Every finding on record at Rehabilitation Center at Sandalwood, The

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two out of three units.Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers cleaned high touch areas; -Ensure hand hygiene was completed during room cleaning; and,-Ensure dwell times were followed per manufacture recommendations. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised [DATE]) was retrieved on [DATE] from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.According to the Hydrogen Peroxide Cleaner Disinfectants (dated 2026), retrieved on [DATE]. from: https://www.cloroxpro.com/products/clorox-healthcare/hydrogen-peroxide-cleaner-disinfectants/?UTM_Campaign=CHP&UTM_Content=Healthcare-Portfolio&gad_campaignid=12892269504&gad_source=1&gbraid=0AAAAADsLA85AqyjqCvlI5MJB9j4oAflA4&gclid=CjwKCAiAs4HMBhBJEiwACrfNZWJE_AtzZ5uMJ4R7PyKAVuDgbW1rvSf-02wA5WnrSSW7YrOQJWSi8xoCE1IQAvD_BwE&gclsrc=aw.ds&utm_campaign=PPH%7CBranded%7CLT%7CP%7CKW%7CCHP%2BHydrogen%2BPeroxide%7CMulti%7CEnglish%7CENKW-ENBR&utm_content=121962823576&utm_medium=cpc&utm_partner=OMD&utm_source=google&utm_term=clorox%20hydrogen%20peroxide%20wipe on [DATE] it was revealed in pertinent part. Wipe the surface until completely wet. To disinfect, keep surface wet for the contact time (1 minute for most bacteria and viruses; 2 minutes for C. auris).II. Facility policy and procedureThe Infection Control: Disinfection of Rooms and Terminal Cleanings policy, undated, was received from the nursing home administrator (NHA) on [DATE] at 2:32 p.m. It revealed in pertinent part, It is the policy of this facility to: Follow checklist for Deep Clean, Isolation, Cleared, and Discharge instructions checklist created based on long term care (LTC) infection Control guidelines. Check list: Collect trash and soiled linens from the room.Remove soiled linens and put them in a bag and take them to the soiled utility room. Collect trash and place it in a garbage bag. Clean trash can inside and out. Clean and disinfect room: Disinfect all surfaces with 10 to 1 bleach solution (wet time 10 minutes). Then, use the antibacterial All Purpose cleaner: doorknobs/ handles; door surfaces; bed rails; headboards; foot boards; nurse call button and cord; phone and phone cord; night stand and bed table (Make sure to clean underneath the bed table all the way to the wheels); television remote; light switches; all furniture; recliner; window sills and curtain rods; mop floor (make sure you use moping procedures as stated in the bathroom except, use a new mop). Clean and disinfect bathroom: mirror; lights; sink; faucets; walls and handrails; tub/ shower; toilet level/ flusher; toilet horizontal surface/seat; check hand soap and paper towels. Fill if necessary; and mop the floor (use a different mop than the bedroom).The Hand Hygiene policy revised [DATE], was received from the NHA on [DATE] at 2:32 p.m. It revealed in pertinent part, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Hand hygiene is one of the most effective measures to prevent the spread of infection. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: After contact with objects ( medical equipment) in the immediate vicinity of the resident and after removing gloves.III. ObservationsOn [DATE] at 9:49 a.m. housekeeper (HK) #1 was observed cleaning resident room [ROOM NUMBER], a double occupancy room. HK #1 performed hand hygiene with alcohol based hand rub (ABHR) and applied clean gloves. HK #1 collected two rags, hydrogen peroxide spray, and Comet cleaner. She applied Comet cleaner to the toilet bowl brush container at the cleaning cart. HK #1 entered the resident's room and went straight to the bathroom where she began spraying the hydrogen peroxide solution to the toilet and took out her phone to time the one minute dwell time (amount of time the surface must remain wet to be effective in disinfecting a surface). While waiting her one minute dwell time she sprayed a dry rag three times with the hydrogen peroxide solution then she wiped down the and rails in the bathroom.-The hand rails failed to remain wet for the one minute dwell time after wiping them down. HK #1 then went back to the toilet, took the toilet bowl brush out of its container, brushed the toilet bowl and replaced it back into her container. She took the same rag that she used to wipe the grab bars and began wiping the toilet rim of the bowl then the lid/seat then outside the toilet to the floor. HK #1 then removed her gloves and returned to her cart. -HK #1 failed to clean the handles of the toilet and failed to clean from cleanest to dirtiest areas. At the cleaning cart HK #1 collected a trash bag and placed the soiled rags into it. HK #1 then washed her hands with soap and water in the room's sink. HK #1 had left the toilet bowl brush and hydrogen peroxide spray on the vanity in the room. She then applied new clean gloves and grabbed a handful of dry clean rags, placed them on a chair in the room near the sink. HK #1 then sprayed the sink with hydrogen peroxide at 9:54 a.m. She then immediately turned on the water at the sink while holding her phone and sprayed the sink again with hydrogen peroxide spray after turning the water off. HK #1 then took a green scrub pad from the same container which held the toilet bowl scrub brush, and began scrubbing the sink bowl, then the handles, turned on the water again splashing water from the faucet onto the handles. HK #1 then took a dry rag and wiped down the sink handles, then the rim of the sink, the vanity counter top and a small shelf over the sink. -HK #1 failed to clean the area from cleanest to dirtiest areas and failed to wait the one minute dwell time before turning on the water or scrubbing the sink.HK #1 used a second dry rag and began cleaning bed B side of the room. HK #1 moved the resident's personal items from the bed side table and sprayed the table with the hydrogen peroxide spray. HK #1 waited the one minute dwell time then wiped down the resident bed side table from top to bottom then replaced personal items back in place. -HK #1 failed to change and perform hand hygiene after cleaning the sink and moving to resident bed B side. HK #1 touched bed B personal items with soiled gloves used to clean the sink area.HK #1 collected trash from bed B, the sink area and then collected bed A's trash and took to the cleaning cart. While wearing the same gloves HK #1 collected the broom and went and swept bed A floor to the door then went to bed B side of the room sweeping debris towards the door. HK #1 then went to the bathroom and swept debris out of the bathroom to the main doorway using a dust pan to collect all debris from all three areas of the room. The toilet bowl brush remained sitting on a chair in the room. After sweeping she collected the stack of rags that were not used in the room and placed them in a soiled bag on the cart. Then collected the toilet bowl brush container and the hydrogen peroxide spray and replaced them back in her cart. HK #1 then reached into her mop bucket and collected one mop pad rung it out and placed it on the floor she began mopping from the door to the sink then bed B then to bed A side of the room around the resident who was sitting in wheel chair in bed A then back to the doorway. HK #1 then went and mopped the bathroom floor.-HK #1 failed to change her gloves after cleaning the sink area, and after cleaning bed B side of the room. HK #1 contaminated her mop bucket solution when she reached in with soiled gloves to obtain a mop pad. HK#1 also failed to use a different mop pad for resident A room and resident B room and another mop pad for the bathroom. HK #1 removed her gloves, performed hand hygiene with ABHR and placed a sign at the door for the wet floor. HK #1 said she was done cleaning this resident room at 10:02 a.m.-HK #1 failed to clean bed A's side of the room and did not ask the resident who was present during cleaning if she could clean her area. HK #1 failed to clean high touch surfaces in the room like, call buttons, light switches, handles to any door within the room and television remotes. HK #1 was observed to clean a second double occupancy room at 10:03 a.m. HK #1 moved her cleaning cart to room [ROOM NUMBER]. HK #1 performed hand hygiene with ABHR then applied clean gloves. Collected two dry rags and one trash bag. She applied Comet to the toilet bowl brush and green scrub pad and the hydrogen peroxide spray. HK #1 knocked on the door resident in bed A was still eating her breakfast. HK#1 went to the bathroom and began spraying the toilet rise and toilet. HK #1 moved the toilet riser scrubbed the toilet bowl with toilet bowl brush flushed toilet. She then began wiping the toilet after one minute dwell time was completed. HK #1 wiped the toilet riser first starting with the seat of the riser, then rim then lifted the lid and lastly she wiped the handles of the riser. HK #1 moved the toilet riser further out of her way to access the toilet. Using the same rag she began wiping the toilet bowl rim then wiped the toilet on the outside to the floor. -HK #1 failed to clean the riser and toilet in a hygienic manner from the cleanest area to dirtiest areas. HK #1 took a new rag and moved the toilet riser back into place. She then sprayed the dry rag three times with hydrogen peroxide spray. She then wiped down the grab bars and a small shelf in the bathroom. -HK #1 failed to follow the one minute dwell time for the hydrogen peroxide on the grab bars and shelf.HK #1 removed a trash bag with soiled rags from the room, removed her gloves, completed hand hygiene with soap and water then collected trash from the trash can at the sink then bed B and last bed A trash. HK #1 placed trash onto her cart. She then applied ABHR to her hands then applied clean gloves. Collected two new rags and went to the sink, where she had left the toilet bowl brush and green scrub pad on the sink counter. HK #1 then sprayed the sink with the hydrogen peroxide. She then took the green scrub pad from the container wiping the sink rim then bowl then the handles. She used the green scrub pad to wipe down the soap dispenser, paper towel dispenser then the counter top of the vanity and re scrubbed the sink bowl again.HK #1 then collected a dry rag, wiped the sink counter, rim of sink, then the bowl and the handles last. HK #1 then collected another dry rag, went to bed B side of the room, removed emptied dishes from the bed side table and placed them on the personal protective equipment (PPE) cart just outside the resident room. HK #1 then sprayed the bedside table with hydrogen peroxide, waited the one minute dwell time then wiped the bedside table from top to bottom. HK #1 then collected the toilet bowl brush container, hydrogen peroxide spray and rags and returned to her cart. -HK #1 failed to clean the sink in a hygienic manner.HK #1 collected the broom from her cart, swept bed B side of the room to the bathroom, swept the bathroom and finished with bed A side of the room moving all debris from all three areas to the doorway where she collected debris in the dustpan.HK #1 then reached into her mop bucket, pulled one mop pad out and rang it out. Mopped the floor from the doorway to under the sink then bed B side of the room to the bathroom. She mopped the bathroom and continued mopping the floor of bed A side of the room. The resident in bed A was still eating her breakfast and picked up her plate to move around so HK #1 could mop the area she was sitting in. -HK #1 failed to change her gloves after cleaning the sink area and prior to moving to clean bed B side of the room. HK #1 failed to use a different mop pad for each of the three areas of the resident room and she contaminated her mop water again when she reached in with soiled gloves to obtain the mop pad. HK #1 removed her gloves, performed hand hygiene with ABHR and said the room was finished at 10:17 a.m. HK #1 placed a wet floor sign at the door and reminded the residents the floor was wet. IV. Staff interviews HK #1 was interviewed on [DATE] at 10:18 a.m. after observations of her cleaning two double occupancy rooms in the facility. She said every resident room was cleaned daily. HK #1 said she performed deep cleaning of rooms only when a resident has expired or moved to another room. HK #1 said deep cleans meant they cleaned everything in the room down to the mattress, closet and any drawers in the room. HK #1 was unsure what high touch surfaces in a resident's room were. She said call lights, light switches and door handles were all cleaned during deep cleans. HK #1 said it was important to clean the resident room to help prevent the spread of infections. HK #1 said the hydrogen peroxide was the disinfectant the facility used. She said the surface had to remain wet for one minute to be effective. She said she was unaware the grab bars and shelves in the bathroom and above mirror did not remain wet for the required one minute. She said she did not know she did not clean from top to bottom or from cleanest areas to dirtiest areas. HK 31 said she should clean from cleanest to dirtiest to help prevent the spread of germs from dirtier areas to cleaner areas.HK #1 said she had been working in the facility for 18 years and this was how she was shown to clean resident rooms. She said she was not provided any education on how to clean resident rooms in her native language. The environmental service director was interviewed on [DATE] at 10:30 a.m. He said new staff came in and were paired with a housekeeper to observe and learn how to clean a resident room after they complete the basic orientation with human resources. The environmental service director said the hydrogen peroxide disinfectant needed to remain wet on the surface for one minute to be effective per the manufacturer guidelines. He said rooms were to be cleaned daily along with high touch surfaces/areas that should be cleaned daily. The environmental service director identified the following areas as high touch surfaces/areas: call light, door knobs, grab bars, hand rails, call lights, phones, bed controls and light switches. He said disinfecting them daily helps prevent the spread of infection.The environmental service director said rooms were to be cleaned in this order. He said the staff should start in the bathroom and have rags just to be used in the bathroom, along with trash bags to place dirty rags into after use. He said then they should spray the bathroom down with disinfectant and wait the one minute most of his staff pull their phone out to time the one minute. He said then they could start wiping from the bottom of the toilet upwards. The environmental service director said staff could clean from the floor around the toilet outside to the rim and then the toilet bowl should be scrubbed with Comet and toilet bowl scrub brush. He said the toilet needed to be flushed after being scrubbed. He said then staff should obtain a new clean reg and wipe down the door handles, doors and walls especially if anything was visibly soiled. Staff should then move to the mirror and dust the bathroom light fixtures. He said the last item staff were to clean in the bathroom was the floor. The environmental service director said the bathroom got its own mop pad.The environmental service director said staff should remove their gloves and wash hands with soap and water or use ABHR before applying new gloves to start the resident rooms. He said the HKs could clean a resident's room with the resident in the room but needed to ensure the spray did not land/touch the resident. He said the HKs were to spray and wipe down surfaces and work around resident personal items as some residents do not like HK to touch their personal belongings. He said staff should start on bed B side of the room and make progress towards the main doorway. He said then the room could be mopped with one mop pad; it did not matter if it was a double occupancy room. The environmental service director said he did not provide HK with training information in their native language but relied on other staff to assist with translation. The infection prevention (IP) and the regional clinical resource were interviewed on [DATE] at 11:15 a.m. The RCR said housekeeping staff were educated during outbreaks but most education and training for housekeepers came from the environmental service director. The regional clinical resource said education was not provided to staff in their native languages. The regional clinical resource said high touch areas in a resident's room were to be disinfected daily to prevent the spread of infection.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) to ensure the highest practicable quality of life and care, for two (#12 and #70) of three residents reviewed for ADLs out of 35 sample residents.Specifically, the facility failed to:-Ensure denture care was provided for Resident #12; and,-Ensure Resident #70 received meal assistance. Findings include: I. Facility policy and procedure The Activities of Daily Living policy, dated 7/1/24, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:41 p.m. The policy read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (constricting of the airways and difficulty breathing), chronic kidney disease, alzheimer's disease (a progressive neurodegenerative disorder causing dementia) and muscle weakness. The 1/13/26 minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required setup or clean up assistance in order to complete oral hygiene. B. Interviews and observations On 2/5/26 at 10:47 a.m. Resident #12 took out her top denture. The area of the denture which fits to the palate of the mouth was coated with whitish yellow matter. Resident #12 said she cleaned her dentures herself and that she used tabs and soaked them. On 2/9/26 at 4:26 p.m. Resident #12's top denture was caked with white and yellow film along the palate side and along the tooth/gums sides. On 2/10/26 at 8:18 a.m. Resident #12 took out her top denture. The denture was coated with a yellow film along the area which fit with the palate as well as the tooth and gum sides. Resident #12 said It feels funny as she looked at the denture. Resident #12's family member was interviewed on 2/10/26 at 5:12 p.m. The family member said Resident #12 did not have a lower denture and that she did need help cleaning her top denture. The family member said, more often than not, Resident #12's denture did not seem clean because she could see stuff on the resident's denture when she visited. The family member said she also supplied Resident #12 with denture tablets and the number of tablets rarely goes down Certified nursing aide (CNA) #7 was interviewed on 2/11/26 at 9:02 a.m. Resident #12 showed CNA #7 her top denture. CNA #7 said it looked dirty. CNA #7 asked Resident #12 if she could brush her denture for her. Resident #12 looked at her denture and said it looked gross. CNA #7 brushed Resident #12's denture. When done brushing it, the denture was pink and had no yellow or white coating on it. D. Record review The ADL care plan, dated 12/30/25, documented that the resident required partial assistance from staff with personal hygiene and oral care. Review of the February 2026 point of care charting documented the resident only received oral hygiene care once a day on 2/4/26, 2/5/26 and 2/9/26. Review of the February 2026 point of care charting documented that on 2/5/26, the resident completed oral hygiene care independently. -However, Resident #12's MDS documented she needed set up or cleanup assistance. Review of the February 2026 point of care charting documented that on 2/10/26, the resident was offered oral hygiene care one time, at 12:59 p.m. The resident refused oral hygiene care. No additional oral hygiene care was documented as offered or completed that day. E. Staff interviews CNA #7 was interviewed on 2/10/26 at 9:06 a.m. CNA #7 said staff should approach Resident #12 and explain why they wanted to help her with care. CNA #7 said Resident #12 was more willing to let staff complete care if she understood why it was important. CNA #7 said staff cleaned her dentures and that Resident #12 did not do her own denture. CNA #7 said she generally brushed the denture and used a toothbrush and toothpaste to brush it. CNA #7 said she would also rinse them and put them back in the residents cup or the resident would put them back into her mouth. The NHA and the regional clinical resource were interviewed together on 2/11/26 at 6:00 p.m. The regional clinical resource said any nursing staff including CNAs were responsible for brushing residents' teeth or dentures. She said oral hygiene should be performed at least daily but if they want to brush their teeth after every meal, their teeth should be brushed after every meal. The NHA said oral hygiene was important to promote hygiene and prevent infections, thrush, or sores. She said oral hygiene care was documented in ADL tasks and on the resident's care plan. III. Resident #70 A. Resident status Resident #70, older than 65,was admitted to the facility on [DATE]. According to the February 2026 CPO, diagnoses included hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction (blood flow to the brain was interrupted, leading to brain tissue damage) affecting left dominant side, dysphagia (difficulty swallowing) following cerebral infarction, and muscle weakness. The 1/5/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The assessment revealed the resident was dependent on staff assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The assessment revealed the resident required substantial/maximal assistance while eating. The assessment revealed the resident did not exhibit any behavior related to rejection of care. B. Resident representative interview Resident #70's representative was interviewed on 2/5/26 at 1:25 p.m. The representative said Resident #70 needed one-to-one feeding assistance. She said she did not observe staff providing that assistance. She said the staff entered the room, placed the meal tray on the table and left. She said it took an extended period of time for staff to return. C. Observations During a continuous observation on 2/9/26, beginning at 1:15 p.m. and ending at 6:15 p.m., the following was observed: At 1:16 p.m. Resident #70 was attempting to feed herself during lunch. No staff entered her room or were observed providing one-to-one assistance with her meal. At 3:13 p.m. the lunch tray was still on the table. The resident stopped her attempts to eat for a while. Staff had not entered the resident room since the beginning of the observation. At 5:51 p.m. CNA #3 passed the dinner tray in Resident #70's room. CNA #3 put aside the lunch tray and place the dinner tray on the table. She unwrapped the food plate, cleaned resident hands and just asked if Resident #70 needed anything else and left. At 6:02 p.m. CNA #1 entered the resident's room, just asked if the resident needed anything, then left with the lunch tray. CNA #1 came back bringing a drink and left. No one-on- one meal assistance was provided. The family member was not observed providing one-to-one meal assistance to the resident. At 6:15 p.m. no staff entered the resident's room or were observed providing assistance with her meal. D. Record review The ADL care plan, initiated 12/31/25 and revised 1/6/26, documented Resident #70 had ADL self care performance deficit related to limited mobility. Intervention included providing substantial assistance with eating by one staff member. The nutrition care plan, initiated 12/31/25 and revised 1/23/26, documented Resident #70 had potential nutritional problem related to dysphagia. Pertinent interventions included providing one-to-one assistance with meals and protein shakes, and providing assistance or cueing with meals as needed. The nutrition evaluation, dated 12/31/25, documented Resident #70 had swallowing/chewing difficulties due to dysphagia. The registered dietitian recommended providing one-to-one assistance with meals. The evaluation documented Resident #70 required total dependence for dining ability. -However, the care plan was not updated to indicate the resident required set-up assistance. The occupational therapy progress report, from 12/31/25 to 1/17/26, revealed Resident #70 had set a short-term goal for eating from substantial/maximal assistance to partial/moderate assistance. The report documented Resident #70 was demonstrating slow progress but required significant assistance with all transfer, mobility, dressing, toileting, bathing, grooming/hygiene, and feeding tasks. A nursing progress note, dated 2/9/26, documented the speech therapist recommended Resident #70 was cleared for set up assistance with meals and did not require one-to-one meal assistance. Staff were educated to check on Resident #70 frequently and provide assistance with meals once Resident #70 became too fatigued to continue eating independently. She was not at a choking risk. E. Staff interviews CNA #1 was interviewed on 2/10/26 at 5:36 p.m. CNA #1 said she reviewed the Kardex (staff directive tool) to determine which residents needed meal assistance. She said she also asked other CNAs during shift change about residents who needed meal assistance. CNA #1 said Resident #70 needed meal assistance but she did not need to be fed based on the information provided by the assistant director of nursing (ADON). She said staff would check on the resident while she was eating. CNA #1 said the Kardex for Resident #70 indicated she needed substantial assistance by one person for meals. Registered nurse (RN) #1 was interviewed on 2/10/26 at 5:55 p.m. RN #1 said he determined if residents needed meal assistance based on speech therapy evaluations, personal assessments after speaking with the residents and hospital referral documentation. RN #1 said Resident #70 needed meal assistance. He said sometimes Resident #70 could feed herself as she could use the silverware. RN #1 said the nurse report indicated the resident needed one-to-one assistance. RN #1 said the resident's husband came to help her at dinner time. He said staff should be expected to assist her during breakfast and lunch time. The ADON was interviewed on 2/11/26 at 8:09 a.m. The ADON said CNAs identified residents who require meal assistance based on therapy service evaluations, physician's orders and verbal communication during the report. She said Resident #70's meal assistance was just set up and supervision. The ADON said upon admission Resident #70 received one-to-one meal assistance throughout the entire meal service. The ADON said the resident had since gained strength and was able to feed herself using her right hand, requiring only supervision. The ADON said if Resident #70 became fatigued, staff could provide assistance but sometimes she did not allow staff to assist her. She said Resident #70 just needed staff to set up the table, not physically being there to feed her. The RD was interviewed on 2/11/26 at 2:05 p.m. She said Resident #70 required one-to-one meal assistance upon admission due to a choking risk related to dysphagia. She said based on the speech therapy evaluation, dated 2/6/26, Resident #70 was no longer at risk of choking and did not require one-to-one meal assistance. The regional clinical resource and the director of nursing (DON) were interviewed on 2/11/26 at 6:00 p.m. The regional clinical resource said the CNAs identified residents requiring meal assistance mostly through point of care (POC) charting, the Kardex, shift change reports and report sheets. The regional clinical resource said Resident #70 did not require one-to-one meal assistance upon admission. The regional clinical resource said Resident #70 started to decline over time and had abnormal laboratory results. The regional clinical resource said Resident #70 had a poor intake, ate very slowly at her own pace and did not want to be rushed during meals. The regional clinical resource said Resident #70 needed assistance when she was fatigued but at times she refused the assistance. She said meal assistance was taking an hour to complete. The regional clinical resource said meal assistance was not recommended for choking risk but rather when Resident #70 was fatigued. She said the recommendation did not come soon enough and was not aware if meal assistance had been formally discontinued for the resident.

Based on record review and interviews, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for one (#80) of five residents reviewed for quality of care out of 35 sample residents. Specifically, the facility failed to ensure Resident #80 was assessed by a registered nurse (RN) following a fall on 12/13/25. Findings include:I. Facility policy and procedureThe Fall Management System policy and procedure, revised 1/20/26, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:41 p.m. It 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 minimize complications if a fall occurs. When a resident sustains a fall, a physical assessment will be completed by a registered nurse, with results documented in the medical record.II. Resident #80 A. Resident statusResident #80, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included cerebral atherosclerosis (narrowing and hardening of the brain arteries), epilepsy, dementia, heart failure and a history of falling. The 1/20/26 minimum data set (MDS) assessment revealed Resident #80 had short term and long term memory problems per staff assessment. The assessment further revealed she was severely impaired in her daily decision making. The MDS assessment revealed Resident #80 was dependent on staff for all of her activities of daily living (ADL). B. Record reviewResident #80's fall care plan, initiated 12/1/25, documented she was at risk for falling due to confusion, deconditioning, incontinence, poor communication and comprehension, unaware of safety needs, restlessness, and agitation. Pertinent interventions included anticipate and meet needs, call light within reach, appropriate footwear, if restless staff to encourage resident to sit at nurse's station for more direct observation, keep needed items in reach (initiated 12/1/25), if resident is sleepy after meals offer her to lie down (initiated 12/15/25), educate daughter to tell staff when she is leaving for the day, commode to be removed from bedside and placed in bathroom when not in use for safety, keeping the wheelchair out of line of sight (initiated 12/26/25), reach out to hospice to ask for assistance to sit with resident (initiated on 2/2/26), reach out to hospice about a bolster mattress and completing a medication review by pharmacist (initiated 2/5/26). The fall risk assessment, dated 12/13/25, documented Resident #80 was a high fall risk. A review of Resident #80's electronic medical record (EMR) revealed the following progress note:A nursing progress note documented by a licensed practical nurse (LPN), dated 12/13/25 at 2:17 p.m., documented that Resident #80 fell while the LPN was on break. The note further documented that the LPN found Resident #80 sitting in a chair. The note documented that Resident #80 denied pain, was able to move all of her extremities. -However, the note did not document that an RN completed an assessment or was consulted regarding the fall. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/10/26 at 5:25 p.m. She said when a resident fell she would call for an RN to come and do an assessment prior to moving the resident. Certified nurse aide (CNA) #5 was interviewed on 2/11/26 at 9:56 a.m. She said when a resident fell she called for the nurse and stayed with the resident. The director of nursing (DON) and the regional clinical resource were interviewed together on 2/11/26 at 5:50 p.m. They said they had an extensive plan of correction (POC) in place for falls that was implemented on 12/23/25. They said the POC went over getting the staff trained on lifts, gait belts and got more staff hired for better continuity of care. They said the POC covered how interventions were communicated between staff members. They said the RN assessment was not part of their POC.

Based on observations, record review and interviews, the facility failed to provide a resident choices regarding their personal funds for one #11) of two residents reviewed for personal funds out of 35 sample residents. Specifically, the facility failed to provide resident choices for storage of funds. Findings include:I. Facility policy and procedureThe Accounts Receivable policy, dated 1/1/26, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:41 p.m. The policy reads in pertinent part: The resident has the right to manage their financial affairs. Residents are not required to deposit their personal funds into the facility resident trust account.II. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included cancer, type two diabetes, heart failure and chronic kidney disease.The 11/29/25 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 substantial/maximal assistance with transfers.B. Record reviewA progress note log activity note written by the business office manager (BOM) ,dated 1/27/26 at 12:47 p.m., documented the BOM left a message for Resident #11's power of attorney (POA) concerning money that Resident #11 was keeping in his room and suggested depositing it into the resident fund management system (RFMS). A progress note log activity note written by the BOM, dated 1/27/26 at 1:32 p.m., documented the POA would call Resident #11. The note documented if the BOM did not get the resident's money by the next day, the BOM would give her a call back.A progress note log activity note written by the BOM, dated 1/29/26 at 1:56 p.m, documented Resident #11 deposited money into his RFMS account.A resident statement from resident fund management service, dated 2/11/26, documented Resident #11's account was opened on 11/26/25 and had a current balance of $210.00C. Resident interview/observationsResident #11 was interviewed on 2/11/26 at 4:07 p.m. Resident #11 said the facility currently held his money in an account. Resident #11 said he could take out $50.00 a day when requested.Resident #11 said he wanted to keep his money in his room. Resident #11 said a couple of days before Thanksgiving last year, the facility had let him keep a bundle of cash, about $200.00 to $300.00, in his room in a locked drawer. He said they gave him a key to lock his drawer. Resident #11 held up a blue spiral keychain-bracelet with a key hanging on it. Resident #11 said his POA called him and told him that someone at the facility told her to tell him to open an account. Resident #11 said about a day after he started using the locked drawer, a staff member told him he had to bring his bundle of cash to the front desk. Resident #11 said he did not know the name of the person who directed him to bring the cash to the front. Resident #11 said he thought it was a nurse. Resident #11 said he wanted to keep his money in his room. Resident #11 said this made him mad. Resident #11 said he had to request cash when he needed it. Resident #11 said it was easier for him to buy things before, when he had cash on hand.III. Staff interviewsThe business (BOM) was interviewed on 2/11/26 at approximately 4:00 p.m. The BOM said residents who have accounts could access their money by going up to the front desk and asking the receptionist for money. She said the receptionist created a receipt which the residents sign and then receive their requested cash amount. The BOM said residents could pull out $50 a day and could take out more if they requested. The BOM said residents had the option to keep their money in their rooms, but they discouraged it. She said they discouraged it because people were coming and going throughout the facility, and other residents were present too. She said occasionally things were taken, so they tried to keep jewelry, money, and other things of value safe. The BOM said if residents wanted to keep their money in their room they have the right to do so. The BOM said residents had drawers with locks on them anThe BOM said the facility staff did not know that Resident #11 had cash at first. She said they later they saw Resident #11 had a lot of money and activities staff asked the resident if the facility could keep his money in the bank. The BOM said she called the POA and told her the facility was concerned about the potential of him losing money. The BOM said the POA said Resident #11 had done this before and that she did not realize he had money on him again. She said the POA told her she would call him and talk to him about it. The BOM said afterward, the resident brought his money up to the front for deposit. The BOM said she believed the activities staff spoke to him and told him they had a banking system. She said she also spoke to the resident about the locked drawers. The BOM said if the resident wanted to keep his money in his room, he could. She said it caused them concern, but he could if he wanted to. The receptionist was interviewed on 2/11/26 at 4:30 p.m. The receptionist said she remembered that Resident #11 had a decent amount of cash, about $200.00 worth. She said that some staff members were worried that Resident #11 would misplace his cash. The receptionist said Resident #11 was encouraged to put his money into an account. She said she did not know who was worried about his cash, but she thought it was the BOM and some nurses. She said Resident #11 called her and asked how to set up an account, for which she directed the resident to the BOM. The receptionist said later, Resident #11 came up to the front desk and said he was told to bring his money to the front. She said she then helped Resident #11 sign the necessary forms and get his money deposited into an account.

Based on interviews and record review, the facility failed to implement policies and procedures that ensured potential irregularities identified by the consulting pharmacist (CP) and documented in monthly drug regimen reviews (MRRs) as recommendations, would be timely reviewed and acted upon by the medical provider, medical director, and the director of nursing (DON). This failure affected four of four residents (#51, #60, #15, #64) whose records were reviewed. In an interview, the CP responsible for the facility's MRRs stated she emailed the residents' MRRs to the DON monthly. There had been no response to the MRR recommendations for four months, beginning in January 2024. She further stated she had repeatedly notified the medical director, the DON, and the nursing home administrator (NHA) that she was not receiving any response from the facility to her recommendations. A review on 4/25/24 of an executive summary report by the pharmaceutical company revealed multiple MRR recommendations in January 2024 (163), February 2024 (143), March 2024 (131), and April 2024 (138) that had not been returned to the CP to show they had been reviewed and responded to by the medical provider. Further, on 4/24/24 at 2:00 p.m., the DON provided MMRs for Residents #51, #15, #60, and #64 that were not reviewed and signed by the medical provider until 4/25/24, during the survey. These included: -MRRs for Resident #51, dated 3/20/24, 3/22/24, and 4/10/24, which included recommendations to address two medications with anticoagulation properties, an antipsychotic medication without a clinically appropriate indication for use, and an antidepressant. -MRRs for Resident #15, dated 11/10/23, 12/14/23, 1/15/24, 3/22/24, and 4/9/24 which included recommendations to address gradual dose reduction (GDR) of an antipsychotic and antidepressant, lab studies, and pain medication. -MRRs for Resident #60, dated 11/10/23, 12/14/23, 2/15/23, and 3/21/24, which included recommendations addressing GDRs of antidepressants and inquiries about two medications with anticoagulation properties. -MRR for Resident #64, dated 3/22/24, which identified the resident's anticoagulant lacked the diagnosis listed in the resident's diagnosis list. The facility's failure to implement policies and procedures that ensured timely review and response to MRR recommendations created a situation of immediate jeopardy for serious resident harm - potential adverse consequences due to the lack of timely oversight of the residents' medication therapies. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to implement policies and procedures that ensured potential irregularities identified by the consulting pharmacist (CP) and documented in monthly drug regimen reviews (MRRs) as recommendations would be timely reviewed and acted upon by the medical provider, medical director, and the director of nursing (DON). In an interview, the CP responsible for the facility's MRRs stated she emailed the residents' MRRs to the DON monthly. There had been no response to the MRR recommendations for four months, beginning in January 2024. She further stated she had repeatedly notified the medical director, the DON, and the NHA that she was not receiving any response from the facility to her recommendations. A review on 4/25/24 of an executive summary report prepared by the pharmaceutical company revealed multiple MRR recommendations in January 2024 (163), February 2024 (143), March 2024 (131), and April 2024 (138) that had not been returned to the CP to show they had been reviewed and responded to by the medical provider. Further, on 4/24/24 at 2:00 p.m., the DON provided MMRs for Residents #51, #15, #60, and #64 that were not reviewed and signed by the medical provider until 4/25/24, during the survey. These included: -MRRs for Resident #51, dated 3/20/24, 3/22/24, and 4/10/24, which included recommendations to address two medications with anticoagulation properties, an antipsychotic medication without a clinically appropriate indication for use, and an antidepressant. -MRRs for Resident #15, dated 11/10/23, 12/14/23, 1/15/24, 3/22/24, and 4/9/24 which included recommendations to address gradual dose reduction (GDR) of an antipsychotic and antidepressant, lab studies, and pain medication. -MRRs for Resident #60, dated 11/10/23, 12/14/23, 2/15/23, and 3/21/24, which included recommendations addressing GDRs of antidepressants and inquiries about two medications with anticoagulation properties. -MRR for Resident #64, dated 3/22/24, which identified the resident's anticoagulant lacked the diagnosis listed in the resident's diagnosis list. The facility's failure to implement policies and procedures that ensured timely review and response to MRR recommendations created a situation of immediate jeopardy for serious resident harm - potential adverse consequences due to the lack of timely oversight of the residents' medication therapies. B. Facility notice of immediate jeopardy On 4/25/24 at 3:15 p.m., the NHA was notified of the facility's failure to implement policies and procedures that ensured potential irregularities identified in monthly drug regimen reviews (MRRs) would be timely reviewed and acted upon by the medical provider, medical director, and the DON created a situation of immediate jeopardy for serious harm if immediate action was not taken. C. Plan to remove immediate jeopardy On 4/25/24 at 5:47 p.m., the NHA implemented an interim plan to ensure the safety of all residents until a formal final plan could be submitted on 4/26/24. It read, in part, that immediately following the discovery of missing follow-up of MRRs for residents, the MRRs for Residents # 51, #15, #60, and #64 were reviewed and given to residents' providers for review and follow-up on recommendations. Based on physician review, appropriate changes were made to residents' medication regimens as needed. Education was completed with DON and Assistant DON regarding follow-up with MRRs on 4/25/24. On 4/26/24 at 1:05 p.m. the facility submitted its final plan to remove immediate jeopardy. The plan read: Immediately following discovery of missing follow up of Medication Regimen Reviews for residents. 1. MRRs for Residents #51, #15, #60, and #64 were reviewed and given to residents' providers for review and follow up on recommendation. Based on physician review, appropriate changes were made to residents' medication regimen[s] as needed. 2. Family and physician notification for Resident #51, #15, #60 and #64 was completed on 4/25/24. 3. Education completed with DON and assistant director of nursing (ADON) regarding follow up with MRRs on 4/25/24. Identification of Others: Prior to the notification of Immediate Jeopardy on 4/25/24, DON/designee began reviewing January 2024 to present MRRs with resident's provider on 4/23/24 to assure recommendations were reviewed by the provider. This included all residents with recommendations. All recommendations will be reviewed and completed by residents' providers by 4/29/24. Systemic Measures: 1. Beginning 4/25/24 the DON/designee will begin reporting to the NHA and vice president (VP) of Clinical Services to ensure monthly MRR follow up has been completed. Review tool to be completed to document completing of review. 2. Beginning 4/25/24 the pharmacy consultant will email monthly reports to the attending physician, the Medical Director, DON, NHA, VP of Clinical Services, and Director of Operations for review and follow up. In addition, hard copies will be provided to providers during regular visits to the community. 3. Facility pharmacy consultant will complete an Interim Medication Regimen Review (IMRR) on all new residents admitted to the facility twice per week to ensure new admissions are reviewed that would discharge from the facility prior to when monthly MRRs are completed. Monitoring 1. MRRs will be reviewed monthly by DON/designee to ensure recommendations have been reviewed/completed by the provider. Findings will be reported to the QAPI (quality assurance performance improvement) meeting held monthly for further review and recommendation. D. Removal of immediate jeopardy On 4/26/24 at 1:05 p.m., the NHA was notified that the facility's plan to remove immediate jeopardy was accepted based on the facility's actions in implementing the measures above. However, the deficient practice remained at an F level, the potential for more than minimal harm that is widespread. II. Facility policy and procedures A. The NHA provided the facility's Drug Regimen Review Policy, dated 7/10/23, on 4/25/24 at 5:28 p.m. It read in pertinent part: -Drug regimen review (DRR) consists of reviewing and analyzing prescribed medication therapy and medication use, including nursing documentation of medication ordering and administration. -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. -Findings and recommendations are reported to the Administrator, director of nursing (DON), the primary physician, and the medical director, where appropriate. -The consultant pharmacist documents the date each review is completed on the appropriate form and briefly notes the findings. -Facility responsibility: To establish policies and procedures that address response timeframes for monthly DRR. -The consultant pharmacist (CP) documents potential or actual mediation therapy problems and communicates them to the primary physician and the DON. A written report is provided to the physician within seven working days. The physician's response is documented in the consultant pharmacist review record or elsewhere in the resident's medical record. -The physician response is provided to the consultant pharmacist for review and then filed by the facility. -The facility maintains copies of signed reports on file for at least one year. B. Procedures for implementation of the facility's policies and procedures - pharmacist, DON, and medical provider expectations 1. The CP was interviewed on 4/24/24 at 2:29 p.m. and again at 4:59 p.m. about the procedures for facility access to MRR recommendations. The CP said she sends the MRR recommendations through the facility's computer portal to the DON directly. She said the DON was shown how to use the portal to access pharmacy recommendations by the pharmaceutical provider's account manager and by her in February 2024. 2. The DON was interviewed on 4/25/24 at 12:44 p.m. about the procedures for accessing and distributing MRR recommendations to medical providers for review and response. The DON said the CP reviewed the residents' medications monthly, created a report with medication recommendations, and sent the report through the facility computer portal. The DON said the pharmacist sent an email once she had completed her recommendations. The DON then retrieved the recommendations from the computer portal. She said it was her responsibility to print the report with the CP's recommendations and to distribute it to the appropriate medical provider. The DON said after the medical provider reviewed and responded to the recommendations, she was responsible for returning the MRR with responses to the CP. She said she printed a copy of the report which she kept in a binder in her office. 3. A medical provider was interviewed on 4/25/24 at 4:36 p.m. about the system for review and response to MRR recommendations. The provider said the process when receiving MRR recommendations was to review the resident's history, recommendations for GDRs, indications for psychotropic medications, and to pay special attention to anyone who was on long-term psychotropic medication. He said the medical provider who was on site making rounds was responsible for checking for MRR reports that were left in the provider mailbox. He said the medical providers check the box on Mondays and Fridays and they usually received MRRs monthly. He said medical providers also included physician assistants and nurse practitioners who made rounds and who were responsible for checking for MRRs. The recommendations were responded to while the medical provider was on site unless it was a more complex recommendation. In that case, the MRR report was put back in the mailbox. If it was a critical recommendation, it was returned to the DON. III. Interview with the CP and review of a summary report by the pharmaceutical company of the number of MRRs sent to the facility in 2024, revealed the facility's policy and procedures failed to ensure potential irregularities identified in MRRs as recommendations would be timely reviewed and acted upon by the medical provider, medical director, and the DON. A. CP interview The CP was interviewed on 4/24/24 at 2:29 p.m. and 4:59 p.m. She said it had been a struggle, a delay, in getting responses to MMR recommendations back from the facility. She said she had not received responses from the facility to her medication recommendations for four months. She said most of the recommendations from December 2023 had yet to be returned and, that she had not received any of the more recent, January 2024 to April 2024, recommendations back that confirmed the medical provider had reviewed and responded to the recommendations in the MRR. She stated review and responses to the recommendations in the MRR were not only for compliance with regulatory requirements but also to ensure the safety of the residents, the efficacy of the medications, preventing falls, death, and bleeding, as well as recognizing and reducing polypharmacy. B. Review of MRR summary report. A review on 4/25/24 of an executive summary report by the pharmaceutical company revealed multiple MRR recommendations in January 2024 (163), February 2024 (143), March 2024 (131), and April 2024 (138) that had not been returned to the CP to show they had been reviewed and responded to by the medical provider. III. A review of MRRs for Residents #51, #15, #60, and #64 provided by the DON on 4/24/24 at 2:00 p.m., confirmed the facility's policy and procedures failed to ensure potential irregularities and recommendations identified in MRRs would be timely reviewed and acted upon by the medical provider, medical director, and the DON. A. Resident #51 1. Resident status Resident #51, age 86, was admitted on [DATE]. According to the April computerized physician orders (CPO), the resident's diagnoses included right hemiarthroplasty for a right hip fracture, and Alzheimer's disease and dementia without behavioral, psychotic, or mood disturbance. The 3/22/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. He required substantial/maximal assistance with toileting, bed mobility, transfers, and supervision with eating and personal hygiene. The MDS documented the resident did not have physical or verbal behaviors or psychosis symptoms including hallucinations or delusions. A comprehensive review of Resident #51's behavioral monitoring from 3/22/24 to 4/25/24 revealed the resident did not have verbal or physical behaviors. A review of the resident's care plans revealed in part, plans for mood, antipsychotic medication, anticoagulant medication, and falls. The mood care plan, initiated on 3/22/24 and revised on 4/5/24, indicated Resident #51 had a history of depression and was currently taking an antidepressant and displayed minimal to no signs/symptoms of a depressed mood. Interventions included to administer psychiatric medications as ordered, monitor signs/symptoms of depression, notification of social work or physician of a decline, and psychiatric services as needed. The antipsychotic medication care plan, initiated on 3/18/24, indicated Resident #51 currently was prescribed an antipsychotic medication for dementia. Interventions included to administer medications as ordered, monitor for adverse side effects, monitor for changes in mood or behavior, monitor for falls, and psychiatric evaluation and services as needed. The anticoagulant care plan, initiated on 3/18/24, indicated Resident #51 was on an anticoagulant for a diagnosis of deep vein thrombosis (blood clot) prophylaxis. Interventions included to administer medications as ordered, monitor signs and symptoms of bleeding, monitor labs as ordered. The fall care plan, initiated on 3/15/24 and revised on 3/18/24, read Resident #51 was at risk for falls. Interventions included to anticipate needs, assist with activities of daily living (ADL), encourage the use of the call light, ensure wearing of appropriate footwear, fall mat, place in line of sight in common areas, high/low bed, orient, and physical and occupational therapy. A review of post-fall assessments dated 3/20/24, 4/3/24. 4/17/24 and 4/20/24 revealed four falls without injury. A review of the April CPO revealed the resident's medications included: -An order for Risperdal (an antipsychotic) 0.25 milligrams (mg) by mouth once a day for Alzheimer's disease, ordered on 3/15/24 and discontinued on 3/18/24. -An order for Risperdal 0.25 mg by mouth once a day in the evening, ordered on 3/20/24. -An order for Aspirin 81 mg once a day for prophylaxis, ordered on 3/16/24. -An order for Clopidogrel (Plavix), an antiplatelet blood thinner, 75 mg once a day for fracture, ordered on 3/16/24. 2. MRR review a. MRRs 3/20, 3/22, and 4/10/24 with multiple recommendations The 3/20/24 MRR documented three recommendations. -Resident #51 was receiving aspirin and Plavix daily; this was not recommended unless the resident had a recent stent in the past six months. If no recent stent, consider discontinuing one of the medications. -Recommended labs: CMP, CBC, HgA1c, TSH (thyroid stimulating hormone), and lipid panel. -Recommended to consider lowering the dose of Risperdal due to the concurrent use with fluoxetine (an antidepressant) which can increase the risk of central nervous system depression (decreased neurological function including decreased breathing, heart rate, and consciousness) and psychomotor impairment (decreased muscular coordination and function). The 3/22/24 MRR documented four recommendations. -Recommended monitoring pain levels and effectiveness while Resident #51 was on pain medications whether as needed or routine and monitor for side effects. -Recommended to clarify the diagnosis of use of aspirin, recommended discontinuing it if it was for primary prevention due to the increased risk of major bleeding in older age. -Recommended clarifying the diagnosis in Resident #51's diagnosis list for Risperidone (Risperdal) and Plavix. -Recommended adding monthly fasting blood glucose levels or a quarterly HgA1c while Resident #51 was on a Risperdal. The 4/10/24 MRR documented one recommendation. -Recommended that Alzheimer's was not an appropriate indication for Risperdal without behaviors and to update the diagnosis and order directions. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, and the DON. A comprehensive review of Resident #51's electronic medical record (EMR) and MRRs above on 4/24/24, revealed no documentation that the above recommendations had been reviewed and acted upon by the medical provider, the medical director, and DON prior to 4/25/24, during the survey. 47818 B. Resident #15 1. Resident Status Resident #15, age 75, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included dementia with behavioral disturbances, bipolar disorder (mental illness causing shifts in mood, energy, activity levels, and concentration), personality disorder (thoughts, feelings, and behaviors different from an established societal norm), anxiety, arthritis, history of falls, contractures (permanent tightening of the muscles and tendons causing joints to shorten and stiffen) of right foot ankle and hand and chronic kidney disease. The 3/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance from one staff member for dressing, toileting, and setup with personal hygiene. Section E of the MDS indicated Resident #15 had not exhibited behavioral symptoms of hitting, kicking, pushing, grabbing, threatening others, screaming at others, or cursing at others. A review of the resident's care plan revealed the resident had a care plan for antipsychotic medication, initiated on 9/21/23 and revised on 10/13/23. It read Resident #15 was taking an antipsychotic medication for a diagnosis of bipolar disorder to assist with symptom management. Although a review of the psychotropic medication review on 12/19/24 revealed no documentation of behaviors for either of the resident's diagnoses to support and clarify the rationale for the use of the antipsychotic or the antidepressant, a review of January, February, March, and April 2024 MAR revealed orders with a start date of 9/21/23 for: -Risperdal (an antipsychotic) oral tablet 0.5 MG by mouth at bedtime for vascular dementia with behaviors. -Effexor (an antidepressant) oral capsule extended release (ER) 24 hour 150 mg (Venlafaxine HCl). Give 150 mg by mouth one time a day for MDD (major depressive disorder). 2. MRR review a. MRRs 11/10/23, 12/14/23, 1/15/24, 3/22/24, and 4/9/24 - with recommendations The 11/10/23 MRR identified Resident #15 was receiving multiple medications that had the potential of affecting electrolytes and renal clearance. Recommendations included obtaining the following labs: comprehensive metabolic panel (CMP) (The 14 tests included in a CMP are: alkaline phosphatase(ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, blood urea nitrogen (BUN), creatinine, sodium, potassium, carbon dioxide, chloride, albumin, total protein, glucose, and calcium) a complete blood count (CBC) (a CBC is used to identify conditions including anemia, infection and leukemia), an A1C (measures blood sugar), and a lipid panel. The 12/14/23, MRR inquired if a gradual dose reduction (GDR) for the medication Effexor had been attempted for Resident #15 or was a GDR likely to worsen or destabilize the resident's condition, had a GDR been tried in the past and failed and if so on what date, or was there another response the physician would like to provide. The 1/15/24 MRR inquired if a GDR for the Risperdal had been attempted for Resident #15 or was a GDR likely to worsen or destabilize the resident's condition, had a GDR been tried in the past and failed and if so on what date, or was there another response the physician would like to provide. The 3/22/24 MRR inquired if a GDR for venlafaxine (Effexor) 150 mg (started on 9/21/23; no GDR on file) and Risperdal 0.75 mg (started 10/5/23; no GDR on file) could be attempted or would a GDR likely to worsen or destabilize the residents condition, had a GDR been tried in the past and failed and if so on what date, or was there another response the physician would like to provide. The MRR also asked for a monthly fasting blood glucose check or quarterly HbA1C (blood test used to diagnose type 2 diabetes) related to the use of an antipsychotic medication. The 4/9/24 MRR indicated that combining methocarbamol (muscle relaxant) and oxycodone (narcotic pain medication), per the April medication administration record ordered on 4/5/24 for muscle spasm and severe pain, increased risks of central nervous system (CNS) depression, psychomotor impairment, and respiratory depression and recommended monitoring adverse effects and the following labs were needed: CMP, CBC, a1c and a lipid panel. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, or the DON. A comprehensive review of Resident #15's electronic medical record (EMR) on 4/25/24 and MRRs above revealed no documentation that the above recommendations had been reviewed and acted upon by the medical provider, the medical director, and the DON prior to 4/25/24, during the survey. 47024 C. Resident #60 1. Resident status Resident #60, age 75, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the April 2024 CPO, diagnoses included severe persistent asthma, chronic respiratory failure with hypoxia (low oxygen), visual loss in both eyes, morbid obesity, chronic pain, anxiety disorder, depression, and muscle weakness. The 8/23/23 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required extensive assistance from one person with dressing, bathing, locomotion while in the wheelchair, and extensive assistance from one to two people for bed mobility, toileting, and transfers. A review of the resident's care plan revealed plans for antidepressant medication and bleeding. The care plan for antidepressant medication documented the resident was prescribed antidepressant medication for a diagnosis of depression and anxiety. Interventions included to administer medications as ordered, monitor for adverse effects of usage, monitor for changes in mood or behavior, monitor for falls and psychiatric evaluation and services as needed or scheduled. The care plan for bleeding documented that the resident was at risk for bleeding due to taking an anticoagulant medication for coronary artery disease. Interventions included to administer medications as ordered, and monitor for discolored urine, black tarry stools, sudden severe headache, and nausea and vomiting. 2. MRR review a. MRRs dated 11/10/23, 12/14/23, 2/15/24 and 3/21/24 - with recommendations The MRR for 11/10/23 documented Resident #60 was receiving aspirin 81 mg and Plavix 75 mg. The pharmacist documented a recommendation for discontinuation of one of these medications as well as a GDR for Sertraline, an antidepressant medication. The MRR for 12/14/23 recommended a GDR of Duloxetine, an antidepressant medication The MRR for 2/15/24 documented inquiries for regarding Sertraline and Duloxetine, as well as aspirin and Plavix. The MRR for 3/21/24 recommended a GDR for Sertraline and Duloxetine. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, or the DON. A comprehensive review of Resident #60's electronic medical record (EMR) and MRRs above on 4/24/24 revealed no documentation that the above recommendations had been reviewed and acted upon by the medical provider, the medical director, and DON prior to 4/25/24, during the survey. D. Resident #64 1. Resident status Resident #64, over age 65, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the April CPO diagnoses included a history of falling, long-term use of anticoagulant, fracture of the neck of the right femur, atrial fibrillation, chronic congestive heart failure, peripheral vascular disease (narrow blood vessels in the limbs) and myocardial infarction (heart attack). According to the 2/19/24 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required supervision for oral hygiene, rolling from side to side, and moving from sitting to lying in bed. The resident required partial assistance with upper body dressing, bed-to-chair transfers, toilet transfers, and maximal assistance for toileting hygiene and lower body dressing. The care plan for bleeding documented that the resident was at risk for bleeding due to taking an anticoagulant. Interventions included to administer medication as ordered, monitor for discolored urine black tarry stools, severe headache, nausea, and vomiting, monitor labs, and notify the provider with any concerns. The order detail dated 2/19/24 at 4:10 p.m. documented an order summary of Apixaban, an anticoagulant, one tablet by mouth every day and evening shift for status post hip surgery. 2. MRR review a. A 3/22/24 MMR documented the anticoagulant Eliquis (Apixaban) did not have the correct diagnosis listed in the resident's diagnosis list. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, or the DON. A comprehensive review of Resident #64's electronic medical record (EMR) and MRR above on 4/24/24 revealed no documentation that the inquiry about the diagnosis for Eliquis had been reviewed and acted upon by the medical provider, the medical director, or the DON prior to 4/25/24, during the survey. IV. Facility failure to timely address the facility's known failure to ensure medical providers, the medical director, and the DON reviewed the monthly MRRs and responded to recommendations timely The NHA, interviewed on 4/25/24 at 4:33 p.m., said he was not aware until 4/24/24 (during the survey) that after receiving MRR recommendations from the CP, the recommendations were processed and provided to medical providers. A medical provider, interviewed on 4/25/24 at 4:36 p.m., said he was not aware MRRs had not been given to him by the DON since January 2024. -However, interviews with the CP revealed leadership had been informed multiple times of the facility's failure to review and respond to MRR recommendations timely. Further, the DON, who was directly involved in implementing the facility's policies and procedures to ensure timely review and response to MRR recommendations, was aware. Yet, there was no evidence steps were taken to correct the problem until 4/25/24, during the survey, when the NHA was notified the failure created a situation of immediate jeopardy with the potential for serious harm. A. Interview with the CP The CP was interviewed on 4/24/24 at 2:29 p.m. and 4:59 p.m. She said the facility leadership was aware of the problem with MRR reviews and responses. She said she brought it up every month, stating she had informed the medical director, as well as another physician who was very involved and who attended the psychotropic/GDR meetings that she was not receiving any MRR recommendations back from the facility. She also said she informed the DON and the NHA, in person, during each psychotropic/GDR meeting of this, and the DON told her they were working on it. She said she sent an email on 4/10/24, again asking about responses to MRR recommendations and noting the importance of having the recommendations completed. She stated the review and response to the recommendations in the MRR were not only for compliance with regulatory requirements but also to ensure the safety of the residents. B. Interview with the DON The DON was interviewed on 4/24/24 at 12:44 p.m. The DON said after a medical provider had reviewed and responded to the recommendations in the MRR, she sent the MRR report back to the CP through the portal. She also printed a copy of the report and placed it in a binder in her office. The DON said there was not a binder for 2024 because one had not been started. On 4/24/24 at approximately 2:00 p.m., the DON delivered the pharmacy recommendation binder for July 2023 to December 2023. The DON, NHA, and infection preventionist agreed the facility did not have a binder for pharmacy recommendations in 2024. V. Facility follow-up after survey exit 4/26/24. The NHA emailed information on 4/29/24 at 4:12 p.m., addressing Residents #51, #15, #60, and #64, and a letter from the pharmaceutical company explaining the number of MRRs sent to the facility in 2024. A. Regarding the pharmaceutical company letter (undated) explaining the number of MRRs sent to the facility in 2024. The letter read th[TRUNCATED]

Based on interviews and record review, the facility failed to provide timely and effective interventions to prevent weight loss for one (#41) of four residents reviewed for weight loss out of 35 sample residents. Resident #41 was admitted to the facility for long term care on 1/14/23 and readmitted on [DATE] with diagnoses of hyper-[NAME] syndrome (a rare immunodeficiency syndrome), anemia (low blood count) and dementia. Resident #41 had multiple food allergies, including soy protein, brussels sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. On 10/1/23, Resident #41 weighed 139 pounds (lbs). On 10/15/23, Resident #41 weighed 119.2 lbs, which indicated the resident had lost 19.8 lbs. The registered dietitian (RD) requested the resident to be reweighed on 10/16/23, 10/19/23, 10/24/23 and 10/26/23. The resident was not reweighed until 10/26/23, 10 days after the initial reweigh was requested, where she weighed 116.5 lbs. The resident had lost 16.2% (22.5 lbs) in 25 days, which was considered severe. The facility did not implement a nutritional intervention to address the resident's severe weight loss until 11/7/23 when a nutritional orange juice supplement was added three times a day. The physician had ordered the resident's weight to be obtained weekly beginning 11/11/23 and ending on 1/15/24. During this time the facility failed to follow physician orders and weigh the resident consistently on a weekly basis to closely monitor the resident's weight loss. On 2/8/24, Resident #41 weighed 110.3 lbs. The resident had lost an additional 6.2 lbs from 11/6/23 to 2/8/24. Despite the resident losing an additional 6.2 lbs from 11/6/23 to 2/8/24, the facility did not implement additional nutritional interventions. On 3/15/24, Resident #41 weighed 103 lbs. On 3/19/24, 3/20/24, 3/22/24 and 3/26/24 the RD requested the resident to be reweighed. The facility did not reweigh the resident until 4/1/24 where she weighed 100.5 lbs. The resident sustained a 6.6% (7.3 lbs) weight loss, which was considered severe from 2/8/24 to 3/15/24 in one month. The facility implemented fortified mashed potatoes on 3/31/24, 16 days after the resident sustained a severe weight loss. On 4/1/24 the resident triggered for severe weight loss of 27.7% (38.5 lbs) in six months from 10/1/23 to 4/1/24. The facility did not reassess and implement further nutritional interventions to address the resident's severe weight loss. Due to the facility's failures to closely monitor the resident's weight, obtain timely reweighs and implement timely nutritional interventions, Resident #41 sustained a 27.7% (35.8 lbs) weight loss in six months, which was considered severe. Findings include: I. Facility policy and procedure The Weight and Height Management policy and procedure, revised on 12/6/18, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m. It read in pertinent part, Residents will be weighed a minimum of monthly by nursing, unless otherwise ordered by the physician. Upon admission, residents will be weighed weekly for four weeks unless contraindicated (resident preference, pain, end of life). The registered dietitian (RD) will evaluate weekly admission body mass index (BMI), baseline weights and weight trends to recommend weight frequency. The physician will be notified of significant weight loss. If a weight change as noted above is accurate the direct care nurse or RD should review and evaluate recent acute temporary care plan to identify possible reasons for the weight change. The RD/designee will review weights and make recommendations, based on potential weight gain or loss trends. II. Resident #41 A. Resident status Resident #41, age 77, was admitted on [DATE] readmitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included hyper-[NAME] syndrome, anemia and dementia. The 3/19/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on staff for toileting. She required substantial/maximal assistance with personal hygiene, bed mobility, transfers and required supervision with touch assistance and cueing with eating. The assessment documented the resident was 63 inches (five foot, three inches) tall and weighed 103 lbs. The resident had a weight loss of 5% or more in one month or a weight loss of 10% in six months that was not physician prescribed. B. Record review The nutrition care plan, initiated on 9/28/23 and revised on 4/3/24, revealed Resident #41 had significant unplanned weight loss. The resident had a history of significant unplanned weight loss. The care plan documented the 3/27/24 nutrition assessment of the resident's current oral intake and the supplement of six ounces (oz) nutritional white grape juice three times a day was determined to be not sufficient to meet the resident's assessed caloric needs. The resident had pneumonia on 3/8/24. The interventions included encouraging high protein foods, monitoring weights, providing a gluten restricted diet, providing her meals in her room without assistance, providing cueing and encouragement, encouraging the resident to eat and drink throughout day, monitoring the amount of food and fluid intake at meals, providing six oz of nutritional white grape juice three times a day and offering four oz of fortified mashed potatoes with gravy at lunch. -The care plan did not document how frequently the resident was to be weighed. The April 2024 CPO revealed an order for weekly weights due to significant weight loss, ordered 11/11/23 and discontinued 1/15/24. The April 2024 CPO revealed an additional order for monthly weights on the first weekend of every month, ordered 1/15/24. -A review of the resident's medical record revealed the resident's weekly weight was not obtained on 11/18/23, 11/25/23, 12/2/23, 12/16/23, 12/23/23, 1/6/24 and 1/13/24. -A review of the resident's electronic medical record (EMR) revealed the resident's weight was not obtained in January 2024. The resident's weights were documented in the resident's EMR as follows: -On 10/1/23, the resident weighed 139 lbs; -On 10/15/23, the resident weighed 119.2 lbs; -On 10/26/23, the resident weighed 116.5 lbs; -On 10/31/23, the resident weighed 116.0 lbs; -On 11/6/23, the resident weighed 116.5 lbs; -On 12/7/23, the resident weighed 115.5 lbs; -On 12/28/23, the resident weighed 114.0 lbs; -On 2/8/24, the resident weighed 110.3 lbs; -On 3/15/24, the resident weighed 103 lbs; and, -On 4/1/24, the resident weighed 100.5 lbs. The resident sustained a 16% (22.5 lbs) weight loss, which was considered severe, from 10/1/23 to 10/26/23 in less than one month. The resident sustained a 6.6% (7.3 lbs) weight loss, which was considered severe, from 2/8/24 to 3/15/24 in one month. The resident sustained a 11.9% (13.5 lbs) weight loss, which was considered severe, from 12/28/23 to 4/1/24 in three months. The resident sustained a 27.7% (38.5 lbs) weight loss, which was considered severe, from 10/1/23 to 4/1/24 in six months. The April 2024 CPO revealed the following diet and nutritional supplementation orders: -Gluten restricted diet, regular texture, regular/thin consistency, ordered 9/26/23; -Magic cup once a day, ordered 10/4/23 discontinued 11/7/23; and, -HS (bedtime) snack, ordered 9/14/23. The 9/28/23 nutrition assessment documented the resident was independent with eating. Her weight was 140.5 lbs.She was on a gluten restricted diet with multiple food allergies, which included soy protein, brussel sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. The 9/28/23 nutrition assessment further documented the resident's current oral intake at meals was not sufficient to meet her assessed calories and protein needs. The interventions included encouraging the resident to consume high protein foods, continuing four oz Magic cup ice cream (frozen nutritional supplement) every day and continuing to monitor and follow up as needed. The 10/16/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested. -However, the facility failed to obtain the reweigh when it was requested. The 10/19/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from the previous weight of 139 lbs. A reweigh was requested. -However, the facility again failed to obtain the reweigh when it was requested. The 10/24/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested. -However, the facility again failed to obtain the reweigh when it was requested. The 10/26/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested. -However, Resident #41 was not reweighed until 10/26/23, 10 days after the RD initially requested the resident to be reweighed. -When the reweigh was obtained, Resident #41 weighed 116.5 lbs and had sustained a 16.2% (22.5 lbs) weight loss in 25 days, which was considered severe, from 10/1/23 to 10/26/23. The 11/7/23 nutrition progress note documented the resident's weight loss was due to insufficient oral intake at meals. The resident's preferences were reviewed and the Magic cup was discontinued per the resident's request. The current interventions included weekly weights. The RD reviewed with the resident to eat high protein foods and recommended starting a nutritional orange juice three times a day. The progress note documented the resident fed herself and received assistance and cueing as needed. -The resident sustained a 16.2% (22.5 lbs) weight loss, which was considered severe from 10/1/23 to 10/26/23 in less than one month. The facility did not implement a new nutritional intervention to prevent further weight loss until 11/7/23. The 12/31/23 nutrition progress note documented the resident's weight was down to 114 lbs on 12/28/23. Her average oral intakes at meals were 50% and, along with the current intervention of the nutritional orange juice, were insufficient to meet current caloric and protein needs. Other current interventions included continue with encouraging high protein foods, nutritional juice and the goal of increasing oral meal intakes of equal or more than 50%. The 12/31/23 quarterly nutrition assessment progress note documented the resident had significant unplanned weight loss. The resident was on a gluten restricted diet with multiple food allergies and was able to feed herself in her room with assistance, cueing and encouragement. Her average oral intake was 58% at meals. The progress note documented the Magic cup was not sufficient to meet her assessed caloric and protein needs so six oz of nutritional orange juice three times a day was implemented to help meet nutritional needs. -The Magic cup was discontinued on 11/7/24 when the nutritional orange juice was ordered. -The resident weighed 114 lbs on 12/28/24. The facility did not implement additional nutritional interventions to prevent further severe weight loss, despite the resident's continued downward trend of weight loss. The 1/31/24 nutrition progress note documented the RD requested a weight to be taken in January. -However, there was no weight documented in the resident's weight section of the EMR for January 2024 (see resident's weights above). The 2/1/24 nutrition progress note documented the resident weighed 108.5 lbs. The resident had a decrease of more than five lbs from her previous weight. A reweigh was requested. -Review of the resident's EMR did not reveal when the resident's weight of 108.5 was obtained. The 2/5/24 nutrition progress note documented a reweigh requested. On 2/8/24 the resident weight was documented as 110.3 lbs, which continued to show a downward trend in weight loss. -However, the facility failed to add any additional nutritional interventions to prevent further weight loss. The 2/29/24 nutrition progress note documented Resident #41 ate in her room, was able to feed herself and received assistance and cueing. Her oral intakes at meals were 42% on average. The current nutrition interventions included nutritional orange juice. The 2/29/24 progress note further documented the resident's current oral intake and nutritional orange juice three times a day was not sufficient to meet nutritional needs. Resident #41 requested chocolate milkshakes. -However, review of the resident's EMR did not reveal the chocolate milkshakes were initiated per the residents request. The 2/29/24 nutrition progress note additionally documented Mighty shake (nutritional supplement) and [NAME] Ready Care shakes (nutritional supplement) contained soy and the resident had a soy allergy. The nutritional orange juice three times a day was changed to nutritional white grape juice. -The RD documented the resident's oral intake and nutritional interventions were not sufficient to meet the resident's nutritional needs. However, the RD did not increase nutritional supplementation to help meet the resident nutritional needs after she had sustained further weight loss or explore other nutritional interventions or supplementation that would accommodate Resident #41's multiple food allergies. The 3/19/24 nutrition progress note documented the resident weighed 103 lbs, which was down from her previous weight of 110 lbs on 2/8/24. The RD requested for the resident to be reweighed. -However, the facility failed to obtain the reweigh when it was requested. The 3/20/24 nutrition progress note documented the RD requested the resident to be reweighed. -However, the facility again failed to obtain the reweigh when it was requested. The 3/22/24 nutrition progress note documented the RD requested the resident to be reweighed. -However, the facility again failed to obtain the reweigh when it was requested. The 3/26/24 nutrition progress note documented the RD requested the resident to be reweighed. -However, the facility again failed to obtain the reweigh when it was requested. -However, Resident #41 was not weighed until 4/1/24, 13 days after the RD initially requested the resident to be reweighed. -When the reweigh was obtained, Resident #41 weighed 100.5 lbs and had sustained a 6.6% (7.3 lbs) weight loss in one month, which was considered severe, from 2/18/24 to 3/15/24. -In the time between when the reweigh was requested and the time it was obtained, from 3/15/24 to 4/1/24, Resident #41 lost an additional 2.4% (2.5 lbs), which was not significant, but continued to demonstrate the continued downward trend of weight loss. The 3/31/24 nutrition quarterly assessment documented Resident #41 had weight loss. The note documented the resident's current oral meal intake and nutritional white grape juice three times a day was not sufficient to meet her assessed nutrition needs.The resident had a history of pneumonia on 3/8/24. The interventions included a goal of consuming 50% or greater for meals, gaining one to two lbs per week and offering four oz fortified mashed potatoes with gravy for lunch. The February 2024 medication and treatment administration record (MAR/TAR) documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days. -However, the February 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. The March 2024 MAR/TAR documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days. -However, the March 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. The April 2024 MAR/TAR documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days. -However, the April 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. A review of the April 2024 CPO and the medical record failed to reveal documentation of an interdisciplinary team (IDT) meeting regarding Resident #41's weight loss. A review of the meal intakes for Resident #41 from 3/25/24 to 4/22/24 revealed the following: -Out of 29 opportunities for breakfast, the resident ate 50% or less 11 times and 25% or less five times; -Out of 29 opportunities for lunch, the resident ate 50% or less nine times, 25% or less three times and the meal was not documented one time; and, -Out of 29 opportunities for dinner, the resident ate 50% or less seven times, 25% or less four times, refused one time and the meal was not documented three times. A review of snack intakes for Resident #41 from 3/27/24 to 4/22/24 documented the resident did not take a snack on 3/27/24, 4/7/24, 4/9/24, 4/12/24 and 4/16/24. -The documentation failed to reveal the type of snack offered and the amount consumed when the resident did accept a snack. The visual bedside Kardex report (a tool utilized by certified nurse aides (CNA) to provide personalized consistent care) indicated the resident needed to be encouraged to eat meals upright and remain upright for 30 minutes after eating. -It did not indicate Resident #41 needed supervision with touch assistance and cueing for meals. -It did not indicate the resident liked to eat her meals in her room and needed assistance when eating in her room. A review of the feeding assistance documentation for Resident #41 from 3/25/24 to 4/22/24 indicated Resident #42 received set up help only or no set up assistance from staff for meals on multiple occasions. -The feeding assistance documentation revealed Resident #41 received physical assistance with eating only one time during the 3/25/24 to 4/22/24 timeframe. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 1:50 p.m. LPN #1 said a print out was generated monthly on who needed to be monitored for weights. Residents who had trending or significant weight loss would be put on the weekly weight list. She said the RD communicated which residents needed to be weighed weekly with the nursing staff. She said Resident #41 was receiving nutritional juice three times a day with a bedtime snack. She said the resident usually ate in her room. She said she did not think Resident #41 was receiving assistance to eat while she was in her room. She said residents who had weight loss should be receiving supervision for meals. The RD was interviewed on 4/25/24 at 9:00 a.m. The RD said when residents triggered for weight loss they were put on weekly weights. The RD said if there was a change of five pounds or more from their previous weight they were reweighed to ensure the accuracy of the weight. She said she provided a list of residents that needed to be weighed to the assistant director of nursing (ADON). She said if the weights were not completed she would follow up with the ADON to ensure the weights were done. The RD said weights were monitored in addition to how well residents were doing with their supplement and their nutritional interventions. She said when residents' weights became stable they would be taken off of weekly weights and weighed monthly. She said residents who triggered for weight loss were discussed weekly at the IDT meeting. She said she did not know where the IDT discussions were documented. She said residents who needed additional assistance with meals were encouraged to eat in the dining room where staff was able to provide additional assistance and supervision or cueing if required. The RD said meal intakes were monitored for all meals and should be documented for all residents, including the residents who triggered for significant weight loss. The RD said Resident #41 triggered for weight loss on 10/15/23. She said she placed Resident #41 on weekly weights on 11/11/23 and was placed back on monthly weights on 1/15/24, because Resident #41's weight had stabilized. She said she monitored how Resident #41 did with her supplement and nutritional interventions. She said she knew the current order for Resident #41 said monthly weights but she was aware Resident #41 needed to be weighed weekly due to continued weight loss. -Despite the RD indicating in her interview that Resident #41 had been put back on monthly weights on 1/15/24, documentation of the resident's weights in the EMR revealed the resident's weight continued to trend downward consistently (see record review above). -Despite the RD indicating in her interview that she was aware the Resident #41 needed to be weighed weekly due to her continued weight loss, the facility did not put the resident back on weekly weights when she continued to lose weight (see record review above). The RD said Resident #41 had multiple food allergies and was on a gluten restricted diet with regular texture and thin liquids. She said she was placed on nutritional grape juice on 11/7/23 She said nutritional juices contained additional calories and protein. She said Resident #41 seemed to like the nutritional grape juice better than the orange juice. She said she had added fortified mashed potatoes, which had additional butter and milk in them, to Resident #41's menu for lunch. She said the staff encouraged Resident #41 to eat in the assisted dining room but since the resident chose to eat in her room, CNAs should be providing additional supervision and cueing. CNA #3 was interviewed on 4/25/24 at 9:35 a.m. CNA #3 said residents that required assistance and supervision should ideally go to the restorative dining room for assistance. She said the Kardex would indicate if a resident needed assistance with their meals. She said Resident #41 ate in her room, however, she said she did not know if the resident required any additional assistance with meals. The NHA was interviewed on 4/25/24 at 9:30 a.m. The NHA said nutritional assessments were conducted on admission, yearly, quarterly and with a change of condition. He said he would try to locate where the nutritional IDT meetings were documented. -However, the nutritional IDT progress notes were not provided by the NHA prior to the survey exit on 4/26/24.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication regimen review (MRR) by not providing physicians with the pharmacist recommendations so the physicians could respond to the recommendations timely which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. Facility policy The Quality Management Plan/QAPI program (Quality Assurance and Performance Improvement) policy and procedure, revised 11/15/2018, was provided by the nursing home administrator (NHA) on 4/26/24 at 12:50 p.m. It read in pertinent part, Our quality assurance and performance improvement (QAPI) program objective is to evaluate the availability, appropriateness, effectiveness, and effectiveness, and efficiency of resident care, and is a continuous program of evaluating medical, nursing care, social services, activities, dietary, housekeeping, maintenance, infection control, and pharmacy services. Quality Assurance encompasses all departments within our communities that provide care and services to our residents and impact clinical care, quality of life, residents' choice, and transitions of care. This includes care and services provided to our Rehab and Long-Term Care residents by each department in our organization. Procedure 1. Quality Assurance Performance Improvement (QAPI) meetings are scheduled a minimum of monthly but occur more frequently as decided by the NHA and include the medical director(s), nursing home administrator, director of nursing, pharmacist, department managers and frontline staff or residents as appropriate. The nursing home administrator ensures that the meeting is routinely scheduled, an agenda specific to that community is established and data and information is recorded. 2. Topics of discussion may include, but are not limited to, skin and wounds, infection prevention and control, accidents/incidents, admissions/hospitalization s, concerns/complaints, self-reported occurrences, pharmacy, survey follow-up, QAPI PIPs (performance improvement plans), weights, quality measures, medical records, and other areas identified through data collection, meetings, and events/incidents. Committee members are assigned to address and monitor specific topics based on their areas of expertise or their functions. 3. Reports are submitted in writing and discussions at the meetings include any recommendations from the committee and the Medical Director. 4. Other committees are established as needed to identify and address areas of concern and report to the Quality Assurance Performance Improvement committee as directed. 5. Projects and ongoing programs are measured at routine intervals and may be analyzed using Root Cause Analysis, Plan-Do-Study-Act (PDSA) and Fishbone Analysis as needed to ensure that the interventions are appropriate to the problem. Monitoring may consist of monthly data collection and new interventions may be recommended to achieve the desired goals of the particular topic. 6. Quality Assurance Performance Improvement is an ongoing, living, and ever-changing program that adapts itself to the unique needs of each community. Through the various sources of data and their facility assessment, each community identifies its personal focuses/issues and addresses them by creating unique goals and interventions. Monitoring occurs until goals are achieved or surpassed, then may be periodically reviewed to ensure sustained compliance. II. Cross-reference citations Cross-reference F756: The facility failed to provide the physicians with the pharmacist recommendations from the MRR so the physicians could respond to those recommendations. The facility's failure to follow up and act on the pharmacist recommendations put residents in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviews Medical provider (MP) #1 was interviewed on 4/25/24 at 4:35 p.m. MP #1 said the medical director was out of the country and was not available for an interview. MP #1said, during the psychiatric pharmacology review meetings, residents' medication histories, gradual dose reductions (GDR) of psychotropic medications and indications for residents' medications were reviewed. He said it was important to minimize or stop unnecessary medications if possible. He said the MRR forms from the pharmacist were put in a box at the nurses station and the providers, including nurse practitioners and physician assistants, would check the box when they were at the facility. He said the turnaround time for completing MRR forms was as soon as possible. MR #1 said the providers could either agree or disagree with the pharmacist's recommendations. He said if a provider disagreed with the recommendations, they would usually include a note as to why. He said after the recommendations were completed it was put back in the box for the director of nursing (DON) to process and send back to the pharmacist, unless it was a time critical recommendation and then it would be taken to the DON immediately. MP #1 said he was not aware that MRRs had not been given by the DON to the medical providers and the consultant pharmacist (CP) had been without a response from the providers since January 2024. He said it was important to follow up on the recommendations to ensure each residents' drug regimen was appropriate and to prevent adverse outcomes related to medications from occurring for the residents. The NHA was interviewed on 4/26/24 at 12:22 p.m. The NHA said the facility had a QAPI committee which met monthly and consisted of the required members and department heads. He said the committee last met on 4/16/24 and the pharmacist had attended via phone. He said the committee identified concerns through daily reviews, tracking and trending, key indicators and trends against benchmarks. He said the QAPI committee did analysis of concerns and determined what actions needed to be taken. The NHA said the QAPI committee did a performance improvement plan (PIP) at least yearly. He said the committee currently was addressing falls, weight loss, pressure ulcers, employee turnover and recruitment, survey review, activities, maintenance and life safety concerns. He said the committee had the infection preventionist (IP) addressing antibiotic stewardship and vaccination rates. The NHA said the committee was addressing skin tears through incidents or risk management, medication errors, rehospitalization s, quality measures, team reports, pharmacy updates and physician updates. The NHA said some of the topics discussed at the QAPI committee meetings came from risk meetings and morning interdisciplinary team (IDT) meetings. The NHA said the QAPI committee had not identified concerns from the MRR. He said the pharmacist's recommendation had not been provided to the physicians so that the physicians could respond in a timely manner.

Based on interviews and record review, the facility failed to provide an environment free from accident hazards and risks as possible for three (#60, #52 and #43) of seven residents reviewed for accidents/hazards out of 35 sample residents. Specifically, the facility failed to -Ensure neurological checks were completed per standards of practice after Resident #60 sustained unwitnessed falls; and, -Ensure staff were properly trained to assist Resident #52 and Resident #43 with slide board transfers after the residents sustained falls during transfers. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, revised on 2/1/24, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m. It read in pertinent part, A fall is defined as the failure to maintain an appropriate lying, sitting, or standing position, resulting in an individual's sudden, unintentional relocation either to the ground or into contact with another object below the starting point. Neurological evaluations will be implemented with any witnessed incident/fall involving a potential head injury or all unwitnessed incident/fall. II. Failure to complete neurological checks after unwitnessed falls A. Resident #60 1. Resident status Resident #60, age 75, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included severe persistent asthma, chronic respiratory failure with hypoxia (low oxygen), visual loss in both eyes, morbid obesity, chronic pain, anxiety disorder, depression and muscle weakness. The 2/20/24 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required supervision for oral and personal hygiene. She required substantial assistance for toileting. She was dependent on staff for showering. The assessment indicated the resident had two or more falls with no injury during the review period. 2. Record review The fall care plan, initiated on 8/29/23 and revised on 3/18/24, documented the resident was at risk for falls related to weakness, disorientation, history of falls and side effects of medications. The interventions included offering to take the resident to the activities room to work on a quilt, assessing the resident's bed for safety, encouraging the resident to be in common areas while awake and in her wheelchair, ensuring the resident had a safe environment, ensuring the resident was wearing appropriate footwear when ambulating and ensuring the resident's bed was in the low position while she was in bed. a. Fall incident 12/23/23 - unwitnessed A nursing note dated 12/23/23 at 12:41 a.m. documented the resident was found lying on the floor on her left side in front of the bed. The resident said she was sitting on the side of the bed and was unable to stop herself from falling. The note documented neurological checks were initiated. -However a request was made for the neurological checks following the resident's fall on 12/23/23. The director of nursing (DON) said the facility did not have documentation indicating neurological checks were completed after the resident sustained an unwitnessed fall on 12/23/23 (see interview below). b. Fall incident on 2/5/24 - unwitnessed A nurse note dated 2/5/24 at 6:43 a.m. documented an unwitnessed fall. The note documented the fall had occurred on 2/4/25 at 6:40 p.m. The resident was found on the floor and the resident's neurological status was within normal limits. -However a request was made for the neurological checks following the resident's fall on 2/5/24. The DON said the facility did not have documentation indicating neurological checks were completed after the resident sustained an unwitnessed fall on 2/5/24 (see interview below). c. Fall incident on 3/23/24 - unwitnessed A nurse note dated 3/23/24 at 3:58 p.m. documented the resident sustained an unwitnessed fall. The resident was found lying on the floor in front of her bed when staff were responding to her call light. The resident said she was trying to transfer herself to bed and her legs gave way. She said the CNA had told her she would be back to help her into bed. The resident sustained a skin tear to the right upper arm. A nurse note dated 3/24/24 at 5:31 a.m. documented the resident was continuing with neurological checks. -However a request was made for the neurological checks following the resident's fall on 3/24/24. The DON said the facility did not have documentation indicating neurological checks were completed after the resident sustained an unwitnessed fall on 3/24/24 (see interview below). 3. Staff interviews The DON was interviewed on 4/25/24 at approximately 11:30 a.m. The DON said Resident #60's fall on 3/23/24 was unwitnessed and neurological checks should have been completed. She said if the staff did not do neurological checks after a resident sustained an unwitnessed fall they would not be able to identify if any neurological problems had come up. She said Resident #60's fall on 3/23/24 should have been reviewed in the IDT meeting. She said new interventions should have been put into place. III. Failure to ensure staff were trained properly on resident slide board transfers A. Resident #52 1. Resident status Resident #52, age 68, was admitted to the facility on [DATE]. According to the April 2024 CPO, diagnoses included chronic embolism and thrombosis (blood clots) of the left subclavian vein (a deep vein to the heart), chronic obstructive pulmonary disease (COPD), paraplegia (inability to move lower part of the body), chronic kidney disease, adjustment disorder and depression. The 4/1/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent for eating and oral hygiene, required set-up assistance with upper body dressing, required maximal assistance with putting on footwear, bathing, toileting and toilet hygiene. A. Record review The care plan for falls, initiated on 7/4/23 and revised on 4/3/24, documented the resident was at risk for falls related to impaired sensation to bilateral lower extremities. Interventions included anticipating and meeting the resident needs, applying pillows to aid in positioning the resident when lying in bed, encouraging the resident to use the call light, ensuring the call light was within reach and educating the resident about having a staff member present when attempting to transfer into a car. A nursing note dated 11/1/23 at 12:03 a.m. documented CNA #2 reported the resident had slid from the bed during a slide board transfer from the wheelchair back to bed. An IDT review note dated 11/1/23 at 9:17 a.m. documented staff were re-educated on slide board transfers. -However, a lifts, transfers, gait belts, slide boards and slings educational sign in sheet, dated 10/25/23 and 11/2/23 revealed CNA #2 did not attend the educational training sessions. B. Resident #43 1. Resident status Resident #43, aged over 65, was admitted to the facility on [DATE]. According to the April 2024 CPO, diagnoses included atrial fibrillation (abnormal heart beat), acute respiratory failure, depression, insomnia (inability to sleep), anxiety disorder, and muscle weakness. The 3/27/24 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required set-up assistance with oral hygiene, supervision to roll left and right. The resident required moderate assistance with upper body dressing and transitioning from sitting to lying in bed. The resident required maximal assistance with toileting hygiene, bathing, lower body dressing and putting on footwear. 2. Record review The fall care plan, initiated on 9/23/23 and revised on 11/5/23, documented the resident was at risk for falls related to weakness and side effects of medications. The interventions included: anticipating and meeting the residents needs, encouraging the resident to use the call light, using foam wedges for positioning when lying in bed, utilizing physical therapy to evaluate the resident for a cushion/pillow and make recommendations, and utilizing a pillow for positioning. A nurse note dated 10/5/23 at 4:50 p.m. documented the resident fell during a transfer. The resident said her legs were not strong enough to hold her up and that was why she fell . A nurse note dated 10/5/23 at 4:58 p.m. documented a CNA reported the resident fell on her left knee when she was unable to complete a slide board transfer. -However, a lifts, transfers, gait belts, slide boards and slings educational sign in sheet, dated 10/25/23 and 11/2/23 revealed CNA #3 did not attend the educational training sessions. C. Staff interviews The NHA was interviewed again on 4/24/24 at 2:29 p.m. He said there had been training for the staff on how to safely transfer a resident. He said CNA #2 was working at the time of Resident #52's fall and CNA #2 did not receive the transfer training. He said CNA #2 should have received immediate training on the correct way to complete a slide board transfer after she was involved in Resident #52's fall. The NHA said CNA #3 was working at the time of Resident #43's fall, however, he said CNA #3 did not receive the transfer training. He said CNA #3 should have received immediate training on the correct way to complete a slide board transfer after the CNA was involved in Resident #43's fall.

Based on observations, record review and interviews, the facility failed to ensure one (#5) of one resident reviewed for ancillary services, such as dental services, out of 35 sample residents received routine and 24-hour emergency dental care. Specifically, the facility failed to provide Resident #5 with timely dental care when she sustained a broken tooth. Findings include: A. Resident status Resident #5, under age 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included heart failure, arthrodesis (joint fusion to relieve arthritis pain) and chronic pain. The 3/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with all activities of daily living (ADL). B. Resident interview Resident #5 was interviewed on 04/22/24 at 2:29 p.m. Resident #5 said a piece of her tooth fell out last month (March 2024) while she was brushing her teeth and she needed to see a dentist. Resident #5 said her tooth was painful at times and she tried not to chew her food on the left side of her mouth where the broken tooth was located. Resident #5 said she had informed multiple staff members about her tooth and her need to see a dentist. Resident #5 was interviewed again on 4/25/24 at 9:00 a.m. Resident #5 said the social services coordinator (SSC) told her she was not seen by the dentist at the facility on 4/23/24 because the dental team did not want to see residents while a state survey was in process and left the building (see record review and interviews below). C. Record review The ancillary care plan, initiated 3/25/22 and revised 6/24/22, revealed Resident #5 was being seen by in house dental services. It documented the facility would ensure Resident #5's dental needs would be met. Pertinent interventions included facility staff scheduling appointments for ancillary providers as requested/needed/ordered. A 3/17/24 progress note documented at 1:18 a.m., revealed Resident #5 informed nursing staff a piece of her tooth fell out while brushing her teeth. Nursing staff documented a message had been left for Resident #5's family member and the SSC. A 3/17/24 progress note documented at 4:01 p.m., revealed Resident #5 informed registered nurse (RN) #2 she needed some teeth pulled. RN #2 documented Resident #5 needed antibiotics and a scheduled blood thinner (eliquis) to be held prior to being seen by the dentist. RN #2 documented a message had been left for the SSC with instructions to provide a healthcare provider with the dental procedure date so orders could be placed addressing the above mentioned medications. A 3/18/24 progress note documented Resident #5 was seen by a medical assistant regarding an upcoming dental procedure and Resident #5 needed preventive antibiotics and her eliquis held for three days prior to getting some teeth pulled. The progress noted revealed Resident #5 needed several teeth pulled and had a history of blood clots. A 4/22/24 progress note documented Resident #5 had a dental appointment on 4/23/24 and orders had been received from a nurse practitioner (NP) for eliquis to be held and for antibiotics to be started prior to the dental procedure. A 4/23/24 progress note written by RN #2 documented Resident #5 was not seen by the dentist (on 4/23/24) because she was not on the dental list to be seen. RN #2 documented the information regarding Resident #5 not being seen by the dentist because she was not on the list was given to the SSC. The SSC informed RN #2 Resident #5 would be on the list to be seen by the dentist when the dental team was back in the facility. D. Interviews The SCC was interviewed on 4/25/24 at 10:00 a.m. The SCC said residents were on a rotating schedule with a mobile dental team who came to the facility for residents' routine dental visits. The SCC said the dental team could be accommodating to residents for immediate dental needs such as a resident voicing mouth discomfort or pain or if nursing staff recognized something that needed immediate attention. The SCC said there was paperwork indicating a resident needed emergent services she had to to the dental team for residents to be seen immediately. The SCC said she was first made aware of Resident #5 having mouth pain on 3/17/24 and was told again on 4/23/24 so she put Resident #5 on the list to be seen by the dentist that same day. The SCC said she did not know if the dental team was contacted in March 2024 to schedule Resident #5 for emergency services. The SCC said she was unable to locate paperwork which indicated Resident #5 had been scheduled to see the dentist related to her broken tooth in March 2024. The SCC said the team's dental assistant told her they did not want to be in the facility (on 4/23/24) when a state survey was ongoing and had left the facility. The vice president of operations (VPO) for the dental team company was interviewed on 4/26/24 at 11:00 a.m. The VPO said it was her understanding the facility had asked the dental team to leave the building during the survey process and the VPO was currently working with the facility's administration team to get clarification. The VPO said Resident #5 was not on the list to be seen on 4/23/24 and the dental team was not notified in March 2024 that Resident #5 needed to be seen for emergency dental services. The VPO said if the facility had requested Resident #5 be seen for emergency dental services, the dental team would have received paperwork from the facility requesting emergency dental services. The VPO said she would begin the process to have Resident #5 seen by the dentist as soon as possible for her broken tooth.

Based on observations, interviews and record review, the facility failed to ensure one (#63) of one resident reviewed for activities of daily living out of 35 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to: -Provide Resident #63, who had difficulty with communication, with an appropriate communication tool to ensure the resident was able to effectively communicate his needs to staff; and, -Create a person-centered care plan for Resident #63 which addressed his communication deficits. Findings include: I. Facility policy and procedure The Person-Directed Care Plans policy and procedure, reviewed 7/12/22, was provided by the nursing home administrator (NHA) on 4/25/24 at 1:50 p.m. It read in pertinent part, The purpose of long term person-directed care plans is to tell a resident story. Care plans will be developed consistent with the resident's specific conditions, risks, needs, behaviors, preferences, and current standards of practice. Measurable goals and individualized interventions will be identified. II. Resident #63 A. Resident status Resident #63, age 90, was admitted on [DATE], and readmitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included atherosclerosis of coronary artery bypass graft (heart disease), depression, dysphagia (difficulty in swallowing) and cognitive communication deficit (difficulty with communicating including difficulty with understanding, producing language, and nonverbal communication skills such as gestures and facial expressions). The 1/23/24 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 substantial/maximal assistance with bed mobility, transfers, and upper body dressing. He was dependent on lower body dressing, toilet hygiene, wheelchair mobility and shower/bathing. He used a tube feeding for eating. The assessment documented the resident had a cognitive communication deficit diagnosis. The assessment documented the resident had adequate hearing and his speech clarity was clear with distinct intelligible words. He made himself understood with the ability to express ideas and wants considering both verbal and non-verbal expression. The assessment documented the resident had the ability to understand others with clear comprehension. The assessment documented the resident did not have a restorative nursing program for communication. The care area assessment (CAA) was not triggered for communication to be addressed in the care plan. B. Resident observation and interview Resident #63 was interviewed on 4/22/24 at 11:37 a.m. Resident #63 was seated in his wheelchair in his room. Resident #63 had a book and an iPad on his side table. Resident #63 was alert but did not respond to simple words such as hello or yes/no questions when asked. He did not make any sounds with his voice. -Attempts to communicate with and understand Resident #63 were not successful during the interview and there was nothing observed in the resident's room, such as signage with communication instructions, to indicate how to communicate effectively with the resident. Resident #63 was interviewed again on 4/23/24 at 10:13 a.m. Resident #63 was seated in his wheelchair, his bed was made, his television was on. Resident #63 was able to shake his head slightly to some yes and no questions. Resident #63 pointed to his mattress but it was unclear what he was attempting to communicate. -Attempts to effectively communicate and understand the resident were again unsuccessful during the interview and there was nothing observed in the resident's room, such as signage with communication instructions, to indicate how to communicate effectively with the resident C. Record review -Resident #63's comprehensive care plan, initiated 1/16/22, revealed there was no care plan related to his cognitive communication deficit and no interventions related to ensuring the resident was able to effectively communicate his care needs to staff. -The mood/antidepressant care plan, revised 2/2/23, documented an intervention to encourage the resident to express any feelings of anger, frustration and sadness. -However, the care plan did not reveal how the resident would be able to communicate and express his feelings. The cognitive care plan, revised 2/2/23, revealed the resident did not have a diagnosis of dementia but displayed episodes and moments of confusion. The interventions included using consistency when conversing/interacting with the resident. -The care plan did not reveal how the resident would be able to communicate with the staff. A 10/12/23 speech-language pathologist (SLP) evaluation revealed Resident #63 was evaluated for treatment of speech, language, voice, communication and/or auditory processing. The resident was referred to SLP due to exacerbation of cognitive impairment, decreased safety awareness, increased need for assistance from others and decreased speech intelligibility. The treatment diagnosis was cognitive communication deficit. The overall treatment goal was to improve the resident's intelligibility of speech. The short term goal of SLP treatment was for the resident to demonstrate adequate vocal hygiene (proper breath support and maintaining adequate hydration) with greater than 75% of opportunities in order to improve vocal quality with communication of his basic wants/needs. The resident's baseline on 10/12/23 revealed he required maximum assistance and education related to the goal was provided. The long term goal of SLP treatment was for the resident to increase his ability to communicate using conversational responses/exchanges during structured communication exchanges with minimal cues in order to communicate his basic wants/needs and in order to participate in meaningful interactions. The resident's baseline on 10/12/23 revealed the resident required moderate cueing. Resident #63 was discharged from SLP services on 11/17/23 after a total of six visits due to the highest practical level achieved. At discharge on 11/17/23, the short term goal of SLP treatment was not met as the resident was 60% accurate (not 75%) and required moderate assistance. At discharge on 11/17/23, the long term goal of SLP treatment was not met and the resident continued to require moderate cueing. The SLP discharge recommendations revealed the resident appeared at baseline and was to continue with long term care and family support for the highest quality of life. -Although the resident continued to require moderate cueing and assistance with communication at discharge from SLP treatment, there was no evidence of continuity of care and follow up with the nursing staff and daily care team to prevent a decline and maintain Resident #63's communication abilities. D. Staff interview The director of rehabilitation (DOR) was interviewed on 4/25/24 at 11:46 a.m. The DOR said the therapy staff did not write care plans but there should have been verbal communication with the nursing staff to update the care plan after the SLP therapy ended. The DOR said she did not know how the caregivers for Resident #63 interacted with him. She said some of the caregivers knew him well and communicated with gestures and the resident could communicate some. The DOR said she would recommend signage or a communication board to be used with Resident #63 and she would let nursing staff know to put something in the care plan to follow through on communication with the resident. The DOR said physical therapy (PT) was currently seeing the resident due to a decline in transfers and they noted a decline in his communication as well. The DOR said the current SLP was out on vacation, but due to Resident #63's decline in communication, she would get an order for a new SLP evaluation so new recommendations for the resident's communication could be put in place from the SLP. The director of nursing (DON) was interviewed on 4/25/24 at 12:01 p.m. The DON said Resident #63 communicated in a low voice whisper. The DON said he would also nod his head and communicate with his daughter through an iPad. The DON said Resident #63 should have a communication care plan so new staff members or agency staff would know how to communicate with him and know his preferences. The DON said Resident #63 nodded in the morning when asked how he was doing. The DON was not sure how he was able to communicate needs such as his pain levels. During the interview with the DON, the DON asked an unnamed certified nurse aide (CNA) who was passing by in the hallway about Resident #63. The CNA said she communicated with the resident by asking him yes or no questions. She said she would show the resident two outfits and he would point to the one he wanted to wear for the day. The CNA said she gave Resident #63 extra time in order to communicate his needs to her. The DON said it would have been important to communicate the CNA's effective ways of communicating with the resident in a care plan so other caregivers would know the communication techniques. The DON said the purpose of a care plan was to understand how to take care of a resident but she did not see a communication care plan for Resident #63. The DON said she would have a discussion and get the resident's care plan updated so staff know how to communicate with and take care of Resident #63.

Based on observations, record review and interviews, the facility failed to ensure one (#17) of one resident out of 35 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents'choices. Specifically, the facility failed to ensure Resident #17 received a new CPAP (continuous positive airway pressure) mask timely. Finding include: I. Resident #17 A. Resident Status Resident #17, age 89, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included obstructive sleep apnea (intermittent obstruction of the airway during sleep), chronic respiratory failure with hypoxia (decreased oxygen) and dependence on supplemental oxygen. The 3/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required extensive assistance of one staff member with dressing and personal hygiene. B. Observations and resident interview Resident #17 was interviewed on 4/22/24 at 11:00 a.m. The resident had a reddened area across the bridge of his nose and reddened lines on either side of his nose. Resident #17 said his CPAP mask was not fitting well. The resident said he had recently received a new mask but it was still irritating the bridge of his nose. Resident #17 said the facility was doing nothing to prevent the irritation to his nose. On 4/22/24 at 1:30 p.m., Resident #17 had a reddened area across the bridge of his nose and reddened lines on both sides of his nose. On 4/23/24 at 10:00 a.m., Resident #17 had a reddened area across the bridge of his nose and reddened lines on both sides of his nose. C. Record review The skin breakdown care plan, initiated on 6/25/23 and revised on 4/13/24, revealed Resident #17 was at risk for skin breakdown related to wearing a CPAP at night which placed him at risk around the CPAP mask sites. It indicated Resident #17 would not have areas of redness or skin breakdown through the review date. Pertinent interventions included checking the CPAP mask for correct fit and possibly replacing the mask if needed. The 3/29/24 situation, background, assessment, recommendation (SBAR) communication form identified Resident #17 had a skin tear to the bridge of his nose on 3/29/24. The assessment of the skin tear concluded the CPAP mask for Resident #17 might be too tight. The SBAR indicated Resident #17's wife was notified and it was reported to medical provider (MP) #1 on 3/29/24. The 3/29/24 change of condition (COC) assessment indicated Resident #17 had redness to the bridge of his nose from possible tightness of the CPAP mask. The assessment further indicated the resident needed a new CPAP mask for nightly which fit properly because the current one was rubbing the bridge of his nose. The COC indicated the assistant director of nursing (ADON) had ordered him a new mask, wound care orders had been requested, the family was notified and medical provider (MP) #1 was notified. -However, review of the resident's medical record did not reveal wound care orders for treatment or monitoring. The 3/29/24 interdisciplinary (IDT) review note, written by the ADON indicated Resident #17's CPAP mask would be checked for the correct fit and determine if the mask needed to be replaced. The 4/15/24 progress note, written by the ADON, indicated a call to the CPAP equipment distributor was made and the company was notified Resident #17 needed to be fitted for a new CPAP mask. The note documented a technician from the CPAP equipment distributor would see Resident #17 at the facility on 4/16/24. The 4/16/23 progress note indicated Resident #17 was fitted for a new CPAP mask and connection tubing by the CPAP equipment distributor. The 4/25/24 incident note, written by the ADON, indicated Resident #17 had a 0.5 centimeter (cm) x 1.5 cm blanchable (temporary obstruction of blood flow) red area to the bridge of his nose from a tightly fitting CPAP mask that had recently been replaced. The incident note indicated Resident #17 reported the new mask was fitting better and orders were placed to monitor the blanchable redness to Resident #17's nose. The 4/26/24 IDT progress note indicated Resident #17 continued to a have reddened blanchable area on his nose despite the intervention of having Resident #17 fitted for a new CPAP mask. The progress note indicated Resident #17 would have a physician's order for skin prep to his nose. -However, a review of Resident #17's electronic medical records (EMR) on 4/26/24 failed to reveal a physician's order for monitoring or treating the reddened area of the nose. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 10:00 a.m. LPN #1 said Resident #17 had recently received a new CPAP mask because the old one was too tight and caused a reddened area to the bridge of his nose. LPN #1 reviewed Resident #17's EMR and referred to a 3/29/24 SBAR communication note (see above) noting the first appearance of a reddened area to the bridge of the resident's nose. LPN #1 was unable to locate a physician's order for wound care or to monitor the area. LPN #1 said it took a couple of weeks from the discovery of the reddened area on 3/29/24 for Resident #17 to get fitted for a new mask and skin prep was applied as a barrier between the nose and mask until he received a new CPAP mask. LPN #1 said Resident #17 did not have an order to apply skin prep as a barrier in the EMR. The ADON was interviewed on 4/25/24 at 11:30 a.m. The ADON said he was made aware of the redness to the bridge of Resident #17's nose from a risk management note documented on 3/29/24. The ADON said he checked in with the resident daily about the redness of his nose and his discomfort levels. The ADON said it was not until 4/14/24 that he felt the resident's ill-fitting CPAP mask was an issue that warranted a call to order a new one. The ADON said he did not document the conversations or track the reddened area to the bridge of Resident #17's nose. The ADON said medical provider initiated physician's orders for wound care. He was unaware of why an order was not put into the EMR for Resident #17 and said he would have to look into it. The ADON said addressing the fit of the CPAP mask sooner for Resident #17 could have prevented the continuation of the reddened area on the bridge of his nose. -Clarification from the ADON for for why wound care treatment orders were not initiated (on 4/25/24, see record review above) for Resident #17 was not provided prior to the survey exit on 4/26/24.

Based on observations, record review and interviews, the facility failed to ensure two (#15 and #10) of two residents reviewed for limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #15 was monitored for the use of splints (devices that stabilize a part of your body and hold it in place); and, -Ensure Resident #10 was properly positioned in her wheelchair to ensure her head was in a comfortable position. Findings include: I. Resident #15 A. Resident Status Resident #15, age 75, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included hemiplegia (severe or complete loss of strength) and hemiparesis (weakness or the inability to move on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side, arthritis (painful inflammation and stiffness of the joints) and contracture (shortening and hardening of muscles and tendons often leading to deformity) of the right hand. The 3/26/24 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 from one staff member for dressing, toileting and set-up assistance with personal hygiene. The assessment indicated Resident #15 had functional limitations in range of motion in her lower and upper extremities on one side. B. Observations and resident interview Resident #15 was interviewed on 4/22/24 at 10:31 a.m., Resident #15 was in her room watching television. There was a sign on the wall providing instructions for the application of a hand and elbow splint to be applied to the resident's right arm. There were two splints located on a nightstand next to Resident #15's bed. Resident #15 said only certain staff knew how to apply her splints correctly. Resident #15 said she occasionally would refuse to allow certain staff members to apply the splints since they did not know how to properly apply them. During a continuous observation on 4/23/24, beginning at 10:00 a.m. and ending at 12:00 p.m. Resident #15 was not wearing her splints. C. Record review The occupational therapy (OT) evaluation and treatment plan, with a certification period of 12/12/23 to 2/9/24, revealed Resident #15 would safely wear a resting hand splint and elbow extension splint on her right hand, right wrist, right fingers and right elbow for up to two hours and Resident #15 would tolerate wearing a right elbow splint for eight hours a day to promote range of motion and maintain skin integrity. The OT evaluation indicated goals for Resident #15 included reducing contractures and increasing strength. A review of the April 2024 CPO revealed the following physician orders related to Resident #15's contractures: -Resident #15 was to wear a right elbow extension splint during evening hours to reduce contracture and maintain range of motion ROM), ordered 3/7/24; and, -Resident #15 was to wear a right right hand splint during daytime hours to reduce contracture and maintain range of motion, ordered 3/7/24. -However, the March 2024 medication and treatment administration record (MAR/TAR) and April 2024 MAR/TAR failed to include documentation to indicate Resident #15's splints had been applied per the OT recommendations. -Review of the CNA (certified nurse aide) task documentation failed to reveal documentation indicating the resident's splints were being applied per the OT recommendations. -A review of Resident #15's comprehensive care plan did not reveal a care plan focus for Resident #15's use of splints for her contractures to her right elbow and hand. D. Staff interviews CNA #1 was interviewed on 4/24/24 at 9:30 a.m. CNA #1 said she was unable to find where to chart splint use for Resident #15. CNA #1 said she was unsure what type of splints Resident #15 used. She said she thought Resident #15 might use a right hand splint. CNA #1 said the use of splints and braces were usually located in the CNA task documentation and CNAs charted on the type of splint, duration of splint being on and if a resident declined to wear it. CNA #1 said if documentation for splint use was not found in the CNA task documentation, it might be located on the TAR for the nurses to chart on. Licensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 9:35 a.m. LPN #1 said she was unable to find a physician's order for documenting Resident #15's splint use. LPN #1 said Resident #15 had a right hand splint and right elbow brace to help with her contractures. LPN #1 said Resident #15 was inconsistent with wearing the splints and it depended on the day or who was working because Resident #15's mood would fluctuate and she had a history of being non compliant with the splints. LPN #1 said staff needed to document in the resident's medical record when she refused to wear it. -Despite LPN #1's interview indicating Resident #15 sometimes refused to wear her splints, the medical record failed to reveal any documentation which indicated the resident refused her splints (see record review above). The director of rehabilitation (DOR) was interviewed on 4/25/24 at 9:32 a.m. The DOR said the therapy department was only able to add standard orders to a chart. The DOR said the therapy department was not responsible for updating the resident's plan of care. The DOR said the nursing staff and the resident, if applicable, were provided verbal education from therapy on recommendations for using splints. The DOR said she verbally communicated standing orders to the ADON or the DON and they would add the order to a resident's MAR /TAR for documentation purposes and add the information to a care plan. The DOR said she could not remember if she had spoken to the ADON or the DON about adding the order for splint use for Resident #15 to the MAR/TAR or adding it to the care plan. The DOR said Resident #15 was using an elbow brace and hand splint for her right affected arm to reduce the worsening of contractures. The DOR said Resident #15's contractures could worsen if she did not use the splints consistently. The DOR was unable to locate documentation to reveal the use of splints for Resident #15. 47024 II. Resident #10 A. Resident status Resident #10, age 70, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included muscle spasm, cervicalgia (pain in the neck), major depressive disorder, chronic obstructive pulmonary disease (COPD), anxiety disorder, chronic kidney disease, chronic pain syndrome, hemiplegia and hemiparesis (inability to move one side of the body) affecting the left non-dominant side and diabetes mellitus type II. The 3/26/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for oral hygiene, toileting, bathing, upper and lower body dressing, rolling left to right, moving from sitting to lying, picking up objects and mobilizing in the wheelchair. B. Observations On 4/22/24 at approximately 11:10 a.m. Resident #10 was sitting in her wheelchair with her head leaning to the right with her chin resting slightly above her collarbone. On 4/23/24 at approximately 1:00 p.m., during the resident council meeting, Resident #10 was in attendance sitting in her wheelchair slumped to the right side with her head pressed against the right side of the headrest and tilted downward. On 4/23/24 at approximately 3:35 p.m. Resident #10 was sitting in the dining room for an activity with her head tilted downward onto her chest. The position of her head made it so the resident was only able to look at the table. On 4/25/24 at approximately 12:24 p.m. Resident #10 was sitting up in her wheelchair with her head tilted to the right with her chin down towards her chest. She was trying to eat her lunch. On 4/25/24 at approximately 1:10 p.m. Resident #10 was sitting in her wheelchair with her head tilted to the right with her chin resting on her collarbone. C. Resident interview Resident #10 was interviewed on 4/22/24 at approximately 11:10 a.m. Resident #10 said she had asked for a new head brace for her wheelchair but had not gotten one. She said the head brace that was on her current wheelchair did not hold her head in an upright position which caused her pain. Resident #10 was interviewed again on 4/25/24 at approximately 1:10 p.m. Resident #10 said she felt her head was not in a good position and she needed to be repositioned in her wheelchair. She said her head was still not positioned correctly. D. Record review A review of Resident #10's comprehensive care plan did not reveal the use of the resident's wheelchair headrest or how to properly position the resident in the wheelchair. A daily skilled note dated 11/22/23 at 10:13 a.m. documented the staff looked at the resident's wheelchair headrest due to the resident stating it was broken and not working. The staff had to use towels to keep her head upright. A daily progress note dated 3/13/24 at 2:06 p.m. documented a staff member contacted the resident's medical equipment provider regarding adjustment/replacement of the wheelchair headrest on 2/26/24 and 3/13/24. The progress note documented the facility was awaiting a response for an appointment to be scheduled for the medical equipment provider to come in and adjust the headrest. A daily progress note dated 3/15/24 12:55 p.m. documented a sheepskin was applied to the resident's wheelchair headrest for comfort and skin protection while waiting for a wheelchair headrest replacement. A daily progress note dated 4/1/24 at 1:14 p.m. documented the wheelchair provider assessed the Resident #10's wheelchair, adjusted the headrest and recommended ensuring the resident was seated all the way back in the chair with her hips square and staff needed to be educated on proper alignment of the resident in her wheelchair to maximize her comfort. The Kardex (tool used by staff to provide person centered care), dated 4/25/24, was provided by registered nurse (RN) #1. It documented the resident used a soft neck brace. -The Kardex did not include how to position the resident correctly in her wheelchair. E. Staff interviews The DOR was interviewed on 4/25/24 at approximately 12:55 p.m. The DOR said Resident #10 received her wheelchair about two years ago (2022). She said an outside company adjusted the resident's wheelchair. She said the facility staff tried to adjust the resident's headrest but it did not help. The DOR said the resident continued to say something was wrong with her headrest. The DOR said the wheelchair provider came to the facility on [DATE] and they said placing a different head rest would not make any difference for her. The DOR said the wheelchair company said the facility needed to position the resident better in the wheelchair. The DOR said the wheelchair provider said resident should be all the way back in the chair and to adjust her hips first so her shoulders would follow and be straight. The DOR said the CNAs positioned the resident when they got her out of bed and into the wheelchair in the morning. The DOR said she and the assistant director of nursing (ADON) took pictures of the resident's appropriate positioning to show staff how the resident should be positioned in her wheelchair. She said the pictures were in a notebook at the nurse station. She said the resident had contractures in her neck and the headrest was for support and comfort. RN #1 was interviewed on 4/25/24 at 1:15 p.m. RN #1 said there was not a notebook at the nurses station that explained how to position Resident #10. She said the positioning information should be in the Kardex for the CNAs. She said the Kardex was an extension of the resident's plan of care to help the CNAs know how to provide individualized care to the residents.

Based on record review and interviews, the facility failed to ensure one (#191) of two residents out of 35 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure consistent communication and documentation with the dialysis center occurred regarding care and services provided for Resident #191. Findings include: I. Facility policy and procedure The Dialysis Care Policy, reviewed 7/12/23, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m., It read in pertinent part, Coordination of dialysis care will include communication about code status, change in medications, current vital signs, weight management, required treatments, care concerns and appropriate interventions and fluid restriction management limitations. This information will be sent with the resident to their dialysis appointments. II. Resident #191 A. Resident status Resident #191, age 78, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included congestive heart failure (CHF) and end stage renal disease (ESRD). The 4/26/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He was dependent with toileting, required substantial/maximal assistance with transfers, partial/moderate assistance with bed mobility and set up assistance with eating. B. Record review The nutrition care plan, initiated 4/22/24, documented Resident #191 was at a nutritional risk related to ESRD and dialysis. It indicated the resident received dialysis three days a week. The dialysis care plan, initiated 4/7/24, documented resident Resident #191 had ESRD and required dialysis. Interventions included dialysis as ordered, dietary to evaluate as needed, monitor fistula (a connection between the artery and vein for dialysis access) in left arm and monitor for complications from dialysis. A review of the dialysis treatment record from 4/9/24 to 4/24/24 revealed Resident #191 received dialysis on 4/9/24, 4/11/24, 4/12/24, 4/15/24, 4/17/24, 4/19/24 and 4/22/24. A review of the hemodialysis communication record forms from 4/9/24 to 4/24/24 revealed there was no hemodialysis communication form in the chart on 4/11/24, 4/12/24, 4/15/24, 4/17/24 and 4/19/24. -A hemodialysis communication form for 4/22/24 revealed the facility pre-dialysis portion of the communication form was filled out, however, the dialysis portion was not completed. -Review of Resident #191's electronic medical record (EMR) failed to reveal documentation to indicate communication between the facility and the dialysis center had occurred on 4/11/24, 4/12/24, 4/15/24, 4/17/24 and 4/19/24. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 11:10 a.m. LPN #1 said each resident that went to dialysis had a book that went with them to and from dialysis. She said the facility filled out the top portion of the form with vital signs, medications given and sometimes the resident's weight. She said the form was sent to dialysis with the resident along with a face sheet and medical orders for scope of treatment (MOST). LPN #1 said the form was important for communication between the facility and the dialysis center to ensure the residents were receiving continuity of care. She said the forms were a permanent part of the resident's medical record and were uploaded in the electronic medical record (EMR) by the medical records department. The dialysis registered nurse (DRN) was interviewed on 4/24/24 at 11:50 a.m. The DRN said the facility usually sent the communication form with residents that received dialysis. She said she thought she saw one for 4/22/24 for Resident #191 but she was unsure if the communication forms had been completed for the previous week. The director of nursing (DON) was interviewed on 4/24/24 at 12:30 p.m. The DON said dialysis forms were completed before dialysis by the facility staff. She said the dialysis center then filled out their portion of the form and sent it back with the resident. The DON said if the communication form did not return from the dialysis center to the facility, the facility should call the dialysis center to obtain the documentation to ensure continuity of care for the resident. She said she was unable to locate the dialysis communication forms on the missing dates for Resident #191 (see record review above). The DON said she had checked with the medical records department and was unable to locate the forms. She said she would check with the dialysis center to see if the forms were left there. -The missing dialysis communication forms were not provided by the facility by the end of the survey on 4/26/24. Registered nurse (RN) #3 was interviewed on 4/24/24 at 1:10 p.m. RN #3 said, in the rehabilitation wing of the facility, the nursing staff sent packets with residents that went to dialysis which included the dialysis communication form. He said the communication form should return in the packet back from the dialysis center. He said he was not usually at the facility when residents came back from dialysis but he said communications forms got put into a dialysis binder and then sent to medical records to be uploaded into the EMR. He said staff were unable to locate Resident #191's communications forms. RN #3 said if forms did not return back from the dialysis center, the facility staff should call the dialysis center to find out where the form was.

Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #2) of three residents reviewed for pressure injuries/ulcers out of five sample residents. Specifically, the facility failed to: -Ensure Resident #2's was provided and encourage proper repositioning to prevent the development of new pressure injuries; and; -Ensure Resident #1's pressure injury treatment was consistently changed per physician orders. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/1/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedures The Pressure Wound Prevention and Skin Management facility policy, revised 1/20/24, was received from the nursing home administrator on 1/31/24 at 9:58 a.m. The policy documented in pertinent part, The primary purpose of the pressure wound prevention and skin management is to reduce the occurrence of pressure injuries and promote healing of wounds. Identification, prevention, and treatments will be based on National Pressure Injury Advisory Panel (NPUAP) definitions, recommendations, and practice standards. Treatment should be based on individual needs. III. Resident #2 A. Resident status Resident #2, age 86, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included unspecified dementia, heart failure and malnutrition. The 1/9/24 minimum data set (MDS) assessment revealed the resident was significantly cognitively impaired with a brief interview for mental status score of one out of 15 on the brief interview for mental status (BIMS). She required total assistance with eating, hygiene, dressing, position changes in bed, and transfers to the wheelchair. B. Observation Resident #2 was at risk for pressure injuries. Observations showed the resident was not repositioned every two hours as recommended by the wound physician (see interview below). On 1/30/24 at 2:59 p.m., the resident was lying in bed. The resident did have an air mattress. Continuous observations began at 3:29 p.m. -At 3:29 p.m., the resident continued to be in the same position. She continued to lay on her back with no repositioning. -At 4:53 p.m., licensed practical nurse (LPN) #2 administered medication to the resident; however, did not offer to reposition the patient. -At 5:45 p.m., the resident was assisted with her dinner meal while she continued lying on her back. The unidentified certified nurse aide (CNA) did not offer to reposition the resident before or after offering assistance with her meal. -At 6:25 p.m., the resident was turned onto her side by the director of nurses (DON) with a positioning device. On 1/30/24 between 3:29 p.m. and 6:25 p.m. the resident was not encouraged, offered or provided repositioning and had two new pressure ulcers (see wound observation below). C. Wound observations The resident's wound was observed on 1/31/24 at 9:21 a.m. with the wound physician and the DON. The DON removed the dressing and two new coccyx stage 2 pressure ulcers that were medial on the coccyx with one wound superior to the other. The wound physician measured the coccyx pressure ulcers as one centimeter (cm) x 1 cm x 0.1 cm and 0.5 cm x 0.5 cm x 0.1 cm. Both wounds were identified as new by the wound team. The wound physician said he was not notified of new wounds on this resident. D. Record review The Braden scale completed 1/8/24 revealed the resident only responds to painful stimuli or had sensory impairment over half of the body. The resident scored an 11 which indicated she was at high risk for pressure injury. The care plan, 1/9/24, showed the resident had one stage 4 pressure injury and one stage 2 pressure injury. Pertinent goals included prevention of pressure injuries, care and treatment for existing pressure injuries, and comfort-focused care. -The stage 2 pressure injury healed per the wound physician documentation on 1/17/24. The January 2024 treatment administration record (TAR) showed a physician order for pressure relieving devices, floating heels in bed and frequent incontinence care per the resident's needs. The review of wound physician notes revealed the resident was at risk for pressure injuries and she currently had a stage 4 to the thoracic spine following surgical debridement and a stage 2 on coccyx had healed on 1/17/24. E. Staff interviews CNA #1 was interviewed on 1/31/24 at 9:02 a.m. CNA #1 said Resident #2 could not make her needs known and required assistance with turning, bathing, meals and transfers. CNA #1 said the resident usually accepted care and was cooperative. The wound physician was interviewed on 1/31/24 at 11:22 a.m. The wound physician said the resident's pressure ulcers were unavoidable, however, the resident should be turned every two hours in bed and every 15 minutes when sitting in the chair. The DON was interviewed on 1/30/24 at 6:34 p.m. The DON said she was familiar with Resident #2's skin issues. She said Resident #2 had a stage 4 pressure injury to her upper back and the previous stage 2 on her coccyx was healed. The DON was interviewed again on 1/31/24 at 1:49 p.m. The DON said two stage 2 pressure ulcers found today on Resident #2 were new and unknown to staff. The DON said when an area of skin concern, such as redness, nursing staff were to notify the physician, family and the DON. 50315 IV. Resident #1 A. Resident status Resident #1, over the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders, diagnoses included kyphosis (curvature of the spine), osteoarthritis and a pressure wound on his mid back. The MDS assessment from 1/23/24 documented the resident had no cognitive impairments with a score of 14 out of 15 on the BIMS assessment. -The MDS failed to document the pressure injury status. B. Resident interview Resident #1 and his representative were interviewed on 1/30/24 at 5:00 p.m. The resident said there was a wound on his back that has been there on and off for about two years. He said he had been wheelchair and bed bound since then, and with his severe kyphosis, it was in a difficult spot to heal. He said the nurses were not always the best at getting the dressing changed and sometimes it comes off and causes him to have pain. When it was on properly, he said the wound did not cause him pain. The representative said she brought in a sheepskin cushion for the back of his chair because the facility did not provide anything. She said she brought in wound care supplies from the local pharmacy because the staff were always using different dressings and she was concerned the wound was worsening. C. Observations During the interview with Resident #1 and representative on 1/30/24 at 5:00 p.m. the representative lifted the jacket of the resident up to expose the dressing. The large foam dressing covered the wound and was dated 1/27 with initials. On 1/30/24 at 5:45 p.m., the DON observed the date on the dressing was last changed on 1/27/24. D. Record review The January 2024 CPO showed an order for the mid back pressure ulcer stage 2. The order read to cleanse with wound cleanser, skin prep to periwound and apply optifoam gentle with silver. This was to be completed every Monday, Wednesday, and Saturday with a start date of 1/17/24. The January 2024 treatment administration report (TAR) the order to change the dressing on Resident #1's mid back pressure ulcer stage 2 wound was completed on 1/29/24 during the day. -However, observations (see above) showed the dressing was last changed on 1/27/24. E. Staff interviews LPN #1 was interviewed on 1/30/24 at 5:17 p.m. He said Resident #1's dressing got changed every Monday, Wednesday, and Saturday and as needed (PRN). After reviewing the treatment administration record, he said the last dressing was changed on 1/29/24 (Wednesday). He said the wound dressing orders included cleansing the wound with wound cleanser, skin prep around the wound, silver dressing and cover with a foam dressing. He said skin assessments were done weekly on Wednesdays. He said if he noticed something new, he would report it to the assistant director of nurses (ADON) and the DON. The DON was interviewed on 1/30/24 at 5:45 p.m. The DON said wound rounds were done with the wound doctor every Wednesday morning. She said nurses were supposed to be providing care and treatment per the physician order. The DON and clinical nursing consultant (CNC) were interviewed on 1/31/24 at 1:30 p.m. The DON said there was a lack of education with nursing staff regarding dressing changes. She said she spoke to LPN #1 regarding the missed dressing change for Resident #1, provided education about dressing changes and following physician orders. The DON said she was not aware dressing changes were not getting done and said the facility had adequate supplies and staffing to get the dressing changes completed per physician orders. She said she occasionally stepped in to help with dressing changes when asked by families or staff.

Based on record review and interviews, the facility failed to ensure four (#17, #18, #58 and #62) of six residents received adequate supervision to prevent accidents out of 33 sample residents. Specifically, the facility failed to: -Develop and implement a person-centered care plan that identified Resident #17 fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #17; -Ensure registered nurse (RN) assessments were completed following falls for Resident #18; -Ensure Resident #58 plan of care identified that the resident was a wander risk and had eloped from the facility on one occasion with person-centered interventions to prevent further elopement episodes, ensure a physician's order was in place with consent obtained for the use of the wanderguard system and monitored the placement and function of the wanderguard; and, -Ensure Resident #62 was being monitored during meals due to his high aspiration rate. Findings include: I. Resident #17 A. Resident status Resident #17, age over [AGE] years, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), psychotic disorder with delusions, unspecified dementia with behavioral disturbances, mood disorder, depression, repeated falls and age related macular degeneration. The 11/1/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required staff supervision or touch to move from a seated to standing position and to transfer from her bed to a chair. Since admission she had fallen with and without injuries. The resident had disorganized thinking, and at times had difficulty with focused attention. B. Resident interview Resident #17 was interviewed on 1/9/23 at 10:06 a.m. She was lying on her bed with her call light plugged in and hanging on the floor, with the call light button wrapped around her wheelchair wheels at the foot of her bed. She said she did not know how to get someone to help her go to the bathroom so she just had to go to the bathroom in her bed. She said she did not know where her call button was to call staff for help. Resident #17 was interviewed again on 1/10/23 at 9:20 a.m. She was seated in her wheelchair with her bedside table in front of her, seated next to the head of her bed. The call light hung straight down the wall with the call light button on the floor. She said she could call for help when she pushed the red button on the call light. She said she did not know where her call light was today. She said the call light was good to have because it let the staff know she needed help. C. Record review The 7/18/22 comprehensive care plan revealed in pertinent part, -Focus: Resident #17 was at risk for falls with over estimating what she can do for herself. The resident had a history of falls. -Goal: Resident #17 will not sustain an injury if a fall occurs through the next review date. -Interventions: Ensure her call light was within reach. Encourage her to call for help. Increase frequency of rounding for safety. A sign (would be) on the bathroom door reading 'call for assist.' A sign (would be) in her room to encourage her to call for assistance. The desktop file system which documented a summary of the resident's care to the nursing staff was provided by the NHA on 1/9/23 at 12:00 p.m. It revealed in pertinent part, -Ensure the resident's call light was within reach. Increase frequency of rounding for safety. Monitor resident's whereabouts. Sign on bathroom door (to read) call for assist. Frequent checks (by nursing staff) to make sure the call light was within reach (see director of nursing interview below about frequent checks). D. Observations On 1/4/23, 1/5/23, 1/9/23, and 1/10/23 there was no sign on her bathroom door reading 'call for assist.' She also did not have a sign in her rooms to encourage her to call for assistance (see comprehensive care plan above). Call light observations The resident's call light was plugged in at the foot of her bed up on the wall approximately five to six feet. From the plug on the wall hung a long cord. At the other end of the cord was a hand held, off white device that fit in the palm of a hand, with a red top bottom to push. When the call light's red bottom was pushed it alerted the nursing staff that a resident had called for help. The entry door into the resident's room also had a light above it. When a resident pushed the red button, the light above the door lit up also. The call light in the resident's room was not within her reach or pinned nearby. The call light hung straight down the wall, and the call button was on the floor on the following dates, -On 1/5/23 at 9:09 a.m, 11:00 a.m., and 11:17 a.m. (at 11:21 a.m. the resident had fallen out of bed and onto the floor, see observation below). -On 1/9/23 at 10:06 a.m., 2:33 p.m., 2:55 p.m., 3:25 p.m., and 4:30 p.m. -On 1/10/23 at 9:20 a.m. E. Resident fall during survey On 1/5/23 at 11:17 a.m. the resident was seated on the floor with her back against her bed and her legs straight out in front of her. Her call light was hung straight down the wall, between the wall and her bed, with the call light on the floor. The call light was not within reach for the resident to grab and push the button for help. The resident's body was wrapped in a large peach colored comforter. Certified nurse aide (CNA) #5 entered the room at 11:21 a.m. and then called down the hallway for the licensed practical nurse (LPN) #2. CNA #5 sat on the bed next to the resident who sat on the floor. LPN #2 entered the room, asked the resident about the fall and if she had hit her head. LPN #2 then left the room and brought back registered nurse (RN) #3. After RN #3 spoke to the resident, she told the resident someone would take her vitals, and then the three staff members helped Resident #17 get back into bed. CNA #5 told Resident #17 she needed to remember to use her call light. CNA #5 went to place the call light next to the resident and discovered the call light did not have a clip on it to pin to the blanket so that it would remain in place. CNA #5 tried to turn the call light on but it did not work. LPN #2 said he would get a call light for the resident that was not broken. LPN #2 brought in a new call light, plugged it in, tested that it worked, and pinned it next to the resident who was lying in bed. F. Staff interviews after the 1/5/23 fall CNA #5 was interviewed on 1/5/23 at 11:45 a.m. She said she did not know the resident's call light did not work. She said today the resident did not have her call light within reach. CNA #5 said she did not know where any signs were in the resident's room to remind her to use her call light. CNA #5 said today the resident was wrapped in the comforter blanket that was on her bed. She said the resident could fall in her comforter blanket because it was big and bulky. LPN #2 was interviewed on 1/5/23 at 4:00 p.m. He said today Resident #17 was moved to a room closer to the nurses station. He said staff would be able to observe her more closely. He said she had frequent falls (1/5/23 was fall #9 for the resident when she was moved closer to the nurses station). Registered nurse (RN) #1 was interviewed on 1/9/23 at 4:30 p.m. She said she had never seen Resident #17 utilize her call light. She said she did not know where the resident was currently in the building. She said some days the resident rested in bed and other days she moved freely in the building in her wheelchair. G. Fall investigations On 1/9/23 at 10:45 a.m. the nursing home administrator (NHA) provided the fall investigations for the resident. Resident #17 had nine falls between 9/6/22 and 1/5/23. The interdisciplinary team (IDT) notes after the resident's falls documented all falls were unwitnessed. The NHA said on the bottom right corner of each fall investigation were handwritten initials of managers who attended the morning meetings. Also on the bottom right corner were handwritten notes of interventions (See director of nursing interview below about the handwritten intervention notes). -On 9/7/22 Resident provided with a 42 (inches) bed (fall 9/6/22). -On 9/14/22 Staff to smooth out blankets when rounding (fall 9/13/22). -On 9/19/22 Collect labs on resident to see if anything clinical was going on (fall 9/17/22). -On 10/13/22 Prioritize rounding to include (the) resident in the beginning of rounds. Declutter floor during rounds (fall 9/13/22). -On 11/2/22 Resident currently in isolation due to having COVID-19. Increase the frequency of safety checks, due to the door having to be closed (fall 11/2/22). -On 11/3/22 Keep the door open during the isolation period (second fall on 11/2/22). -On 12/9/22 Encourage (the) resident to keep bed in a lower position (fall 12/8/22). -On 1/5/23 Resident to be moved to room closer to the nurses station (fall 1/5/23). -On 1/10/22 Increase frequency of rounding on the resident (fall 12/27/22). Interventions added on 1/10/23 during the survey, which was 13 days after the fall. H. Staff interviews CNA #2 was interviewed on 1/10/23 at 11:25 a.m. She said Resident #17 did not utilize her call light. She said when the resident wanted help she would just scream and yell for staff to come and help her. She said she did not know where signs were in the resident's room to remind the resident to use her call light. The director of nursing (DON) was interviewed on 1/10/23 at 2:00 p.m. He said resident falls were discussed in morning meetings when the interdisciplinary team (IDT) met. He said Resident #17's falls were reviewed, and then the IDT would sign their initials on the bottom of the fall incidents. He said at the bottom of the fall incident sheets interventions were hand written as well as the initials of the IDT members who were in the meeting that day. He said the intervention information was verbally communicated to the nursing staff on the floor. He said he did not have proof that the information was provided in a meeting to the floor staff about the resident's interventions for her falls. He said with an intervention of frequent rounding he did not know how often that was. He said generally the nursing staff were to check on residents approximately every two hours. He said frequent rounding would mean more checks on the residents. He said he did not have documented staff education that intervention was communicated to the staff. He said he did not know exactly how often extra rounding (checks) meant. He said he did not have any written logs that the staff had checked extra times on the resident. He said he did not have a physician order/documentation in the resident's electronic medical records (EMR) that the interventions to increase frequency of rounding for the resident's falls were implemented. He said in the EMR it was documented the call light was within reach when the light was observed on the floor and not in reach. He said he would educate the staff right away to make sure no one checked the call light was in reach in the EMR when it was not. I. Facility follow-up On 1/12/23 at 4:41 p.m. the NHA emailed information about Resident #17. The NHA wrote, Different interventions are put in place and if it recognized the intervention was not effective, a new intervention would be implemented. She wrote the IDT reviewed each fall and interventions were implemented. -There was no documentation the handwritten interventions via the IDT team were communicated after each fall to the nursing staff according to the interview with the DON (see above). The DON verified in an interview increased rounding was an intervention yet there was no documentation the staff increased rounding nor was there documentation the staff were educated to do so. The DON said he did not know how much or when exactly increased rounding meant in the intervention. 47350 II. Failure to conduct and document RN assessments after falls A. Professional reference Colorado Department of Regulatory Agencies, State Board of Nursing: Practice Act and Laws. 2022. https://dpo.colorado.gov/Nursing/Laws retrieved on 1/19/23 at 2:21 p.m. The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the registered nurse (RN) or medical doctor (MD) for further or 'full' assessment. B. Resident status Resident #18, age 80, was admitted on [DATE]. According to the January 2023 CPO, the diagnoses included congestive heart failure, chronic kidney disease stage 3, hypertension, depression and dementia. The MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with one person assistance with transfers and dressing independent with one person assistance with toileting and independent with set up for bed mobility, eating and personal hygiene. C. Record review The 12/28/22 nursing progress notes documented that licensed practical nurse (LPN) #3 was assisting Resident #18 when she started coughing and lost her balance and slid down the bathroom wall to the floor. The resident was assisted back to bed by three staff members. It indicated the registered nurse (RN) was notified. -A review of the resident's medical record did not reveal documentation that an RN completed an assessment of the resident prior to the resident being moved from the floor or following the fall in the bathroom. D. Staff interviews The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He confirmed that an RN must conduct an assessment after a fall occurred and before the resident was assisted off the floor. He said that the RN assessment should be documented in the resident's medical record. III. Failure to ensure monitoring was in place for resident who silently aspirates A. Resident status Resident #62, age 63, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included multiple sclerosis, dysphagia (swallowing difficulty), pneumonia, chronic obstructive pulmonary disease (COPD), gastrostomy tube. The November 2022 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required the supervision of one person with transfers, dressing and was independent with the assistance of one person with toileting and independent with set up for bed mobility, eating and personal hygiene. B. Observations On 1/4/23 at 12:00 p.m. Resident #62 was observed sitting up and eating lunch of a regular consistency in his room. Staff were not observed in his room or immediately outside of his room. The resident had an occasional loose cough while eating his meal. On 1/9/23 at 11:30 a.m. Resident #62 was observed sitting up and eating lunch of a regular consistency of chicken, sweet potatoes and vegetables in his room. Staff were not observed in his room or immediately outside of his room. The resident had an occasional loose cough while eating his meal. C. Record review The nutrition care plan, initiated on 5/26/21 and revised on 6/17/22, revealed that the resident's ordered diet was nothing by mouth (NPO) due to dysphagia and high risk of aspiration pneumonia, choking and death. The interventions included encouraging the resident to eat in the dining room to ensure he was observed while eating, reminding the resident of the risks associated with not following the recommended diet and encouraging the resident to follow the diet recommendations. The January 2023 CPOs documented: -Diet order: NPO - ordered on 5/17/21; -Check the gastric residuals every shift. If residuals are more than 200 ml (milliliters) hold the tube feeding - ordered on 10/26/21 -On 1/4/23 tube feeding Jevity to start every night at 5:30 p.m. On 8/26/21 a videofluoroscopic swallow study was completed and revealed moderate to severe oropharyngeal dysphagia with silent aspiration and an ineffective cough. The recommendations included direct swallow therapy, conducting a conversation with the resident about goals of care and discussing the risk. It directed that modifications to the resident's diet were recommended to mitigate the resident's risk of aspiration with a brief speech follow up and aspiration precautions if the resident chose to pursue an oral diet. On 10/28/21 an acknowledgement of the risks of pursuing an oral diet which included coughing, choking, rehospitalization , aspiration pneumonia and death was signed by the resident. -There was no additional documentation in the chart reviewing the resident's risk of aspiration due to having a regular diet after 10/18/21. D. Staff interviews Certified nursing assistant (CNA) #4 was interviewed on 1/10/23 at 11:25 a.m. She said that Resident #62 was NPO but he chose to eat a regular diet. She said they tried to watch the resident closely because he had a history of aspiration pneumonia. She said he sometimes would eat in the dining room but he preferred to eat in his room. Registered nurse (RN) #2 was interviewed on 1/10/23 at 11:35 a.m. She said that resident was NPO but wanted to eat by mouth and refused his tube feedings. She said he had a recent aspiration pneumonia and could tell he was having respiratory difficulty by checking his oxygen saturation and providing oxygen. She was not aware of any special precautions or monitoring while the resident was eating. The registered dietitian (RD) was interviewed on 1/10/23 at 5:05 p.m. She said that the resident's diet order was NPO but he chose to eat by mouth. She said he continued to be administered medications and additional water through his gastrostomy tube. She said he did not want staff to monitor him during meals. She confirmed that the interdisciplinary team (IDT) had not discussed how to effectively monitor the resident's risk for aspiration. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said the resident should not be eating but he chose to eat a regular diet after multiple conversations with staff and providers regarding the risk. He said that the resident should be monitored for aspiration and interventions such as sitting up, staff listening for signs of choking and coughing. 47818 IV. Resident #58 A. Resident status Resident #58, age 89, was admitted on [DATE]. According to the January 2023 CPO, the diagnoses included unspecified dementia without behavioral disturbances, psychotic disturbances, mood disturbances, and anxiety. The 12/6/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. B. Observations On 1/5/23 at 1:10 p.m. a wanderguard device was observed attached to left side of the crossbar underneath the wheelchair seat of Resident #58. On 1/9/23 at 9:30 a.m. Resident #58 was observed sitting at the nursing station asking staff, repeatedly, to call her parents. The facility staff redirected Resident #58 to a group activity. -At 1:52 p.m. Resident #58 was observed to be in her room alone talking to herself. The resident was crying and placed her face into the palms of her hands. -At 2:57 p.m. Resident #58 remained sitting in her room, sleeping in her wheelchair. C. Record review The 12/12/22 social services progress note revealed that on 12/11/22 Resident #58 had been found outside of the facility by a staff member after her daughter was unable to locate her in the facility. It indicated a wander risk assessment was completed on 12/11/22 and a wanderguard was placed on the resident's wheelchair. The 12/11/22 wander risk assessment documented the resident was at a high risk. It indicated she was able to move about the facility without staff assistance in her wheelchair, wandered aimlessly within the facility or off the facility grounds The 12/13/22 interdisciplinary team progress note revealed that staff were encouraged to check on the resident frequently following a visit from her family, as the resident would look for visitors after they left the facility. A review of the resident's electronic medical record did not reveal documentation that the resident's history of wandering or episode of elopement from the facility on 12/11/22 had been addressed in the comprehensive care plan. It did not include any person-centered interventions to prevent the resident from eloping from the facility. -The facility failed to obtain a physician's order for the use of the wanderguard device and consent prior to placing the device upon the resident. -The facility failed to ensure the wanderguard device was placed in a location that would not be lost, and that staff were monitoring the placement and function. D. Staff interviews Registered nurse (RN) #1 was interviewed on 1/10/23 at 3:00 p.m. She said she was not familiar with the implementation of the wanderguard system at the facility because she worked for an agency. She said she did not know if Resident #58 was an elopement risk or wandered throughout the facility. Certified nurses aide (CNA) #2 was interviewed on 1/10/23 at 3:00 p.m.She said Resident #68 was a wander risk and had a wanderguard device. She said the facility staff escorted the resident to and from meals and activities. The social services assistant (SSA) was interviewed on 1/10/23 at 3:30 p.m. She said that if a resident was observed wandering, an interdisciplinary (IDT) discussion occurred regarding the implementation of a wanderguard device. She said consent should be obtained from a legal representative prior to placing the wanderguard device. She said the resident's legal representatives were asked to provide verbal consent. She said the conversation should be documented in a progress note in the resident's medical record. She confirmed that the resident's comprehensive care plan did not directly address the resident's history of wandering and episode of elopement. She said in the fall risk care plan, it was identified that the resident was at risk for wandering. She confirmed there were no interventions to address the resident's risk of elopement. She said the facility had placed the wanderguard device on the resident's wheelchair. She said it was placed on the wheelchair because Resident #58 was typically in her wheelchair. She said other residents in the facility had been observed trying to take off the wanderguard when it was placed on their person, so they decided to place it on the wheelchair. She said Resident #58 did not have any episodes of trying to remove the wanderguard device. She said the facility had not attempted to place it on the resident's wrist or ankle. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said that when a resident was identified as an elopement risk the legal representative and physician was notified. He said the IDT determined interventions to put into place such as changing the location of the resident's room or initiating a wanderguard device. He said when a wanderguard device was placed, a physician's order should be obtained for the use of the wanderguard device and a physician's order to check the placement and function every day. He acknowledged that placement of the wanderguard device on the wheelchair could be problematic as there was a possibility of the resident being in a separate location as the wheelchair, or the wheelchair could get mixed up with another resident's

Based interviews and record review the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for two (#13 and #133) of six residents reviewed out of 33 sample residents. Specifically, the facility failed to: -Respect the wishes of Resident #13 to receive showers and not bed baths; and -Provide showers according to Resident #133's plan of care/preference. Findings include: I. Facility policy The Dignity, Voice, and Choice policy and procedure, revised 8/10/22, was provided by the nursing home administrator (NHA) on 1/10/22 at 4:00 p.m. It revealed in pertinent part, Residents will be cared for in a manner and environment that maintains or enhances their dignity, privacy, and respect in full recognition of their individuality. Choices and decision making belong to our residents. Bathing services are provided per residents' preferences, time, day, caregiver, shower or bath preferences and are honored as much as reasonably possible. Choices include, if they would like a bath or a shower. II. Resident #13 A. Resident status Resident #13, age 70, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, morbid obesity, hypertension (high blood pressure), and myopathy (muscle weakness). The 9/27/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance with dressing. He had total dependence on staff for transfers, toilet use, personal hygiene, and to transfer from his bed to a wheelchair. He required substantial/maximum assistance with bathing. He did not reject care from staff. B. Resident interview Resident #13 was interviewed on 1/4/23 at 10:35 a.m. He said I only receive bed baths, never showers. I have been asking for a real shower for months. I have not had a real shower in four months. I am a big man and need a lift to get out of bed. He said he needed the staff to use a lift to transfer him from his bed to a shower chair. He said his only concern at the facility was that he did not receive showers. He said he wanted showers twice a week. He said he did not want bed baths. He said he had told the nursing staff for several months that he wanted a real shower but the staff did not provide it. He said he told the social worker (see interview below) about wanting a real shower about a week ago. He said he had not heard back from any staff yet about the situation. Resident #13 was interviewed again on 1/9/23 at 2:31 p.m. He said last Friday (1/6/23) during the state survey the director of nursing (DON) came to speak to him. He said the DON said from now on staff would provide showers and not bed baths for him. He said he received a shower last Friday (1/6/23) for the first time in several months. He said he understood the concern with him being a large man. He said the staff did just fine with the lift. He said at least for now the staff was working on providing him showers. C. Record review The 9/15/22 comprehensive care plan revealed Resident #13 required extensive assistance of one staff member with bathing and showering. He needed assistance to get out of bed. He had total dependence on three staff members to utilize a lift for transfers. The resident's weight on 12/30/22 revealed the resident weighed 369 pounds. The bath report sheets for Resident #13 were provided by the nursing home administrator (NHA) on 1/10/23 at 8:52 a.m. Each bath report sheet had the resident's name on them and the date. Not all of Resident #13's bath sheets documented what he received, a bed bath or a shower. The following November 2022 bath report sheets did not reveal if the resident received a bed bath or a shower on 11/1/22, 11/4/22, 11/8/22, 11/11/22, 11/18/22, 11/25/22, and 11/29/22. -On 11/15/22 the bath report sheet documented the resident had received a bed bath. The December 2022 bath report sheets revealed: -The resident received a bed bath on 12/6/22, 12/16/22, 12/20/22, and 12/30/22. -The resident's bath report sheets did not record what type of bathing (shower or bed bath) was received on 12/2/22, 12/9/22, 12/13/22, 12/23/22, and on 12/27/22. The January 2023 bath report sheets revealed: -On 1/3/23 and 1/6/23 the bath report sheets did not document what type of bathing was provided (shower or a bed bath). The 12/28/22 care conference notes were provided by the social service assistant (SSA) on 1/10/23 at 10:15 a.m. The notes revealed (the resident) wanted showers with facility staff using a (mechanical) lift. III. Staff interviews The SSA was interviewed on 1/10/23 at 10:10 a.m. She said Resident #13 had a recent care conference and he requested to receive showers not bed baths. She said he requested the staff use a mechanical lift for him to get him out of bed and into a shower chair. She said information obtained in care conferences were passed on to the departments that could resolve the situation. The DON was interviewed on 1/10/23 at 12:45 p.m. He said the facility had a technical issue with the mechanical lift. He said the issue had been recently fixed and now the lift worked. He said Resident #13 would be provided with a mechanical lift to get out of bed and into a shower chair so that he could receive showers and not bed baths. The DON said he did go in Resident #13's room last Friday (1/6/23) and resolved the situation. He said the resident had received mostly bed baths when he wanted a shower instead. 38185 IV. Resident #133 A. Resident status Resident #133, age 88, was admitted on [DATE] and discharged on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included fracture of the left femur (hip), history of falls and a history of seizures. The 10/17/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review According to the certified nurse aide (CNA) tasks sheet, the resident was scheduled to receive bathing on Wednesday and Friday evenings, per Resident #133's preference. The 10/13/22 grievance form documented the resident and her responsible party had a concern that the resident was not receiving showers according to her preference or plan of care. The resident did not receive a shower on her scheduled day of 10/12/22. The resolution indicated the CNA was provided education regarding providing showers according to the shower schedule. The bath sheets provided by the facility, during the survey process, documented the resident receiving a shower on 10/13/22 and 10/26/22, only twice out of six opportunities. C. Staff interviews The director of nursing (DON) and the infection preventionist (IP) were interviewed on 1/10/23 at 5:30 p.m. He said when a resident was admitted to the facility, an interview was conducted to determine the resident's shower preferences. He said the resident was then placed on the shower schedule based on those preferences. The IP confirmed Resident #133 did not receive bathing according to her preferences.

Based on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for two (#36 and #58) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to prevent: -Resident #36 from physical abuse by Resident #83. Resident #83 had documented aggressive behaviors prior to the physical abuse incident on 8/22/22; and, -Resident #58 from physical abuse by Resident #17. Resident #17 had prior behaviors which the facility documented that she did not get along with prior roommates. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 1/12/23), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse. Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning. II. Facility policy and procedure The Abuse and Neglect policy and procedure was provided by the nursing home administrator via email on 1/10/22 at 5:24 p.m. It revealed in pertinent part, All residents have the right to be free from abuse. Residents will not be subjected to abuse from anyone including staff, residents. Definitions Abuse The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of any resident, even those in a coma, may cause physical harm, pain, or mental anguish. Physical abuse Includes hitting, slapping, punching, and kicking of residents. This refers to behaviors directed at residents and not staff or visitors. III. Altercation between Resident #36 and #83 A. Incident on 8/22/22 The 8/22/22 incident progress note revealed, It was reported another resident came behind (the) resident and punched him in the right shoulder. Resident is not afraid of the other resident. PA (physician assistant) was notified, DON (director of nursing) notified, resident is (own) responsible party and axo3. (alert and oriented to person, place, and time) The interdisciplinary (IDT) progress notes were provided by the nursing home administrator (NHA) on 1/9/23 at 11:07 a.m. It revealed in pertinent part, -On 8/22/22 It was reported another resident came behind (the) resident and punched him in the right shoulder, resident is not afraid of the other resident. -On 8/23/22 Writer (former NHA) followed up with (the) resident regarding being hit by another resident. (Resident #36) reports that (the) other resident (#83) hit him in the shoulder blade. Resident reports it did not hurt, and he is okay. Writer asked if he was fearful of (the) resident and he reports no, he understands (the) resident is confused and did not know what he was doing. Writer told him to let her know if any concerns arise. -On 8/24/22 Residents separated. Skin assessment completed, no concerns identified. Resident is not fearful and expresses no concerns. Continue to monitor other resident given diagnosis of dementia. B. Residents #36 1. Resident status (victim) Resident #36, age 74, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), acquired absence of right and left leg below the knee, morbid obesity, bipolar disorder, pain in the right shoulder, and depression. The 12/13/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance with bed mobility, transfers, dressing, and toilet use. He utilized limb prosthesis. 2. Resident interview Resident #36 was interviewed on 1/5/23 at 11:02 a.m. He said some guy followed him from the lunchroom to his bedroom. He said he (Resident #36) propelled his wheelchair back into his (Resident #36's) bedroom. He said Resident #83 came into his room. He said he Kept wailing, punching me on my shoulder over and over again. At least 10-12 times he punched me. I was aggravated. I told him to stop but he wouldn't let up. I yelled for a certified nurse aide (CNA) #1. He said CNA #1 pulled Resident #83's wheelchair away from me. He said his shoulder hurt for a few minutes. He said as long as the man was not smacking him he felt safe. He said he thought the man was psychologically impaired. He said he heard a rumor that the man did not live in the facility any longer. He said CNA #1 told Resident #83 to let go of my wheelchair. He said CNA #1 told him she was sorry that he had to go through being hit by the other resident. He said the man would not stop punching him until CNA #1 heard him yell for help. C. Resident #83 (perpetrator) 1. Resident status Resident #83, age over 80, was admitted on [DATE] and discharged on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included dementia, anxiety disorder, major depressive disorder, and hypertension (high blood pressure). The 8/8/22minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He required extensive assistance with bed mobility, transfers, locomotion on and off the unit, toilet use, dressing, and personal hygiene. 2. Record review The August 2022 medication administration treatment record (MAR) documented the resident was given the following medications on the day of the abuse 8/22/22: -Buspirone, 5 MG (milligrams) every morning and at bedtime for anxiety ordered on 8/1/22. -Risperidone 6 MG (milligrams one time per day for behavioral and psychological symptoms of dementia (BPSD) and mood disorder ordered on 8/2/22. The nursing progress notes (prior to the 8/22/22 incident) revealed, -On 8/6/22 the resident (#83) approached a certified nurse aide (CNA) from behind and began punching her in the arm and shoulder. The CNA removed herself from the situation and told a nurse. The nurse spoke to the resident who said, Yeah I did it because you are a stupid (expletive). -On 8/9/22 the resident (#83) was wandering in and out of other resident rooms and was exit seeking. -On 8/13/22 the resident (#83) called a CNA racist and sexist names, and tried to hit her. -On 8/18/22 the resident (#83) was documented hitting staff when they tried to put him to bed. -On 8/21/22 redirected (Resident #83) several times going in and out of other resident's rooms. The behavioral progress notes (prior to the 8/22/22 incident) revealed in pertinent part, -On 8/7/22 Resident #83 hit a kitchen employee in the lower back and clenched an activity employee's fingers very hard. Resident had a history of non-compliant with care, wandering, and impulsive behaviors. The wife was called and said in the past humor helped redirect him when he behaved in that manner. -On 8/11/22 Resident #83 kicked staff, threatened to harm staff, was exit seeking, used profanity at staff. Resident was able to be redirected 50% of the time and 50% he was not. -On 8/11/22 resident was exit seeking and when a staff member tried to redirect him he grabbed the staff members name tag off of her neck, kicked them in the shin, and called them profanities. He did not respond to interventions. The 8/23/22 administrative progress note revealed after the 8/22/22 incident, resident had dementia and did not have intent (to hit). The 8/9/22 comprehensive care plan on revealed an intervention to please provide the resident with space if he became overwhelmed, this would allow him time to calm down, and to reapproach him at another time (by staff). The 8/29/22 comprehensive care plan on revealed the resident frequently became aggressive with others, to include both staff and fell ow residents. It was often difficult to redirect him, but at times responded to being offered coloring, magazines, videos or music. Behavior notes after the incident 8/22/22 revealed, On 8/23/22 the resident was combative towards a CNA when trying to change him. The 8/25/22 care conference note revealed, the resident at times was agitated and exhibited behaviors (such as combativeness) toward others. D. Staff interviews The NHA was interviewed on 1/10/23 at 9:45 a.m. She said she was not the administrator when Resident #83 hit Resident #36. She said the current director of nursing (DON) was not working in the facility at that time either. She said the social service director at the time of the incident did not work in the facility any longer either. She said Resident #83 was in the facility from 8/1/22 to approximately 9/11/22. She said Resident #83 came from the company's sister facility (within the same corporation) in the same state. She said at the time it was thought that a change would do the resident good. She said there were other incidents with Resident #83 also after the resident-to-resident incident with Resident #36. She said Resident #83 had been moved to a memory care unit in a different facility. She said she would provide what paperwork she did have about the altercation. She said she did not know why the former administration did not prevent Resident #83 from abusing Resident #36. -She said there was no paperwork about Resident #83's transfer into the facility. She said when a person transferred from a sister facility the paperwork was different than when a person admitted from somewhere else. She said there was no paperwork to provide about Resident #83's behavior or what the reason was for his transfer to the current facility. She said the electronic records contained his approximately six weeks in the facility and that was all that was available. She said there were no referral notes from the transferring facility about the resident. She said she did not know why the resident was transferred from the sister facility to their facility. -The NHA at 10:00 a.m. provided a facility physical abuse report on 8/28/22 of Resident #83. This physical abuse occurred six days after the prior physical abuse on 8/22/22. Resident #83 went into another resident's room and hit them in the back several times. Resident #83 on the same day hit another resident while passing them in the hallway. She said interventions for the residents were implemented, which included the resident being moved to a facility with a memory care unit. CNA #1 was interviewed via the phone on 1/10/23 at 10:28 a.m. She said she remembered the incident that happened to Resident #36. She said she was in the hallway in front of the nurses station when she heard yelling from Resident #36's room. She said she ran to the room and could see Resident #83 repeatedly punching Resident #36 in the back. She said it was far more than one time. She said Resident #83 would not stop punching when she and Resident #36 told Resident #83 to stop. She said she had to pull Resident #83's wheelchair backwards to get him to stop punching. She said she moved Resident #83 into the hallway and called for the registered nurse (RN) to come to the room. She said that she and the RN offered to call the police but Resident #36 said he was okay and did not need the police called. She said because the resident said he did not need the police the facility staff did not call the police and report the incident. She said she had observed many days Resident #83 prior to the incident going into other resident rooms that were not his. When asked if Resident #36's description of the incident was correct, that he was Wailed on, punched, 10-12 times, CNA #1 said what Resident #36 said what happened in the incident was correct. The DON was interviewed on 1/10/22 at 12:45 p.m. He said he was not the director of nursing at the facility when the incident occurred between Resident #36 and Resident #83. He said he was the DON at the sister facility where Resident #83 lived. He said he remembered two staff members from the admitting facility came to the sister facility to do a psychiatric evaluation on the resident but that was all he knew. He said he thought it was because the resident wandered. He said the other facility had stairs and this facility did not have any stairs. E. Facility follow-up On 1/12/23 at 4:40 p.m. the NHA emailed the following information. It revealed in pertinent part, No allegations of abuse were reported. The resident (#83) who was involved with the behavior had a BIMS of 3 (severe impaired cognition). It was not possible for the community to establish intent, knowingly, recklessly, or willfully. The facility did not report the 8/22/22 resident-to-resident physical abuse stating the resident had a BIMS of 3 as a reason. The NHA wrote the resident was unable to have the capacity to commit a willful act and therefore could not be deliberate. -However, the facility did report the same resident (#83) on 8/28/22 (six days later) to the State Agency for resident-to-resident abuse. His mental status had not changed in six days following the first incident and was not a variant at that time to report the second abuse. The resident who was in receipt of the behavior did not want to contact the police. -Mandatory reporters must contact the authorities in cases of physical abuse even if the resident did not want the police notified. The NHA wrote in her email the term wailing was used by the surveyor. The term wailing was used by the victim in an interview (see Resident #36 and CNA #1 interviews above). -Resident #36 was punched by Resident #83 (see incident progress note). IV. Altercation between Resident #58 and Resident #17 A. Incident 12/15/22 The facility reported on 12/15/22 at 8:30 p.m. a CNA witnessed Resident #17 kick Resident #58. The CNA separated the two residents. The summary of the care plan after the altercation revealed, the resident had a diagnosis of a psychotic disorder with delusions and a mood disorder. She exhibited mood/behaviors as evidenced by her anxiety and tearfulness. She was triggered by some interactions with peers. The interventions put in place after the incident was not to have the two roommates live in the same room any longer. B. Resident #58 Resident #58, age under 90, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, atrial fibrillation, cerebral infarction (stroke), stage three chronic kidney disease, peripheral vascular disease, and depression. The 12/6/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She had disorganized thinking, and had delusions. She required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. C. Resident #17 1. Resident status Resident #17, age over 80, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), psychotic disorder with delusions, unspecified dementia with behavioral disturbances, mood disorder, depression, repeated falls, and age related macular degeneration. The 11/1/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required staff supervision or touch to move from a seated to standing position and to transfer from her bed to a chair. Since admission she had fallen with and without injuries. The resident had disorganized thinking, and had difficulty with focused attention at times. 2. Record review The 2/16/22 and revised on 3/11/22 comprehensive care plan revealed the resident had a diagnosis of psychotic disorder with delusions and a mood disorder. The resident was triggered by some interactions with peers. The resident did not realize/understand that some of her peers were quiet and preferred to keep to themselves. Due to this the resident felt she was not welcomed or that she annoyed others. She reported to staff that everyone was out to get me, or they hate me. The resident had a history of not allowing a roommate to engage in certain activities of choice within a shared room, not letting the roommate leave or use the restroom. The resident denied that she engaged in that behavior. The resident was educated on adjustment to roommate and proper reactions but did not recall the education/interventions provided. -Goal: The resident would be redirected within minutes of staff intervention and will not suffer any psychosocial distress from her behavior/mood. -Interventions: Redirect the resident to a different location/environment/scenery during increased times of behaviors and/or mood distress. The 3/21/22 comprehensive care plan revealed the resident had paranoia. She had roommates that did not want to be her roommate anymore due to her exhibiting paranoia behaviors. The resident raised her voice at others, pointing her fingers, and touching their belongings. Her paranoia also caused her to barricade herself in her room. The 3/11/22 comprehensive care plan psychosocial need revealed the resident had behaviors that showed a difficulty getting along with roommates/peers. The 9/2/22 comprehensive care plan revealed the resident had a history of depression, bipolar, and psychotic disorder. A review of the social service progress notes for Resident #17 revealed: -On 4/1/22 the resident brought the social worker to her room. The resident raised her voice at her roommate for previously opening a window and for the roommate having a fan pointed towards her. The resident grew agitated at her roommate for being agreeable to what she wanted and continued to raise her voice at the roommate. -On 4/6/22 the resident said she was happy with her roommate but it would not last. -On 4/7/22 said that a male stole hers and her roommates television remotes. The resident continued to refuse psychiatric medications or counseling. The resident said everyone thinks I'm crazy, but I'm not, only I know the truth. -On 4/15/22 the resident appeared to be agitated, moving in circles in her power (wheel) chair and making statements. She said So help me God, send me to the crazy house. Resident had moments of frantic behavior, took the roommates' remote and said it was hers, and tossed a phone from the social worker's hand. -On 5/15/22 the resident made statements in regards to her prior roommate saying, Me and her really had it out. She was lying and taking my stuff. A review of the nursing behavioral progress notes for Resident #17 revealed: -On 4/1/22 the resident was awake most of the night worrying about her roommate and the roomate's male friend. The resident was fixated on whether the male was a son, husband, or boyfriend. The conversation was all over the place, skipping from one subject to another not finishing the previous subject, and (the) resident displaying some agitation/anxiety. On 4/22/22 a nurse practitioner after a post hospital emergency room (ER) visit documented the resident had made statements of self harm and resident went to the hospital for a mental evaluation. She was returned to the facility because of the underlying diagnosis of dementia. The facility was seeking other placement for the resident. She continued to be paranoid. The resident said she was kidnapped, and that the kidnappers treated her very well. She said her wheelchair was bugged and people could listen to her conversations. She had ongoing beliefs that people were coming into her room at night to mess with her oxygen. D. Staff interviews The nursing home administrator (NHA) was interviewed on 1/10/23 at 9:45 a.m. She said Resident #17 had not lived with another roommate since the incident when she kicked her roommate. She said an analysis was done and revealed the two residents were incompatible roommates.

Based on record review and interviews, the facility failed to develop and update a comprehensive care plan for three (#53, #58 and #7) out of 33 sample residents for services that were to be furnished to attain or maintain the practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #53's comprehensive care plan addressed the resident's use of antidepressant medication; -Ensure Resident #58's use of anticoagulant medication was addressed in the comprehensive care plan with person-centered interventions; and, -Ensure Resident #7's behaviors were identified in the comprehensive care plan with person-centered interventions in place. Finding include: I. Facility policy and procedure The Person Directed Care Plan policy and procedure, revised on 7/12/22, was provided by the nursing home administrator (NHA) on 1/12/23 at 11:47 a.m. It read, in pertinent part, Baseline care plans will be completed within 48 hours of admission by the required departments and a copy or summary will be shared with the resident/representative prior to the completion of the Comprehensive Assessment. Care Plan Assessments will be completed by 14th calendar day after a resident's admission, 14 days after the Assessment Reference Date on an annual, significant change, or significant correction MDS has been completed. Care plans will be developed consistent with the residents' specific conditions, risks, needs, behaviors, preferences, and current standards of practice. Measurable goals and individualized interventions will be identified. The care plan will be revised and updated as necessary to reflect the resident's current status. II. Resident #53 A. Resident status Resident #53, age 88, was admitted on [DATE]. According to the January 2023 computerized physician order (CPO), the diagnoses included dementia and adjustment disorder with depressed mood. The 11/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required supervision with one person assistance with transfers, dressing and toileting. She was independent with set up assistance for bed mobility, personal hygiene and eating. She did not exhibit any physical or verbal behaviors directed at others. It indicated the resident did not exhibit any behaviors during the assessment period. B. Record review The January 2023 CPOs documented the following: -Lexapro 5 MG (milligram) by mouth once per day for depression-ordered on 5/20/22. A review of the resident's comprehensive care plan failed to identify the resident's use of an antidepressant administration. The 8/18/22 care conference note documented the resident reported feeling lonely. The 11/8/22 social services progress note documented the resident was feeling down due to medical and family issues. However, this was not addressed in the resident's comprehensive care plan. The facility failed to identify the resident's depression, the resident's reporting of feeling down and lonely in the comprehensive care plan and put effective person-centered approaches in place. C. Staff interviews Registered nurse #2 was interviewed on 1/10/23 at 2:05 p.m. She said that Resident #53 was very nice but she often stayed in her room and did not participate in group activities or go to the dining room. She said that the resident did like visiting with people. She said the resident was not tearful but expressed being lonely. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He confirmed that the behavior identified on Resident #53's comprehensive care plan was not current. He said that the resident had expressed feelings of being depressed and that an antidepressant had been started. He confirmed that when a resident was placed on an antidepressant, current behaviors, identifying causes of depression, antidepressant medication monitoring and other interventions such as counseling should be identified on the comprehensive care plan with identified person-centered approaches. 47818 III. Resident #58 A. Resident status Resident #58, age 89, was admitted on [DATE]. According to the January 2023 CPO, the diagnoses included unspecified dementia without behavioral disturbances, psychotic disturbances, mood disturbances, and anxiety. The 12/6/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review The January 2023 CPO documented the following physician order: -Apixaban (Eliquis) Oral Tablet 5 MG (millgram) (anticoagulant), give 1 tablet by mouth every morning and at bedtime for afib. The comprehensive care plan was reviewed on 1/9/23. It did not reveal a care plan for Resident #58's use of an anticoagulant medication. Cross-reference F684: the facility failed to ensure Resident #58 was monitored for the side effects for the use of an anticoagulant medication. C. Staff interviews Registered nurse (RN) #1 was interviewed on 1/10/23 at 1:10 p.m. She said Resident #58 ' s was prescribed Apixaban, which was an anticoagulant medication. She confirmed the resident ' s use of the anticoagulant medication was not identified on the comprehensive care plan. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said monitoring side effects identified in the comprehensive care plan of any residents who received anticoagulant medications. He said the MDS coordinator was responsible to ensure a care plan identifying the use of the medication was in place. IV. Resident #7 A. Resident status Resident #7, age 95, was admitted on [DATE]. According to the January 2023 CPO, the diagnoses included mild cognitive impairment of uncertain or unknown etiology, mixed incontinence, rash and nonspecific skin eruption, depression, unspecified. The 10/18/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Record review The 12/12/22 progress note documented Resident #7 blocked a nurse in the doorway when she attempted to assist another resident. It indicated that Resident #7 had concerns with going out for appointments as she had not left the facility for an appointment in a long time and was nervous to do so. The 12/20/22 nursing progress note documented that Resident #7 was having inappropriate sexual behaviors. Resident #7 asked a certified nurse aide (CNA) to rub cream on her labia and anus in a sexual manner. A review of the resident's electronic medical record did not reveal documentation that the resident's behavioral history had been identified in the comprehensive care plan and did not indicate any person-centered interventions to address the resident's behaviors. C. Staff interviews The social services assistant (SSA) was interviewed on 1/5/23 at 12:00 p.m. She said she was aware of the behaviors displayed by Resident #7. She said that Resident #7 did not like to leave the facility for appointments because of incontinence issues and a facial rash. She said she was aware Resident #7 had exhibited sexual inappropriateness. She said that behaviors should be identified in the comprehensive care plan. She said social services was responsible for creating the care plans involving behaviors. She confirmed a care plan had not been developed that identified Resident #7's behaviors.

Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#67) of seven out of 33 sample residents. Specifically, the facility failed to ensure that Resident #67, who was high risk and had skin breakdown, was offered and repositioned in a timely manner. Findings include: I. Professional reference According to Pechlivanoglou, P. et al. Turning high risk patients: An economic evaluation of repositioning frequency in long term care. Journal of the American Geriatrics Society. 2018 July; 66(7): 1409-1414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6097929/ retrieved on 1/12/23. According to current US (United States) practice guidelines, nursing home residents should be repositioned as frequently as required by their condition. Practice guidelines in Canada and the US recommend that patients at high risk of pressure ulcers be repositioned every two hours. II. Resident #67 A. Resident status Resident #67, age 80, was admitted on [DATE] and readmitted [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included type 2 diabetes mellitus (DM), peripheral vascular disease (PVD), aphasia (difficulty speaking) from a cerebral vascular accident (stroke), hypertension and chronic kidney disease. The 10/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, toileting and limited assistance of one person for personal hygiene. B. Observations On 1/5/23 at 9:00 a.m. Resident #67 was observed lying in bed on his back. -At 11:05 a.m. an unidentified physical therapist entered room and offered Resident #67 physical therapy. The resident declined, the physical therapist left the room and the resident remained in the same position. -At 11:40 a.m. an unidentified certified nursing assistant (CNA) delivered a lunch tray to Resident #67 and placed it on the bedside table. The resident was not offered repositioning and remained in the same position. -At 3:40 p.m. Resident #67 was observed lying in the same position. During a continuous observation on 1/9/23 beginning at 8:50 a.m. and ended at 12:50 p.m. Resident #67 was observed lying in bed on his back. -At 10:20 a.m. an unidentified CNA entered the resident ' s room and removed the resident ' s breakfast dishes. She did not offer or provide repositioning to the resident. -At 11:50 a.m. lunch meal tray was delivered to the resident by an unidentified CNA. She did not offer or provide repositioning to the resident. The resident was observed with the lunch plate sitting on his stomach while he was eating. -At 12:50 p.m. the resident was observed lying on back with a lunch plate sitting on his stomach. -No repositioning was offered or provided to Resident #67 for four hours. On 1/10/23 at 10:10 a.m. registered nurse (RN) #2 and CNA) #3 entered Resident #67 ' s room to provide incontinence care. CNA #3 unfastened the resident ' s incontinence brief and assisted the resident to turn on his left side and held the resident ' s position during peri care. RN #2 donned gloves and pulled briefs away from the resident. Resident #67 was incontinent with a small soft bowel movement. RN #2, using wipes, wiped front to back. The resident ' s left buttock was reddened and excoriated from moisture associated skin damage (see record review below). RN #2 applied barrier cream and a clean brief. CNA #3 repositioned Resident #67 to the left side and tucked the pillow behind the resident's back. C. Record review The skin integrity care plan, initiated on 6/15/22 and revised on 10/4/22, documented that the resident had an increased risk for skin breakdown related to decreased mobility and episodes of incontinence. The interventions included checking for incontinence at routine intervals, providing cleansing pericare thoroughly after incontinent episodes, providing daily skin check by the CNA ' s during care, encouraging the resident to change positions frequently and assisting if unable, floating the resident ' s heels while in bed and applying a pressure relieving bed mattress. The January 2023 CPO documented a physician ' s order to apply barrier cream with zinc and leave open to air two times per day to the left buttock for moisture associated skin damage (MASD). The 12/28/22 wound care physician assessment documented the resident had sustained MASD to the left buttock on 12/27/22, measuring 10 cm (centimeters) width x 2 cm length. IV. Staff interviews CNA #3 was interviewed on 1/10/23 at 10:30 a.m. He said that residents who were dependent on staff should be rounded on for incontinence care every hour and repositioned every two hours. He said that Resident #67 was unable to reposition himself and required staff assistance. The director of nursing was interviewed on 1/11/23 at 5:30 p.m. He confirmed that residents with decreased mobility that required extensive assistance, with a past and current history of skin breakdown, should be offered to be repositioned every two hours. He said Resident #67 required assistance from facility staff with repositioning. He said due to the resident ' s history of skin breakdown and current skin condition, he should be offered to be repositioned every two hours.

Based on observations, interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#58) out of 33 sample residents. Specifically, the facility failed to ensure Resident #58 was monitored for use of an anticoagulant medication. Findings include: I. Resident status Resident #58, age 89, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included long term (current) use of anticoagulants. The 12/6/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. II. Observation On 1/5/23 at 1:10 p.m. Resident #58's top left forearm was observed to have a large brown oval shaped skin discoloration. III. Record review The January 2023 CPO documented the following: -Apixaban (Eliquis) Oral Tablet 5 MG (millgram) (anticoagulant), give one tablet by mouth every morning and at bedtime for afib. -The comprehensive care plan was reviewed on 1/9/23 and did not reveal documentation that the facility had identified the resident's use of an anticoagulant medication or were monitoring the resident for the use of the medication. Cross-reference F656: the facility failed to ensure the comprehensive care plan identified Resident #58 ' s use of an anticoagulant medication. A review of the medication administration records (MAR) and treatment administration records (TAR) for November 2022, December 2022, and January 2023 revealed no physician orders for the monitoring of side effects for use of an anticoagulant medication. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 1/10/23 at 1:10 p.m. She said anticoagulant medication use should be monitored for bleeding and bruising daily and as needed. She said a physician's order should be written to monitor for the side effects of the anticoagulant use. She said Resident #58's was prescribed Apixaban, which was an anticoagulant medication. She said Resident #58's medical record did not have a physician's order to monitor the side effects of the use of an anticoagulant medication. She confirmed the resident's use of the anticoagulant medication was not identified on the comprehensive care plan. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said monitoring side effects should be located in the MAR and identified in the comprehensive care plan of any residents who received anticoagulant medications. He said the MDS coordinator was responsible to ensure the physician's order for monitoring and a care plan identifying the use of the medication was in place.

Based on observations, record review, and staff interviews, the facility failed to ensure two (#86 and #15) of four out of 31 sample residents received the care and services necessary to prevent the development of pressure ulcers and to promote healing of pressure ulcers. For Resident #86, the facility failed to prevent the development of pressure injuries for this high risk resident who was admitted post [CONDITION(S)]. Resident #86 was admitted to the facility on [DATE] with intact skin. On [DATE], nine days after admission, the resident developed an open area to her coccyx that progressed to unstageable full thickness necrosis by [DATE], then to stage four full thickness with infection and deterioration by [DATE]. Upon admission to the facility, the staff identified that the resident was at risk for pressure injuries. However, a person-centered care plan was not developed and comprehensive interventions were not put in place to prevent the development of pressure injuries for this resident. In addition, daily skilled nurses' notes about skin condition were inconsistent and incomplete, and treatments were not consistently documented and/or performed. The facility's failure to implement person-specific interventions and accurately document daily skin assessments contributed to the development of pressure injuries for Resident #86. Furthermore, Resident #15 was at risk for developing pressure ulcers due to being admitted to the facility with fracture of unspecified part of neck of the left femur (hip) and unspecified fracture of the upper end of the left humerus (upper arm) and requiring extensive assistance from staff (see minimum data set assessment [DATE]). The facility inaccurately assessed the resident's risk for pressure ulcers when admitted to the facility (see Braden Scale assessment [DATE]). The facility failed to identify and implement interventions to prevent pressure ulcers from developing, and failed to consistently perform physician-ordered treatments. Due to the facility failures, Resident #15 developed an avoidable deep tissue injury to the left heel on [DATE] which was documented as a stage 3 pressure ulcer after debridement on [DATE]. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org ([DATE]): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. According to the National Pressure Injury Advisory Panel, https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/Unavoidable_in_COVID_Pandemi.pdf , 2021: Before any decision is made about the avoidability or unavoidability of a pressure injury that developed during the COVID-19 crisis, all factors should be considered on a case-by-case basis, including both the [MEDICATION(S)] issues in the critically ill patient and the extrinsic issues in the health care facility at the time of the injury. Every reasonable effort should be taken to prevent pressure injuries. The mere diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Facility policy and procedure The Pressure Wound Prevention and Skin Management policy, revised [DATE], was provided by the director of nursing (DON) on [DATE]. It read in pertinent part: The primary purpose of the pressure wound prevention and skin management program is to reduce the occurrence of pressure injuries and promote healing of wounds. Identification, prevention, and treatment will be based on the National Pressure Ulcer Advisory Panel (NPUAP) definition, recommendations, and practice standards. The admitting nurse will complete a head to toe skin assessment within the first eight hours of admission. A Braden Scale will be completed within the first eight hours of admission and weekly for the next four weeks. Based on the Braden score, appropriate interventions will be implemented. Treatment orders will be obtained as part of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Based on resident's history, clinical status, head to toe assessment, and Braden Scale, an acute temporary care plan should be initiated, or wound/skin care plan focus areas may be entered into the long term care plan. Interventions to promote healing and/or prevent breakdown may include incontinence management, a turning and repositioning care plan, initial treatments, off-loading devices and any other pressure relieving strategies and resident's goals for treatment. Based on individual resident preferences and needs a more comprehensive plan for skin management may be initiated. Using the Pressure Injury QA (quality assurance) Investigation tool, the DON/designee will evaluate the cause of all new in-house acquired pressure injuries. This will be initiated during the next business day following identification of a pressure wound. Based on this evaluation additional interventions may be implemented. III. Failure to prevent pressure injuries for Resident #86 A. Resident #86's status Resident #86, age 80, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She required extensive assistance from two staff members with all activities of daily living. She was identified at risk for developing pressure ulcers, and was marked as admitted with one deep tissue injury (DTI,contrary to the initial skin assessment below). She was utilizing a pressure reducing device in bed and wheelchair. B. Record review The Braden Scale for Predicting Pressure Ulcer Risk assessment was conducted on admission [DATE]. The resident's score was 12, high risk for developing pressure ulcers. The baseline care plan (documented on paper, not part of electronic medical records) initiated on admission on [DATE], revealed the resident was totally dependent on two staff members for bed mobility, transfers, and toileting. She had 20 staples on her left hip that required daily dressing changes. Turning and repositioning and cushions or wedges were listed under skin breakdown interventions. The summary of the baseline care plan included a note that the resident was at risk for skin breakdown due to incontinence and immobility. She did not have any breakdown. Interventions included frequent checks for toileting and repositioning. -No turning or repositioning schedule was documented. -The comprehensive care plan did not include a section for skin integrity or ADLs. The section for nutrition, initiated on [DATE] and revised on [DATE], revealed the resident required additional nutritional supplements due to DTI on the left heel and unstageable tissue damage (UTD) on coccyx. Interventions included to assist the resident with meals and to provide supplements for wound healing. -The care plan did not include any interventions related to skin care, pressure injury prevention or post surgery hip precautions. The acute temporary care plan (documented on paper, not part of electronic medical records), initiated on [DATE] with no revision date, documented that the resident was at risk for developing/transmitting COVID-19 virus due to recent hospitalization . The interventions included to monitor for signs and symptoms of infection, wear masks and maintain social distance. -There were no other ongoing acute concerns documented on the care plan. The initial skin assessment dated [DATE] documented skin was clean, warm, and dry. Left hip had an incision measuring 17 centimeters (cm) with 20 staples and no signs of infection. The resident had no [CONDITION(S)], her heels were intact, and her coccyx was red but blanchable. 1. Daily skilled nurses notes Daily skilled nurses notes between [DATE] and [DATE] did not mention skin concerns and skin sections on the notes were left blank. -On [DATE] the notes documented left heel was boggy and skin prep was applied, bunny boots were placed on. The rest of the skilled nurses notes between [DATE] and [DATE] documented the presence of the incision on the left hip. The status of the left heel was not mentioned (even though per wound care notes, see below, the resident was treated by a wound care physician starting [DATE]). -On [DATE] the note revealed the resident had an open area on her coccyx. Measurements, description, further actions and interventions were not mentioned on the note. The skilled nurses notes between [DATE] and [DATE] documented that the dressing to coccyx was changed, and skin prep applied to the left heel on one occasion. There were no additional skilled notes after [DATE]. 2. Wound care physician notes The wound care physician notes revealed that the resident was seen by the wound care physician as early as [DATE] for a DTI to the left heel, and on [DATE] she was seen for a coccyx wound. -On [DATE] the resident was seen for unstageable DTI to the left heel measuring 1.2 cm by 1 cm. with recommendations to apply skin prep once a day for the next 30 days, float heels in bed, off-load wound and reposition the resident per facility protocol. -On [DATE] the resident was seen for an unstageable DTI to the left heel measuring 0.9 cm by 1.5 cm with the same recommendations. The wound was healing and decreasing in size. In addition, a new unstageable wound to the sacrum was documented as unstageable due to necrosis full thickness wound measuring 5.5 cm by 7.1 cm. Debridement was completed the same day. The resident's family was notified and consented to further treatments. Recommendations included to apply santyl dressing with oil [MEDICATION(S)]. -On [DATE] the wound care physician documented the resident continued to have two wounds. Wound #1 was to the left heel measuring 1.1 cm by 1.4 cm with no changes. Wound #2 on the coccyx was debrided and staged as stage four full thickness measuring 8 cm by 9.8 cm and was deteriorating. It was noted that given the patient's overall poor prognosis the wound could represent a Kennedy ulcer. Recommendations included santyl with calcium alginate dressing with an ointment. The family was in agreement with the plan of care and was considering a hospice evaluation for the resident. 3. Wound care treatments on the TAR between [DATE] and [DATE] The order for skin prep to both heels every shift for boggy heels was initiated on [DATE] (four days after admission). On the same day the order was added to make sure the resident had blue/bunny boots to both feet when in bed every three hours for boggy heels. The TAR was consistently signed for both orders. The order between [DATE] and [DATE] documented: cleanse area with normal saline, pat dry. Apply Santyl (edge to edge) with [MEDICATION(S)] to wound bed, cover with dry dressing daily, one time a day for Wound Care Coccyx. -The treatment was not signed as completed on two occasions ([DATE] and [DATE]) out of seven. The order between [DATE] - [DATE] documented: cleanse coccyx wound with Dakin's solution, pat dry. Apply Santyl/Alginate calcium/Mupuricon mixture (edge to edge). Cover with padded sacral dressing daily, one time a day for Wound care Coccyx. -The treatment was not signed as completed on one occasion ([DATE]) out of three. 4. Primary care physician (PCP) note PCP #1 on ,d+[DATE] 21 documented the following progress note: Unfortunately, patient's development and rapid deterioration of wounds is anticipated and unavoidable in the setting of significant dementia and severe protein calorie malnutrition coupled with very poor mobility and limited ability to reposition due to left hip precautions and use of abductor pillow while in bed. 5. Medical director note The medical director note on [DATE] documented: I was asked by the facility to review the care of [Resident #86] and provide an opinion regarding her wounds. I have reviewed her overall care since admission on [DATE] and I have examined her personally, once on admission and again on [DATE]. Briefly, she is an 80 yof w (year-old female with) advanced dementia, dysphagia, protein calorie malnutrition and history of multi falls. Shortly after arrival, she was noted to have left heel DTI on [DATE] and a few days later a stage 4 sacral Pressure Injury. Wound care services have been seeing her and notes are well documented. It is not uncommon for a DTI and Pressure Injury to become obvious several days to 2 weeks after the initial insult. These are deep injuries, involving muscle and periosteum. This sort of injuries are even more troubling in a patient like [Resident #86]. She had a significant general decline as evident by very poor nutritional status and multiple other comorbids listed by her attending physician. It is my opinion that unfortunately [Resident #86] is suffering from End Stage Skin Failure in addition to, or resulting from, other significant medical issues listed. Unfortunately, she will continue to decline despite best efforts and treatments provided. Her current DTI and Pressure Injury have not been avoidable and she remains at high risk of further decline. C. Resident interview and observations The resident was interviewed on [DATE] at 12:27 p.m. She was in bed, positioned on her back. She stated she was doing well today. She said she did not have any pain, or discomfort. She was nor aware if she had any wounds. An alternating air mattress was observed on her bed; the setting on the mattress was comfort level three. No blue boots were observed on her feet/legs. -at 2:15 the resident was observed in bed on her back, blue boots off -at 3:40 p.m. the resident was in bed on her back, blue boots on -at 4:45 p.m. the resident was in bed on her back, blue boots on On [DATE] the resident was observed at 9:45 a.m., she was positioned on her back in bed, blue boots on -at 10:50 a.m. the resident observed on her back in bed blue boots on -at 11:20 a.m. the resident in bed on her back, blue boots on -at 1:30 p.m. the resident in bed on her back, blue boots on D. Wound care observations Wound care observations were conducted on [DATE] at 2:00 p.m. in the presence of wound care physician #1. Wound #1 on the left heel measured 1.2 cm by 0.9 cm., appeared as a dry scab with no redness, no discharge, no pain with touch. It was classified as a DTI and was improving. The wound was open to air. Wound #2 on the coccyx was covered with foam dressing with no date on it. The dressing was removed with moderate dark yellow drainage. The wound measured 8.0 cm by 9.8 cm. The appearance of the wound was dark yellow to black with a foul odor. Redness around the wound bed was extending to about 1 cm. The wound care physician #1 described the wound as 100 percent necrotic tissue with moderate drainage. He completed debridement of the wound. He stated the wound deteriorated since last week, the tissue appeared infected and the resident would require antibiotics. E. Staff interviews Wound care physician #1 was interviewed on [DATE] at 5:30 p.m. He said Resident #86 was likely having Kennedy ulcers. He said currently her coccyx wound was a stage four pressure injury with potential infection to the tissue and bone. He said he discussed wound conditions with the resident's daughter and she was looking for a hospice evaluation. The treatment would depend on if the family elected hospice care or not. He said the wound dramatically deteriorated since last week, the same as the resident's overall condition. He said his recommendations were documented in his wound care notes and included dressing changes and general nursing care such as turning and repositioning the resident. He said the resident was on an air mattress, however it was not a substitute for turning and repositioning. He said the resident should be turned and repositioned at least every two hours. Considering that she was after the hip surgery and still had an abductor pillow in place, her weight should be offloaded since she could not be completely on one side. He said his expectations were that dressings should be labeled with the date and he routinely reminded staff to date dressings. However, on several occasions with different residents once in a while he ran into undated dressing in the facility. He said to his knowledge the resident was admitted with both wounds. Later he corrected himself and stated he had a different date of admission for the resident. He said based on the date of admission [DATE], wounds were considered to be acquired in the facility. Regarding Kennedy ulcers he said it was a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he could not say with certainty one way or the other because he did not follow the resident prior to [DATE] and did not know if all recommended interventions for prevention of pressure injuries were in place. Registered nurse (RN) #2 was interviewed on [DATE] at 2:30 p.m. She said she was the regular nurse who worked morning and day shift on the rehab unit and was familiar with Resident #68. She said the resident was admitted after hip surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident was declining and the family was considering hospice care. Regarding the wounds she said the resident had an open wound stage 4 on her coccyx and healing DTI to the left heel. She said she changed dressings daily for the coccyx wound and it was not improving. She said ideally skin conditions should be documented under skilled nurses notes or weekly skin assessments. She said recently the template for the skilled nurses notes changed and it was confusing what and where they should be documented. She said she made an effort to document every day, but probably missed a few days as sometimes was too busy to document. Regarding the air mattress she said she would usually ask the patient if they were comfortable with the setting and if so, leave it on that setting. Regarding the resident's position being on her back, she said the resident probably was on the side and currently was repositioned to her back. She said ideally the back should be avoided, but in her situation with an abductor pillow it would be difficult. She said the resident did not refuse care and always was cooperative. The medical director was interviewed on [DATE] at 3:30 p.m. He said his role in wound care in the facility was to review the wound care notes, track progress, incidents, and prevalence of pressure ulcers as well as review the plan of care for residents. He said every resident who had wounds (regardless of the origin) in the facility was followed by a wound care physician. He said he reviewed the record for Resident #86 and documented his opinion. In his opinion the resident was suffering from end stage skin failure that occurred due to other medical conditions that the resident had. He believed the resident was admitted to the facility with existing compromised skin conditions, and it is documented in literature that skin injuries in some cases could appear as late as 14 days after the actual injury to the tissue. He said considering the overall medical condition of Resident #86 he believed that her wounds were unavoidable. His expectations were that nurses would complete Braden assessments in conjunction with head to toe skin assessment and put in place specific interventions to prevent the development of pressure ulcers upon admission. He said in his review he focused on medical diagnoses, medical conditions and treatments. He did not review the nursing care. CNA #3 was interviewed on [DATE] at 4:30 p.m. He said he was working PRN (as needed) and worked different shifts. He said he was familiar with the resident and assisted her with meals. He said the resident was repositioned every two hours. He said all care was documented in the computer under tasks. He attempted to log in to show where he documented the care, but was unable to do so as his password expired and he was not sure how to reset it. CNA #2 was interviewed on [DATE] at 10:30 a.m. She said the resident required assistance with feeding, bed mobility and pretty much everything else. She said the resident was offered to be repositioned frequently but she usually refused as she was more comfortable on her back. She said she would communicate refusals to nurses, but she did not have any place to document that the resident refused. The assistant director of nursing (ADON) was interviewed on [DATE] at 12:21p.m. She said she was working in the facility for the last three weeks. Her responsibilities included auditing health records, overseeing grievances, and participating in wound rounds and care conferences. She said on admission the resident's skin condition was assessed and all documented under initial assessment notes. All residents were assessed for risk of developing pressure injuries on the Braden scale, and if scored high, immediate interventions such as turning and repositioning, proper mattress surface should be put in place. She said all interventions must be documented on the care plan for nurses to be aware what care the resident required and in addition it should be documented under tasks to ensure that CNAs were aware and completed the tasks. She said all residents after hip fractures were at increased risk of developing pressure injuries due to decreased mobility. She said she did not audit the records for Resident #86 because she was working primarily in a long term care section of the facility. The rehabilitation section was covered by another nurse manager whose last day of work was one day prior to the day of the interview. Regarding air mattresses that were used in the facility, she said she was not familiar with this type of mattress, so she never did set it up and did not know what settings it should be set to. The director of nurses (DON) was interviewed [DATE] at 2:30 p.m. in the presence of the nurse consultant and ADON. She said to her knowledge the resident was admitted with both wounds and they were deteriorating due to overall medical conditions. She said the resident was followed by the wound care team and received appropriate treatments. She said the care plan was missed for unknown reasons but she believed the resident received appropriate care and unfortunately that care was not documented. Regarding the mattress, she said she was not familiar with this type of matters, never set it up and did not know who was in charge of making sure it was set to the appropriate setting. The quality management specialist (QMS) was interviewed on [DATE] at 2:30 p.m. She said it was a nursing responsibility to be familiar with the type of mattresses that were used and appropriate settings that they should be set to based on individual resident needs. She said turning and repositioning was an intervention that was automatically applied to every resident with decreased mobility. She said usually it was not documented as a separate task under CNA care. However if a resident's condition was complicated and required specific interventions, it should be documented. She said Resident #86 did require specific interventions because she had an abductor pillow that would make it more challenging to off load the weight. IV. Resident #15 A. Resident status Resident #15, age greater than 90, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 12 out of 15. He required two-person extensive assistance for bed mobility, transfers, dressing, and toilet use. He required one-person extensive assistance for personal hygiene. He was at risk of developing pressure ulcers/injuries, however he did not have any pressure ulcers/injuries at the time of the [DATE] MDS assessment. B. Record review The [DATE] Braden Scale assessment (a guide utilized for assistance with predicting pressure ulcer risk) documented Resident #15 was not at risk for developing pressure ulcers based on a score of 19 out of 23 (a higher score indicates less risk of developing pressure ulcers). Review of Resident #15's baseline care plan, which was initiated on [DATE], revealed the resident had the potential for skin breakdown related to urinary incontinence and decreased mobility due to his left [CONDITION(S)]. Pertinent interventions included an alternating pressure mattress (APM), encouraging resident to reposition, and promoting adequate nutrition. -The baseline care plan did not include an intervention for floating Resident #15's heels off of the mattress. -Despite diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #15 was slightly limited in mobility: able to make frequent though slight changes in body or extremity position independently; and he had no apparent problem with friction or shear: moved in bed and in chair independently and had sufficient muscle strength to lift up completely during movement. Resident #15's Nursing Admission Screening assessment dated [DATE] documented the resident had a dressing to two incisions on his left hip, a bruised left upper arm, and his skin was otherwise clean, dry and intact upon admission to the facility on [DATE]. Review of Resident #15's comprehensive care plan, which was initiated in the electronic medical record (EMR) on [DATE], after the resident developed the DTI to his left heel, revealed the resident was at risk for skin breakdown and included interventions for daily skin checks by certified nurse aides (CNAs) during activities of daily living (ADLs), floating heels in bed as tolerated, and skin prep to heels two times per day. Review of progress notes for Resident #15 revealed the following: [DATE]: Incision to left hip with dressing (bruising noted around dressing). Left arm in sling with bruising to left arm. [DATE]: A practitioner/provider note documented in pertinent part, On exam, also has blanchable (turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed) redness to [MEDICATION(S)] spine and mid/upper back. High risk for developing pressure injury/skin breakdown. Reviewed all this with daughter. Requested the wound team to follow-up on skin and registered dietician (RD) to follow-up on supplem[TRUNCATED]

Based on interviews, observations and record review, the facility failed to ensure the pain of one (#290) of three of 41 sample residents was managed in a manner consistent with the resident's goals and preferences. Specifically, the facility failed to take steps to manage Resident #290's pain through timely response to his requests for pain medication and the development and implementation of resident-specific non-pharmacological interventions. The facility failures contributed to an increase in severity of the resident's pain. Findings include: I. Facility policy and procedure The Pain management policy, revised on 4/5/15, was provided by the vice president of clinical operations (VPCO) on 6/28/18 at 3:40 p.m. It revealed, in pertinent part, The primary focus of the pain management program is resident comfort and well-being. The pain interview will include: .what makes the pain better or worse, including non-pharmacological interventions. The resident care plan focus statement should include personalized information gathered during the interview. The Medication administration general guidelines, revised on 9/1/16, was provided by the director of nursing (DON) on 6/28/18 at 4:15 p.m. It revealed, in pertinent part, Medications will be administered in accordance with written orders authorized by the attending physician or designee. Medications will be administered based on the resident's schedule and preferences as well as specific medication and physician requirements. II. Resident #290 A. Resident status Resident #290, age 65, was admitted on [DATE] from the hospital where he had undergone spinal fusion surgery. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 6/21/18 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. Record review revealed documentation the resident experienced a high level of pain; however, the documentation failed to include the resident's preferred non-pharmacologic interventions to manage his pain: -The 6/14/18 pain interview and evaluation completed by nursing revealed the resident had experienced a 10 out of 10 pain level (with 10 being the worst pain) since he had been admitted to the facility. He identified his accepted level of pain was a level 2 out of 10. The 6/14/18 pain interview and evaluation did not include information on the resident's preferred non-pharmacologic interventions for managing his pain or information on what historically made the pain better or worse. -The 6/14/18 nursing admission screening revealed the resident had pain but it, too, did not indicate what non-pharmacological interventions were effective in relieving his pain. -The 6/21/18 MDS indicated the resident had a scheduled and an as needed (PRN) pain medication regimen. It further revealed the resident had frequently experienced pain during the assessment period. The resident said the pain made it difficult to sleep at night and limited his day-to-day activities. The MDS documented the resident experienced a 9 out of 10 pain level. Record review revealed the resident's pain management plan was as follows: -The (MONTH) (YEAR) CPO revealed the resident had orders to receive the following medications for pain: -- [MEDICATION NAME] Ointment 5% apply to bilateral knees and back topically for [MEDICAL CONDITION] pain - ordered on [DATE]. -- [MEDICATION NAME] extended release 15 MG by mouth every 12 hours for acute postoperative pain for 14 days - ordered 6/15/18. -- [MEDICATION NAME] capsule 300 milligram (MG) by mouth two times a day for [MEDICAL CONDITION] pain and give 600 MG by mouth at bedtime for [MEDICAL CONDITION] pain - ordered on [DATE]. -- [MEDICATION NAME] HCI tablet 10 mg by mouth every six hours as needed for pain 7-10 level - started on 6/24/18. -- [MEDICATION NAME] tablet 750 mg by mouth every eight hours as needed for muscle spasms - ordered on [DATE]. -The resident's chronic pain care plan, initiated on 6/26/18, revealed the resident had chronic pain located in the back and knees. It indicated the nursing staff would offer non-pharmacological interventions along with scheduled and PRN pain medication. Interventions included: offer non-pharmacological interventions for pain first i.e. ice, heat, repositioning, and so on. The care plan did not indicate whether the non-pharmacological interventions listed represented the resident's preferred and/or historically effective methods to assist in managing his pain. B. Failure to take steps to manage Resident #290's pain through timely response to his request for pain medication and implementation of preferred and/or effective non-pharmacologic interventions to relieve pain. Observations, interview and record review revealed the resident expressed high levels of pain that were neither timely nor comprehensively addressed by staff and which resulted in an increase in the resident's level of pain. 1. Interview and record review the morning of 6/25/18 Resident interview: The resident was interviewed on 6/25/18 at 11:30 a.m. He confirmed he had recently had spinal fusion surgery. He said he had been in a lot of pain since his surgery. He said the pain affected his sleep and his ability to participate in activities of daily living. -He said he was on a scheduled pain medication regimen and as needed (PRN) pain medication. He said his PRN pain medication had recently been reduced on 6/24/18 from every four hours to every six hours. He said since his admission, the nursing staff had been slow to provide his PRN pain medication at times, including this morning (6/25/18). -He said because of this, the nurse practitioner (NP) had encouraged him to notify the nursing staff 20 minutes before his PRN medication was due if he needed it in order to ensure he received the medication on time. He said he activated his call light at 7:15 a.m. this morning and notified the nurse he was in misery with pain. He said he reminded her the medication was due at 7:30 a.m. He said after informing him the medication was not due yet, the nurse did not offer any non-pharmacologic interventions to address his pain and she did not return to his room with his PRN pain medication until 8:40 a.m. He said his pain continued to worsen while he waited over an hour for the nurse to return. He said his pain level was initially a level 7 out of 10 but was a level 9 out of 10 when the nurse returned with his pain medication. Record review: The 6/25/18 physician progress notes [REDACTED]. Review of the (MONTH) medication administration record (MAR) revealed on 6/21/18, the resident received his PRN medication (at that time available every 4 hours) at 2:00 a.m. and then not again until 11:59 a.m. This represented 10 hours between the administration of the PRN medication. The (MONTH) (YEAR) MAR also revealed the resident was administered PRN [MEDICATION NAME] 10 mg on 6/25/18 at 1:00 a.m. (pain level 8 out of 10) and then again at 8:32 a.m. (seven hours and 32 minutes in between doses, pain level 9 out of 10) although, per the 6/25/18 orders (see above), the resident was able to receive the PRN [MEDICATION NAME] at 7:00 a.m. The resident received his pain medication an hour and a half after it was available to him and almost an hour after he made his request for the medication to the nurse. 2. Observations, interview and record review the afternoon on 6/25/18 afternoon. Observations and resident interview: The resident was observed on 6/25/18 beginning at 2:07 p.m. until 3:20 p.m. The resident sat in the hallway next to the nursing medication cart. He informed the nurse at 2:07 p.m. that his medication was due in approximately 20 minutes. He informed the nurse he was in a lot of pain. The nurse told the resident his medication was not due yet and she would administer it when it was due. She was observed walking away from the resident down the hallway. She did not offer any non-pharmacological interventions to address the resident's pain. The resident continued to sit by the nursing medication cart, waiting for his medication. The resident appeared agitated and in distress, furrowing his brow and squinting. He moved his wheelchair back and forth, fidgeted with his hands and placing his hands by his mouth and rubbing his brow and cheeks. The resident was interviewed again at 2:45 p.m. He said he was very upset. He said he reminded the nurse his pain medication was due soon and she had not come back to the medication cart to administer it. He said he always reminded the nursing staff when he was in a lot of pain, approximately 20 minutes before the medication was due, in an attempt to receive the medication on time and relieve his pain. He said his pain level continued to increase while he was waiting for the medication. He said, initially, he started at a level 7 out of 10 but now his pain level was 8 out of 10. At 2:48 p.m., the resident was observed wheeling himself back to the nursing medication cart. The resident continued moving his wheelchair back and forth, fidgeting with his hands. He was observed verbalizing he was in pain to another staff member who indicated she would inform his nurse. At 3:05 p.m. the nurse returned to the medication cart and informed the resident she would administer his pain medication right then. She was observed administering the resident's pain medication at 3:10 p.m. The resident was observed at 3:40 p.m. He was sitting comfortably in his wheelchair, not moving back and forth, speaking with his wife. The resident had a pleasant expression on his face and smiled at his wife. Record review: The (MONTH) (YEAR) MAR revealed the resident was administered [MEDICATION NAME] 10 mg on 6/25/18 at 3:10 p.m., six hours and 40 minutes following the previous dose administered at 8:32 a.m. His pain level was documented as 8 out of 10. Per the 6/25/18 orders and the resident's previous PRN pain medication administration, the resident was able to receive [MEDICATION NAME] medication at 2:32 p.m. The resident was not administered the medication until 40 minutes after the prescribed time. 3. Observations and interview the morning of 6/27/18 The resident was observed on 6/27/18 at 8:30 a.m. sitting in his wheelchair in his room. A certified nurse aide (CNA) entered the room to deliver his breakfast. She asked how he was feeling and the resident responded he was in a lot of pain. At 8:53 a.m. registered nurse (RN) #2 was observed entering the room. She informed the resident the CNA had reported he was in pain. She told him she would be right back with pain medication. She did not offer the resident any non-pharmacological interventions to relieve his pain. After leaving the resident's room, RN #2 was observed at the medication cart opening up the narcotic count sheet and the locked narcotic drawer. She was observed punching out a medication from the narcotic drawer and putting it in the medication cup along with the resident's other morning medications. At 9:00 a.m. RN #2 entered the resident's room to administer the medications. Resident interview: The resident was interviewed on 6/27/18 at 10:26 a.m. He said he was in a lot of pain this morning prior to receiving his scheduled pain medication at 9:00 a.m. He said no one offered to provide any non-pharmacological interventions after he had reported to the CNA he was in a lot of pain at 8:30 a.m. C. Staff interviews Staff interviews confirmed the facility, in not administering Resident #290's PRN pain medication timely and in not developing and implementing non-pharmacological interventions, failed to manage the resident's pain in a manner consistent with his goals and preferences. RN #1 was interviewed on 6/28/18 at 10:28 a.m. She said a pain assessment was completed upon admission, every shift and before and after pain medication was administered. She said the goal of pain management was to ensure the resident was comfortable and was at their accepted level of pain. -She said non-pharmacological interventions should be provided prior to administering PRN pain medications. She said typically the facility provided re-positioning as a pain intervention. She said non-pharmacological interventions should be documented when attempted on the MAR and the nursing progress notes. She said each resident should be asked upon admission what non-medication pain interventions had worked in the past. She said that should be documented on the pain assessment. -She said PRN pain medications should be administered upon resident request as long as the request fell within the time period indicated in the physician's orders [REDACTED].>The assistant director of nursing (ADON) #2 was interviewed on 6/28/18 at 11:50 a.m. She said a pain assessment was conducted upon admission and as needed. She said a pain scale was conducted every shift and documented on the MAR or the nursing progress notes. -She said each resident upon admission, should be asked what non-medication interventions have assisted with pain in the past. She said it should be documented on the initial pain assessment and carried over to the care plan. She said the facility's standard non-medication interventions included re-positioning, heat, ice, and so on. She said non-medication interventions should be attempted before PRN pain medication was administered to the resident. She said each attempt should be documented on the MAR and the nursing progress notes. -She said PRN pain medication should be administered to the resident when his or her pain was not being controlled with non-pharmacological interventions or if a resident refused non-pharmacological interventions, and should be given within the time period specified on the physician's orders [REDACTED].>-She confirmed the documentation in the resident's medical record revealed only re-positioning had been attempted. She confirmed the resident's medical record did not identify any interventions the resident had attempted and been successful with in the past. She confirmed if repositioning did not provide relief for the resident, other non-pharmacological interventions should have been attempted and documented. -She confirmed the resident had been routinely requesting the PRN pain medication. She confirmed the resident's accepted level of pain was a 2 out of 10. -She agreed the resident should have been administered his PRN pain medication in a timely manner. She agreed the facility was not meeting the resident's pain needs. She said there was no reason why the nurses did not administer the medications once they were within the identified time-period according to the physician order. -She confirmed the resident should have been administered the as needed pain medication on 6/25/18 at 7:15 am. when he requested it, that staff should have attempted non-pharmacological interventions on 6/25/18, when the resident requested his PRN pain medication at 2:07 p.m. and that the PRN medication should have been administered at 2:32 p.m. The NP was interviewed on 6/28/18 at 1:00 p.m. She said the resident was recently admitted to the facility due to spinal fusion surgery. She said the resident had a history of [REDACTED]. She said pain management was important to ensure the resident was able to participate during therapy services. She said if his pain was not being managed it could hinder his progress with therapy and ultimately his discharge home. She said the resident's goal was to return home with his spouse. -She confirmed the resident was anxious regarding the 6/25/18 pain medication reduction and had expressed difficulty receiving his PRN pain medication on time since his admission to the facility. She confirmed she had advised the resident to request his pain medication, if he needed it, 20 minutes prior from the nursing staff to ensure it would be administered on time. -She agreed the resident should be given the PRN pain medication when he requested it, as long as the time was within the identified parameters on the physician order. The director of nurses (DON) was interviewed on 6/28/18 at 12:45 p.m. She said a pain assessment was conducted upon admission, quarterly, change of condition and as needed. She said the goal of pain management was to reduce the resident's level of pain, provide comfort, increase the resident's quality of life and enable the resident to participate in activities they choose. -She said non-pharmacological interventions should be attempted before PRN pain medication was administered. She said each non-pharmacological intervention should be based off the resident preferences and should be identified upon admission. She said non-pharmacological interventions should be documented on the MAR and in the nursing progress notes. -She said as needed pain medications should be administered following a failed non-pharmacological approach, if the resident is showing signs and symptoms of pain, and when requested by the resident. She said the only time a PRN pain medication should not be administered is when a resident request is outside the time period indicated on the physician order. -She agreed the facility was not managing the resident's pain by not providing the PRN pain medication upon his request. She confirmed the resident's PRN medication had been administered late twice on 6/25/18, stating the medication should have been administered when the resident requested it.