of feeling sad. The 9/28/24 MDS assessment revealed Resident #23 never felt bad about himself, he never felt he was a failure, and he never felt he let himself or his family down and he never had thoughts he would be better off dead or had thoughts of hurting himself. The 12/29/24 MDS assessment revealed Resident #23 felt bad about himself, felt he was a failure, felt let himself or his family down half or more of the days during the assessment look back period and he had thoughts he would be better off dead or of hurting himself in some way for several days during the assessment look back period. -However, despite the resident's expressions of not wanting to be here anymore and feeling bad about himself changing from the 9/28/24 MDS assessment to the 12/29/24 MDS assessment and the 4/1/25 MDS assessment (see resident status above), the facility failed to assess and monitor the resident for signs and symptoms of depression and suicidal ideation. A request for Resident #23's psychotherapy documentation was made on 6/24/25. Review of the documentation provided revealed the last documentation of a psychotherapy visit for Resident #23 was 6/14/22. The 6/14/22 psychotherapy intake note revealed Resident #23rated his anxiety at a five out of 10 and his depression was a 10 out of 10 every day. The note revealed the resident stated he was left to fight battles by himself. -No documentation was provided by the facility to indicate Resident #23 had seen a psychotherapist since 6/14/22. Review of Resident #23's June 2025 CPO revealed the following physician's orders: Counseling evaluation and treatment, ordered 6/5/25. -However, the resident was not seen by counseling services as ordered (see social services director (SSD) interview below). The 6/25/25 suicide lethality assessment (completed during the survey) revealed Resident #23 did not have a suicide plan and agreed to a safety plan. The mood care plan, initiated on 6/26/25 (during the survey), revealed Resident #23 had a mood problem related to bipolar disease, living long term in a nursing facility, overall health needs and history of interpersonal relationship strains. Interventions included monitoring, recording and reporting to the physician risk for harm to self regarding suicidal plan, past attempts, risky actions, patient health questions (PHQ-9) changes, verbal statements of not wanting to live and sense of hopelessness or helplessness. -However, the suicide lethality assessment and the mood care plan were not initiated until after the concern was brought to the facility's attention during the survey. III. Staff interviews The SSD was interviewed on 6/25/25 at 5:39 p.m. The SSD said she completed the social services section of the MDS assessment. She said sometimes the MDS coordinator (MDSC) completed the section. She said if there was a significant change in the PHQ-9 score (a tool used to determine depression), she opened the current assessment and looked at the previous assessment to see what was different. The SSD said she followed up with nursing to collaborate on what interventions should be implemented to help Resident #23. She said his PHQ-9 score varied depending on when you interviewed him because he had dialysis three times a week and sometimes he did not answer the questions. She said if the MDSC had told her his PHQ-9 score increased, she would have offered counseling and seen what Resident #23 wanted to do. She said the 4/25/25 quarterly MDS assessment PHQ-9 score was high because it was the day his son was getting married. The SSD said the score was high because he answered yes to several questions and he said he felt that way several days to almost every day. She said if she completed the assessment and the PHQ-9 score was high, she would elaborate on why he answered yes to feeling better off dead. She said she would ideally document the conversation in a progress note. The SSD said Resident #23 had a break in psychiatry services for about six months because his provider went on leave. She said she did not offer for the resident to go to a psychiatrist outside of the building because the resident had dialysis three times a week and she thought that was a lot for him. She said she did not talk to the resident's physician or psychiatrist about his depression or suicidal ideation. She said she did talk to the resident's physician two weeks ago about the resident being upset about his son's wedding. She said if the physician talked about depression or suicidal ideation with the resident, it would be in the physician's progress note. Certified nurse aide (CNA) #2 was interviewed on 6/26/25 at 3:25 p.m. CNA #2 said Resident #23 did not have any behaviors. CNA #2 said she was not aware of any signs or symptoms of depression or a history of suicidal ideation or attempts for the resident. Licensed practical nurse (LPN) #1 was interviewed on 6/26/25 at 12:40 p.m. LPN #1 said Resident #23 did not have any behaviors. LPN #1 said she was not aware of any signs or symptoms of depression or a history of suicidal ideation or attempts for the resident. The MDSC was interviewed on 6/26/25 at 4:28 p.m. The MDSC said she completed the last three PHQ-9 interviews on the MDS assessment for Resident #23. She said the PHQ-9 was a screening tool for signs and symptoms of depression. She said the higher the score, the higher the indication of depression. She said she collaborated with the SSD to consider offering behavioral health to residents with high PHQ-9 scores. She said if a resident answered yes to thoughts of being better off dead or hurting themselves she said she asked the resident to explain why they felt that way. She said she should document the reason in a progress note. She said Resident #23 answered yes to thoughts of being better off dead or hurting himself. She said she did not document a progress note for why the resident answered that way, but she said she should have. The MDSC said he answered yes to these questions because he was upset about his son's upcoming wedding and how he did not have money to get him a wedding present. The corporate licensed clinical social worker was interviewed on 6/26/25 at 4:28 p.m. The corporate licensed clinical social worker said there should be a progress note when residents answered yes to thoughts of being better off dead or hurting themselves. She said the most important thing was to have a conversation and provide psychosocial support. She said she would know psychosocial support occurred by a progress note. She said when there were no behavioral health services for six months, staff should have had a conversation with Resident #23 to see if the resident wanted to go out to a community behavioral health provider instead of waiting. She said if a resident expressed suicidal ideation, she said a resident could have harmed themself. IV. Facility follow-up The NHA provided the following follow-up on 6/27/25 at 4:32 p.m., following the survey exit: The NHA said Resident #23 was assessed for suicidal ideation by the SSD on 6/25/25 with no suicidal ideation noted. He said the resident was seen by a therapist on 6/26/25 (during the survey) and the therapist assessed Resident #23 as negative for suicidal ideation. -Resident #23's care plan was updated on 6/26/25, which identified a history of passive suicidal ideation and person-centered interventions. -Staff education was initiated for appropriate identification and reaction to suicidal ideation and depressive symptoms. -All residents that were interviewable were interviewed, and a PHQ-9 was completed. For the residents that were unable to be interviewed, the corporate licensed clinical social worker completed an observation of them for depression signs and symptoms on 6/26/25. Mental health services were offered for those with high PHQ-9 scores and a suicidal lethality assessment was completed as appropriate. Resident #23 attested to a conversation on 4/1/25 with the MDSC regarding mental health services. -A performance improvement plan was initiated on 5/21/25, identifying inappropriate follow-up from high PHQ-9 scores. -Audits were completed that demonstrated significant improvement in appropriate reactions to and identifying risk of suicidal ideation and depressive symptoms. -The 6/26/25 therapist note revealed Resident #23 was diagnosed with major depressive disorder, recurrent, moderate. The goal was to reduce symptoms by learning strategies to help him not feel so overwhelmed by his emotions. The note revealed the recommendations and services to be provided included a psychological consultation was recommended to assist staff in developing and implementing behavior plans to reduce the resident's affective and/or cognitive symptoms and providing the resident with individual therapy to reduce the resident's affective and/or cognitive symptoms. The service plan revealed that the estimated frequency and duration of treatment was two times per month for four months. Resident #23's PHQ-9 score was 15, indicating an increase from the facility's 4/1/25 PHQ-9 score of 13. -The 6/26/25 PHQ-9 interview and suicidal audit provided by the NHA was blank, indicating the audit was not completed.

Based on observations, record review, and interviews, the facility failed to ensure one (#78) of five residents reviewed for activities out of 37 sample residents received an ongoing program of activities designed to meet their needs and interests, and promote physical, medical, and psychosocial well-being. Specifically, the facility failed to offer and provide a personalized activity program for Resident #78. Findings include: I. Facility policy and procedure The Activities policy and procedure, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 4:32 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate. II. Resident #78 A. Resident status Resident #78, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included dementia with agitation, anxiety disorder and insomnia. The [DATE] minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He required set-up assistance for eating, oral hygiene, toileting, showering, dressing and personal hygiene. The [DATE] MDS assessment revealed the resident said it was somewhat important to have books, newspapers and magazines to read, to listen to music, to be around animals such as pets and to participate in religious services or practices. The assessment revealed it was very important to the resident to go outside to get fresh air when the weather was good. The assessment revealed the resident did not refuse care. B. Resident interview Resident #78 was interviewed on [DATE] at 3:50 p.m. as he was walking out of his room with his walker. He said he was going on a walk and he was going to see Oz. C. Resident observation During a continuous observation on [DATE], beginning at 12:35 p.m. and ending at 2:17 p.m., the following was observed: At 12:35 p.m. Resident #78 was in his room sitting on his bed, eating lunch on an over-the-bed table. The door was closed. At 1:21 p.m., he was standing near his bathroom and near the window. There was a daily chronicle (a two page daily newsletter), two books and a magazine on his overbed table. During a continuous observation on [DATE], beginning at 12:13 p.m and ending at 2:13 p.m., the following was observed: At 12:13 p.m. Resident #78 was in his room sitting in a char next to his bathroom and the window. There were no activities near him. At 12:58 p.m. a therapy dog with a visitor was observed in the lobby of the facility. At 12:59 p.m., activities assistant (AA) #1 went into the room across from Resident #78's room and said the therapy dog was in the building. At 1:14 p.m. a therapy dog was observed walking down Resident #78's hallway with another resident (Resident #64). From 1:16 p.m. to 1:22 p.m. the therapy dog, a visitor, AA #1 and Resident #64 walked in and out of rooms on the right side of Resident #78's unit (unit #2). -However, the therapy dog was not directed to go in any rooms on the left side of unit #2. Resident #78 resided on the left side of the unit. D. Record review The activities care plan, revised [DATE], revealed the resident had a past interest in mountain climbing and had a lifelong interest in staying active. He was a United States [NAME] Corps Veteran. He enjoyed going outside on nice weather days, drawing and writing poetry. He resided in the facility with his spouse. He liked therapy animal visits, keeping up with current events and enjoyed being social with others. Resident #78 was a Christian and was independent in his faith. He had cognitive deficits and needed reminders of activities. Interventions included inviting him to church and bible study, offering him opportunities to go outside when the weather was nice and offering him therapy animal visits The [DATE] activities calendar was reviewed. It revealed there were eight religious activities scheduled from [DATE] to [DATE]. It revealed there were four animal therapy activities from [DATE] to [DATE]. A review of Resident #78's electronic medical record (EMR) revealed no documentation to indicate that the resident had participated in religious activities or animal therapy activities from [DATE] to [DATE]. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 3:46 p.m. CNA #1 said the activities department was responsible for carrying out the activities schedule. She said Resident #78 liked to walk by himself and he liked to go outside. She said he and his wife moved to the facility together. She said his wife died about six months ago and he had been depressed and was in his room a lot more. She said activities were important for residents because it helped the residents socialize and were an opportunity for the residents to leave their rooms. She said it helped the residents feel like the facility was not a prison. Registered nurse (RN) #1 was interviewed on [DATE] at 3:58 p.m. RN #1 said the activities department was responsible for carrying out the activities schedule. She said Resident #78 liked to exercise and he liked to walk around the facility early in the day. She said he liked to attend group activities. She said he participated in the activities as a passive participant. She said activities were important for residents because it kept the residents active and part of the community. She said it helped the residents to not be bored. She said activities brought joy to residents. The activities director (AD) was interviewed on [DATE] at 4:00 p.m. The AD said she documented activities as a progress note and the two activities assistants documented activities in the EMR under the task section. She said Resident #78 liked to go outside, waffle Wednesdays, animal therapy, reading to connect and snacks. She said he liked to observe activities but not participate. She said she did not know animal therapy skipped his room on [DATE]. She said the resident stopped attending religious activities after the resident's wife passed away. She said when a resident, such as Resident #78, was sitting in a chair with no activities in front of him, she said staff could offer the daily chronicles, offer a snack and encourage him to leave his room. She said activities were important for residents because it helped residents find a reason to live, to wake up, and most importantly, to have fun.

Based on record review and interviews, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#21) of five residents reviewed for PASRR out of 37 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR Level II notice of determination (NOD) for Resident #21. Findings include: I. Professional reference The National Center for Biotechnology Information, National Library of Medicine guidance website, dated 5/16/23, retrieved on 7/1/25, from http://www.ncbi.nlm.nih.gov/books/NBK513310 read in pertinent part, A neurocognitive assessment, also known as cognitive testing or a neuropsychological evaluation, is a series of tests designed to measure various aspects of brain function. Neuropsychological evaluations require the use of standardized instruments to assess cognitive functions, behavior, social-emotional functioning (mood, personality), and in certain cases, adaptive functioning and academic achievement. Neuropsychologists have specialized training in brain-behavior relationships and perform comprehensive cognitive evaluations in addition to providing treatment. Clinical neuropsychologists are doctoral level health care providers who have specialized training in brain-behavior relationships and perform comprehensive evaluations in addition to providing certain forms of treatment. II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included dementia and major depressive disorder. The 5/15/25 minimum data set (MDS) assessment revealed Resident #21 was cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. B. Record review Resident #21's PASRR Level II, dated 5/27/25, included the evaluation which revealed the resident had been evaluated for mental illness due to a qualifying diagnosis of major depressive disorder. The resident was to receive a neurocognitive evaluation (an assessment to determine how different parts of the brain function to understand the impact of neurological conditions and brain injuries). Resident #21's mood care plan, revised 5/16/25, revealed that Resident #21 used antidepressant medications to treat insomnia (difficulty sleeping) and depression. The care plan indicated the resident had a Level II PASRR due to a diagnosis of major depressive disorder. Interventions included monitoring for target behavior symptoms of pacing, wandering, disrobing, inappropriate responses to verbal communication and violence/aggression towards staff/others (5/16/25), and documenting all behaviors (5/16/25) and providing medications as ordered (5/16/25). -The care plan failed to identify Resident #21's PASRR Level II recommended the resident to have a neurocognitive evaluation (see PASRR Level II above). The June 2025 CPO revealed the following physician orders: Trazodone (an antidepressant medication) 50 milligrams (mg)- give one tablet by mouth at bedtime for insomnia, ordered on 6/5/25. Sertraline (an antidepressant medication) 25 mg- give one time a day for major depression disorder, ordered on 6/25/25. The June 2025 CPO failed to reveal a physician's order for a neurocognitive evaluation since the resident's admission to the facility on 5/9/25. Progress notes were reviewed from 5/9/25 through 6/23/25 and no social service notes were found regarding scheduling or attempting to schedule a neurocognitive as recommended on REsident #21's PASRR Level II. III. Staff interviews The social services director (SSD) was interviewed on 6/25/25 at 12:26 p.m. She said she handles the PASRRs at the facility which included sending in new PASRRs, sending in updated PASRRs and implementing notice of determination recommendations. The SSD said the recommendations in the notice of determination were required for residents who were identified as having a qualifying mental illness diagnosis. She said if a resident refused the recommendations, it should be documented in the resident's electronic medical record and the care plan. The SSD said following the recommendations were important in order to identify problems, provide support to the resident, and utilize the information obtained in the PASRR evaluation. The SSD said Resident #21 had a Level II PASRR for major depression disorder and his recommendations included obtaining a neurocognitive evaluation but she could not find any notes showing the evaluation had been scheduled or completed. She said she would contact his community provider for his neurocognitive assessment. IV. Facility follow up On 6/27/25 at 4:32 p.m. the nursing home administrator (NHA) sent an email regarding Resident #21's neurocognitive assessment. It read in pertinent part, A facility therapist completed a neurocognitive evaluation with cognitive coping management. Attached was a behavioral health progress note, dated 6/10/25, conducted by the facility's corporate licensed clinical social worker, with no documentation that neurocognitive testing was completed (see above credential requirements for a neuropsychologist and definition of neurocognitive evaluations.)

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation and documentation for one (#99) of three residents reviewed for a safe and orderly discharge out of 37 sample residents. Specifically, the facility failed to ensure thorough documentation, including physician notification, when Resident #99 and her representative left the facility against medical advice (AMA). Findings include: I. Resident #99 A. Resident status Resident #99, age [AGE], was admitted on [DATE] and left the facility to her representative's home on 4/2/25. According to the April 2025 computerized physician orders (CPO), diagnoses included anxiety, fracture of patella and hypertension. The 4/1/25 minimum data set (MDS) assessment revealed an assessment had not been completed for Resident #99. B. Resident representative interview The resident's representative was interviewed on 6/24/25 at 10:12 a.m. The representative said Resident #99 was admitted to the facility after a fall with a fracture at home. The representative said the resident was not allowed to turn her light on after her roommate went to sleep or she would disturb her roommate, the food served was terrible and the facility was unclean. The representative said when she told the nursing staff she wanted to discharge the resident because of the conditions, she was told by the nursing staff that they would have to speak to the physician first but they would not be able to reach the physician until the next day, so she discharged Resident #99 AMA. She said she took the resident home with her and found her placement for therapy in another facility. C. Record review The discharge care plan, initiated on 4/1/25 (the day prior to the resident's admission to the facility), revealed Resident #99 wished to discharge to her home or another facility. Interventions, initiated 4/1/25, included establishing a pre-discharge plan with the resident, family or caregivers and evaluating progress and revising the plan as needed. A medication administration record (MAR) progress note, documented by the infection preventionist (IP) on 4/2/25, revealed Resident #99 left the facility AMA. -There was no documentation in the resident's electronic medical record (EMR) to indicate that the resident's physician was notified of the resident and her representative's request to discharge from the facility or why the facility could not notify the physician until the following day (see representative interview above). -There was no documentation in the EMR to indicate that the physician was notified that the resident discharged from the facility AMA. -Additionally, there was no documentation in the EMR to indicate that facility staff attempted to discuss the resident's reasons/concerns which prompted the request to discharge with the resident and her representative. -There was no documentation in the EMR to indicate the facility attempted to discuss an alternative/appropriate discharge plan (instead of AMA) with the resident or the resident's representative. An AMA discharge form, dated 4/2/25, revealed the resident's representative refused to sign the form. III. Staff interviews The IP was interviewed on 6/24/25 at 2:00 p.m. The IP said Resident #99 admitted from the hospital after a fall with a fracture. The IP said the resident's representative had not been happy with facility and discharged Resident #99 AMA on 4/2/25 to the representative's home. The IP said there should be a progress note regarding the resident leaving AMA in the EMR, but she was unable to locate any documentation. The social services director (SSD) was interviewed on 6/24/25 at 2:15 p.m. The SSD said Resident #99 was discharged back to the hospital on 4/2/25 but could not recall the details of the discharge. -However, per the resident's representative and staff interviews, Resident #99 left the facility AMA on 4/2/25 to the representative's home (see above). The minimum data set coordinator (MDSC) and the assistant director of nursing (ADON) were interviewed together on 6/26/25 at 5:25 p.m. The MDSC said there was no documentation in Resident #99's EMR regarding the resident's AMA discharge. The ADON said the process for an AMA discharge was for nursing staff to speak with the resident and find out why they wanted to leave AMA or find out what their issues were. She said if the facility could not solve the residents' issues, nursing staff would describe the AMA process and have the resident or their representative sign an AMA form. The ADON said the physician would be notified of the discharge and a progress note would be made. She said she could not explain why there was no documentation in Resident #99's EMR to explain where she was discharged to or why she left AMA.

Based on record review and interviews, the facility failed to ensure two (#207 and #21) of five residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 37 sample residents. Specifically, the facility failed to: -Ensure Resident #21's behavior care plan had resident specific behaviors and triggers identified; -Document consistent behaviors for Resident #207 and Resident #21 to justify the continued use of psychotropic medications; and, -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions, for Resident #207 and Resident #21's psychotropic medications. Findings include: I. Facility policy and procedure The Chemical Restraint and Psychotropic Medication Management policy, dated April 2025, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:42 p.m. It read in pertinent part, The facility's interdisciplinary team (IDT) will review the comprehensive assessment to ensure the plan of care shows individualized, person-centered care approaches to manage with non-pharmological interventions. II. Resident #207 A. Resident status Resident #207, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included anxiety, insomnia (difficulty sleeping) and dementia. The 5/28/25 minimum data set (MDS) assessment revealed Resident #207 was severely cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. The MDS assessment indicated the resident had not had any behaviors during the assessment look back period. B. Resident interview Resident #207 was interviewed on 6/25/25 at 9:57 a.m. Resident #207 said she missed her husband and was lonely without him. Resident #207 said it made her feel anxious when she could not remember where he was and depressed when she thought he left her there. She said it made her feel better when the staff helped her call him and offered her reassurance and reminders that she would be with him again. C. Record review The behavior care plan, revised 5/28/25, revealed Resident #207 used psychotropic medications related to dementia with anxiety. Interventions included monitoring for occurrences of target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication and violence or aggression towards staff or others (initiated 5/28/25). The mood care plan, revised 6/9/25, revealed Resident #207 used anti-anxiety medication related to an anxiety disorder. Interventions included monitoring for occurrences of target behavior symptoms of tearfulness, signs of over worrying and verbalizations of feeling nervous. Non-pharmacological interventions included one-on-one, offering the resident an activity, adjusting the room temperature, offering the resident a back rub, repositioning, giving food or fluids, redirecting, removing the resident from the environment and offering the resident to use the toilet (initiated 6/9/25). The depression care plan, initiated 6/23/25 (during the survey), revealed Resident #207 used anti-depressant medication related to insomnia. Interventions included educating the resident, family, and caregivers of the risks, benefits, and side effects of the medication and monitoring for hours of sleep and providing non-pharmacological interventions such as one-on-one, activities, adjusting the room temperature, offering the resident a back rub, repositioning and giving fluids (initiated 6/23/25). -Review of Resident #207's care plan did not reveal the resident's expressions of depression had been included (see depression screen below). Review of Resident #207's June 2025 CPO revealed the following physician's orders: Clonazepam (antianxiety medication) 0.5 milligrams (mg). Give two times a day for anxiety, ordered 5/23/25. Trazodone 100 mg. Give one time a day at bedtime for insomnia/anxiety, ordered 5/23/25. Monitor behaviors for antidepressant use: tearfulness, difficulty sleeping or verbalizations of feeling sad or nervous. Intervention: 1. One-on-one 2. Activity 3. Adjust room temperature 4. Back rub 5. Change position 6. Give fluids 7. Give food 8. Redirect 9. Remove the resident from environment 10. Toilet 11. Other, ordered 5/23/25. Monitor behaviors for antianxiety use: tearfulness, signs or symptoms of overworrying and verbalizations of feeling nervous. Intervention: 0. Back rub 1. Redirect 2. Speak to or approach in a calm manner 3. Reposition 4. Offer snacks, fluids, milk 5. Assess for pain, ordered 5/23/25. Venlafaxine (antidepressant medication) 300 mg. Give one time a day for anxiety, ordered 5/24/25. Review of Resident #207's medication administration records (MAR) and treatment admission records (TAR) from 4/23/25 to 6/25/25 revealed the following: The May 2025 (5/23/25 to 5/31/25) MAR/TAR revealed there was no documentation to indicate Resident #207 exhibited behaviors during the month. The June 2025 (6/1/25 to 6/25/25) MAR/TAR revealed there was no documentation to indicate Resident #207 exhibited behaviors during the month. The 5/28/25 admission depression screen revealed Resident #207 felt down, depressed or hopeless for seven to 11 days out of 14 days, felt tired or had little energy for seven to 11 days out of 14 days, and felt bad about herself, felt she was a failure, or felt she let herself and her family down for seven to days days out of 14 days. Review of Resident #207's electronic medical record (EMR) from 5/23/25 to 6/24/25 revealed the progress notes documented for Resident #207 did not indicate the resident exhibited any behaviors. III. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the June 2025 CPO, diagnoses included dementia and major depressive disorder. The 5/15/25 MDS assessment revealed Resident #21 had moderate cognitive impairments with a BIMS score of nine out of 15. The MDS assessment mood section revealed Resident #21 was, at times, socially isolated. B. Record review Resident #21's behavior care plan, revised 5/16/25, revealed Resident #21 used psychotropic medications related to depression. Interventions, revised 5/16/25, included to monitor for occurrences of target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, and violence or aggression towards staff or other (revised 5/16/25). -The care plan did not include any resident specific non-pharmacological care approaches or resident specific target behaviors of isolation, obsessions, need for routine, and hoarding tendencies that were identified in the Level II preadmission screening and resident review (PASRR) evaluation (see Level II PASRR evaluation below). Review of Resident #21's June 2025 CPO revealed the following physician's orders: Monitor behaviors for antidepressant use: tearfulness, lack of interest in activities of choice and/or verbalizations of feeling sad. Intervention: 1. One-on-one 2. Activity 3. Adjust room temperature 4. Back rub 5. Change position 6. Give fluids 7. Give food 8. Redirect 9. Remove the resident from environment 10. Toilet 11. Other, ordered 5/9/25. Trazodone (an antidepressant medication) 50 mg. Give one tablet by mouth at bedtime for insomnia, ordered 6/5/25. Sertraline (an antidepressant medication) 25 mg. Give one time a day for major depression disorder, ordered 6/25/25. -The behavior monitoring physician's order failed to include resident specific target behaviors of obsessions, need for routine, and hoarding tendencies that were identified in the Level II PASRR evaluation and included offering activities as an intervention, despite the Level II PASRR identifying the resident's preference to be alone (see Level II PASRR evaluation below). Review of Resident #21's MAR and TAR from 4/23/25 to 6/25/25 revealed the following: The May 2025 (5/23/25 to 5/31/25) MAR/TAR revealed there was no documentation to indicate Resident #21 exhibited behaviors during the month. The June 2025 (6/1/25 to 6/25/25) MAR/TAR revealed there was no documentation to indicate Resident #21 exhibited behaviors during the month. Review of Resident #21's EMR from 5/9/25 to 6/25/25 revealed the progress notes documented for Resident #21 did not indicate the resident exhibited any behaviors. Resident #21's Level II PASRR evaluation, dated 5/27/25, for mental illness and/or intellectual disabilities included the evaluation which revealed the resident had been evaluated for mental illness due to a qualifying diagnosis of major depressive disorder. During the evaluation, it was revealed to the reviewer by Resident #21's ex-wife (whom he was still very dependent on) that he had a fall at his assisted living facility and broke his hip and some of his ribs, resulting in placement in the skilled nursing facility he was currently at. The resident's preference was to be solitary and his favorite thing, per the ex-wife, was to be alone. Due to these preferences, Resident #21 had only been successful working at night because there were fewer people on that shift. The recent placement at the facility had been upsetting for him because of all the people around. She reported that he cried the previous day because he wanted to go back to his assisted living facility so badly. The ex-wife reported that Resident #21 had obsessive compulsive traits such as hoarding tendencies and a need for structure and routine and he had a daily habit of writing down the weather report and tracking whether it was accurate. A social services note, dated 6/4/25, revealed Resident #21's community provider had informed the social services director (SSD) that the resident may not be able to return to his prior level of function due to continuing difficulty with mobility and toileting. The SSD updated the resident's daughter on his increased needs and that he may not be able to return to his prior level of functioning. -The EMR failed to reveal any documentation to indicate that the SSD spoke with Resident #21 or the staff regarding the potential trigger (see Level II PASRR evaluation above). -The EMR failed to reveal the behaviors displayed that prompted the addition of a second antidepressant medication (Sertraline) on 6/25/25 (during the survey). IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/24/25 at 2:44 p.m. She said Resident #207 had behaviors of becoming anxious and confused, hoarding items in a bag because the resident believed she was discharging home soon and worrying where her husband was. CNA #1 said Resident #207's husband was residing in the same facility, but was now at a different facility. CNA #1 said the interventions that worked were to remind her why her spouse was not there and offering to help her call him before she went to bed. CNA #1 said Resident #21 did not have any behaviors of depression and he preferred to be by himself. She said the CNAs documented in the CNA charting but there was only a list of generic, template behaviors and interventions available in the CNA charting and if the appropriate behavior or intervention were not on the template, the CNA would tell the nurse so the nurse could make a progress note. Licensed practical nurse (LPN) #1 was interviewed on 6/24/25 at 3:00 p.m. LPN #1 said Resident #207 was impulsive, did not wait for staff to assist her to the toilet, and was confused because she believed her spouse was going to take her home everyday. LPN #1 said she did not know what signs and symptoms of anxiety and depression looked like for Resident #207. LPN #1 said Resident #21 did not have any behaviors and she was not aware of any triggers for him. She said resident behaviors and interventions to monitor and to use were in a behavior monitoring physician's order and showed up on the TAR; however, it was a generic template. She said the nurses could look in the resident's care plan, but she said nurses generally did not look there. LPN #1 said if the behavior was concerning, the nurse could document a progress note. CNA #3 was interviewed on 6/24/25 at 3:30 p.m. CNA #3 said Resident #207 had behaviors of isolating from activities when sad and when she missed her husband. CNA #3 said non-pharmological interventions that the staff attempted for Resident #207 included encouraging her to attend activities, bringing activity items to her to do in her room, calling her husband so she could talk to him and providing her reassurance that she was safe without him. CNA #3 said Resident #21 did not have any behaviors or triggers for depression. CNA #3 said the CNAs documented in the CNA charting but there was only a list of generic, template behaviors and interventions available. She said new behaviors were communicated to the CNAs through verbal reports in staff huddles. Registered nurse (RN) #1 was interviewed on 6/24/25 at 4:26 p.m. RN #1 said she did not know Resident #207 or Resident #21 very well. She said the nurses documented behaviors in the progress notes as a behavior note. RN #1 said resident behaviors, interventions to monitor and to use were in a behavior monitoring physician's order and showed up on the TAR. She said new behaviors were communicated to the staff through verbal reports in staff huddles and non-pharmological interventions were on the TAR but were not customized to the specific resident. The SSD, the regional clinical resource (RCR) and the assistant director of nursing (ADON) were interviewed together on 6/26/25 at 2:00 p.m. The SSD said the facility determined the efficacy of psychoactive medications by ensuring the residents' behaviors associated with the medications were documented. She said all psychotropic medications should have behavior monitoring in place. The SSD said the non-pharmological interventions were listed on the behavior monitoring physician's order and the resident's care plan. She said using non-pharmological interventions was important because those interventions should be utilized first, before pharmacological interventions were explored. The SSD said the non-pharmological interventions for each resident were selected from a generic template, not customized to be resident specific. The ADON said the nursing department initiated the behavior monitoring physician's orders in the CPO and the behaviors were determined based on information from the resident, family, or medical record. She said the IDT reviewed the behavior tracking in the psychotropic medication monthly meeting with the physicians and the pharmacist. The ADON said the information from the behavior monitoring was utilized to make decisions regarding adding, changing or discontinuing medications. She said behaviors should be documented by nurses on the TAR and in a progress note and CNAs should document behaviors in their charting, which was a generic template. She said the IDT communicated new non-pharmological interventions in staff huddles and discussed what had worked and what had not worked, but did not customize the behavior monitoring with that information. The ADON said the information would be put in the resident's care plan and the expectation was that the staff looked in the care plan for the target behaviors and non-pharmological interventions. She said she was unaware the staff were not looking in the care plan for this information. The RCR said the facility did not develop resident specific care approaches, to include medication specific target behaviors and person-centered interventions for each resident on psychotropic mediations and needed to improve this process.

Based on observations, record review and interview, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for three (#3, #12 and #9) of four residents out of 20 sample residents. Specifically, the facility failed to ensure Resident #3, #12 and #9 received timely person-centered assistance with meal set up and/or eating. Findings include: I. Facility policy and procedure The Activity of Daily Living policy, reviewed September 2023, was received from the director of nursing (DON) on 10/23/24 at 11:30 a.m. The policy read in pertinent part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff to maintain eating, grooming, personal hygiene, communication, oral hygiene, transfers and ambulation. ADLs will be care planned to reflect the residents' specific needs. II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dysphagia (difficulty swallowing), Alzheimer's disease with late onset (disease that impacts memory and thinking), dementia with agitation (condition which causes a gradual decline in cognitive abilities) and macular degeneration (disease that causes vision loss). The 10/15/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. She required substantial/maximum assistance with eating. B. Observations During a continuous observation on 10/21/24, beginning at 5:20 p.m. and ending at 6:13 p.m., the following was observed: Certified nurse aide (CNA) #3 and an unidentified CNA each had three residents who required assistance with eating. At 5:28 p.m. Resident #3 had not received her meal and began to repeatedly hit the table, her chest and her head with her hand. Resident #3 continued to hit the table, her chest and her head until CNA #1 moved the resident to another table at 5:39 p.m. CNA #1 proceeded to stand between Resident #3 and another resident who required assistance with eating. CNA #1 provided eating assistance to Resident #3 while simultaneously providing redirection and occasional assistance to the other resident who required assistance with eating, who kept trying to scoot himself away from the table. During a continuous observation on 10/22/24, beginning at 11:08 a.m. and ending at 12:47 p.m., the following was observed: CNA #6 was seated between Resident #3 and another resident who required assistance with eating. At 11:42 a.m. CNA #6 began to assist the other resident with eating At 11:44 a.m. Resident #3's lunch was delivered to the table and placed out of her reach due to her need for assistance with eating. Resident #3 made a repeated motion of reaching for the food on her plate, which was not within her reach, and then bring her hand to her mouth without any food and suck on her fingers. Resident #3 began to hit the table with her hand in between her attempts to retrieve food off of her plate. -CNA #6 did not attempt to distract Resident #3 from hitting the table or making any attempt to offer the resident a bite of food from her plate. At 12:08 p.m., after assisting the other resident with their entire meal, CNA #6 began to assist Resident #3 with eating her meal (24 minutes after the resident's plate had been served). During a continuous observation on 10/22/24, beginning at 5:03 p.m. and ending at 6:18 p.m., the following was observed: At 5:47 p.m. Resident #3's dinner plate was placed on the table in front of her and out of reach. At 5:49 p.m. Resident #3 began to hit her hand on the table. At 5:50 p.m. another resident who required assistance with eating was served her meal and CNA #3 began to assist her with eating, even though the other resident's food had been served after Resident #3's meal. At 5:54 p.m. Resident #3 was redirected to stop hitting the table. -CNA #3 did not attempt to assist Resident #3 with eating and continued to only assist the other resident with eating. At 5:55 p.m. CNA #3 began to provide assistance with eating to Resident #3 while continuing to provide eating assistance to the other resident simultaneously. -Resident #3 was not provided with eating assistance until almost ten minutes after her meal was served. C. Record Review The care plan, initiated 10/9/24 and revised 10/16/24, revealed Resident #3 had a nutritional risk related to Alzheimer's and dementia. Pertinent interventions included, providing the resident's diet as ordered by the physician, providing meals in the dining room if the resident was in agreement and providing full staff assistance with meals. III. Resident #12 A. Resident status Resident #12, age less than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included cognitive communication deficit. The 8/21/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of one out of 15. She required supervision or touching assistance with eating. B. Observations During a continuous observation on 10/22/24, beginning at 11:08 a.m. and ending at 12:47 p.m., the following was observed: The meal consisted of a piece of chicken with gravy, rice, mixed vegetables, peach cobbler. At 11:40 a.m. Resident #12's meal was served to her. The resident did not make any attempts to begin eating her meal At 12:23 p.m. CNA #4 noticed that Resident #12 had not eaten any food and offered to cut up the resident's chicken for her. After the chicken had been cut up, Resident #12 began to eat lunch, 43 minutes after her meal had initially been served. C. Record Review The care plan, initiated 8/16/24, revealed Resident #12 required set up and clean up assistance with eating. Resident #12 had a weak left arm and required assistance with meals as needed. IV. Staff interviews CNA #8 was interviewed on 10/23/24 at 11:40 a.m. CNA # 8 said CNAs were supposed to only be assigned two residents at a time that required assistance with eating. CNA #8 said the facility had recently admitted additional residents that required eating assistance and staff had been assigned three or four residents at one time to assist with meals. CNA #8 said she would assist two residents at the beginning of the meal and two more residents at the end of the meal. CNA # 8 said she would sit in between two residents and use both her hands to feed the residents simultaneously. CNA #8 said it was important to prevent one resident's food from becoming cold while another resident was being assisted. CNA #8 said Resident #3 was dependent on staff and required full assistance with eating during meals. CNA #8 said that Resident #3 usually ate the majority of her meals if she was assisted. CNA #8 said Resident #12 required minimal assistance with eating but needed assistance with cutting up her food so she could eat it herself. CNA #8 said Resident #12 should have had her food cut up by staff when her tray was served. CNA #8 said Resident #12 would become agitated if her hands became dirty or sticky. CNA #8 said Resident #12 had the capability to cut up soft foods but she would not cut them up because of her dislike of having potentially dirty hands. CNA #8 said Resident #12 would not have been unable to cut up a piece of chicken without assistance. CNA #9 was interviewed on 10/23/24 at 11:40 a.m. CNA #9 said CNAs should not be assigned more than two residents at a time to assist with eating. CNA #9 said she would sit in the middle of two residents and use both of her hands to assist the residents with eating so both residents were able to eat at the same time. CNA #9 said the facility admitted more residents that required eating assistance during meals. CNA #9 said Resident #3 required full eating assistance at each meal. CNA #9 said Resident #3 should have been assisted to eat at the same time as the other resident, not after the other resident was finished eating. CNA #9 said any CNA assisting other residents to eat should know that both residents should be assisted at the same time. CNA #9 said there may have been staff brought in to help with assisting the residents with eating who were not aware of the process. CNA #9 said Resident #12 did not require assistance with eating but she did require help to cut up food, such as chicken. CNA #9 said even though Resident #12 was able to cut up some foods, such as a burrito, the resident would not do it for fear of getting her hands messy. CNA #9 said Resident #12's food should be cut up for her at the time the meal was served. The DON, the assistant director of nursing (ADON), the clinical resource nurse (CRN) and registered nurse (RN) #1 were interviewed together on 10/23/24 at 12:01 p.m. The DON said a CNA could only assist two residents with eating at one time. The DON said a CNA needed to be seated while they were providing residents with eating assistance. The ADON said a nurse should be pulled from a medication cart to help with assisting residents with eating if needed. RN #1 said dining tables should be served at the same time so staff could assist the residents at the table with eating at the same time. 42838 V. Resident #9 A. Resident status Resident #9, age 79, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbances. The 8/15/24, minimum data set (MDS) assessment revealed the resident was cognitively impaired based on the staff assessment for mental status. She had poor long term and short term memory. Decision making skills were moderately impaired. She required set up assistance with meals. B. Observations On 10/22/24 during the breakfast meal, the following observations were mad: At 8:16 a.m. Resident #9 was lying in bed and was served her breakfast tray which consisted of a pancake. The pancake was not cut up and the resident was not eating her breakfast. At 8:38 a.m. Resident #9 still had not eaten her meal and had not received any meal assistance from staff. At 10:35 a.m. Resident #9 still lying in bed and her breakfast meal had not been touched. On 10/22/24 during a continuous observation of the lunch meal, beginning at 12:11 p.m. and ending at 1:08 p.m., the following observations were made: At 12:11 p.m. Resident #9 received her lunch meal. She received pork, rice, a blend of vegetables and apple crisp. At 12:22 p.m. Resident #9 was not eating her lunch and she had not received any assistance with eating from staff. She had not touched her meal since it had been served. At 12:39 p.m. Resident #9 had not eaten anything and no staff had checked on or encouraged her to eat. At 12:50 p.m. Resident #9 was picking at her food with her fingers. She ate the vegetables and the whipped cream off the top of the apple crisp, however, no staff had assisted her with eating the other items on her plate. At 1:08 p.m. an unidentified CNA removed Resident #9's food tray. She was not offered any encouragement to eat or another alternative for food. The resident had only consumed approximately 20 percent (%) of her meal. On 10/23/24 during a continuous observation of the breakfast meal, beginning at 8:14 a.m. and ending at 8:43 a.m., the following observations were made: At 8:14 a.m. CNA #10 delivered a breakfast room tray to Resident #9 while she was lying in bed. She was served scrambled eggs, hashbrowns, toast, oatmeal and some potato chips. At 8:18 a.m. Resident #9 was awake and was picking at her meal with her fingers. At 8:27 a.m. Resident #9 was still picking at her food with her fingers. She had not received any assistance to eat from staff. At 8:28 a.m. RN #1 went in to Resident #9's room, told the resident she was not eating her oatmeal and the resident responded no. Resident #9 had eaten the eggs but had not touched the hashbrowns or the oatmeal. -RN #1 did not offer Resident #9 an alternative to the oatmeal or offer to assist the resident with eating it. At 8:29 a.m. RN #1 left the resident's room. At 8:40 a.m. Resident #9 still had her toast in her hands. She had not eaten any more of it (half eaten). She had not touched the hashbrowns or the oatmeal. She took the potato chips off of the tray and did not eat them. She had not drunk any of her grape juice. At 8:43 a.m. CNA #8 went into Resident #9's room and removed the meal tray. -CNA #8 did not provide any encouragement to eat to the resident or offer her any substitutes to the meal. Resident #9 had only eaten the eggs and half of her toast. C. Record review The care plan, revised 10/12/23, identified Resident #9 was a nutritional risk due to a dementia diagnosis. Pertinent interventions included a regular diet, including thinned liquids, providing meals in the dining room if the resident was in agreement, offering and encouraging snacks/fluids between meals, offering the resident portable meal options if she was not eating in the dining room and offering soft foods when the resident's dentures were not in use. D. Staff interviews CNA #8 was interviewed on 10/23/24 at 10:15 a.m. CNA #8 said Resident #9 had cognitive impairments. She said the resident was able to feed herself but she required meal set up and encouragement to eat. She said the resident ate much better when she could pick the food up with her fingers. CNA #8 said Resident #9 did not do well eating in the dining room and she liked to eat in bed. RN#1 was interviewed on 10/23/24 at 10:35 a.m. RN # 1 said Resident #9 preferred to eat in her room and was anxious when she was out in the dining room. RN#1 said Resident #9 was able to feed herself but she required encouragement to eat and set up assistance. RN #1 said Resident #9 preferred little bowls and finger foods.

Based on observation, interview and record review the facility failed to provide adequate supervision during use of assistive devices to keep residents free from safety hazards for two (#10 and #11) of three residents out of 20 sample residents. Specifically, the facility failed to ensure wheelchair pedals were attached to Resident #10's and Resident #11's wheelchairs prior to pushing the residents within the facility. I. Facility policy and procedure The Fall Management System policy, reviewedNovember 2023, was received from the director of nursing (DON) on 10/22/24 at 4:55 p.m. The policy read in pertinent part, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. II. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included cognitive communication deficit, generalized muscle weakness, repeated falls and dementia. The 8/1/24 minimum data set (MDS) assessment revealed the resident had short term and long term memory impairment with moderate impairment in making decisions regarding daily life. The resident had both short and long term memory problems. He required physical assistance with activities of daily living (ADL). B. Observations During a continuous observation on 10/22/24, beginning at 11:08 a.m. and ending at 12:47 p.m., the following was observed: At 11:13 a.m. Resident #10 was pushed into the dining room by an unidentified staff member without foot pedals on his wheelchair which caused the resident to hold his feet up off the floor. At 12:13 p.m. Resident #10 was pushed out of the dining room by an unidentified staff member. The resident's wheelchair did not have foot pedals on it. On 10/23/24 at 11:30 a.m., the physical therapist (PT) was observed asking Resident #10 to lift his feet while he pushed the resident in his wheelchair from the dining room to his room. C. Record review The fall risk care plan, initiated 4/25/24 and revised 4/30/24, revealed Resident #10 was at risk for falls related to weakness and impaired mobility. Interventions included encouraging activities and time in the common area for increased supervision, anticipating and meeting the resident's needs and keeping the resident's call light within reach. The fall care plan, 5/6/24 and revised 5/21/24, revealed that Resident #10 had sustained previous falls without injury related to a history of falls, dementia, weakness, lack of safety awareness, and impulsivity. Interventions included placing a call don't fall sign in the resident's room and bright colored tape on the resident's call light. -The care plans did not include an intervention to ensure Resident #10's foot pedals were in place in order to prevent potential falls when the resident was being pushed in his wheelchair. The fall risk assessment dated [DATE] revealed Resident #10 as a high fall risk. III. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included spastic hemiplegia (paralysis or severe loss of strength on one side of the body) affecting the right dominant side, abnormal involuntary movements, generalized muscle weakness, lack of coordination, encephalopathy (brain syndrome that can cause confusion, memory loss, twitching), cognitive communication deficit, and non-traumatic intracranial hemorrhage (a type of stroke that cause blood to pool between the brain and skull preventing oxygen from reaching the brain tissue). The 6/27/24 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. The MDS assessment revealed he required minimal assistance with use of a manual wheelchair. B. Observations On 10/22/24 at 11:49 a.m. Resident #11 was assisted to the dining room by an unidentified staff member. The resident did not have foot pedals on his wheelchair which caused the resident to hold his feet up off the floor. On 10/22/24 at 5:39 p.m. Resident #11 was observed being wheeled into the dining room without foot pedals on his wheelchair which caused the resident to have to hold his feet up off the floor. C. Record review The October 2024 Kardex (a tool utilized to provide consistent resident care) revealed Resident #1 was a high fall risk, required frequent rounding and staff was to encourage activities in the common area for increased supervision. IV. Staff Interviews The DON was interviewed on 10/23/24 at 1:34 p.m. The DON said some residents refused to have foot pedals on their wheelchairs. The DON said staff education regarding ensuring foot pedals were in place on residents' wheelchairs when they were being pushed was frequently provided in daily huddles on every shift. The DON said the foot pedals could be placed on the chair and then removed once the resident has been transported to the location. She said there was no system in place as to where the foot pedals were kept so they were easily accessible to staff for transportation of residents. The director of rehabilitation (DOR) was interviewed on 10/23/24 at 2:44 p.m. The DOR said wheelchair pedals were kept in a residents' closet if they were not attached to the wheelchair. The DOR said he provided education to residents on an as needed basis about wheelchair foot pedal importance and safety. He said if a resident dropped their feet suddenly to the floor when they were being transported in a wheelchair without foot pedals attached, it could cause the resident to be propelled forward out of the wheelchair and sustain a fall.

Based on record review and interviews, the facility failed to manage the pain of two (#7 and #8) of three residents out of nine sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to ensure pain medication had documented parameters for Resident #7 and Resident #8. Findings include: I. Professional reference The American Medical Directors Association (AMDA) The Society for Post-Acute and Long-Term Care Medicine Pain in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline.[NAME], MD (2021), retrieved on 5/8/24 from www.paltc.org, read in pertinent part, When several options for administering analgesics are ordered for a patient, nursing staff need adequately detailed guidance concerning how and when to select a PRN medication from among the several options that have been ordered. II. Facility policy and procedure The Pain Recognition and Management policy and procedure, dated 12/2023, was provided by the director of nursing (DON) on 5/1/24 at 3:50 p.m. It read in pertinent part, It is the policy of this facility that pain management is provided to residents who require such services, consistent with professional standards of practice. III. Resident #7 A. Resident status Resident #7, age 69, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included left sided-paralysis (hemiplegia) and left sided weakness (hemiparesis) following a stroke (cerebral infarction), contracture of muscle in left upper arm, pain in joints of left ankle and left foot and arthritis of many joints (polyosteoarthritis). The 4/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. It indicated that the resident was on a scheduled pain regimen and received as needed pain medication. The assessment revealed the resident had frequent pain which frequently interfered with daily activities. B. Resident interview Resident # 7 was interviewed on 5/1/24 at 1:45 p.m. Resident #7 said he had pain in his left foot, left elbow and shoulder. He said it was a stabbing pain. Resident #7 said he received both Tylenol and Norco pain medications on an as needed (PRN) basis. He said when he received the PRN Tylenol it did not address his pain effectively. He said he lost sleep at night due to the pain. C. Record review The April 2024 CPO documented the following physician orders: Acetaminophen (Tylenol) 325 mg (milligrams) two tablets every six hours as needed for general discomfort/pain/fever, not to exceed 3 gm (grams) from all sources, ordered on 2/13/24. Norco (hydrocodone-acetaminophen) 5-325 mg one tablet every eight hours as needed for pain. ordered on 4/16/24. -The physician's orders for the acetaminophen and Norco pain medications did not indicate the pain level parameters for which to administer each of the medications. -The Norco physician's order did not indicate to not exceed 3 gm of Acetaminophen. D. Staff interviews Registered nurse (RN) #1 was interviewed on 5/1/24 at 2:00 p.m. RN #1 said parameters around pain medications were important to have documented on the physician's orders to ensure the resident's pain was adequately addressed. She confirmed Resident #7 had pain in his left foot, elbow and shoulder. She confirmed that Resident #7's pain medications (Tylenol and Norco) did not have parameters for when to administer the medications. IV. Resident #8 A. Resident status Resident #8, age under 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and chronic post-traumatic headache. The 3/7/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. The assessment revealed the resident had frequent pain which interfered with daily activities. B. Record review The April 2024 CPO documented the following physician order: Norco (hydrocodone-acetaminophen) 5-325 mg one tablet every eight hours as needed for oral pain, ordered on 5/18/23. Tylenol 325 MG (acetaminophen) 650 mg by mouth every six hours as needed for mild pain/fever, do not exceed 3 gm within 24 hours, ordered 12/6/23. -The physician's order for the acetaminophen and Norco pain medications did not indicate the pain level parameters for when to administer each of the medications. -The Norco physician's order did not indicate to not exceed 3 gm of acetaminophen. The March 2024 and April 2024 medication administration record (MAR) listed the pain scale utilized for administration of the PRN Norco as a numerical 1-10 scale. -It did not specify what pain levels on the scale of 1-10 the medication should be administered for. -The MAR did not specify what type of pain scale was utilized for Tylenol or what specific pain levels the medication should be administered for. -According to the March 2024 and April 2024 MAR, Norco had been administered when the resident had a pain level ranging from 2-7. C. Staff interviews Charge nurse (CN) #1 was interviewed on 5/1/24 at 2:00 p.m. CN #1 said Resident #8 was able to ask for pain medications. She said the resident had an order for Norco and Tylenol. She said Resident #8 typically asked for pain medications around 2:00 p.m. She said for mild pain, a pain level of 1 to 5 on a pain scale of 1-10, she would administer Tylenol to the resident. RN#1 was interviewed on 5/1/24 at 3:20 p.m. RN #1 confirmed pain parameters were not indicated on the physician's orders for Resident #8's Tylenol or Norco. She said the pain medications needed to have parameters indicated for what pain levels the medications should be administered for.

Based on observations, record review and interviews, the facility failed to ensure one (#2) of three residents out of nine sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure identified person-centered fall interventions, which were care planned, were implemented consistently for Resident #2 following a fall with a left wrist fracture. Findings include: I. Facility policy and procedure The Fall Management System policy policy, dated 11/2023, was provided by the director of nursing (DON) on 5/1/24 at 11:26 a.m. It read in pertinent part, It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls. Care plan interventions will be developed to prevent falls. II. Resident #2 status Resident #2, age under 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included paraplegia, contractures to ankles, pressure ulcer and type I diabetes mellitus. The 4/14/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required substantial/maximal assistance with transfers. The assessment indicated the resident did not have a history of falls. A. Resident interview Resident #2 was interviewed on 4/30/24 at 4:28 p.m. Resident #2 said she fell a few weeks prior. She said she had been in bed, was reaching for something and fell out of the bed. She said she did not ask for help from the facility staff. She said she had fractured her wrist. B. Observations On 4/30/24 at 4:45 p.m., Resident #2 was lying in bed. There was an air mattress on the bed with no bolsters (foam raised edges) present. A fall mat was in front of the dresser, across the room, and not beside the bed. -Resident #2 said she did not know where her reacher was. The reacher was observed in the wheelchair, behind the bed, out of reach of the resident. On 5/1/24 at 9:13 a.m. Resident #2 was lying in bed. There were no bolsters on the air mattress and the fall mat was across the room in front of the dresser and not beside the bed. At 9:58 a.m., the resident continued to lie in bed. Certified nurse aide (CNA) #1 was interviewed and confirmed the fall mat was in front of the dresser and not in front of the bed. He said he would move it to its proper location. He confirmed there were no bolsters on the mattress. At 10:10 a.m. Resident #2 was laying in bed and the fall mat was beside the bed. -There were no bolsters on the mattress. At 3:30 p.m. the resident was laying in bed, the fall mat was beside the bed and the bolsters were now present on the mattress. C. Record review The admission fall risk assessment for Resident #2, dated 4/8/24, indicated she was at a medium fall risk. A progress note, dated 4/15/24, documented Resident #2 had a fall on 4/13/24 when she was reaching for the bed controls. It documented the resident sustained a contusion to the midline of the forehead and complained of pain to the left forearm. An x-ray, dated 4/14/24, revealed the resident sustained a fracture of the left wrist. The fall intervention implemented was to provide the resident with a reacher. The post-fall interview with Resident #2, dated 4/15/24, documented staff offered the resident a bolster to the air mattress and a fall mat next to the bed. It indicated that the resident was agreeable to the new interventions. The fall care plan, initiated 4/8/24 and revised 4/15/24, identified Resident #2 had an actual fall. It indicated Resident #2 was at risk for falls. The interventions, updated on 4/14/24 and 4/15/24, included providing bolsters on the air mattress, providing a floor mat beside the bed, providing a reacher to the resident and rearranging the resident's room for better ergonomics and resident preference. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/1/24 at 9:58 a.m. CNA #1 said he provided care for Resident #2 on a regular basis. He said he did not know the meaning of the falling star sticker that was placed on the name plate outside of the resident ' s room. He said Resident #2 had sustained a recent fall but he was not aware of any fall interventions for the resident. CNA #1 observed the fall mat in front of the dresser. He said he did not know the fall mat needed to be by the bed. He said the resident did not have any bolsters on the mattress. Registered nurse (RN) #1 was interviewed on 5/1/24 at 10:10 a.m. RN #1 said the falling star program was an awareness program for residents who were at risk for falls. She said Resident #2 was at risk for falls. She said it was everyone's responsibility to ensure the fall risk interventions were in place. RN #1 said fall mats should be placed next to the bedside. She said she could not recall where the fall mats were when she went into Resident #2' room that morning when she administered the resident' medications. RN #1 said the current mattress Resident #2 was using did not have bolsters, which was identified as an intervention in the resident ' s comprehensive care plan. She said the bolsters should be on the mattress. She said the reacher should be within reach of the resident. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 5/1/24 at 2:15 p.m. The ADON said the interdisciplinary team (IDT) reviewed all falls. The ADON said all interventions were discussed during the IDT meeting, documented in the comprehensive care plan and put into place following the meeting. The DON said the falling star sticker indicated a particular resident was considered a high fall risk. She said it was an internal system and was not part of the facility policy. Both the DON and the ADON said they did not check to ensure Resident #2's interventions were put into place following the IDT meeting. The ADON said the facility did not follow through on Resident #2's fall interventions to ensure they were in place.

Based on observation, interview and record review, the facility failed to ensure one (#74) of one resident reviewed for dementia care out of 40 sample residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop a comprehensive plan of care, to include person-centered interventions to engage Resident #74 and address his wandering behaviors. Findings include: I. Facility policy and procedure The Dementia care policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 12/7/23 at 4:05 p.m. The policy read in pertinent part: It is the policy of this facility that all residents will have an individualized plan of care and have the least restrictive approaches to care; The staff are offered specialized training in the care of the dementia population, appropriate approaches to care and managing behaviors; The interdisciplinary staff will initiate a thorough clinical assessment; The monitoring of mood, behavior, and/or any psychosocial related issues to identify possible underlying medical problems which may be causing the behavior problems; The interdisciplinary team will review findings of evaluations and develop a plan of care addressing the resident's needs. II. Resident status Resident #74, over age 65, was admitted to the facility on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included severe vascular dementia with anxiety, cognitive impairment, depression, bilateral (in both ears) hearing loss and difficulty walking. The 10/10/23 minimum data set (MDS) assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of six out of 15. The resident required a walker or wheelchair for mobility and supervision with walking 10 feet and walking 50 feet and no wandering behavior exhibited. III. Observations During continuous observations on 12/11/23 from 8:47 a.m. to 9:16 a.m. Resident #74 was sitting in the living room/common area watching television. During continuous observation from 10:30 a.m. to 11:51 a.m. Resident #74 was in the living room watching television. Resident #74 was taken to his room at 10:48 a.m. At 11:44 a.m. the resident was in bed asleep. During continuous observation from 2:20 p.m. to 3:00 p.m. activities staff were preparing for Bingo. Resident #74 was in bed asleep. During continuous observation on 12/12/23 from 11:30 a.m. to 12:11 p.m. Resident #74 finished the lunch meal and was taken back to his room at 12:11 p.m. -The observations revealed the resident was not engaged and according to the resident's family (see record review below) the resident was social and liked to be around people. IV. Record review The care plan for impaired cognitive function, initiated 10/10/23, documented the resident was at risk for impaired thought processes related to cognitive impairments. The interventions included engaging in simple, structured activities that avoid overly demanding tasks. The care plan for activities, initiated 10/13/23, documented the resident enjoyed listening to all types of music, reading the daily chronicles, watching tv and playing bingo. The resident needed cues and prompting while playing bingo. The resident was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Interventions included encouraging attendance at special events, activities and meals, helping the resident get to and from activities, inviting the resident to scheduled activities, offer animal visits, opportunities to go outside, providing alternative activities, and to provide the resident with that were of interest and empower the resident by encouraging/allowing choice, self-expression and responsibility. -The facility failed to develop and implement wandering and mood/behavior care plans prior to the survey from 12/6-12/12/23. Nursing note dated 10/12/23 at 5:57 a.m. documented the resident had needed redirection at time and was up and down through the night with confusion. Nursing note dated 10/13/23 at 12:32 a.m. documented the resident had been up through the night. Nursing note dated 10/13/23 at 9:19 p.m. documented the resident needed frequent reminders to use his walker during the shift. Social services summary note dated 10/18/23 at 6:30 p.m. documented the resident had cognitive impairment related to the diagnosis and needed frequent reorientation and cueing. The resident's family reported the resident liked to be social and around people. Social services assessment evaluation, cognitive patterns, moods and behavior section, dated 10/18/23 at 6:30 p.m. documented the resident had a BIMS of six and was generally confused and needed frequent reorientation and cueing in the facility. V. Staff interviews Registered nurse (RN) #3 was interviewed on 12/7/23 at 2:05 p.m. She said Resident #74 confused another female for his wife and Resident #74 followed her around the facility sometimes. Registered nurse (RN) #4 was interviewed on 12/7/23 at 2:55 p.m. She said she was assigned as the MDS nurse. She said when a resident was admitted to the facility, each discipline completed required assessments and identified care areas of need for the resident. She said after the resident needs were identified, the responsible discipline initiated an individualized care plan that included a care area for focus, a specific goal and interventions for goal achievement. Certified nurse aide (CNA) #8 and CNA #9 were interviewed on 12/12/23 at 8:57 a.m. The CNAs said the resident liked to walk around rather than use his wheelchair and he needed to be redirected to use the chair. The CNAs said the resident was redirected with naps, snacks or drinks. -None of the strategies used for redirection were indicated on his care plan (see above). The SSD was interviewed on 12/12/23 at 9:01 a.m. She said Resident #74 wandered in the halls, lobby and dining room. She said she had seen the resident appear to be looking for something; however, he did not remember what he was looking for. She said dementia care plans should specifically identify triggers and interventions. She said there should be interventions put into place for a resident who believed another resident was their spouse. She said those interventions should include redirection if the staff were observing interactions or behaviors. She said the staff had some training on the interventions and they were specific to residents. The NHA said was interviewed on 12/12/23 and 12:18 p.m. He said there was one time when Resident #74 confused another female resident for his wife but that was the only time and it had not happened again. -However, staff interviews revealed the resident did confuse another resident for his wife and followed her around sometimes. The SSD was interviewed again on 12/12/23 at 1:48 p.m. The SSD said Resident #74 confused a female resident for his wife sometime around 11/20/23. She said the female resident had seen Resident #74 was coming toward her room and had told him to stop and go away. She said the interdisciplinary team (IDT) discuss interventions to keep Resident #74 away from the female resident. The director of nursing (DON) and NHA were interviewed on 12/12/23 at 2:39 p.m. The DON said Resident #74 thought a female resident looked like his wife and he was walking toward her room. When residents wandered, the staff worked to keep the residents off other halls but it was not official supervision. The NHA said there was an incident a few weeks ago when Resident #74 followed a female resident to her room. The NHA said the staff did not feel it was an issue. The NHA said it was not reported by staff because they did not think it was a big deal. The DON said the staff hold huddle meetings twice a day. The DON said she could not remember if Resident #74's wandering had been discussed in the huddle meetings. The DON said she did not keep notes about huddle meetings. VI. Facility follow-up On 12/13/23 following the survey the facility provided: -Dementia care plan, initiated on 10/10/23 and revised on 12/6/23 with additional interventions. -Elopement/wandering care plan initiated on 12/6/23. The care plan for elopement risk/ wandering, initiated 12/6/23 during the survey, documented the resident wanders aimlessly within the facility. Interventions included distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books and to document wandering behaviors and attempted diversional interventions. -Mood and behavior care plan initiated on 12/7/23. The mood/behavior care plan, initiated 12/7/23 during the survey, documented the potential for a mood/behavior problem related to dementia diagnosis. The resident can wander without intent at times and mistaken other residents for his wife. He lacks some awareness of personal space. The resident is at risk for restlessness, agitation, and altered perceptions of reality and hallucinations and wandering. Interventions included anticipate and meet needs, approach in a calm manner, assist to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately, and intervene as necessary to protect the rights and safety of others. -Huddle summary notes dated 10/25/23 to 11/19/23 listing residents who wandered including Resident #74. -Huddle summary notes dated 11/20/23 -?? Listing residents who wandered including Resident #74. -However, the huddle notes did not document interventions for the residents who wandered or personalized interventions for those residents. In addition, the DON said she did not keep notes of what was discussed in the huddles (see above).

Based on observations, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#65) of one resident reviewed for respect and dignity out of 40 sample residents. Specifically, the facility failed to: -Ensure Resident #65 was treated with respect and dignity from facility staff after she reported concerns; -Ensure Resident #65 was offered alternative activities when facility administration requested she not enter the activities hallway; -Ensure Resident 65's care plan was updated to with her involvement, included accurate resident needs and interventions; and, -Ensure Resident #65's concerns and interventions were documented in her medical record. Findings include: I. Facility policies The Promoting/Maintaining Resident Self-Determination, revised March 2023, was received by the nursing home administrator (NHA) on 12/12/23 at 8:50 a.m. and read in pertinent part, It is the policy of this facility to protect and promote rights by promoting and facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. Procedure: -All staff members involved in providing care to residents will promote and facilitate resident self-determination; -It is the resident's right to determine what, if anything, they would prefer to do or not to do each day in accordance with physician orders and resident's abilities; -Each resident has the right to choose their schedules consistent with their interests, assessments, and plan of care; -Each resident has the right to make to choices about aspects of his or her life in the facility that are significant to the resident; -All aspects of care and services will be discussed in the care plan meeting and documented as such; -The care plan will reflect resident choices when applicable; -Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -All aspects of care and services will be discussed in the care plan meeting and documented as such; -The care plan will reflect resident choices when applicable; -Each resident has the right to participate in activities, including social, religious, and community activities that do not interfere with the rights of other residents on the facility; -The facility will accommodate for the resident preference to the extent possible and as agreed upon by the resident sponsor and physician. B.The Care Planning policy, revised in June 2023, was received by the NHA on 12/11/23 at 7:14 p.m. and read in pertinent part, It is the policy of this facility that the interdisciplinary (IDT) shall develop a comprehensive care plan for each resident. Procedure -The care plan is developed by the IDT which includes, but is not limited to social service staff members, registered nurses (RN) and others as necessary. -To the extent possible, the resident should participate in the development of the care plan. II. Resident #65 A. Resident status Resident #65, age 87, was admitted on [DATE]. According to the December 2023 computerized physician's orders (CPO), diagnoses included muscle weakness, orthopedic aftercare, unsteady on feet, back pain and hypertension. The 10/12/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a score 15 out of 15 on the brief interview for the mental status (BIMS) exam. The resident did not walk but used a manual wheelchair to get around the unit with limited assistance. She needed extensive assistance from staff to complete activities of daily living for bed mobility, transfers, bathing, dressing, toileting and personal hygiene. The resident had no behavior psychosis and had no history of physical or behavioral symptoms directed at others and the resident was not on any antipsychotic medication at the time of the assessment. The staff assessment of the resident's mood was not completed but indicated the resident never felt lonely or isolated from those around her. The resident had no wandering behaviors. The resident had no behavioral symptoms. B. Resident observation and interviews Resident #65 was interviewed on 12/7/23 at 9:50 a.m. Resident #65 was observed in her room, with the door closed. She sat in her wheelchair next to her bed. The resident's hair was dyed purple. Resident #65 said she had a problem with one male resident (#74). She said that he resided on hallway four, across the hallway from the activities room. She said since Resident #74 a few months ago approached her several times in the facility's common areas. She said he reached out to touch her on the arms or shoulders and talked to her like she was his wife. She said Resident #74 made her feel uncomfortable and it gave her the creeps that he sought her. Resident #65 said a few weeks ago Resident #74 wandered into her room while she was in bed and she yelled at Resident #74 to go away and he left her doorway. She said he wandered into her room just once but she has noticed him in the hallway outside her room at other times. Resident #65 said she normally went to activities but she noticed the DON helping Resident #74 to the activity and she said felt she had no choice but to stay in her room to avoid him. Resident #65 said the NHA was aware of her concern because he told her last week they could not send him away. Resident #65 said the NHA told her last week he would ask staff to monitor Resident #74. Resident #65 said after speaking with the NHA she noticed staff had Resident #74 sat at a table in the dining room across the room from her but once he was seated, they did not monitor him. She said a few weeks ago the social services director (SSD) told her that she resembled Resident 74's wife. She said changing her hair color maybe worked because he stopped wandering to her room. Resident #65 said she used to keep her door open and now she kept it closed and it was in an attempt to hide herself from Resident #74. Resident 65 was interviewed again on 12/11/23 at 10:40 a.m. Resident #65 said she was frustrated and said no staff from the facility had followed up with her to let her know what was being done for her. She said they keep offering me counseling and she asked, why am I the one that needs counseling? I have done nothing wrong. She said they offered to help her move to another facility but she had many friends where she was and did not want to leave. She said in November 2023 staff tried using the stop sign across her doorway but she wanted it removed because it had acted like a target. She said at that time she was the resident on the hallway with a stop sign and it let Resident #74 know right where to find her. She said, but they keep asking me to put the stop sign back up. The resident said the NHA met with her earlier on 12/11/23 and he told her she was the problem. She said The NHA told her she needed to understand that Resident #74 did not know where he was or what he was doing. Resident #65 said that made her especially mad because she knows very well some residents did not think clearly. -The facility had updated the resident's behavior care plan (see below) that she could perseverate on the intent of other wandering residents and making unfounded allegations (see care plan below). The resident denied she had neither perseverated on wandering residents nor made unfounded allegations. She said no staff members spoke with her about updating her care plan interventions and did not understand why the facility made that statement. She denied that she was triggered by wandering males of lower cognitive functioning in her space and said it was really the opposite. She referred to another male resident that walked in the hallways and said she understood he was lost. Resident #65 said the difference was Resident #74 thought she was his wife and kept seeking her out. The resident was interviewed again on 12/12/23 at 11:00 a.m. She said the SSD met with her again on 12/12/23 and she agreed to counseling. Resident #65 said she agreed to counseling because she felt it was pushed on her. She said the NHA met with her again on 12/12/23 and asked her to stay off hallway four, where Resident #74 resided. She said the NHA told her if Resident #74 could not enter hallway two it was fair that she stay off hallway four. Resident #65 was visibly upset as she spoke. She said she now felt the NHA was not being fair to her. Tears formed in the resident's eyes and she said she attended many activities on hallway four. She said the NHA did not offer her any alternatives and she now felt he told her to stay in her room. Cross-reference F744: the facility failed to provide dementia care and services to Resident #74. C. Record review Resident #65's comprehensive care plan imitated 8/11/23 included a care focus for potential to have adjustment issues due to admission. The care plan documented a care focus to address a resident-to-resident physical altercation. The care focus initiated 8/11/23 with a target completion date of 10/30/23. The care focus revealed the goal was to receive daily opportunities for social contact through the review date. The goal specific interventions for Resident #65 included: -Encourage to participate in conversation with staff, other residents daily; -Learn to recognize/help to identify stressors which may be early warning signs of problem behavior. Intervene and remove stressors where possible; -Needs the opportunity to communicate feelings regarding attended activities; -Needs the opportunity to communicate feelings regarding nursing home admission; -Provide with as many situations as possible which give control over environment and care delivery. -The facility identified and planned care for Resident 65's need for daily conversation with staff, to attend regular activities and her need to be provided with control over her environment. However, after the occurrences in November and December 2023, the resident said staff have made her feel that she needs to stay in her room and to stay off the activities hallway. The behavior care plan, initiated 12/7/23 (during the survey), identified Resident #65 could have the potential for a behavior problem with a history of perseverating on the intent of other wandering residents and a history of making unfounded allegations. Interventions to meet the resident needs included (in part): -Approach in a calm manner; -Anticipate and meet needs; -Caregivers to provide opportunity for positive interaction; -Stop and talk with him/her passing by; -Counseling offered, but declined on 11/2023 and accepted 12/7/23; -Discuss behavior, explain why behavior is inappropriate and/or unacceptable; -Intervene as necessary to protect the rights and safety of others; -Approach/speak in a calm manner, divert attention, remove from the situation and take to alternate location as needed, reassure resident that she is safe; -Offer resident to participate in bingo, exercise class; -Report any allegation per facility protocol; -Praise any indication of progress/improvement in behavior; -Provide a program of activities that is of interest and accommodated resident's status; and, -Triggers: wandering males of lower cognitive functioning in her space. -Review of the resident's progress note revealed the resident had no documented concerns or altercations with residents in the facility prior to 12/7/23. On 12/7/23 at 2:53 p.m., the SSD had a conversation with Resident #65 and documented in pertinent part: Resident #65 said she was having discomfort with Resident #74. Resident #65 agreed to try counseling services to address psychosocial effects. Resident #65 declined to move rooms within the facility and declined to have a stop sign put back up on her door. Resident #65 reported that she may be interested in moving to a different facility. At the conclusion of the interview Resident #65 appeared at baseline mood and functioning. IV. Staff interviews The SSD was interviewed on 12/7/23 at 11:45 a.m. The SSD said she offered Resident #65 counseling, to replace the stop sign across her doorway and to help her move to another facility and the resident declined all offers. The SSD said she had previously offered counseling to Resident #65, around 11/22/23. She said she did not have any documentation of the conversations with Resident #65. The SSD said she knew about one time Resident #74 confused Resident #65 for his wife. The SSD said the stop sign was used as a deterrent to direct wandering residents in another direction. She did not recall when that occurred and it was around 11/22/23. -However, this was not documented in Resident #65's record. The SSD said when the stop signs were implemented in November 2023 the resident's care plan should have been updated. She said it was her responsibility to update care areas of resident behavior needs. She said she did not update the care plan for Resident #65 because the situation in November 2023 was not a big issue. She said she regularly offered counseling to residents in response when concerns were reported to her. The SSD was interviewed again on 12/12/23 at 12:10 p.m. She said the medical record entry she made on 12/7/23 at 2:48 p.m. was the first documentation she had on the resident's concern. She said 2:48 p.m. reflected the actual time of her interview with the resident on 12/7/23 because she was delayed due to other matters. The SSD said she did not report the resident concerns from November 2023 to the NHA because Resident #65 was not distressed. She said the resident was just telling me something. The SSD said Resident #65 talked to her following the incident in November 2023 and then she stopped talking to about and said the issue was exacerbated only this week, after the start of the survey. The SSD said to her knowledge Resident #65 did not have a paranoid diagnosis, had made no other allegations towards staff, residents or visitors. The SSD was aware Resident #65 had dyed her hair green and then purple. The SSD said the resident dyed her hair because Resident #74 was seeking Resident #65. She said dying hair could be an emotional or mental thing which prompted her to offer Resident #65 counseling. The SSD said she had follow up interviews with the Resident on 12/11/23 and 12/12/23 and Resident #65 continued to decline to place a stop sign across her doorway. She said on 12/12/23 Resident #65 agreed to be referred for counseling. Certified nurse aide (CNA) #6 was interviewed on 12/7/23 at 10:55 a.m. She said she was familiar with Residents #65 and #74. She said she has worked the hallways where Resident #65 and #74 resided. She said she was aware of the situation with Resident #74 approaching and seeking out Resident #65 now and then because she looked like his wife. CNA #6 said she and other staff members thought it was funny and they laughed about it, sometimes with Resident #65. CNA #6 said she was unaware when Resident #65 dyed her hair but she received the hair dye from the activities assistant sometime last week. Restorative nurse aide (RNA) #1 was interviewed on 12/7/23 at 1:40 p.m. She said she was familiar with Residents #65 and #74. She said the resident attended activities regularly in group activities in the dining room, enjoyed outings for shopping with the group and attended smaller group activities in the activity room. RNA #1 said Resident #65 told her about Resident #74 mistaking her for his wife. She said Resident #65 discussed dying her hair as a disguise, to confuse Resident #74. RNA #1 said she did not think it was a serious concern and the resident never told her she was afraid. She said the resident talked about him seeking her out and staff thought that was cute and funny. She said she provided the hair dye for Resident #65 and suggested the resident first try a spray on (temporary) dye that was green, in case she did not like the change. RNA #1 said in the previous week, the resident wanted permanent hair dye and she provided the resident with purple, permanent hair dye. The RNA could not recall the dates she spoke with Resident #65 about Resident #74, provided the hair dye and said did not keep documentation about the concern. RNA #1 was interviewed again on 12/12/23 at 11:30 a.m. She said she was aware Resident #65 was told to stay off hallway four. She said that would probably upset Resident #65 because she attended group activities in the activities room located on hallway four. RNA #1 said in the room on hallway four, she held group Bible studies, had question and answer sessions about other readings and Resident #65 visited individually regularly just to talk and say hello. RNA #1 said she had no immediate activities replacement options for Resident #65 but she would see what could be offered off hallway four. Registered nurse (RN) #3 was interviewed on 12/7/23 at 2:05 p.m. She said she was aware Resident #74 confused Resident #65 for his wife and that Resident #74 followed her around the facility sometimes. RN #3 said Resident #65 told her Resident #74 went into her room and it made her feel uncomfortable. She said Resident #65 told her she told Resident #74 to get away from her and he left her alone so she did not see it as an issue. RN #3 said Resident #65 agreed to try placing a stop sign across her doorway. RN #3 said she could not remember when the stop sign was placed but thought it was around the middle of November 2023. She recalled around Thanksgiving Resident #65 wanted the stop sign removed from her doorway when Resident #65 realized her room was the only room on hallway two that had a stop sign and thought it would act as a target and help Resident #74 locate her room. RN #3 said she did not believe Resident #65 was bothered very much by Resident #74 because staff joked and laughed with Resident #65 when they realized she resembled the wife of Resident #74. RN #3 said she not tell anyone about Resident #65 being uncomfortable because she and other staff thought it was cute and harmless that Resident #74 confused Resident #65 for his wife. RN#3 said she thought the situation changed when she noticed in late November 2023 Resident #65 dyed her hair in the previous week. RN #3 said around the time the stop sign was placed across Resident #65's doorway, the DON told staff in a huddle meeting they needed to watch Resident #74 and keep him off hallway two. RN #3 said when a resident had a stop sign placed across their doorway, the nurse should write a progress note and notify DON, the physician and obtain an order to use the stop sign. She said she was unaware of physician orders for the stop sign or any monitoring or tracking behavior for Resident #65. The DON and NHA were interviewed together on 12/12/23 at 2:39 p.m. The DON said she was aware of one time in November 2023 Resident #65 had a concern that she resembled Resident #74's wife. The DON said she did not remember how she found out about the resident's concern. She said she was told by someone and did not remember by whom. She said in November 2023 the SSD spoke with her after she talked with Resident #65 and said the concern was not a problem. The DON said she did not recall telling staff specifically to keep Resident #74 off hallway two. She said when residents wander without supervision staff redirect off every hallway as needed, it was not official supervision to redirect a wandering resident. The DON said she held huddle meetings twice a day for staff education and care plan updates. She said she did not keep huddle notes. The NHA said the DON did not have detailed information for Resident #65 because what occurred in November 2023 was not an issue. He said it was a minor incident a few weeks ago. The NHA said Resident #65 dyed her hair a couple of different colors maybe to make a fashion statement. The NHA said Resident #74 had not been observed wandering and was currently asleep in his room, which was his baseline. The NHA said he had not interviewed Resident #65 regarding her concerns. He said the SSD completed the interviews. The NHA said Resident #65 asked yesterday or today about the possibility of Resident #74 be moved to another facility. The NHA said he was unaware what trauma Resident #65 had previously suffered. He said he thought she had some trauma to make her want to stay in her room. He said he did not ask her to stay in her room. The NHA said Resident #65 had previously been offered a stop sign to place across her doorway and had declined offers for counseling. The NHA said he did not want Resident #65 to be uncomfortable or scared. The NHA said earlier in the day he requested Resident #65 to stay off hallway four. He said she had not abided by the agreement to stay off hallway four. He said he watched her enter the hallway but he did not confront her or say anything. The NHA said he had not seen anything that indicated there was a problem between Residents #65 and #74. The DON agreed with the NHA and said there was not a problem identified.

Based on interviews and record review, the facility failed to provide services by qualified persons for two (#21 and #9) out of two residents reviewed out of 23 sample residents. Specifically, the facility failed to ensure for Resident #21 and Resident #9: -Staff who were licensed practical nurses (LPN) did not perform duties outside of their scope of practice including performing intravenous/peripherally inserted central catheter (IV/PICC) line flushes and procedures without qualifications or certification; and, -LPN's did not chart under the registered nurse (RN) designated orders on the medication and treatment administration record (MAR/TAR) and in the progress notes for a procedure that was to be completed by an RN. Findings include: I. Professional reference The Code of Colorado Regulations, Chapter 1 licensure, undated, viewed on 2/23/23, https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=695 , read in pertinent part, Historical Note: Prior to January 1, 2006, Chapter IX rules required LPNs in Colorado to obtain separate IV certification, which was then attached to their licenses. LPNs were granted either an IV or IV-2 certification status after completion of a Board-approved IV course. IV-2 status included education in central line IV therapy. LPNs without IV-2 status, as of January 1, 2006, were ruled to no longer have IV certification. LPNs without IV-2 status, including any LPN/LVN endorsing into Colorado from another jurisdiction, must bear the responsibility, with their employer, of acquiring the necessary education, training and experience to safely perform within the IV scope of practice pursuant to section 3 of these rules. The approval process for IV Therapy and venous blood sampling authority contained in these rules replaces the previously applicable bi-level certification. II. Facility policy and procedures The Documentation of Medication Administration policy and procedure, revised April 2007, was provided by the nursing home administrator (NHA) on 2/17/23 at 3:12 p.m. It read in pertinent part, The facility shall maintain a medication administration record to document all medications administered. A nurse or certified medication aide shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. Documentation must include, as a minimum: name and strength of the drug; dosage; method of administration (oral, injection and site); date and time of administration; reason(s) why a medication was withheld, not administered, or refused (as applicable); Signature and title of the person administering the medication; and resident response to the medication. III. Resident #21 A. Resident status Resident #21, age 62, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included infection and inflammatory reaction due to internal left knee prosthesis (knee replacement), diabetes, and sepsis (infection). The 1/16/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required extensive assistance with one person for transfers, dressing and toilet use. He required limited assistance with one person for bed mobility, locomotion on/off unit, and personal hygiene. B. Record review Review of the January 2023 CPO revealed the following order to be completed by an RN: RN to flush PICC line with 10 cubic centimeters (cc) normal saline (NS) evert shift for IV therapy. PICC lumen flushes, positive blood return, dressing dry and intact, site without signs/symptoms of infection. Discontinue this order when the PICC line is removed/discontinued. Start date 1/13/23. Review of the January 2023 MAR/TAR revealed the following: On 1/14/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/19/23 (evening) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/19/23 at 9:17 p.m. revealed, completed by RN and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress notes on 1/19/23 for that treatment. On 1/19/23 (night) LPN # 1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress note dated 1/20/23 at 3:43 a.m. revealed, completed by RN and signed by LPN #1. -However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 1/20/23 for that treatment. On 1/23/23 (night) LPN # 4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/24/23 at 2:35 a.m. revealed, to be completed by RN and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/24/23 for that treatment. On 1/25/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/27/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/27/23 (evening) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/27/23 at 9:05 p.m. revealed, completed by RN and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/27/23 for that treatment. On 1/27/23 (night) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/28/23 at 3:14 a.m. revealed, to be completed by RN and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/28/23 for that treatment. On 1/28/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/28/23 (evening) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/28/23 at 9:02 p.m. revealed, To be completed by RN and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/28/23 for that treatment. Review of the February 2023 MAR/TAR revealed the following: On 2/1/23 (night) LPN #1 documented the RN procedure was administered by her. On 2/4/23 (evening) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/4/23 at 7:54 p.m. revealed Completed by RN and signed by LPN #1. -However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/4/23 for that treatment. On 2/7/23 (evening) the documentation was blank, there was no documentation that the physician orders had been followed. On 2/8/23 (night) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/9/23 at 3:52 a.m. revealed completed by RN and signed by LPN #1. -However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/9/23 for that treatment. On 2/9/23 (evening) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/9/23 at 9:36 p.m. revealed completed by RN and signed by LPN #1. -However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/9/23 for that treatment. On 2/12/23 (evening) the documentation was blank, there was no documentation that the physician orders had been followed. On 2/15/23 (night) the documentation was blank, there was no documentation that the physician orders had been followed. Review of the February 2023 CPO revealed the following order to be completed by an RN: Obtain complete blood count (CBC), comprehensive metabolic panel (CMP) and C-reactive protein (CRP) (night shift nurse to have lab requisition completed) RN to draw via PICC every day shift, every Tuesday, for septic arthritis and bacteremia. Start date 1/17/23. Review of the February 2023 MAR/TAR revealed the following: On 2/7/23 (day) LPN # 2 documented the RN procedure was administered by her. -LPN #1, LPN #2 and LPN #4 did not have intravenous certifications. IV. Resident #9 A. Resident status Resident #9, age 82, was initially admitted on [DATE], and readmitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included left foot chronic ulcer (sore) non-pressure, chronic atrial fibrillation (heart disorder), and hemiplegia (paralysis on one side after a stroke). The 12/28/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with one person for transfers and limited assistance with one person for bed mobility, locomotion on/off unit, dressing, toilet use, and personal hygiene. B. Record review Review of the February 2023 CPO revealed the following order to be completed by an RN: RN to flush PICC with 10 cc NS every shift for IV therapy. D/C this order when PICC is removed/discontinued. Start date 2/7/23. Review of the February 2023 MAR/TAR revealed the following: On 2/10/23 (night) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress note dated 2/11/23 at 1:35 a.m. revealed completed by RN and signed by LPN #1. -However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/11/23 for that treatment. -LPN #1 did not have an intravenous certification. V. Staff interviews LPN #2 was interviewed on 2/16/23 at 3:24 pm. She said she charted any treatments or procedures that she completed as ordered for residents. LPN #2 said she did chart on Resident #21 for the IV treatments but she did not do the IV and PICC treatments. LPN #2 said that each nurse should chart what treatments they do and she regretted charting for the RN, but the RN did it. LPN #2 said the RN should have done the charting for themselves. The director of nursing (DON), assistant director of nursing (ADON), and infection preventionist (IP) were Interviewed on 2/16/23 at 4:35 pm. They said it was the practice and standard at the facility to have nurses chart what procedures and medication administration they completed. They said the nurse staff should chart for themselves what they did. They said other nurses cannot chart and sign for them. They said on the MAR/TAR the nurse who completed the treatment should chart and document that they completed the treatment. They said a check mark on the MAR/TAR indicated that the treatment was administered. They said if a box on the MAR/TAR was completely empty it meant the dose or treatment was not done or missed. They said if there was not a check mark and there was a number nine, the nurse should do a progress note. They said the progress note would usually indicate if the resident was in the hospital, the resident refused, or medications were held for parameters. They said the progress noted should clarify the reason why the treatment or medication were not checked and administered. They said if the MAR/TAR said other/see progress note, that means the nurse who signed it was the nurse who administered it. They said they would expect the name of the nurse who administered it and they should chart that they administered a medication or treatment. They said it was not okay for an LPN to draw blood via a PICC line for a lab, or flush the PICC line if the order says it should be done by an RN. They said they completed education with LPN #2. They said the LPNs should not perform duties and procedures outside their scope of practice because it was not safe to do so. VI. Facility follow-up On 2/16/23 at 1:10 p.m. the DON provided the IV certification of the one LPN who had her certification. Of the eight LPNs employed by the facility including the contract LPNs, one had her IV certification, which was LPN #3. -LPN #3 did not chart on Resident #21 or Resident #9 (see above).

Based on record review and interview, the facility failed to take steps to protect three (#3, #14, and #46) female residents, out of five residents reviewed in a total sample of 33 residents, from abuse by one resident (#117). (Cross-reference F610) Specifically: Resident #117, independent and ambulatory with a walker, was known by staff to exhibit inappropriate behavior toward female residents. The facility failed to take steps to address the resident's known behaviors, contributing to three reports of abuse by Resident #117; one incident involving Resident #14, dependent and cognitively impaired, on 5/20/18; a second incident involving Resident #3, moderately cognitively impaired but totally dependent, on 5/21/18; and a third incident involving Resident #46, alert, oriented and dependent, on 8/12/18. Resident #46 reported Resident #117's abuse left her frightened by her vulnerability, continuing to struggle with the incident, and in therapy to help minimize her distress from the incident. Findings include: A. Facility policy and procedure A copy of the facility's policy and procedure on Abuse Reporting and Investigation dated 7/2017 was provided by the nursing home administrator (NHA) on 11/12/18 at 8:37 a.m. The policy read in part, If an incident or suspected incident of resident abuse is reported, the administrator will ensure that any further potential abuse is prevented. B. Reported abusive incidents by Resident #117, involving Resident #14, #3, and #46. Record review revealed three reports of abuse by Resident #117 involving Resident #14, dependent and cognitively impaired, on 5/20/18, Resident #3, moderately cognitively impaired but totally dependent, on 5/21/18, and Resident #46, alert, oriented and dependent on 8/12/18. 1. Incident 5/20/18 An incident report completed by the NHA on 5/21/18 read that it was reported by the nursing staff that Resident #117 was found in (Resident #14's) room with his hands under the blanket. Review of Resident #14's record revealed the resident, age 82, was admitted on [DATE]. According to the 11/18 computerized physician orders [REDACTED]. According to the 7/7/18 minimum data set (MDS) assessment, the resident was rarely understood, and her brief interview for mental status (BIMS) score was not assessed. Resident #14 had problems with short and long term memory and she had disorganized thinking and inattention. She required extensive assistance with bed mobility and transfers. She required assistance of one person with ambulation and used a wheelchair. 2. Incident 5/21/18 An incident report dated 5/21/18 read an incident had occurred between Resident #117 and Resident #3. Per written statement by Licensed Practical Nurse (LPN) #3, LPN #3 observed Resident #117 in bed with Resident #3 and Resident #117 had (Resident #3) by the wrist, forcing her hand on his groin. Review of Resident #3's record revealed the resident, age 72, was admitted on [DATE]. According to the 11/18 CPO, her [DIAGNOSES REDACTED]. According to the 11/6/18 MDS assessment, the resident was moderately cognitively intact with a BIMS score of 12 out of 15. Resident #3 had no problems with short and long term memory and she did not have any behaviors. The resident was totally dependent on staff for mobility, required assist of one person for locomotion on the unit, and used a wheelchair. (Resident #3 was unavailable for interview during survey) 3. An incident report dated 8/12/18 read Resident #46 was accusing Resident #117 of touching her breast without permission. Per written statement, Resident #46 reported she awoke to a hand violently shaking her breast and pinching her nipples. Review of Resident #46's record revealed the resident, age 51, was admitted on [DATE]. According to the 11/18 CPO, her [DIAGNOSES REDACTED]. According to the 10/18/18 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #46 had no problems with short and long term memory and she did not have any behaviors. The resident required maximum assistance with activities of daily living (ADLs). Review of the resident's care plan revealed no history or care plan for false accusations. She had a history of [REDACTED]. According to the note by social services director (SSD), dated 6/15/18, (Resident #46) spends most of her time in her room watching (movies) on her tablet and engaging in independent leisure activities. (Resident #46) is typically pleasant with others and does not have any significant behavior directed towards others. C. Facility failure to prevent repeated incidents of abuse by Resident #117 from 5/20/18 to 8/12/18. Record review revealed staff was aware Resident #117 exhibited inappropriate behavior toward female residents, especially after his spouse passed away in (MONTH) (YEAR). The facility failed to take steps to monitor and address these known behaviors. Record review and interview also revealed the reports of abuse on 5/20/18 and 5/21/18 were not thoroughly investigated to determine what actions were necessary to protect facility residents. The corrective actions taken were limited and ineffective, and Resident #117's abuse continued; a third incident was reported on 8/12/18 which Resident #46 stated left her frightened by her vulnerability, continuing to struggle with the incident, and in therapy to minimize her distress. 1. Failure to monitor and address Resident #117's known inappropriate behaviors Resident #117, age over 90, was admitted on [DATE] and was discharged from the facility on 9/7/18. According to the 9/18 CPO, [DIAGNOSES REDACTED]. According to the 9/7/18 MDS assessment, the resident was rarely understood, and his BIMS score was not assessed. Resident #117 had no problems with short and long term memory. The resident did not exhibit any behaviors towards others. He required supervision with most activities of daily living. He ambulated independently and used a walker. He did not speak English. (Per interview with the director of nurses (DON), the facility did not use a translator, but rather the resident's medical durable power of attorney (MDPOA) to communicate with the resident.) a. Record review and staff interviews revealed staff was aware the resident exhibited inappropriate behavior. According to a progress note dated 6/1/18 by the social service director (SSD), SSD observed throughout the day due to concerns of (Resident #117) entering other female residents' rooms. SSD observed (Resident #117) attempting to enter several different rooms throughout the facility however, when (Resident #117) realized that SSD noticed him entering a room, (Resident #117) put his head down and walked away. SSD spoke with MPOA (medical power of attorney) about these concerns. SSD will follow up with any future needs or concerns. According to the 15 minute resident safety checklist, on 7/7/18 between 1:00 a.m. and 1:45 a.m., Resident #117 was caught in other residents room and was going in to rooms. In an interview with Licensed Practical Nurse (LPN) #3 on 11/14/18 at 12:37 p.m., he said he had heard Resident #117 had an inappropriate behavior of walking into other resident's rooms. In an interview with the social services assistant (SSA) on 11/15/18 at 2:55 p.m. (the social service director was unavailable), she said she had worked with Resident #117 when she was a certified nurse aide (CNA). She said Resident #117's inappropriate behaviors increased after his wife passed away in early (MONTH) of (YEAR). She said mostly he wandered in other residents' rooms or would stand at the door and gaze at the resident in the room. In an interview with CNAs #7 and #1 on 11/14/18 at 1:34 p.m., they said they knew Resident #117 had inappropriate behavior and after his wife passed away, his behaviors with ladies spiked up. They said he was looking or staring at other female residents, usually during night shift and night staff had reported it at least a couple of times. b. Failure of facility to respond to known behaviors Record review revealed no evidence Resident #117's behaviors were considered by the interdisciplinary team or in care conferences with his MDPOA and evaluated, in particular after he lost his spouse, in order to determine whether it was necessary to address his behaviors, if there were triggers to his behaviors and how they could be addressed. Review of social service notes revealed no documentation of the resident's known inappropriate behaviors other than the note on 6/12/18 above. There was no documentation of follow up to the concerns discussed with the resident's MDPOA. Review of progress notes revealed no follow up notes regarding the incident on 7/7/18, what was occurring, what was involved, and how staff responded. Review of Resident #117's care plan revealed no reference to Resident #117's inappropriate behaviors until 8/13/18, after the resident's third abusive incident involving Resident #46. The care plan, initiated 8/13/18, read resident had inappropriate sexual behavior. Interventions included to check on resident every 15 minutes, provide one on one supervision as appropriate, offer tasks that divert attention, monitor behavior episodes and attempt to determine the underlying cause, and report inappropriate sexual behaviors. The care plan was not resident-specific and lacked sufficiently detailed instructions for staff in order to ensure facility residents' safety from Resident #117's inappropriate behaviors. -The care plan failed to identify the sexually inappropriate behaviors staff was to monitor. -The care plan failed to identify when one on one supervision would be appropriate -The care plan failed to identify what resident-specific tasks should be implemented by staff to divert the resident's attention. 2. Cross-reference F610. Failure to thoroughly investigate the incident involving Resident #14 and Resident #117 a. Incident and facility response See above; review of a 5/21/18 incident report read Resident #117 was found in Resident #14's room with his hands under the blanket. A summary of the facility's abuse investigation, dated 5/21/18 and provided by the NHA on 11/13/18, read the on call registered nurse (RN) #2 received a call at 11:46 p.m. on 5/20/18 from the night shift agency nurse. The agency nurse reported an incident that occurred between Resident #14 and Resident #117. RN #2 documented she reported the incident to the DON. Certified nurse aide (CNA) #8 in her written statement (undated) wrote that during the evening shift on (MONTH) 20th she was looking for Resident #117 and located him in Resident ' s #14 room. She observed Resident #117's hands under the Resident ' s #14 blanket close to the waistline. She said Resident #117 was redirected to his room where he stayed between five and ten minutes. Later she realized that Resident #117 had made his way back to Resident #14 ' s room but at this time, he was not touching Resident #14. CNA said she re-directed Resident #117 to his room and living room area where he stayed for the rest of the night. The incident report completed by NHA on 5/21/18 read the Resident #117 was placed on one on one observation to make sure he did not go back to Resident #14. b. Failures in facility response There was insufficient evidence the facility thoroughly investigated the 5/20/18 incident in order to determine what actions were necessary to prevent its recurrence and to ensure residents' safety and well-being. Specifically: Record review revealed no evidence the facility attempted an interview with Resident #14, and progress notes for Resident #14 did not include any notes from nurses or social services regarding the incident. Moreover, there was no evidence the resident's status was assessed post-incident for physical, verbal or nonverbal evidence of abuse. While a written statement was obtained from CNA #8, there was no evidence the agency nurse was interviewed about what was reported to her that evening or how Resident #117 was behaving prior to the incident in order to determine if there were triggers to his inappropriate behavior which staff could monitor. Finally, the sole intervention implemented following the 5/20/18 incident was one to one observations (duration not defined). However, there were no monitoring logs that evidenced the one to one monitoring had consistently occurred or what the logs had revealed. And, as evidenced by the second reported incident the next day (see below), one to one observations were ineffective. In an interview on 11/15/18 at 5:30 p.m., the NHA he did not think the incident occurred as it was documented because he knew Resident #14 well and she would let everyone know if anything like that described happened to her. He said he believed CNA #8 inaccurately documented what she observed, because he talked to the CNA later and she could not confirm if Resident #117 had physical contact with Resident #14 under the blanket. 3. Cross-reference F610. Failure to thoroughly investigate the incident involving Resident #3 and Resident #117 a. Incident and facility response See above; an incident report dated 5/21/18 read an incident had occurred between Resident #117 and Resident #3 on 5/21/18 at 10:45 a.m. witnessed by LPN #3. LPN #3, in his written statement dated 5/21/18, wrote he was alerted by Resident #3's roommate, who told him that Resident #3 needed help as there was a man in their room. Upon entering the room, LPN #3 observed Resident #117 in bed with Resident #3. Resident #117 had (Resident #3) by the wrist forcing her hand on his groin. LPN #3 stopped Resident #117 and assisted him to his room. According to the incident report dated 5/21/18, Resident #117 was placed on one on one observation. LPN #3 was interviewed on 11/14/18 at 1:34 p.m. He confirmed Resident #117 was independent with ambulation and was able to walk by himself with the help of a walker. He also confirmed Resident #117 was put on one to one observations after the incident which meant staff followed the resident all the time to make sure he did not enter other resident rooms. One to one observations were done for 72 hours and if no behaviors were noted, observations were lifted. He said Resident #117 was moved to another hallway after the incident. b. Failures in facility response There was insufficient evidence the facility thoroughly investigated the 5/21/18 incident in order to determine what actions were necessary to prevent another incident and to ensure residents' safety and well-being. Specifically: Review of the facility incident report and investigation revealed no evidence Resident #3 was interviewed about the incident. While the resident received a skin check, there was no evidence the resident was assessed post-incident regarding her psychosocial status and whether she was fearful of Resident #117. There were no social service notes about the incident. Record review revealed no evidence Resident #117's behaviors were considered by the interdisciplinary team or in care conferences with his MDPOA and evaluated, in order to determine whether it was necessary to address his behaviors, if there were triggers to his behaviors and how they could be addressed. Moreover, although Resident #117 was moved to another hallway, there was no documentation by the interdisciplinary team or any other discipline explaining in what way this would address the resident's inappropriate behaviors. Finally, the intervention implemented following the incident was again one to one observations (duration not defined) which had not been effective since implemented after the first incident 5/20/18. Again, there were no monitoring logs that evidenced the one to one observations had consistently occurred or what the logs had revealed. The NHA was interviewed on 11/15/18 at 5:30 p.m. He did not comment when asked how the 5/21/18 incident occurred while the Resident #117 was on one to one monitoring continuously for 72 hours after the incident on 5/20/18. 3. Incident involving Resident #46 and Resident #117 a. Incident per Resident #46 interview Resident #46 was interviewed on 11/14/18 at 3:15 p.m. Resident stated she initially did not remember all of the circumstances of the incident involving Resident #117 which she said happened on 8/12/18, midmorning or early afternoon. She stated her door is always open and she was napping as she frequently naps throughout the day. She said she was awakened to a hand violently shaking her breast and pinching her nipples. She said she looked for her call light, but was unable to locate it, so she started yelling out for help. She said she recognized Resident #117, whose room was at the end of the hallway. When she began yelling out for help, he stopped and looked over at her roommate. Resident #46 stated she told to Resident #117 don't you dare, and told him to leave and he walked out of the room. Resident #46 said she continued to yell out and scream for help, but Resident #117 returned to her room. (Resident #46's roommate was nonverbal, lethargic and on hospice and not able to be interviewed) She said the following day she was having pain and her catheter was not working correctly, and when the nurse looked at her catheter, it came right out. She stated it was the following day that she started remembering Resident #117 was trying to touch her private parts below the waist. She stated that she has begun remembering more and more about the incident as time has gone by. She stated she could still hear his little giggle as he was assaulting her and the scraping of his walker as he moved around the room. Resident #46 said Resident #117 was placed on one on one observations following the incident, but she stated she saw him walk by her room at least twice without supervision. Resident #46 said she still struggles with the incident and is always gripping her call light tight. She said she is currently seeing a therapist who comes in once a week and that has really helped. b. Facility documentation of incident and response See above; an incident report dated 8/12/18 read Resident #46 was accusing Resident #117 of touching her breast without permission. The incident report contained an undated letter signed by the director of nursing (DON). It read: All hall 2 residents were asked if any residents have been in there (sic) rooms that shouldn ' t have been? Residents also asked if they feel safe here? Interviews done by (DON) and (LPN #3). Interviews done at 8/12/2018. Upon completion of all interviews it was determined that (Resident #117) had not been in there (sic) room and staff also reported to nursing that there were no known accounts of (Resident #117) going into any other resident rooms by their knowledge. The facility investigation included two written statements; one statement by Resident #46 and another by LPN #5. The written statement by Resident #46 was consistent with her interview (see above). The written statement by LPN #5, dated 8/12/18 at 11:00 p.m. revealed Resident #46 reported the incident with Resident #117. The statement by LPN #5 was consistent with Resident #46's interview (see above). c. Failures in facility response Record review revealed the facility failed to take sufficient steps to prevent a recurrent incident. As in the previous incidents, Resident #117 was placed on one to one observation, an intervention that (see above) was not effective. And, while a care plan was opened 8/13/18, it was not resident-specific for sufficiently detailed in order to prevent recurrent incidents (see above). Record review also revealed no mention of the 8/12/18 incident in Resident #46's progress notes, either by nursing or social services despite the resident's expressed distress regarding the incident. The NHA was interviewed on 11/13/18 at 10:41 a.m. and on 11/15/18 at 5:30 p.m. He said the facility was not able to substantiate her allegation of abuse because Resident #46 changed her story many times and her story became more dramatic every time she changed it. He also said staff did not confirm that Resident #117 was in her room at the time and residents and staff did not observe Resident #117 walking into Resident #46's room. He said he thought the incident did not happen and Resident #46 overheard the conversation about abuse and came up with a story. However, Resident #46's report of the incident was consistent as documented by her in her written statement on 8/12/18, by LPN #5 in her written statement 8/12/18, and by Resident #46 during her interview on 11/14/18 at 3:15 p.m. Moreover, the NHA said the facility was using video recording in the hallways but the cameras on the hallways where Resident #117 was residing during incidents on 5/20, 5/21 and 8/12/18 had not been working for the last few months. d. Evidence Resident #46 sustained harm Progress notes by clinical nurse specialist dated 9/11/18 read Resident #46 said was raped a few days ago - not penetration but felt all over the body and pulled out suprapubic catheter. Called for help - no one came. Man left but came back. Did not have call light within reach. Frightened by vulnerability and inability to fight him off. The SSD was interviewed on 11/13/18 at 4:43p.m. She said she was aware of the incident between Resident #117 and Resident #46. She said an investigation was done by NHA and DON and she was not involved. She said she was new to this position and she had not talked to Resident #46 about the incident, she only asked Resident #46 if she would like some counseling and helped her with the arrangement. She said Resident #46 was seeing a senior counselor once a week. She said the resident was referred after she expressed feelings of distress due to sexual assault incident on 8/12/18.

Based on record review and interview, the facility failed to have evidence all incidents of abuse or potential abuse involving four (#3, #14, #39 and #46) of five residents out of 33 sample residents, were thoroughly investigated and steps were taken to prevent further abuse. (Cross-reference F600) Specifically: Record review and interview revealed three reports of abuse by Resident #117; one report involving Resident #14 on 5/20/18; a second report involving Resident #3 on 5/21/18; and a third report involving Resident #46 on 8/12/18. There was insufficient evidence any of these reported incidents were thoroughly investigated in order to determine what actions were necessary to protect residents from abuse by Resident #117, after the initial incident on 5/20/18. Resident #46 reported Resident #117's abuse left her frightened by her vulnerability, continuing to struggle with the incident, and in therapy to help minimize her distress from the incident. Record review and interview also revealed the facility failed to thoroughly investigate an incident on 11/9/18 involving Resident #39 being pulled by another resident (#64) toward him in order to ensure the interaction between the residents was not abusive. Findings include: I. Facility policy and procedure A copy of the facility's policy and procedure on Abuse Reporting and Investigation dated 7/2017, was provided by the nursing home administrator (NHA) on 11/12/18 at 8:37 a.m. The policy read in part, When an incident is reported, the manager, DON (director of nursing), and NHA will immediately begin an investigation and arrange for immediate safety of persons being mistreated. II. Abusive incidents by Resident #117 involving Residents #14, #3, and #46 A. Resident #117 1. Resident status Resident #117, age over 90, was admitted on [DATE] and was discharged from the facility on 9/7/18. According to the 9/18 computerized physician orders [REDACTED]. According to the 9/7/18 minimum data set (MDS) assessment, the resident was rarely understood, and his brief interview for mental status (BIMS) score was not assessed. Resident #117 had no problems with short and long term memory. The resident did not exhibit any behaviors towards others. He required supervision with most activities of daily living. He ambulated independently and used a walker. He did not speak English. 2. Cross-reference F600. Record review and interviews revealed staff was aware the resident exhibited inappropriate behavior which increased after his spouse passed away in (MONTH) (YEAR). According to the progress note dated 6/1/18 by social service director (SSD), SSD observed throughout the day due to concerns of (Resident #117) entering other female residents' rooms. SSD observed (Resident #117) attempting to enter several different rooms throughout the facility however, when (Resident #117) realized that SSD noticed him entering a room, (Resident #117) put his head down and walked away. According to the 15 minute resident safety checklist, on 7/7/18 between 1:00 a.m. and 1:45 a.m., Resident #117 was caught in other residents room and was going in to rooms. Interviews with Licensed Practical Nurse (LPN) #3, the social services director (SSD),certified nurse aides (CNA) #7 and #1 revealed staff had heard about Resident #117's inappropriate behavior of entering other residents' rooms and standing in the doorway and gazing into female residents' rooms. These behaviors spiked after his spouse passed away. B. Abusive Incidents 5/20, 5/21 and 8/12/18 1. Resident #14 a. Resident status Review of Resident #14's record revealed the resident, age 82, was admitted on [DATE]. According to the 11/18 CPO, her [DIAGNOSES REDACTED]. According to the 7/7/18 MDS assessment, the resident was rarely understood, and her BIMS score was not assessed. Resident #14 had problems with short and long term memory and she had disorganized thinking and inattention. She required extensive assistance with bed mobility and transfers. She required assistance of one person with ambulation and used a wheelchair. b. 5/20/18 incident involving Resident #14 and Resident #117 An incident report completed by the NHA on 5/21/18 read that it was reported by the nursing staff that Resident #117 was found in (Resident #14's) room with his hands under the blanket. A summary of the facility's abuse investigation, dated 5/21/18, provided by the NHA on 11/13/18, read the on call registered nurse (RN) #2 received a call at 11:46 p.m. on 5/20/18 from the night shift agency nurse. The agency nurse reported an incident that occurred between Resident #14 and Resident #117. RN #2 documented she reported the incident to the DON. CNA #8 in her written statement (undated) wrote that during the evening shift on 5/20/18, she was looking for Resident #117 and located him in Resident ' s #14 room. She observed Resident #117's hands under Resident ' s #14 blanket close to the waistline. She said Resident #117 was redirected to his room where he stayed between five and ten minutes. Later she realized Resident #117 had made his way back to Resident #14 ' s room but at this time he was not touching Resident #14. CNA said she re-directed Resident #117 to his room and living room area where he stayed for the rest of the night. The incident report completed by NHA on 5/21/18 read the Resident #117 was placed on one on one observation to make sure he did not go back to Resident #14. c. Failures in facility response There was insufficient evidence the facility thoroughly investigated the 5/20/18 incident in order to determine what actions were necessary to prevent its recurrence and to ensure residents' safety and well-being. Specifically: Record review revealed no evidence the facility attempted an interview with Resident #14, and progress notes for Resident #14 did not include any notes from nurses or social services regarding the incident. Moreover, there was no evidence the resident was assessed post-incident for physical, verbal or nonverbal evidence of abuse. Review of Resident #117's record revealed the incident was documented in the record. However, the review revealed no care plan was opened to address Resident #117's known inappropriate behaviors. While a written statement was obtained from CNA #8, there was no evidence the agency nurse was interviewed about what was reported to her that evening or how Resident #117 was behaving prior to the incident in order to determine if there were triggers to his inappropriate behavior which staff could monitor. Finally, the sole intervention implemented following the 5/20/18 incident was one to one observations (duration not defined). However, there were no monitoring logs that evidenced the one to one observations had consistently occurred or what the monitoring had revealed. And, as evidenced by the second reported incident the next day, one to one observation was an ineffective intervention. In an interview on 11/15/18 at 5:30 p.m., the NHA he did not think the incident occurred as it was documented because he knew Resident #14 well and she would let everyone know if anything like that described happened to her. He also said he believed CNA #8 inaccurately documented what she observed because he talked to the CNA later and she could not confirm if Resident #117 had physical contact with Resident #14 under the blanket. 2. Resident #3 a. Resident status Review of Resident #3's record revealed the resident, age 72, was admitted on [DATE]. According to the 11/18 CPO, her [DIAGNOSES REDACTED]. According to the 11/6/18 MDS assessment, the resident was moderately cognitively intact with a BIMS score of 12 out of 15. Resident #3 had no problems with short and long term memory and she did not have any behaviors. The resident was totally dependent on staff for mobility, required assist of one person for locomotion on the unit, and used a wheelchair. (Resident #3 was unavailable for interview during survey) b. 5/21/18 incident involving Resident #3 and Resident #117 An incident report dated 5/21/18 read an incident had occurred between Resident #117 and Resident #3 on 5/21/18 at 10:45 a.m. witnessed by LPN #3. LPN #3, in his written statement dated 5/21/18, wrote he was alerted by Resident #3's roommate, who told him that Resident #3 needed help as there was a man in their room. Upon entering the room, LPN #3 observed Resident #117 in bed with Resident #3. Resident #117 had (Resident #3) by the wrist forcing her hand on his groin. LPN #3 stopped Resident #117 and assisted him to his room. According to the incident report dated 5/21/18, Resident #117 was placed on one on one observation. LPN #3 was interviewed on 11/14/18 at 1:34 p.m. He confirmed the account of the 5/21/18 set forth in his written statement. He said Resident #117 was independent with ambulation and was able to walk by himself with the help of a walker. He also confirmed Resident #117 was put on one to one observations after the incident which meant staff followed the resident all the time to make sure he did not enter other resident rooms. One to one observations were done for 72 hours and if not behaviors were noted, observations were lifted. He said Resident #117 was moved to another hallway after the incident. c. Failures in facility response There was insufficient evidence the facility thoroughly investigated the 5/21/18 incident in order to determine what actions were necessary to prevent another incident and to ensure residents' safety and well-being. Specifically: Review of the facility incident report and investigation revealed no evidence Resident #3 was interviewed about the incident. While the resident received a skin check, there was no evidence the resident was assessed post-incident regarding her psychosocial status and whether she was fearful of Resident #117. There were no social service notes about the incident. Record review revealed no evidence Resident #117's behaviors were considered by the interdisciplinary team or in care conferences with his MDPOA and evaluated in order to determine whether it was necessary to address his behaviors, if there were triggers to his behaviors, and how the behaviors should be addressed. No care plan was opened to address the inappropriate behaviors witnessed by staff on 5/20 and 5/21/18. Moreover, although Resident #117 was moved to another hallway, there was no documentation by the interdisciplinary team or any other discipline explaining in what way this would address the resident's inappropriate behaviors. Finally, the intervention implemented following the incident was again one to one observations which had not been effective since implemented after the first incident 5/20/18. Again, there were no monitoring logs that evidenced the one to one observations had consistently occurred or what the logs had revealed. The NHA was interviewed on 11/15/18 at 5:30 p.m. He did not comment when asked how the 5/21/18 incident occurred while the Resident #117 was on one to one observations continuously for 72 hours after the 5/20/18 incident. 3. Resident #46 a. Resident status Review of Resident #46's record revealed the resident, age 51, was admitted on [DATE]. According to the 11/18 CPO, her [DIAGNOSES REDACTED]. According to the 10/18/18 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #46 had no problems with short and long term memory and she did not have any behaviors. The resident required maximum assistance with activities of daily living (ADLs). Review of the resident's care plan revealed no history or care plan for false accusations. She had a history of [REDACTED]. According to the note by social services director (SSD), dated 6/15/18, (Resident #46) spends most of her time in her room watching (movies) on her tablet and engaging in independent leisure activities. (Resident #46) is typically pleasant with others and does not have any significant behavior directed towards others. b. 8/12/18 incident involving Resident #46 and Resident #117 Resident #46 was interviewed on 11/14/18 at 3:15 p.m. Resident #46 stated she initially did not remember all of the circumstances of the incident involving Resident #117 which she said happened on 8/12/18, midmorning or early afternoon. -She stated her door is always open and she was napping, stating she frequently naps throughout the day. She said she awakened to a hand violently shaking her breast and pinching her nipples. She said she looked for her call light, but was unable to locate it, so she started yelling out for help. She said she recognized Resident #117, whose room was at the end of the hallway. -When she began yelling out for help, he stopped and looked over at her roommate. Resident #46 stated she told to Resident #117 don't you dare, and told him to leave and he walked out of the room. Resident #46 said she continued to yell out and scream for help, but Resident #117 returned to her room. (Resident #46's roommate was nonverbal, lethargic and on hospice and not able to be interviewed) -She said the following day she was having pain and her catheter was not working correctly, and when the nurse looked at her catheter it came right out. She stated it was then she started remembering Resident #117 was trying to touch her private parts below the waist. -She stated that she has begun remembering more and more about the incident as time has gone by. She stated she could still hear his little giggle as he was assaulting her and the scraping of his walker as he moved around in her room. -Resident #46 said Resident #117 was placed on one on one observations following the incident, but said she saw Resident #117 walk by her room at least twice without supervision. -Resident #46 said she still struggles with the incident and is always gripping her call light tight. She said she is currently seeing a therapist who comes in once a week and that has really helped. An incident report dated 8/12/18 read Resident #46 was accusing Resident #117 of touching her breast without permission. The incident report contained an undated letter signed by the DON. It read: All hall 2 residents were asked if any residents have been in there (sic) rooms that shouldn ' t have been? Residents also asked if they feel safe here? Interviews done by (DON) and (LPN #3). Interviews done at 8/12/2018. Upon completion of all interviews it was determined that (Resident #117) had not been in there (sic) room and staff also reported to nursing that there were no known accounts of (Resident #117) going into any other resident rooms by their knowledge. The facility investigation included two written statements dated 8/12/18; one statement by Resident #46 and another by LPN #5. The written statement by Resident #46 was consistent with her interview (see above). The written statement by LPN #5, dated 8/12/18 at 11:00 p.m. revealed Resident #46 had reported the incident with Resident #117. The statement by LPN #5 was consistent with Resident #46's interview (see above). c. Failures in facility response Record review revealed the facility failed to take sufficient steps to prevent a recurrent incident. Specifically: As in the previous incidents, Resident #117 was placed on one to one observations, an intervention that (see above) was not effective. Review of Resident #117's record revealed a care plan was opened 8/13/18; however, the care plan was not resident-specific and lacked sufficiently detailed instructions for staff in order to ensure facility residents' safety from Resident #117's inappropriate behaviors. The care plan failed to identify the sexually inappropriate behaviors staff was to monitor, failed to identify when one on one observations would be appropriate, and failed to identify what resident-specific tasks should be implemented by staff to divert the resident's attention. Record review also revealed no mention of the 8/12/18 incident in Resident #46's progress notes, either by nursing or social services, despite the resident's expressed distress regarding the incident. The NHA was interviewed on 11/13/18 at 10:41 a.m. and on 11/15/18 at 5:30 p.m. He said the facility was not able to substantiate Resident #46's allegation of abuse because Resident #46 changed her story many times and every time her story became more dramatic. He said staff did not confirm that Resident #117 was in her room at the time and other residents and staff did not observe Resident #117 walking into Resident 46's room. He said he thought the incident did not happen and Resident #46 overheard the conversation about abuse and came up with a story. However, Resident #46's report of the 8/12/18 incident was consistent as documented by her in her written statement 8/12/18, by LPN #5 in her written statement 8/12/18, and by Resident #46 during her interview on 11/14/18 at 3:15 p.m. Moreover, the NHA said the facility was using video recording in the hallways but the cameras on the hallways where Resident #117 was residing during incidents on 5/20, 5/21 and 8/12/18 had not been working for the last few months. d. Evidence Resident #46 sustained harm Progress notes by clinical nurse specialist dated 9/11/18 read Resident #46 said was raped a few days ago - not penetration but felt all over the body and pulled out suprapubic catheter. Called for help - no one came. Man left but came back. Did not have call light within reach. Frightened by vulnerability and inability to fight him off. The SSD was interviewed on 11/13/18 at 4:43 p.m. She said she was aware of the incident between Resident #117 and Resident #46. She said an investigation was done by NHA and DON and she was not involved. She said she was new to this position and she had not talked to the Resident #46 about the incident, she only asked Resident #46 if she would like some counseling and helped her with the arrangement. She said Resident #46 was seeing senior counselor once a week. She said the resident was referred after she expressed feelings of distress due to sexual assault incident on 8/12/18. III. Potentially abusive incident involving Resident #39 and Resident #64 A. Resident #39 Resident #39, age 85, was admitted on [DATE]. According to the 11/18 CPO, her [DIAGNOSES REDACTED]. According to the 10/11/18 MDS assessment, the resident was rarely understood; her cognitive skills for daily decision making were severely impaired. She had problems with short and long term memory and had disorganized thinking and inattention. She required extensive assistance with bed mobility and transfers. She was able to ambulate with an assistance of one person. B. Record review According to the note dated 11/9/18 from DON who witnessed the situation, at approximately 7:50 (a.m.) this nurse walked into the main living room and witnessed (Resident #64) holding onto this resident's hand and pulling resident towards him with the intention of kissing (Resident #39). (Resident #39) laughing per usual and moving towards (Resident #64). C. Facility response An incident investigation was initiated on 11/9/18, and Resident #64 was placed on 15 minute checks (the duration of the 15 minute checks was not identified). The investigation included a summary of yes and no questions regarding abuse by five residents and five staff members. D. Failures in facility response Review of the facility's incident investigation revealed no attempt to interview Resident #39 about the incident on 11/9/18. Record review revealed no evidence Resident #39 was monitored after the incident in an effort to determine whether she had a favorable or unfavorable response to Resident #64's actions. Progress notes for Resident #39 did not include any notes from nurses or social services regarding the incident. There was no mention of the incident in the resident's medical record. Further review of Resident #39's record did not reveal evidence the resident had been assessed to determine whether she consented to an intimate relationship with Resident #64 or any other resident. Her care plan, likewise, did not include information whether the resident desired or was involved in an intimate relationship with Resident #64 or other residents. The DON was interviewed on 11/15/18 at 5:20 p.m. She said she did not recognize the incident involving Resident #39 and Resident #64 as abuse. She said Resident #39 was smiling back to Resident #64 and the way Resident #64 pulled her was gentle. She said the reason an investigation was completed was because the facility investigates everything.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically the facility failed to prevent residents from accessing excessively hot coffee in the dining room. The findings include: 1. Failure to protect residents from excessively hot coffee was identified during a recertification completed 1/14/13. The facility alleged the practice was corrected as of 2/12/12. 2. Findings on Revisit a. Expectations According to the U.S. Consumer Product Safety Commission, "Avoiding tap water scalds," Publication 5098 1 2, p.1: Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns. b. Documents provided by the dietary manager (DM) regarding coffee temperatures revealed: For the month of April 2013, coffee temperatures were recorded only three times a day, once with each meal, and only one temperature was written for the six dispensers. -Coffee temperatures were not documented for breakfast or lunch on 4/11/13, and had been recorded as 155 degrees at breakfast on 4/9/13 with no intervention noted. -No additional temperature log or monitoring tool was available when requested from the DM. c. Observations and Interviews On 4/11/13 at 1:15 p.m. observation of the dining room revealed that there were four residents in the dining area occupying various tables, talking and drinking coffee. Four dietary aides also were present. The dirty dishes and cups were being cleared by two dietary aides. The kitchen service window was still open and a dietary aide could be seen preparing dessert for a subsequent meal. There were five coffee dispensers and a hot water dispenser available to residents and guests in the dining area by the dining area sink. One of the residents in the dining area was accompanied by a family member who asked the resident if she wanted coffee, then went to the coffee dispensers and poured a cup of regular coffee for the resident. The coffee was visibly steaming. Coffees temperatures were immediately obtained revealing: regular coffee was 160 degrees Fahrenheit (F), one decaffeinated coffee was 155 degrees F, another decaffeinated coffee was 159 degrees F, and the hot water was 130 degrees F. Two dispensers were empty. The dietary aide was asked who had taken the temperature of the coffee and she stated that she had taken the temperature of the hot water, but did not know who had taken the temperature of the coffee. When she took comparative temperatures, hers all read within one degree of the temperatures obtained during the initial observation noted above (160, 155, and 159 degrees F). The dietary aide was asked what temperature the coffee was supposed to be. She stated that it was to be below 150 degrees prior to being put out for the residents. She stated that the coffee was too hot. She produced a log of coffee temperatures that was to be documented on hourly; however, the last temperature noted was documented for the previous day on 4/10/13. A dietary aide stated that she had temperatures logged on a scrap piece of paper and when this paper was produced, it only had the temperatures of the food served for lunch and no beverage temperatures. The dietary manager (DM) then came out of the kitchen with a thermometer and started taking the temperature of the coffee. She stated that it was fine and that it was 130 degrees F. Both thermometers used above were placed in the coffee cup the DM was holding and read 160/161 degrees F. She stated that the thermometer must be bad and walked away, leaving the coffee dispensers accessible to the residents. The dietary aide went back to clearing the tables. The coffee dispensers remained accessible to residents in the dining area until 1:31 p.m. when the admissions director was notified that the DM had left the coffee dispensers accessible to residents. The admissions director had the coffee dispensers removed immediately. 3. Interviews Interview with the nursing home administrator (NHA) on 4/11/13 at 1:35 p.m. revealed that the facility had a faulty mixing valve so the cold water was not getting mixed in with the hot coffee as it was brewed. When asked if staff should have tested the temperature of the coffee and let it cool before putting it out he stated, "It should have never been put out there. I don't know what happened." On 4/11/13 at 3:03 p.m. the DM provided an in-service and write ups for the dietary aides. -When asked what her responsibility was regarding oversight of the coffee temperatures, she stated her responsibility would be to randomly check the coffee temperatures and the logs. -When asked who would ensure the thermometers were calibrated correctly she stated that it was usually the cooks who did it daily. She added that she had calibrated all the thermometers when the admissions director had removed the coffee from the dining room. -She stated that she did not know what time the last coffee went out, but she did know that it had been put out after lunch was served. When asked if the coffee should have been removed from the common area once the temperature was verified as over 150 degrees (see above), she stated that it had been removed shortly after. 4. Facility Follow-up An in-service training had been conducted at 2:15 p.m. on 4/11/13 (day of observations - see above). It read that coffee would be below 150 degrees before it came out to the dining room. Three employee counseling records were provided stating that the counseling was for not making sure the coffee was below 150 degrees before it went out to the dining room. (See above; four dietary aides and the DM were present when the hot coffee was discovered.)

Based on observations, record reviews, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for residents, including ten of 40 sample residents (#107, #50, #37, #93, #60, #11, #51, #80, #19, and #62). Specifically, the facility failed to: I. Ensure the seven cognitively impaired residents residing on the secured unit (#50, #37, #93, #60, #11, #51, #80) were free from the risk of abuse by resident #107 who was documented with aggressive, abusive and threatening behavior toward residents and staff, including grabbing his roommate around the neck on 12/18/12, to, per resident #107, "choke the sh--t out of him." II. Prevent residents from accessing excessively hot coffee in the dining room and medications from unlocked medication carts. III. Ensure a resident #62's fall was timely reported and adequately assessed. The findings included: I. Safety of Residents on the Secured Unit A. Immediate Jeopardy Record review revealed resident #107, who was independently ambulatory, had a history of [REDACTED]. He was hospitalized [DATE] after attacking a staff member with a wheelchair foot pedal, choking her, and spraying other secured unit residents with an aerosol. He returned to the facility secured unit on 11/27/12 with new medication orders. Record review and interview revealed that following resident #107's return, the facility failed to provide the supervision and interventions necessary to protect the residents on the secured unit, all of whom were cognitively impaired, from resident #107's aggressive, abusive and threatening behavior. On 12/18/12, resident #107 was discovered by a certified nurse aide (CNA) breaking his window, per the resident "to get fresh air," and then lunged at his sleeping roommate and grabbed the roommate by his neck, per the resident, "to choke the sh--t out of him." Observations on 1/2/13 in the secured unit during lunch revealed resident #107 wandering about the unit. The resident's whereabouts were not being supervised or monitored. Interview with the CNA involved in the 12/18/12 incident revealed that following the incident, no plan was developed to increase resident #107's supervision and no direction or education was given to staff on how to keep all residents on the secured unit safe from resident #107's aggressive, abusive and threatening behaviors. The facility's failure to take steps to ensure the safety of residents on the secured unit created a situation of immediate jeopardy for serious harm. On 1/3/13 at 6:04 p.m., the nursing home administrator (NHA), the Assistant Administrator (AA), the Director of Nurses (DON) and the Assistant DON (ADON) and the medical director (by speaker phone) were informed of the facility's failure to ensure the safety of residents on the secured unit created a situation of immediate jeopardy for serious harm. B. Plan to Remove Immediate Jeopardy 1. On 1/3/13 at 9:15 p.m., the fourth draft of the facility's plan to remove immediate jeopardy was presented, reviewed and accepted following observations on the unit that the plan was being implemented. The plan documented in its entirety: "The management staff at (the facility) has implemented the following interventions regarding (resident #107): 1. 1:1 staff was started at 1755 (5:55 p.m.) on 1/3/13. 1:1 staff will remain in place until stabilization has occurred or alternate placement arrangements have been made. 2. At 1845 (6:45 p.m.) all nursing staff present in facility was called to DON office for a meeting regarding (resident #107's) specific plan of care and the facility's abuse prevention policy was reviewed. 3. At 1930 (7:30 p.m.), phone call was made by DON to (resident's) PCP (primary care physician) regarding medication needed to reduce sexual drive. Conversation was held with (nurse practitioner). Her recommendations were to discuss initiation of different medications with (resident's physician) tomorrow (1/4/13). 4. Contact will be made with the Medical director, psychiatrist and PCP on 1/4/13 for consultation regarding resident's treatment to ensure a collaborative effort to promote the best possible medication regime and treatment plan. 5. At 1935 (7:35 p.m.), (resident #107's) care plan was updated to reflect current plan including specific behaviors exhibited and specific nursing interventions. 6. Roommate has been moved to another room to ensure his safety as of 2015 (8:15 p.m.) on 1/3/13." 2. A performance improvement plan dated 1/3/13 was also presented. The plan documented: -Identified area for assessed improvement: Residents residing on the Alzheimer's Unit will be kept free from harm at all times from (resident #107). -Plan: "Resident will have stable behaviors to keep other resident safe or alternate placement will be found. -Action Steps to Implement Plan: 1. 1:1 staffing effective immediately until alternate placement can be obtained or medication stabilization is complete to ensure the safety of other residents. 2. PCP contacted immediately for medication to reduce sexual drive and discussion of starting alternate medications will be had between PCP and PA tomorrow. 3. Care plan will be updated to reflect current behavioral symptoms and appropriate interventions and evaluation. 4. Staff education regarding specific plan of care, redirection techniques, abuse prevention, and appropriate documentation provided to all nursing staff. 5. Communicate with psychiatrist, PCP, and medical director as needed regarding changes in behavior, medication review, and communication with other entities/facilities. 6. Encourage PCP to communicate with psychiatrist for effective medication regime and treatment plan. 7. Roommate will be moved to ensure his safety. 3. A 1/3/13 sexual inappropriateness care plan was also implemented. The care plan showed the resident exhibited inappropriate sexual behaviors with females. Approaches included: --Monitor for behaviors of sexual inappropriateness such as sexual comments and inappropriate touching. --Intervene as needed, provide privacy as appropriate, diversion through an activity of interest such as engaging in a conversation about motorcycles, trucks. --1:1 staffing until medication stabilization or alternate placement is obtained. --Staff education regarding redirection techniques and provide medications as ordered, communicate any change in behavior with MD immediately. On 1/3/13 at 9:15 p.m. the immediate jeopardy was removed; however, deficient practice remained at an E level (potential for more than minimal harm at a pattern). C. Failure to Ensure Safety of Residents on the Secured Unit 1. Characteristics of the Secured Unit a. Residents During survey 1/2/13 - 1/14/13, eight residents, four males and four females, resided on the secured unit. All were elderly (between 70 and 90+). Resident #107, age 66, was the youngest resident on the unit. He roomed with resident #50, age 91. Resident #107 was admitted [DATE]. The resident's [DIAGNOSES REDACTED]. Per his 12/4/12 Minimum Data Set (MDS), the resident was unable to complete the cognitive exam (brief interview of mental status/BIMS), had memory impairments, delusions, and exhibited physical and verbal behavioral symptoms toward others. He was independent with ambulation. Resident #50, age 91, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Per 10/25/12 MDS, the resident was severely cognitively impaired (3/15 on the BIMS). His communication care plan dated 7/24/12, showed the resident had a cognitive deficit related to cognitive loss and hearing impairment. Resident #37, age 81 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His 11/18/12 MDS showed the resident was severely cognitively impaired (4/15 on the BIMS). Per his 1/6/12 secured unit care plan, the resident resided in a secured unit as he benefited from the smaller, structured environment. Resident #93, age 72, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The 11/5/12 MDS showed the resident was unable to complete the BIMS due to her cognitive impairment. The resident's long and short term memory were impaired and per care plan, she was unable to communicate. Resident #60, age 76, was most recently admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her 9/20/12 MDS showed the resident was severely cognitively impaired (4/15 on the BIMS). The 9/16/10 thought process care plan approaches included reducing distractions and negative environmental stimulus as much as possible. Resident #11, age 97, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her 10/11/12 MDS showed the resident was rarely or never understood. She was unable to complete the BIMS, had long and short term memory impairment and, per care plan dated 10/12/11, confusion related to dementia. Resident #51, age 87, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her 11/15/12 MDS showed the resident was severely cognitively impaired (3/15 on the BIMS). The 5/23/12 dementia care plan showed the resident was alert and oriented to herself only and approaches included to 'assess for safety.' Resident #80, age 83, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The 10/15/12 MDS showed the resident was severely cognitively impaired (3/15 on the BIMS). The resident's comprehensive care plan dated 11/17/12 showed the resident was alert and oriented to self only and had communication deficits related to dementia. b. Staff The assistant administrator (AA) was interviewed on 1/3/13, beginning at 3:57 p.m. The AA stated the secured unit was staffed with two CNAs during the 6:00 a.m. - 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift. She said there was one CNA during the 10:00 p.m. - 6:00 a.m. shift. The AA said a licensed nurse was not assigned to the unit on a full time basis but a nurse periodically goes onto the unit to check on residents. The licensed practical nurse (LPN) who currently worked the night shift was asked on 1/3/13 at 3:57 p.m. how often she goes to the unit during her shift. She said she is on the unit from midnight to 1:30 a.m. and again from 3:00 a.m. to 3:30 a.m. She said when she goes onto the unit the CNA comes off the unit to do rounds or to take a break. 2. Resident #107 - Knowledge of Resident's Aggressive, Abusive, and Threatening Behaviors on the Secured Unit. a. Record review revealed the presence of aggressive, abusive, and threatening behaviors beginning shortly after admission and escalating 11/9/12. Resident #107's progress notes were reviewed back to his admission on 10/17/12. The notes indicated incidents of violent, sexually forward, or otherwise inappropriate behaviors that, at times, required repeat administration of anti-anxiety and anti-psychotic medications (Ativan and/or Seroquel). -10/19/12, 10:20 p.m.: "At 1630 (4:30 p.m.) CNA states resident was taking other resident's food, banging on doors, stabbing himself in the wrist and tried to throw a chair through the door. Medicated with .5 mg Ativan. at 1645. At 1700 (5 p.m.) medicated with another 1.5 mg Ativan and 25 mg Seroquel. Checked on him at 1730 (5:30 p.m.) and he was slowing down. At 1815 (6:15 p.m.) resident was sitting up sleeping in tv area. Resident was asleep the remainder of the shift." -10/20/12, 1:32 p.m.: "Resident was being very rude to other residents and staff. Cursing and calling other residents names. Nurse was informed and resident was given medication. He began to settle down for only a short period of time. Resident also is very unsteady when walking as has ALMOST fallen over numerous times." -10/22/12, 11:47 a.m.: "(Speech therapist) attempted to see pt (patient) in early afternoon. Pt was easily agitated and was unable to focus on questions and prompts. Pt made several responses regarding death and killing, "I like to kill other kids." Treatment session was terminated. CNAs caring for pt reported to this therapist that the pt. has been aggressive toward them and other residents. This information was shared with pt's nurse, DON, and therapy team. -10/31/12, 2:03 a.m.: "Resident was noted awake and wandering around on the secured unit ...Medicated with PRN Tylenol for pain and routine dose Ativan ... -11/09/12, 4:30 p.m.: "Resident restless and pacing floor on unit. Resident attempting to remove items off of med cart and grabbing at staff and other residents. Resident states he does not want to go to Folsom Prison. Ativan 1 mg given po for increased agitation with poor results. Multiple attempts to redirect resident with poor results." -11/09/12, 5:00 p.m.: "Reported that resident striking staff with foot peddles (sic). Negative verbalization towards staff. Resident observed spraying substance at residents on unit. (Physician) called and informed of resident's behavior towards staff. New orders received to transfer to (the hospital)." -11/09/12, 6:21 p.m.: "Social services note Interim Note: (Resident) exhibited behaviors of violence this evening AEB (as exhibited by) hitting a CNA with a foot peddle, choking, and negative verbalization towards CNA. Also, he attempted to spray a substance in other residents' eyes. Staff alerted to unit. CNA escorted off unit. Currently, staff are monitoring (resident) while awaiting orders from MD for possible transfer to ER. SSD (social service director) contacted guardian to give information ..." An e-mail sent by the assistant administrator (AA) to the nursing home administrator (NHA) and medical director (MD) dated 11/9/12 documented: "I just wanted you all to be aware that we had an episode tonight. (The resident) in the Alzheimer's unit is one of the residents we were trying to titrate down off of his antipsychotics. He was stable for most of the day there did not seem to be any triggers. He hit a CNA in the side of the head with a foot pedal. He then began choking the same CNA. He was pulled off by the other CNA and then began spraying residents in the face with deodorant. He was medicated, retrained, and we got an order for [REDACTED]. We will not be taking him back until he has gone to (a behavioral health unit) for med management. He has not had prior issues of this nature until this incident." b. Facility Response to Resident's Behaviors - Failures in Facility Response Resident #107's physician progress notes [REDACTED]." -10/22/12: "Pt had come to (the facility) with fewer meds than apparently had been on previously. Restarted Seroquel and higher dose of Ativan according to new records discovered at the end of the day on Friday. Appears more stable at this time. Will continue same treatment for [REDACTED]. The course has been episodic. It is of moderate intensity. Pt was restarted on Seroquel 25 mg QHS on Friday, as well as an increased dose of Ativan. Pt has had a few episodes of increased agitation. He does not remember where he is and has become physically threatening. Episodes have been less frequent and more mild since starting higher dose of Ativan." -10/26/12: "Pt is seen today for agitation and behavior issues per nursing staff request ...diagnosed with [REDACTED]. Currently he is doing well without any significant affective symptoms. Pt was started on higher dose of Ativan last Friday ..." -10/29/12: "...Will decrease Ativan d/t concerns over fall risk and monitor closely for increased behavior. Decrease Ativan to .5 milligrams (from 1 milligram) every four hours scheduled, continue 1 milligram every four hours as needed. Pt has been less agitated since starting Ativan, but has had unsteady gait and a fall from bed over weekend. Pt was previously a threat to self and others, he has been agitated with staff and had struck them with hands and eating utensils." -10/31/12: "(The resident) presents with a [DIAGNOSES REDACTED]. The course has been episodic. It is of moderate intensity. Pt has had a few episodes of increased agitation. He does not remember where he is and has become physically threatening. Episodes have been less frequent and more mild since starting higher dose of Ativan ...Nursing staff is concerned that Ativan is exacerbating unsteadiness. He was started on a lower dose of Ativan 2 days ago due to this concern ..." (There were no further physician progress notes [REDACTED].) On 1/9/13 at approximately 10:00 a.m., the resident's complete care plan was requested from medical records. -An interim care plan, dated 10/17/12 was provided. Review of the care plan provided and in place prior to 11/9/12, identified the resident was care planned for "Behaviors." Approaches included to monitor and document behaviors, redirect as needed, provide activities as appropriate, intervene (when) inappropriate behaviors, refer to social services, and unit placement. -The care plan lacked any specific references to the resident's inappropriate, aggressive or threatening behavior. -There were no specific nursing interventions regarding the need to closely monitor the resident, although staff was aware he wandered the unit and engaged in aggressive and threatening behaviors at times. Moreover, record review (progress notes, nurses' notes) revealed no documentation of a collaborative effort in the development of the resident's care plans in order to maintain resident safety. c. hospitalization [DATE] - 11/27/12 According to the hospital history and physical dated 11/9/12, "The patient is a [AGE] year-old male with dementia and history of traumatic brain injury. He has been living at (the facility) where he was admitted on [DATE]. He is in their locked unit due to his severe dementia. He was brought in for evaluation today because he had an altercation with a resident in which he sprayed hairspray on the resident and then apparently threatened to choke a staff member. He was brought in for evaluation ...." According to the hospital transfer/discharge summary, the resident was discharged back to the facility on [DATE]. The summary documented in pertinent part: -"... The patient is a [AGE] year-old male who had a history of [REDACTED]. He was admitted to (the facility) on 10/17/12. Apparently, he had been doing well there, but they have been tapering off his Ativan. He became increasingly aggressive and he was transferred to the emergency department for further evaluation ... -The patient was admitted to observation status. He was seen by psychiatry and by neurology, psychiatry recommended using Zyprexa for mood stabilization. Ultimately, they did discover from discussion with the facility that his Ativan dose had been decreased and this correlated with the time of the change in his behavior. (The psychiatrist) put him back on scheduled Ativan with PRN doses. His mental status and mood markedly improved. He has been cooperative, compliant, and is not felt to be a danger to return to any type of nursing facility. Unfortunately, we face several challenges with placing this patient throughout the subsequent several weeks, but at the time of this dictation (the psychiatrist) has graciously agreed to be available to (the facility) for any psychiatry or medication related issues. He has also written a letter to the state that these medications are not to be weaned off and he should remain on these indefinitely." A letter written from the psychiatry unit chief of the hospital dated 11/26/12 documented: -"(The resident) was admitted from (the facility) to the (hospital) on 11/9/12 for aggressive and assaultive behavior. He was a reasonable functioning adult until he had a severe traumatic brain injury ....Eventually he was begun on Ativan which did markedly help reduce his aggression and improve his mood. -He was transferred to (the facility) October of 2012 and did reasonably well with no major complaints or problems until an attempt was made to decrease his Ativan to reduce his sedation. Almost immediately, his affect and behavior deteriorated with frequent sudden episodes of severe agitation often times without any warning or provocation. Several staff members and fell ow residents were either threatened or assaulted with some episodes being very serious leading to this (hospital) admit ... -During his (hospitalization ) he was aggressive verbally and/or physically assaultive toward (hospital staff) every day requiring a one to one staff member at all times and requiring physical restraints on many occasions. Several staff members had minor injuries as a result of his aggression .... -It is very clear that there is no hope of any many meaningful cognitive recovery whatsoever for (the resident) now or in the future. (The resident) will require high doses of Ativan for the rest of his life to control his aggressive tendencies ...I also agreed with the plan of using anti-testosterone agents to help reduce the risk of aggression and the potential need of other agents over time to help reduce aggression." Upon the resident's readmission to the facility on [DATE], the resident was prescribed the following pertinent medications: --Zyprexa (antipsychotic) 2.5 milligrams every night --Zyprexa 2.5 milligrams twice daily as needed --Depakote (anticonvulsant) 250 milligram, 3 tabs every night --Lorazepam (Ativan/sedative hypnotic) 1 milligram three times daily as needed --Lorazepam (Ativan) 1 milligram four times a day --Prometrium (progresterone micronized) 200 milligrams every day 3. Resident #107's Behaviors after Readmission - Facility Response - Failures in Facility Response a. Behavior Documentation Nursing documentation revealed the resident continued to exhibit aggressive and inappropriate behaviors. Specifically: -11/28/12, 4:40 a.m.: "Resident noted continued agitation/confusion. Noted to be talking to "someone in the floor" ...Within 15 minutes of LN (licensed nurse) leaving secure unit, CNA calls for assist secondary to res. attempting to break a broom, throwing a tub of applesauce at wall, and lastly picking up a metal stool and attempting to throw stool at window. LN consulted with RN. Call placed to nurse manager. RN to secure unit to 1-1 with res. while CNA assists other residents and LN makes call to MD to acquire further treatment options." -11/28/12, 10:28 a.m.: "Resident is agitated this a.m. Resident attempted to throw objects. Resident was not able to be redirected. Ativan given and effective. Resident ate meals and took meds without difficulty after Ativan has been given ..." -11/29/12, 12:47 p.m.: "Resident is presenting some sexual behaviors. Resident exposed himself twice and attempt to touch staff. Resident will be seen (by physician) tomorrow." -12/1/12, 8:25 a.m.: "... Res up to toilet, but was refusing to use the bathroom in his room. Staff able to get res to use his toilet, but res then came out into the hall about 30 minutes later and began to urinate in a trash can before he could be stopped. Res noted to be sexually inappropriate this shift i.e. taking his penis out of his brief and trying to rub it on staff, refusing to put on pants when coming out of his room, asking staff to lay in bed with him, etc. Res also found in AM yanking roommate's sheets. Res able to be easily redirected but was up often this shift and appears to have gotten very little sleep." -12/1/12, 7:52 p.m.: "Resident with behaviors off and on throughout shift, declaring love to CNAs, wanting to buy items to show his love, attempting to grab inappropriate body parts. Resident redirected with no complications." -12/2/12, 6:41 a.m.: "... Res monitored closely since mat alarm not working. Res up most of this shift sitting in lobby watching T.V., refusing to go to bed and wandering in and out of his own room. CNA stated res was sexually inappropriate to her i.e. CNA asked res to lay down in bed and try to get some sleep and res told CNA he would sleep better if she got in his bed and "f---" him. CNA stated res also grabbed her a few times and tried to push her in to his bed. CNA stated she was easily able to redirect res and politely informed res of his inappropriateness ..." -12/3/12, 7:43 a.m., "Res up sitting in lobby watching T.V. til about 0100. Res stayed in bed resting quietly with his eyes closed until about 0445. CNA stated res then got up and was trying to pick up a fell ow res T.V. CNA stated when asked res said he was going to use the T.V. to break the fish tank so the fish could be free. CNA was able to easily redirect res. CNA stated res was using racial black slurs toward her all shift. Res very touchy and inappropriate with this nurse at beginning of shift i.e. holding my hand and not letting go, rubbing my back, asking to give me a foot massage, and telling me to go to bed with him. This nurse politely told res that I worked here and that kind of affection was not okay. No more inappropriate behaviors noted after that." -12/3/12, 10:09 p.m., "Reported by CNAs that resident was pulling down briefs and making sexual comments. Resident ambulating on Unit CNAs states able to redirect resident with good results ..." -12/6/12, 3:40 a.m., "Resident noted to be awake throughout NOC (night). Was observed becoming aggressive toward CNA, following CNA into another resident room yelling. Noted to be making both physical threats and loud, derogatory-racial statements. LN intervened, attempting distraction methods, redirection. Resident noted continued verbal aggressiveness toward CNA. LN had CNA leave secure unit x2 to attempt to defuse resident aggressive behavior. Currently awaiting CNA from another unit to trade positions for remainder of NOC shift." -12/7/12, 12:53 a.m.: "Resident was noted with increased aggressive/agitated behaviors 2245 (10:45 p.m.) - current. LN witnessed res. pull drawer out of bedside stand and throw it across the floor. On inquiry by LN, resident stated it was "the noise." LN noting floor mat alarm sounding. Attempts x3 were made to diffuse behaviors, redirect-but not effective. LN medicated res. with PRN Ativan 1 mg po approx. 20 mins after having had routine dose of 1 mg Ativan po. Resident was loudly yelling "for all the prisoners" and wandering into other sleeping resident rooms. Resident was unable to be redirected. Awaiting results of meds administered. -12/7/12, 8:04 p.m.: "Res. noted to cont. up and anxious throughout time from midnight until 0615am. Required 1:1 asst to prevent from wandering into other resident rooms/and to prevent violent behavior with inanimate objects. LN gave res 0600 Ativan in bed at 0645, with LN noting res. much more calm-appearing "sleepy". Will report NOC agitation/aggression and wandering activity. Vital signs are stable." -12/7/12, 2:34 p.m.: "Resident continues to have increased sexual behaviors. Resident has been inappropriate with staff. Md aware." -12/7/12, 9:58 p.m.: "Resident verbally sexually inappropriate with CNA x 1 this shift ..." -12/8/12, 7:11 p.m.: "Res verbally sexually inappropriate toward CNA one time this shift. CNA states she was able to easily redirect res. CNA stated res was up on and off all shift, but CNA was able to care for res and get him back to bed quickly." -12/9/12, 7:05 a.m.: "Res not noted to be sexually inappropriate this shift. CNA stated one time res alarm was sounding and when she came in the room res was by roommate's bed and it looked like he was going to urinate on it. CNA stated that while she was trying to get res to the bathroom res urinated in a trash can. CNA stated later on in the night res alarm was sounding and she came in the room to find res urinating in the sink. CNA educated res both times on where the bathroom was and that it was inappropriate to urinate in a trash can or sink. Res stated he knew where the bathroom was and that he knew he was urinating in the sink and trash can, but was unable to tell the CNA why he didn't use the bathroom." -12/10/12, 7:08 a.m.: "Up on and off a few times this shift. Res was sexually inappropriate toward this nurse this shift. This nurse was responding to res alarm and found him outside the doorway of his room. Despite this nurse's many attempts res refused to go back to bed or sit in the lobby. Res tried a few times to go into another resident's room, but was redirected with some difficulty. While this nurse was trying to redirect res he was grabbing this nurse by the arms and trying to pull my face towards his, trying to kiss my hand, trying to rub my arms and trying to hug me stating "I love you". This nurse informed res that it was inappropriate for him to be so touchy with me and trying to kiss me, but res laughed and said he didn't care. This nurse was finally able to get res back to bed, but when I was trying to get res to lay down he told me to take my pants off and was trying to pull me down onto his bed. Res was easily directed that time to stop pulling on this nurse and lay down." -12/11/12, 6:28 a.m.: "Resident noted to be up and down throughout night ...Noted to make inappropriate reference to his rear end during toileting. Redirected, where in resident says, "I don't care" when LN asked him to not use foul-language. Noted resident resistant to assist to bed x2 in NOC. Preferred to sit in living area and watch TV. Noted to sleep no more than 1 hour total during nightshift." -12/13/12, 7:36 a.m.: "Resident noted to be awake and mildly agitated throughout NOC last night. Overheard talking to CNA making inappropriate sexual comments to CNA. When LN attempts to redirect-resident makes inappropriate comments to LN. LN expresses to resident that language like this is not acceptable. Resident replies with," I dont care about appropriate..." -12/15/12, 6:56 a.m.: "Res made one sexual comment this shift when he told this nurse I could lay in his bed whenever I wanted to and winked at me. Res was easily redirected and no further inappropriate sexual behaviors noted. Res up on and off throughout beginning of shift. Res took midnight Ativan without issue, but refused his 0600 Ativan despite 3 attempts by this nurse." -12/16/12, 6:33 a.m.: "Res up for short period of time around 2330 (11:30 p.m.) stating that the building was on fire. Res was banging on the AU doors and CNA was unable to calm him down or redirect him. This nurse went back and gave res scheduled Ativan and staff was able to direct res away from the door. CNA states res colored for a little while after stating that was the only way the fire department was going to come. CNA states she was able to get res to bed about 45 minutes later and res stayed in bed for the rest of this shift. No further behaviors noted and no inappropriate sexual behaviors noted or reported this shift ..." -12/17/12, 7:29 a.m.: "No inappropriate sexual behaviors noted this shift. CNA states res stayed in bed til about 0500 (5 a.m.) when he got up and urinated in the trash can in his room. Res then began wandering in the hall and trying to enter other resident's rooms. CNA stated it didn't take her long to be able to direct res back to bed ..." b. Facility Response and Failures in Response Review of physician progress notes [REDACTED]. -Specifically, a note 11/30/12 documented outbursts of aggression requiring multiple doses of PRN Ativan

Based on observation, record review, staff and resident interviews, the facility failed to ensure six of 40 sample residents (#116, #119, #63, #75, #97 and #32) received the necessary care and services to attain and/or maintain their highest practicable physical, mental, and psychosocial well-being. Specifically,the facility failed to: -Timely and adequately address residents' pain (#116 and #75), contributing to unrelieved pain. -Implement a bowel movement protocol (#119) -Communicate with [MEDICAL TREATMENT] (#97) -Assess bruising of unknown origin (#32, #63) The findings include: 1. Resident #116 Resident #116, [AGE] years old, was admitted to the facility from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. hypoxemia, and frequent falls. There was no Minimum Data Set (MDS) information available, although a 5 day MDS should have been available during the survey (1/2/13 - 1/14/13). Record Review: The resident was care planned for pain 12/23/12. due to left fractured humerus. The approaches were: -Administer pain medication as ordered. Evaluate, record, report effectiveness. -Adjust if ineffective -Assess effects of the pain medications for sleep, self care, appetite etc. Handle gently and try to eliminate any environmental stimuli. The pain assessment done at the admission had listed her pain between a 5-7 range. According to the Occupational therapist notes the resident was to have therapy 5-7 seven days. The goal was for her to return to assisted living. Review of the January 2013 Medication Administration Record (MAR) revealed the resident had the following medications ordered for pain: -[MEDICATION NAME] one or two tabs every 6 hours as needed for pain. -[MEDICATION NAME] 50 mg every 8 hours as needed for pain. -Tylenol 650 mg every 6 hrs as needed for pain. The MAR for January 2013, reviewed 1/8/13 revealed the following medications were administered: [MEDICATION NAME] 5/325/mg 1 tab on 1/6 and 1/8/13; [MEDICATION NAME] 5/325 mg 2 tabs on 1/7/13; and [MEDICATION NAME] 50 mg on 1/1, 1/6, and 1/7 and per interview below, 1/8/13. No Tylenol 650 mg was administered as of 1/8/13, and none of the pain medications were administered on 1/2, 1/3, 1/4, 1/5/13. The MAR for December 2012 included the same orders for pain medication. The following medications were administered: [MEDICATION NAME] 5/325 mg one tab on 12/11, 12/13 12/14, 12/16, 12/17, 12/18, 12/19, and 12/29; [MEDICATION NAME] 5/325/mg 2 tabs on 12/12, 12/13, and 12/24; [MEDICATION NAME] 50 mg on 12/22, 12/23, 12/25, and 12/31; and Tylenol 650 mg on 12/27/12. The resident did not receive any pain medication on 12/15, 12/20, 12/21, 12/26, 12/28, and 12/30/12. And, the resident received medications more than once a day on only one day, 12/13/12. Observations and Interviews 1/8/13: The resident was interviewed on 1/8/13 at approximately 9:00 a.m. She said her arm pain was severe. She stated that it was close to a 10 (on a scale of 1 - 10 with 10 being excruciating pain). She was grimacing, had her arm out of the sling, and barely moved her left arm. The licensed practical nurse (LPN) was notified and she stated she had just medicated her with [MEDICATION NAME]. The LPN, who cared for the resident routinely, was interviewed on 1/8/13 at approximately 10:00 a.m. She stated she did not like the resident to receive narcotics at night. She stated it made the resident difficult to take care of the next morning. She added the family also did not like the resident to receive narcotics. The resident was interviewed again on 1/8/13 at 9:40 a.m. The resident stated she was still having severe pain (She did not respond to inquires about how she would rate her pain.) The resident was sitting in her room and her facial expression indicated she was in pain. The LPN was notified and stated that she had just medicated her again this time with [MEDICATION NAME] 1 tab. The resident was interviewed again on 1/8/13 at approximately 10:30 a.m. The resident stated her pain was 'still at a 9.' The resident appeared uncomfortable. The LPN was informed and she stated she would give the resident another [MEDICATION NAME] and call the doctor for a scheduled medication. The LPN contacted the physician assistant (PA) on 1/8/13. The LPN reported that the PA would see the resident two days later on 1/10/13. The LPN said the PA wanted to see the resident before changing any medication. Observations and Interview 1/9/13: On 1/9/13 at 2:40 p.m. the resident was interviewed again about her pain. She stated the pain medication was not working and still had significant pain. When told her pain would be reported to the nurse, the resident said in a strained voice "Don't go, don't leave me." -The LPN was promptly told of the resident's complaint and she stated she was telling the 3-11 (next shift) nurse about the pain. She stated the resident was due for pain medication since the last administration of [MEDICATION NAME] 2 tabs was 4 hours ago. She said they would give her 2 [MEDICATION NAME] tabs. On 1/9/13 at approximately 11:30 a.m. Occupational therapy (OT) and Director of therapy (DT) were interviewed. -When asked if they checked to see if the resident was medicated before therapy worked with the resident, both stated they did check to see if she was medicated; however, see MARs above; the resident had not received pain medication daily in December or January, even though she was receiving therapy 5-7 times a week. -The DT stated OT had asked to have the resident medicated before OT because she was in such pain. They stated that the resident has had a recent increase in pain in the last couple of weeks. She had pain with range of motion and has been refusing therapy due to her pain. The therapists offered other therapies to help with the pain (E stimulation and diathermy), but the resident had refused. The DT stated they had requested another x-ray to see if there was something else going on in the arm. Interview and Record Review 1/10/13: On 1/10/13 at approximately 10:30 a.m. the PA was observed in with the resident. The resident complained about pain in her stomach and with movement of her arm. The PA stated that they would order another x-ray of her arm. The PA was interviewed about the resident's pain medication. She stated that she was going to order [MEDICATION NAME] 650 mg every 4 hours to start. But review of the orders written on 1/10/13 by the PA revealed orders for scheduled pain medication for both Tylenol ([MEDICATION NAME]) and [MEDICATION NAME]; [MEDICATION NAME] 50 mg three times per day and Tylenol 650 mg every 4 hours. The [MEDICATION NAME] was remained as ordered previously (as needed basis). However, the new order to administer 650 mg of Tylenol ([MEDICATION NAME]) 6 times a day would provide the resident 3900 mg of [MEDICATION NAME] daily. The additional administration of [MEDICATION NAME], 1-2 tabs depending on level of pain every 6 hours as needed for pain, would exceed the acceptable daily limit of [MEDICATION NAME] (4000 mg for the day). Record Review 1/14/13: On 1/14/13 at approximately 10:00 a.m. the resident's x-ray report was reviewed. The PA had ordered an x-ray of the resident's elbow. According to the PA, interviewed 1/14/13 at approximately 10:30 a.m., she ordered an x-ray of the elbow because the hospital notes said there was a distal fracture. On 1/14/13 the hospital medical records department was contacted. Medical records staff stated there were no x-rays taken during the resident's hospital admission 12/7/12-12/11/12. She did find an x-ray taken on 12/3/12 in the emergency room report. The impression of the x-ray was "acute [MEDICAL CONDITION] humeral neck possibly involving the greater tuberosity." There was no reference to a distal fracture. 2. Resident #75, a [AGE] year-old male, was admitted to the facility on [DATE]. According to the face sheet, his [DIAGNOSES REDACTED]. According to the annual Minimum Data Set ((MDS) dated [DATE], the resident was cognitively intact. He required limited assistance with bed mobility and transfers. He required extensive assistance with walking, dressing, toilet use, and personal hygiene. The resident was totally dependent on staff to assist with bathing activities. The resident was on a scheduled pain regimen and also received as needed (PRN) pain medications. The resident was almost constantly in pain which made it hard for him to sleep at night and limited his day-to-day activities. Resident/Spouse Interviews: On 1/2/13 at 3:41 p.m., the resident was asked if he had discomfort such as pain, heaviness, burning, or hurting with no relief. The resident replied, "Yes. Even after the medicine my pain is from a four to an eight out of ten and I don't have full relief." On 1/8/13 at 10:04 a.m., the resident's spouse stated, "One of my biggest concerns is his pain. He has chronic pain and the medication seems to control it to an extent, as long as he gets the medication on time." Record Review: The pain care plan dated 12/3/12 showed the resident experienced pain related to a chronic physical or psycho-social disability. Interventions included: --Evaluate pain every shift --Educate resident/significant other about pain/pain relief measures --Teach/utilize appropriate pain scale --Provide support and re-assurance --Record response to [MEDICATION NAME] and adjuvant therapies, adjusting medication as needed --Medicate resident as ordered per pain --Observe resident for effectiveness of pain relief --Reposition resident as necessary --Monitor for side effects According to the pain assessment dated [DATE]: -the resident had received scheduled pain medications, PRN pain medications, and non-medication interventions. -the resident states he has had frequent pain/hurting in the last 5 days that has made it hard for him to sleep at night and limited his day to day activities. According to the physician orders, the resident was prescribed the following pertinent pain medications: --[MEDICATION NAME] 500 milligrams every eight hours as needed --[MEDICATION NAME]-[MEDICATION NAME] 300 - 30 milligrams every six hours as needed for headache --[MEDICATION NAME] 10 - 325 milligrams every four hours as needed --[MEDICATION NAME] 16 milligrams every twelve hours --[MEDICATION NAME] 4 milligrams every six hours as needed The resident's medication administration record (MAR) was reviewed back to December 2012. The MAR revealed the resident's pain was often not rated on a numeric scale to show how effective the medications were. Medications were also shown to often not fully relieve the resident of his pain. The resident received 500 milligrams of PRN [MEDICATION NAME] on the following dates and it was not documented to be fully effective: --12/8/12 at 7:00 a.m. for pain in the right shoulder. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/13/12 at 7:16 p.m. for pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/22/12 at 9:00 p.m. for pain. The drug was documented to be "not effective" in treating the resident's pain. --12/26/12 at 7:04 a.m. for pain. The drug was documented to be "somewhat effective" in treating the resident's pain. The resident received 300-30 milligrams of PRN [MEDICATION NAME]-[MEDICATION NAME] on the following dates and was not documented to be fully effective. --12/5/12 at 10:11 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/7/12 at 9:59 p.m. for headache. The drug was documented to be "not effective" in treating the resident's pain. --12/8/12 at 12:33 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/11/12 at 10:33 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/12/12 at 8:19 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/13/12 at 3:25 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/18/12 at 7:56 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/22/12 at 9:05 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/23/12 at 8:34 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/26/12 at 10:00 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/27/12 at 8:23 p.m. for headache. The drug was documented to be "somewhat effective" in treating the resident's pain. The resident received four milligrams of PRN [MEDICATION NAME] on the following dates and was not documented to be fully effective: --12/5/12 at 5:03 p.m. for right arm pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/6/12 at 9:13 p.m. for nine out of ten pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/8/12 at 12:33 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/9/12 at 4:07 p.m. for right shoulder pain. The drug was documented to be "not effective" in treating the resident's pain. --12/11/12 at 5:34 p.m. for pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/11/12 at 8:33 p.m. for pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/12/12 at 8:19 p.m. for right arm pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/13/12 at 3:25 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/14/12 at 8:19 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/15/12 at 2:58 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/17/12 at 3:05 p.m. for right shoulder and back pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/18/12 at 3:41 p.m. for right shoulder pain and at 7:56 p.m. for back pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/19/12 at 4:31 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/20/12 at 3:50 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/21/12 at 3:48 p.m. and 9:31 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/22/12 at 6:02 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/25/12 at 5:20 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/26/12 at 7:04 a.m. and 3:14 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/28/12 at 5:12 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/29/12 at 3:15 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/30/12 at 3:54 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/31/12 at 5:24 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. The resident received 10 - 325 milligrams of PRN [MEDICATION NAME] on the following dates and was not documented to be fully effective: --12/12/12 at 3:03 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/13/12 at 3:25 p.m. and 7:16 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/15/12 at 2:58 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/17/12 at 3:05 p.m. and 7:28 p.m. for right shoulder and back pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/18/12 at 3:41 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/19/12 at 4:31 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/20/12 at 3:30 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/21/12 at 3:48 p.m. and 9:31 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/22/12 at 6:02 p.m. and 9:05 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/23/12 at 5:41 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/25/12 at 5:20 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/26/12 at 7:04 a.m., 3:14 p.m., and 10:00 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/27/12 at 8:23 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/28/12 at 5:12 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/29/12 at 3:15 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/30/12 at 3:54 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. --12/31/12 at 5:24 p.m. for right shoulder pain. The drug was documented to be "somewhat effective" in treating the resident's pain. The resident's December 2012 nursing notes were reviewed and showed he had shoulder surgery on 11/30/12. The resident was on [MEDICATION NAME] while hospitalized , but this was discontinued upon his readmission to the facility. On the dates the resident states his pain medication was not fully effective in treating his pain, there was no documented follow-up. He was readmitted following the surgery on 12/3/12. The resident was documented to express dissatisfaction with his pain regimen on: --12/4/12, 1:50 a.m.: "Pt (patient) in bed asleep and able to make needs known. Pt c/o (complains of) moderate pain and upset about pain med change with [MEDICATION NAME]." --12/5/12, 12:18 a.m.: "Pt very frustrated this shift. Constantly yelling out (in) room for help. Pt appears anxious and not able to focus. Pt very negative and blaming staff... for not being here to help him ...Pt c/o severe pain and very unhappy about [MEDICATION NAME] being dc'd (discontinued). Note left (with physician) to reconsider putting it back into his schedule." --12/5/12, 3:02 p.m., " ...Resident has been on his call light every 10 min. He requests his [MEDICATION NAME] to be reinstated that had gotten d/c'd from (the hospital). (Physician) is here today and explained to him that that is why he had his right shoulder surgery to take less pain meds. That when the shoulder heals he should be in less pain. He is non-compliant with his right shoulder ....The surgeon gave strict orders not to use that right arm and leave in the sling. He took the sling off and continues to propel himself down the hallways with the surgical arm. He doesn't want to listen to (the physician) and there is a plan to have a meeting with his wife who insists we get the [MEDICATION NAME] order back in place despite the entire reason for having the surgery was decrease his need for... narcotics." --12/8/12, 1:49 p.m., " ...Pt continues to ask for [MEDICATION NAME] ...Pt c/o severe pain in right shoulder." --12/9/12, 10:15 p.m., "Pt seeking [MEDICATION NAME] and had to be reminded constantly that he does not have scheduled [MEDICATION NAME] anymore after Dr dc'd it. Pt c/o severe pain w/o (without) relief from pain meds. Pt irritable at bedtime." --12/11/12, 10:24 p.m., "Pt demanding [MEDICATION NAME] and reminding nurse of med times constantly. [MEDICATION NAME] in narc(otics) drawer but no (order) to continue [MEDICATION NAME] or order in the MAR. Needs verification. Pt c/o severe pain w/o relief from pain meds." --12/15/12, 5:38 p.m., " ...Pt was watching the clock for his pain pills. Pt c/o severe pain in his right shoulder that is relieved for "only a short while." --12/23/12, 12:22 a.m., " ...Pt requests PRN meds Q4H (every four hours) with some relief from "severe pain 9/10 in right shoulder." The December 2012 MAR also showed the resident did not receive the scheduled 16 milligrams of [MEDICATION NAME] from the evening shift of 12/19/12 until the evening shift of 12/23/12. The notes for the eight missed doses only show, "Not administered: drug/item unavailable." The nursing notes were reviewed on 12/19/12 and 12/23/12 and did not show a reason why the drug was not available. Further, there was no documentation regarding attempts to contact the pharmacy or the resident's physician for an alternative. Staff Interview: On 1/7/13 at 2:08 p.m., the registered nurse (RN) assigned to the resident's hallway stated if a medication was documented to be somewhat effective, she assessed if the resident could have more medications or different medications to treat pain. On 1/7/13 at 2:15 p.m., the director of nursing (DON) said she expected licensed nurses to be using a numeric scale to rate pain before the administration of medication and after. On 1/8/13 at 1:30 p.m. the DON said if a medication was documented to be not effective or semi-effective, she expected the nursing staff to try an alternate method to treat the pain and to notify the doctor. The DON acknowledged using effective and somewhat effective were not objective measures of rating pain. The DON was asked to look into the reason the resident's scheduled [MEDICATION NAME] was not available from 12/19/12 - 12/23/12, but by the end of survey (1/14/13), this information was not provided. On 12/8/12 at 5:50 p.m., the DON provided an in-service given to nursing staff. The 12/8/12 in-service read: "When documenting pain assessments, you need to have the patient rate and describe their pain, then document your intervention. Follow-up with re-assessing the patient's pain again and documenting what the patient rates their pain at following the intervention: "Example: At 1 pm Sally rates her pain at 6/10 sharp and shooting back pain. Sally is repositioned and medicated immediately. At 1:35 the nurse re-assesses her pain. Sally states it is now at 2/10 and she states that it's acceptable to her." It is not ok to document effective or somewhat effective without rating the pain." 3. Resident #97 Resident #97 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's MDS dated [DATE], revealed that she was understood and could understand, she had no long-term or short-term memory loss. She needed extensive assist for dressing, toileting and personal hygiene. The resident was coded as receiving [MEDICAL TREATMENT] three days a week. The resident had a care plan for [MEDICAL TREATMENT] dated 11/14/12. The goal was no complications related to [MEDICAL TREATMENT]. The approaches in pertinent part were: -Encourage communication with [MEDICAL TREATMENT] center. -Monitor labs and weights as ordered. -Monitor shunt site for signs of infection -Notify MD of weight gain and or fluid volume excess. -Notify MD with acute changes in condition. The resident was interviewed on 1/9/13 at 4:20 p.m.. She said she had just come back from [MEDICAL TREATMENT]. She was asked if she ever brought reports back from [MEDICAL TREATMENT]. She said no, and then said she had given a piece of paper to the facility van driver. Review of the medical record revealed no notes from [MEDICAL TREATMENT], including lab reports or the resident's dry weight so that weights could be accurately noted and fluid volume gain tracked. Review of the nurse's progress notes from 11/1/12-1/10/13 revealed there were five references to the resident going or coming back from [MEDICAL TREATMENT]. There were six entries regarding check of the [MEDICAL TREATMENT]. -A progress notes on 11/30/12, a [MEDICAL TREATMENT] day, noted the resident's blood sugar reading was documented at 36 (well below normal range) at 4:00 a.m. There was no indication whether the resident was sent to [MEDICAL TREATMENT] or that the [MEDICAL TREATMENT] center was notified of the low blood sugar. -Other progress notes documented the resident's blood sugar was above 400 (well above normal range). The BS were elevated on the following dates: On 11/5/12 the blood sugar was 582; on 11/11/12 the blood sugar was so high it would not register on the glucometer; on 11/19/12, the blood sugar was 422; on 11/22/12 the blood sugar was 395, 522, and 495 throughout the day There was no indication the [MEDICAL TREATMENT] center was notified of these blood sugar readings. Both 11/5/12 and a 11/19/12 were [MEDICAL TREATMENT] days. The director of nurses (DON) and the assistant director of nurses (ADON) were asked for the reports from the [MEDICAL TREATMENT] center on 1/10/13 at approximately 4:00 p.m. They both stated they never received reports from the [MEDICAL TREATMENT] center including lab reports such as the resident's protein and potassium levels. There was a form from [MEDICAL TREATMENT] listing an appointment the following week; however, there was no current information concerning the resident. 4. Resident #119, age 55, was admitted to the facility on [DATE]. According to the 1/13 Computerized Physician order [REDACTED]. Hospice notes dated 12/28/12 documented the resident had co-morbidities that included end stage liver disease secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident had an increase in weakness. a. Facility Protocol Review of the facility's constipation protocol revealed it read in part: -"...All residents admitted with or placed on narcotic medications will have the following 1) if the resident is receiving routine narcotic medication, the nurse will request as order for routine Senna S if no other laxative is ordered. 2) If the resident has received prn (as needed) narcotic medications for more than 2 consecutive days, the nurse will request an order for [REDACTED]. -If a resident has not had a bowel movement for two days: 1. On the morning of day 3, the day shift nurse gives a laxative (ie Milk of Magnesia or prn order from the physician) and documents this, plus any results. 2. If the resident still has not had a bowel movement by the evening of the 3rd day, the evening shift nurse gives a suppository (as ordered) and documents this plus any results. 3. If there are no results from the suppository, then the night shift nurse gives a fleet enema as ordered .. " b. Record review A physician telephone order dated 1/7/13, documented the current [MEDICATION NAME] (narcotic [MEDICATION NAME]) order was discontinued. [MEDICATION NAME] 20 mg/ml 0.25-0.5 ml every two hours for pain was to be started. The 1/13 Medication Administration Record (MAR) documented the resident had a physician order [REDACTED]. The 1/13 CPO documented an order for [REDACTED]. The MAR showed the resident received the [MEDICATION NAME] four times a day on average. The current physician's orders [REDACTED]. The medical record failed to show documentation of the resident's bowel movements. On 1/8/13, the computerized system identified the resident as daily charting alert for lack of bowel movement for the past 3 days. Review of the 1/13 MAR failed to show a laxative was ordered or administered per protocol. c. Interview The registered nurse (RN) was interviewed on 1/10/13 at 12:30 p.m. -The RN confirmed after reviewing the 1/13 CPO, that the resident did not have an order for [REDACTED]. -The RN stated the standing orders for the constipation protocol was to administer the resident Milk of Magnesia on the third day and then to administer a suppository if the resident continued to not have a bowel movement. -The RN was unable to locate the date when the resident last had a bowel movement since the alert started on 1/8/13. The RN stated the resident was prone to constipation due to the use of the daily narcotics. -The RN reviewed the MAR and confirmed the resident had not received any laxative. 5. Resident #63, age 89, was admitted to the facility on [DATE]. According to the facility admission record, the resident's [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score was 5 (severe impairment 0-7). According to the resident's skin breakdown care plan, dated 10/12/12, the resident was at risk for skin breakdown related to limited sensory, incontinence, and limited mobility. The approaches included: -Avoid shearing skin during positioning, transferring and turning -Diet as ordered. Monitor weights and or intakes -Elevate heels off bed -Encourage physical activity, mobility and range of motion to maximal potential as tolerated. -Inspect skin with care daily. Pay particular attention to the bony prominence -Keep clean and dry as possible. Minimize skin exposure to moisture -Keep linens clean, dry and wrinkle free -Moisturize dry skin -Podiatrist as appropriate -Pressure reduction sitting/W/C (wheelchair) surface -Pressure reduction support surface in bed -Provide incontinence care each incontinent episode -Report any signs of skin breakdown (sore, tender, red, or broken areas). a. Facility Expectations - Incident Reports Review of the facility's Incident Report policy and procedure revealed in pertinent that incident reports should be completed for bruises. An event should be opened in the computer and a copy placed in the director of nursing (DON) box. b. Observations On 1/02/13 at 4:56 p.m. the resident was observed to have a bruise on her left hand that was purple/red in color and fading. It was approximately one inch by one-fourth an inch in size. On 1/7/13 at 2:15 p.m. the resident was observed to have bruising noted to her right wrist and forearm. The wrist bruise was dark purple and round, approximately dime-size and the forearm bruise was dark purple, approximately 1 x 1.5 inch with an approximately 1 centimeter (cm) open area in the middle of it. The bruise noted to the resident's left hand that had been observed on 1/2/13 was present, but had faded to light purple in color. On 1/8/13 at 9:55 a.m. the resident was observed to have two bruises (one with a scab) on her left forearm just below her elbow. The bruises were elongated; the bruise closest to her elbow was approximately .5 inch x .25 inch with a small 1 cm scab. The bruise below it was approximately 1 inch x .25 inch. The two bruises almost touched. The bruises from the 1/2/13 and the 1/7/13 observations (see above) were also noted at this time. The registered nurse (RN) on the floor was present during the observation and she confirmed all the above noted br