Every finding on record at Ridgeview Post Acute

Based on record review and interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with state law for four of four allegations of abuse.Specifically, the facility failed to:-Report an allegation of physical abuse between Resident #1 and Resident #2 on 11/18/25 within two hours of the incident; .-Report an allegation of physical abuse between Resident #3 and Resident #4 on 1/19/26 within two hours of the incident;-Report an allegation of physical abuse between Resident #5 and Resident #6 on 2/8/26 within two hours of the incident; and,-Report an allegation of physical abuse between Resident #4 and Resident #11 on 3/22/26 within two hours of the incident.Findings include:I. Facility policy and procedureThe Abuse Prevention and Reporting policy, revised June 2025, was provided by the nursing home administrator (NHA) on 4/7/26 at 2:32 p.m. It read in pertinent part, The administrator/designee will complete the initial report to the state survey and certification agency within 24 hours electronically via the occurrence reporting portal and complete the report within five days from the initial report.-However, the facility was required to report any abuse allegations within two hours of the incident.II. Record reviewThe facility investigations for four physical abuse allegations were provided by the NHA on 4/7/26 at 9:00 a.m. The investigations documented the following:The alleged physical abuse between Resident #1 and Resident #2 occurred on 11/18/25 at 8:20 a.m. -However, the facility reported the alleged abuse on 11/19/25 at 10:22 a.m., 26 hours after the incident occurred.The alleged physical abuse between Resident #3 and Resident #4 occurred on 1/19/26 at 5:00 a.m. -However, the facility reported the alleged abuse on 1/19/26 at 7:07 p.m., 14 hours after the incident occurred.The alleged physical abuse between Resident #5 and Resident # 6 occurred on 2/8/26 at 8:30 a.m. -However, the facility reported the alleged abuse on 2/8/26 at 9:40 p.m., 13 hours after the incident occurred.The alleged physical abuse between Resident #4 and Resident #11 occurred on 3/22/26 at 11:59 a.m. -However, the facility reported the alleged abuse on 3/23/26 at 11:56 a.m., 24 hours after the incident occurred.III. Staff interviewsThe NHA, the director of nursing (DON) and the clinical resource nurse were interviewed together on 4/8/26 at 2:09 p.m. The NHA said he thought the two hour rule for reporting abuse allegations applied only to those allegations which resulted in serious bodily harm. The NHA said he was provided guidance by a consultant on 4/7/26 that physical abuse allegations had to be reported within two hours. The NHA said he would look at the facility's policy and change the policy accordingly if it did not align with the guidance that was provided to him. The clinical resource nurse said she showed the NHA the occurrence reporting manual. The clinical resource nurse said the facility missed the two hour reporting guidelines for the four physical abuse allegations.

Based on record review and interviews, the facility failed to ensure one (#3) of four residents reviewed out of 16 sample residents was kept free from resident-to resident physical abuse.Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/6/26 to 4/8/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/25/26.I. Incident of physical abuse by Resident #4 toward Resident #3 on 1/19/26On 1/19/26 at 5:00 a.m. certified nurse aide (CNA) #3 heard activity from the room shared by Resident #3 and Resident #4. When CNA #3 entered the residents' room, she observed Resident #4 was standing near Resident #3's bed and was attempting to remove a pillow from beneath Resident #3's head. CNA #3 separated the residents and assisted Resident #4 to her side of the room. Approximately 20 minutes later, CNA #3 saw Resident #4 take a pillow from her own bed and go to Resident #3 and Resident #4 hit Resident #3 three times with the pillow. Resident #3 was upset and was screaming get her away from me! CNA #3 intervened and redirected Resident #4. II. Facility action to correct the deficient practiceThe facility moved Resident #3 to a different room on 1/19/26 and Resident #4 was no longer assigned a roommate.Resident #4 continued with one-to-one supervision during waking hours and did not have any additional roommates after the incident between her and Resident #3.The facility implemented a new process after the 1/19/26 incident, which included staff obtaining and completing an abuse packet immediately after an incident.The facility discussed the 1/19/26 physical abuse incident between Resident #4 and Resident #3 in the facility's monthly quality assurance performance improvement (QAPI) meeting.-However, on 3/22/26, Resident #4 had an encounter with another resident where Resident #4 held onto another resident's arm lightly for a few seconds and then let go. The facility did not substantiate the encounter as abuse, however the encounter prompted the facility to provide further abuse education with staff (see below). On 3/24/26, the assistant director of nursing (ADON) provided education regarding redirecting residents using snacks and activitiesThe education included information about why redirection works, redirection instructions, helpful phrases to use, reminders and specific interventions for Resident #4, including offering snacks that she preferred, such as chocolate pudding and oatmeal cookies, redirection to her room and resident preferences for specific games. The education was only signed by 15 nursing staff members.However, on 3/25/26, the clinical resource nurse provided further in-depth education to all staff regarding abuse prevention and management. The education included definitions of abuse, tips for preventing abuse and who staff should report allegations of abuse to. The education was signed by 52 staff members from all disciplines.III. Facility policy and procedureThe Abuse Prevention and Reporting policy, revised June 2025, was provided by the nursing home administrator (NHA) on 4/7/26 at 2:32 p.m. It read in pertinent part, It is the policy of this facility that residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation. Residents will not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff or other agencies serving the residents, family members or legal guardians, friends or other individuals. All allegations of abuse are investigated. Any staff member who has reasonable cause to believe or reason to suspect any situation that may be considered abuse will immediately report to the charge nurse. The staff member will intervene and ensure that the resident is safe. Make sure that all residents are kept safe during the investigation. If a resident is the assailant, make sure that they are kept out of the reach of other residents and increase monitoring of the assailant.IV. Facility investigation of the abuse incident between Resident #4 and Resident #3 on 1/19/26The facility's abuse investigation was provided by the NHA on 4/7/26 at 9:00 a.m.The facility documented the date of the incident as 1/19/26 at 5:00 a.m.The facility investigation documented CNA #3 heard activity from the room shared by Resident #3 and Resident #4. It documented when CNA #3 entered the room, she observed Resident #4 was standing near Resident #3's bed and was attempting to remove a pillow from beneath Resident #3's head. It documented Resident #4 then picked up a pillow and made contact with Resident #3 with the pillow. It documented CNA #3 intervened and redirected Resident #4.The facility's investigation concluded that there was a verbal exchange between Resident #3 and Resident #4 and Resident #4 used a pillow and made contact with Resident #3. It documented information that was obtained through interviews, chart review and assessments did not result with any significant findings. -However, a witness interview revealed Resident #3 was upset after the incident (see interview below) and Resident #3 was moved to a different room.V. Resident #4 (assailant)A. Resident statusResident #4, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included dementia, insomnia, chronic obstructive pulmonary disease (COPD - a lung disease) and depression.The 3/7/26 minimum data set (MDS) assessment identified Resident #4 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #4 required set-up assistance with eating, was able to transfer herself independently and required substantial assistance with dressing and showering.The MDS assessment identified Resident #4 had wandering behavior one to three days per week. B.Observation and interviewOn 4/6/26 at 10:15 a.m. Resident #4 was in her room. The resident had no roommate and had a CNA in her room providing one-to-one observation and assistance for the resident. The CNA was sitting in the corner of the room and Resident #4 was sitting up in her bed and was anxious, rocking back and forth. Resident #4 said her previous roommate made a lot of noise. Resident #4 said she did not remember any incidents with other residents, including her previous roommate, at the facility.C. Record reviewResident #4's potential for behavior problem verbal/physical aggression related to dementia diagnosis care plan, revised 4/6/26, revealed Resident #4 had a history of being physically aggressive towards others, a history of saying she would kill staff and would make repetitive statements, such as I hate you and I hate living here. The care plan documented Resident #4 perseverated on various topics that made her upset, even if they had been addressed and resolved. The care plan documented Resident #4 had a history of being verbally rude to others around her, had thrown food, drinks and markers at other residents, had pulled the hair bow of another resident and had thrown and hit others with pillows. The care plan documented triggers for Resident #4 included touching her items, crowds, strangers or doing something from behind her. Pertinent care plan interventions included ensuring Resident #4's hearing aids and glasses were used when needed, having the resident's room located next to the nurses' station, providing activities of interest, anticipating and meeting the resident's needs, encouraging the resident to express feelings appropriately, decreasing interactions with other residents as able, keeping her at arm's length from others when able, providing distraction and redirection as needed, educating family/caregivers on successful coping and interaction strategies, encouraging more days at her senior day care offsite facility and providing one-to-one observation with staff during waking hours.A nursing progress note, dated 1/19/26 at 1:46 p.m., documented the nurse was notified by a CNA that Resident #4 was witnessed throwing a pillow towards her roommate (Resident #3). The note documented the pillow made contact with Resident #3 before the CNA could intervene. The note documented the CNA separated the residents. The note documented Resident #4 was not interviewable after the incident due to her cognition.VI. Resident #3 (victim)A. Resident statusResident #3, age [AGE], was admitted on [DATE] and discharged on 1/29/26. According to the January 2026 CPO, diagnoses included dementia, COPD, stroke and kidney disease.The 1/1/26 MDS assessment revealed the facility was unable to complete a BIMS assessment for Resident #3. The MDS assessment revealed Resident #3 required set-up assistance with eating and required substantial assistance with dressing, showering and transferring.The MDS assessment identified Resident #3 had no behavior symptoms directed toward others. B. Record reviewResident #3's potential behavioral problem, paranoia, accusatory behavior related to dementia and history of stroke, initiated 5/22/25, revealed Resident #3 at times yelled out about people on the television watching her and/or her friends, called out that she was naked when she was not and said water was cold when it was at normal temperatures. Pertinent interventions included medications as ordered with monitoring for side effects, anticipating need, approaching in a calm manner, redirecting the resident away from television when distressing to the resident, discussing behavior if reasonable, explaining and reinforcing why it was inappropriate and intervening as necessary to protect the rights and safety of others, removing the resident from the situation and taking resident to alternative location as necessary.A nursing progress note, dated 1/19/26 at 6:00 a.m., documented Resident #3 was a recipient of a physically aggressive behavior from her roommate. The note documented Resident #4 walked toward Resident #3, who was lying supine in bed. It documented Resident #4 made physical contact with Resident #3 three times before being separated by staff. It documented the incident had begun with a verbal exchange between the roommates. It documented Resident #3 said she was hit several times by her roommate for no reason and she did not hit back. The nursing note documented Resident #3 denied pain or discomfort as a result of the physical aggression by Resident #4. It documented that Resident #3 did not want to be in the same room with Resident #4 and therefore Resident #3 was moved to another room.A social services progress note, dated 1/19/26 at 1:00 p.m., documented Resident #3's representative was notified regarding the incident between Resident #4 and Resident #3. The representative was advised of Resident #3's room change, which occurred on the same day of the incident. VII. Staff interviewsCNA #3 was interviewed on 4/8/26 at 10:40 a.m. CNA #3 said she heard Resident #3 and Resident #4 arguing. She said she went into the residents' room and saw Resident #4 was standing next to Resident #3's bed and was trying to take Resident #3's pillow from under her head. CNA #3 said she separated the residents and assisted Resident #4 to her side of the room. CNA #3 said about 20 minutes later she saw Resident #4 take a pillow from her own bed and go to Resident #3 and Resident #4 hit Resident #3 three times with the pillow. CNA #3 said she removed Resident #4 from the room in her wheelchair. CNA #3 said that Resident #3 was upset and was screaming get her away from me! The NHA, the director of nursing (DON) and the clinical resource nurse were interviewed together on 4/8/26 at 2:09 p.m. The NHA said Resident #4 had been without a roommate for a long time. The NHA said Resident #4 had previously had incidents with other residents so the facility had given her a room by herself. He said the resident had not had any incidents with other residents for at least seven months (prior to the incident with Resident #3), so the facility developed a plan to determine if Resident #4 could transition back to having a roommate. The NHA said the situation with Resident #3 had been working out well and Resident #3 and Resident #4 shared a staff member who remained with them during the day, however, he said the incident 1/19/26 happened at night when the residents' room was in view of the nurses' station (directly across the hallway). The NHA said CNA #3 saw Resident #4 attempt to remove Resident #3's pillow from underneath her head. He said CNA #3 separated her from Resident #3 and then Resident #4 later hit Resident #3 with Resident #4's pillow. The NHA said CNA #3 then separated the residents and escorted Resident #4 from the room. The NHA said Resident #3 was not fearful, but was moved to another room as she did not want Resident #4 as a roommate any longer. The NHA said that Resident #3's television was on and he thought that was the reason Resident #4 went over to Resident #3. The DON said if someone destroyed another resident's peace early in the morning, he could see why the person whose peace was disrupted would be upset. The clinical resource nurse said the witness statement provided during an interview with CNA #3 was not signed by CNA #3 to confirm that she agreed with the statement. The NHA and the clinical resource nurse said they planned to ensure that witness interview statements were signed in the future. The DON said the facility had a new process which began after the 1/19/26 incident between Resident #3 and Resident #4 and included staff obtaining an abuse packet immediately after an incident. The DON said he was working with the nursing team on the process to ensure the staff members would write a statement when the incident occurred. The NHA said it made sense that Resident #3 would be upset after the incident and he said he guessed that she was upset and concerned about it at the time and this was why she was moved out of the room quickly.The NHA said multiple interventions were put into place for Resident #4 to prevent further incidents. The NHA said Resident #4 had not had a roommate since the incident between her and Resident #3. The NHA said the facility had arranged with Resident #4's representative for her to reinitiate an adult day care program which Resident #4 had attended. The NHA said the nursing and CNA staff received reeducation for abuse and dementia care. The NHA said every abuse incident investigation was discussed in the facility's quality assurance performance improvement (QAPI) meetings each month and a meeting had included the incident between Resident #4 and Resident #3.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of four medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Medications were labeled with the date it was opened; -Discontinued medications were removed from the medication cart in a timely manner; -Medications were properly disposed in a disposal receptacle; and, -Resident medication was stored in the proper location. Findings include: I. Facility policy and procedure The Storage of Medication Policy, revised [DATE], was provided by the director of nursing (DON) on [DATE] at 2:56 p.m. The policy read in pertinent part, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Eye medications are stored separately from ear medications and inhalers. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Medications awaiting destruction that can not be disposed of immediately should be recorded on a log to include the name of the individual storing the medication, resident name, the prescription number, if applicable, the quantity of the medication, the strength of the medication and the date of disposition. II. Observations and interviews On [DATE] at 12:08 p.m. the Golden unit medication cart was observed with registered nurse (RN) #3. -An opened Albuterol (inhaler) 90 micrograms (mcg) box was not labeled with the date opened for use. RN #3 said the inhaler should have been labeled with the date when it was opened. On [DATE] at 12:45 p.m. the Golden unit medication cart was again observed with RN #3. Two boxes of Haloperidol two milligrams per milliliter (mg/ml) were in the bottom drawer of the medication cart. -The medications were labeled with a resident's name who no longer resided at the facility RN #3 said the resident had been discharged approximately one week earlier and the resident's Haloperidol medications should have been given to the DON after discharge for proper disposal. On [DATE] at 2:00 p.m. the Montrose medication storage room was observed with licensed practical nurse (LPN) #5. -The medication refrigerator contained an open vial of tuberculin purified protein, five tuberculin units per 0.1 ml which was not labeled with the date the vial was opened. LPN #5 said she opened and used the medication earlier that day ([DATE]) and had forgotten to write the date opened on the vial. On [DATE] at 8:06 a.m. a white medication tablet and a beige medication tablet were observed on the floor near the Sterling unit medication room. LPN #1 took the pills to the DON to have them identified. On [DATE] at 8:13 a.m. one yellow round medication tablet was observed on the floor near the [NAME] nurses station. RN #1 took the pill to the DON to have it identified. RN #1 said medications should not be on the floor. RN #1 said the medication should have been seen on the floor and the nurse should have immediately disposed of the medication. RN #1 said nurses should stay with residents to ensure medications were swallowed. On [DATE] at 1:59 p.m., a certified nurse aide with medication authority (CNA-Med), and RN #1 administered artificial tears to Resident #31. After RN #1 administered the artificial tears to Resident #31, the resident retrieved an opened box of artificial tears from a drawer in his room and gave the box to RN #1. RN #1 said he did not know where Resident #31 got the artificial tears that he retrieved from the drawer in his room. RN #1 said Resident #31 should not have artificial tears in his room because there was not a physician's order for the resident to administer his own artificial tears. III. Staff interviews The DON was interviewed on [DATE] at 2:49 p.m. The DON said the Haloperidol found in the Golden medication cart was for a resident who was deceased on [DATE]. The DON said staff were instructed to give her all discontinued medications and she should receive discontinued medications as soon as possible after a resident had expired. The DON said staff should date medications upon opening. The DON was interviewed again on [DATE] at 9:40 a.m. The DON said the Albuterol inhaler should have been labeled with the date it was opened. The pharmacist consultant (PC) was interviewed on [DATE] at 3:33 p.m. The PC said one of the medications found on the floor of the Sterling unit was an Apixiban (blood thinner) 2.5 mg tablet. The PC said medications should be disposed of properly and nurses should stay with residents to verify residents swallowed medications or did not drop medications on the floor. The PC said the yellow medication found on the floor on the [NAME] unit was Aspirin 81 mg. The DON was interviewed a third time on [DATE] at 3:46 p.m. The DON said the white tablet found on the floor near the Sterling unit medication was an acetaminophen 325 mg tablet. The DON said staff should stay with residents to ensure all medications were swallowed and medications should be disposed of properly and not found on the floor. IV. Facility follow-up On [DATE] at 4:42 p.m. the DON provided a staff education document titled Medication Administration. The education contained 23 staff signatures and was dated [DATE] (during the survey). The education included a Medication Reminders/Tips Sheet and documented the following in pertinent part, -Residents must be observed taking medications; -Proper disposal if medication is dropped; -Notify nurse on duty if medication seen at bedside or on the floor; and, -Physician order is needed for self-administration of medication.

Based on observations, record review and interviews, the facility failed to ensure residents were provided services that meet professional standards. Specifically, the facility failed to ensure narcotic medications were documented on the narcotic log at the time of removal from the locked narcotic drawer on two of four medication carts. Findings include: I. Facility policy and procedure The Controlled Medications Storage and Reconciliation policy, revised January 2024, was provided by the director of nursing (DON) on 7/15/23 at 12:23 a.m. It read in pertinent part, It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments, with the exception that controlled medications and those medications subject to abuse may be stored with non-controlled medications as part of a single unit package medication distribution system, if the supply of the medication(s) is minimal and a shortage is readily detectable. This facility will maintain a process for monitoring, administration, documentation, reconciliation and destruction of controlled substances. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: -Date and time of administration; -Amount administered; and, -Signature of the nurse administering the dose, completed after the medication is actually administered. II. Observations and interviews On 7/11/24 at 11:52 a.m. the medication cart on the [NAME] unit was observed with registered nurse (RN) #2 and licensed practical nurse (LPN) #4. RN #2 compared the narcotic log to the actual narcotic count for Resident #16's hydrocodone five milligrams (mg)/acetaminophen 325 mg pills. -The narcotic log revealed 59 remaining pills, however, the actual count revealed 58 remaining pills. RN #2 said she administered one hydrocodone/acetaminophen pill to Resident #16 on 7/11/24 at 8:11 a.m. and she had forgotten to document the removal of the medication from the locked controlled substance drawer of the medication cart. On 7/11/24 at 12:45 p.m., the medication cart on the Golden unit was observed with RN #3. The following discrepancies were found: -Resident #32's lorazepam 0.5 mg narcotic log revealed 11 remaining pills, however, the actual count revealed 10 remaining pills. RN #3 said she administered one lorazepam 0.5 mg pill on 7/11/24 at 7:35 a.m. to Resident #32 and had not yet documented the removal of the medication from the locked controlled substance drawer. She said she was supposed to document the narcotic in the narcotic log when she removed it from the medication card containing the medication. -Resident #109's pregabalin 100 mg narcotic log revealed 20 remaining pills, however, the actual count revealed 19 remaining pills. RN #3 said she administered one pregabalin pill to Resident #109 on 7/11/24 at 8:48 a.m. and had not yet documented the removal of the medication from the locked controlled substance drawer. -Resident #109's oxycodone 20 mg narcotic log revealed 62 remaining pills, however, the actual count revealed 61 remaining pills. RN #3 said she administered one oxycodone pill to Resident #109 on 7/11/24 at 11:08 a.m. and had not yet documented the removal of the medication from the locked controlled substance drawer. -Resident #94's tramadol 50 mg narcotic log revealed 53 remaining pills, however, the actual count revealed 52 remaining pills. RN #3 said she administered one tramadol pill to Resident #94 on 7/11/24 at 11:17 a.m. and had not yet documented the removal of the medication from the locked controlled substance drawer. III. Staff interview The DON was interviewed on 7/11/24 at 2:49 p.m. The DON said she would check the policy to see when the narcotics were supposed to be documented. The DON said staff were provided recent education regarding documentation of controlled substances. She said more education was indicated and would be provided to staff regarding the timely documentation of narcotics on the narcotic count log. IV. Facility follow-up On 7/17/24 at 4:42 p.m. (after the survey) the DON provided a staff education document entitled Medication Administration and dated 7/10/24. The document contained an excerpt from the Controlled Medications Storage and Reconciliation policy which emphasized immediate documentation on the narcotic sign-out sheet when retrieving a medication dose from the controlled storage. The in-service record was signed by 18 staff members. On 7/17/24 at 4:42 p.m. the DON provided an additional document entitled Employee 1:1 (one-to-one) Education which included specific education that was provided to two individuals with emphasis on the staff members ensuring the narcotic count was up to date at all times during their shift and ensuring narcotics were signed out immediately.

Based on record review, observations and interviews the facility failed to ensure two (#19 and #100) of three residents reviewed for out of 45 sample residents were free from involuntary seclusion. Specifically, the facility failed to ensure Resident #19 and Resident #100 who resided in the secured unit, had the required ongoing documentation of the review and revision to meet the criteria and if the interventions met the needs of the resident. Findings include: I. Facility policy and procedure The Elopement and Unsafe Wandering policy, revised December 2023, was provided by the director of nursing (DON) on 7/16/24 at 5:25 p.m. It read in pertinent part, It is the facility's policy to provide a safe environment for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. II. Resident #19 A. Resident status Resident #19, age 82, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia. The 5/17/24 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a BIMS score of one out of 15. The resident required substantial assistance with transfers, oral hygiene, toileting, showering and personal hygiene. The resident was completely dependent on staff to wheel her manual wheelchair. The MDS assessment identified that wandering was not exhibited. B. Observations During a continuous observation on 7/15/24, beginning at 12:00 p.m. and ending at 12:32 p.m., the resident was in her wheelchair at a dining table in the secured unit dining room. Her head was down and she was sleeping on and off. She had a stuffed animal cat in her arms. C. Record review The elopement care plan, revised 5/23/24, revealed Resident #19 was at risk for elopement secondary to a history of elopement, Alzheimer's disease and poor safety awareness. The resident could exhibit behaviors including exit seeking, unplanned exiting, aimless walking and wandering or none. Interventions included documenting wandering behavior, documenting attempted diversional interventions and monitoring and documenting observed behavior and episodes every shift. -The resident's electronic medical record (EMR) did not reveal that the facility identified a certain time of day for wandering and elopement attempts. -The resident's EMR did not reveal that the facility identified a pattern for purposeful wandering. -The facility did not identify wandering and elopement de-escalation behaviors. The 2/9/24 elopement and wandering evaluation revealed the resident scored an 11, which indicated the resident was a high risk for elopement and wandering. The evaluation indicated the resident did not have a history of elopement and did not make statements about a desire to leave the facility. The resident wandered aimlessly with the potential to go outside and had active exit-seeking behavior. The resident wandered to intrude on the privacy or activities of others. The wandering behavior was the same as the prior evaluation. -The resident's EMR revealed there were no elopement attempts between 12/1/23 and 7/16/24. The certified nurse aide (CNA) behavior symptom tracking was reviewed on 7/16/24. It revealed there was no wandering observed between 6/16/24 to 7/16/24. A review of the resident's EMR on 7/16/24 did not reveal there was documentation that wandering was monitored, if interventions were used and if the interventions were effective in January 2024, February 2024, March 2024, April 2024, May 2024, June 2024 and from 7/1/24 to 7/16/24. The 12/13/23 interdisciplinary team (IDT) progress note revealed the resident wandered into another's resident's room. -A review of the resident's EMR revealed there was no documentation that wandering was monitored, if interventions were used and if the interventions were effective after the resident wandered into another resident's room on 12/13/23. -A review of Resident #19 EMR from 12/14/23 to 7/16/24 did not reveal any additional progress notes that the resident had wandering behaviors. III. Resident #100 A. Resident status Resident #100, age 81, was admitted on [DATE], According to the July 2024 CPO, diagnoses included dementia, displaced fracture of left femur, mood disturbance, psychotic disturbance and anxiety. The 6/25/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of zero out of 15. The resident was dependent with eating, oral hygiene, toileting, showering, dressing, and personal hygiene. The resident was completely dependent on staff to wheel his manual wheelchair. The MDS assessment did not identify that wandering was exhibited. B. Observations During a continuous observation on 7/15/24, beginning at 12:00 p.m. and ending at 12:32 p.m., the resident was observed in his wheelchair in the secured unit dining room. The resident was assisted by an unknown staff member to a dining table. At 12:15 p.m. the resident left the table and walked throughout the dining area. At 12:20 p.m. an unidentified staff member asked the resident if he was hungry and redirected the resident to the opposite side of the dining table. The unknown staff member brought the resident's lunch tray to the dining table. The resident ate his lunch until 12:32 p.m. C. Record review The elopement care plan, initiated on 7/11/24 (during the survey), revealed the resident was at risk for elopement and wandering related to impaired safety awareness and cognitive decline. Interventions included documenting wandering behavior and attempted diversional interventions. -The resident's EMR did not reveal that the facility identified a certain time of day for wandering and elopement attempts. -The resident's EMR did not reveal that the facility identified a pattern for purposeful wandering. -The facility did not identify wandering and elopement de-escalation behaviors. The mood and behavior care plan, revised on 7/15/24 (during the survey), revealed the resident had potential for mood or behavior problems related to insomnia, dementia, mental disorder and pain. The resident had periods of confusion, agitation and wandering without intent. Interventions included taking the resident outside, offering food and drinks and redirecting the resident away from the other residents'rooms if necessary. The 6/19/24 elopement and wandering evaluation revealed the resident scored a five, which indicated the resident was a low risk for elopement and wandering. The resident did not have a history of elopement, he did not make statements about a desire to leave the facility, and he did not wander to place the resident at significant risk of harming themselves or others. -The resident's EMR revealed there were no elopement attempts between 6/5/24 and 7/16/24. The CNA behavior symptom tracking was reviewed on 7/16/24. It revealed there was no wandering observed between 6/16/24 to 7/16/24. The July 2024 CPO revealed the resident had a physician's order that indicated to monitor and document observed wandering behavior. The physician's order indicated to document the following: exit seeking, 2 - unplanned exiting, 3 - aimless walking and wandering, and 4 - none, ordered 6/18/24. The June 2024 MAR revealed the resident had episodes of aimless walking and wandering on 6/19/24, 6/21/24 and 6/23/24. The July 2024 MAR revealed the resident had episodes of aimless walking and wandering on 7/5/24 and 7/6/25 and had episodes of exit-seeking on 7/6/24. -A review of the resident's EMR revealed that there was no documentation of what interventions were used when the resident had episodes of aimless walking and wandering and when the resident had episodes of exit-seeking. IV. Staff interviews The DON, the nursing home administrator (NHA) and the social service resource (SSR) were interviewed together on 7/15/24 at 3:29 p.m. The NHA said the residents had a care plan for wandering to tell the staff what to do if the resident wandered. The DON said if a resident wandered, the staff should intervene and redirect them. The SSR said if a resident wandered staff should offer an activity as a distraction. The DON said the licensed nurses documented in the resident's EMR if they observed wandering. The DON said CNAs documented in the behavior tracking log or would tell the nurse. The DON said she knew the interventions were effective for the residents because if the staff used an intervention that was not effective, they would notify her via text message. The DON said she told the staff verbally to try another intervention. The DON said the effectiveness of the interventions was not monitored or documented. The DON was interviewed again on 7/16/24 at 2:59 p.m. The DON said the nurses and the CNAs monitored the residents for wandering behaviors. The DON said the nurse documented wandering in the MAR and the CNAs documented in the behavior activity tracking log. The DON said she was familiar with Resident #19. The DON said did not know the resident's wandering was not documented and interventions were not documented for their effectiveness. The DON said she was familiar with Resident #100. The DON said she was not aware the resident's interventions were not documented for their effectiveness.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services for one (#54) of one resident reviewed for hospice care services out of 45 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication would be documented between the facility and the hospice provider for Resident #54; and, -Ensure hospice agency staff notes were easily accessible to the facility staff and have consistent documentation of hospice care visits in Resident #54's record. Findings include: I. Facility policy and procedure The End of Life Care, Hospice and Palliative Care policy, revised December 2023, was provided by the director of nursing (DON) on 7/11/24 at 9:13 a.m. It revealed in pertinent part, Hospice services will be offered as appropriate and as ordered by the physician. The services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with hospice will include processes for orienting staff to facility policies and procedures which may include documentation and record keeping requirements. II. Resident #54 A. Resident status Resident #54, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included dementia, anxiety and depression. The 6/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview of mental status (BIMS) score of zero out of 15. The assessment revealed the resident received hospice services. B. Record review The hospice care plan, revised 3/5/24, revealed the resident had a terminal prognosis related to senile degeneration of the brain. Interventions included working cooperatively with the hospice team to ensure the resident's needs were met. -The care plan did not define the services to be provided under hospice care by either the hospice provider or the facility. A review of Resident #54's electronic medical record (EMR) revealed no documentation of visits from the hospice provider from 7/1/24 to 7/16/24 (see interview below). A request for Resident #54's hospice binder was made on 7/15/24 at 2:12 p.m. -Licensed practical nurse (LPN) #2 said he was unable to locate the hospice binder for Resident #54. A second request for the binder was made on 7/16/24 at 9:48 a.m. -LPN #2 was again unable to locate the hospice binder. III. Interviews and observations LPN # 2 was interviewed on 7/15/24 at 2:12 p.m. LPN #2 said he knew the hospice staff made visits based on a binder kept in the nurse's station. LPN #2 said Resident #54 receive hospice services. LPN #2 looked for the binder that included documentation from the hospice services provider during the interview. LPN #2 was unable to locate the binder that included the communication between the facility and the hospice company. LPN #2 was interviewed again on 7/16/24 at 9:48 a.m. He said he knew when hospice staff made visits based on the resident's electronic medical record. LPN #2 showed where the visits were located in the EMR. LPN #2 was unable to show the visits made for the past week (7/9/24 to 7/16/24). He said using the EMR to document visits was a new process. The director of nursing (DON) was interviewed on 7/16/24 at 2:59 p.m. The DON said the social services director (SSD) was the designated hospice coordinator for the facility. The DON said the facility did not have a SSD at that time. The DON said she was the hospice coordinator until the SSD positon was filled. She said the staff knew the frequency of the hospice team visits based on what the hospice company communicated to the DON and the resident's care plan. The DON said after the hospice staff completed a visit with the resident the hospice staff checked in with the unit nurse or the DON. The DON said the unit staff knew what the visit was about based on a verbal report. The DON said the facility had a binder at the nurse's station for hospice staff to document when they visited. The DON said hospice staff did not always use the binder. The DON said Resident #54's binder was not up to date because the DON had access to the hospice EMR so she could check to see what the visit was about if hospice did not give a verbal report. The DON said the unit nursing staff did not have access to the hospice's EMR. The DON said she was unaware she was responsible for establishing a communication process to ensure the resident's needs were addressed and met 24 hours per day and the communication process was documented.

Based on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public on one of four units. Specifically, the facility failed to provide the necessary housekeeping and maintenance services to maintain resident room [ROOM NUMBER], #307, #316, #318, #303, #302 and #311 in a sanitary and comfortable manner. Findings include: I. Facility policy and procedures The Safe and Homelike Environment policy, revised 12/2023, was provided by the director of nursing (DON) on 7/16/24 at 11:33 a.m. The policy revealed the term environment referred to any environment in the facility that was frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A homelike environment de-emphasized the institutional character of the facility setting, to the extent possible; and allowed the resident to use personal belongings that supported a homelike environment. A use of the determination of homelike, should include the resident's opinion of the living environment. The term orderly was defined as an uncluttered physical environment that was neat and well kept. The term sanitary included, but was not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment included, but was not limited to, equipment used in the completion of the activities of daily living. The facility would create and maintain, to the extent possible, a homelike environment that de-emphasized the institutional character of the setting. Housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly and comfortable environment. Any unresolved environmental concerns would be reported to the nursing home administrator (NHA). Resident areas would have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. II. Resident room observations On 7/15/24 at 9:06 a.m. resident room [ROOM NUMBER] was observed. The observation revealed sheetrock damage on two room walls, chipped paint on one room wall, two small holes on the wall under the sink, debris in the room corners, sheetrock damage around the room sink, two unused metal curtain holders over the window, black discoloration on the room cove base, black marks on the entrance room door, a torn bathroom linoleum floor, one black plunger and one white toilet brush standing upright on the bathroom floor, multiple dead bugs in the bathroom light fixture, black marks on the bathroom door frame and a nonfunctional bathroom exhaust fan. On 7/15/24 at 9:12 a.m. resident room [ROOM NUMBER] was observed. The observation revealed separated linoleum flooring under the room sink, sheet rock damage on the room wall by the sink, six unused metal anchors in the wall by the sink, multiple dead bugs in the bathroom light fixture, a loud squeaking bathroom exhaust fan, black marks on the bathroom door, black marks on the bathroom's metal heater cover, one white toilet brush in a holder standing upright in the bathroom, four large sections of torn linoleum flooring in the bathroom, one white urine collection hat on the floor behind the toilet (not dated, labeled with a resident or bagged in plastic) and chipped paint on the bathroom door frames. On 7/15/24 at 9:19 a.m. resident room [ROOM NUMBER] was observed. The observation revealed debris in the room corners, loose room cove base, chipped paint on the room walls, a missing string pull cord extender for a room wall light, four small holes on the wall by the sink, the room sink drained slowly, unpainted sheetrock patches behind the headboard of the bed by the window, one room floor tile with two chipped areas on the tile, room metal heater cover end cap was loose, black marks on the bathroom metal heater cover, black marks on both bathroom doors, chipped paint on both bathroom door frames, two black plungers and one white toilet brush standing upright on the bathroom floor, one loose bathroom ceiling tile, a loose metal room heater cover, chipped paint on the metal room heater cover, a nonfunctional bathroom ceiling exhaust fan and chipped paint on the entrance door frame. On 7/15/24 at 9:27 a.m. resident room [ROOM NUMBER] was observed. The observation revealed a missing metal room heater cover under the window, chipped paint on one wall by the bathroom, sheetrock damage on the room wall at the footboard by the first bed and debris in the room corners. On 7/15/24 at 9:33 a.m. resident room [ROOM NUMBER] was observed. The observation revealed debris in the room corners, paint chips on one wall by the bathroom, one black plunger and one white toilet brush standing upright on the bathroom floor, one loose ceiling tile, a missing exhaust fan in the bathroom, four missing bathroom wall tiles, chipped paint on the bathroom door frame, cracked bathroom linoleum floor, two white urine collection hats on a shelf in the bathroom (not dated, labeled with a resident name or bagged in plastic), black marks on the bathroom door, chipped paint on the wall by the sink and chipped paint on the wall by the footboard of the bed by the window. On 7/15/24 at 9:46 a.m. resident room [ROOM NUMBER] was observed. The observation revealed debris in the room corners, chipped paint on both bathroom doors, chipped paint on both bathroom door frames, multiple dead bugs in the bathroom light fixture, one black plunger and one white toilet brush standing upright on the bathroom floor, a bathroom sheetrock patch needed painting, three small holes in the wall by bed one, sheetrock damage above the cove base under the room sink, four room sheetrock patches were unpainted by the room sink, one loose ceiling tile over the bed by the window, four unused metal wall anchors in the wall by the window, one ceiling panel with a missing corner and one water damaged ceiling tile. On 7/15/24 at 9:57 a.m. resident room [ROOM NUMBER] was observed. The observation revealed four missing pieces of the horizontal window blinds, debris in the room corners, chipped paint on the bathroom door frame, chipped paint on the room wall by the bathroom door, multiple dead bugs in bathroom ceiling light fixture, chipped paint on the bathroom doors, one black plunger standing upright on the bathroom floor, two portions of the bathroom metal heater cover were bent outward (sharp to the touch), one male urinal (not dated, labeled with a resident name or bagged in plastic) sitting on the toilet tank lid, one missing bathroom transition strip and chipped paint on the wall to the left of the sink. III. Staff interviews An environmental tour of the facility was conducted with the nursing home administrator (NHA) and the maintenance supervisor (MS) on 7/15/24 at 12:49 p.m. Each of the above residents' rooms were observed with the NHA and the MS for the environmental concerns. The MS said facility staff submitted work orders by calling him, telling him in person or by using the facility's management computerized system. The NHA said the staff had been in-serviced on the use of the facility's management computerized system system. The MS said he reviewed the facility's management computerized system work order requests on a daily basis. The NHA said that staff could place work orders in the facility's computerized healthcare software system. The NHA said the computerized healthcare software system would then generate a work order in the facility's management computerized system. The MS said he did not have any work orders of the observed environmental concerns, submitted in the facility's management computerized system system. The MS said resident rooms were inspected each month. The MS said resident rooms were routinely audited for environmental issues. The NHA said resident rooms and bathrooms were cleaned daily. The NHA and the DON were interviewed together on 7/16/24 at 9:44 a.m. The DON said urine collection hats should be thrown away after they were used. The DON said the urine collection hats should not be stored in resident rooms. The DON said the male urinal should have been stored in a plastic bag. The DON said the urine collection devices could be an infection control issue. The NHA said the plungers and toilet brushes were removed from the resident bathrooms on 7/15/24 (during the survey).

Based on interviews and record review, the facility failed to take steps to protect one (#19 and #256) of eight residents from physical abuse out of 45 sample residents reviewed for abuse. Specifically, the facility failed to prevent Resident #19 from physical abuse by Resident #256. Findings include: I. Facility policy and procedure The Abuse: Prevention of and Prohibition Against policy, revised 11/29/23, was provided by the director of nursing (DON) on 7/10/24 at 2:28 p.m. It read in pertinent part, Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. II. Incident of physical abuse between Resident #256 and Resident #19 on 6/13/24 A. Facility investigation of the altercation on 6/13/24 The witness statement, dated 6/13/24, written by a certified nurse aide (CNA), documented Resident #256 and Resident #19 were sitting at the dining room table. The residents went back and forth talking to each other. They told each other to be quiet. They said do not tell me what to do and I will knock the black out of you. Resident #256 grabbed a hold of Resident #19's hair and would not let go. The 6/13/24 nurse incident note revealed Resident #256 and Resident #19 were sitting at the dining room table. They were talking back and forth telling each other to be quiet. The note documented the residents were saying do not tell me what to do and I will knock the black out of you. The staff went to separate the residents and Resident #256 grabbed Resident #19's hair and did not want to let go. The unit nurse, the therapist and another staff member separated the residents and redirected both residents from one another. The therapist took Resident #256 outside for redirection and distraction. Resident #19 was redirected and removed to an alternate area. The progress note documented no skin changes were noted on either resident. The progress note documented neither resident recalled the event and remained at baseline. The facility's conclusion of the internal investigation was Resident #256 pulled Resident #19's hair. The facility's investigation summary revealed Resident #256 was sent to a higher level of care on 6/13/24 for the safety of self and others and for psychosocial safety and stabilization. The facility investigation revealed Resident #256 had four incidents with other residents prior to the incident on 6/13/24. Resident #256 had an incident on 2/23/24, 2/24/24, 4/10/24 and 4/28/24 with other residents The interventions for each incident included to redirect the resident and provide frequent checks. -Resident #256 and Resident #19 had a previous incident on 4/28/24. -Review of Resident #256's comprehensive care plan did not reveal There were not new person-centered interventions after Resident #256 was involved in multiple resident to resident altercations (see care plan below). B. Resident #256 - assailant 1. Resident status Resident #256, age greater than 65, was admitted on [DATE] and discharged on [DATE] to a local hospital. According to the June 2024 computerized physician orders (CPO), diagnoses included vascular dementia, cognitive communication deficit and muscle weakness. The 4/25/24 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment did not identify the resident displayed behaviors during the assessment period. 2. Record review The care plan, dated 2/19/24 and revised 6/20/24, identified the resident had verbal and physical aggression related to her dementia. Resident #256 was agitated when staff attempted to assist her and she responded physically when she became frustrated. Interventions included monitoring the resident and her surroundings to minimize known stressors such as multiple residents too close to the resident (5/23/24) and redirecting as needed(5/10/24). -The care plan did not identify new interventions implemented after the 2/23/24 and 2/24/24 resident to resident altercation incidents. C. Resident #19 - victim 1. Resident status Resident #19, age 82, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included Alzheimer's disease and dementia. The 5/17/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of one out of 15. The MDS assessment identified the resident displayed verbal behaviors toward others. 2. Record review The care plan, revised 7/15/24, identified the resident had a history of being verbally and physically aggressive if others were in her walking path and she could become aggressive if another resident had an object she wanted. Interventions include offering to take her outside (5/17/24) and redirecting her when she yelled at others (6/20/24). V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 6/15/24 at 2:12 p.m. He was familiar with Resident #256. LPN #2 said he was not present on 6/13/24 when the altercation took place. He said he was aware Resident #256 and Resident #19 were involved in a resident to resident altercation. He said the residents that resided in the secured unit were confused and often argued among themselves. LPN #2 said he stepped in when arguing occurred, tried to separate the residents when they argued and he tried to distract the residents. The nursing home administrator (NHA) was interviewed on 7/16/24 at 10:57 a.m. The NHA said the 6/13/24 altercation between Resident #265 and Resident #19 was substantiated as physical abuse. He said after the altercation, the facility immediately separated the residents and redirected them. The NHA said the intervention used to prevent the 6/13/24 altercation was to redirect the resident. The NHA said this intervention was not effective.

Based on observations, interviews, and record review, and facility policy the facility failed to ensure each resident received the care and supervision necessary to avoid accident hazards for three (#47, #85 and #92) of seven residents reviewed for accident hazards out of 52 sample residents. Specifically, The facility failed to: - Ensure Resident #47, who had severe cognitive impairment, received sufficient supervision to ensure safety while smoking on 2/13/23. Additionally, cigarette butts were not extinguished properly and placed in appropriate receptacles. A smoking blanket and smoking aprons were not readily available in the smoking area. Staff in the vicinity did not take action when a hot ash from the resident's cigarette fell into their lap after the resident burned themselves attempting to light one cigarette off of another; and, - Provide adequate supports and supervision to prevent Resident #92 from eloping through a window on the memory care unit (MCU) on 10/6/22. The resident was located 17 minutes later approximately 0.68 miles from the facility. The facility responded by ensuring the windows of the MCU could not be opened wide enough to be used as an egress. However, the facility's system for monitoring the wander prevention system failed to identify alarms that were not working. The extent of the facility's failure to provide adequate supports and supervision to avoid accident hazards related to smoking and elopement was likely to cause serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy situation on 2/15/23 at 9:30 a.m. and a plan to remove IJ was requested at that time. The Plan to Remove IJ was accepted by the State Survey Agency on 2/17/23 at 8:32 a.m. The IJ was removed on 2/17/23 at 5:52 p.m. after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of a pattern of no actual harm, with potential for more than minimal harm that was not immediate jeopardy for F689. Findings include: I. Smoking A. Policy A review of a facility policy titled, Smoking Policy, revised 11/2022, revealed, It is the policy of this facility to provide to its' [sic] residents a safe smoking environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of other residents residing in the facility. The policy did not indicate whether a Brief Interview for Mental Status (BIMS) score would be considered in the determination of supervision required. B. Observations Observations on 2/13/23 at 10:00 a.m. revealed two residents being supervised while smoking in the designated smoking area outside the MCU. There were cigarette butts on the cement, on the ground, in a salt bucket, in pots with dead plants, in a trash can filled with other trash, and in the two designated ashtrays. The emergency/fire blanket box was empty. Observations on 2/13/23 at 11:05 a.m. of the smoking area located off the Montrose Unit revealed extinguished cigarette butts along the grass next to the sidewalk and fence in the area with posted No Smoking Area signs and in the grass around the patio portion of the designated smoking area. Observation on 2/13/23 at 1:20 p.m. revealed three residents from the MCU (Residents #6, #200, and #42) were smoking with Activity Assistant (AA) #1's supervision. Resident #200 and Resident #42 discarded their cigarette butts in the proper containers, while Resident #6 threw their lit cigarette butt on the ground. Observation on 2/13/23 at 1:55 p.m. revealed four of the six chairs in the smoking area outside the MCU had visible burn holes. Resident #47 was observed on 2/13/23 at 2:10 p.m. sitting in a wheelchair in the designated smoking area attempting to light a cigarette with the butt of a lit cigarette. Resident #47 yelled, Ouch, and dropped the cigarette butt onto their lap. Resident #47 flicked the cigarette butt onto the ground. Cigarette ashes were observed in the fold of resident's pants in the groin area. The Business Office Manager (BOM) was standing by and walked over and picked up the cigarette butt from the ground near Resident #47's wheelchair but stated she was unaware that Resident #47 was trying to light a cigarette with another lit cigarette butt and confirmed there were ashes in the fold of resident's pants in the groin area that she was unaware of. Resident #47 then pulled a lighter from their jacket pocket and lit the remaining cigarette. C. Record Review A review of Resident #47's Admission Record revealed Resident #47 had diagnoses including unspecified dementia, altered mental status, cognitive communication deficit, hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, and unspecified lack of coordination. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 had a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated the resident used a wheelchair for mobility and required supervision and one-person physical assistance with locomotion on the unit and only supervision and set-up assistance with locomotion off the unit. Review of Resident #47's care plan revealed a focus area, dated as initiated on 5/11/22, that indicated the resident was at risk for impaired cognitive function/dementia or impaired thought processes and presented with mild cognitive deficits including forgetfulness, confusion, poor impulse control, poor judgment, and short and long term memory loss. Further review revealed a focus area, dated as initiated on 4/21/2020, that indicated Resident #47 had the potential for injury related to smoking and being an independent smoker. The care plan indicated Resident #47 had a history of unsafe smoking habits, such as smoking in their room, but had responded well to education and safe smoking agreements and continued to safely smoke independently. A review of Resident #47's Smoking Evaluation, dated 2/09/23, revealed no indication of cognitive impairment or dexterity problems and no need for adaptive clothing/devices/assistance. The document did not indicate whether the resident could smoke independently or required supervision. A review of Resident #47's Smoking Evaluation, dated 2/13/23, revealed the resident had cognitive impairment and dexterity problems but had no need for adaptive clothing/devices/assistance. The document did not indicate whether the resident could smoke independently or required supervision. D. Interviews During an interview on 2/13/23 at 1:24 p.m., AA #1 revealed all the supervised smoking residents' smoking paraphernalia was kept in separate containers for each resident in a bag that was placed in an unsecured utility room on a shelf. AA #1 stated that during smoke breaks, the residents were provided with a cigarette and staff lit the cigarette for each resident. AA #1 stated when the residents were finished smoking, she told the residents to look for an ashtray in which to discard the cigarette butts. AA #1 stated she made sure to watch each resident discard their cigarette butts into the proper receptacles. AA #1 stated she was unaware that one of the residents smoking during the 1:00 p.m. smoke break threw their cigarette butt into the grass and not into a designated receptacle. She stated she was aware of all the cigarette butts on the ground in and around the patio area because that area was rarely clean. AA #1 stated she had reported this to nursing staff, but it had been a long time and she was unable to remember when or to whom she reported. AA #1 stated there was one resident who required the use of a smoking apron and there used to be an apron located in the smoking area, but it was no longer there, and she was not sure where the aprons were stored now. AA #1 stated all the residents assessed as independent smokers kept their own smoking paraphernalia on their person, and she was not sure if the facility provided locks for the residents to secure them. AA #1 stated staff did not supervise independent residents when they were smoking. During an interview on 2/13/23 at 1:50 p.m., the Director of Life Safety stated he saw a lot of cigarette butts on the ground around the smoking area outside the MCU. He stated the maintenance director position was vacant, and he floated between different buildings, but the maintenance team was responsible for cleaning up the smoking areas weekly. During an interview on 2/13/23 at 1:51 p.m., the Assistant Maintenance Director stated he only went out to the smoking area outside the MCU when the area needed attention from maintenance, which was not very often. During an interview on 2/13/23 at 1:52 p.m., the Administrator stated he did not come out to the smoking area outside of the MCU very often and was unaware of all the cigarette butts on the ground. He indicated he did not know there was no fire blanket in the designated box. During interviews on 2/13/23 at 1:55 p.m., the Administrator, the Director of Life Safety, and the Assistant Director of Maintenance stated they did not know there were burn holes in the chairs in the smoking area outside the MCU. During an interview on 2/14/23 at 9:15 a.m., the Staffing Coordinator/Certified Nurse Aide (CNA) #13 revealed there were set times for smoke breaks for supervised smokers, at 7:00 a.m., 10:00 a.m., 1:00 p.m., and 4:00 p.m. She stated independent smokers could smoke whenever they chose. CNA #13 stated that restorative and activities staff were responsible for supervising the smokers. CNA #13 stated that all the supervised residents' smoking paraphernalia was stored on the units in designated drawers. CNA #13 stated the Kardex indicated which residents required supervision, and there was a list located on each unit at each nurses' station that indicated which residents were supervised and independent. CNA #13 was unable to state how many residents were supervised smokers and was only able to name three residents. CNA #13 stated during supervised smoking times, staff took the residents' smoking paraphernalia to the smoking areas. CNA #13 stated staff handed residents their cigarettes and would light the cigarette for the resident and remain outside with the residents while they smoked, to ensure the butts were disposed of properly. CNA #13 stated there were no residents that required the use of a smoking apron, but she was unable to state where the aprons were located if a resident did require the use of one. CNA #13 stated she had seen them in the past, located on other units, but was not sure if they were there now. CNA #13 stated there were some staff that smoked in the smoking areas, but staff should notify maintenance if they observed discarded butts on the ground. CNA #13 stated she was familiar with Resident #47, and in her opinion, the resident was not a safe smoker. CNA #13 stated Resident #47 would light cigarettes in the facility and was not safe holding a cigarette when agitated. CNA #13 stated Resident #47 would wave the lit cigarette around. CNA #13 stated she was aware Resident #47 was evaluated as a safe independent smoker, but she thought the resident should be supervised. CNA #13 stated she thought staff kept the residents' smoking paraphernalia in a drawer at the nurses' station. During an interview on 2/14/23 at 9:35 a.m., Registered Nurse (RN) #18 revealed he did not think Resident #47 should be an independent smoker because the resident was noncompliant, and the resident's dexterity was not good. RN #18 stated staff kept Resident #47's cigarettes, but the resident was allowed to keep their lighter. RN #18 stated that Resident #47 was very sneaky and would get cigarettes from other residents and family. RN #18 stated staff tried to keep an eye on Resident #47 but unfortunately, the resident was not assessed to require supervision and had been assessed to be an independent smoker. During an interview on 2/14/23 at 9:46 a.m., AA #26 revealed the interdisciplinary team (IDT) completed the smoking assessments that identified which residents required supervision when smoking, and there was a list located at each nurses' station and on the wall in the activities room. AA #26 stated the list indicated which residents were independent and which required supervision, along with the smoking times. AA #26 stated the activities department was responsible for supervising at 10:00 a.m., 1:00 p.m., and 4:00 p.m., but AA #26 was unsure if there was an actual list that stated which staff were responsible for supervising smoking. AA #26 stated Resident #47 was an independent smoker, and she had never observed anything concerning but she did not observe Resident #47 smoking since the resident was independent. AA #26 indicated staff kept Resident #47's cigarettes, but she was unsure about the lighter. AA #26 stated cigarette butts were monitored when staff were outside, and that staff should be ensuring the cigarette butts were picked up. AA #26 stated the reason there were so many butts on the ground was because it was hard to keep it up and that the residents were noncompliant. AA #26 stated she thought the residents needed to be reeducated all the time about properly disposing of the cigarette butts and that no staff were required to be present when the independent smokers were smoking. During an interview on 2/14/23 at 10:52 a.m., the Admissions Coordinator revealed he had completed training related to smoking on 2/13/23. He stated the training went over the expectation that staff should monitor residents and ensure they were safe while smoking. The Admission Coordinator stated he received an email that morning notifying him that he would be required to monitor smoking from 10:00 a.m. until 12:00 p.m. that day. The Admissions Coordinator stated he was supposed to remain outside for the entire two-hour period and that the Business Office Manager was there before him from 8:00 a.m. until 10:00 a.m. The Admissions Coordinator stated another staff would be there from 12:00 p.m. until 2:00 p.m. The Admission Coordinator stated during the training staff were provided with a list that identified which residents were to be supervised while smoking and which were independent. The Admissions Coordinator stated he would not be able to identify all residents by their face so he would need to look in the electronic health record to determine who they were. He was unable to state how he would know their name to look them up if he did not recognize their face, then stated he would ask another staff. The Admissions Coordinator stated supervised smokers' cigarettes were kept at the nurses' station, but he was not sure about the lighters. The Admission Coordinator indicated he observed Resident #79 light their own cigarette and asked the resident about that. He stated the resident told him they had their own lighter. The Admission Coordinator stated he was not aware that the resident was not supposed to have their own lighter. He indicated he never asked the resident to provide the lighter to him and he did not report that to anyone. During an interview on 2/14/23 at 1:56 p.m., the Director of Nursing (DON) revealed that upon admission and quarterly, nursing staff completed the Admission Smoking Assessment and that the activities staff and social services helped make sure the residents had cigarettes. The DON stated the activities staff would let nursing staff know if they observed anything during smoke breaks that would require another assessment to be completed. The DON stated that staff would make one smoking observation of the resident to complete the smoking assessment. The DON stated she observed Resident #47 smoke yesterday evening and had never observed the resident doing anything unsafe during smoking. The DON stated she had spoken with other staff about Resident #47 but none of them identified any concerns. The DON stated there was no documentation of where or how the information was obtained to complete the smoking assessments. The DON stated she had heard that something had occurred the previous day when Resident #47 was smoking but she was unsure of what specifically occurred and that she was unaware that several staff interviewed stated they did not think Resident #47 was a safe smoker. The DON stated another smoking assessment would be completed on Resident #47. The DON also stated the smoking list had been updated and that Resident #79 was moved to supervised smoking, with staff to have possession of the resident's cigarettes and lighter. During a follow-up interview on 2/17/23 at 9:57 a.m., the BOM revealed there was training related to smoking anytime there was a change in policy, or a change in the number of smokers, and the last update was on 2/15/23. The BOM stated the last training prior to that was a couple months previously in 2022 but she was unsure of the date. The BOM stated there were supervised and independent smokers and there was a list that identified which residents were to be supervised, which was located at each nurses' station and was updated anytime there was a change. The BOM stated the independent smokers were allowed to smoke whenever they wanted and were allowed to keep their own cigarettes and lighters, but the supervised smokers would go out at 7:00 a.m., 10:00 a.m., 1:00 p.m., 4:00 p.m., 7:00 p.m., and 10:00 p.m., but that was changed to 10:45 p.m The BOM stated that all the supervised smokers' paraphernalia was kept by staff and that the nurses would get the residents' cigarettes and take them out and staff would light the residents' cigarettes for them. The BOM also stated that staff should take the cigarette butts from the residents and dispose of them properly in the ashtrays. She indicated if staff observed a resident discard their cigarette butt on the ground, they should pick it up and dispose of it in the ashtray. The BOM stated maintenance completed weekly ground checks and was responsible for keeping the ashtrays clean and the grounds cleared, but she was not sure who was responsible for checking to ensure the emergency fire blanket and aprons were available at each of the smoking areas. The BOM indicated she was unable to show the surveyor where the aprons were located because she was not sure. The BOM also stated she was not sure if staff ever made random observations of the independent smokers to ensure they were still smoking safely. During an interview on 2/17/23 at 12:25 p.m., the Maintenance Aide (MA) revealed it was his responsibility to ensure the smoking areas were free of cigarette butts on the ground, that the emergency fire blankets were stored at each smoking area, and to empty the ashtrays and trash cans. The MA stated that was completed on Wednesday or Friday of each week. He stated he had completed the task in the main smoking area on 2/13/23 (a Monday) but forgot to check the smoking area located outside the MCU. The MA stated the last time the MCU smoking area checks were completed was on Wednesday, 2/01/23, but there was no documentation of the check that day or of any of the weekly checks. The MA stated residents should not be discarding lit cigarette butts on the ground, that the residents on the MCU were supposed to be supervised, and that staff should have been disposing of the residents' cigarette butts. The MA stated he had been informed by staff that this was an issue, but only on one occasion. The MA indicated he did not know what happened to the missing emergency/fire blanket outside the MCU, but he had not been checking to ensure it was there prior to the survey. During an interview on 2/17/23 at 1:44 p.m., the DON revealed the nurses were trained on completing the initial smoking assessment and should complete at least one observation of a resident smoking as part of the assessment, but this was not documented. The DON stated nursing, activities, and social services staff were responsible for completing these assessments. The DON stated nursing staff did the initial assessment, and activities staff or social services staff would complete the assessment post-admission. The DON indicated staff should ensure all residents who required supervision during smoking were alert and that all their smoking paraphernalia was held by staff. The DON stated there was a list of supervised and independent smokers located at each nurses' station and the activities staff should have their own list. The DON stated staff would provide each supervised resident a cigarette and light it for them. The DON indicated staff should observe residents smoking and assist those residents with properly disposing of the cigarette butts as needed. The DON stated staff observing the supervised smokers should ensure the proper disposal of the cigarette butts. The DON stated that if staff were supervising appropriately, there should not have been any discarded cigarette butts on the ground and that maintenance should ensure there was no accumulation of cigarette butts. The DON stated probably a lot of staff had been smoking and discarding their butts on the ground. The DON stated staff would make random observations of the independent smokers, or if there were concerns, but otherwise staff were not observing independent smokers. She stated there should have been another observation of each resident when their quarterly smoking assessment was completed. The DON stated that staff redirected supervised residents when they tried to get cigarettes from other residents and should have been going into the independent smoking area to ensure there were no supervised smokers out there without supervision, The DON stated she would have expected the BOM to intervene when Resident #47 dropped the cigarette on themselves. During an interview on 2/17/23 at 3:45 p.m., the Administrator revealed he expected all smoking assessments to be completed as accurately as possible. He indicated staff were supervising residents who required supervision, based on what was in the smoking policy and according to their training. The Administrator stated ideally, there should not have been residents discarding cigarette butts on the ground, and staff who were present should have been picking them up. The Administrator indicated discarded lit cigarette butts were not sanitary and were not safe due to being a possible fire hazard. The Administrator stated maintenance should have been completing routine rounds, cleaning up any discarded cigarette butts, and disposing of them properly. He revealed he would have expected staff to intervene if any resident had visible ashes on their clothing or when a resident dropped a lit cigarette on themselves. He also stated he expected maintenance to complete their weekly rounds to ensure fire safety blankets were located at each smoking area and that staff were making rounds of smoking areas throughout the day to ensure resident safety and well-being. 31524 II. Elopement A. Policy Review of a facility policy titled, Elopement, dated 11/2022, indicated, It is the policy of this facility to investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON [Director of Nursing] or designee. If resident not located, notify the Administrator and DON, the resident's legal representative, and law enforcement officials. Provide search teams with resident information. When a departing individual returns to the facility, the Charge Nurse shall examine the resident for injuries and to notify attending physician. B. Record review 1. Resident 92 A review of Resident #92's Admission Record revealed the facility admitted the resident with diagnoses that included dementia with behavioral disturbance and agitation, cognitive impairment, and encephalopathy (a disease that affects brain structure or function and causes an altered mental state and confusion). A review of Progress Notes, dated 10/3/22, revealed Resident #92 was admitted to a room on an unsecured hall with the diagnosis of dementia and was identified to be at risk for elopement. A review of an Elopement/Wandering Evaluation, dated 10/3/22, revealed Resident #92 had dementia, ambulated independently, was disoriented, and had the potential to go outside with active exit-seeking behavior. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired. The MDS indicated the resident did not exhibit wandering behaviors. According to the MDS, the resident required only supervision and set-up assistance with locomotion on and off the unit and did not use a mobility device. A review of Resident #92's Care Plan, dated as initiated on 10/04/22 and revised on 10/6/22, revealed Resident #92 was an elopement risk related to wandering aimlessly with exit seeking. The care plan indicated the resident had failed attempts with a wandering alert bracelet and was transitioned to the secured unit. Interventions included to assess for fall risk, disguise exits, distract the resident from wandering by offering music, juggling, nutrition, and exercise, document wandering behaviors and attempted diversional interventions, and identify wandering patterns. A review of Progress Notes, dated 10/4/22, revealed Resident #92 was placed on a wandering alert bracelet on 10/3/22 due to signs of exit seeking. The notes indicated on 10/4/22, Resident #92 attempted to leave the facility through a fire door in the dining room. Staff were alerted and redirected Resident #92 back into the facility. A review of Resident #92's Progress Notes, dated 10/5/22, revealed Resident #92 was transferred to the MCU due to exit-seeking behavior with attempts to get out of the facility. The wandering alert bracelet proved to be ineffective, so the facility transitioned Resident #92 to the MCU per their family member's request, to avoid Resident #92 going to the hospital for behaviors. A review of Resident #92's Secure Neighborhood Placement Evaluations, dated 10/5/22, revealed Resident #92 wandered throughout the facility with a wandering alert bracelet and attempted to climb the fence in the smoking areas. A review of Resident #92's Progress Notes, dated 10/6/22, revealed Resident #92 climbed through a window of another resident's room on the MCU at 3:49 p.m. and went over the fence of a courtyard. At 3:50 p.m., staff were directed on the elopement and separated in different directions in order to search for Resident #92. Resident #92 was found ambulating on the street at 4:01 p.m. and was transported back to the facility, with no injuries noted. Resident #92's family member was notified of the incident and preferred medication adjustments, refusing to have Resident #92 sent to the emergency room . A review of the Initial Report for Facility, dated 10/6/22, revealed Resident #92 climbed through a window of another resident's room on the MCU at 3:49 p.m. and jumped the fence. A Code Pink was called to the MCU at 3:50 p.m., and all staff were directed on elopement and where to search. The interdisciplinary team (IDT) members separated and went in different directions away from the facility. Resident #92 was oriented to self only, confused, had impaired memory, wandered, and was admitted within the last 72 hours. Facility staff found Resident #92 down the street at approximately 4:01 p.m. A review of the facility's Missing Person incident investigation, dated 10/6/22, revealed Resident #92 climbed through a window of another resident's room on the MCU at 3:49 p.m. and jumped the fence. Facility staff found Resident #92 on the street, 0.68 miles from the facility, at approximately 4:01 p.m. with no injuries noted. Resident #92 was missing from the facility for approximately 17 minutes. The police, ombudsman, physician, and responsible party were notified. The facility placed Resident #92 on frequent checks and continued placement on the MCU per the family, physician, and facility recommendation. 2. Resident #85 A review of Resident #85's care plan, initiated on 01/11/23, revealed the resident was a high risk for elopement/wanderer related to impaired safety awareness and dementia. A review of Resident #85's Elopement Risk Assessment, dated 11/26/22, revealed Resident #85 scored 24, indicating a high risk for elopement. 3. Monitoring records A review of a list dated 2/13/23, of residents with wandering alert bracelets, revealed two residents who were not on the MCU had the bracelets, one of whom was Resident #85. Multiple observations during the survey conducted from 2/13/23 to 2/17/23 revealed Resident #85 walking up and down unsecured hallways and standing close to exit doors, talking about going on a trip to the mountains without direct staff supervision. A review of the Resident Monitoring Systems: Check operation of door monitors and patient wandering system, dated October 2022 to February 2023, revealed: - 10/13/22: five doors were checked, all passed. - 10/16/22: two doors were checked, both passed. - 10/26/22: five doors were checked, all passed. - 11/7/22: six doors were checked, all passed. - 12/1/22: six doors were checked, all passed. - 12//22: four doors were checked, all passed. - 01/10/23: all seven doors were checked, all passed. - 01/17/23: all seven doors were checked, all passed. - 2/3/23: four doors were checked, all passed. C. Observations Observation on 2/13/23 at 1:20 p.m. revealed Resident #92 asking to get out the exit door to the MCU courtyard and pushing buttons on the keypad next to the door. Observation on 2/14/23 at 12:11 p.m. revealed the Assistant Maintenance Director testing the facility's wandering alert system at six of the seven exit doors. The exit door to the side smoking area did not lock when the Assistant Maintenance Director opened the door with a wandering alert device in hand. D. Interviews During an interview on 2/14/23 at 9:53 a.m., Certified Nursing Assistant (CNA) #2 stated she was doing her routine rounds on 10/06/22 when she noticed Resident #92 was no longer in the MCU's common area. CNA #2 then stated she checked each room and noticed a window open in another resident's room. CNA #2 immediately notified Licensed Practical Nurse (LPN) #3, who then initiated a search for Resident #92. During an interview on 2/14/22 at 10:04 a.m., LPN #3 stated Resident #92 climbed out of another resident's room window on the MCU. LPN #3 immediately notified the DON, the facility called a Code Pink, and staff immediately started searching for Resident #92. During an interview on 2/14/23 at 10:18 a.m., the DON stated Resident #92 started exit-seeking once admitted to the facility, so staff placed a wandering alert bracelet on the resident. Resident #92 continued to exhibit exit-seeking behaviors, so in coordination with the provider and Resident #92's family member, it was determined to place Resident #92 on the MCU. In October 2022, Resident #92 climbed out a window and jumped the fence of a secured outdoor area. Once LPN #3 notified her that Resident #92 had eloped, a Code Pink was called, and facility staff went in different directions from the facility to search. The DON indicated staff found Resident #92 down the street from the facility. The DON stated maintenance put stoppers on the windows of the MCU to prevent them from completely opening to prevent future elopements. During an interview on 2/14/23 at 10:50 a.m., LPN #3 stated Resident #92 had dementia with confusion and was not safe on the street on their own. During an interview on 2/14/23 at 12:04 p.m., the Physician's Assistant (PA) stated he had followed Resident #92 since admission and the resident was disoriented with exit-seeking behaviors. The PA revealed Resident #92 was not safe in the community on their own due to advanced dementia [TRUNCATED]

Based on interview, record review, and facility document review, the facility failed to ensure the employee performing the Registered Dietitian (RD) role and signing resident assessments as an RD was, in fact, registered as a dietitian with the Commission on Dietetic Registration (CDR). This had the potential to affect all 96 residents. Findings included: A review of the Colorado Revised Statues Title 6. Consumer and Commercial Affairs S 6-1-707. Use of title or degree-deceptive trade practice, dated 01/01/2019, revealed, (1) A person engages in a deceptive trade practice when, in the course of the person's business, vocation, or occupation, the person: (a)(I) Claims either orally or in writing, to possess either an academic degree or an honorary degree or the title associated with said degree, unless the person has, in fact, been awarded said degree from an institution. (b) Claims either orally or in writing to be a dietitian, dietician, certified dietitian, or certified dietician or uses the abbreviation C.D. or D to indicate that such person is a dietitian, unless such person: (II) Meets one of the following: (A) Completes at least nine hundred hours of a planned, continuous, preprofessional work experience in a nutrition or dietetic practice under the supervision of a qualified dietitian; or holds a certificate of registered dietitian through the commission on dietitian through the commission on dietetic registration. A search for evidence of the Dietitian's registration status on the CDR website revealed, No individuals in the CDR database who are credentialed and match the information provided. A review of a facility document titled, Job Description Dietitian, dated 12/27/2019, revealed, The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility. A review of the facility's undated employee roster revealed Registered Dietician next to the Dietitian's name. A review of an undated letter from the CDR revealed the Dietitian was eligible to take the registration examination for dietitians on 12/05/2019. A review of an undated nutrition summary for Resident #300 revealed the Dietitian signed with a handwritten signature and wrote RD next to her signature. A review of Resident #300's Nutrition Evaluation, dated 08/25/2022, revealed the Dietitian electronically signed the assessment with RD next to her name. A review of Resident #43's Nutrition Evaluation, dated 01/09/2023, revealed the Dietitian electronically signed the assessment with RD next to her name. A review of Resident #86's Nutrition Evaluation, dated 01/16/2023, revealed the Dietitian electronically signed the assessment with RD next to her name. During an interview on 02/16/2023 at 4:24 PM, the Dietitian Resource stated he was new to the role of Dietitian Resource, and the facility's Dietitian had been eligible to take the RD examination since 2019. The Dietitian Resource stated he was not sure why the Dietitian had not yet been registered but thought she had taken the test a couple of times. During an interview on 02/17/2023 at 10:53 AM, the Dietitian stated she started as the Dietitian in March of 2020 and was eligible to take the RD exam since December 2019. The Dietitian further stated she was not an RD and had taken the exam to become registered four or five times but had not yet passed. The Dietitian further stated she never received clarification on what she could and could not do since she was not registered and was never told not to put RD after her name when completing assessments. The Dietitian further stated no other RD who was registered was signing off or reviewing her assessments and notes. During an interview on 02/17/2023 at 1:45 PM, the Director of Nursing (DON) stated she knew the Dietitian was not an RD but did not know the Dietitian was signing assessments with the RD credential next to her name. The DON further stated it was not appropriate to sign the medical record with an invalid credential. During an interview on 02/17/2023 at 3:45 PM, the Administrator stated he expected his staff to work under the proper credentials. The Administrator further stated he knew the Dietitian was not registered but was not aware that she was documenting the RD credentials next to her name. The Administrator then stated it was not appropriate to sign assessments and notes with an invalid credential. The facility's policy and procedures titled, Registered Dietitian/Qualified Dietitian, revised March 2019, specified, Policy: It is the policy of this facility that the dietary department is under the supervision of a registered dietitian or qualified dietitian as defined by CMS [Centers for Medicare & Medicaid Services] regulations. Procedures: 1. The dietary department is under the supervision of a registered dietitian or qualified dietitian. A registered dietitian or qualified dietitian is one who is qualified based upon: A. Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. B. Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. C. Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a registered dietitian by the Commission on Dietetic Registration or its successor organization, or meets the requirement of paragraphs listed above. 2. The dietitian is responsible for overseeing, but not necessarily limited to: A. Assessing nutritional needs of geriatric and physically impaired persons; B. Developing therapeutic diets' C. Developing regular diets to meet the specialized needs of geriatric and physically impaired persons; D. Developing and implementing continuing education programs for dietary services and nursing personnel; E. Participating in interdisciplinary care planning; F. Budgeting and purchasing food and supplies; and G. Supervising food preparation, dietary sanitation and regulatory compliance. Note: Support staff work under the supervision of the registered dietitian (RD) or qualified dietitian. Support staff include dietetic technicians registered (DTR), nutrition associates (four year degree in nutrition/dietetics), certified dietary managers (CDM), chef, food service managers, etc. The RD or qualified dietitian may delegate certain tasks based on the scope of practice and competency level of each member of the nutrition team.

Based on interview, record review, and facility policy review, the facility failed to provide a comfortable and homelike environment for 1 (Resident #92) of 3 sampled residents who resided on the Memory Care Unit (MCU). Specifically, staff placed a mattress on the floor of the MCU's common area for Resident #92 because a room was not available in the MCU until the next day. Findings included: Review of a facility policy titled, Resident Environmental Quality, dated 2022, indicated, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. A review of Resident #92's Admission Record revealed the facility admitted the resident on 10/03/2022 with diagnoses that included unspecified dementia with behavioral disturbance and agitation, cognitive impairment, encephalopathy, and altered mental status (AMS). An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. According to the MDS, the resident did not exhibit a behavioral symptom of wandering. A review of Resident #92's Care Plan, dated as initiated on 10/04/2022 and revised on 10/06/2022, indicated the resident wandered aimlessly, exhibited exit-seeking behaviors, and was transitioned to the secured unit. Further review of Resident #92's Care Plan revealed a focus statement, dated as initiated on 10/06/2022 and revised 11/09/2022, which indicated the resident was resistive to care related to adjustment to the nursing home, wandered, and chose to sleep on various surfaces throughout the unit. Additionally, a focus statement dated as initiated 10/10/2022 revealed the resident had a behavior problem of wanting to lie/sit on the floor. Review of a Nursing Progress Note Late Entry, dated 10/04/2022 at 8:30 PM, indicated a perimeter security device was initiated for Resident #92 on 10/03/2022 because the resident was showing signs of exit-seeking. Additionally, the note indicated the Director of Nursing (DON) spoke to the resident's family member about moving Resident #92 to the MCU when a room became available in two days. A review of an Interdisciplinary Team (IDT) Progress Note Late Entry, dated 10/05/2022, indicated Resident #92 was transferred to the MCU due to exit-seeking behavior with attempts to leave the facility. A review of census information in the facility's electronic health records software revealed Resident #92 was admitted to a room in the MCU the following day, on 10/06/2022. A review of a Nursing Progress Note, dated 10/06/2022, revealed Resident #92 had been homeless for years and was accustomed to sleeping on the floor. Staff were to encourage Resident #92 to not sleep directly on the floor and to choose a different surface, such as a mattress on the floor, to meet their preference. Review of Care Conference Notes, dated 10/06/2022, revealed the facility held a care conference with Resident #92's family member and discussed concerns related to Resident #92's continued exit-seeking behavior and attempts to sleep on the floor intermittently throughout the units and building. The care conference also addressed moving Resident #92 into a private room on the MCU to decrease stimulation and plans to place the resident's mattress on a bed frame rather than the floor. The facility discussed with Resident #92's family member their concerns with keeping Resident #92 safe, and the family member expressed appreciation that the facility moved Resident #92 to the common area of the MCU until a bed in a room was available. Resident #92's family member reiterated to not send Resident #92 to the hospital if possible because that increased the resident's confusion. A review of the facility's reportable incident investigation, dated 10/06/2022, revealed the Administrator received an anonymous report that staff had been instructed to have Resident #92 sleep on a mattress on the floor in the common area of the MCU. MCU staff and residents were interviewed following the allegation. Resident #92 indicated that due to their prior living situation, they preferred to sleep and spend time on the floor. Upon admission to the facility, Resident #92 attempted to lie on the ground on other units, refused to be redirected back to their assigned room, and wandered throughout the facility with exit-seeking behaviors. Facility staff with family coordination decided to place Resident #92 in the MCU for safety due to the resident's wandering and exit seeking behavior, but a room would not become available until the next day. Resident #92's family member was aware the facility placed a mattress on the floor of the MCU in the line of sight of staff for safety. Review of a written statement dated 10/06/2022 and signed by Licensed Practical Nurse (LPN) #3 indicated the certified nursing assistants (CNAs) informed him that the mattress was placed on the floor in case Resident #92 chose to lie down. Review of a written statement dated 10/06/2022 and signed by Certified Medication Aide (CMA) #12 revealed Resident #92 did not sleep on the mattress in the common area but sat on the mattress for five minutes and would not sit anywhere or stop pacing. During an interview on 02/16/2023 at 9:20 AM, LPN #3 stated that when Resident #92 first came to the MCU there was not an open room, so staff provided a mattress on the floor of the common area for Resident #92. LPN #3 further stated he came in the next day and saw the mattress on the floor, but he never saw Resident #92 sleeping on the mattress. LPN #3 then stated he thought they moved two residents out of the MCU to make room for Resident #92, but he did not know which residents were moved. During a follow-up interview with LPN #3 on 02/16/2023 at 10:15 AM, the LPN stated he did not think it was appropriate to place a mattress on the floor of a common area for a resident to sleep on. LPN #3 further stated the mattress was on the floor of the MCU for Resident #92 for only one night. The next day, they rearranged residents so Resident #92 could have a room. During an interview on 02/16/2023 at 10:18 AM, CNA #13 stated providing a mattress on the floor of the MCU's common area was not appropriate and it would be concerning to her if she saw a resident's mattress there. During an interview on 02/16/2023 at 1:35 PM, CNA #14 stated she did not think it was appropriate to place a mattress on the floor of the MCU common area because that was not good for the resident. During an interview on 02/16/2023 at 2:50 PM, the Admissions Coordinator stated the facility supplied a mattress, bed frame, side table, bedside table, television, and closet to each resident when admitting a resident to a room. The Admissions Coordinator indicated if facility staff opted to place a mattress directly on the floor instead of a bed frame, this should be care planned. The Admission's Coordinator then stated it was not appropriate to place a mattress on the floor in a common area because that was a resident dignity and privacy issue. He further stated resident care needed to be provided and it was not appropriate to provide that in a common area. During an interview on 02/16/2023 at 4:15 PM, the Maintenance Aide stated that when Resident #92 was admitted to the MCU, there was not a room available. Resident #92 had a mattress on the floor in the common area for only that one night. The Maintenance Aide did not put the mattress there, but he did pick it up the following day. He further stated that staff normally placed females with female roommates and males with male roommates, so they switched out a couple residents to make room for Resident #92. The Maintenance Aide then stated it was not appropriate to have a resident sleep on a mattress on the floor of a common area. Residents should have a room, but they did not have one available for Resident #92 on the MCU that night, so they put the mattress in the common area. During an interview on 02/17/2023 at 1:45 PM, the DON stated she expected staff to respect resident rights and privacy because the facility was their home. The DON then stated if a resident was lying on the ground in a common area, staff would put a mattress on the ground in the common area but did not intend for Resident #92 to live in the common area. The DON indicated the mattress was placed on the floor in the common area for Resident #92 because the resident was trying to lie on the floor, not because there was no room for the resident. During an interview on 02/17/2023 at 3:45 PM, the Administrator stated he expected staff to adhere to the education they received about honoring resident rights and privacy. The Administrator further stated it would only be appropriate to place a mattress on the floor of the common area for a resident if it was the wishes of the resident or family, and it should be care planned. The Administrator further stated a mattress should not be placed on the floor for staff convenience.

Based on observations and interviews, the facility failed to follow infection control measures to prevent potential cross-contamination and spread of [CONDITION(S)]-CoV-2 COVID-19, during testing procedures on staff and residents. Specifically, the facility failed to: -Ensure COVID-19 testing of staff and residents was conducted properly to prevent the spread of an infectious disease, to include the utilization of proper personal protective equipment (PPE); -Maintain social distancing while performing the rapid ([MEDICATION(S)]) tests; and, -Properly disinfect the testing area between tests. On 1/12/22 at 9:28 a.m. outside agency staff were observed rapid testing Resident #80 for COVID-19 without wearing gloves and gown, with the resident's door open (see observation below). On 1/13/22 at 7:55 a.m. staff were observed self-testing for COVID-19. They did not perform social distancing and failed to protect other individuals, equipment and supplies located within three feet of the testing area from aerosolized droplets during the testing procedures (see observation below). In addition to staff not social distancing while performing rapid tests, staff did not protect other individuals and equipment and supplies located within three feet of the testing area from aerosolized droplets expelled during the testing procedure; and staff did not disinfect the testing area between testing. They failed to protect individuals, equipment and supplies located within three feet of the testing area from aerosolized droplets during the testing procedures. Record review revealed the facility had been in a COVID-19 outbreak status since 12/26/21, which included positive cases for both residents and staff. The facility failures beginning 1/12/22 created an immediate jeopardy situation, a situation that was preceded by the facility's outbreak status where four staff members and four residents had tested positive for COVID-19 just days earlier on 1/10/22 and 1/11/22. Cross-Reference F880, failure to maintain a safe and sanitary environment to prevent the development and transmission of a communicable disease Findings include: I. Facility status [CONDITION(S)]-CoV-2 COVID-19 According to the facility's line list report, updated 1/17/22, the facility outbreak status confirmed by the local County Health Department (CHD) on 12/26/21 was as follows: -As of 12/26/21, one facility staff had tested positive for [CONDITION(S)]-CoV-2 COVID-19 with a polymerase chain reaction (PCR) test; -As of 12/27/21, one resident had tested positive for [CONDITION(S)]-CoV-2 COVID-19 with a PCR test and 10 more facility staff had tested positive for [CONDITION(S)]-CoV-2 COVID-19 (seven with PCR tests and three with [MEDICATION(S)] tests); -As of 12/26/21 and 12/27/21 the resident and all staff who were positive according to the line list report had one major symptom of COVID-19; and, -The facility remained in outbreak status during survey 1/12/22 to 1/18/22 with a total of 34 residents (nine confirmed with PCR test and 25 with an [MEDICATION(S)] test); and a total of 32 staff (14 confirmed with PCR test and 18 with an [MEDICATION(S)] test) who were COVID-19 positive. The facility had five unvaccinated residents refusing the vaccine and two unvaccinated staff who had medical exemptions. II. Immediate Jeopardy A. Findings of immediate jeopardy Observations and interviews revealed the facility failed to follow infection prevention measures to prevent cross contamination and spread of [CONDITION(S)]-CoV-2 COVID-19, as required during mandatory testing on all staff and residents during a facility outbreak of [CONDITION(S)]-CoV-2 COVID-19. The facility's failure to follow outbreak testing requirements created an immediate jeopardy situation due to the likelihood the facility's failures would lead to the transmission of [CONDITION(S)]-CoV-2 COVID-19. B. Facility notice of immediate jeopardy On 1/13/22 at 12:30 p.m., the nursing home administrator (NHA), clinical resource nurse (RCN) #1 and director of nursing (DON) were notified that the failures in the facility's infection control program and testing created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm related to [CONDITION(S)]-CoV-2 COVID-19. C. Plan to remove immediate jeopardy On 1/13/22 at 6:00 p.m., RCN #1 presented the following plan to address the immediate jeopardy situation. The following was implemented: 1. Resident #80 was assessed by RN (registered nurse) and the resident does not have visible signs or symptoms of COVID on 1/13/22 (sic). An [MEDICATION(S)] test was completed by facility staff after notification and the resident was negative for COVID on 1/12/22. a. Facility completed education with all three (name of outside agency) staff on 1/12/22 on notifying facility staff of concerns in regards to possible symptoms and allowing facility staff to complete a proper test on a resident while residing in the facility. b. This education also included usage of proper PPE when testing residents. Facility staff will be the only staff to complete COVID testing on residents moving forward. c. DON (director of nursing) updated COVID-19 policy to include that only facility staff can conduct COVID-19 testing on residents on 1/13/22. 2. Facility moved the testing center for employees to a private room at the front of the building on 1/13/22 at approximately 10:00 a.m. Initially facility closed the doors to the front of the building to limit residents going to the front of the building where testing is taking place, this was completed on 1/13/22 (sic) at 12:00 (p.m.) to allow building to complete a plan. a. Facility initiated a full house education on 1/13/22 at approximately 10:30 a.m. to complete the testing in the center, complete proper disinfecting before and after testing, social distancing while waiting for tests, to keep door closed during the testing, and to wait in designated areas for test results. b. This education will be provided to all employees prior to starting a shift. Any employees who are unable to come in for education will be called and logged on separate in-service sheet and will review and sign prior to starting next shift. Whole house education will be completed by 1/17/22. c. Facility completed 1:1 (one-to-one) education with employee who was identified by surveyors testing in an open area with other residents in common area, this education was completed on 1/13/22 (sic). d. IP (infection preventionist) to complete education to front (sic) desk screeners on 1/13/22 in regards to monitoring the employees while waiting for results to socially distance in reserved areas up in the front of the building. The reserved areas include the dining room, and the front lobby. e. Facility will initiate audits of the testing areas 5x (five times) weekly at various times to monitor for staff being compliant with social distancing and disinfecting. The audit will start on 1/14/22 (sic) and go until 12 weeks of compliance is achieved. This will be reviewed in QAPI (quality assurance performance improvement) for the areas of the (sic) system that are improved and any issues identified. D. Removal of the immediate jeopardy On 1/13/22 at 6:00 p.m. the NHA, RCN and DON were notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at an F scope, widespread potential for more than minimal harm. III. Professional referennce According to the CDC guidance, Guidance for [CONDITION(S)]-CoV-2 Point-of-Care and Rapid Testing, updated 1/19/22, available from: https://www.cdc.gov/coronavirus/2019-ncov/lab/point-of-care-testing.html#print, accessed on 1/25/22. It read in pertinent part: Rapid point-of-care tests provide results within minutes (depending on the test) and are used to diagnose current or detect past [CONDITION(S)]-CoV-2 infections in various settings, such as: Long-term care facilities and nursing homes. Specimen Collection & Handling of Point-of-Care and Rapid Tests -Proper specimen collection and handling are critical for all COVID-19 testing. For personnel collecting specimens or working within six feet of patients suspected to be infected with [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which could include an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a lab coat or gown. Disinfect surfaces within 6 feet of the specimen collection and handling area at these times: -Before testing begins each day; -Between each specimen collection; -At least hourly during testing; -When visibly soiled; -In the event of a specimen spill or splash; and, -At the end of every testing day. IV. Facility policy and procedures The Resident and Staff Testing for COVID-19 policy and procedure, updated 1/13/22, was provided by the DON on 1/13/22 at 5:00 p.m. It documented, in pertinent part, It is the policy of this facility that all residents and staff will be offered testing for COVID-19 according to most recent CDPHE (Colorado Department of Public Health and Environment) and CMS (Centers for Medicare/Medicaid Services) guidelines. The facility will follow the most stringent guidelines at that time. It is the policy of this facility that only facility staff members are to administer COVID-19 test on residents. Procedures for Residents: The residents will be offered to be tested for COVID-19 with PCR for any of the following reasons: -After identification of 1 (one) positive staff or resident in the facility -If the facility is in a COVID-19 outbreak or outbreak testing-according to the outbreak testing schedule; -If a resident shows signs/symptoms of COVID-19; -If a resident is unvaccinated and leaves the campus and stays out overnight in past 14 days; -If a resident was notified of a high risk exposure; and, -If the facility participated in weekly prevention testing for residents. Procedures for Staff: Staff is required to participate in COVID-19 testing for the following reasons: -After identification of 1 (one) positive resident or staff member; -If the facility is in a COVID-19 outbreak or outbreak testing-according to the outbreak testing schedule; -If a staff member shows signs/symptoms of COVID-19; -If a staff member is unvaccinated then he/she will participate in the surveillance testing according to the most recent CDPHE/CMS guidelines. The rate of testing will be dependent on CDPHE guidelines and county rates; and, -If a staff member has high risk exposure to COVID. V. Failure to perform rapid testing of resident using appropriate PPE A. Observations On 1/12/22 at 9:20 a.m. the physical therapist assistant (PTA) #1 asked LPN #1 about Resident #80's COVID status and if Resident #80 had been tested . PTA #1 told LPN #1 that he reported to certified nurse aide with medication authority (CNA/MA) #1 the previous day (1/11/22) the resident had a scratchy throat and diarrhea. LPN #1 told PTA #1 that she was not aware Resident #80 was having signs and symptoms of COVID-19. LPN #1 told PTA #1 the facility was in outbreak status and all residents and staff were being tested and he needed to talk with the IP. Shortly after, the occupational therapist (OT) entered the unit with rapid testing supplies; then the OT, PTA #1, and an interpreter entered Resident #80's room. -At 9:28 a.m. the OT was observed collecting Resident #80's nasal swab (rapid test) for COVID-19 with the door open and without appropriate PPE (gown and gloves). The OT completed the rapid test without consultation with the facility's IP or DON prior to testing the resident (see interview below). B. Staff interviews The OT, PTA #1 and interpreter were interviewed on 1/12/22 at 10:14 a.m. They said they all worked for an outside agency and provided services to residents, like therapy services. PTA #1 said Resident #80 told him he was having COVID-19 symptoms on 1/11/22 in the morning (scratchy throat, bowel issues). PTA #1 said Resident #80 did not report diarrhea but the resident told him his stomach was bubbly. PTA #1 said he had worked with the resident for the past two weeks and he reported his concerns to CNA/MA #1 on 1/11/22. The OT said she went to the receptionist to get a rapid test for Resident #80. She said when she collected Resident #80's rapid test, she should have used appropriate PPE (gloves and gown) and should have closed the door since this posed a risk for spreading COVID-19 to others. They said they did not consult with the IP or DON prior to testing the resident for COVID-19 with a POC rapid test. The DON was interviewed on 1/12/22 at 11:35 a.m. She confirmed the outside agency staff did not consult with the IP or DON prior to testing Resident #80. She provided documentation of education that was conducted with the OT, PTA #1 and interpreter on 1/12/22 (see follow-up below). CNA/MA #1 was interviewed on 1/13/22 at 2:28 p.m. She said she had worked at the facility since September 2021, and her shift varied since she was in school (she worked 7:00 a.m. to 7:00 p.m. shift). She said she worked on 1/11/22 with Resident #80 and was told by a CNA (she could not remember who the CNA was) that Resident #80 had a headache, but he had no other symptoms of COVID-19 and his vital signs were within normal limits. She said she notified the IP about the resident having pain, she checked on him later in the day and he said he did not have any pain. The IP was interviewed on 1/18/22 at 2:28 p.m. She said CNA/MA #1 told her the resident was complaining of pain and she had just given the resident Tylenol. She said CNA/MA #1 did not specify where the resident had pain or that he complained of headache. She said if she was made aware Resident #80 had any signs/symptoms of COVID-19 she would have assessed the resident. The medical director was interviewed on 1/18/22 at 5:08 p.m. He said he been the medical director for a number of years. He said he routinely visited the facility to attend the facility's QAPI. He said he was notified of the facility's immediate jeopardy in testing. He said he had not observed the facility's testing area, but if concerns had come up he would have conducted ad hoc (as needed) review. He said it was unfortunate that outside staff performed testing without appropriate PPE and it was also unfortunate that staff were performing testing while residents were present and were not socially distancing. He said he planned to review the facility's testing policy and procedures in their next QAPI. C. Facility follow-up On 1/12/22 at 11:35 a.m. the DON provided written education with signed acknowledgement that was provided to the OT, PTA #1 and interpreter on 1/12/22. It included the following: When suspecting COVID for any resident in the facility (name of facility) please be sure to notify nurse on unit to ensure that residents are being assessed by nurse in facility and testing being done, if needed, by the at the facility. If suspected COVID or any signs of symptoms observed PPE (gown, gloves, mask, googles/face shield) needs to be worn before entering the room at all times and following proper PPE donning and doffing. VI. Failure of staff to follow proper infection control guidelines when COVID-19 self testing A. Observations On 1/13/22 at 7:55 a.m. a physical therapist assistant (PTA) #2, the nursing home administrator (NHA), a receptionist (RCP) #1, two residents and two other unidentified staff were observed in the common testing area. One unidentified male resident was sitting in a wheelchair next to the window and two unidentified staff were observed sitting on the couch in the common testing area. Resident #15 was sitting in a wheelchair in front of the receptionist (without a facial covering), PTA #2 was standing to the left of Resident #15 and observed self-testing for COVID-19 and the NHA was standing to the right of the resident, not socially distancing six feet apart. In addition to staff (observed above) not socially distancing while performing the rapid tests, staff did not protect other individuals and equipment and supplies located within three feet of the testing area from aerosolized droplets expelled during the testing procedure. Staff were observed not disinfecting the testing area between testing. B. Staff interviews The receptionist (RCP) #1 was interviewed on 1/13/22 at 8:15 a.m. She said she conducted the daily screening for all staff and visitors who entered the building. She said she assisted the staff with their daily testing. She said she did not handle the tests, however, she did document the test results once completed. She said the staff self tested . She said residents were able to be in the front lobby when staff tested . The business office manager (BM) was interviewed on 1/13/22 at 8:30 a.m. She said she had two receptionists scheduled for the front desk daily. She said they both assisted with screening all staff and visitors who entered the facility. She said the staff conducted a rapid test daily before each shift and conducted a polymerase chain reaction (PCR) test twice a week. She said the receptionist did not wear a gown or gloves because the staff self tested . She said there are no barriers or social distancing markers set up to assist with social distancing. She said the staff did not sanitize the testing area or desk after each test, however, the staff were instructed to sanitize their hands before and after testing. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 1/13/22 at 8:40 a.m. They said the staff were conducting daily rapid testing due to the current COVID-19 outbreak status in the facility. The staff conduct PCR testing twice a week on Monday and Thursdays. The staff self-tested themselves and reported the test results to the receptionist who documented the results. They said the receptionist managed the front desk area and conducted the daily screening process for all staff and visitors who entered the facility. The DON said the daily check in process for staff included answering the screening questions, checking temperatures, the use of hand sanitizer and then the staff would self test either utilizing the rapid test or the PCR test depending on the day. The rapid test provided immediate results, while the PCR test was sent out daily and could take multiple days for the results to be provided. The DON and ADON said staff should be social distancing and staying six feet apart while they conducted their tests. They said they did not have barriers in place and did not have the receptionist or staff wearing full PPE because the staff were self testing. They said they did not have staff disinfect the testing area because each test was pre-packaged. The DON said residents should not be within six feet of a staff member testing in the front lobby area and said social distancing should have been implemented. The DON and ADON said the COVID-19 testing of staff should be conducted in a separate room away from other staff and residents. They said staff should be disinfecting the testing area after each test. C. Facility follow-up The facility's staff COVID-19 testing process was updated and reviewed on 1/18/22 at 2:22 p.m. It revealed the following: -The entrance to the front lobby had a sign explaining the staff COVID-19 testing days and screening process; -The front lobby had red X's placed six feet apart on the floor from the front door to the front desk to indicate where staff would stand while waiting to be screened in and for testing; - The front lobby was also a designated waiting area for testing with signs indicating where staff could wait, social distancing six feet a part; -There was a small dining room labeled room [ROOM NUMBER] that was also a designated waiting area with signs indicating where staff could wait, social distancing six feet a part; -The staff testing area had been moved from the front desk to an enclosed office space next to the front lobby. The office had a door to close for sanitization purposes and was behind a closed fire door separating the residents from the testing area; -The office space designated for testing had a sign indicating the testing process. It read in pertinent part, Take rapid test and PCR test in the front office with the door closed, sanitize the testing area after you test, sit in designated waiting area for 15 minutes for test results and notify the receptionist of your results. Dispose of the test in the red biohazard bin.; -The office space designated for testing had a second sign indicating the disinfection process that read in pertinent part, Staff must disinfect (use disinfectant wipes provided) the testing area before and after testing and leave the area wet for 1 minute prior to testing; and, -The office space designated for testing had a third sign identifying the testing center rules that read, Only 1 person in the room at a time, staff must sanitize their hands before going into the room and after exiting the room.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure an unvaccinated resident (Resident #11) was socially distanced (six feet apart) from a confirmed COVID-19 positive resident (Resident #14) and Resident #2 (who was not COVID-19 positive) while consuming their lunch meal; -Ensure staff wore proper personal protective equipment (PPE) when entering Resident #65's and Resident #293's isolation rooms for COVID-19; and, -Ensure staff wore PPE (N95 mask) correctly to ensure secure fit. On 1/12/22 at 12:10 p.m. staff were observed to seat Resident #11 at a dining table for lunch with a positive COVID-19 resident. The observation also revealed there was space available to allow the residents to socially distance (see observation below). On 1/12/22 at 8:37 a.m. and 12:15 p.m. certified nurse aide (CNA) #1 was observed to enter Resident #65's and #293's rooms, who were on isolation for COVID-19, with appropriate PPE (gown and gloves, see observation below). On 1/12/22 at 3:32 p.m. CNA #2 was observed wearing his N95 mask incorrectly, failing to ensure a secure fit. The back/bottom strap of the mask was observed hanging in front of his face (see observation below). Record review revealed the facility had been in a COVID -19 outbreak status since 12/26/21, which included positive cases for both residents and staff. The facility's failures beginning 1/12/22 created an immediate jeopardy situation; a situation that was preceded by the facility's outbreak status where four staff members and four residents had tested positive for COVID-19 just days earlier on 1/10/22 and 1/11/22. Furthermore, Resident #11 started experiencing signs and symptoms of COVID-19 on 12/13/21 and was confirmed COVID-19 positive on 1/15/22 which placed residents at risk for harm. Cross-reference F886, the facility failed to follow infection control measures to prevent the potential cross- contamination of [CONDITION(S)]-CoV-2 COVID-19, during testing procedures on staff and residents. Findings include: I. Facility status [CONDITION(S)]-CoV-2 COVID-19 According to the facility's line list report, updated on 1/17/22, the facility outbreak status confirmed by the local County Health Department (CHD) on 12/26/21 was as follows: -As of 12/26/21, one facility staff had tested positive for [CONDITION(S)]-CoV-2 COVID-19 with a polymerase chain reaction (PCR) test. -As of 12/27/21, one resident had tested positive for [CONDITION(S)]-CoV-2 COVID-19 with a PCR test and 10 more facility staff had tested positive for [CONDITION(S)]-CoV-2 COVID-19 (seven with a PCR test and three with an [MEDICATION(S)] test). -As of 12/26/21 and 12/27/21 the resident and all staff who were positive according to the line list had one major symptom of COVID-19. The facility remained in outbreak status during survey 1/12/22 to 1/18/22 with a total of 34 residents (nine confirmed with PCR test and 25 with an [MEDICATION(S)] test); and a total of 32 staff (14 confirmed with PCR test and 18 with an [MEDICATION(S)] test) who were COVID-19 positive. The facility had five unvaccinated residents refusing the vaccine and two unvaccinated staff who had medical exemptions. II. Immediate Jeopardy A. Findings of immediate jeopardy Observations, record review and interviews revealed the facility failed to follow infection prevention measures to prevent cross-contamination and spread of [CONDITION(S)]-CoV-2 COVID-19. There were multiple observations during survey 1/12/22 to 1/18/22 which revealed multiple failures in the facility's infection control program, including failure to ensure COVID-19 testing of staff and residents was conducted properly to prevent the spread of an infectious disease, failure to properly and appropriately use PPE, and failure to properly and effectively socially distance staff during testing and residents with known positive COVID-19 cases. The facility's failure to follow proper infection control practices created an immediate jeopardy situation due to the likelihood the facility's failures would lead to the transmission of [CONDITION(S)]-CoV-2 COVID-19. B. Facility notice of immediate jeopardy On 1/13/22 at 12:30 p.m., the nursing home administrator (NHA), clinical resource nurse (RCN) #1 and director of nursing (DON) were notified that the failures in the facility's infection control program created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm related to the transmission of [CONDITION(S)]-CoV-2 COVID-19. C. Plan to remove immediate jeopardy On 1/13/22 at 6:00 p.m., RCN #1 presented the following plan to address the immediate jeopardy situation. The following was implemented: 1. Resident #65 is COVID positive but is asymptomatic at this time. CNA #1 to be educated over the phone on 1/13/22 in regards to proper PPE usage in isolation rooms and skilled checklist completed. 2. Resident #293 is COVID positive and not symptomatic at this time. CNA #1 to be educated over the phone on 1/13/22 in regards to proper PPE usage in isolation rooms. 3. Resident #3 (however, this resident number was incorrect as it was Resident #2) was assessed by RN (registered nurse) today and has tested negative on [MEDICATION(S)] test on 1/13/22. 4. Resident #11 and Resident #14 were placed at a table together by staff, IP (infection preventionist) educated CNA #3 on 1/13/22 in regards to proper social distancing and keeping COVID positive Residents away from COVID negative Residents. a. IP initiated full house education to all staff on 1/13/22 in regards to which residents were COVID positive, proper PPE usage and isolation, social distancing on the secured unit, and proper wearing of mask. b. The full house education will be completed by 1/17/22, any employee unable to come in and complete in person education will be called and educated or educated prior to start of next scheduled shift. c. Facility completed 1:1 (one-to-one) education with van driver (certified nurse aide #2) in regards to proper usage of N95 mask and offered a different mask on 1/13/22. d. Facility arranged tables in the secured unit to be six feet apart on 1/13/22 at 1300 (1:00 p.m.), two tables were moved on the secured unit away from other residents to encourage the COVID positive residents to socially distance on secured units. e. Staff will continue to encourage residents to wear masks, if residents require redirection or become agitated, staff will utilize the trigger/behavior cards available for the residents to assist them in redirection of those residents as part of the education stated above, this education will be provided to all staff who work the secured unit, education to be completed by 1/17/22. f. Facility will initiate audits of the secured unit for seven meal times throughout the week to monitor staff redirecting residents with COVID to socially distance, and that no COVID positive and COVID negative residents are seated at the same table. g. Facility will also initiate an audit to monitor 10 employees weekly for proper donning and doffing of PPE in and out of isolation rooms, and for staff appropriately wearing masks, these audits will continue until 12 weeks of compliance has been achieved; the audit will start on 1/14/22 (sic) and go until 12 weeks of compliance is achieved. h. This will be reviewed in QAPI (quality assurance performance improvement) for the areas of the (sic) system that are improved and any issues identified. D. Removal of the immediate jeopardy On 1/13/22 at 6:00 p.m. the NHA, RCN and DON were notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at an E scope, a pattern for more than minimal harm. III. Failure to ensure an unvaccinated resident (Resident #11) was socially distanced (six feet apart) from confirmed COVID-19 positive resident (Resident #14) and Resident #2 (who was not COVID-19 positive) while consuming their lunch meal. A. Professional reference The Centers for Medicare & Medicaid Services Nursing Home Visitation Frequently Asked Questions (FAQs) updated 1/6/22, retrieved 1/19/22 from https://www.cms.gov/files/document/nursing-home-visitation-faq-1223.pdf revealed in pertinent part: If the facility is using a contact tracing approach for an outbreak investigation, those residents who are identified as potentially being a close contact of the individual who tested positive for COVID-19, are considered to have had close contact and should not participate in communal dining or activities. Residents who have not received a COVID-19 vaccine and have had close contact with someone with COVID-19 infection should be placed in quarantine for 14 days after the close contact, even if [CONDITION(S)] testing is negative. A resident who is unable to wear a mask due to a disability or medical condition may attend communal activities, however they should physically distance from others. If possible, facilities should educate the resident on the core principles of infection prevention, such as hand hygiene, physical distancing, cough etiquette, etc. and staff should provide frequent reminders to adhere to infection prevention principles. A resident who is unable to wear a mask and whom staff cannot prevent having close contact with others should not attend communal activities. To help residents prevent having close contact, such as in the case of a memory care unit, the staff should limit the size of group activities. They should also encourage frequent hand hygiene, assist with maintaining physical distancing as much as possible, and frequently cleaning high-touch surfaces. If a resident refuses to wear a mask and physically distance from others, the facility should educate the resident on the importance of masking and physical distancing, document the education in the resident's medical record, and the resident should not participate in communal activities. B. Facility policy The Infection Control and Prevention policy, updated 6/28/21, was provided midday by RCN #1 and NHA on 1/12/22. It documented in pertinent part, It is the policy of this facility to include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. Infection Prevention Control: Supplies and Practices Hand Hygiene Supplies: -Place FDA (Food and Drug Administration)-approved alcohol-based hand sanitizer with 60-90% alcohol in every resident room (ideally inside and outside of the room) and in other resident care and common areas. -Perform hand hygiene according to the CDC (Centers for Disease Control) guidance. CDC Performing Hand Hygiene using an alcohol-based hand sanitizer or soap and water as identified by CDC. Personal Protective Equipment: Facilities should have policies and procedures addressing: -Under what circumstances and what type(s) of PPE are to be used; -Proper donning/doffing sequence and technique; -Process for appropriate disposal; and, -Proper cleaning, decontamination and storage of any reusable equipment or supplies. Select, maintain inventory, and supply appropriate PPE, where needed, to HCP (healthcare personnel) according to Occupation Safety and Health Administration (OSHA) PPE standards and CDC Standard and Transmission-based Precautions. Include containers for disposal of PPE supplies where needed. -PPE may include facemasks, N95 or higher-level respirators, gowns, gloves, and eye protection (i.e. face shield or goggles). Environmental Cleaning and Disinfection: -Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas. -Ensure availability of and use EPA (Environmental Protection Agency)-registered, hospital-grade disinfectants from list N-disinfectants for coronavirus (COVID-19) -Ensure HCP (healthcare personnel) are appropriately trained to use and manufacturer's instructions for all cleaning and disinfection products (e.g., concentration, application method, and contact time). Education: Prevention Practices -Educate residents, healthcare personnel, and visitors about [CONDITION(S)]-CoV-2, current precautions being taken in the facility, and action they should take to protect themselves. Testing Plan for Testing Residents and HCP Guidance addressing when to test resident HCP for [CONDITION(S)]-CoV-2 and how to interpret results of [MEDICATION(S)] test is available at the following links: -Testing Guidelines for Nursing Homes -Interim Guidance on Testing Healthcare Personnel for [CONDITION(S)]-CoV-2 -[CONDITION(S)]-CoV-2 [MEDICATION(S)] Testing in Long Term Care Facilities. Source Control and Distancing Implement Source Control Measures Use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose. -Residents, if tolerated, should wear a well-fitting form of source control upon arrival and throughout their stay in the facility. Residents may remove their source control when in their rooms but should put it back on when around others (e.g., HCP or visitors enter the room) and whenever they leave their room or go outside of the facility. CDC-Options to improve fit or masks. Implement Physical Distancing Measures -Maintain physical distance between people (at least 6 feet), except when closer distance is required for the provision of care. -HCP are to practice physical distancing and wear source control when in break rooms or common areas. -The following activities can be considered for residents who do not have current suspected or confirmed [CONDITION(S)]-CoV-2 infection, are recovered, and have had close contact with a person with [CONDITION(S)]-CoV-2 infection: -Communal dining and group activities at the facility with social distancing, source control and frequent hand hygiene. C. Resident #14 1. Resident status Resident #14, age 59, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/20/21 quarterly minimum data set (MDS) assessment revealed the resident was unable to complete an interview for a brief interview for mental status (BIMS). The resident had short and long term memory problems, and had moderate impairment with cognitive skills for daily decision making. The resident had disorganized thinking, inattention, and did not reject any cares from staff. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required supervision with locomotion on the unit, and with eating. Resident #14 was confirmed COVID-19 positive via [MEDICATION(S)] test on 1/10/22. 2. Record review The 1/10/22 nursing progress note documented the resident had a positive COVID-19 diagnosis. The 12/16/21 care plan revealed the resident would decline to wear a mask in the common areas even when staff requested her to wear a mask. The resident was to be encouraged to maintain a six foot distance between others when out of their room. D. Resident #11 1. Resident status Resident #11, age 90, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/28/21 quarterly minimum data set (MDS) assessment revealed the resident was unable to complete an interview for a mental status score (BIMS). The resident had short and long term memory problems, and had severe impairment with cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and did not reject any cares from staff. The resident required supervision with locomotion on the unit, and with eating. The resident used a front wheel walker and a wheelchair. Resident #11 was not vaccinated. 2. Record review The 7/21/2020 care plan revised on 10/31/21 revealed Resident #11 declined the COVID-19 vaccine. The 11/8/21 care plan revealed, Resident is at risk for COVID-19. Resident does not maintain her mask in open spaces. Encourage resident to maintain 6 ft distances between others when out of the room. The 12/26/21 CPO revealed the resident was to be encouraged to socially distance from others of six feet or greater, and to redirect as needed to keep a six feet distance, and to document if the resident was non-compliant. The 1/15/22 nursing progress note revealed the resident had a positive COVID-19 test result (three days after eating lunch with a COVID-19 positive resident, see below). E. Resident #2 1. Resident status Resident #2, age 76, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/6/22 quarterly minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status score (BIMS). She had highly impaired vision. She did not reject cares from staff. She required extensive assistance with bed mobility, transfers, toilet use, personal hygiene, locomotion on the unit, and eating. The resident was totally dependent upon staff for bathing. 2. Record review The 1/2/22 care plan revealed the resident was at risk for COVID-19. -The care plan did not reveal the resident was to maintain six ft social distance from others in the common areas. F. Observations On 1/12/22 from 12:10 p.m. to 12:50 p.m. lunch was observed in the secured unit. At 12:10 p.m. Residents #11 and #2 were escorted in their wheelchairs by certified nurse aide (CNA) #4 to a table in the common area on the secured unit which was an approximately three feet square table. Resident #14 (COVID-19 positive) walked to the same table and sat down with Resident #11 (unvaccinated for COVID-19) and Resident #2 (vaccinated). CNA #4 told Resident #14 it was okay to sit at the table where Residents #11 and #2 were seated. CNA #4 did not encourage Resident #14 or Resident #11 to sit at other available tables in the dining area. To the left of Resident #14 sat Resident #2. Resident #14 (COVID-19 positive) sat across the three foot table from Resident #11 (unvaccinated for COVID-19). The three residents were not socially distanced six feet apart from one another. The residents were not wearing masks. Residents #11, #14, and #2 ate lunch and drank liquids while being seated together. At 12:16 p.m., registered nurse (RN) #1 pulled up a chair and sat in between Residents #14 and Resident #2. RN #1 did not wear gloves as she assisted Resident #11 and #2 with their meals. RN #1 did not sanitize her hands in between assisting the two residents with eating. During the meal, the residents fed themselves and RN #1 assisted with bites of food to Resident #14 and Resident #2. -RN #1 used each resident's own silverware but she did not wear gloves or sanitize her hands in between assisting Resident #14 and Resident #2 with eating. RN #1 used both her right and left hands to assist Resident #14 and Resident #2. RN #1 took her ungloved right hand to pick up the spoon from Resident 14's plate, scooped some food onto it, brought the food to Resident 14's mouth, and sat the spoon back down onto the plate. RN #1 did not sanitize her hands and used her ungloved right hand to assist Resident #2 in the same manner. RN #1 repeated this for 10 minutes with both her ungloved left and right hands for both Resident #14 and Resident #2. RN #1 did not sanitize her hands in between assisting each resident with eating. At 12:45 p.m. RN #1 stood up and walked away from the table. The three residents continued to sit together. Resident #14 (COVID-19 positive) put her spoon that was in her mouth into the pudding of Resident #2. Then Resident #2 put her spoon in the same pudding that Resident #14 ate from. At 12:50 p.m. Resident #14 stood up and walked away from the table. G. Staff interviews Activity assistant (AA) #1 was interviewed on 1/13/22 at 9:49 a.m. She said she was the resident assistant for the memory care unit. She said the staff did not wear gloves while working on the memory care unit. She said the staff sanitized their hands between residents when the staff were assisting residents with eating. She said the staff did not wear gloves but the staff did sanitize their hands in between every resident they provided care to. She said the staff should not have seated a COVID-19 positive resident with the only resident on the unit who was not vaccinated against COVID-19. She said the staff could easily have seated the COVID-19 positive residents at a table that was isolated and six feet away from others. She said the memory care residents did not stay in their rooms to eat. She said the staff could rearrange the tables to be six feet apart. She said the staff should encourage any COVID-19 positive residents to sit together. She said the tables the residents sat at in the dining room were about three feet square tables. AA #1 said to certified nurse aide (CNA) #4, You should never seat an unvaccinated resident with a COVID-19 positive resident. She said, We need to make sure the unvaccinated resident would be safe and socially distanced from others. CNA #4 was interviewed on 1/13/22 at 9:55 a.m. She said, It was me who sat the COVID-19 positive resident with the unvaccinated resident yesterday for lunch. I did not know we should not do that. She said the residents in the memory care unit usually ate in the dining room not in their rooms. She said Resident #11 had a fever today (the unvaccinated resident) and was in bed. The director of nursing (DON) was interviewed on 1/13/22 at 9:50 a.m. She said the staff should not have seated the COVID-19 positive resident with the unvaccinated for COVID-19 resident. She said the nurse should have washed her hands in between assisting each resident with eating. She said it was not good that a COVID-19 positive resident (#14) put her contaminated spoon in Resident #2's pudding and then Resident #2 ate her own pudding. She said the residents should be six feet socially distanced from each other. She said in the memory care unit it was difficult to keep residents socially distanced but the staff should always encourage the residents to socially distance. She said she had talked to Resident #11's family and they did not want the resident to get her COVID-19 vaccination. The DON said, I can't believe the staff put the COVID-19 positive resident with other residents. I will fix this right away. She said she would educate the staff on the memory care unit to seat the COVID-19 positive residents at one table by themselves. She said the staff would be educated to not put COVID-19 positive residents with the residents who were not vaccinated or those who tested negative with COVID-19. The medical director was interviewed on 1/18/22 at 5:08 p.m. He said he was the medical director for a number of years. He said he routinely visited the facility to attend the facility's QAPI. He said he was notified of the facility's immediate jeopardy in infection control. He said it was unfortunate that staff were performing testing while residents were present and were not socially distancing or wearing appropriate PPE. He said it was difficult to keep residents socially distanced in the secure unit, but agreed if staff knowingly sat residents together (not six feet apart) that was a problem. He said he planned to review the facility's infection control and testing policy and procedures in their next QAPI. H. Facility follow-up The regional clinical nurse (RCN) #2 was interviewed on 1/18/22 at 12:20 p.m. She said staff would be provided training to not seat COVID-19 positive residents with those who did not have COVID-19. She said moving forward the COVID-19 positive residents would be placed at a table together to eat in the memory care unit. She said staff on the memory care unit were educated after the IJ on how to seat COVID-19 positive residents. She said she requested the staff to perform a return demonstration of how and where to seat the residents. She said she called any staff that were not working to educate them concerning the matter. The DON was interviewed on 1/18/22 at 1:00 p.m. She said the tables in memory care were moved six feet apart to enable six feet social distancing. She said a separate table was set up in a separate area for residents who were COVID-19 positive. She said the residents who did not have COVID-19 would be seated away from the table with the COVID-19 positive residents. She said the staff had been educated beginning on 1/14/22 to encourage and seat the residents in their appropriate sections. The DON said she misunderstood who had assisted residents with eating on 1/12/22. She said she thought CNA #4 had assisted the residents She said she would speak with RN #1 who had assisted the COVID-19 positive resident at a table with the resident who did not haveCOVID-19. She said it was sad Resident #11 was now positive for COVID-19. -The facility did not provide any additional follow-up concerning further trainings for COVID-19 positive residents in the dining room before the exit of the survey on 1/19/21. IV. Failure to ensure staff wore PPE appropriately A. Observation and interview On 1/12/22 at 3:32 p.m. CNA #2 was observed wearing his N95 mask incorrectly which would not ensure a secure fit. The back strap was observed hanging in front of his face. He said it was ill fitting. I don't like having the straps rubbing on my head. He said he did not ask the IP about being fitted for a new N95 mask. B. Administrative interview On 1/13/22 at 12:00 p.m. the DON and RCN #1 were interviewed. The DON said she was not aware CNA #2 had problems with his mask fitting. She said CNA #2 would be educated on how to properly wear an N95 mask. Today he is wearing his N95 mask appropriately. She said she would schedule CNA #2 for fit testing of a new N95 mask as soon as possible if it was truely ill fitting. VI. Failure to ensure staff wore proper personal protective equipment (PPE) when entering resident isolation rooms A. Professional reference According to the CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated 9/10/21, retrieved on 1/25/22 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, in pertinent part: Health care providers who enter the room of a patient suspected or confirmed to be infected with [CONDITION(S)]-CoV-2, should adhere to standard precautions and use NIOSH (National Institute for Occupational Safety & Health)-approved N95 or equivalent or higher-level respirator, gown, gloves and eye protection (goggles or a face shield that cover the front and sides of the face). B. Observations Certified nurse aide (CNA) #1 was observed on 1/12/22 at 8:37 a.m. CNA #1 entered the isolation room of Resident #65 without wearing a gown or gloves. Resident #65 was on COVID-19 isolation precautions. Resident #65's room had isolation droplet precaution signage posted on the door and on the wall outside the room. In addition there was a sign posted on the resident's door regarding appropriate PPE to be worn prior to entering the room. The room had a purple bin placed outside the room which stored the personal protective equipment (PPE) for staff to utilize. CNA #1 was observed on 1/12/22 at 12:10 p.m. CNA #1 entered the isolation room of Resident #293 without wearing a gown or gloves. Resident #293's room had isolation droplet precaution signage posted on the door and on the wall outside the room. In addition there was a sign posted on the resident's door regarding appropriate PPE to be worn prior to entering the room. The room had a purple bin placed outside the room which stored the personal protective equipment (PPE) for staff to utilize. C. Staff interviews CNA #3 was interviewed on 1/13/22 at 9:33 a.m. She said all staff should put on the personal protective equipment (PPE) from the isolation carts outside the isolation room. She said the PPE included a gown, gloves, an N95 (face respirator) mask and goggles or a face shield. She said regardless of whether the staff were providing care or dropping something off in the room they should put on the appropriate PPE before entering a resident isolation room. Licensed practical nurse (LPN) #2 was interviewed on 1/13/22 at 9:33 a.m. She said all staff should put on the proper PPE before entering a resident isolation room regardless of what care they were providing. She said the proper PPE included a gown, gloves, an N95 mask and a face shield. She said she would remind the staff to utilize the proper PPE before entering resident isolation rooms. The director of nursing (DON) was interviewed on 1/13/22 at 10:35 a.m. She said all staff should wear a gown, gloves, N95 and face shield or goggles when entering a resident isolation room regardless of what type of care was being provided. She said all staff were wearing the N95 mask and face shield at all times because of the current COVID-19 outbreak status. She said all certified nursing aides were trained on appropriate PPE utilization when entering a resident isolation room (she did not give a specific time frame of training). She said she would provide additional training to the staff observed entering the isolation rooms without the proper PPE (after issues were identified in infection control with the immediate jeopardy).

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 infection control and COVID-19 testing. Findings include: I. Facility policy The Improvement Performance QAPI (quality assurance performance improvement) policy, updated December 2020, was provided by the nursing home administrator on 1/19/22 at 11:19 a.m. It documented in pertinent part, It is the policy of this facility to develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, and to resolve identified problems. The primary purposes of Quality Assessment and Assurance Plan are .To identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans. The committee responds to quality deficiencies and serves a preventative function by reviewing and improving systems. The facility's QAPI Committee, having identified the root causes which led to their confirmed quality deficiencies, must develop appropriate corrective plans of action. Action plans may include: -Revision of P&P (performance plan); -Training for staff concerning changes; -Plans to purchase or repair equipment; -Improve the physical plan; and, -Standards for evaluating staff performance. Implementation of facility's action plans: -Staff training; -Deployment of changes to procedures; -Monitoring and feedback mechanisms; and, -Process to revise plans that are not achieving or sustaining desired outcomes. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct them. F880 During a recertification survey 1/17/2020 the facility was cited at an E pattern level. During an infection control focused survey 12/1/2020 the facility was cited at an F widespread level. During the recertification survey on 1/18/22 the facility was cited an K (immediate jeopardy) for not having an effective infection control program. III. Cross-reference citations Cross-reference F886: The facility failed to have an effective program to test for COVID-19 residents, facility staff and individuals providing services to residents of the facility. This deficiency was cited at an L scope, immediate jeopardy, for failure to ensure COVID-19 testing of staff and residents was conducted properly to prevent the spread of an infectious disease. IV. Interviews The NHA and supporting nursing home administrator (SNHA) were interviewed on 1/18/22 at 5:58 p.m. The NHA said the facility's last QAPI meeting was held on 12/8/21 and all department heads attended the meeting. Specifically, they identified some concerns with grievances and wrapped up with identification of social services agreements. He said they reviewed any social service related concerns and reviewed resident council minutes from the previous months. All departments reviewed any concerns. He said systemic concerns such as falls, nursing concerns, infection control, COVID updates, who is out with COVID, those with infections currently in building if they met criteria were reviewed. He said they discussed nosocomial versus community acquired infections and if there were any patterns identified. The SNHA said the QAPI was a robust meeting with a ton of participation from housekeeping to nursing, dietary including the medical director (MD) and it was very integrated. He said they reviewed facility wide systems, and departments would voice concerns or ideas for improvement. He said in the last review the MD closely reviewed the antibiotic stewardship program and wound care. The facility changed the wound physician, they provided a lot of education to staff and wounds were no longer an issue. The SNHA said with regards specifically related to the immediate jeopardy in testing and infection control, they discussed COVID-19. He said policies/practices related to infection control were reviewed along with any recent positive COVID-19 cases and the facility was not in outbreak status. He said the facility was well aware Omicron cases were increasing in the country; however, it was not increasing in the facility's community. He said the facility staff took things serious and they would implement preventative measures and follow-up. He said every facility could have better system in place to set up a testing site for COVID-19, the building was old with minimal areas which were ideal for testing. They acknowledged the state's guidance with implementing a safe sanitary testing site for facility employees and observations of breaks in infection control practices and planned to review the facility's systems at the next QAPI meeting.

Based on observation, record review and interviews, the facility failed to ensure services provided met professional standards of quality for one (#79) of eight out of 47 sample residents. Specifically, the facility failed to ensure Resident #79's blood pressure was within physician ordered parameters prior to administering hypertensive medication. Findings include: I. Facility policy The Medication Administration policy, updated August 2020, was provided by the nursing home administrator on 1/19/22 at 11:19 a.m. It documented in pertinent part, It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR) as appropriate. Should a drug be withheld, refused, or given other than at the scheduled time it should be appropriately documented on the MAR. II. Resident status Resident #79, age 82, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/14/22 minimum data set (MDS) assessment, revealed Resident #79 required extensive one-person assistance with most activities of daily living (ADLs). III. Observation and interview The morning of 1/17/22 registered nurse (RN) #1 was observed passing medication on the Montrose unit. -At 9:40 a.m., RN #1 prepared Resident #79's medications which included [MEDICATION(S)] 10 mg (milligram) one tablet by mouth. -At 9:46 a.m., RN #1 took Resident #79's blood pressure (BP) prior to administering her medication, it was 125/65. -At 9:51 a.m. RN #1 was interviewed as she updated Resident #79's electronic medication administration record (EMAR) order to include BP as there was a hold parameter indicated on [MEDICATION(S)] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . IV. Record review The December 2021 CPO documented an order dated 12/11/21, which read: [MEDICATION(S)] 10 mg tablet give one by mouth daily for hypertension hold for systolic blood pressure less than 110. Review of the December 2021 medication administration record (MAR) revealed Resident #79 received blood pressure medication even though her blood pressure was below parameter or was not taken. -On 12/22/21, Resident #79's blood pressure was below parameter at 104/63. -On 12/24/21, Resident #79's blood pressure was not taken or documented, but it was documented she received [MEDICATION(S)]. Review of the January 2022 medication administration record (MAR) revealed Resident #79 received blood pressure medication four times when her blood pressure was not taken or below parameter: -On 1/1/22 Resident #79's blood pressure was below parameter at 98/44. -On 1/2/22 Resident #79's blood pressure was not taken or documented. -On 1/6/22 Resident #79's blood pressure was documented as not applicable (N/A). -On 1/13/22 Resident #79's blood pressure was not taken or documented. -Review of Resident #79's progress notes for December 2021 and January 2022 revealed no documentation of the resident's blood pressure being taken or any further pertinent information related to her hypertension medication ([MEDICATION(S)]) being given even though her blood pressure was below parameter or her blood pressure not documented or being taken. V. Staff interview The director of nursing (DON) was interviewed on 1/18/22 at 5:45 p.m. She said nurses should follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said blood pressure medication typically had a hold parameter to make sure the blood pressure was taken before the medication was given and it meets the required parameters. She said if a medication was held there should have been a corresponding progress note with physician communication why the medication was held.

Based on observations, record review and interviews, the facility failed to ensure an incident involving one resident (#17) of three residents reviewed was thoroughly investigated and remained free from neglect out of 17 sample residents. The facility failed to ensure a timely and thorough investigation to Resident #17 sustaining a blister to her left leg, which included witness statements and question staff and other residents, document all findings and determine the root cause for the blister to Resident #17 left leg, to ensure future events were avoided. Resident #17 sustained an injury to her left upper leg. She reported to the director of nursing that she spilled her drink and was taken by the certified nurses aide (CNAs)to her room, where a CNA dried her pants with a hairdryer and burned her leg. The facility failed to conduct a timely root-cause investigation in order to determine the cause of the blister and keep the resident safe from future accidents, in addition, the facility failed to keep accurate medical records pertinent to the event. Findings include: I. Facility policies and procedures The Incident Reporting policy was provided on 1/14/21 at 2:10 by the director of nursing (DON). The policy revealed if the incident involved a resident, the staff member would complete a nurses note entry detailing the event, and what post incident interventions were done. The DON would complete an investigation of the incident within twenty-four hours of the event. This investigation, at a minimum, must attempt to identify any trends which might indicate resident abuse. The final disposition section of the incident/accident report was to be completed within twenty-four hours of the incident/accidents. II. Resident #17 A. Resident status Resident #17, age 62, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. The 10/16/20 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. The resident did not display any behaviors, hallucinations, delusions, verbal or physical behaviors, no rejection of care, or wandering. She required extensive assistance from two people with bed mobility, transfers, dressing, toilet use, and person hygiene. She had impairment on both lower extremities, and was not able to stabilize without staff assistance. She used a wheelchair for ambulation. The resident used an indwelling catheter, and was frequently incontinent of bowel. B. Resident interview The resident was interviewed on 1/13/21 around noon. She said several weeks ago she spilled water on her left upper thigh, and was taken back to her room by a certified nurses aide (CNA) who dried her pants with a hairdryer. She said when the CNA was drying her pants she felt pain in her leg and told her to stop. She said the CNA stopped, and later she discovered that she had a blister on her leg. She said she reported the incident to the DON. She did not recall the name of the CNA. She said CNA was still working with her and she was not fearful of her. C. Record review The care plan, initiated on 2/25/2020 and revised on 9/7/2020, revealed the resident had an indwelling catheter due to a [MEDICAL CONDITION] bladder. Interventions included to change the catheter bag and tubing as ordered and to monitor, record, and report any changes or signs of infection to the physician. -The care plan was not updated on or after 12/12/2020 with new interventions after the blister was discovered on the resident's left leg (see below). The care plan, initiated on 3/20/2020 and revised 1/6/21, revealed that the resident had potential to demonstrate verbally and physically aggressive behaviors due to ineffective coping skills, [MEDICAL CONDITION] disorder and poor impulse control. She had a history of [REDACTED]. Staff were to assist in redirecting the resident when she was upset and to keep her and others safe.The resident had a history of [REDACTED]. Interventions included to provide positive feedback for good behavior, emphasize the positive aspects of compliance, respect personal space, and not attempt to approach resident from behind as this can potentially cause her distress. The 12/12/2020 skin assessment by licensed practical nurse (LPN) #1, revealed that the resident had Clear fluid filled blister, skin prep applied on the left front thigh measuring two point five by two point five centimeters (cm). There were no supporting nurses notes on 12/12/2020 to clarify where the blister came from, who was notified, any investigation on the origin of the blister, and no interventions to prevent the future occurrence. On 12/14/2020, the nurse's incident note by RN #2 read, It's been reported that resident have a fluids (sic) filled, (blister like) on her left thigh, area clean with skin prep and left open. Surrounding area is red, not warm to touch, resident denied pain at this time. Physician and DON made aware. Resident self responsible. We will monitor the area and change the order when open. On 12/15/2020, RN #3 documented in the nurses notes, Resident seen by wound physician today. Resident presents with a blister to the left thigh. Resident denies any pain at this time. New order: Skin prep once daily. Physician and DON notified. On 12/16/2020, the above note by RN #2 was struck down and marked as incorrect entry by an unknown user. On 12/17/20, five days after the blister was discovered, a late entry note was documented by the DON with the effective date of 12/15/2020. The note read, Fluid filled blister, approximately three cm. round, noted to anterior left thigh. Area located at placement of foley leg strap. Resident reported that staff had found the area and reported to nurse for further tx (treatment) and eval (evaluation). Wound physician evaluated the area on 12/15 and continued orders to evaluate and treat. Area remains intact and fluid filled. Leg strap to be placed on the right thigh at this time until the area is resolved. Resident was updated with the plan and agreed. Staff to continue to monitor. On the same day, 12/17/2020, the DON documented, IDT reviewed skin changes, staff notified to place leg strap to right thigh until area resolved. On 1/7/21, progress notes revealed Resident seen by wound physician this morning. Wound have been resolved. Discontinue all wound orders. Physician notified, resident is self responsible. The wound care notes were reviewed from 12/15/2020 to 1/7/21.The initial wound assessment by wound care physician #1 was documented on 12/15/2020. The blister was located on the left thigh and measured three centimeters by three centimeters. There was no etiology of the blister documented in any wound care notes. Wound care physician #1 followed the resident from 12/15/2020 to 12/31/2020. On 1/7/21, wound care physician #2 documented that the blister on the left thigh was resolved. III. Facility's investigation The investigation was provided by the DON on 1/13/21. The investigation contained the following documents: A. The incident report The incident report, dated 12/15/2020, (three days after the blister was discovered) read fluid filled blister noted to anterior left mid-thigh. Area to be approximately three centimeters round. Area intact and raised. Area found via staff and reported to nurse. Immediate actions included nurse documented findings and wound physician evaluated 12/15 and orders written to monitor and to treat. No other injuries observed at the time of the incident. The pain level was three out of 10. The assessment revealed the resident was alert, oriented and wheelchair bound. Resident had a foley catheter and leg strap noted to be at the same area of noted blister found. No witness was found for the investigation. The incident report was completed by the DON. B. A printed and signed note by DON with no date A printed and signed note by DON with no date, revealed that the resident reported to her that a CNA used a hairdryer to dry the wet area on her pants. The resident named the CNA who used the hairdryer. She also pointed to the location of the hairdryer and confirmed that it was the hairdryer that was used. The DON documented that blow dryer noted to have packaging over plug and was new, which had noted to have never been used. (Resident) shown blow dryer cord and that the plug in hadn ' t been used due to packing and (resident) reported I don ' t know. Area then assessed and noted blister to leg was under catheter strap placement. (Resident) then reported that she never has any issues with (named CNA) and she likes her. The document included that the DON interviewed CNA #10 (who was named by the resident), and the CNA stated she never used the hairdryer on the residents' clothes and was not working that shift. The CNA was educated on proper use of hair dryers. C. Interview conducted by behavioral health director (BHD) The undated, typed note, signed by BHD, read that she interviewed the resident on 12/16/2020 regarding the spot on her leg. The resident reported the same story as above, that she spilled water and her wet pants were dried with a hairdryer by CNA #10. The resident reported that she felt safe and not fearful of CNA #10. D. Printed copies of the resident's care plan, medications and treatment administration record, and wound care notes were included in the investigation package. The investigation did not include interviews with staff members who worked on 12/12/2020, when the blister was initially reported, or with other residents on the unit. There were no physician notes on the etiology of the blister. E. Skin assessment The skin assessment was conducted by a RN #2 on 1/13/2021 around 1:30 p.m. The resident was positioned on her back in bed. Both of her legs were assessed for skin integrity. On her left leg, two to three inches above the knee, was observed a red round to oval scar. The resident stated that was the location of the blister that she was talking about earlier. No other skin issues identified. Resident had an indwelling catheter in place that was connected to a large foley bag. No leg straps observed. F. Hairdryer observation On 1/13/21 around 2:00 p.m., with the permission and in the presence of the resident, the DON entered the resident's room and asked the resident if she could take a look at the hairdryer. The resident stated the hairdryer was in the drawer that she pointed to. The DON reached into the drawer and pulled out a black hairdryer. The cable on the hair dryer was loosely folded and the plug pins were covered with a removable plastic cover. The resident was asked if she ever used this hairdryer. She said she did not use the hairdryer, but other people used it in her presence. The hairdryer did not have a red zip tie around the plug pins as later reported by DON. (See interview below). IV. Staff interviews CNA #10 was interviewed 1/13/21 around 12:30 p.m. She said she worked with the Resident #17 on several occasions. She said she was aware that the resident named her as a person who caused a blister by using a hairdryer on her clothes. She said she did not know that resident had a hairdryer and never used one with Resident #17 or any other residents. She said she did not work on 12/12/2020, when the blister was discovered, or the day before 12/11/2020. She believed Resident#17 gave her name because she was new to the facility and was less known by Resident #17. RN #2 was interviewed on 12/13/2020 around 12:30 p.m. She reviewed the resident's record. She said she recalled writing the note on 12/14/2020, but she did not recall the details of how the blister was discovered. She believed it was reported to her by the nurse from the previous shift. She said she completed a skin assessment and incident report. She reviewed the electronic medical record and could not locate the incident report. She did not know why the incident report was missing. She reviewed the progress notes and did not know why her progress note on 12/14/2020 was struck out as an error entry. LPN #1 was interviewed over the phone on 1/14/21 at 10:44 a.m. She said she recalled the day in December 2020 when she was working with Resident #17. She said on that day she was approached by CNA #11, who reported to her that the resident had a blister on her leg. She said she looked at the leg, and both the resident and the CNA told her that there was a leg bag for the catheter that was rubbing against the skin. She said the resident was using an indwelling catheter for a long time and she did not observe blisters caused by the catheter bag or tubing in the past. She said she reported the blister to a registered nurse (RN) who was working that day. She said she believed it was the RNs responsibility to complete all needed paperwork and report it to the management staff. She did not recall the name of the RN who was working on that day. She said now she was aware that it was her responsibility to complete an incident report and notify the physician, but back then she did not know that. CNA #11 was interviewed over the phone on 1/14/21 at 11:30 a.m. He said he was familiar with Resident #17 and often worked with her. He said he did not recall any skin conditions or any unusual events with Resident #17 in December 2020. LPN #2, who was also the unit manager, was interviewed in the presence of the SDC on 1/14/21 at 11:40 a.m. She said she was working on 12/12/2020 as a unit manager and she did not recall any nurses reporting to her changes in skin condition for the resident. She said she had a long experience working as a nurse and if it would be reported to her, she would complete a skin assessment, risk management form and would notify the physician and family. She said she knew Resident #17 very well. She said Resident #17 was alert and oriented, did not reject care, and she was not aware of any false allegations from the resident. She said she also was a wound nurse for the last three to four weeks. The previous wound nurse was no longer working in the facility. She said last Thursday (1/7/21) when she looked at the Resident #17's skin, the blister was healed. CNA #12 was interviewed on 1/14/21 around 12:20 p.m. She said she knew Resident #17 well. She said the resident was alert and oriented and able to tell what she wanted and needed. She said the resident did not refuse the care, did not have any behaviors and she was not aware of any false allegations the resident had made. She said the resident was using a Foley catheter and she cleaned the catheter and drained the bag two to three times a shift. She said the resident always used a large Foley bag and she did not see the resident using a leg bag. CNA #7 was interviewed on 1/14/21 around 12:25 p.m. She said she worked with Resident #17 often. She said the resident was alert and oriented, she did not refuse the care and did not make any false allegations against staff. She said the resident had a Foley catheter that she used with a regular large foley bag. She said she did not recall the resident wearing a leg bag. CNA #8 was interviewed on 1/14/21 around 12:30 p.m. She said the resident required care of one to two people, she needed assistance with dressing, transfers, and personal care. She said the resident was alert and oriented, she did not have any behaviors and did not make any false allegations that she knew of. She said the resident used a Foley catheter with a large catheter bag. She said she did not see the resident using a leg bag. Wound care physician #1 was interviewed over the phone on 1/14/21 at 12:11 p.m. She said she was no longer working in the facility. After she reviewed the record, she said she took care of the blister wound for Resident #17. She said it was hard to determine the origin of the blister and with alert and oriented residents, it would be best to ask them. She said she did not ask the resident about the origin of the blister and relied on nurses for communication. She said it would be very hard for a catheter leg bag or tubing to cause the blister. It would require intense and continuous rubbing, and was very unlikely considering the location of the blister (anterior leg, two-three inches straight above the knee), and the fact that the resident was not able to ambulate independently. She said it was unclear what kind of movement by the resident would have caused intense rubbing of the catheter tubing or leg bag on the top of her left leg straight above the knee. She said in her practice, the improper placement of catheter tubings or the bag usually resulted in a pressure injury, not blister. The DON was interviewed on 1/13/21 around 3:40 p.m. Regarding the nurse's note that was struck out, she said, she did not know how to check who struck the note out and why it was done. She said all managers including her were able to do so. She said she believed that blister was reported to her by RN #2 who was working on 12/14/2020. She said she did not know why the incident report was not completed by RN#2 at the same time. She said, she herself, later, completed the incident report. Regarding the blister: the DON said she talked with the resident the same day she learned about the blister. She said Resident #17 told her about CNA#10 who was trying to dry wet pants with a hairdryer. The DON said that she checked the hairdryer and it appeared unused with the plastic cover over the plug pins. In addition, she said the plastic cover over the plug pins was secured with a red zip tie making it impossible for anyone to use the hairdryer. She said this assessment of the hairdryer was done in the presence of the resident and CNA #13. She said she concluded the investigation that the hairdryer was not used, and the blister was caused by the catheter strap. CNA #13 was interviewed on 1/13/21 right after the interview with DON. She was interviewed in the presence of the DON. CNA #13 said she knew Resident #17 and often worked with her. She said the resident had behaviors and at times yelled at her roommate, or threw her items all over the floor. Regarding the observations of the hairdryer with DON on 12/14/20, she said she was not aware that the resident had a hairdryer in her room. After the resident pointed out the location of the hairdryer in the drawer, they pulled it out. She said the hairdryer was in the box in the plastic bag and had white plastic cover over the plug pins. She said the cable was secured with a zip tie and the plastic cover over the plug pins was removable. However, it appeared to be the same in nature as one would observe on new appliances. The nursing home administrator (NHA) was interviewed on 1/13/21 around 5:00 p.m.in the presence of the DON. He said he did not participate directly in the investigation about the blister, but he was aware of it. He said the investigation was conducted by his team members, who he believed he could trust and knew how it should be done. On 1/14/21 around 10:00 a.m., the DON provided several documents. She said the facility conducted an additional investigation regarding the incident. Specifically, she said staff members and residents on the unit were interviewed about the use of the hairdryer and potential abuse. All staff members were educated on proper use of the hair dryers. V. Facility follow up On 1/14/21, the NHA provided a statement via email from wound care physician #2. The note read: ?For (Resident #17), her left thigh blister is not associated with a burn, and can be labeled as shearing etiology.

Based on record review, observations and interviews, the facility failed to keep residents free from abuse for ten (#1, #3, #2, #4, #5, #10, #13, #14, #15, #16) out of ten residents reviewed for abuse out of 15 total sample residents. Specifically the facility failed to: -Protect residents on the secured unit. Multiple residents involved with resident to resident altercations. Some of the altercations resulted in injury, however, the resident to resident altercations had a high likelihood to result in serious harm. -Resident #1 was involved with 11 altercations between May 2020 to November 2020 altercations with other residents. He was both the victim and the assailant. -Resident #2 was involved with two altercations with Resident #3 in August 2020 and October 2020 where he was the assailant -Resident #3 was involved with eight altercations with other residents between May 2020 to October 2020. He was both the victim and the assailant. -Resident #4 was involved with two altercations with Resident #3, where she was the victim -Resident #5 was involved in multiple altercations with Resident #1 as both the assailant and victim -Resident #10 was involved in two altercations where she was the victim of Resident #1 and Residents #3 -Resident #13 was involved in three altercations as the victim and assailant of Resident #1 -Resident #14 was involved in one altercation as the victim of Resident #1 -Resident #15 was involved in one altercation as the vicitim and assailant of Resident #1 -Resident #16 was involved in one altercation as the victim and assailant of Resident #1 Cross reference F744 for dementia care and F865 for quality assurance and performance improvement. I. Immediate Jeopardy A. Findings Triggering Immediate Jeopardy Record review of resident to resident altercations and staff interviews revealed Resident #1 and #3 had been involved in multiple altercations with multiple residents over the past six months. Both Resident #1 and Resident #3 exhibited wandering behaviors, entering other residents' rooms, taking other residents' items, disregard for other residents' personal space, and impulsivity. Review of the resident to resident altercations showed both Resident #1 and Resident #3 were victims and assailants of physical abuse. Resident #2 was the assailant in two altercations caused by Resident #3 getting too close in his personal space. Resident #4 was the victim in two altercations with Resident #3 due to Resident #3 trying to take her belongings and getting too close to her. Observations conducted on the secured unit on 11/24/2020 and 11/25/2020 revealed the residents were wandering around the unit with staff members observing from a distance but not engaging them. Resident #1 was observed wandering on the unit, approaching other residents, touching them, touching their walkers and trying to talk to other residents at a close proximity to their faces. Resident #3 was observed sleeping in another resident's bed as well as wandering around the unit. Multiple staff interviews revealed resident to resident altercations were common on the secure unit, due to residents wandering, not respecting other residents personal space, dementia and mental health diagnoses. The staff interviews revealed they try to watch the residents and keep them away from each other, but could not watch them all the time. Interviews revealed staff had received training related to resident to resident altercations as well as interventions to try to prevent altercations, though review of the altercations and observations showed the interventions were not consistently implemented and were not effective. B. Imposition of Immediate Jeopardy Based on record review, observations and staff interviews (see below) which revealed multiple resident to resident altercations, the facility staff including the nursing home administrator (NHA), director of nursing (DON) and clinical resource (CR) were notified on 11/25/2020 at 4:29 p.m. the failure to implement effective interventions and sufficient facility actions to prevent resident to resident altercations, created a situation of immediate jeopardy with the likelihood of serious harm to residents. C. Facility Response and Removal of Immediate Jeopardy On 11/27/2020 at 12:29 p.m. the clinical resource submitted the following removal plan (draft number five): All 18 residents on the secure unit had the likelihood of being affected by the immediate jeopardy. The following was implemented: Additional staff member was placed on the unit at 11/25/2020 at 1720 (5:20 p.m.) to monitor and engage the residents on the secured unit to ensure that residents individualized needs were met-A licensed CNA was placed on the unit, this staff member is in addition to the scheduled nurse, 2 CNA ' s, and full time activity staff member and full-time social worker. The additional staff member received training from behavioral health program manager on abuse prevention, providing person centered interventions, resident specific triggers and interventions for the 3 identified residents. The facility identified that an additional staff member on the unit 24/7 (24 hours a day, 7 days a week) providing engagement to residents in common areas would sufficient to prevent behaviors and residents to resident altercations. Staff members on the secured unit were educated by behavioral health program manager in regards to resident to resident altercations and abuse prevention. Staff members educated on Resident #1, #2, #3 individualized triggers and interventions to decrease risk of resident on resident altercation. This education was initiated on 11/25/2020 at 2030 (8:30 p.m.), and will continue until all staff is educated by 12/1/2020. Reviewed and updated person centered care plan on 11/25/2020 for Resident #1, #2, and #3. That included non-pharmacological approaches that included meaningful and purposeful activities that accommodated their personal preferences for interventions to de-escalate and engage the residents and help staff identify triggers for the residents. Education was provided by the behavioral health program manager. Resident #1 Triggers: -When other residents are in his walking path ·Others pointing at his face ·Resident actions that are directed towards him in a negative way -Being startled · Raised voices directed at him Interventions: ·Actively listen to feelings and agree ·Offer to call his friend ·Walk around the neighborhood ·When resident is confused or delusional do not attempt to reorient as this causes him distress; agree and meet him in his reality Resident #2 Triggers: ·Others invading his personal space ·When he perceives that female resident or staff are being mistreated -When he perceives that he is constipated Interventions: ·Offer prune juice when he feels that he is constipated ·Offer Resident a snack. -Offer to take resident out for a smoke break ·Offer him a soda pop Resident #3 Triggers: ·Loud noises ·Raised Voices directed at him ·Other waking him up ·He believes everything is his, when his unable to obtain the desired item he gets upset -Loud environment Interventions: ·Attempt to redirect to his own room for naps during the day and do not try to wake him once asleep. ·Offer resident a glass of milk. ·Offer resident a sweet treat such as cookies ·Offer to take resident for a walk around the unit In-service was completed by Behavioral Health Program Manager with all staff on the secured unit regarding abuse prevention, identifying triggers and any person-centered interventions. This education will be completed to all secured staff prior to shift on the secured unit, and will be completed to all staff by 12/1/2020. If staff is unable to come to building for in-service before 12/1/2020 we will call staff and educate over the phone and document, those staff will have to meet with Behavioral Health Program Manager prior to start of next scheduled shift. Dementia and behavioral education will be provided by Behavioral Health Program Manager and is to start on 11/27/2020 and be completed by 12/1/2020, to each staff member assigned to the secure unit before the start of their next shift. Any staff that is unable to come in to receive education will be called and educated over the phone by 12/1/2020 and instructed to meet with Behavioral Health Program Manager before next scheduled shift. Care plans will be reviewed for all residents on the secured unit by 11/27/2020 and residents will be assessed by 11/27/2020. Based on assessment and clinical documentation, care plan were updated to include diagnosis, behaviors, triggers, person centered care and interventions. Staff will be educated on the care plans by 12/1/2020. In-service will be completed by 12/1/2020 by Behavioral Health Program Manager 1. Abuse prevention, 2. Identified residents' specific triggers and interventions. 3. All residents on secured unit care plan updates including diagnoses, behaviors, triggers and interventions. 4. Dementia and behaviors. If there is any type of altercation, a verbal report will be made to the Abuse Coordinator and will be documented. This removal plan was accepted and immediate jeopardy was lifted on 11/27/2020 at 12:41 p.m. on the basis that the facility had provided education to staff, increased staffing on the secured unit, and specified interventions to prevent resident to resident altercations on the secured unit. However, deficient practice remained at an H level, with acutal harm to residents that is pattern. Findings include: I. Facility policies and procedures The Abuse Prevention and Reporting policy, revised March 2020, was provided by the DON on 12/1/2020 at 3:30 p.m. It read, in pertinent part: It is the policy of this facility that: -Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect, and exploitation. -Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. -All allegations of abuse are investigated. -Employees receive instruction on what constitutes abuse and reporting requirements during orientation and periodically during on-going in-service education. -All reported incidents of alleged abuse are immediately investigated and reported per state law and in accordance with the Elder Justice Act. -Any staff member who has reasonable cause to believe or reason to suspect any situation that may be considered abuse will immediately report to the Charge Nurse. The staff member will intervene and ensure that the resident is safe. Make sure that all residents are kept safe during the investigation. -If a resident is the assailant, make sure that they are kept out of reach of other residents and increase monitoring of the assailant -The charge nurse will assess the situation to determine if any emergency treatment is required and provide first aid as indicated. -The charge nurse will document details, injuries, and interventions that were attempted to prevent recurrence. -Social services/designee, as appropriate, will provide ongoing support and counseling to the resident, responsible party, and other residents as needed. -The administrator/designee will complete the investigation and will notify the suspected assailant and victim or responsible party of the conclusions and any corrective actions implemented based on investigative findings. II. Observations On 11/24/2020 between 3:00 and 3:50 p.m. observations were conducted on the secure unit and revealed there were seven staff members on the unit including one registered nurse (RN), two certified nurse aides (CNAs), a physical therapist, two activity staff, and a social service assistant. The nurse was passing medications and the physical therapist was working with a resident, though the other five staff members were standing around the perimeter of the unit or talking to each other. -Resident #1 was wandering throughout the unit approaching other residents, getting very close to them, touching their hands and shoulders to talk to them as well as standing in front of a resident's walker and holding the crossbar to talk to the resident. The SSA intervened after Resident #1 held the resident's walker for approximately two minutes. -Resident #3 was observed wandering around the unit intermittently in the hallways. At 3:47 p.m., Resident #3 was observed sleeping in another resident's bed. II. Resident #1 A. Resident status Resident #1, age 74, was initially admitted on [DATE] and readmitted on [DATE]. According to the computerized physician orders [REDACTED]. The 10/5/2020 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. He had no hallucinations, delusions, wandering, pacing or rummaging captured during the assessment period. Resident #1 had physical behaviors directed at others during the assessment period, such as hitting, kicking, scratching, grabbing or abusing others sexually. He did not use any mobility devices, when he ambulated in his room and in the corridor. Resident #1 required supervision with bed mobility, transfers and eating. He required extensive assistance of two people with dressing, personal hygiene, and toileting. Resident #1 was totally dependent on staff for bathing. B. Record review The behavior care plan initiated 3/20/2020, and revised 9/10/2020 was reviewed. The care plan documented, Resident #1 had the potential to exhibit behavior problems related to Dementia with behavioral disturbances, [MEDICAL CONDITION], and Sexual Disorder. He exhibits impaired insight, judgment and insight and poor impulse control. He was currently prescribed two dual antipsychotic medications to help manage symptoms including physical and verbal aggression, hallucinations, distressing delusions, smearing of bodily fluids, expressing racial slurs, and inappropriate sexual comments/behavior toward others. Staff assist in redirecting and keeping him and others safe. Resident #1 can become physically aggressive if he perceives others to be acting in a threatening manner. Resident #1 had as history of wandering into others rooms and thinking that it was his room. Resident #1's triggers included other resident's actions that are directed towards him, when other residents are in his walking path and others pointing at his face. Interventions as of 3/20/2020 included: administer medications as ordered, anticipate and meet needs, approach in a calm manner, assist to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately, avoid confrontations or arguments, caregivers to provide opportunity for positive interaction, attention, stop and talk with him/her as passing by, explain all procedures to before starting and allow resident to adjust to changes. If reasonable, discuss behavior, explain, reinforce why behavior is inappropriate and, or unacceptable, intervene as necessary to protect the rights and safety of others, divert attention, remove from situation as needed, provide activities program that is of interest and accommodates residents status. When Resident #1 wais confused or delusional do not attempt to reorient as this causes him distress, meet him in his reality. Remove from common areas if becoming activated, assist to a private area to calm down. The preadmission screening and resident review (PASRR) interventions on the care plan included, Resident #1 would benefit from behavioral monitoring for instances of agitation and aggression, redirect when necessary and to prevent Resident #1 from wandering and getting lost. The CNA Kardex (document for CNAs which documents care needs for residents) with instructions for how to care for Resident #1 dated 11/30/2020, was reviewed. The Kardex did not include all interventions for Resident #1's behavior that were on the behavior/dementia care plan (see care plan above) C. Altercations involving Resident #1 1. 5/1/2020 The progress note dated 4/30/2020 at 6:53 p.m. documented in pertinent part, Resident #1 continues to agitate other residents with non stop verbalizing, getting too close, moving chairs to be next to them, as well as constantly after staff with questions relating to his ' reality. ' Resident was continually educated on ' social distancing, ' to no avail. No other behaviors noted this shift other than unwilling to stop verbalizing to us. The progress notes dated 5/1/2020 at 11:27 a.m. documented in pertinent part, Unit nurse reported to this writer that patient was having an increase in behaviors and had hit another resident in the face, causing the other resident to fall backwards, hitting his head on the dining room table and falling to the ground. This writer redirected patient to his room and increased staffing supervision. There was no documentation related to injuries for Resident #1 at that time. The progress notes dated 5/1/2020 at 11:40 a.m. documented in pertinent part, Patient notified that behavior was inappropriate and hitting anyone is not allowed and won't be tolerated. Patient understands at this time. Patient aware that he needs to avoid contact w/o (with other) resident at this time. Medications had been adjusted and began this a.m. Patient reported that there is no fear and he does not feel as if he is in danger. Patient agreed to keep hands to himself. Unit nurse and staff to continue to monitor. However, Resident #1 had severe cognitive impairment to comprehend or remember what he was told. The interdisciplinary (IDT) note dated 5/2/2020 at 12:47 p.m. documented in pertinent part: Two residents with dementia came across each other while out in the hallway. Resident #5 came up to Resident #1 and found him in his way. Resident #5 has a walker and lifted it in the air a few inches off the ground and started shaking it at him. As this happened, staff saw the residents get close and came to intervene. There was a nurse and maintenance director in close proximity who immediately started moving towards the residents. Prior to being able to intervene Resident #1 pushed Resident #5, and then swung to hit him. The swing did reach the resident and this caused Resident #5 to stumble to the ground. It is unclear after seeing the residents where the punch landed, but it appeared to be the face. There was no visible mark of any kind to indicate specifically where it landed and the resident would not admit to being hit. Both residents continued to be upset and neither would allow the nurse to examine them. The nurse was able to assess that there was no bleeding, swelling, redness, or signs of physical or psychosocial harm. The residents were monitored for the remainder of the day to ensure their safety and the safety of all residents in the unit at the time. Both residents report to be free of pain, harm, or fear of any kind. At this time, there is no cause for concern for either the physical or psychosocial well being of these residents or of others on the unit. Both resident's care plans were reviewed and updated to include potential triggers for behavior. The progress note dated 5/3/2020 at 5:34 a.m. documented in pertinent part, Resident is place(d) on 15 minutes check due to altercation with another resident. Resident still go around other Resident and says B word. The progress notes dated 5/3/2020 at 5:30 p.m. documented in pertinent part, Need medication evaluation, increased dangerous behavior that can hurt residents or others. Residents continue to be in personal space and touching other residents even when they said no. Sometimes conversing with other residents when they don't want conversation, very difficult to redirect. The facility was aware that Resident #1 had dangerous behavior that can hurt residents or others. 2. 7/16/2020 The progress note dated 7/16/2020 at 6:27 p.m. were reviewed. The note documented in pertinent part, another resident wheeled wheelchair on resident foot. Resident turned around and hit the other resident on the back of his head for wheeling the wheelchair on his foot. Both residents were separated for safety and resident foot assessed, denies pain, no injury, bump or redness, resident wiggle all toes and ambulate without difficulties. The progress notes dated 7/16/2020 at 3:15 a.m. documented, Resident #1 was standing next to other residents and another resident in a wheelchair was trying to pass through the way. Resident #1 did not have enough room to move out of the other resident's way. The other resident started to wheel over Resident #1's foot and then hit Resident #1. Resident #1 then turned and punched the back of the other resident's head repeatedly. The activities associate then pulled Resident #1 arm back but then Resident #1 then used his other arm to smack the other resident in the head and then that is when a CNA came and split them up. The IDT note dated 7/17/2020 at 9:51 a.m. documented in pertinent part, Resident #1 has a care planned history of being verbally and physically aggressive, experiencing distressing delusions, and being triggered when others are in his walking path. Surveillance videos were reviewed and showed that Resident #1 was standing in the middle of the hallway and Resident #13 was not able to get by with his wheelchair. Resident #1 attempted to move out of the way for Resident #13. As Resident #1 was moving out of the way, Resident #13 elbowed him and Resident #1 turned around to hit him in the neck. Activities assistant attempted to get in between both residents however, Resident #1 was able to get around the activities assistant and hit Resident #13 again. CNA's were able to assist the activities assistant with separating the two residents. It appears that Resident #1 was in Resident #13's way, which frustrated Resident #13, as Resident #1 moved away, Resident #13 elbowed him, which prompted Resident #1 to respond by hitting Resident #13 back. The surveillance video showed that the hitting was at a low level of intensity.Both residents were put on 72 hour monitoring. The previous intervention from the altercation on 5/1/2020, to assist Resident #1 from coming face to face with other residents while walking in the common areas or hallways, was not effective or evaluated by the IDT previous to the altercation occurring on 7/16/2020. There were no new interventions documented until after Resident #1 was involved in another altercation three days later. 3. 7/21/2020 The progress notes on 7/21/2020 at 5:40 a.m. documented, Altercation with another resident. Resident found on the floor on his knees. Altercation not witnessed but overheard by Staff who responded immediately. R.N. (registered nurse) Charge Nurse notified. Above right eye purple center and circular area noted above right brow approx. 6 cm (centimeters). Left reddened area noted at right jaw line. Resident taken to a safe place away from the resident he had altercation with and monitored vital signs and Neuro (neurological) checks. Resident alert but appears shocked and afraid. The IDT note dated 7/28/2020 at 2:57 p.m. documented, based on interviews from all involved residents and staff. Resident #1 wandered into the room. People wandering into Resident #5's room is a trigger for him. Staff heard Resident #5 and Resident #1 arguing and by the time they got to Resident #5's room, it appears that Resident #5 hit Resident #1 in the face. The behavior care plan initiated 3/20/2020, and revised 9/10/2020 was reviewed. Interventions added on 7/22/2020 included offer to take Resident #1 out to the courtyard, offer to take Resident #1 outside to smoke when agitated. On 7/23/2020, interventions were to redirect Resident #1 from other resident's' rooms when he is wandering. 4. 8/19/2020 The progress notes dated 8/19/2020 at 4:05 p.m. documented, staff heard noise and ran to the scene, saw resident and another resident physically hit each other.Resident denies pain. Placed on frequent monitoring. Resident could not give any statement. Superficial Skin tear to the left posterior hand. The IDT note, dated 8/25/2020 at 9:43 a.m documented in pertinent part, Resident #13 was banging on the door to go out to the courtyard. Resident #1 was wandering around the neighborhood and approached Resident #13. As Resident #1 approached Resident #13, Resident #13 grabbed Resident #1's left wrist. Resident #1 then turned to hit Resident #13 in the face. Resident #1 was put on 72 hour monitoring for a change in mood or behavior. The behavior care plan was updated to offer to call Resident #1's son on 8/24/2020 and reminisce with Resident #1 about New Orleans and offer choices about activities on 8/31/2020. 5. 8/27/2020 There were no progress notes from 8/27/2020 through 8/31/2020 regarding the residents behavior. On 9/1/2020 at 11:12 a.m., an IDT note documented the following in pertinent part, IDT review of incident on 8/27/2020. On 8/27/2020 at 10:10 a.m., on the secured neighborhood, Resident #1 wandered into Resident #14's room at 10:13 a.m. Resident #1 wandered back out to the common area and Resident#14 followed him and told Resident #1 to comeback here. Staff intervened and asked Resident #14 what happened. Resident #14 reported that Resident #1 came into his room and hit him on the mouth. Staff assisted in keeping the two residents separated. When social services interviewed Resident #14 at 10:20 a.m., Resident #14 reported that he came back from smoking and found Resident #1 in his room and when Resident #14 told him to leave, Resident #1 hit him on the mouth. Nursing assessment showed no sign or symptoms of redness, pain or injury. However, there was no nursing assessment documented in the progress notes. The IDT notes continued to document, surveillance videos were reviewed and staff were interviewed. It appears that Resident #1 was wandering around the neighborhood when he wandered into Resident #14's room to find a bathroom to use. Staff separated the two residents. Resident #14 was put on 72 hour monitoring for a change in behavior and mood. The behavior care plan was reviewed with no further interventions added. 6. 9/9/2020 The progress notes dated 9/9/2020 at 7:52 p.m. documented at approximately 3:20 p.m. this afternoon, resident hit another resident in the face. Both residents separated for safety. When the writer asked the resident what happened. Resident said, because she is a lady, she thinks she cannot be hit by a man. Writer said, but the lady was only joking with you. Resident said, ' I saw her make a fist, so I defended myself, and hit him first. I don't know if she was joking. Resident #1 said, he apologized for hitting her. ' -There was no documentation regarding injuries or plan to keep the residents safe from further abuse. The IDT note dated 9/10/2020 at 11:37 a.m., documented in pertinent part, On 9/9 (2020) at 3:22 p.m., Resident #10 was talking to the activities assistant when Resident #1 was wandering around the neighborhood and approached Resident #10 from the side. Resident #10 turned to Resident #1 and started talking to him. As Resident #10 was talking to Resident #1, she pointed at him and he then turned to hit her with a closed hand. However, it did not appear to be hard in intensity. Resident #10 was put on 72 hour monitoring for change in mood or behavior. Resident #1's skin assessment conducted and showed no injury or bruising however the skin was red and Resident #10 had a red cheek. The note documented, Resident #1 had a care planned history of being verbally and physically aggressive, experiencing distressing delusions, and being triggered when others are in his walking path or pointing at his face. The behavior care plan was reviewed, on 9/14/2020 the care plan was updated to include validate how Resident #1 is feeling, offer a sweet snack. No further interventions were added to keep the residents safe from abuse. 7. 10/2/2020 The progress note dated 10/2/2020 at 6:51 p.m. was reviewed. The note documented in pertinent part, Nurse was chatting in the nurses station and heard CNA screaming stop, nurse ran out and saw CNA stood between two resident, nurse asked what happened, CNA stated Resident #1 slapped resident Resident #15 and she slapped him back. Nurse assessed the area and performed head to toe assessment, no injury observed at this time. Resident unable to give description. The IDT note dated 10/5/2020 at 9:13 a.m. was reviewed. It documented in pertinent part, Based on surveillance footage and interviews, it appears that the slap was not hard in intensity. Both residents were immediately separated. Both residents voiced that they felt safe.Resident #15 and Resident #1 were put on 72 hour monitoring for change in mood or behavior. There were no additional interventions evaluated or implemented following this altercation. 8. 10/11/2020 The progress notes dated 10/11/2020 at 4:56 p.m. were reviewed. The note documented Resident involved in unwitnessed altercation. Skin check performed. No new injuries noted. -There was no further documentation on 10/11/2020 regarding the altercation or interventions put in place to keep residents safe. The IDT note dated 10/12/2020 at 1:46 p.m. was reviewed. The note documented in pertinent part, On 10/11/2020 at 3:45 p.m., Resident #13 was in his room when Resident #1 wandered into his room. Resident #13 yelled for Resident #1 to get out of his room. Resident #13 then reported to staff that Resident #1 hit him. Staff then separated the two residents. Skin assessment showed that Resident #13 had a swollen area to the left eye and had some redness to his nose. Resident #1 has a care planned history of being verbally and physically aggressive, experiencing distressing delusions, and being triggered when others are in his walking path or pointing at his face. Based on interviews with all involved residents and staff, it appears that Resident #1 was wandering around the neighborhood which is a baseline behavior for him. Skin assessment showed that Resident #13 had a swollen area to the left of his eye and had some redness on his nose. Resident #13 recalls the incident but voiced that they felt safe and were not afraid of the other resident. Resident #13 is on 72 hour monitoring for a change in mood or behavior. A stop sign was placed on Resident #13's door per his request. There were no further interventions documented to keep Resident #1 from wandering into rooms and keeping residents safe. 9. 10/19/2020 The progress notes dated 10/19/2020 at 8:13 a.m. documented, resident was found in another resident's room. With the other resident grabbing him and his shirt. It appears the other resident had punched him and was preparing to punch him again, redirected. R.N. notified. When asked what happened, Resident #1 states that the other resident was cursing at him and hit him motioning to his right forehead and right cheek which both were red and appeared as if they had been struck. Resident denies pain or discomfort. Resident kept separately from other residents involved in the altercation. The IDT note dated 10/20/2020 at 10:16 a.m. documented in pertinent part, Resident #1 reported to staff that Resident #5 hit him on the cheek. Skin showed that Resident #1 had some redness on his forehead and Resident #5 had a scratch on his upper midchest. The skin was not broken. It appears that the scratch on Resident #5's chest was from when Resident #1 grabbed on to Resident #5's shirt. Both residents could not recall the incident however both residents fe(TRUNCATED)

Based on record review, observations, and interviews, the facility failed to keep the residents and resident environment as free from accident hazards as was possible for one (#7) out of 15 sample residents and 18 sample residents residing on the secure unit. Specifically, the facility failed to -Prevent an elopement for Resident #7 in which he left the facility through a malfunctioning exit door and walked 2.5 miles away from the facility. -Ensure facility staff were aware the resident was missing from the facility for one and a half hours and aware Resident #7 was at the hospital until three and a half hours after he left the facility. The hospital contacted the facility; notifying facility staff, Resident #7 sustained a nasal fracture and other minor injuries. -Ensure portable space heaters were not used in resident areas on the secure unit. 18 residents resided on the secure unit of the facility and observations revealed portable space heaters were in use in resident areas which had the potential to cause burns. Findings include I. Elopement A. Facility policy and procedure The Elopement policy, dated 3/2020, was provided by the director of nursing (DON) on 11/30/2020 at 3:00 p.m. It read, in pertinent part: It is the policy of this facility to investigate and report all cases of missing residents. -Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse, DON or designee. -If an employee observes a resident leaving the premises, he/she should: attempt to prevent the departure in a courteous manner; get help from other staff members in the immediate vicinity; and instruct another staff member to inform the charge nurse or DON that a resident has left the premises. -If an employee discovers that a resident is missing from the facility: determine if the resident is out on authorized pass; if the resident was not authorized to leave, initiate a search of the premises; if the resident is not located, notify the administrator and DON, the resident ' s legal representative, and law enforcement officials; provide search teams with resident identification information; initiate an extensive search of the surrounding area; and document the time code pink was called, when the police were notified, when family was notified, when administrator and DON were notified, when the search of the premises was completed and when the search of the outdoor premises were completed -Elopements must be reported to the state health department within 24 hours. -Upon return to the facility the nurse will complete: a skin evaluation, an elopement assessment, a risk management, an incident note, obtain a full set of vitals, and follow up monitoring each shift for 72 hours for any further exit seeking behaviors. B. Resident status Resident #7, [AGE] years old, was admitted to the facility on [DATE]. According to the 12/2020 computerized physician orders [REDACTED]. The 9/19/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of four out of 15 and exhibited wandering behaviors. He required supervision with his mobility and his activities of daily living (ADLs) with one staff member to physically assist with dressing and personal hygiene. He walked independently without the use of an assistive device. C. Care Plans An elopement care plan was initiated on 3/13/2020, it read Resident #7 was an elopement risk related to a history of the resident attempting to leave the facility unattended. The goal was that the resident would not leave the facility unattended. Interventions included: document wandering behavior and attempted diversional interventions; monitor placement of wander guard on left ankle every shift; stop sign placed on unit exit door on 9/14/2020; and monitor for fatigue and weight loss. A behavior care plan initiated on 3/18/2020 and revised on 11/30/2020 revealed the resident had a [DIAGNOSES REDACTED]. The resident may exhibit behaviors including pacing, wandering or exit seeking and irritability. The resident may become annoyed and verbally aggressive when being questioned too frequently or being called the wrong name. The resident currently resides on the secured unit. Interventions included: If the resident was confused or expressed delusions, do not attempt to reorient him, meet him in his reality; offer to call his mom and sister as they are strong support for him; offer to take him out to smoke; staff should introduce themselves and ask his name during interactions. The elopement assessment dated [DATE] revealed the resident scored a 9.0 which indicated low risk. The assessment indicated the resident had mental illness, he ambulated independently, was alert, had one or two elopement attempts in the past six months, and his wandering behavior had remained the same since his last assessment. Additional elopement assessments dated 11/23/2020 and 11/25/2020 revealed the resident scored a 12 which indicated high risk. The change in the assessments indicated the resident was disoriented, his wandering behavior placed him at significant risk of getting to a dangerous place, and his wandering behavior had worsened since his last assessment. Review of the resident treatment administration records (TARs) from 8/2020 through 11/2020 for monitoring of exit seeking behavior revealed the resident had not exhibited exit seeking behaviors during the reviewed time frame. D. Elopement incident On 11/23/2020 the resident had an elopement incident, the facility investigation was reviewed on 11/30/2020 and revealed the resident was identified as missing from the facility at 10:30 a.m. when he could not be located during hydration pass and a search was started. At the same time, the facility social services director (SSD) received a phone call from a local hospital inquiring about an unidentified resident they had at the hospital who gave the name Levi Roybal the SSD told the hospital the facility did not have a resident by that name. The facility and surrounding area search was unsuccessful and the nursing staff then informed administration that the resident could not be located. Once the administration was informed of the missing resident, the SSD called the hospital back and verified the resident they had was Resident #7. The SSD went to the hospital and picked up the resident and returned to the facility at 2:37 p.m. where the resident was admitted to the secure unit. Facility staff were interviewed during the investigation and revealed the resident had been in the common area of the unit at 9:00 a.m. The resident ' s nurse revealed the resident had set off the door alarm earlier in the morning, was redirected, and returned to his room. Other staff and residents on the unit confirmed the resident was on the unit in the common area around 9:00 a.m. A timeline of events revealed security video footage was reviewed and revealed the resident left the facility through an alarmed fire exit door at 9:11 a.m. However, the door was not alarmed due to malfunction. At 10:30 a.m. a certified nurse aide (CNA) was handing out drinks for a hydration pass and did not see the resident in his room or the common area, so she checked the smoking area and notified the nurse the resident could not be located. At 10:30 a.m. the SSD received a phone call from the hospital asking if the facility had a resident named Levi Roybal and the facility did not have a resident by that name. At 10:45 a.m. the nurse was notified by two CNAs that the resident could not be located. A search of the building was initiated by the nurse and two CNAs. At approximately 12:00 p.m. the nurse notified the director of nursing (DON) that the resident could not be located after search of the facility and surrounding grounds. Immediately after the DON was notified, the interdisciplinary team (IDT) members were alerted to the missing resident and an internal search was re-conducted, a three mile radius search was initiated and the police were called. At 12:42 p.m. the door was checked, re-armed, and verified it was working properly. At 1:40 p.m. the SSD called the hospital back upon remembering Resident #7 often goes by different names. At 2:23 p.m. the hospital returned the facility ' s call and provided a picture of the resident to verify his identity. The SSD went to the hospital to pick up the resident and he returned to the facility at 3:15 p.m. and was placed on the secure unit upon return. On 11/23/2020 at 4:55 p.m. an incident note read, in pertinent part, The resident was unable to be located in the facility after 10:00 a.m. staff checked the resident ' s room and all over the facility. The nurse notified the DON, SSD, nursing home administrator (NHA), power of attorney (POA), and the resident ' s physician. Management team started searching for the resident. Received a call from hospital and they notified the resident was found near the 72nd bus stop. The resident had a fall there and was picked up by ambulance and was brought to the hospital. The resident returned to the facility around 3:15 p.m. The resident has a urinary tract infection [MEDICAL CONDITION] and laceration to the nose area. Nurse notified the physician and received an order to clean the laceration with normal saline, apply triple antibiotic ointment, and cover with a dry dressing until seen by the wound doctor. Resident refused to have the area measured, wound dressing was done as ordered. The resident stated he was not in pain. A head to toe assessment was completed and no other skin issues were noted other than small bruises and bumps on both eyebrows. Physician verified order for antibiotic medication for treatment of [REDACTED]. Resident was admitted to the secure unit for safety and elopement risk. Neurological checks were initiated. On 11/23/2020 at 6:04 p.m. an IDT review note read, in pertinent part, On 11/23/2020 at 10:30 a.m. social services received a call from the hospital, they asked if the facility had a resident by the name Levi Roybal the facility does not have a resident by that name, but the facility realized that resident #7 goes by Levi at times. Social services went to the hospital to pick up the resident. Hospital staff reported that the resident was found on the street after a fall. The resident received a nose fracture as a result of the fall. Lab results from the hospital showed that the resident had a UTI as well. When social services interviewed the resident he reported he did not know where he was and that his name was Mondo he reported he felt safe and would like to go home. Police, ombudsman, physician, and responsible party were notified. Resident was put on 72 hour monitoring for a change in mood and behavior. Resident was moved to the secure neighborhood per family and facility recommendation. The resident was found approximately 2.5 miles away from the facility at the bus stop. E. Facility actions In response to the investigation it was identified that the resident ' s previous attempt and alarming the door earlier in the morning had disarmed the door and the nurse did not properly reset the door alarm. All staff were immediately trained on 11/23/2020 on the door alarm system and how to reset it properly if it was set off, resident rounding and head counts to be conducted at least every two hours, as well as the facility policy and procedure related to elopement. The NHA and life safety resource (LSR) contacted the door alarm company on 11/23/2020 to order a change in the door lock and alarm mechanism to eliminate the possibility of human error. Audits of the door were initiated four times per day and were conducted by the NHA and LSR from 11/23/2020 to 12/1/2020 when the door lock and alarm mechanism were replaced by the contracted company during the survey. F. Interviews CNA #9 was interviewed on 12/1/2020 at 10:14 a.m. She stated she worked on the unit where resident #7 spent a lot of time. She stated the alarm on the door of the unit she worked would go off if the door was opened and staff had to enter a code to turn the alarm off and the alarm reset when the door closed. She stated she was working the day resident #7 got out of the facility, and when the resident was not in his room, on either unit or in the smoking area, she and another CNA told the nurse they couldn ' t find him. She stated she received re-education from the DON and NHA related to elopement procedure and the door alarms on the day the resident eloped. CNA #7 was interviewed on 12/1/2020 at 12:01 p.m. She stated she found out about the elopement the day it occurred. She stated a few residents in the facility wandered in the hallways but did not try to exit the facility. She stated the staff were retrained on the facility elopement procedures and the door alarms right after resident #7 returned to the facility. RN#3 was interviewed on 12/1/2020 at 12:05 p.m. She stated she was the nurse on duty when resident #7 eloped. She stated he normally walked up and down the hallways, and sat in the common area of the unit and the adjoining unit. She stated his room was located on the border of the two units so he walked and rested on both units. She stated he had not tried to get out of the facility doors before that morning when he set off the alarm. She stated she was able to redirect him that morning and he walked in the opposite direction and she thought she had successfully reset the alarm. She stated when the resident returned to the facility, the administration did staff education related to resetting the door alarm, following facility elopement procedures and ensuring nurses were accounting for their assigned residents at least every two hours. CNA #8 was interviewed on 12/1/2020 at 12:11 p.m. She stated she had just received elopement and door alarm training last week and she was aware of the resident elopement but was not working that day. She stated there were not many residents in the facility that wandered and no residents she knew of outside of the secured unit who tried to leave the facility. The nursing home administrator (NHA), behavioral health manager (BHM), social services director (SSD) and resident services resource (RSR) were interviewed on 12/1/2020 at 1:21 p.m. They stated immediately after the resident was thought to be missing, the staff initiated a head count and all other residents were accounted for. The staff was immediately retrained on at least every two hour head counts for assigned residents. The security footage was reviewed and staff were interviewed and it was discovered that the door was not properly reset after the resident set the alarm off earlier that morning. The NHA stated all staff were retrained immediately related to that door, as it functioned differently than the other doors throughout the facility. He stated door checks were started immediately and were performed by himself, the life safety resource, and the maintenance director (MD). He stated they called and scheduled for the door alarm to be changed as that is the only door in the facility that left room for human error. He stated the door change was scheduled for later that day (12/1/2020). The BHM stated the resident had been in the facility since 2009, his mother was very involved in his care, he had been on and off the secured unit many times since he was admitted to the facility and secured unit placement was discussed at his most recent care plan meeting with his mother in September. The resident had not eloped prior but did have a history of exit seeking behaviors and had a wander guard long he was admitted in 2009. The NHA stated the staff did not follow all procedures properly. He stated the resident was suspected to be missing by floor staff and floor staff began a search of the facility without alerting management or calling a code pink. He stated the hospital called and spoke to the SSD and inquired about a patient with a name that did not match any of the residents in the facility. Since administrative staff were not alerted to the possible missing resident timely, the SSD did not know it could be resident #7. All staff were re-educated to the facility expectations and protocols for missing persons. He stated the floor staff should have alerted administrative staff immediately. The SSD stated resident #7 usually hung out on the other adjoining unit in the common area and had approached the door on that unit in the past and had set off the alarm once in September. She stated the door had a coded alarm that reset itself and they placed a stop sign on that door to deter the resident from approaching which had been effective. The NHA stated, in hindsight, they should have placed a stop sign on the door in the other unit as it could have deterred him from approaching that door as well. II. Space heaters A. Professional reference The life safety code 19.7.8 reads: Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: -Such devices are used only in non-sleeping staff and employee areas; and -The heating elements of such devices do not exceed 212 degrees Fahrenheit. B. Observations On 11/24/2020 between 3:00 and 3:50 p.m. the following was observed on the secure unit which housed 18 residents: - At 3:13 p.m. a portable space heater was observed plugged in and on in room [ROOM NUMBER]. The space heater was at the foot of the resident bed. The space heater was moderately hot to the touch. There were approximately two feet of space between the space heater and the bed. The resident was sitting in the doorway of the room. - At 3:15 p.m. a space heater was seen unplugged up against the wall in room [ROOM NUMBER]. The space heater was cold to the touch. - At 3:20 p.m. a portable space heater was seen plugged in and on in room [ROOM NUMBER]. The heater was in between a tray table and the foot of the bed in a space that was approximately two feet deep and two feet wide (2'x2'). The heater was moderately hot to the touch. Neither resident who occupied the room was present. - At 3:28 p.m. a space heater was seen in the bathrooms of rooms [ROOM NUMBERS]. The heater was unplugged but warm to the touch. There were no residents present in the rooms. - At 3:40 p.m. The space heater that was previously plugged in and on in room [ROOM NUMBER] was found in the bathroom and was warm to the touch. - At 3:40 p.m. the space heater in room [ROOM NUMBER] was still plugged in and on in the same location. - At 3:47 p.m. the space heater in room [ROOM NUMBER] was still plugged in and on in the same location in the room. Resident #3 was asleep in the bed that was next to the space heater. C. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 11/24/2020 at 3:32 p.m. She said she knew nothing about the space heaters in the resident rooms. She stated sometimes residents get cold. CNA #4 was interviewed at 3:37 p.m. He stated he thought something had happened to the heat and electricity a few weeks ago and some resident rooms were cold. He stated he did not know there were still heaters in the resident rooms. The Activity supervisor (AS) was interviewed at 3:47 p.m. He stated he was hired at the beginning of September and his office was on the secured unit. He stated he was always back on the unit to conduct activities and to help out with supervising residents. He stated he had no information related to the space heaters on the unit. He did not know why they were there. Registered nurse (RN) #1 was interviewed at 3:48 p.m. She stated she worked on the secured unit full time 12 hour shifts days. She stated there was a day a while ago when it was cold back on the secure unit and they brought the space heaters back there to keep residents warm. She stated they brought them back on the unit and never took them out. She stated she did not know that any were being used. The social services assistant (SSA) was interviewed at 3:54 p.m. She stated she worked full time in the facility and spent her afternoons/evenings on the secured unit to help with residents and keep them engaged and separated due to a lot of resident to resident altercations. She stated she had been gone from the facility for the past two weeks and had no information related to the observed space heaters. The MD was interviewed at 4:20 p.m. He stated there was a heat issue on the west side of the building especially on the secure unit a few weeks ago and they were expecting a very cold night and needed a fix to keep residents warm. He stated technicians came in to evaluate and fix the heat but they could not come immediately so the portable heaters were needed. He stated the facility had replaced the roof and were replacing every window in the facility related to the heat issue. He stated the whole system for the building needed to be replaced which they were working on, but it wouldn ' t happen overnight, so when the heat went out on the secure unit and could not be repaired immediately, the heaters needed to be used. The NHA was interviewed at 4:27 p.m. He stated the heaters were purchased and used on the secure unit the first really cold night of the season when the heat was not pushing through the whole building. He stated the forecast was to be 10 degrees that night and was very cold on the secure unit in rooms. He stated the life safety resource (LSR) was able to talk to a rep from the state life safety department and had approved the use of the type of heater the facility purchased for temporary use. He stated 10 heaters were bought and five were used on the secure unit. He stated after that cold night the heaters were removed and locked in the activity office. He stated they were using them only on cold nights if the heat was not effective but the heat had been working since it was repaired at the beginning of the month. He stated the heaters should not have been in use on the unit that day and he did not have a reason or explanation of why they were in use. The DON was interviewed at 4:49 p.m. She stated she did not know how the facility determined when to use the heaters. She stated she assumed they would bring them out and use them if the residents complained of being cold or if the staff noticed the rooms were very cold. She stated she did not know any specifics about how or why rooms were picked for space heater use. She stated the nursing staff had not received any training, that she knew of, on how to use the heaters, what rooms to put them in, where to put them in the room, how to set them or any parameters or instructions on when to use them. She stated the staff should definitely be trained on how and when to use them, if they are being used. The clinical resource (CR) was interviewed at 5:45 p.m. and stated she thought the heaters were bought at the beginning of October, she talked with the LSR and there was an issue with the heat getting to the secure unit. She was uncomfortable with space heaters and did not think they should be used but the LSR said they were approved for emergency use by the state life safety representative. She stated the building was acquired in March by the company and there are/were many physical plant issues. The HVAC system of the whole facility was checked out and identified that the facility needed a new roof, new windows, then needed an entire overhaul and brand new HVAC system and the work had to be in that order. She stated the timeline was six months for the new HVAC and that the work has been bid and approved. On 11/25/2020 at 11:00 a.m. a state life safety representative was interviewed and stated that the department occasionally granted facilities permission to use portable heaters but only in emergency situations. He stated the heaters could not exceed 212 degrees Fahrenheit, and should not be used in resident sleeping areas if at all possible. Also, the emergency use of the heaters should be restricted to 24-48 hours. He stated they would never grant extended or unrestricted use of heaters. He stated facilities had to keep residents safe and warm, though the use of the heaters should have planned and specific parameters and should be monitored closely. The NHA and CR were interviewed a second time on 11/25/2020 at 11:21 a.m. The NHA said he received a bid on 10/2/2020 to redesign the HVAC system. He said they have not received a date when it would be completed. He said the current system works, however, because of its age, the risk was it may have issues on the West side. He said he was not aware the space heaters continued to be used as observed on 11/24/2020. The nurse consultant said prior to the use of the space heaters extra blankets were tried, however, it had not been effective. D. Heater specifications The owners manual for the heaters used in the facility was reviewed on 11/24/2020, it read, in pertinent part: When using electrical appliances, basic precautions should always be followed to reduce the risk of fire, electric shock, and injury to persons, including the following: -This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces. If provided, use handles when moving this heater. Keep combustible materials, such as furniture, pillows, bedding, papers, clothes and curtains at least three feet from the front of the heater and keep them away from the sides and rear. -Extreme caution is necessary when any heater is used by or near children or invalids and when the heater is left operating and unattended. -The output of this heater may vary and its temperature may become intense enough to burn exposed skin. Use of this heater is not recommended for persons with reduced sensitivity to heat or an inability to react to avoid burns. -Don ' t leave this heater on unattended. Review of the manual and specifications for the heaters being used at the facility revealed no indication of how hot the heaters could get. E. Facility actions On 11/24/2020 between 4:20 and 5:45 p.m. all of the portable space heaters were removed from resident areas and were locked in the NHA office. F. Additional interviews The LSR was interviewed on 11/25/2020 at 12:00 p.m. He stated he had misunderstood the guidance from the state life safety representative and the facility should not have used the heaters once the heat was repaired. The NHA was interviewed on 11/25/2020 at 12:15 p.m. He stated the heaters were being removed from the facility and would no longer be used in the facility for any reason. He stated the facility had not provided all staff training related to use of the heaters and they had not had any monitoring plan or parameters for use of the heaters so they should not have been used and would not be used again.

Based on observations, record review and interviews, the facility failed to ensure all residents residing on the secure unit to include seven (#1, #5, #10, #13, #14, #15, and #16) out of 15 sample residents who display or are diagnosed with [REDACTED]. Specifically, the facility failed to implement and consistently follow and implement new person centered interventions related to dementia and behaviors to prevent resident-to-resident altercations for Residents #1 and #5. Resident #1 had multiple alterations which involved Resident #5, #13, #14, #10, #15, and #16. Resident #5 had altercations with Resident #1 and #5. The lack of continuous monitoring for effective interventions lead to continuous altercations cross-reference F600-Free from Abuse and F865 Quality Assurance and Performance Improvement (QAPI). Findings include: I. Professional reference Person-centered care is essential to good dementia care and the underlying philosophy of the 2018 Alzheimer's Association Dementia Care Practice Recommendations. Person-centered care is a philosophy of care built around the needs of the individual and contingent upon knowing the person through an interpersonal relationship. It challenges the traditional medical model of care that tends to focus on processes, schedules, and staff and organizational needs. It requires commitment from everyone within the organization, especially leadership. The Fundamentals of Person Centered Care For Individuals with Dementia published 1/18/2018. Retrieved on 12/10/2020 from https://academic.oup.com/gerontologist/article/58/suppl_1/S10/ 35 II. Facility policy and procedure The Care of Dementia policy, 3/2020, was provided by the director of nursing (DON) on 12/1/2020 at 3:00 p.m. It read, in pertinent part: It is the policy of this facility that all residents will have an individualized plan of care and have the least restrictive approaches to care. Staff are offered specialized trainings in the care of the dementia population, appropriate approaches and managing behaviors. The interdisciplinary staff (IDT) will initiate a thorough clinical assessment. The monitoring of mood, behavior and/or any psychosocial related issues to identify possible underlying medical problems which may be causing the behavior problems. Social services will also meet with resident and attempt to identify possible psychosocial issues that may be causing behaviors and to develop a baseline social history. The IDT will review findings of evaluations and develop a plan of care addressing the resident's needs. The physician will be involved in the plan of care and make any changes to medical regimen as necessary. The facility staff will offer to staff specialized training regarding the dementia disease process utilizing nationally recognized dementia care guidelines as the basis of the education including what to expect with progression of the disease, care of this specialized population, approaches to intervening in a crisis situation and managing/monitoring behaviors. III. Facility census and conditions The Resident Census and Conditions of Residents (CMS-672) was provided by the nursing home administrator (NHA) on 11/24/2020 at 3:15 p.m. It revealed that out of 88 total residents in the facility, 31 (35%) of the residents had a [DIAGNOSES REDACTED]. IV. Resident #1 A. Resident status Resident #1, age 74, was initially admitted on [DATE] and readmitted on [DATE]. According to the computerized physician orders [REDACTED]. The 10/5/2020 minimum data set (MDS) assessment, documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #1 required supervision with bed mobility, transfers and eating. He required extensive assistance of two people with dressing, personal hygiene, and toileting. Resident #1 was totally dependent on staff for bathing. He had no hallucinations, delusions, wandering, pacing or rummaging during the assessment period. Resident #1 had physical behavior directed at others during the assessment period, such as hitting, kicking, scratching, grabbing or abusing others sexually. He did not use any mobility devices when he ambulated in his room and in the corridor. B. Eleven incidents of physical altercations record review The progress notes were reviewed from 5/1/2020 through 11/13/2020. Resident #1, who had a [DIAGNOSES REDACTED]. The resident wandered on a secure unit in the hallways, common areas, and other resident rooms frequently. The facility failed to adequately monitor and engage Resident #1 with dementia, to prevent the altercations. The progress notes dated 5/1/2020 at 11:27 a.m. documented, Resident #1 hit Resident #5 in the face, in the hallway. Resident #5 fell backwards hitting his head. The interdisciplinary (IDT) note dated 5/2/2020 at 12:47 p.m. documented in pertinent part, Two residents with dementia came across each other while out in the hallway. Resident #5 came up to Resident #1 and found him in his way. Resident #5 has a walker and lifted it in the air a few inches off the ground and started shaking it at him. As this happened, staff saw the residents get close and came to intervene. There was a nurse and maintenance director in close proximity who immediately started moving towards the residents. Prior to being able to intervene Resident #1 pushed Resident #5, and then swung to hit him. The swing did reach the resident and this caused Resident #5 to stumble to the ground. The progress notes dated 7/16/2020 at 6:27 p.m. documented Resident #13 wheeled over Resident #1's foot. Resident #1 turned around and hit Resident #13 in the head. The IDT note dated 7/17/2020 at 9:51 documented in pertinent part, Resident #1 was standing in the middle of the hallway and Resident #13 was not able to get by with his wheelchair. Resident #1 attempted to move out of the way for Resident #13. As Resident #1 was moving out of the way, Resident #13 elbowed him and Resident #1 turned around to hit him in the neck. Activities assistant attempted to get in between both residents. Resident #1 was able to get around the activities assistant and hit Resident #13 again. The progress notes dated 7/21/2020 at 5:40 a.m. documented, there was an altercation with another resident. Resident #1 was found on his knees. The areas above his right eye were bruised and his left jaw was red. Resident appears shocked and afraid. The interdisciplinary (IDT) note dated 7/28/2020 at 2:57 p.m., documented that Resident #1 had wandered into Resident #5's room when the altercation occurred. The progress notes dated 8/19/2020 at 4:05 p.m. documented in pertinent part staff heard noise and ran to the scene, saw resident and another resident physically hit each other.The IDT note, dated 8/25/2020 at 9:43 a.m documented in pertinent part, Resident #13 was banging on the door to go out to the courtyard. Resident #1 was wandering around the neighborhood and approached Resident #13. As Resident #1 approached Resident #13, Resident #13 grabbed Resident #1's left wrist. Resident #1 then turned to hit Resident #13 in the face. The IDT note dated 9/1/2020 at 11:12 a.m. documented in pertinent part, IDT review of incident on 8/27/2020. On 8/27/2020 at 10:10 a.m., on the secured neighborhood, Resident #1 wandered into Resident #14's room at 10:13 a.m. Resident #1 wandered back out to the common area and Resident#14 followed him and told Resident #1 to comeback here. Staff intervened and asked Resident #14 what happened. Resident #14 reported that Resident #1 came into his room and hit him on the mouth. There were no progress notes documented regarding the resident behavior on 8/27/2020 through 8/31/2020. The progress notes dated 9/9/2020 at 7:52 p.m. documented that at approximately 3:20 p.m. this resident hit another resident in the face. The IDT note dated 9/10/2020 documented in pertinent part, Resident #1 was wandering around the neighborhood and approached Resident #10 from the side. Resident #10 turned to Resident #1 and started talking to him. As Resident #10 was talking to Resident #1, she pointed at him and he then turned to hit her with a closed hand. The progress notes dated 10/2/2020 at 6:51 p.m. documented that Resident #1 slapped Resident #15 in the face, and she slapped him back. The progress notes dated 10/11/2020 at 1:46 p.m. documented that Resident #1 was involved in an unwitnessed altercation. The IDT note dated 10/12/2020 at 1:46 p.m. documented in pertinent part, Resident #13 was in his room when Resident #1 wandered into his room. Resident #13 yelled for Resident #1 to get out of his room. Resident #13 then reported to staff that Resident #1 hit him. The progress notes dated 10/19/2020 at 8:13 a.m. documented that Resident #1 was found in another resident's room. It appears the other resident had punched him and was preparing to punch him again. The progress notes dated 10/27/2020 at 11:30 p.m. documented Resident was found in another resident's room. The other resident admitted to assaulting the resident. Resident was visibly upset and appeared stunned with discoloration and bruising to the left side of his face and forehead. Resident states that the other resident punched and hit him. On 10/28/2020 at 5:00 a.m. the progress notes documented, Resident complained of bilateral hands and wrists being sore. Resident states they are sore all the time. Resident has never mentioned this complaint before. Left hand purplish blue discoloration noted. Resident able to wiggle fingers .Resident upset and crying speaking freely of when he was assaulted by another resident the night previous and very upset stating, I feel sorry for that guy, he is a monster. Resident was not asked or reminded of the incident, the resident remembered on his own. Remained with the resident until he was resting in bed and able to go to sleep without crying. The progress notes dated 11/13/2020 at 11:55 p.m. documented, Resident #1 and another resident were fighting each other. The IDT note dated 11/16/2020 documented, Resident #1 was standing next to Resident #16 talking to him on secured neighborhood. Resident #16 was holding onto a can of soda and Resident #1 attempted to take it from him. When Resident #16 pulled the soda can back from Resident #1, Resident #1 hit Resident #16 on his right cheek. Resident #16 then swung his arm out and hit Resident #1 on his left arm. The care plan initiated 3/20/2020, and revised 9/10/2020 was reviewed. The care plan had multiple interventions. -However, it did not include effective supervision of Resident #1 with known physical aggression and wandering. Moreover, the interventions were not reviewed for their effectiveness according to interviews with the behavioral health director (BHD). The interventions were not consistently implemented or effective as evidenced by the multiple physical altercations. The care plan interventions included: Resident #1 has potential to exhibit behavior problems related to dementia with behavioral disturbances, [MEDICAL CONDITION], and Sexual Disorder. He exhibits impaired insight, judgment and insight and poor impulse control. He is currently prescribed dual antipsychotic medication to help manage symptoms including physical and verbal aggression, auditory and visual hallucinations, distressing delusions, smearing of bodily fluids,expressing racial slurs, and inappropriate sexual comments, behavior toward others. Staff assist in redirecting keeping him and others safe. Resident can become physically aggressive if he perceives others to be acting in a threatening manner. Resident has history of wandering into other rooms and thinking that it is his room. Triggers: Other resident's actions that are directed towards him, when other residents are in his walking path and others pointing at his face. Actively listen to Resident #1 as he tells stories as he likes knowing that others are listening and are paying attention. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet needs. Approach in a calm manner.Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. Assist Resident #1 or other residents from coming face to face with each other while walking in the common areas or hallways. Avoid confrontations or arguments with Resident #1,caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Explain all procedures to before starting and allow to adjust to changes.For Psychiatry: (name of company)to Provide Psychiatric Services. For Psychology - (company name) May Provide Psychological Services. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable.Intervene as necessary to protect the rights and safety of others. Approach speaking a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Nursing Facility Specialized Rehabilitative Services recommendations per PASRR Level II: Resident #1 would benefit from: behavioral monitoring for instances of agitation and aggression, redirect when necessary and to prevent Resident #1 from wandering and getting lost; physical therapy if he is able to participate to improve his balance and to avoid falls; therapeutic recreation if able, taking in account his past interests in talking to people, music, and history; and ongoing medication management based on the recommendations of his hospital psychiatrist. Observe for side effects and adverse reactions of psychoactive medication: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [MEDICAL CONDITION], social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Offer to call his friend. Offer to call Resident #1's son, offer to play Jazz music, offer to take Resident #1 for a walk around the building with a staff member, offer to take Resident #1outside to smoke when agitated, offer Resident #1 a choice in activities to redirect him,Offer a sweet snack as he enjoys sweets, offer time to talk about how he is feeling Per PASRR Level II recommendations: Resident #1 should be encouraged to attend and participate in any activities or hobbies he enjoys to increase socialization and community participation. Nursing facility to encourage and coordinate contact with Residents family members, friends, providers and other supports in the community as permitted. Nursing Facility Staff should provide ongoing evaluation and documentation of Residents mood, participation in care, treatment, medication management and psychiatric stability. Any significant change in condition, increase or decrease in behaviors or symptoms shall be reported to the attending physician, psychiatrist, and designated OBRA-PASRR for further evaluation as indicated. Praise any indication of progress/improvement in behavior, provide 1:1 engagement when available, provide a program of activities that is of interest and accommodates residents. Provide space to talk about how he is feeling, redirect from other resident's room when he is wandering, referral to an appropriate psychiatric provider as needed, remind of boundaries with other residents, reminisce with photo of places that Resident#1 has lived in the past, reminisce with Resident #1 about his time in New Orleans, remove from common areas if he's becoming activated or disruptive; assist to a private space to help him calm down, reorient to where his room is located, validate how Resident #1 is feeling, when Resident #1 is confused or delusional do not attempt to reorient as this causes him distress; meet him in his real. However, Resident #1 wandered multiple times into other resident rooms, hallways and common areas without adequate proactive redirection or supervision. C. Observations On 11/25/2020 at 11:30 a.m. Resident #1 was sitting in the common area in front of the TV. This was what the CNAs said they tried to do with the resident in their interviews, sit him in front of the TV. On 11/25/2020 at 2:50 p.m, Resident #1 was sitting in the common area in front of the TV. On 11/30/2020 at 9:26 a.m., Resident #5's stop sign was not up on his door. Resident #1 was wandering and talking to other residents. D. Interviews Certified nurse aide (CNA) #2 was interviewed on 11/25/2020 at 11:40 a.m. She said, Resident #1 wanders continuously and wanders into other residents rooms and picks up things. She said the staff try to keep him in the common area watching television, but he always wanders. She said some days a lot and some days a little. CNA #2 said he likes to talk to other residents and gets too close to them. CNA #5 was interviewed on 11/25/2020 at 2:50 p.m. He said Resident #1 wanders freely and causes trouble wherever he goes. CNA #5 said, He needs someone to follow him all the time, he wanders into other residents' areas and they get into it. He said the staff try to get Resident #1 to sit in front of the TV a lot in the common area. CNA #4 was interviewed on 11/25/2020 at 2:57 p.m. He said, Resident #1 likes to get in other residents' business. CNA #4 said we try to redirect him, but he is very social, and others are not. He makes the other residents angry. CNA #4 said someone needs to watch Resident #1 at all times. If they don't, he will get into an argument with someone. He said he tries to watch him when he is working, but did not know what they do on other shifts when he gets into fights. Registered nurse (RN) #1 was interviewed on 11/25/2020 at 11:48 a.m. She said Resident #1 is very friendly and likes to make conversation. She said he walks a lot but he does not understand personal space and gets too close to other residents. She said he has had several physical altercations going into other residents rooms. RN #1 said he likes to talk to the other residents, but it turns into a fight. RN #1 said he has bruising on his face from the last time he got in a fight. She said the staff separated them, but he already had bruising and red marks to his face by then. She said some residents have a stop sign on their door to keep him out, but that does not always work. She said the staff can not watch him all the time. The activity supervisor (AS) was interviewed on 11/25/2020 at 11:33 a.m. He said Resident #1 was pleasant and likes to talk and converse with others. He said, Resident #1 is very educated. The AS said his dementia has affected his understanding of personal space and he got really close to other residents which makes them uneasy. The resident services resource (RSR) was interviewed on 11/25/2020 at 12:46 p.m. She said, Resident #1 has dementia and a [MEDICAL CONDITION]. She said that made him impulsive and caused him to react. The RSR said the secure unit had a lot of altercations. She said the common area needed to be monitored and things happen in an instant. She said Resident #1 wanders in and out of rooms and when he gets too close to others it is risky. The RSR said we need to constantly keep an eye on him. She said, we use medications, even above the recommended dose on the Beers list (criteria for potentially inappropriate medication use in older adults,), but this is what we are left with. She said we track and trend the resident altercations, but I don't have the answer. She said we have dementia on the unit and various levels of cognitive and mental health diagnoses. The DON and nursing home administrator (NHA) were interviewed on 11/25/2020 at 3:24 p.m. The DON said we have adjusted his medications three times, but the behavior keeps happening because the resident is impulsive. The NHA said he had added an activity assistant and has a member of his IDT team on the unit six hours a day during the week, especially at shift change. He said this was not additional staff 24 hours per day. The DON said we have put up stop signs to keep Resident #1 out of resident rooms. She said she was not aware the stop signs did not always work, as her staff reported during their interviews. The NHA said we did not choose these residents, this is what we were dealt when the facility was acquired. He further said, We know some of these residents are not appropriately placed. He said no one will take them, not even our sister facilities. The NHA said we have discussed having two separate units for dementia and psych needs. He said there was no other plan or options, except more psych evaluations or more medications. The DON said, for Resident #1, We can have his medications adjusted again or have psych see him and we could put him on a one to one with a staff member. The NHA said social services tracked the behaviors, and they do not see any trends, it has all been random, the numbers are still not acceptable, but have been trending down . The NHA said the medical director was aware of the altercations. He said the medical director has asked why are they on all these medications, why did we mix dementia residents with residents who have psychiatric conditions? The BHD was interviewed again on 11/30/2020 at 4:16 p.m. She said medication increases are not the first resort, we try other things first. She was asked how she knew if the non pharmacological interventions tried were effective. The BHD said there was no system in place to see if the non pharmacological interventions were effective. The BHD said we review the altercations in our psych pharmacy meeting monthly. She said this is what we have been given. We have tried to discharge some of these residents to other places. The BHD said, I have a sheet I highlight if an intervention has worked for me. It's a little blurb that works for me if a resident is agitated. I don't know if any of the staff have seen them. The CNA's can not see them, they are not on their Kardex. The facility failed to evaluate and implement interventions for a resident with dementia, and ensure the interventions were effective. V. Resident #3 A. Resident status Resident #3, age 74, was admitted to the facility on [DATE]. The December 2020 computerized physician order [REDACTED]. The 9/26/2020 minimum data set (MDS) revealed the resident had severe cognitive impairment and had short and long term memory problems. The resident did not display any physical or verbal behaviors during the lookback period and engaged in wandering behaviors every day of the lookback period. The resident required extensive two-person assistance with dressing, toileting, and personal hygiene, limited one-person assistance with bed mobility, transfers, and supervision and setup help with walking on the unit and eating. B. Record review The revised care plan, updated 3/17/2020, documented the resident had the potential for mood and behavior problems related to dementia, post-traumatic stress disorder ([MEDICAL CONDITION]), and unspecified mood disorder. The resident takes medication for these conditions. The resident is at risk for [MEDICAL CONDITION] including distressing delusions and paranoia, and verbal and physical aggression towards others. The resident has impaired safety awareness, cognition, insight, and judgment related to dementia. The resident is orient only to self and often wanders the secure environment and at times wanders into other resident's rooms and rummages. This places him at risk for other directed violence. The resident has a history of physical aggression toward others. The resident is triggered by loud noises in the environment and being yelled at. Documented interventions include give medications as ordered and monitor for side effects (3/17/2020), anticipate and meet needs (3/17/2020), approach in a calm manner (3/17/2020), assist and develop appropriate methods of coping, expressing self, and interacting with others, caregivers to provide opportunities for positive interaction, and attention (7/7/2020), document behaviors and resident response to interventions (3/17/2020, explain all procedures before beginning and adjust to changes (3/17/2020), intervene as necessary to protect the rights and safety of others, approach and speak to in a calm manner, divert attention, remove from situation to alternate location (3/17/2020), monitor the residents location and interactions with others if the environment appears loud, if another resident is being loud, or following fire alarms/drills (3/17/2020), offer soda (8/10/2020), offer a glass of cold milk (8/19/2020), offer a sweet treat (10/5/2020), offer finger foods when resident is hungry as he has difficulty sitting down and eating (10/26/2020), offer to pray with the resident (10/26/2020), off christian country music (10/5/2020), offer to watch mass on television (8/19/2020), offer to walk with the resident (8/10/2020), praise any indication of progress/improvement in behavior (7/7/2020), praise the resident when engaged in spiritual services and activities (4/30/2020), redirect from entering other resident rooms (7/14/2020), listen to church hymns (3/17/2020), and stop and talk with the resident when passing by (7/7/2020). The care plan also documented the resident was at risk for elopement and wandering related to impaired safety awareness and dementia. Interventions included assessment for fall risk (3/17/020), distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or activities preferred by the resident, and document wandering behavior and attempted diversion interventions (3/17/2020). Even though interventions were added for Resident #3, the interventions did not keep Resident #3 safe from other residents mentioned in this citation. Resident #3 was hit by Resident #5 (see Section VI-see below). C. Incident note An interdisciplinary team (IDT) note dated 10/22/2020 documented an incident of the resident wandering around the neighborhood and eventually into the personal space of another resident who did not want him in her space and yelled for staff. Staff came over and separated the residents. An IDT note dated 10/2/2020 documented a wandering incident from 10/1/2020. The resident was wandering the neighborhood looking for a place to lay down when he entered another resident's room. The occupant of the room was sitting on the bed and Resident #3 tried to lay down anyway and the resident pushed Resident #3. The occupant called out for staff who came to escort the resident out of his room after. An activity note dated 10/2/2020 at 12:52 p.m. documented the resident wandered into another resident's room, the occupant yelled out and staff rushed in to escort Resident #3 to his room. A late entry social services note dated 10/5/2020 documented that social services followed up with the resident regarding an incident on 10/1/2020. The resident could not recall the incident and reported feeling safe when asked. Social services will continue to follow the resident and provide support. An IDT note dated 8/7/2020 documented an incident on 8/5/2020 where the resident wandered into another resident's room and laying down on the bed. When the occupant entered the room and found Resident #3 asleep in her bed, she attempted to wake him and he left her room. No staff saw him enter her room. A nursing note from 8/5/2020 documented Resident #3 does not speak much and wanders due to medical diagnosis. The resident wandered into room [ROOM NUMBER] and laid down on the empty bed. A nursing note dated 8/30/2020 documented the resident still wandered the dining area during meals taking other residents' plates and drinks. Will continue to monitor. -No interventions or actions from staff were documented to indicate continued monitoring of interventions in place for Resident #3 to maintain highest practicaple, physical, mental, and phycosocial well being. VI. Staff interviews The activities supervisor (AS) was interviewed on 11/25/2020 at 11:24 a.m. He said Resident #3 had a difficult time communicating his needs and would wander the unit, take other residents' drinks and food. He said Resident #3 does not know where his room was and needed frequent reminders of his room and escorts out of other rooms. He said Rresident #3 frequently entered other residents' rooms Registered nurse #1 was interviewed on 11/25/2020 at 11:33 a.m. She said that Resident #3 cannot verbalize his needs or understand instructions. She said he wanders into all the other resident rooms. She said staff had to watch him during meals so he did not take other residents' food or drinks. She said he believes anything he sees is his and does not know otherwise. Certified nurse aide (CNA) #1 was interviewed on 12/1/2020 at 10:21 a.m. She said interventions used for Resident #3 included the stop signs, which seemed to works well when they were up. She said Resident #3 had poor boundaries and that annoyed some of the other residents which placed him in compromising situations at times. She said staff tried to prevent him from entering other residents' rooms with redirection and distractions, such as snacks or beverages. VI. Resident #5 A. Resident status Resident #5, age 79, was admitted on [DATE]. According to the 12/2020 computerized physician orders [REDACTED]. The 11/5/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of four out of 15. He exhibited verbal behaviors and other behavioral symptoms not directed at others. He required extensive assistance of one staff member with dressing, toilet use, and personal hygiene and supervision with bed mobility, transfers, walking and other activities of daily living (ADLs). He used a walker for mobility. He received an antipsychotic and antianxiety medication daily. B. Care plans A dementia care plan was revised on 10/22/2020 and read, in pertinent part: Resident is at risk for impaired cognitive function related to dementia with behaviors. Resident presents with severe cognitive deficits including forgetfulness, confusion, disorientation, poor impulse control, poor judgment, short term and long term memory loss, history of aggressive behaviors and history of exit seeking. He is able to voice his needs. He needs a calm environment, reassurance and redirection when necessary. Pertinent interventions included: Identify yourself at each interaction; Face when speaking and make eye contact. Reduce any distractions, turn off TV, radio, close door etc. Use simple, directive sentences; Provide with necessary cues stop and return if agitated; Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A behavior care plan was initiated on 3/17/2020 and revised on 11/24/2020 and read, in pertinent part: Resident has potential for a behavior problem related to dementia. Resident has impaired safety awareness, cognition, insight, and judgment related to dementia, and poor problem solving skills. He exhibits disorganized thought processes and frequently misperceives social situations. He had a history of [REDACTED]. He may raise his walker and shake it at others, which can be perceived as threatening and places him at risk for other directed vi (TRUNCATED)

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine and identify what resources are necessary to care for its residents appropriately during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which was facility specific to include, resources, training and specifics about the resident population. Findings include: I. Record review The facility assessment was last reviewed on 5/13/2020 by the nursing home administrator (NHA) and the quality assurance and performance improvement committee. The facility assessment failed to include the following: - Staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff; - Identification of all contracts, memoranda of understanding and other agreements to provide services or equipment to the facility during day to day operations and emergencies; - Identification of facility resources needed to provide competent resident support during day to day operations and emergencies; - How the facility evaluated what policies and procedures may be required in the provision of care, and how you ensure those meet current professional standards of practice; - An accurate facility assessment which was unique to the facility; and - Identification the facility had a locked secured unit. II. Staff interviews The social service director (SSD) was interviewed on 11/25/2020 at 12:35 p.m. The SSD said 18 residents resided on the secured unit. The unit had residents with Alzheimer ' s disease, dementia, mental health [DIAGNOSES REDACTED]. The NHA was interviewed on 11/30/2020 at approximately 11:00 a.m. The NHA reviewed the facility assessment, and confirmed the facility assessment provided on 11/27/2020 at approximately 1:00 p.m., was the complete assessment. The NHA was interviewed a second time on 11/30/2020 at approximately 4:00 p.m. The NHA said the facility assessment was reviewed last on 5/13/2020 by himself and the interdisciplinary team. He said a basic template was used and was based it on the demographics of the facility and the specifics of the population. The NHA agreed the assessment was missing pertinent information and was not complete.

Based on interview and record review the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice for one (#1) of three residents reviewed for skin assessments, out of six sampled residents. Specifically, the facility failed to: -Develop and implement a consistent skin monitoring system to address various altered skin integrity issues. -Notify Resident #1's physician (PHYS) regarding the skin integrity changes. -Develop and implement a skin monitoring system designed to identify the potential for alterations in skin integrity due to daily administration of [MEDICATION NAME]; an antibiotic (Ab) medication pharmaceutically known to alter skin integrity. Resident #1's skin integrity had changes which involved bruising which changed to blisters, and bleeding. The facility failed to monitor Resident #1's skin prior to starting [MEDICATION NAME] and after starting failed to monitor the side effects to [MEDICATION NAME] and subsequently prevent: dispersion of bruising on her body, some bruising of which changed to blisters, and large amounts of bleeding she sustained from the injury to her skin integrity; the extent of which required her to be hospitalized , causing the resident to receive a blood transfusion and deemed a potential risk of elder abuse. Findings include: I. Facility policy According to the Policy/Procedure-Nursing Assessment: Skin Assessment, provided by the director of nursing (DON) on 6/26/2020, the care plan would be implemented. There was no documentation in this policy which identified the facility had a system to consistently monitor a resident's skin for medication side effects, such as with antibiotics. II. Professional reference According to the Mayo Clinic: [MEDICATION NAME], 2020, https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/side-effects/drg- 229, (6/26/2020), [MEDICATION NAME] could cause side effects such as: red [MEDICAL CONDITION], redness or other discoloration of the skin, unusual bleeding or bruising, hives, welts; one was to check with a healthcare professional regarding these side effects. According to the RxList: [MEDICATION NAME] (Doryx), 2020, https://www.rxlist.com/doryx-side-effects-drug-center.htm, (6/26/2020), side effects included darkened skin color and one was to get emergency medical help if there were severe skin reactions which included skin pain, red or purple skin rash that spread, and caused blistering and peeling. According to the RxList: [MEDICATION NAME] (Doryx), 2020, https://www.rxlist.com/[MEDICATION NAME]-[MEDICATION NAME]-side-effects-drug-center.htm#overview, (6/26/2020), side effects involving the skin included: maculopapular and [DIAGNOSES REDACTED]tous rashes, toxic [MEDICATION NAME] necrolysis, and exfoliative [MEDICAL CONDITION], III. Resident #1 A. Resident status Resident #1, less than [AGE] years of age, was admitted on [DATE] and discharged on [DATE]. The June 2020 computerized physician orders (CPO) revealed [DIAGNOSES REDACTED]. According to the 5/12/2020 minimum data set (MDS) assessment she was unable to complete the brief interview for mental status (BIMS) and received a designation of 99. She had open non-pressure related [MEDICAL CONDITION] and required the application of nonsurgical dressings. On the 6/13/2020 MDS, it was an incomplete record, there was no documentation section which addressed the non-pressure related [MEDICAL CONDITION] present on her skin. The resident required extensive assistance with all activities of daily living.The resident had two falls without injury and other [MEDICAL CONDITION], rashes or cuts. The resident was receiving hospice services. B. Record review 1.Computerized physician's orders According to the June 2020 CPOs, Resident #1 was admitted under the care of the physician (PHYS) on 2/20/2020; the facility-identified, provider of contact, with respect to Resident #1's ongoing care needs, which included her skin integrity. 2.Care plans The care plan, initiated on 5/8/2020 and revised on 6/8/2020, identified she had an actual impairment to skin integrity due to decreased mobility. Interventions included to monitor the side effects of antibiotics, which could exacerbate skin injury, and report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc., to the PHYS. The care plan, initiated on 5/20/2020 and revised on 5/21/2020, identified she was administered [MEDICATION NAME] for [MEDICAL CONDITION] of the lower extremities. Interventions included to monitor and document side effects, and report any new or worsening symptoms to the PHYS. Staff were to monitor, document, and report to the PHYS: tender skin, reddened area that spread, red spots on reddened skin, and blisters that formed. C. Failure to continually monitor various skin integrity issues to resolution; before [MEDICATION NAME] was being administered. According to the 5/28/2020 Hospice Comprehensive Assessment and Plan of Care Update Report, she had a 5/20/2020 hospice physician order for [REDACTED]. 1.Record review A.Absence of daily skin monitoring documentation Record review of Resident #1's medical record revealed there was no daily monitoring of her skin for the side effects while she administered [MEDICATION NAME], nor monitoring of her skin after its administration. There was no documentation in the hospice notes to reflect bruising on Resident #1's body was monitored on a continual basis. There was no documentation that the interdisciplinary team (IDT) developed a plan to monitor the bruises on her skin until they resolved. B. Failure to perform skin assessment on shower day According to the 5/19/2020 progress notes, Resident #1 refused a shower; there was no documentation the facility assessed Resident #1's skin for altered skin integrity. C.Care plan The care plan, initiated on 2/27/2020. It identified she had a self-care performance deficit. Interventions included she required one to two staff for toileting, bed mobility, and transfers. The care plan, initiated on 5/2/2020 and revised on 5/4/2020, identified she had [MEDICAL CONDITION] to bilateral gluteal folds. Interventions included to monitor and document location and size of skin injury, report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc., to the PHYS. D. Failure to provide physician order skin treatment According to the May and June 2020 treatment administration records (TARs) there was no documentation her altered skin integrity was monitored on a continual basis. According to June CPO's, Resident #1 had a 5/2/2020 order for the facility to: cleanse the [MEDICAL CONDITION] to Resident #1's right and left gluteal folds with wound cleanser, apply [MEDICATION NAME] and cover them with border foam dressing, twice a day, until healed. Review of the following skin evaluations and subsequent review of Resident #1's medical record (to include the May 2020 TAR) revealed there was no further documentation to reflect the altered skin integrities documented on the skin evaluations were monitored until they resolved: -On 5/14/2020 Resident #1 had scabs to her bilateral lower extremities and mild redness to her pannus area. There was no documentation to indicate the size and number of scabs she had and the measurement of the area of redness to her pannus area; actions which would be taken to indicate a monitoring system was in place. E. Failure to notify Resident #1's PHYS of changes to her skin integrity According to the 6/2/2020 skin evaluation, provided by the facility on 7/8/2020 at 4:27 p.m., after a fall she sustained bruising in her lower extremities which turned into blisters. There was no documentation to reflect Resident #1's PHYS was informed of the bruising which turned into blisters; there was no physician orders to indicate a need to treat blisters was communicated to the PHYS. According to the 6/4/2020 electronic MAR (eMAR) Resident #1 had extensive bruising to her legs. There was no further documentation in this eMAR note which identified the quantity, exact location, size, and color of all the bruises. There was no documentation Resident #1's PHYS was notified of all the bruises. According to the 6/6/2020 skin evaluation, the facility documented Resident #1 had old bruises on bilateral upper extremities. There was no further documentation in this progress note which identified the quantity, location, size, and color of all the bruises. Record review of her medical record revealed there was no prior documentation of bruising to her upper extremities from May 2020 to 6/6/2020 and no documentation to reflect Resident #1's PHYS was notified of all the bruises to her bilateral upper extremities. According to the progress notes: -On 6/5/2020 Resident #1 was found on the floor in a pool of blood, hospice was contacted. There was no documentation to reflect Resident #1's PHYS was informed of the bleeding. -On 6/8/2020 Resident #1 had bruises, blisters, and open areas to bilateral legs. There was no further documentation which identified the quantity, exact location, size, and color of all the bruises. There was no documentation to reflect Resident #1's PHYS was notified of all the bruises. -On 6/10/2020 a post-fall assessment revealed no acute injuries. There was no documentation which identified the facility performed a skin assessment and to monitor the quantity, exact location, size, and color of all the bruises Resident #1 had on her body at this time. There was no documentation to reflect Resident #1's PHYS was notified of all the bruises on Resident #1's body. -On 6/13/2020 at 4:00 a.m. she bled from a right, front leg hematoma and was sent to the emergency room (ER); and was admitted into the hospital. The facility notified hospice. There was no documentation to reflect Resident #1's PHYS was notified of the hematoma. Failure to monitor skin integrity due to side effects of [MEDICATION NAME] V. Resident #1 began receiving [MEDICATION NAME] According to the 5/28/2020 Hospice Comprehensive Assessment and Plan of Care Update Report, she had a 5/20/2020 hospice order for 100 mg of [MEDICATION NAME] twice a day through 5/30/2020. According to the May 2020 MAR indicated [REDACTED]. A. Failure to continually monitor various skin integrity issues to resolution; -On 5/21/2020 Resident #1 had excoriation on her abdominal fold. There was no documentation to indicate Resident #1's scabs to her bilateral lower extremities resolved; actions which would be taken to indicate a monitoring system was in place. -On 5/28/2020 there was no documentation to indicate Resident #1's scabs to her bilateral lower extremities or the excoriation on her abdominal fold resolved; actions which would be taken to indicate a monitoring system was in place. -On 5/30/2020 there was no documentation to indicate Resident #1's scabs to her bilateral lower extremities or the excoriation on her abdominal fold resolved; actions which would be taken to indicate a monitoring system was in place. The facility documented there were no 'new' skin issues. B. Failure to provide skin treatment According to the 5/25/2020 progress note an unidentified staff documented they were to cleanse the [MEDICAL CONDITION] to Resident #1's bilateral gluteal folds with wound cleanser, apply [MEDICATION NAME] and cover them with border foam dressing, but could not complete the treatment because they had to tend to another resident's urgent needs. There was no documentation the facility completed this treatment on this day. According to the May 2020 TAR, there was no documentation the facility provided the treatment order to cleanse the [MEDICAL CONDITION] to Resident #1's bilateral gluteal folds with wound cleanser, apply [MEDICATION NAME] and cover them with border foam dressing on 5/25/2020 and 5/28/2020. There was no documentation in the progress notes or Resident #1's medical record the facility provided the treatment on 5/28/2020. C. Altered skin integrity led to bleeding requiring hospitalization According to the 6/5/2020 hospice record Resident #1 was found on the floor in a pool of blood and the facility called 911. According to the 6/5/2020 skin evaluation Resident #1fell at 4:00 a.m. and later bled from her lower extremities and was sent to the hospital. V. Follow up A. Hospital documentation of altered skin integrity and concerns of harm According to the the 6/13/2020 emergency medical system (EMS) report Resident #1 had a right lower leg hematoma which burst, due to a fall, which resulted in the exposure of bone and tendon. There was large amounts of blood on the floor, the right lower leg was drenched in blood, there was 750ml of blood on the floor, a significant portion of flesh was missing from the right lower leg, and the bleeding was not controlled. According to the 6/13/2020 hospital documents Resident #1 had acute blood loss [MEDICAL CONDITION], required a blood transfusion, had bruising all over her body in various stages of healing, her platelets were 6 on arrival, she could be spontaneously bleeding from this, and there were concerns of elder abuse. The discharge summary revealed she had diffuse ecchymoses (bruising) on all extremities. The impression was acute blood loss with bruising; a forensic nurse examiner was contacted to investigate Resident #1's bruising. Resident #1's representative requested hospital admission due to facility concerns of Resident #1's bruising. Resident #1 did not return to the facility. B. Police report of altered skin integrity and concerns of harm According to the undated police report, Case #13CN 716, Resident #1 fell and was found with large amounts of blood on the floor, approximately 750ml of blood, the bleeding was not controlled at this time, and she was transported to the hospital from the facility. VI. Facility interviews A.Staff interviews The DON, assistant director of nursing (ADON) and the nursing home administrator (NHA) were interviewed on 6/19/2020 at 3:20 p.m. The DON said the follow-up for all skin issues should be consistent and there were skin issues identified on one skin assessment for Resident #1 (she did not identify which one) which the facility should have continued to monitor until the skin issue was resolved. The nurse management team had done some education with nurses about monitoring and tracking wounds and skin issues but the facility had not started a performance improvement plan (PIP). The licensed practical nurse (LPN) # 4 and registered nurse (RN) #3 were interviewed on 6/26/2020 at 7:13 p.m. They said nurses were to monitor for all changes in a resident's skin, to include medication side effects. Nurses were to document if there were changes in residents' skin, like bruising or bleeding. and notify the physician if there were side effects to medications that affected a resident's skin. Nurses were to monitor resident's skin changes, such as bruising or bleeding, until they resolved. The DON was interviewed a second time on 6/26/2020 6:50 p.m. She said she knew antibiotics could thin the blood and cause bruising. The facility did not monitor for side effects [MEDICATION NAME] on Resident #1's skin and should have. The facility did not discuss the concerns of her skin (bleeding, bruising, blisters, or need for labs) with the hospice doctor nor her PHYS, and should have. In the future, the facility would ill monitor residents' skin when on [MEDICATION NAME] and other antibiotics. B. Physician interview The PHYS was interviewed on 7/12/2020 at 7:12 p.m. She said she was Resident #1's primary care physician. She said [MEDICATION NAME] was an antibiotic which could cause unusual bruising and altered skin issues, to include bleeding. Staff should monitor residents' skin who were administered [MEDICATION NAME], daily, with each administration and thereafter because effects to skin could occur even after residents no longer received the medication. Staff should look for ecchymotic (bruise-like) areas on their skin and check for bleeding. She would have written an order for [REDACTED]. The facility did not inform her that Resident #1 was administered [MEDICATION NAME]; nor that she had bleeding, blistering, and bruising issues of her skin. She wanted to know about Resident #1's condition while she was administered [MEDICATION NAME]; although she was on hospice, she was Resident #1's PHYS. It was also important for her to have been notified because [MEDICATION NAME] could interact with her other medications, Resident #1 could have experienced an allergic skin reaction to it (which would be different than the side effects of bruising), and her platelets could have been altered which could have increased her risk for bleeding. When a resident has any skin change while on [MEDICATION NAME], the standard of practice would be to notify her the PHYS, notify the family, immediately stop administering the [MEDICATION NAME], and send the resident to the hospital for evaluation. No other antibiotic would be administered until they were worked-up at the hospital. Moving forward, she wanted the next nurse who took an order for [REDACTED]. The facility should monitor all bruising (bruise-like skin changes) from when it occurs and until it is resolved; if not resolved it should be reviewed in case there is a bleeding problem. C. Non-facility pharmacist interview The a non-facility pharmacist (NFPHAR) was interviewed on 6/28/2020 at 8:30 a.m. She said [MEDICATION NAME] can cause hypersensitive skin reactions, changes in skin, which can appear discolored or like bruises. If there were skin reactions while on it, [MEDICATION NAME] should be discontinued and skin treatments should be implemented. VII. Facility follow-up A.Skin assessments 1.Performance improvement plan (PIP) related to skin assessment The DON provided an undated performance improvement plan (PIP) which documented the following, in pertinent part: -Issue: Incomplete skin assessment/documentation and follow-up; -Identification of others: The facility has determined that all residents have the potential to be affected. -Actions taken/systems put into place to reduce the risk of future occurrence include: 1. In-service education program addressing skin assessment guidelines, documentation and follow-up, 2. Audit completed on 6/30/2020 included review of recent skin assessment findings, current treatment orders, and confirming skin assessment schedule. -Ongoing monitoring to ensure the practice will not recur: 1. Five skin assessments x weekly x twelve weeks. 2. The PIP will be monitored at the monthly quality Assurance meeting until compliance has been met. B.Monitoring antibiotic use 2. Performance improvement plan (PIP) The in-service training report was provided by the DON which documented on 6/30/2020 eight nurses received the education. The DON provided an undated PIP which documented the following, in pertinent part: -The facility identified it did not monitor the side effects of an antibiotic according to its care plan. -On 6/30/2020 the DON trained the nursing staff to monitor for the side effects of medications due to all residents had the potential to be affected by medication side effects; particularly antibiotics (Abs). -The current census was to be reviewed to identify residents who received Ab treatments. Have the physician initiate an order for [REDACTED]. -Ongoing monitoring would occur by: All new medications would be reviewed within 48 hours and initiation of side effect monitoring on Ab classification was ensured. An admission template would be utilized. -The order listing reporting would be reviewed within 48 hours and initiation of side effect monitoring on Ab classification was ensured. A daily clinical review template would be utilized. -The infection surveillance log would be reviewed for observed side effects (if any documented) during the monthly Quality Assurance meeting; until compliance was met. A surveillance log template would be utilized.

Based on interviews and record review the facility failed to ensure one resident (#2) out of three residents was free from neglect. Specifically: Resident #2, resided on the secured unit, and was cognitively impaired. The facility failed to ensure had had adequate supervision while outside and according to the National Weather Service historical weather records at https://w2.weather.gov/climate/index.php?wfo=bou, the official high temperature for 6/12/2020 was 91 degrees Fahrenheit and was recorded at 1:00 p.m. The resident was not provided adequate hydration for the over five hours of sitting outside. As a result, the resident had [MEDICAL CONDITION] type activity, and he was found unresponsive by staff, he was transferred emergently to the hospital and found to have a [DIAGNOSES REDACTED]. Cross reference F610: Failure to investigate neglect. Findings included: A. Facility policy and procedure The Incident accident Reporting policy and procedure proved by the director of nursing (DON) on 6/30/2020 at 8:45 p.m., revised May 2020, documented in pertinent part: -An Incident/Accident Report will be completed for incidents or accidents involving residents. -The administrator will coordinate an investigation of the event as needed. This investigation would be separate from the Incident/Accident Report Investigation. B. Resident status Resident #2, under the age of [AGE] years old, was admitted to the facility on [DATE] and discharged on [DATE]. According to the June computerized physician's orders [REDACTED]. The resident did not have a [DIAGNOSES REDACTED]. The 5/29/2020 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required assistance with activities of daily living (ADL) but was independent with eating and ambulation. The MDS coded the resident as receiving both an antipsychotic and anti depressant medication. The resident was 73 tall and weighed 174 pounds. The resident resided on the secured unit. C. Paramedic Interview On 6/26/2020 at 1:17 p.m. the paramedic who had been dispatched to the facility and picked up Resident #2 was interviewed. She said that when she arrived at the facility none of the staff at the front door were aware of why she was there. After she informed them that she had been dispatched about a resident on the secure unit they escorted her back to the secure unit. She said she, with her coworkers, entered the secure unit and then were sent to the shower room. In the shower room she observed the resident sitting in a wheelchair, in his clothes, receiving a shower. She said the resident was red in appearance, felt hot to the touch and was unresponsive. She said his heart rate was 182 beats per minute. She said facility staff who were in the shower room were unable to say exactly how long the resident had been outside. She said one nurse said five hours and another employee said thirty minutes. She said the resident was transported to the hospital. She said when they got to the hospital the emergency room physician said that the resident had suffered hyperthermia and heat stroke. D. Surveillance Video The secured unit had a fenced in courtyard. On 6/30/2020 at 7:03 p.m. the surveillance video was reviewed with the nursing home administrator (NHA) and the regional vice president (RVP). The video revealed the following: -10:39 a.m. until 1:30 p.m. Resident #2 was in the courtyard, and staff were intermittently going outside; it was unknown what staff did because once staff were seen going outside, there was no video surveillance. According to the assistant director of nursing (ADON) (see interview below) he was sitting under the gazebo, towards the edge closest to the walkway and facility, the area was partially shaded during the time of observation (6/26/2020 at approximately 3:00 p.m.) -1:30 p.m. Resident #2 was escorted by staff inside to be weighed. -1:50 p.m. until 2:25 p.m., at 1:50 p.m. Resident #2 went back outside. Two certified nurse aides (CNA) went outside for approximately one to three minutes. It was unknown what the CNAs did when outside. -2:25 p.m. until 3:06 p.m. one CNA glanced out the window toward the courtyard, the resident remained outside. -3:13 p.m., the activity assistant (AA) went outside for 10-15 seconds; it was unknown what she did. -3:13 p.m. until 3:38 p.m. a CNA looked out the window twice. At 3:19 p.m. the activity director (AD) was outside briefly (see AD interview below). -3:38 p.m. until 4:04 p.m. a CNA briefly went outside (less than two minutes) then came back inside; it was unknown what they did. -4:04 p.m. three CNAs go outside, and immediately came inside and gets a nurse. -4:06 p.m., LPN #1 was observed to go outside -4:11 p.m., CNA brought Resident #2 inside the facility by using a wheelchair and immediately went into shower room with Resident #2. LPN #1 was observed on the video to bring a vital machine cart into shower room. -4:20 p.m., the ambulance arrived -4:51 p.m., EMS was observed to take the resident off of the secured unit on gurney. Although, CNAs, AA, AD and LPN #1 went to the courtyard, it was unknown whether they spoke to the resident to determine if he wanted to come inside (his BIMS was three out of 15) or offer hydration. Additionally, from 2:25 p.m. to 3:13 p.m. the resident was outside without any staff contact, a total of 48 minutes. The NHA and the RVP were interviewed on 6/30/2020 at 7:03 p.m., while reviewing the surveillance video. The NHA and the RVP agreed that there was no evidence to indicate when staff went outside that Resident #2 was offered hydration or was offered to come inside based on the surveillance video. E. Record review 1. Care plan The resident had a [DIAGNOSES REDACTED]. The care plan also failed to include the resident ' s history of [MEDICAL CONDITION] activity. 2. Hospital history and physical The hospital history and physical form, dated 6/12/2020 at 5:25 p.m. documented the resident's chief complaints was hyperthermia (abnormally high body temperature)/altered mental status. The document further read: This patient comes to the emergency department via EMS (emergency medical service). Resident is a [AGE] year old male with a PMHx (past medical history) of hypothermia, AMS (altered mental status), subarachnoid hemorrhage, aneurysm, anxiety, and recent pneumonia [DIAGNOSES REDACTED]. Per EMS, patient was outside in the sun between 2-5 hours, as nursing staff did not check on for several hours. Today is a very hot day. Temperatures are nearly 100 degrees F. Patient was found unconscious by nursing staff at his nursing home with no change after putting he patient in cold shower. Patient remained unconscious upon EMS arrival, with them noting some tonic or [MEDICAL CONDITION] activity in route to the ED (emergency department). EMS then administered 0.5 mg IV (intravenous) [MEDICATION NAME] and patient subsequently became more alert and responsive, with tremors ceasing. EMS then administered an additional 2 mg Versed. Upon arrival to the ED, patient is easily aroused to voice .He states he remembers being outside, and when I asked him if nursing staff forgot about him, he laughed. On physical examination the patient appeared in moderate to severe acute cardiorespiratory distress and was alert and answering questions appropriately. Initial vital signs are interpreted as febrile (having or showing symptoms of a fever), [MEDICAL CONDITION](rapid heartbeat), tachypnea (rapid breathing) and [MEDICAL CONDITION] (oxygen deprivation). Mucous membranes of the mouth are dry. Sunburn to bilateral thighs. Medical decision making and course in the ED with interpretation/review of diagnostic studies: After considering the history, physical exam, signs and presenting symptoms I believe that this patient has symptoms of hyperthermia. Differential [DIAGNOSES REDACTED]. Laboratory results interpreted: Renal function was found to be acute [MEDICAL CONDITION] with BUN (blood urea nitrogen) and Creatinine of 18 and 1.61 respectively. Final impressions/Diagnoses: [REDACTED]. Suspected [DIAGNOSES REDACTED], 3. Heat exposure, 4. Hyperthermia . 3. Change of condition 6/12/2020 The medical record was reviewed and revealed the resident experienced a change of condition on 6/12/2020 resulting in unresponsiveness. The 6/12/2020 Event/Change of Condition note documented: Possible [MEDICAL CONDITION] activity, 1625 (4:25 p.m.) resident was non-responsive, shaking, vital signs: 107/75, 98.0, p(ulse)111, r(espiratory) 21, Oxygen at 2 liters (72%). Physician and family notified. Resident sent to hospital. 4. Medication Administration Record [REDACTED] The June 2020 MAR indicated [REDACTED]. The facility did not monitor other fluid intake on the MAR. F. Facility investigation The facility investigation was provided by the NHA on 6/26/2020. The investigation was completed on 6/23/2020 (11 days after the resident went to the hospital and four days after the survey start date). The investigation included a summary of the video surveillance on 6/12/2020, the day of the event. The interviews from one CNA on the unit and LPN #1 were completed on 6/26/2020. The CNA interview documented that she had not seen the resident go outside because she was completing showers but was notified by the nurse that Resident #2 was outside. She said she offered him water and asked him if he wanted to come inside but he refused. She said she went to the nurse to tell her that he was red and warm to the touch and sunscreen was applied. She said she went to get another CNA to see if they could help her get the resident inside. She said an activities staff told her that the resident had thrown up. She said Resident #2 was not acting like himself and was transferred to a wheelchair and brought inside to the shower room. She said she, the nurse and the other CNA attempted to cool him then Resident #2 started screaming a female name. The LPN #1 interview documented that the resident went outside at approximately 12:30 p.m. after lunch with a CNA; she said the CNA sat with him initially. She said the Resident was weighed and then reweighed at approximately 2:00 p.m. then Resident #2 went back outside. She said the resident had a Boost Breeze while outside and the CNA took water to the resident. She said the resident remained outside until the CNA came and got her, they took the resident inside via wheelchair. The DON was notified and the Resident was taken to the shower room to be cooled, the resident's hands were shaking slightly and not at baseline. Oxygen saturations levels were checked and were low and Oxygen was administered and vitals were taken. The physician and family were contacted and the resident was sent out emergently. Reported to wife possible [MEDICAL CONDITION] activity. The DON provided How Hot Weather Affects Senior Citizens with Alzheimer ' s and Dementia. She said education was provided after 6/19/2020 and included information related to this article and to place residents on 15 minute checks. There was no further information. Sign in sheets were provided and documented the 6/21/2020 sign in sheet documented 15 CNAs and one nurse were educated and one nurse. The 6/22/2020 sign in sheet documented seven CNAs were educated and the 6/23/2020 sign in sheet documented six CNAs and one nurse were educated. G. Interviews Licensed practical nurse (LPN) #1 was interviewed on 6/19/2020 at 2:18 p.m. LPN #1 said Resident #2 was transferred to the secured unit, because he had multiple elopement attempts. She said he had behaviors and was ambulatory. She said he would go outside on occasion with assistance, and staff from the activities department would go out frequently and take residents. She said on 6/12/2020 the resident had gone outside sometime between 12:30 p.m. - 1:00 p.m. She said at approximately 1:50 p.m., he was assisted back inside at .to reweigh him as his earlier weight had not looked correct. She said after he was reweighed he was assisted back outside. She said she knew the CNA had given the resident a Boost breeze (dietary supplement juice) while he was outside. She said Resident #2 had been outside from approximately 2:00 p.m. to 4:00 p.m. She said around 4:00 p.m., a CNA took him water and found him shaking, maybe he had a [MEDICAL CONDITION]. She said the CNA went and got her and then went and brought him inside. She said they took him straight to the shower room, they took vitals twice. He felt warm so they put the shower on and soaked him down pretty good. The LPN #1 said the resident remained clothed when they wet him in the shower. She said the director of nursing (DON) was notified and called EMS and sent him to the hospital. The assistant director of nursing (ADON) was interviewed on 6/19/20 at 2:25 p.m. She said she remembered seeing Resident #2 sitting outside under the awning and had a Boost drink. She said she did not know how long he had been outside but he was sent to the hospital because he had a change in vitals and was unresponsive when he came inside. The NHA and DON were interviewed on 6/19/20 at 3:20 p.m. The DON said that when Resident #2 had gone to the hospital he wasn't looking too good, he had thrown up, we thought he might have had a [MEDICAL CONDITION]. The DON confirmed the resident did not have a history of [MEDICAL CONDITION]. The DON and the NHA both confirmed after the resident went to the hospital they did not complete a timeline or review why the resident went to the hospital. The DON said moving forward they will make sure resident that are out there (in the courtyard) are supervised and make sure they aren't there for long periods of time - I honestly don't know what we could have done different he was offered drinks, LPN #1 was by the door. The NHA, DON, ADON, director of clinical services (DCS) and clinical resource (CR) were interviewed on 6/26/20 at 5:12 p.m. The NHA said their investigation related to Resident #2 was completed on 6/23/2020. He said he had talked to the CNA who was working on the secure unit at the time and LPN #1. He said the surveillance video had been reviewed and it was clear the resident had never been left outside alone. The activity assistant (AA) was interviewed on 6/26/20 at 3:40 p.m. She said she was working the day Resident #2 was outside. She said when she saw him, he was sitting outside throwing up and she told the CNA. She said she saw staff go outside to assist him and bring him inside. She said when he came inside he continued to throw up, and was visibly tired and his eyes were squinted. CNA #6 was interviewed on 6/26/2020 at 4:10 p.m. He said if a resident goes out into the courtyard he will sit with them the entire time they are outside. CNA #5 was interviewed on 6/26/2020 at 4:20 p.m. He said that someone should always be with residents when they go outside. The activity director (AD) was interviewed on 6/30/2020 at 4:58 p.m. She said she passed through the courtyard on 6/12/2020 in the afternoon at approximately 3:00 p.m. because she said she had a phone call at 3:15 .m. She said she would pass through the courtyard instead of going through the building occasionally. She said she had seen Resident #2 sitting with another resident outside in the courtyard. She said he waved and said hello. She said at that time there was no other staff in the courtyard and she did not remember specifically about whether there was anything to drink for the resident.

Based on observations, record review and interviews; the facility failed to ensure one (#3) of three residents reviewed for nutrition out of 49 sample residents maintained acceptable parameters of nutritional status. Specifically the facility failed to ensure a formal nutritional assessment was completed for Resident #3 following a severe weight loss (greater than 7.5 percent), failed to implement the registered dietitian's recommendations to address identified weight loss and failed to implement care planned interventions to prevent weight loss. Resident #3 had a 9.92 percent (%) weight loss in a three month period between 10/2/19 and 1/8/2020. Findings include: Resident #3, age 82, was admitted on [DATE]. According to the January 2020 computerized physician orders [REDACTED]. A. Resident status The 10/4/19 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of seven out of 15. The resident had disorganized thinking, he did not reject care assistance and required supervision, cuing and encouragement with eating. The resident's height was 68 inches and he weighed 103 pounds at the time of the assessment. He did not have a swallowing disorder. Record review revealed Resident #3 had sustained a severe weight loss over the last three months. Review of the weights and vitals summary revealed the following: 7/2/19 104.6 pounds 8/27/19 104.8 pounds 9/1/19 101.8 pounds 10/2/19 102.8 pounds 11/5/19 101.4 pounds 12/2/19 95.4 pounds 1/8/2020 92.6 pounds -Resident had a 9.92 % severe weight loss in the last three months. -Resident had an additional 2.94 % weight loss in the last 30 days. B. Facility response to the resident's severe weight loss Progress notes revealed the facility documented knowledge of the resident's weight loss and poor appetite in early January 2020. Recommendations were identified and the resident's care plan was revised. Progress notes read in pertinent part: -10/3/19 7:36 p.m. Nurses note - quarterly charting: Resident is alert to self only but able to voice his needs. Resident only communicates in Spanish and requires Spanish speaking staff to interpret. He is on a regular diet with thin liquids but his appetite is very poor. - 10/8/19 12:37 p.m. Social Service - Care Plan Notes: Care conference held today with social service director, registered nurse and activities director. The Guardian was invited but did not attend. Resident is on a regular diet, regular texture and thin liquid diet. Res receives med pass eight oz. three times a day for nutritional support. Current weight 102.8 pounds, weight is stable. -12/30/19 5:35 p.m. Nurses note: Quarterly charting continues. Alert and oriented to self. Ate 50% of all meals, accepts nutrition supplements between meals. Fluid encouraged as tolerated. -1/1/2020 11:36 a.m. Nurses note: Resident needs limited assistance with activities of daily living. Encourage fluid, snacks and nutritional supplement between meals. Ate breakfast approximately 50 percent and 360 oz of fluid. -1/3/2020 7:09 p.m. Nurses note: Residents appetite is poor. Dietitian was here to visit resident and advised this nurse of documented weight loss and decreased BMI. This nurse advised the dietician of the resident's poor appetite and that he only drinks 50 percent of med pass supplement. -1/8/2020 12:46 p.m. Nurses note: Resident being followed for weight loss. Will change supplements to food based items. Will continue weekly weights. -1/12/2020 3:59 p.m. Nurses note: Resident consumed approximately 50 percent at meals in the dining area and has accepted snacks, fluids and med pass for nutritional support. The resident's care plan was revised 1/7/2020. It read, Resident is at increased risk for nutrition risk related to anorexia nervosa, low body mass index (BMI), dementia and other pertinent diagnosis. -The resident goals and target date read: to maintain current weight plus or minus five percent or to have a gradual weight gain of one to two pounds per week towards a BMI (body mass index) within normal limits through the next review date of 4/16/2020. -Approaches included: liberalized diet; provide and encourage fluids, offer preferred foods, offer meal alternates, provide diet/nutrition education with translator, monitor weights and labs, encourage meal intake greater than 60 % for all meals, notify the registered dietitian if oral intake declines, and provide supplement as ordered four oz. house supplement twice a day for nutrition support (2/9/19); clarified the order and on 7/10/19 the supplement was increased to eight oz. house supplement started 7/17/19. Review of the January 2020 CPO revealed an order for [REDACTED]. C. Failures in facility response to Resident #3's severe weight loss 1. The facility failed to ensure the registered dietitian (RD) completed and documented a formal nutritional assessment for Resident #3 following his severe weight loss. Review of the most recent Dietary Data Set and Progress Note assessment, dated 10/11/19 revealed: The resident's weight was 102.8 pounds at 68 inches (five feet six inches) on 10/2/19, with no significant change in weight over the past 30, 90 or 180 days from the assessment date 10/11/19. The resident's diet order was regular consistency with thin liquids supplements as ordered (eight ounce house supplement three times a day). Dining ability: able to feed himself with set up. Requires cues and encouragement related to poor appetite. Nursing reports oral intake declines at times and will only drink 50 percent of supplement at times. Continue to encourage oral intake of preferred foods and beverages. Continue to follow the nutrition plan of care and follow up as needed. There were no additional dietary data set progress notes completed after 10/11/19 despite the resident's 9.92% severe weight loss over the past three months. The RD was interviewed on 1/16/2020 at 2:03 p.m. The RD said she took the role of interim dietitian mid-December 2019. She said she is allotted six hours to assess and make recommendations for all of the facility's residents with dietary concerns and was just now getting up to date with the residents' nutritional care needs. She said, After taking the position I reviewed all of the residents for weight loss for the past 30 days and noticed that Resident #3 had a significant weight loss in that time period. We set up a standard of care meeting to discuss recommendations to address the resident's nutritional needs. On 1/3/2020, I made the recommendation for staff to give the resident a 206 enhanced chocolate chip cookie, twice as day and magic cup daily. I did not write up a formal written assessment for my review and recommendation, but I sent the dietary orders to the director of nurses (DON) to order and add the nutritional and supplementation to the resident's diet. 2. The facility failed to ensure the RD recommendations were implemented Notes titled 30 Day Weight Evaluations read: Based on 30 day look back period dated 12/26/19, provided by the consultant clinical dietitian (interim) registered dietitian (RD) in a follow up email forwarded by the nursing home administrator on 1/21/2020 at 5:08 p.m., Resident #3 had a 5.92 percent weight loss in 27 days. Recommendations included: continue nutrition plan of care to monitor weights and oral intake monthly. Additional recommendations document in the email titled Recommendations for Residents with Significant Weight Loss per Standards of Care (SOC) Meeting, dated 1/3/2020, revealed the following recommendations: -weekly weights, -keep eight ounces house supplement three times a day, -add 206 chocolate chip cookie twice a day, with lunch and dinner, -magic cup daily between lunch and dinner. Spoke to nursing 1/3/2020 Resident #3 does not like liquid supplement. However, review of Resident #3's January 2020 medication administration record (MAR) for nutritional supplement administration revealed only med pass house supplement was administered with consumption documented varying from refused to 100 percent (240 oz.) consumed. -There was no documentation to administer magic cup or 206 cookies or any indication these nutritional supports were provided to the resident. -There was no recommendation for weekly weights on the resident's January 2020 CPO, MAR or treatment administration record (TAR). And, review of the resident's record revealed no documentation of weekly weights. In an interview with the RD on 1/16/2020 at 2:03 p.m., she confirmed, after checking the resident's MAR and TAR, the recommendations she had made were not on the MAR, TAR, or the care plan (see above). The RD said she would check with the facility on the status of the nutritional supplements, write up a formal assessment for Resident #3 and get the care plan updated today. 3. The facility failed to ensure Resident #3 received supervision, cueing or encouragement at mealtime as care planned when intake was less than 60%. Certified nurse aide (CNA) #14, was interviewed on 1/16/2020 at 12:26 p.m. CNA # 14, who was familiar with Resident #3, said Resident #3 liked to be independent and did not always respond well to encouragement to eat more, some days eating well and all of his food, but usually he will eat almost half of his food. Review of the resident ' s meal intake record for a 30 day period from 12/16/19 to 1/16/2020 revealed, when intake was documented, the resident most often ate less than 60%: -Intake refused for 4 out of 90 meals (4.4 %) -Intake was 0-25% for 8 out of 90 meals (8.8%) -Intake was 26-50% for 18 out of 90 meals (20%) -Intake was 51-75% for 22 out of 90 meals (24.4%) -Intake was 76-100% for 13 out of 90 meals (14.4%) (There was no documentation for 25 out of 90 meals (27.7%)) Notwithstanding the resident's frequent intake of less than 60%, observations on 1/13 and 1/14/2020 revealed Resident #3 was not supervised, cued, or encouraged to eat during his meal. Specifically: -On 1/15/2020 at 11:52 a.m., Resident #3 was observed seated at a dining room table in the front of the dining room with one other resident. Staff served him a drink and his meal, regular dietary consistency. The two CNAs on duty sat at the table in the back of the dining room and assisted three residents with their meals. Staff did not check on the status of the resident's meal consumption or provide him supervision, cueing or encouragement to eat his meal. He ate 25 % of the food on his plate before getting up from the table and going back to his room. Staff only approached the resident's table at the end of the meal service when all the residents had finished eating in order to clear the plates. -On 1/15/2020 at 5:02 p.m., Resident #3 was observed sitting at a dining room table in the front of the dining room waiting for his meal. Staff served him and left the area. There were two CNAs on duty; one CNA was physically assisting two residents with their meals in the back of the dining room and the other CNA was busy redirecting two residents involved in an altercation. The nurse on duty was redirecting four other residents seated just outside of the eating area to return to their seats to eat their meals. None of the staff on duty offered Resident #3 supervision, cuing or encouragement to eat his meal. He ate only a few bites of the food on his plate before getting up from the table to return to his room. Staff only approached the resident's table at the end of the meal service when all residents had finished eating in order to clear the plates. E. Interview with the DON indicated potential systemic failures in ensuring facility residents received the care and services necessary to maintain acceptable parameters of nutritional status. The DON was interviewed on 1/17/2020 at 10:23 a.m. She said she was new to the DON role and the facility had recently changed dietitians. She said the RD is not familiar with the residents in the building and her time is limited to get everything done. She said she had just given the RD a list of monthly weights for January. -The DON said that typically, when the RD recommends/orders nutritional supplements or treatments for a resident, the RD sends the orders to her and she enters the orders into the resident ' s record either on the MAR/TAR, as appropriate to the type of order. -The DON said she did not know what happened with the RD's recommendations for Resident #3, stating maybe the RD had sent her the recommendations and they were in her inbox. However, she said moving forward, she will be pulling a weight loss report so they can closely monitor residents for weight loss. -The DON further stated, It is really difficult to know the Resident #3 true weight because he wears that heavy coat most of the time and several varying layers of clothing. He rarely takes off the coat and most of the time will not take it off to be weighted. He also may or may not be wearing any number of additional shirts and sweaters. The nurses do not document the layers of clothing he wears during weighing; so you cannot tell from weight to weight his accurate weight. The DON was interviewed again on 1/17/2020 at 12:58 p.m. The DON said she checked the resident's MAR and TAR following the above discussion and she confirmed the recommendations for weekly weights and additional nutrition supplement (magic cup and 206 cookie) were not on either record. She said if there was an order to weight the resident weekly it would have been added to the TAR. If the nurses were weighing him weekly, they could have written it into the progress notes. She was not sure where the orders came from to weigh the resident weekly. I will check with the RD and get the orders clarified.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and two (#7 and #1) of three residents reviewed for accident hazards out of 20 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically: Resident #7 experienced eight falls within three months of admission. The resident's first five falls were out of bed; at least two of these falls related to toileting. Thereafter, the resident experienced three more falls while out of bed. Although interventions were initiated, there was insufficient evidence they consistently were implemented, were resident-specific, and were based on an analysis of the resident's previous falls. The resident's fourth fall resulted in a fractured hand, nose bleed, and superficial lacerations and bruising to the face. Resident #1 experienced three falls in two months. The facility failed to develop effective interventions to address the resident's continued failure to seek assistance with transfers. Findings include: I. Facility policy and procedure The facility fall policy updated on ,[DATE] read in pertinent part: All residents on any admission, readmission, and at least quarterly are assessed for fall risk and appropriate interventions initiated immediately to reduce the risk of injury from falls. II. Resident #7 Resident #7, age 70, was admitted on [DATE]. The (MONTH) (YEAR) computerized physician orders [REDACTED]. A. Resident status According to a [DATE] minimum data set (MDS) assessment, the resident was frequently incontinent of urine and not on a urinary toileting program. The resident had moderate cognitive impairment. She required extensive assistance (two + staff assistance) with activities of daily living and mobility. The resident had experienced a fall within ,[DATE] months of admission. According to the care plan developed within 48 hours of admission, the resident was visually impaired and noted to be legally blind. According to physician progress notes [REDACTED]. The care plan, initiated [DATE], identified a problem with falls. The approaches included: Keep call bell in reach ([DATE]), fall mat in place next to bed (added [DATE]), bolster to edge of bed (added [DATE]) and mattress next to bed on floor (added on [DATE]). The resident's Fall Risk Data Set completed [DATE] revealed the resident scored an 11 out of 18 which indicated the resident was at high risk for falls with full weight bearing status, minimum assist with transfers, in chair mobility. Although identified on her [DATE] MDS assessment as moderately cognitively impaired, she was identified on the Fall Risk Data set as severely cognitively impaired. Staff interviews (see below) revealed the resident's cognitive status fluctuated throughout the day and she had periods of confusion. B. Record review - falls from bed - facility failures Review of incident notes, facility investigations with facility interviews, and risk management reports revealed Resident #7 fell out of bed and onto the floor five times. Two of the falls were associated with injuries. There was insufficient evidence the falls were thoroughly investigated for triggers and patterns in order to develop effective, resident-specific interventions and prevent injury. 1. Fall #1 - [DATE] at 12:30 a.m. Fall and facility response: The fall investigation report and nursing notes revealed a fall on [DATE] at 12:30 a.m. According to the fall investigation, the resident was found on the floor next to her bed sitting flat on buttocks with both legs straight out. The resident was also noted and documented to be barefoot. The post incident immediate actions included to continue bed in the lowest position, keep call light within reach, floor mat/mattress placed next to bed for protection and more frequent checks to be performed. A therapy screening was requested on [DATE] and completed on [DATE], which recommended occupational therapy (OT) and Physical therapy (PT). Failures in facility response: There was no evidence in the fall investigation report that the facility had investigated why the resident fell out of bed in order for the facility to develop resident-specific, effective interventions. Specifically, there was no evidence the facility investigated whether the resident was attempting to leave the bed to address a need such as toileting or was restless or confused. Likewise, there was no evidence the facility investigated whether the resident, who was legally blind, rolled out of bed, unaware she was at the edge of the bed. There was no evidence in the post incident actions that the resident's voiding pattern would be monitored to see if scheduled toileting might prevent a recurrent incident. In addition, the plan for more frequent checks was not defined to ensure staff understood what this meant. 2. Fall #2 - [DATE] at 11:30 p.m. Fall and facility response: The fall investigation report dated [DATE] at 11:30 p.m. revealed the resident was found on the floor next to the bed sitting on her buttocks with a skin tear to her right second toe and right wrist. The report further documented the property involved was floor- tile/wood and the activity at the time was from bed without assistance. The post incident immediate actions included to encourage the resident to use the call bell when assistance was needed, and the call light was placed within reach of the resident. A therapy screening form was requested on [DATE] and completed on [DATE], which recommended occupational therapy (OT) and Physical therapy (PT). Failures in facility response: Despite the similarity of this fall to her fall about 12 hours earlier, there was no evidence in the fall investigation report that the facility considered these similarities in developing interventions to prevent another incident. In addition, as with her first fall, there was no evidence the facility investigated why the resident fell out of bed, whether it was to address a need such as toileting or restlessness, or whether the resident rolled out of bed, unaware she was at the edge of the bed. Finally, the fall investigation documented tile/wood floor was involved in the fall; however,, there was no discussion about the placement of the fall mat at the time of the fall which, per care plan, was to be placed next to the bed as of [DATE] for protection. There was no evidence in the post incident actions that the resident's voiding pattern would be evaluated to see if scheduled toileting might prevent a recurrent incident. Moreover, although ineffective, post incident actions continued to include encouraging the resident to use her call light; there was no evidence the facility re-evaluated this intervention or considered whether another type of intervention, such as increased supervision, might be more effective. As with previous post incident actions, more frequent checks a post incident action after her earlier fall [DATE], was not defined to ensure staff understood what this meant. 3. Fall #3 - [DATE] at 12:00 a.m. Fall and facility response: The fall investigation report dated [DATE] at 12:00 a.m. revealed a certified nurse aide (CNA) found the resident on the floor with redness under her left eye and left knee. The report further documented the property involved was floor- tile/wood and the activity at the time was from bed without assistance. The post incident immediate actions included the bed was in the lowest position and to encourage the resident to use the call bell for assistance with all transfers. A therapy screening form was requested on [DATE] and completed on [DATE], and recommended occupational therapy (OT) and Physical therapy (PT). Failures in facility response: Despite the similarity of this fall to her previous two falls, there was no evidence in the fall investigation report that the facility considered these similarities in developing interventions to prevent another incident, or, as with her first fall, investigated why the resident fell out of bed - whether it was to address a need such as toileting or restlessness, or the resident rolled out of bed, unaware she was at the edge of the bed. In addition, although the fall investigation documented tile/wood floor was involved in the fall, there was no discussion about the placement of the fall mat which, per care plan, was to be placed next to the bed as of [DATE] for protection. There was no evidence in the post incident actions that the resident's voiding pattern would be evaluated to see if scheduled toileting might prevent a recurrent incident. Moreover, although ineffective, post incident actions continued to include encouraging the resident to use her call light; there was no evidence the facility re-evaluated this intervention or considered whether another type of intervention, such as increased supervision, might be more effective. Finally, record review revealed although the therapy screen was completed [DATE], the first documented physical therapy session from provided paperwork from the facility was not until [DATE] at 4:45 p.m., after the resident had sustained several more falls (see below). 4. Fall #4 - [DATE] at 8:32 a.m. Fall with injury and facility response: No fall investigation report was provided for this incident. However, the nurses' progress note dated [DATE] at 8:32 a.m. revealed the resident fell from bed facedown and was found on the floor bleeding from her nose. She had swelling to the forehead and she was sent to the hospital via ambulance. The resident returned to facility from hospital with facial contusions and metacarpal contusion per nursing progress notes at 3:40 p.m. A diagnostic imaging report from [DATE] reported an acute right fifth metacarpal fracture. A computerized Tomography (CT) report from [DATE] reported left-sided periorbital soft tissue swelling. Failures in facility response: See care plan above; a bolster to the edge of the bed was added to prevent further falls from bed. However, as with her previous falls, there was no evidence the facility investigated why the resident continued to fall out of bed in order to develop effective interventions, or to determine if her fall mat was in place or properly placed at the time of the fall. In addition, the care plan continued to read that staff should encourage the resident to use the call light even though there was no documentation she had used the call light previously when she fell from bed. And, the care plan continued to lack staff instruction to increase supervisory checks rather than relying on the resident's use of the call light to summon assistance. 5. Fall #5 - [DATE] at 3:09 a.m. Fall and facility response: Per nursing documentation, the resident was found on the floor, lying face down closest to the resident room door. The resident was returned to bed with bed in the lowest position and a fall mattress beside bed. A medication change was made on [DATE] to discontinue the current [MEDICATION NAME] dose. The dose was lowered to 25 mg twice a day. And, mattress next to bed was added to her care plan. Facility failures: There was no evidence of a fall investigation to determine where resident was going and why, and whether her call light was accessible or used. Likewise, there were no plans on how frequently staff should be checking on the resident. A post incident action continued to be to encourage her use of call light. C. Record review - additional falls - facility failures 1. Fall #6 - [DATE] at 4:20 p.m. Resident was found on the floor of another resident ' s room per nursing notes. No interventions were documented. 2. Fall #7 - [DATE] 10:00 p.m. Resident #7 was found on the on the floor lying on right side after falling out of the wheelchair. The resident's [MEDICATION NAME] had been increased to 50 mg bid on [DATE] as documented in the nursing progress notes. There was no fall investigation report or post incident actions after this fall. There was no plan to increase monitoring of the resident following her fall and medication increase several days earlier. 3. Fall #8 - [DATE] at 6:23 p.m. The nurses notes dated [DATE] documented the resident had a fall in the courtyard. The note did not include any immediate interventions provided or describe the circumstances of the resident's fall to prevent a re-occurrence. D. Observations -On [DATE] at approximately 9:00 a.m.,the resident was observed sitting at the dining room table with her breakfast tray in front of her. The resident had a cast on her right hand. The resident had put sugar from a packet into her cereal and the top piece of the sugar packet was floating in her hot cereal. The resident continued to eat the cereal and when told she had a piece of paper in her cereal, attempted unsuccessfully to get the paper out with her spoon. The CNA who was asked to assist the resident said the resident was legally blind. -On [DATE] at 9:15 p.m., Resident #7 was observed lying in bed, bed in the lowest position and mattress next to bed. The call light, a documented intervention to prevent a fall, was observed to be at the resident's feet and not within reach. -On [DATE] at 7:42 a.m., the resident was observed lying in bed. The call light, a documented intervention to prevent a fall, was observed on the floor next to her bed and out of reach. C. Staff Interviews The licensed practical nurse (LPN #2) was interviewed on [DATE] at 8:40 p.m. LPN #2 said she was the nurse on duty when the resident fell on [DATE] at 11:30 p.m. and [DATE] at 12:00 a.m. -After reviewing the nurses' notes, the LPN recalled that on [DATE], the resident was found on her side by the bed, confused and stating she needed to go to the bathroom. The LPN said the fall on [DATE] was very similar; the resident was found on the floor next to her bed lying on her face with small skin tears to right wrist and right toes along with other small superficial scrapes as well. She could not remember if the resident was on the floor mat but said she would have written it in her note if the resident was found on the mat. She thought the resident was lying directly on the floor. The LPN said the resident, again, was attempting to go to the bathroom. -The LPN could not recall the resident's orientation status prior to her falls, but stated the resident was confused at times, would usually scream if she needed assistance but would not use the call light to call for assistance. LPN #1 was interviewed on [DATE] at 9:18 p.m. The staff member reported resident was able to use the call light and was able to make her needs known. The LPN described Resident #7 as alert and oriented to person and place and sometimes person, place, and time during the day but acknowledged the resident was more confused in the evening and occasionally called out for her mother around midnight. LPN #4 was interviewed on [DATE] at 8:15 a.m. The staff member stated that the resident was able to use the call light; however, it depended on her mental status which changed throughout the day. The staff member reported that at times the resident was alert and oriented but other times confused. The LPN said when the resident was alert, she was only alert to person and could sometimes make her needs known and sometimes she could not. III. Resident #1 Resident #1 was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. A. Resident status The most recent MDS assessment dated [DATE] showed the resident had cognitive impairments. A brief interview for mental status was attempted; however, the resident was unable to complete the assessment. The staff assessment showed the resident had memory impairments, and memory recall was location of his room. The resident had moderately impaired decision making which indicated decisions were poor and cueing and supervision were required. The resident required extensive assistance with the assist of one staff for transfers and personal hygiene. The resident had a history of [REDACTED]. The care plan dated [DATE] identified the resident had a potential for injury related to falls due to dementia, pain, and [MEDICAL CONDITION] drug use, and incontinence. Pertinent interventions included to ensure call light within reach and answer promptly, encourage the resident to await assistance. The Fall Risk (MDS) data set [DATE] showed the resident had mild-moderate impairment, was incontinent daily and required assistance with transfers. The resident had a score of 10 which indicated a high risk for falls. The [DATE] social service note documented the resident had behaviors of loss of interest and wandering. B. Record review Record review revealed the resident experienced three unwitnessed falls, one with an injury within two months. The facility failed to ensure appropriate and effective approaches were put into place. 1. Fall #1 The incident report dated [DATE] at 9:30 p.m., showed the resident screamed for help. He was found sitting on the floor inside his bathroom. The resident said he slid out of his chair while transferring himself from the chair to the bathroom. The resident had no injuries. The follow up to the fall documented staff were educated to facilitate more interaction with the resident, to educate the resident to be aware of his location on the unit, and to offer the toilet more frequently. There was no evidence the facility investigated the circumstances of the resident's fall in order to develop effective interventions. There was no evidence the resident's toileting schedule was studied to determine how frequently to offer toileting assistance. 2. Fall #2 The incident report dated [DATE] at 9:45 p.m., documented the resident was shouting for help. He was found on the floor on back beside the heating vent in his room. The follow up to the fall on [DATE] documented the resident was evaluated by PT and OT and educated staff to toilet resident late in the evening prior to hour of sleep and as needed. There was no evidence the resident's care plan was updated with the above directive. 3. Fall #3 The incident report dated [DATE] at 3:00 p.m., showed the resident was found on the floor. The resident said he was getting into his wheelchair when the incident occurred. The resident suffered a skin tear on his left elbow and a bump on his head. The follow up to the fall documented the resident was monitored frequently, engage in afternoon activity and re-educate the resident to transfer only with assistance and to use the call light. See above; the interventions to transfer with assistance and to use the call light had been on the care plan since [DATE]. Both were known to be ineffective interventions and there was no evidence the facility considered alternatives to these interventions to keep the resident safe. C. Observations and interviews Observations and interviews confirmed planned interventions (see above care plan and post fall follow up) were ineffective. On [DATE] at approximately 4:00 p.m. the resident was observed for approximately 30 minutes in his wheelchair in his room alone. He was going through his roommate's drawers. No staff was observed to check on the resident during that time as they were getting resident ready for dinner. On [DATE] at approximately 2:00 p.m. the resident was in his wheelchair, self propelling himself in the secured unit. No staff were in the area to monitor the resident's whereabouts. On [DATE] at approximately 1:30 p.m. the resident was observed sitting in a recliner in another resident ' s room. A certified nurse aide (CNA) was interviewed and said the resident self transferred himself into the recliner in the other resident's room. She said the resident often transferred himself without help and did not call for help. She said he was not supposed to transfer himself. On [DATE] at 8:40 p.m. LPN #2 was interviewed. The LPN reviewed the nurses' notes and confirmed she was on duty when the resident fell on [DATE]. She said he was found on the floor next to the heating element. She said he was trying to go to bed to lie down and reported he had hit his head. She said she always told him to not to get up by himself and to use the call light but the resident did not always remember to use the call light for assistance. On [DATE] at approximately 8:00 a.m. LPN #5 was interviewed. The LPN said the resident ' s cognitive status depended on the day. She said some days the resident was able to follow directions and other days he was confused and unable to follow instructions.

Based on interviews and record review, the facility failed to ensure one (#3) resident with psychosocial difficulties out of 37 sample residents received care and services necessary to attain and maintain his highest practicable level of psychosocial well-being. Specifically, the facility failed to ensure adequate communication and monitoring of Resident #3's psychosocial status. The resident had a history of [REDACTED]. Resident #3 became visibly angry and upset after being informed that a large, painful wound on his shoulder from [MEDICAL CONDITION] wound not ever heal. He walked out the facility on [DATE] after 10 p.m., was struck by the train and died . Cross-reference F689: The facility failed to implement procedures to ensure residents were safe and accounted for in the facility. Facility staff did not initiate a search for Resident #3 until more than five hours after he left the building. Cross-reference F697: The facility initiated a severe decrease in Resident #3's opioid pain medications and failed to take steps to ensure his pain was manage during this decrease. Findings include: A. Resident status and background 1. Resident #3, under [AGE] years of age, was admitted to the facility on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) of 13 of 15. A PHQ-9 interview (a mood interview tool to screen for depression) revealed sleep disruption on 7 to 11 of 14 days and also reported feeling tired on 7 to 11 of 14 days. The resident expired after leaving the facility unaccompanied on [DATE]. 2. The resident's care plan, dated [DATE], revealed the resident was at risk for alteration in his psychosocial well-being as evidenced by self-isolation related to depression. The goal was the resident would be free from signs of psychosocial distress. Approaches included providing 1:1 emotional support as needed, encouraging him to express feelings related to his condition, and notifying the resident ' s physician (MD), family, or responsible party of concerns as needed. B. Failure to take steps to manage Resident #3's pain following reduction in his pain medications (Cross reference F697) Resident #3 had a history of [REDACTED]. Even with significant doses of routine and as needed pain medications, his pain levels were elevated above his acceptable level of pain of 3 out 10 (10 being the worst pain). The resident's pain medications were reduced beginning [DATE], and documentation revealed and interviews confirmed, the resident's physical, mental and psychosocial well-being declined as evidenced by frequent complaints of pain at and above a level 8 out of 10, nausea and cramping, self-isolation, declining activity participation and other increasing signs and symptoms of depression (lethargy and lack of engagement). The facility failed to take steps to manage the resident's pain after his pain medications were reduced. Specifically, the facility failed to take steps to ensure his medication reduction proceeded in a deliberate manner to minimize resident pain and discomfort, failed to assess and monitor Resident #3's pain prior to and after his pain medication was reduced, failed to create person-centered interventions to address his pain and how to manage his pain reduction, and failed to implement an order referring the resident to pain clinic and communicate to the resident's provider the resident's unmanaged pain. B. Failure to monitor the resident's psychological responses following the pain medication reduction. 1. Interviews revealed a close friend of the resident as well as staff observed Resident #3 experienced increased sign and symptoms of depression following his pain medication reduction [DATE]; however, there was no documentation the resident's signs and symptoms were being monitored. Resident #3's friend was interviewed on [DATE] at 11:27 a.m. He said he visited the resident frequently, and that he had noticed a change in the resident ' s mood over the previous month. He said while the resident was always a lone wolf (a loaner), he had been more withdrawn and tired when he came to visit. He said the resident had previously engaged in conversation and had appeared to enjoy their time together, however; over the past month he had stated that he was too tired to talk, and had been reluctant to get out of bed. Registered nurse (RN) #1 was interviewed on [DATE] at 12:18 p.m. She said she had worked with the resident for a long time. She described him as keeping mostly to himself and said the resident usually stayed in his room. She said he had one friend who came to visit frequently, but was estranged from his family. She said the resident had a history of [REDACTED]. She said the resident had recently undergone a dose reduction in his [MEDICATION NAME], and said the resident had expressed breakthrough pain more frequently during the reduction (Cross reference F697). She said the resident had begun to self-isolate even more, and that he had been less engaged when his friend came to visit. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:23 p.m. He said he had worked at the facility for about a month and had primarily worked on Resident #3's unit. He said the resident usually kept to himself, and did not talk to the staff or to other residents. The LPN said in the month he had worked there, he perceived the resident to be very depressed and said that he had struggled with pain management and with a large open wound on his shoulder. The resident's physician (MD #1) was interviewed on [DATE] at 6:48 p.m. She said people who were dependent on opioid medication, such as [MEDICATION NAME]([MEDICATION NAME]) could experience a variety of side effects during a reduction, including physiological symptoms such as cramping, nausea, and shakes, and emotional symptoms such as increased irritability, sleep disturbances, and depressive symptoms. -She said as a result, she would have expected the facility to initiate additional monitoring of the resident when the reduction was initiated to identify any concerns with his mood, sleep patterns, or behavior. -She said any concerns related to the resident ' s psychosocial status should have been referred to her immediately. She stated she had not been made aware of any increases in isolation behavior. 2. Review of Resident #3's nursing notes from [DATE] forward failed to reveal documentation the resident was monitored for psychosocial effects after his pain medications were reduced. There was no documentation of communication with MD #1 or from social services about the resident's depression or about the signs and symptoms observed by staff (see above). C. Appointment [DATE] and facility failure to communicate Resident #3's response to the appointment A review of the physician documentation from [DATE] revealed Resident #3 saw a wound physician on this day for follow up on the wound to his right shoulder. RN #1 was interviewed on [DATE] at 12:18 p.m. She confirmed Resident #3 had gone out for an appointment with the wound physician on [DATE]. -The RN said when Resident #3 returned from the visit with the wound physician, he had told her that the wound physician informed him his wound was never going to heal. She said he did not appear to be dealing well with that news and clarified that he had been angry and visibly upset. -The RN acknowledged she had not written a nursing note about the appointment or about the resident ' s reaction to it. She said his response to the visit with the wound physician should have been written down but it was not. However, she said she verbally communicated this information at change of shift. -The RN said when a resident had a change in behavior or mood it was important to communicate it so staff could monitor the resident. She said some of the things they could do included more frequent checks on the resident, conversing with them, and calling the physician if needed. LPN #1 was interviewed on [DATE] at 12:23 p.m. He said he knew the resident had a large open wound on his shoulder. He said he had worked [DATE], and he had not been aware of the need for any increased monitoring or check-ins that day. He said he had not been informed of the resident's response to the visit with the wound physician the previous day. The social services director (SSD) was interviewed on [DATE] at 2:48 p.m. He said nursing staff was responsible for communicating any new concerns related to a resident's psychosocial well-being to social services. -He said he would expect to be notified of any changes in resident behavior or concerns about how a resident was adjusting to his or her situation so he or his social services assistant (SSA) could check in with the resident to see what they could do to help. - He said social services had not been informed of RN #1's observations of Resident #3's anger and visible distress following his wound appointment. He said if either he or the SSA been aware of the resident's response to the visit, they would have conducted a follow up visit and could also have initiated monitoring so staff would be more aware to check in on the resident. MD #1, interviewed on [DATE] at 6:48 p.m. said she had not been made aware of RN #1's concerns with the resident's psychosocial status on [DATE]. A review of the nursing notes from [DATE], [DATE], and [DATE] did not reveal documentation of any concerns related to the wound care appointment or the resident's psychosocial status following the appointment. D. An adult protection services intake screening dated [DATE] revealed the resident left the facility at 10:01 p.m. on [DATE]. He was struck by a train at approximately 10:20 p.m. and died . Resident #3's friend was interviewed on [DATE] at 11:27 a.m. He said Resident #3 had left the faciity on the night of [DATE], and at 10:20 p.m. was struck by a train. The friend said the police and coroner's office were investigating the resident's death as the conductor had testified Resident #3 had been sitting down on the tracks and made no attempt to move when they sounded the train's horn. At the time of the investigation, the coroner's report was not yet finalized for review.

Based on interview and record review, the facility failed to ensure one (#3) of three residents out of 36 sample residents had an effective pain management regimen. Resident #3 had a history of [REDACTED]. Even with significant doses of routine and as needed pain medications, his pain levels were elevated above his acceptable level of pain of 3 out 10 (10 being the worst pain). The resident's pain medications were reduced beginning [DATE], and documentation revealed, and interviews confirmed, the resident's physical, mental and psychosocial well-being declined as evidenced by frequent complaints of pain at and above a level 8 out of 10, nausea and cramping, self-isolation, declining activity participation and other increasing signs and symptoms of depression (lethargy and lack of engagement). The facility failed to take steps to manage the resident's pain after his pain medications were reduced. Specifically, the facility failed to take steps to ensure his medication reduction proceeded in a deliberate manner to minimize resident pain and discomfort, failed to assess and monitor Resident #3's pain prior to and after his pain medication was reduced, failed to create person-centered interventions to address his pain and to manage his pain reduction, failed to implement an order referring the resident to pain clinic and communicate to the resident's provider the resident's unmanaged pain, and failed to monitor the resident's physiological and emotional responses during the pain medication reduction (Cross reference F742). Findings include: 1. Resident status Resident #3, under [AGE] years of age, was admitted to the facility on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The resident walked out of the facility on [DATE] and did not return. He was later found deceased . (Cross reference F689 and F742). According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) of 13 of 15. A PHQ-9 interview (a mood interview tool to screen for depression) revealed sleep disruption on 7 to 11 of 14 days and also reported feeling tired on 7 to 11 of 14 days. The resident experienced pain at an 8 of 10 on a scale of 1 to 10. The resident's most recent quarterly pain assessment dated [DATE] revealed the resident experienced pain from a large wound on his right shoulder caused by [DIAGNOSES REDACTED]. The pain was frequent, and caused the resident to experience difficulty sleeping at night, and it limited his activities. The pain was at an 8 of 10, and was aching and sharp in nature. The pain was worsened by movement, and moderately relieved by medication. The resident's goal for pain management was to sleep comfortably and be comfortable with movement. His tolerable level of pain was a 3. 2. Pain medication management plan a. Medications up to [DATE] - frequency and effectiveness A computerized physician order [REDACTED]. A review of the medication administration record (MAR) revealed the resident received 90 mg MS routinely from (MONTH) (YEAR) to [DATE]; however, he continued to have pain higher than his acceptable level of 3 most of the time, frequently reporting his pain at a level of 8. A review of MAR for the PRN order of IR MS revealed staff documented the severity of the pain, the intensity level of the pain, non-medical interventions attempted, and type of pain. Documentation of non-pharmacological interventions and the nature of the pain were not specified on the MAR. Post administration follow-up was not consistently conducted with follow-up score being documented on only one administration. b. Change in pain medication management plan [DATE] A telephone physician order [REDACTED]. - The resident's scheduled dose of MS 90 mg twice a day was reduced to 30 mg twice a day. - The frequency with which the resident was able to request and receive his PRN IR MS 30 mg was reduced from every four hours to every eight hours. -A pain clinic referral was ordered These orders became effective on [DATE]. 3. Facility failure to take steps to manage the resident's pain after his pain medications were reduced. a. Failure to ensure the resident's opioid reduction proceeded in a deliberate manner to minimize resident pain and distress. The facility's director of nursing (DON) and assistant director of nursing (ADON) were interviewed on [DATE] at 12:18 p.m. They said when conducting a medication reduction, the facility utilized an interdisciplinary team (IDT) meeting to review the resident's pain management plan, the cause, location, and nature of the resident's pain, and other interventions that could be used to support the resident through the reduction. They said reductions should be gradual, with a drop to the next dosing level occurring approximately every two weeks so the facility and physician could monitor the resident's pain and any side effects of the reduction (such as withdrawal symptoms) prior to proceeding to the next reduction. The DON said Resident #3's reduction was a severe one, and that if it had occurred after she had started, she and the physician would have explored whether a more gradual reduction could have been implemented. However, she said neither she nor any of the current IDT staff had worked in the building at that time, and she had not been able to locate the IDT's notes on the reduction to clarify what the rationale for the decision had been. The resident's primary care physician (MD #1) was interviewed on [DATE] at 6:48 p.m. She said she had followed the resident since his admission to the facility in (MONTH) (YEAR). She said his primary concern was a large wound in his right shoulder from a [DIAGNOSES REDACTED]. She said the resident had the wound for several years and it was not healing due to infection and [MEDICAL CONDITION]. The physician said the wound was very painful, and the resident had been receiving [MEDICATION NAME] help manage his pain. She said the resident historically had been on a very high dose, 90 mg of extended release [MEDICATION NAME]([MEDICATION NAME]) twice a day with the availability of an as needed (PRN) dose of 30 mg of immediate release [MEDICATION NAME] (IR MS) every four hours. Although review of the pharmacy recommendations for (MONTH) and (MONTH) (YEAR) did not demonstrate any recommendations related to Resident #3's MS Contin, the physician said the pharmacy had identified the resident's dose of [MEDICATION NAME] being high and had recommended a reduction. She said usually when this happened, the facility's IDT would meet to determine how best to manage the reduction. She said usually this included increased monitoring, the initiation of additional non-opioid medications to manage pain and withdrawal symptoms, and usually a referral to a pain clinic. However, she said the facility had experienced frequent turnovers in their IDT positions. She said the last time she had worked with a DON on a reduction had been several months prior and the facility had three different people in the DON position since that time. The physician said usually an opioid reduction was done via a gradual taper; one medication would be reduced at a time, and the resident's dose lowered to the next lowest dose for two weeks, and then lowered further in two week increments until the target dose was reached. She said this was necessary because opioid medications caused dependency, and a rapid reduction could cause withdrawal symptoms and instability with mood and temperament. The physician said the reduction for Resident #3 had not been consistent with the deliberate and gradual taper process recommended for opiate withdrawal. She said she had received an urgent call on [DATE] from the resident's charge nurse who had been in the process of re-ordering the resident's [MEDICATION NAME] had been informed the pharmacy was not willing to provide the large supply needed to fill the resident's order and the insurance provider would not pay for more than 30 mg twice a day and a PRN order of 30 mg every eight hours. She said that although she was concerned about the reduction, they had felt that amount was still better than nothing. The physician said no member of the facility's IDT team at the time (none of whom were still present at the facility) had been involved in the discussion about the reduction, and there had not been a conversation about what other alternatives could be used. She said she had placed an order to refer the resident to a pain clinic, even though he had previously been resistant to that option, in order to explore some potential options for pain management. b. Failure to assess and monitor Resident #3's pain prior to and after his pain medication was reduced. See above; the resident's last comprehensive pain assessment was [DATE], ten months prior to his pain medication reduction [DATE]. There was no evidence a pain assessment was conducted prior to the pain medication reduction in order to identify any changes in his pain severity, the nature of his pain, the effect of the pain on his activities of daily living, effective and non-effective impact non-pharmacological interventions. Record review further revealed no comprehensive pain assessment since the pain medication reduction [DATE]. A review of the MAR for ,[DATE] and ,[DATE] revealed the pain severity, intensity, type, and non-pharmacological interventions were no longer documented on the MAR for PRN administrations. A review of the ,[DATE] MAR revealed the resident requested his PRN medication twice on [DATE], [DATE], and [DATE] and all three times it was available on [DATE] and [DATE]. However, the MAR did not include documentation of the resident's pain level at the time of the administration, assessment of the pain's location or nature, or any evidence of non-pharmacological interventions. In addition, no follow up was documented on the MAR to demonstrate the resident's pain level after the administrations or if the administration was effective or not effective. A review of the nursing notes from [DATE] to [DATE] revealed follow up for some of the administrations of as needed (PRN) MS. However, no follow up assessment was present for 28 (62%) of 45 as needed administrations of pain medication to determine the resident's pain level after the administration or whether the administration was effective. Moreover, nursing notes from [DATE] forward did not mention the resident's pain medication reduction and nursing staff (other than the follow up mentioned above) did not comment on the nature of the resident's pain. c. Failure to create person-centered interventions to address the resident's pain and how to manage his pain reduction. Review of the resident's care plan revealed no updates were made to the resident's care plan to reflect the resident was undergoing a drug reduction or to guide staff on how to monitor the resident for increased pain or withdrawal symptoms during the reduction. d. Failure to communicate to the resident's provider the resident's unmanaged pain and lack of pain clinic involvement in managing his pain. (1) Review of nursing notes from [DATE] forward revealed no documentation the resident's provider was notified of the resident's persistent, elevated pain levels and his symptoms (see below) following the pain medication reduction. MD #1 was interviewed on [DATE] at 6:48 p.m. She said she would have wanted to know that the staff were having concerns about the resident's pain levels so she could work on addressing the pain. She said staff had not notified her of any concerns with the medication reduction. (2) MD #1 said she ordered a referral to a pain clinic in conjunction with a reduction partially to help acclimate the resident to the idea of the reduction, and partially to assist with creating a targeted, resident specific plan to manage his pain. She confirmed she had ordered a referral to a pain specialist for Resident #3, although she said he had refused such referrals in the past. She said she would have wanted to know if the referral had not been made. A review of the facility's documentation related to appointments and referrals did not demonstrate a referral to the pain clinic, ordered [DATE], had been attempted. The social services director (SSD) was interviewed on [DATE] at 3:53 p.m. He said although social services handled some referrals, such as ancillary services or mental health, the referral for the pain clinic was handled by the nurse and the staff member responsible for scheduling. An interview was attempted with the transportation and scheduling staff (TS) on [DATE] at 4:05 p.m. She was not available for interview. e. Failure to monitoring of the resident's physiological and emotional responses during the pain medication drug reduction (cross reference F742). Interviews with facility staff and a frequent visitor revealed the resident demonstrated increased isolation/lack of engagement during the reduction as well as lethargy. These concerns were not tracked, communicated to social services, or shared with the resident's physician. (Cross reference F742) The nursing notes from [DATE] forward did not mention the resident's pain medication reduction or include documentation the resident was monitored for psychosocial effects related to the reduction. 4. Record review and Interviews a. Record review Record review revealed that following the resident's pain medication reduction, he experienced physical, mental and psychosocial decline in his well-being. A review of the MAR and treatment administration record (TAR) for ,[DATE] indicated the resident experienced pain above his target level of 3 on 14 (77%) of 18 scheduled pain assessments. The resident demonstrated pain at an 8 or higher on 4 (22%) of 18 scheduled assessments. A review of the MAR/TAR for ,[DATE] indicated five of the 56 scheduled pain assessments were not conducted. Of the 51 that were conducted, the resident experienced pain above his target level of 3 on 42 (83%) of the time. He experienced pain at an 8 or higher on 15 (29%) of them. The resident ' s pain was not assessed at the time of PRN administrations. A physician note dated [DATE] indicated the resident appeared with a flat affect and had a decreased range of motion in his right arm. A physician note dated [DATE] indicated the resident was seen by a wound physician. This physician noted a decrease in range of motion to the resident's right shoulder. The note indicated the resident had expressed he was not getting pain medication to assist with the wound pain. The physician recommended a referral to a pain clinic, although, see above; a referral had already been ordered [DATE]. Despite the interviews with RN #1 and the resident's visitor (see below), the nursing notes did not reveal any monitoring or documentation about changes in the resident's mood or isolation. b. Interviews Interviews confirmed decline in the resident's physical, mental and psychosocial well-being following his pain medication reduction. Registered nurse (RN) #1 was interviewed on [DATE] at 12:18 p.m. She said the resident had pain from a large open wound in his right shoulder which was from [MEDICAL CONDITION]. She said he had MS prescribed for pain management, as well as [MEDICATION NAME] for nerve pain. -She said the facility had recently initiated a drug reduction from the resident's previous dose of 90 mg twice a day, which he had been on for several months. -She said the resident generally experienced pain at an 8 out of 10, and had struggled with the reduction, experiencing cramping and nausea the day it started, and more frequent and deeper instances of breakthrough pain. She said she administered the PRN [MEDICATION NAME] it was available and the resident requested it, but said he had expressed that he was still in a great deal of pain. The RN said there were no additional PRN [MEDICATION NAME] ordered for the resident when he was in pain and an additional dose of MS was not available. Resident #3's friend was interviewed on [DATE] at 11:27 a.m. He said he was a close friend of Resident #3 and often came to see him in the facility. He said the resident had severe pain from [MEDICAL CONDITION] wound in his shoulder. He said the resident received medications to manage the pain, but they had not been consistently effective. -He said the resident had undergone a required reduction of his pain medication beginning in February. He said the physician had told the resident it would be a difficult reduction at first, but that the facility would put interventions in place to help manage the pain. He said, however, that although he had asked, he was not aware of any other steps taken to relieve the resident's pain. -He stated he had noticed the resident was more tired and less receptive to his visits during the reduction. He said the resident was generally a lone wolf (loner) but that in the past, he had been happy to have him visit. He said during (MONTH) and early March, the resident had expressed that he was too tired to talk or visit when he came to see him. He said the resident had told him he was experiencing severe pain during the reduction, and had attributed being tired partially to pain.

Based on observation, interview and record review, the facility failed to ensure one (#1) of three sample residents received the care and services with bathing she was assessed to need and ordered to receive to maintain good grooming and personal hygiene. Specifically, for a number of months, the facility failed to provide the resident showers three times a week as ordered as well as the assistance she was assessed to need when she was showered. These failures contributed to resident odors, the resident's nonparticipation in facility activities and feelings of embarrassment, shame, depersonalization, and self-disgust. Findings include: Resident #1, under [AGE] years old, was admitted to the facility 9/13/17. According to the computerized physician orders [REDACTED]. Resident Status: A minimum data set (MDS) assessment dated [DATE], revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 of 15. She required physical assistance of one person for bathing. A review of the resident's care plan did not document guidance on her preferences or need for assistance for showers. However, a physician order [REDACTED]. Observation and Resident and Roommate Interviews: 1. The resident was observed in her room on 1/9/18 at 3:38 p.m. Her hair looked greasy and a sour, yeasty odor was present in the room from a distance of five feet from the resident. -The resident said she required hands on assistance during showers because she was unable to reach to wash the back of her body or her feet. She said she had always had difficulty getting her scheduled showers, but that this had worsened since she moved to a new room on a different unit approximately one month ago. -The resident said she was supposed to get three showers a week, specifically Mondays, Wednesdays, and Saturdays; however, the staff frequently did not offer her a shower. She said while she was able to sponge bathe her armpits and the front of her upper body in the sink, this was inadequate to wash most of her body. The resident said she had frequently gone several days and sometimes more than a week without a shower. 2. Resident #1's roommate, who was alert and oriented, was interviewed on 1/10/18 at 11:00 a.m. She voiced concerns about resident #1 who she said needed staff assistance for showers. She said they had roomed together for approximately a month and she had noticed staff did not offer or provide the resident her showers. She said the resident generally received only one shower a week, and that she had an odor as a result of a yeast infection and infrequent bathing. She said her roommate frequently became tearful and expressed humiliation and self-disgust because of the shower situation. Record Review: Record review revealed the facility failed to provide the resident showers three times a week as ordered as well as the assistance she was assessed to need when she was showered. A review of nursing notes as well as the ADL (activities of daily living) tracking and shower documentation from 11/1/17 to 1/10/18 demonstrated the resident missed multiple showers, and review of the shower schedule revealed the resident was not on the current bathing schedule. 1. A review of the ADL tracking from 11/1/17 to 1/11/18 revealed multiple occasions when the resident went for several days without a shower. No refusals were documented in the tracking. -There was no documentation of a shower being offered or given from 11/1/17 to 11/8/17, a period of seven days. -There was no documentation of a shower being offered or given from 11/9/17 to 11/13/17, a period of four days. -There was no documentation of a shower being offered or given from 11/23/17 to 11/28/17, a period of six days. -There was no documentation of a shower being offered or given from 11/30/17 to 12/10/17, a period of 11 days. -There was no documentation of a shower being offered or given from 12/12/17 to 12/17/17, a period of five days. -There was no documentation of a shower being offered or given from 12/23/17 to 12/29/17, a period of six days. 2. A review of shower documentation in January 2018 demonstrated multiple instances in which the resident was documented to bathe with a level of assistance that was inconsistent with her assessed assistance needs. -Bathing documentation on 1/3/17, 1/5/17, and 1/7/17 indicated the resident only received assistance to transfer and did not receive assistance with bathing. -Bathing documentation on 1/8/17 and 1/10/17 indicated the resident received set-up assistance only. 3. The shower schedule for the resident's unit was observed on Wednesday, 1/10/18 at 2:05 p.m. The resident's name did not appear on the schedule. The shower schedule for the resident's unit was observed a second time on 1/11/18 at 9:30 a.m., after conversations with Registered Nurse (RN) #1, the director of nursing (DON), nursing home administrator (NHA) #2, and the regional clinical director (RCD) #1 regarding the resident's missed showers (see below). The resident's name did not appear on the schedule. Staff Interviews: Certified nurse aide (CNA) #1 was interviewed on 1/10/18 at 2:00 p.m. She said residents who required assistance with showering were scheduled on a shower schedule that was posted at the nursing station. She said the CNAs relied on the schedule to ensure residents received their showers. -The CNA said she usually worked on the resident's unit; she said the resident had moved over from a different unit about a month ago. She said that although she was familiar with the resident, she had never given her a shower; however, she was aware the resident required hands on assistance for transferring and dressing due to strength and mobility deficits. -The CNA confirmed by observation that the resident's name did not appear on the shower schedule. Registered nurse (RN) #1 was interviewed on 1/10/18 at 2:15 p.m. She said she had worked with the resident both on her current unit and on her previous unit. She said the resident required physical assistance for not only the transfer and dressing component of bathing, but for the actual bathing task itself due to limitations with her ability to reach parts of her body, such as her lower back or her feet. -The RN said that the shower schedule was created by the CNAs so they could work the resident's shower preferences into their existing schedule. -The RN said she had noticed the previous week that the resident was not on the shower schedule, and had asked the CNAs to add her, but upon review of the schedule, she said this had not been done. She said that as a result, Resident #1 frequently did not get her showers which she described as unacceptable, saying that everyone had a right to be clean. She said she knew the resident felt poorly about herself when she had not been bathed, and she was aware the resident had an offensive odor from the yeast infection. The DON, NHA #2, and RCD #1 were interviewed on 1/10/18 at 4:00 p.m. They said the resident should have been placed on the shower schedule to remind the CNAs when the resident was supposed to get her showers. They said that while residents always had the right to determine the number of showers they wanted, or to refuse scheduled showers when offered, the CNAs had to offer the resident the number of showers they were supposed to receive for their care needs and personal preferences. RN #1 was interviewed a second time on 1/11/18 at 9:35 a.m. She confirmed by observation that the resident still did not appear on the shower schedule. She said the CNAs had spoken with the resident about her shower preferences on 1/10/18, so she was concerned this information had not been added to the shower schedule. Resident Harm: The resident was interviewed three times about a variety of subjects, and during each interview, she reiterated her concerns about showers. While discussing this concern, the resident became visibly upset and tearful, and expressed feelings of shame, depersonalization, and self-disgust. She described limiting her interactions with other residents when she had not been bathed for a while. Specifically: -On 1/9/18 at 3:50 p.m., while discussing her concerns about bathing, the resident became tearful and distressed. She said she had a yeast infection in the folds of her groin as a result of the lack of bathing, and said she was embarrassed and ashamed of how she smelled. She said when she was unable to receive the assistance she needed to maintain good hygiene she felt like she was less than human. -On 1/10/18 at 9:08 a.m., while discussing the emergence of her yeast infection and the lack of bathing, the resident again became tearful. -On 1/11/18 at 9:50 a.m. the resident said that not receiving regular showers had negatively impacted her quality of life. Specifically, she said the lack of bathing had contributed to her developing a yeast infection, which she said was uncomfortable, and gave her an offensive and distinct odor. She said while she had made friends during her stay at the facility, she was not always comfortable to go out and socialize because she felt like she stunk. She said there were a number of activities she would have liked to attend, but that she did not go when she smelled, because she did not want to gross other people out, like (she) grossed (herself) out.

Based on observations, interviews and record review, the facility failed to keep one (#89) of six sample residents free from pressure ulcers. Specifically, the facility failed to prevent the development of a new pressure sore, and promote the healing of the pressure sore. -The facility failed to evaluate the impact of the interventions and revise care approaches as needed specific to the resident's needs. -The resident, who had [MEDICAL CONDITION] and required extensive assistance with bed mobility, transfers and other activities of daily living, was admitted to the facility with a stage 4 pressure sore to the sacrum, and acquired pressure sores to the coccyx and buttocks after admission. -The facility failed to assess, develop and implement measures to prevent further skin breakdown. The resident had an indwelling Foley catheter and developed a "new" pressure sore to the penis, first documented by the wound care specialist on 9/8/14 as being "more than two months old" and which had not healed as of 3/12/15. -The facility failed to conduct timely, thorough and accurate assessments, document an accurate minimum data set, update the care plan with adequate interventions to promote healing, document skin and wound condition in the medical record, consistently administer catheter care and physician-ordered dressing changes, provide adequate turning and repositioning to offload pressure, and keep the resident's catheter bag and tubing off the floor to help prevent infection. The facility failures contributed to the resident developing a stage 3 pressure ulcer to the penis, which had not healed as of 3/12/15. Findings include: Resident #89 Resident #89, age under [AGE] years, was admitted to the facility from the hospital on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. 1. Failure to accurately assess and document pressure sores on the minimum data set Resident Status: According to the 2/27/15 minimum data set (MDS) assessment, the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15, with no behaviors and no rejected cares. He needed extensive two-plus person assistance for bed mobility and transfers, extensive one-person assistance for all other activities of living, and was totally dependent on staff for bathing. The resident had an indwelling catheter and an ostomy. He was at risk for development of pressure ulcers, and had unhealed pressure ulcers. The MDS noted one stage 4 pressure ulcer and no stage 3 pressure ulcers. - The 12/5/14 MDS indicated the resident was at risk for development of pressure ulcers and had unhealed pressure ulcers. No stage 3 pressure ulcers were documented. - The 9/5/14 MDS indicated the resident was at risk for development of pressure ulcers and had unhealed pressure ulcers. No stage 3 pressure ulcers were documented. However, see below, the resident had a stage 3 pressure ulcer during the review periods of all the above MDS assessments. Record review revealed the resident was admitted with an ostomy on 12/20/13. The care plan dated 2/24/14 revealed that the ostomy and Foley care plan were documented on the same page. Both included the same interventions which included: promoting hydration, foley catheter care each shift and ruling out urinary tract infections. The Foley catheter was implemented on 5/4/14, and a suprapubic catheter was implemented on 1/5/15. 2. Failure to develop accurate comprehensive care plans with interventions to identify and promote healing of pressure ulcers Care Plan Review: The skin integrity care plan, dated 2/24/15, was very specific and in documentation indicated that the care plan was for the resident's previously acquired pressure ulcers. The care plan did not address the stage 3 pressure ulcer on the resident's penis. There was no additional documentation to indicate that the care plan had been revised or updated. The interventions for impaired skin integrity included: promotion of adequate fluid and protein, weekly skin checks, turning and repositioning frequently and provision of incontinent care. The care plan had no updates or revisions over the last 13 months. The resident's care plan for nutrition dated 2/24/14 indicated that the resident's potential for alteration in nutrition was related to the resident's depressive order. Interventions for facility staff included: having resident participate in meal choices, assisting with meal set up and offering yogurt daily for breakfast. The care plan had no updates or revisions over the last 13 months. There was no evidence of nutritional interventions to promote healing of pressure ulcers. A care plan dated 2/24/14 in the area of self care deficit related to the resident's [DIAGNOSES REDACTED]. The interventions included providing total assistance for completion of activities of daily living (ADLs), assist of two staff with bed mobility, total assist with toileting and transfers. The care plan had no updates or revisions over the last 13 months. The resident had a urinary catheter placed on 5/4/14. The care plan for Foley catheter care dated 2/24/14, documented that the resident had a urinary catheter. The interventions for cares included: promoting hydration, Foley care each shift and notifying physician of changes. The care plan had no updates or revisions over the last 13 months. -However, medical record review revealed the resident had a suprapubic catheter placed on 9/2/14, but the care plan was not updated accordingly, and there was no evidence of catheter care provision each shift (see below). A review of the care conference notes, dated 9/18/14, indicated in the section titled "concerns or comments," that there were no concerns noted at the time, although the resident had stage 3 pressure ulcer to the penis (see wound care specialist notes below). Physician Orders The computerized physician orders [REDACTED]. -Datrolene 25mg three times daily for spasms; -[MEDICATION NAME] three times daily for spasms; -[MEDICATION NAME] 20mg daily for [DIAGNOSES REDACTED]. -Under "treatments," nursing staff was to cleanse the penis with wound cleanser and apply skin prep to open area. 3. Failure to prevent new pressure ulcers from developing Record Review: A review of the resident's admission history and physical, dated 12/20/13 and authored by the resident's primary physician at the time, indicated that the resident was admitted to the facility with one stage four pressure ulcer to the sacrum. Wound specialist progress notes, dated 3/2/15, documented that the resident had the following pressure areas: stage 4- sacrum (admitted with), stage 4-coccyx (acquired), stage 3-penis (acquired), no staging- buttocks (acquired). Medical record review revealed the sacrum, coccyx and buttocks wounds were healing. The resident was admitted with the sacral stage 4 wound, for which he had numerous surgeries and removal of bone within the past year and a half, and which was healing. The acquired stage 4 coccyx wound developed on 11/2/14, the acquired buttocks wound was documented in the wound progress notes as ongoing and not staged. However, the resident acquired an additional stage 3 pressure ulcer to the penis, which developed per the physician wound progress notes, on 9/8/14. Review of the nursing progress notes dated 9/2/14 indicated that the resident had a cystofix (repair of the bladder) and suprapubic catheter placement. The nursing notes dated 9/3/14 indicated that the resident's catheter bag was draining bloody urine. A review of the resident's medical record, specifically the nursing progress notes, revealed that after 9/2/14, there was no documentation by the facility nursing staff regarding the resident's new pressure ulcer on the penis (see new pressure sore note below). Likewise, no facility skin or wound assessments documented the new pressure sore on the resident's penis, although on 9/8/14 the wound care specialist documented the pressure ulcer was "more than two months old." A review of the nursing progress notes dated 9/1/14 through 3/12/15 revealed that the nursing department was not charting on the characteristics of the wounds on a daily basis. However, see below, multiple entries were not documented and the resident stated nurses were not consistently administering his wound dressings. Wound Care Specialist Notes: Wound care specialist progress notes dated 9/8/14 documented that the resident had a new penile glans pressure ulcer that was more than two months old, and caused by the resident's urinary catheter (durable medical equipment DME). The pressure area to the penis was staged by the provider as a stage 3. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 1.5cm length, 1cm wide and .01cm deep. The treatment orders were cleanse and apply alginate with silver and cover wound with gauze around penis. The dressings were to be changed daily. The wound plan of care was to discuss the increase in foul odors and treatment changes with facility. Wound care specialist progress notes, dated 9/29/14, indicated that the resident had a penile ulcer that was more than two months old and caused by the resident's urinary catheter ( DME). The pressure area on the penis gland was staged by the provider as a stage 3. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 1.5cm length, 1cm wide and [MEDICAL CONDITION] deep. The treatment orders were cleanse and apply alginate with silver and cover wound with gauze around penis. The dressings were to be changed daily. The wound plan of care was to discuss the increase in foul odors and treatment changes with facility. Wound care specialist progress notes, dated 10/6/14, indicated that the resident had a penile ulcer that was more than two months old. The pressure area was staged by the provider as a stage 3 and documented as caused by the resident's DME. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 1.5cm length, 0.3cm wide and 0.1cm deep. The wound was observed and documented as having drainage. The treatment orders were cleanse and apply alginate with silver and cover wound with gauze around penis. The dressings were to be changed daily. The wound plan of care was to discuss the need for daily dressing changes. The document indicated that the resident's urinary catheter had been removed related to a new pressure area and the constant leaking of urine and the resident had a suprapubic catheter placed. Wound care specialist progress notes, dated 11/6/14, indicated that the resident had a penile ulcer that was more than two months old. The pressure area was staged by the provider as a stage 3 and documented as caused by the resident's DME. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 1.3cm length, 0.3cm wide and 0.1cm deep. The wound was observed and documented as having drainage. The treatment orders were cleanse and apply alginate with silver and cover wound with gauze around penis. The dressings were to be changed daily. The wound plan of care was to discuss the need for daily dressing changes. The document indicated that the resident's urinary catheter had been removed and the resident had a suprapubic catheter. Wound care specialist progress notes, dated 12/1/14, indicated that the resident had a penile ulcer that was more than three months old. The pressure area was staged by the provider as a stage 3 and documented as caused by the resident's DME. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 1.3cm length, 0.3cm wide and 0.01cm deep. The treatment orders were cleanse and apply skin prep, then apply dressing. The dressings were to be changed daily. The wound plan of care was to discuss the need for daily dressing changes. Wound care specialist progress notes, dated 1/5/15, indicated that the resident had a penile ulcer that was more than three months old. The pressure area was staged by the provider as a stage 3 and documented as caused by the resident's DME. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 1.3cm length, 1cm wide and 0.01cm deep. The treatment orders were cleanse and apply skin prep then apply dressing. The dressings were to be changed daily. The wound plan of care was to discuss the need for daily dressing changes. Wound care specialist progress notes, dated 2/2/15, indicated that the resident had a penile ulcer that was more than three months old. The pressure area was staged by the provider as a stage 3 and documented as caused by the resident's DME. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 1.3cm length, 1cm wide and 0.01cm deep. The treatment orders were to cleanse and apply skin prep then apply dressing. The dressings were to be changed daily. The wound plan of care was to discuss the need for daily dressing changes. Wound care specialist progress notes, dated 3/2/15, indicated that the resident had a penile ulcer. The pressure area was staged by the provider as a stage 3 and documented as caused by the resident's DME. The provider indicated that he gave the wound a status of not healed. The measurements at the time of the assessment were 0.8cm length, 0.3cm wide and 0.01cm deep. The treatment orders were cleanse and apply skin prep then apply dressing. The dressings were to be changed daily. The wound plan of care was to continue the previous treatments. 4. Failure to consistently administer physician-ordered wound treatments to heal the stage 3 pressure sore Treatment Records: A review of the resident's treatment sheets, with the orders from the wound physician documented on them, indicated the following: - September 2014 with 30 days had documentation beginning on 9/8/14 (first date of wound) and ending on 9/28/14. No dressing change to penile head wound was documented on 9/29/14 and 9/30/14. - October 2014 with 31 days had 29 days of documentation. No dressing change to penile head wound was documented on 10/30/14 and 10/31/14. - November 2014 with 30 days had documentation 11/1/14 through 11/13/14. There was no documentation of a dressing change or treatment on 11/14/14, or from 11/17/14 until the end of the month. - January 2015 with 31 days had documentation on 1/6/15 and 1/7/15 only. There was no documentation that the treatment was done by the facility nursing staff for 29 of the 31 days. - February 2015 with 28 days had documentation for 28 days of treatment. - March 2015 was in progress with all documentation present from 3/1/15 until 3/9/15. 5. Observations and interviews revealed failures to provide turning and repositioning, properly utilize the resident's air mattress, and keep the catheter bag off the floor for infection control Observations: On 3/5/15 at approximately 9:30 a.m., during stage one of the survey process, the resident was observed sleeping on his back in bed. The bed was observed to have an air mattress as ordered by the medical provider. The mattress was observed to have a fitted sheet over it. The observation of the resident's bed revealed that there were no assistive repositioning devices on or attached to the bed. The resident's trash can was approximately 13 inches from the urinary catheter collection bag that was observed on the floor. The trash can was observed to have a pair of resident care gloves rolled inside out (indicating the gloves were used). On 3/6/15 at approximately 7:45 a.m., the resident was observed sleeping in bed on his back with his catheter bag on the left side of the bed. The resident was observed at 10:00 a.m. in the same position sleeping. The resident was observed in bed sleeping at 12:00 p.m. in the same position, on his back. The resident's catheter collection bag was observed in the same position as well, on the floor next to the trash can. At 12:45 p.m. the resident was observed awake and stated that he always slept all day. On 3/9/15 at approximately 11:45 a.m., the resident was observed asleep in bed. The resident was observed on his back. The resident was observed at 1:00 p.m. in the same position sleeping. On 3/11/15 from approximately 8:45 a.m. until 11:00 a.m., the resident was observed sleeping in bed on his back and in the same position. The urinary collection bag was observed in the same position, on the floor, next to the trash can, for the same amount of time. Resident Interviews On 3/5/15 at 1:15 p.m., an interview was conducted with the resident. The interview revealed the following: - The resident was under [AGE] years old and had resided in the facility for almost one and half years. The resident had been in the same room since admission. - The facility staff was short and there was not enough staff to assist him with repositioning. The staff was not available when the resident needed them. - The resident stated that he did not refuse cares and specifically catheter cares and bathing. - The resident stated that he was paraplegic and depended on staff to take care of him and notice if anything was wrong, since he could not feel anything. He further stated that the only time he knew he had a new pressure area was when the staff informed him or the wound doctor told him. - He was compliant with the dietary requirements and had actually gained weight. - He indicated that the nursing staff was good about informing him prior to cares. He stated that the nursing staff did not regularly change his dressing and provide treatment to his penis. Staff Interviews: An interview with certified nurse aide (CNA) #114 on 3/12/15 at approximately 11:05 a.m. revealed the following: - The CNA had worked at the facility for five years. - The CNA was familiar with the resident and had worked with him daily since his admission. - The resident was able to reposition himself and the CNAs did not have him identified as a resident who needed repositioning. - The resident did not resist cares such as hygiene or showers. - The CNA was responsible for emptying the resident's urinary collection bag and reporting any skin issues to the nurse. - The resident had not ever had an assistive device over his bed to help him attempt self positioning. - The resident was very particular about when he got up and he liked to sleep till after the lunch meal was usually served. He could be short tempered if he was woken up to be repositioned. - The resident stayed in bed from approximately 4:00 a.m. until 1:00 p.m. almost every day, and rarely got up before 1:00 p.m. The resident stayed in bed for approximately nine to ten hours daily. - A bed that had an air mattress on it should not have a fitted sheet over it. It should have a flat or draw sheet on it. An interview with the director of nursing (DON) on 3/12/15 at approximately 1:15 p.m. revealed the following: - The DON had worked at the facility in a number of positions for approximately five years. She had assumed the role of DON six months ago. - A resident who was paraplegic would require assistance with ADLs, transfers and repositioning. - The CNA responsibility included assisting all residents who needed assistance with repositioning. - If a resident had skin issues that were new and not under treatment, all staff were responsible for notifying a nursing staff member. - The wound clinic did the measurements and the charting for the wounds and the nurses only charted if there was an additional problem that was not under the treatment of [REDACTED]. - The DON did not know why the resident's care plans specifically related to pressure ulcers had not been updated, and the care plan was not reflective of the resident's newly acquired pressure ulcer. An interview with the resident's mental health provider on 3/9/15 at 8:30 a.m. revealed the following: - The mental health team had been working with the resident since admission. - The facility did not do anything to motivate the resident to get out of bed. He did not have the cognitive stimuli he needed. - The resident had verbalized many concerns since admission, including an increase in pressure ulcers and not knowing until staff told him, "You got another one."

Based on observations, record review, and staff interviews, the facility failed to ensure that a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion (ROM). Specifically, the facility failed to prevent the worsening of range of motion and functional abilities for one (#39) of one residents reviewed for range of motion out of 38 sample residents. -Resident #39 was not placed on a restorative nursing program after a recommendation was made by physical therapy on 5/20/14. Additionally, per staff interview, the facility did not have a formal program in place to routinely assess for or identify changes in ROM. -These failures contributed to resident #39 developing a decline in range of motion (ROM) and functional abilities. The findings include: Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 2/13/15 annual minimum data set (MDS) assessment, he required extensive assist of two persons with bed mobility, transfers, walking in his room, and walking in the corridor. He required extensive assist of one person with locomotion on and off the unit. He had no impairment in functional limitations of ROM to his upper or lower extremities identified by the facility (however, see resident observations below). The active [DIAGNOSES REDACTED]. No restorative nursing programs were identified. Care Plan The activities of daily living (ADL) care plan read that the resident required extensive assistance for completion of his ADLs. The approaches included to cue and assist as needed with ADLs, encourage participation, PT/OT as needed, provide extensive assist for completion of ADLs, bed mobility and toileting required extensive assist of two staff for completion of task and to use task segmentation as needed. -There was no information in the care plan pertaining to the care or monitoring of his contracture or limited ROM to the right upper extremity/hand. -There was no information in the care plan pertaining to a restorative nursing program (RNP). Resident Observations On 3/6/15 at 10:15 a.m., the resident was sitting in a merry walker on the unit. He was observed to stand up periodically, using his left arm and hand to pull up on the merry walker. The right arm remained at his side with the right hand in a clenched fist position. On 3/9/15 at 9:45 a.m., he was observed sitting in the merry walker. A staff member pulled him in the merry walker to the activity area. His right hand was observed in the clenched position with little use of the right arm. On 3/12/15 at 2:30 p.m., he was in the merry walker holding a large stuffed animal in his left arm. He did not use the right arm and his hand remained in the clenched position. Record Review The physical therapy (PT) evaluation and plan of treatment dated 5/20/14 read the reason for the referral was to create and place the resident on a restorative nursing program (RNP) due to shoulder [MEDICAL CONDITION] (OA). His right shoulder flexion was at 85 degrees and abduction was at 60 degrees. The clinical impression read that he was referred to an RNP to maintain his ROM and his current level of mobility. The occupational therapy (OT) evaluation and plan of treatment dated 8/12/14 read that the reason for the referral was due to an exacerbation of the resident's decrease in ROM. It revealed that his upper extremity ROM was impaired. It read, "Impaired RUE (right upper extremity) contracted" with a right elbow extension of 110 degrees and a shoulder flexion of 50 degrees. He displayed no tolerance of his right shoulder abduction or adduction. It read that he had symmetrical posture throughout and his upper extremity muscle tone was rigid and hypertonic. The OT discharge summary dated 9/23/14 read that his right shoulder flexion was up to 60 degrees which had decreased in range of motion from the PT's 5/20/14 note which measured 85 degrees. His right elbow passive range of motion (PROM) extension was 120 degrees which had shown an improvement of 110 degrees at the start of therapy. The caregiver training included techniques and positioning maneuvers in order to facilitate improved functional abilities. It was documented that his prognosis to maintain his current level of function would be good with consistent staff follow-through of provided training techniques. The resident was not discharged to a RNP. The PT evaluation and plan of treatment dated 10/2/14 revealed that his bilateral lower extremity ROM was within fair limits. He displayed right lower extremity strength of four out of five (good muscle grading). His posture was symmetrical throughout and his lower extremity muscle tone was within normal limits. There was no further mention of the RUE contracture or treatment for [REDACTED]. On 3/10/15 during the survey process, an assessment of the resident's current ROM measurements was requested. The following information was supplied by the facility by PT #7: -The PT evaluation and plan of treatment dated 3/10/15 revealed that he was referred due to a, "New onset of decreased neuro-motor control, a decrease in functional mobility, reduced ability to safely ambulate, decreased coordination, decrease in ROM and a decrease in strength indicating the need for therapy to develop and instruct in a restorative nursing program (RNP)." The RNP would increase his lower extremity ROM and strength, increase his independence with gait and improve the tone in his lower extremities. It read that his bilateral lower extremity ROM was within fair limits with tightness noted at the end range. It revealed that his right lower extremity strength was now at a three out of five (fair muscle grading). It revealed that he displayed a kyphotic posture with his head down. The impression read that he was referred to physical therapy due to a decrease in ROM to his bilateral lower extremities. It read that there was tightness on the end range of his bilateral lower extremities which could be brought about by limited mobility (gait or transfers). He continued to use the stand lift for transfers and he was able to sit to stand in the merry walker. The OT evaluation and plan of treatment dated 3/10/15 revealed that he was referred to therapy due to a: "New onset of decrease in strength, decrease in functional mobility, decrease in transfers, decrease in ROM, reduced balance, decreased postural alignment, reduced static and dynamic balance, reduced activity of daily living (ADL) participation, and pain." It read that his right upper extremity ROM was impaired. The resident was not observed using his right upper extremity spontaneously and held his right hand in a flexed position. There was noted tightness or slight tone in the right upper extremity ROM. ROM to the right shoulder was at 40 degree flexion. The OT note dated 8/12/14 measured 50 degrees flexion which was a ten degree decrease in ROM. Pain was identified to his right hand constantly at a level of four out of ten. He was noted to have a kyphotic posture and his muscle tone to his upper extremity was in a fixed position. There was redness, warmth and slight [MEDICAL CONDITION] noted to his right hand. The impression read that he was referred due to decreased right upper extremity and shoulder ROM, decreased self mobility noted while in the merry walker and increased use of stand lift for transfers thus increasing his risk for contracture, skin breakdown and increasing caregiver burden. Staff Interviews On 3/10/15 at 9:30 a.m., the certified nurse aide (CNA) #28 reported that the resident had been seen by therapy in the past, but was not on an RNP for ROM. On 3/11/15 at 12:30 p.m. the physical therapist (PT) #7 reported that the residents were screened for contractures or changes in ROM only if a referral from nursing was made. Therapy would then screen the resident and pick them up onto skilled therapy if appropriate. She reported that there was no routine system to monitor residents for changes in ROM or contractures. She reported that this resident was not on a RNP but could benefit from the program in order to maintain current ROM. On 3/12/15 at 9:06 a.m., the director of nursing (DON) reported that when nursing staff noticed a change in ROM they would notify her. She reported that she would notify the physician and obtain an order for [REDACTED]. On 3/12/15 at 9:19 a.m. the certified occupational therapy assistant (COTA) #9 reported that the resident was discharged from occupational therapy on 9/23/14 because he was at his baseline with his ROM. He offered no further explanation into the reason for the resident not being on a current RNP and did not acknowledge that the resident had a right upper extremity contracture which required treatment. He had no further explanation for the once identified right upper extremity contracture in the 8/14 OT note or if the resident should have been identified at that time with a contracture.

Based on record review, observations and interviews, the facility failed to ensure eight (#105, #31, #48, #69, #116, #10, #89 and #78) of 48 sample residents were provided the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically: -The facility failed to ensure insulin was administered to the right resident, at the right dose, per the right route to resident #105. A registered nurse was prepared to give resident #105 insulin that was ordered for resident #31. This failure created the potential for serious harm and a situation of immediate jeopardy. -The facility also failed to ensure insulin was administered and blood sugars monitored according to physician orders for residents #48, #69 and #116. -The facility failed to ensure resident #116's pain was managed. This resident, who was nonverbal, had a stage IV pressure ulcer on her coccyx. She was observed moaning, restless, and slapping her leg. Record review revealed elevated pain levels without corresponding evidence of the administration of available medication. -The facility failed to provide appropriate post-[MEDICAL TREATMENT] care and services for residents #10, #89 and #78. The findings include: I. Immediate Jeopardy A. Failure to ensure that insulin was administered per physician orders Observations and interviews revealed that the current physician's orders for insulin were not being followed for residents #105 and #31; the nurse was observed to prepare to administer resident #31's insulin to resident #105 (wrong resident, wrong route, wrong dose). This failure created a situation of immediate jeopardy for serious potential harm. B. Imposition of Immediate Jeopardy On 6/20/13 at 5:39 p.m., the facility was notified by the Health Facilities and Emergency Medical Services Division (HFEMSD) of the State Health Department that the failure to protect residents #31 and #105 from undue adverse medication consequences and failure to provide medications as prescribed created a situation of Immediate Jeopardy for serious potential harm. On 6/21/13 at 11:41 a.m., the facility presented a revised plan to HFEMSD to remove the Immediate Jeopardy situation. The plan implemented by the facility concurrently, included the following: June 21, 2013 Effective 6/20/13, (the facility) is putting the following (into) place in order to abate the Immediate Jeopardy that was called at 5:30 p.m. regarding diabetic management. IDENTIFIED NURSE - Nurse identified with negative diabetic management practices was terminated at 5:45 p.m. on 6/20/13. IN ORDER TO PROTECT RESIDENTS FROM SAME DEFICIENT PRACTICE: - Nurses currently working on the floor have been immediately inserviced regarding diabetic management. - Nurses will not work their next scheduled shift until Diabetic Management education has been provided to include: - Insulin Administration (Diabetic Management) Policy and Procedure Review has been revised to include: 2 nurses must verify the correct insulin dosing apparatus (vial vs. flex-pen) and both nurses must sign the Medication Administration Record (MAR) with the specific time of administering insulin and ensure the "8 rights of Medication Administration" are verified by both nurses per the Lippincott's Nursing Center.com: Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation, Right Reason, and Right Response. -Current nursing staff must complete Diabetic Management skills testing/return demonstrations. Skills testing/return demonstrations will be completed by the nursing staff annually and as needed, evidenced by medication errors, improper techniques and/or resident concerns. -Nursing staff will be assigned the Silverchair learning Diabetic Management module to complete by 6/28/13. -No newly hired licensed nurses will be permitted to administer medications until they have completed the Silverchair Learning module for diabetic management and return demonstrations to appropriate nursing personnel. THE FOLLOWING MONITORING/SUPPORT IS IN PLACE: - A nursing management schedule has been implemented for oversight and support for Charge Nurses 24/7 (all shifts) for the next 7 days. Nursing management will be the 2nd nurse and will be the 2nd signature in the MAR. -Be present for insulin administration. -Bring issues to the nurse administering insulin's attention and complete education/corrective actions as necessary. -Answer questions relating to diabetic management. -Diabetic Management audits will occur during insulin administration for every nurse during every shift for the next 7 days: -Audit tool created to ensure that: 1) Two nurses present for process. 2) Glucometer was cleaned prior to testing. 3) Blood glucose test is verified and within limits to administer insulin if sliding scale was utilized. 4) Blood glucose time is documented on the back of MAR. 5) Hand washing occurs and gloves were applied to hands. 6) Nurse cleans vial. 7) Nurse verifies right resident. 8) Nurse utilized right medication / apparatus. 9) Nurse obtains right dose of medication / sliding scale was utilized. 10) Nurse utilizes right route of medication. 11) Nurse administers at right time. 12) Nurse completes the right documentation (site of injection and time of injection). 13) Nurse administers for the right reason. 14) Nurse observes that the resident exhibits the right response to the medication. 15) Nurse completes the right procedure. 16) Nurse notifies MD of any abnormalities. After the 7 days of audits during insulin administration, 9 random audits per week will occur for 30 days. IMMEDIATE AUDIT TO IDENTIFY POTENTIALLY AFFECTED RESIDENTS: -Audit conducted to ensure residents receiving insulin have parameters as ordered by MD documented on the MAR and Flow Sheets and to ensure resident's Flow Sheets are in place. SYSTEMIC CHANGES: - MAR will reflect documented times for blood sugars and insulin administration and 2nd signatures. - Re-admissions/ new admissions and changes in physician orders will be reviewed during morning Clinical Meeting by DON/Designee to identify any insulin orders to ensure that our Policies and Procedures are met. - Results of Diabetic Management Audits will be reviewed. Nurses not meeting compliance/expectations will receive disciplinary action up to and including termination. C. Removal of Immediate Jeopardy On 6/21/13 at 3:15 p.m., the facility was informed that Immediate Jeopardy was removed based on the review and the facility's implementation of their plan as described above. Record review, observations and interviews revealed that the facility had reviewed all physician orders for insulin and blood glucose parameters, obtained needed clarifications from the physicians, documented the medication errors for residents' #31 and #105, notified the physicians, and conducted inservices for staff. After the removal of Immediate Jeopardy, deficient practice remained at a G level, representing actual harm that was isolated. II. Diabetic Management A. Failure to Ensure Insulin Delivery to the Right Resident, in the Right Dose, by the Right Route 1. Residents #105 and #31 a. Resident #105, age 77, was admitted to the facility on [DATE] and then re-admitted on [DATE] from the hospital. The face sheet of the same date documented admitting [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] revealed the resident had cognitive impairment as indicated with the score of his brief mental status exam (BIMS). The resident scored a 13/15. The resident was unable to recall the current month. The resident required extensive assistance with all activities of daily living (ADL) to include dressing, bathing and hygiene. And, Section N documented that the resident had received an insulin injection for the last 7/7 days in the reporting period. The care plan dated 5/16/13 included areas of care planning for falls, nutrition, wound care and activities. The resident's medical record contained no area of care planning specific for the use of insulin or the [DIAGNOSES REDACTED]. The computerized physician orders (CPO) dated June 2013, indicated the following pertinent medications for diabetic management: -[MEDICATION NAME] 10mg- daily- diabetes -[MEDICATION NAME] 100units/ML Vial, give 5 units in am SQ (subcutaneously)- diabetes. This order was specific that the insulin was from a vial that was specific to the resident. Review of the resident's medication administration record (MAR) indicated that the resident had received an insulin injection daily for the months of March, April , May and through June 20, 2013. b. Resident #31, age 72, was admitted to the facility on [DATE] from the hospital. The face sheet of the same date documented the admitting [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had cognitive impairment as indicated with the score of his brief mental status exam (BIMS). The resident scored an 11/15. The resident had difficulty with communication with unclear speech and difficulty understanding others. The resident required extensive assistance with all activities of daily living (ADL) to include dressing, bathing and hygiene. And, Section N documented that the resident had received an insulin injection for the last 7/7 days in the reporting period. The computerized physician orders (CPO) dated June 2013 indicated the following pertinent medication for diabetic management: -[MEDICATION NAME] 100units/ML Vial (flex pen) , give 10 units in am SQ- diabetes. This order was specific that the insulin was from a vial that was specific to the resident. A flex pen with an interchangeable needle with the resident's insulin was used to deliver the physician ordered amount of insulin. A review of the resident's MAR indicated the resident had received an insulin injection daily for the months of March, April, May, and through June 20, 2013. 2. Observations On 6/20/13 at approximately 9:00 a.m. the registered nurse (RN#1) was observed during morning medication pass, administering morning medications to resident #105. Another RN (RN #2) also was present to observe and monitor the morning medication pass. The observation revealed RN#1 (1) failed to identify the proper route per the resident #105's physician order for [REDACTED].#105; and (3) failed to identify the proper resident (#105) with identifiers used to verify the correct resident prior to medication administration. Specifically: -RN #1 was observed to take the insulin flex pen for resident #31 (wrong resident, wrong delivery method and wrong dosage of insulin) out of the top drawer of the medication cart and place the flex pen on top of the medication administration cart. -The nurse then obtained resident #105's blood sugar using a finger stick -The nurse then returned to the cart and documented the number for the blood sugar and then picked up the insulin flex pen that belonged to resident #31. -RN #2, observing and monitoring the medication pass did not verify the information (right resident, right delivery method, right dose) for resident #105 who was about to receive the wrong amount of insulin and in the wrong delivery method. -RN #1 was asked (by the surveyor) to re-check the physician order for [REDACTED]. RN #1 picked up the flex pen for resident #31 and checked it against the physician order for [REDACTED]." -RN #1, when questioned (by the surveyor), showed where the difference between an insulin order from a vial was documented and where an insulin order for the use of a pre filled flex pen was documented on the MAR. -RN#1 then picked up the flex pen that belonged to resident #31 and began to leave the cart and walk toward resident #105's room. RN #1 was stopped (by surveyor) from entering resident #105's room with medication intended for resident #31. 3. Interviews On 6/20/13 at approximately 9:15 a.m. RN #1 was interviewed. The nurse stated, "I guess you got me in a pretty big med error." The nurse stated she always checks the medication she is giving against the CPO to make sure that she gives the right medication through the right route. RN #1 stated she had checked the route and dosage while the surveyor and RN #2 observed. However, she then stated she would have given the insulin for resident #31 to resident #105 if the surveyor had not stopped her. The director of nursing (DON), assistant director of nursing (ADON), and regional nurse consultant (RNC) were interviewed on 6/20/13 at approximately 4:30 p.m. -The DON, ADON and RNC stated their expectation was that all facility nurses follow the 5 rights of medication administration as taught in nursing schools. These rights would include the right resident, right medication, right time, right dosage and right route. A registered nurse is trained in the 5 rights of medication administration and a facility nurse should know the difference in the delivery systems for the insulin ordered by the physician. -The DON stated a physician order is what the resident should receive, that is why the nurse should check the resident's medication at the medication cart against the CPO to verify the resident is receiving the right medication and the right dosage. Insulin can be life threatening if given in too high or low of a dosage. -The DON and ADON stated RN #1had been formally educated by the facility in the administration of insulin and had been formally written up for improper medication administration on three previous incidents that warranted employee disciplinary action addressing medication administration problems including insulin administration. -The DON said RN #2, who was observing and monitoring the med pass should have been more aware of the situation. -The DON and ADON said facility policy for insulin administration in part reads: the type of insulin, dosage requirements, strength and method of administration must be verified before administration to assure that it corresponds with the order on the medication sheet and the physician's order. -The DON, ADON and RNC stated RN #1 did not follow facility policy. The nurse would have given resident #105 insulin that was intended for resident #31 and thereby would have administered the wrong resident's insulin, via the wrong delivery system, and in the wrong dosage if the surveyor had not stopped her. B. Failure to Ensure Insulin Was Administered and Blood Sugars Monitored as Ordered 1. Resident #69, age 62, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated that the Brief Interview for Mental Status was not conducted because the resident was rarely or never understood. a. Record Review Physician Orders related to diabetes management: Review of Computerized Physician Orders for June 2013 revealed the following orders related to diabetes management: -Order date 4/25/13 - Resident readmitted from hospital; -Order date 4/25/13 - [MEDICATION NAME] HCL 1000 mg tablets - give one tablet orally twice daily; -Order date 4/25/13 - [MEDICATION NAME] 100 u/ml (long-acting) - Give 40 units sub-q once daily in the evening -Order date 4/25/13 - Accucheck twice daily - Notify MD if less than 70 or greater than 400. Review of Physician Orders of 4/25/13 upon re-admission from hospital revealed the following orders related to diabetes management: -[MEDICATION NAME] HCL 1000 mg tablets - give one tablet orally twice daily; -Insulin [MEDICATION NAME] Injection (long-acting) - Give 40 units subcutaneous once daily in evening; -Accucheck twice daily - Notify MD if less than 70 or greater than 400. Review of the Telephone Orders from 4/25/13 through 6/24/13 revealed the following telephone orders related to diabetes management: -5/12/13 - change [MEDICATION NAME] to [MEDICATION NAME] one-to-one conversion; new order [MEDICATION NAME] 40 units subcutaneous daily once daily in evening. Medication Administration Record (MAR) related to diabetes management: -Review of the 4/25/13 - 4/30/13 MAR from re-admission revealed that the 40 units of [MEDICATION NAME]in evening, [MEDICATION NAME] and accuchecks were administered according to the physician's orders upon re-admission of 4/25/13. -Review of the May 2013 MAR revealed that, in addition to the 40 units of [MEDICATION NAME]in evening, [MEDICATION NAME] and accuchecks that were administered according to the physician's orders, an additional dose of insulin was also administered. The May 2013 MAR also revealed that [MEDICATION NAME] 100 u/ml - give 10 units subcutaneous every morning was administered for 9 days, 5/3/13 through 5/11/13. There were no nurses notes related to insulin administration in the MAR. -Review of the June 2013 MAR though 6/24/13 revealed the 40 units of [MEDICATION NAME]in evening, [MEDICATION NAME] and accuchecks were administered according to the physician's orders upon re-admission of 4/25/13. Nurses' Progress Notes related to diabetes management: Review of the Nurses' Progress Notes from 4/25/13 through 6/24/13 revealed no entries related to the additional morning insulin administered 5/3/13 through 5/11/13. b. Interviews On 6/26/13 at 9:30 a.m., the Director of Nursing (DON) and Regional Nurse Consultant (RNC) stated there should have been a telephone order for the 10 units of insulin administered in the mornings of 5/3/13 through 5/11/13. They stated that this telephone order was not in the resident's current chart, and that they would have medical records provide any purged chart pages or unfiled chart pages to locate the order. They stated that the nurse should have received an order before administering the additional morning insulin 5/3/13 through 5/11/13. On 6/26/13 at 12:40 p.m., the DON stated that she was reviewing the purged chart pages and had not yet found any physician order for [REDACTED]. On 6/26/13 at 2:40 p.m., the DON and RNC stated that they were still unable to find a physician's order for the additional morning insulin 5/3/13 through 5/11/13, and that the insulin should not have been administered without an order. 2. Resident #48, age 82, was admitted [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status on MDS dated [DATE] showed a score of 0 on all questions, resulting in score of 0/15, indicating severe cognitive impairment. a. Record Review Physician Orders related to diabetes management: Review of Physician Orders of 3/18/13 upon re-admission from 6-day hospitalization revealed the following orders related to diabetes management: -[MEDICATION NAME] 100 u/ml - give 50 units subcutaneous at bedtime; order dated 3/18/13; -[MEDICATION NAME] 100 u/ml - give 6 units subcutaneous before meals; order dated 3/18/13; (The Physician Orders of 3/18/13 upon re-admission failed to reveal an order for [REDACTED]. Review of Computerized Physician Orders for April 2013 revealed the following orders related to diabetes management: -[MEDICATION NAME] 100 u/ml - give 50 units subcutaneous at bedtime; order dated 3/18/13; -[MEDICATION NAME] 100 u/ml - give 6 units subcutaneous before meals; order dated 3/18/13; -Blood Glucose (FSBS) before meals daily; call MD with FSBS less than 70 or greater than 400; order dated 3/18/13. Review of Computerized Physician Orders for June 2013 revealed the following orders related to diabetes management: -[MEDICATION NAME] 100 u/ml - give 50 units subcutaneous at bedtime; order dated 3/18/13; -[MEDICATION NAME] 100 u/ml - give 6 units subcutaneous before meals; order dated 3/18/13; -Blood Glucose (FSBS) before meals daily; call MD with FSBS less than 70 or greater than 400; order dated 3/18/13. Review of the Telephone Orders from 3/11/13 through 6/20/13 revealed the following telephone orders related to diabetes management: -4/11/13 - Order clarification FSBS twice per day - call MD with FSBS less than 70 or greater than 400. -6/11/13 - Discontinue [MEDICATION NAME] 50 units at bedtime; start [MEDICATION NAME] 50 units in morning. These Telephone Orders, since re-admission on 3/18/13, failed to reveal any order for FSBS before meals daily, or three times per day. From 3/18/13 through 4/11/13, there was no physician order for [REDACTED]. Medication Administration Record (MAR) related to diabetes management: -Review of the March 18 - 30, 2013 MAR from re-admission revealed that FSBS were administered twice per day. Insulin was administered per physician's orders. -Review of the April 2013 MAR revealed that FSBS were administered twice per day. Insulin was administered per physician's orders. -Review of the May 2013 MAR revealed that FSBS were not administered twice per day. The resident was out of the facility from 5/11/13 through 5/18/13, in the care of a family member. Of the 23 days that the resident was in the facility in May, on 4 days, the FSBS was only administered once, including 5/1/13, 5/19/13, 5/25/13 and 5/31/13. There were 3 days in which the FSBS was below 70 (see Blood Sugar Tracking Sheet below). Insulin was administered per physician's orders. -Review of the June 2013 MAR though 6/20/13 revealed that insulin was not administered per physician's orders on 6/2/13, 6/3/13 and 6/9/13. [MEDICATION NAME] 100 units at bedtime was not administered on these days; there were no nurses notes related to insulin administration in the MAR nor in the Nurses Progress notes for these days. Review of the June 2013 MAR though 6/20/13 revealed that FSBS were administered twice per day; on 6/9/13 the FSBS was 66, but there was no documentation of contacting the physician or any nursing action in the MAR or in the Nurses Progress Notes. -Review of the Blood Sugar Tracking Sheet from 5/1/13 through 6/20/13 revealed three dates in May on which the FSBS was below 70 and the MD was notified and nursing action documented. However, there was no entry for 6/6/13 FSBS of 66. Nurses' Progress Notes related to diabetes management: Review of the Nurses' Progress Notes from 3/18/13 through 6/20/13 revealed no entries related to the lack of insulin administration, as in the June MAR or the lack of FSBS twice per day in May. On 6/9/13 the FSBS was 66, but there was no documentation of contacting the physician or any nursing action in the Nurses Progress Notes. b. Interviews On 6/20/13 at 3:30 p.m., the RN on duty stated that any blood sugars below 70 would be documented on the Blood Sugar Tracking Sheet. When looking at the Blood Sugar Tracking Sheet that was in the June MAR, she stated that there were only three dates in May documented, for which the MD was notified and nursing action documented. There was no documentation for the 6/6/13 FSBS below 70 on the Tracking Sheet, nor in the Nurses Progress Notes. She stated that the MD should have been called on 6/6/13 with action taken documented on the Blood Sugar Tracking Sheet. On 6/26/13 at 9:30 a.m., the DON and RNC stated that there should have been a telephone order for the FSBS upon re-admission on 3/18/13. They stated that this telephone order was not in the resident's current chart, and that they would have medical records provide any purged chart pages or unfiled chart pages to locate the order. They stated that the nurse should have received an order before administering the FSBS. They also stated that anytime insulin is not administered per physician's orders, the nurse should clearly document reason on MAR and in Nursing Notes. On 6/26/13 at 12:40 p.m., the DON stated that she was reviewing the purged chart pages and had not yet found any physician order for [REDACTED]. On 6/26/13 at 2:40 p.m., the DON and RNC stated that they were still unable to find a physician's order for the FSBS upon readmission or for holding the insulin in May or June 2013. 3. Resident #116, [AGE] years old, was admitted to the facility on [DATE] with a [MEDICAL CONDITION] ([MEDICAL CONDITION] - right thalamic stroke with left paralysis and dysphagia), SIRS (systemic [MEDICAL CONDITION] response), non-ST elevation [MEDICAL CONDITION] infarction, hypertension, muscle weakness, and lack of coordination. admission orders [REDACTED]. The times were scheduled as UR (upon arising), MD (midday), Eve (evening), and HS (hour of sleep.) A sliding scale (SS) insulin was also ordered and was as follows: Insulin Regular subq every six hours , BS < 70 - give 25 ml orange juice (4 oz), 70 - 180 - 0 units, 181 - 200 - give 2 units, 201 - 250 - give 3 units, 251 - 300 - give 4 units, 301 - 350 - give 6 units, 351 - 400 - give 8 units, and if > 400, call the physician. Review of the 4/13 Medication Administration Record (MAR) indicated no evidence of documented blood sugars: - On 4/9 at midday and at evening, - On 4/11 at HS (hour of sleep), - On 4/13 at evening, and - On 4/17/13 at evening. The blood sugar was documented as 182 on 4/1/13 at HS and there was no evidence that 2 units of regular insulin were given as ordered per the SS. The blood sugar was documented as 183 on 4/1/13 in evening and there was no evidence that 2 units of regular insulin were given as ordered per the SS. The blood sugar was documented as 214 on 4/18/13 at HS and there was no evidence that 3 units of regular insulin were given as ordered per the SS. On 5/2/13, the order was changed to BS twice a day scheduled at UR and Evening. Review of the 5/13 MAR revealed no evidence of documented blood sugars on: - On 5/12 at UR, and - On 5/30 at UR and Eve. The blood sugar was documented as 188 on 5/18/13. There was no documented evidence that 2 units of regular insulin were given as ordered per the SS. III. Pain Management A. The facility policy on pain was requested and received on 6/20/13 from the DON. The policy read: "1. Upon admission, re-admission, quarterly, change of condition and PRN as needed residents will be assessed for pain. 2. Noted pain issues will be addressed with the resident involvement to include identifying non-pharmalogical interventions that help with pain. Also what pain level is accepted target level for the resident. 3. Care plan will be updated accordingly. 4. Physician will be notified of any changes of pain resident is experiencing or noted new issues with pain control specific to the identified resident. Resident and/or POA/family will be notified of any changes made by the physician. 5. Therapy screens will be considered to assist in the management of resident as applicable. 6. If no resolution to pain management concerns is made after IDT intervention, the medical director and/or physician will be contacted for additional input and recommendations to include but not limited to pain clinic referral, psychological services referral, orders for therapy treatment and/or new medications." B. Resident #116 - Cross-reference F 314; pressure ulcers See resident admitted and [DIAGNOSES REDACTED]. Resident #116, who was totally dependent on staff, entered the facility from the hospital on [DATE] with 'intact skin.' In less than two weeks (4/16/13), she had developed a stage II pressure ulcer which by 4/28/13, had become an "unstageable wound to coccyx." (See F314 for further details) 1. Observations -On 6/20/13 at 6:52 a.m., the resident was heard moaning as she lay on her side in her bed, facing the door. -On 6/20/13 at 12:16 p.m., the resident was facing the wall. She was restless; moaning and moving her shoulders. -On 6/25/13 at 4:52 a.m., resident was observed lying on left side, facing the wall. The resident was moaning and slapping her uncovered right leg elevated on a pillow. Another pillow was observed behind her back. The resident's eyes were open; however, the resident did not respond to verbal stimuli. -On 6/25/13 at 6:05 a.m., the resident was still heard moaning and was laying on her left side facing the wall. -On 6/25/13 at 7:28 a.m., the resident was still facing the wall. Her eyes were open and she was observed slapping her right leg. Her right leg was elevated on a pillow. A pillow was observed behind the resident's back. -On 6/25/13 at 8:44 a.m., the resident was observed still lying on left side facing wall. She was moaning and moving her shoulders as if restless. -On 6/26/13 at 5:00 a.m., resident was lying on left side partially on her back, awake and moaning, slapping her right leg and the bed. 2. Record Review The resident was care planned for an alteration in level of comfort as evidenced by pain reported on a "0 to 10 scale" with increased risks secondary to the [MEDICAL CONDITION]. -Although the facility was aware that the resident could not speak, the goals included "will voice relief from pain interventions within 1/2 hour from administration x 90 days, the resident will benefit from non pharmalogical interventions x 90 days, pain will not interfere with the daily routine x 90 days, pain will be reported at acceptable level to resident times 90 days, and the resident will be free from constipation related to narcotic [MEDICATION NAME] x 90 days. Some of the interventions listed: - Pain assessments per protocol, -Identify location and rate of pain prior to and after any interventions, -Medications as ordered, -Hospice evaluation as indicated, and -Attempt and document effectiveness of non pharmalogical interventions as appropriate (breathing, imagery, reposition, heat, ice). A hospice care plan was not in the record. The resident's pain assessment completed on 4/1/13 indicated the numerical 0 - 10 pain scale (Zero meaning no pain and 10 being the worst possible pain) would be used and indicated the resident had no pain. The 3/29/13 admission orders [REDACTED]. On 4/12/13, the physician ordered [MEDICATION NAME] 5/325 one tablet ( per G tube) every six hours as needed for pain. On 4/16/13, the [MEDICATION NAME] was increased to two tablets of 5/325 every four hours as needed for pain. On 5/1/13, the two tablets of [MEDICATION NAME] were scheduled every four hours per G tube. On 5/19/13, Hospice added [MEDICATION NAME] 20 mg/ml, to give 0.25 ml (5 mg) sublingual 30 minutes before pressure ulcer dressing change. On 6/10/13, this was increased to 0.5 ml via the PEG tube every hour as needed. The dressing change was ordered to be done daily. Review of the narcotic sign out sheet, revealed no evidence that [MEDICATION NAME] was given from 5/22/13 at 10:00 p.m. until 5/28 at 4:20 a.m. (7 days), from 5/28/13 at 2:20 p.m. until 6/2/13 at 1 p.m. (4 days), not given on 6/4, and from 6/6 at 1:30 a.m. until 6/7 (no time documented) and again until 6/10/13 at 2 p.m. (3 days.) Review of the 5/13 MAR revealed the pain level was documented as using the facial pain level: -On 5/22 as an 8 on the day shift (7 a.m. to 7 p.m.) and a 9 on the evening shift (7 p.m. to 7 a.m.), -On 5/23 as a 6 on the day shift (7 a.m. to 7 p.m.) and an 8 on the evening shift (7 p.m. to 7 a.m.), -On 5/24 as a 4 on the day shift (7 a.m. to 7 p.m.) and a 7 on the evening shift (7 p.m. to 7 a.m.), -On 5/25 as a 5 on the day shift (7 a.m. to 7 p.m.) and an 8 on the evening shift (7 p.m. to 7 a.m.), -On 5/26 as a 7 on the day shift (7 a.m. to 7 p.m.) and a 7 on the evening shift (7 p.m. to 7 a.m.), -On 5/27 as a 5 on the day shift (7 a.m. to 7 p.m.) and an 8 on the evening shift (7 p.m. to 7 a.m.), -On 5/28 as a 4 on the day shift (7 a.m. to 7 p.m.) and a 7 on the evening shift (7 p.m. to 7 a.m.), -On 5/29 as a 5 on the day shift (7 a.m. to 7 p.m.) and no documentation on the evening shift (7 p.m. to 7 a.m.), -On 5/30 as a 5 on the day shift (7 a.m. to 7 p.m.) and no documentation on the evening shift (7 p.m. to 7 a.m.), and -On 5/31, there was no documentation on the day shift (7 a.m. to 7 p.m.) and as an 8 on the evening shift (7 p.m. to 7 a.m.), Review of the 6/13 MAR, the pain level was documented as using the facial pain level: -On 6/1 as a 6 on the day shift (7 a.m. to 7 p.m.) and a 9 on the evening shift (7 p.m. to 7 a.m.), -On 6/4 as illegible on the day shift (7 a.m. to 7 p.m.) and a 8 on the evening shift (

Based on observation, staff interview and record review, the facility failed to ensure one of 48 sample residents (#116), who entered the facility without pressure sores, did not develop pressure sores. And, the facility failed to ensure that once redness and skin breakdown was identified, care and services were provided to promote healing and prevent further breakdown. Specifically: Resident #116 had a history of [REDACTED]. She entered the facility from the hospital on [DATE] with 'intact skin.' -In less than two weeks ([DATE]), she had developed a stage II pressure ulcer which by [DATE], had become an "unstageable wound to coccyx" that contributed to resident pain. -In addition, the resident had a 10% weight loss one month later and a 14.5 % weight loss two months later. The findings included: A. Definitions/Professional References Stage I identification: Identification of a pressure ulcer while the pressure sore is a Stage I or unblanchable [DIAGNOSES REDACTED] (redness) of intact unbroken skin is critical. When a resident develops a Stage I pressure sore, more vigilant assessments and nursing interventions, such as more frequent turning and repositioning, must be utilized to prevent the Stage I pressure sore from deteriorating into an open wound (Stages II, III, or IV). Residents who have developed a pressure sore are at a higher risk to develop additional pressure sores. According to the U.S. Department of Health and Human Services AHCPR Clinical Practice Guideline for treatment of [REDACTED]." The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines found at website http//www.npuap.org, provide the following definitions: Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages: Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. B. Professional Standards of Care pertaining to the Pressure Ulcers 1. Prevention and Assessment: According to the "Clinical Practice Guidelines, a Quick Reference Guide for Clinicians" for the prevention and treatment of [REDACTED].S. Department of Health and Human Services, pressure ulcers can cause the resident to experience pain and discomfort from tissue damage, wound cleaning, or dressing changes. Thorough resident assessments must be conducted to identify the residents who are at risk to develop pressure sores. All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. Preventive measures include the following: Identify the at-risk residents that need the preventive measures, ensure that the resident's nutritional and water intake is adequate to maintain the skin's tolerance to pressure, and protect the skin from damage from external pressure by utilizing frequent position changes and pressure-relieving devices; e.g., cushions or special mattresses. Pressure ulcers should be assessed for classification or stage, location, size, and condition of the pressure ulcer and surrounding tissue. According to "Clinical Practice Guidelines," "Written repositioning schedules should be developed even when patients are using a pressure-reducing support surface. These surfaces serve only as adjuncts to strategies for positioning and careful monitoring. Reposition the sitting individual so points under pressure are shifted at least every hour." According to "Pressure ulcers in Adults: Prediction and Prevention" by the U. S. Department of Health and Human Services, page 9, under "Mechanical loading and Support Surfaces, "any person at risk for developing pressure ulcers should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals." C. Resident #116 Resident #116, [AGE] years old, was admitted to the facility on [DATE] with a [MEDICAL CONDITION] ([MEDICAL CONDITION] - right thalamic stroke with left paralysis and dysphagia), SIRS (systemic [MEDICAL CONDITION] response), non-ST elevation [MEDICAL CONDITION] infarction, hypertension, muscle weakness, and lack of coordination. 1. Resident Status on Admission Hospital records dated [DATE] indicated the resident had a coccygeal decubitus ulcer. Her weight was documented as 141 pounds on [DATE]. A PEG (Percutaneous endoscopic gastrostomy) tube was placed on [DATE]. Hospital discharge instructions from the transferring hospital dated [DATE], indicated the resident's skin was intact, the resident was a NPO (nothing by mouth) status, [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) bacteremia and was on [MEDICATION NAME] for [MEDICAL CONDITION], and had a history of [REDACTED]. The admission orders [REDACTED]. The resident had occasional diarrhea. Record review conducted on [DATE] revealed the facility's admission form contained a pressure ulcer assessment. The resident was incorrectly identified as having no history of or having a pressure ulcer (see hospital record above noting previous sacral pressure ulcer). The total score was 13, indicating the resident was at high risk for pressure ulcers. Facility admission weight was documented as 138 pounds. The assessment also revealed the resident had no pain. Record review revealed no open areas on admission, but per the admission skin assessment completed on [DATE], revealed the resident had a red, raw area (but not open area) on the sacral region. The facility's admission Minimum Data Set (MDS), dated [DATE], indicated the resident did not speak, was rarely understood and rarely understands others. The resident had both long- and short-term memory impairments and was coded as being severely impaired in the cognitive skills in daily decision-making. -The resident needed extensive assistance of two staff members in all activities of daily living, except eating (dependent upon staff - tube feedings only). -The resident was admitted to the facility with a stage II pressure ulcer (see above the hospital discharge instructions, however, indicating the skin was intact), had a G (PEG) tube, was frequently incontinent of bowel and bladder, weighed 124 pounds and was 65 inches tall. The resident was care planned for memory loss due to brain damage, was unable to communicate, could not comprehend instructions, was at risk for falls, had alteration in elimination, and had alteration in mood/behavior due to [MEDICAL CONDITION] poor cognitive functioning. The resident was also care planned for self care deficit with the use of a Hoyer lift. An undated hand written statement read that the resident preferred to remain in bed. Some of the interventions listed included: -Physical therapy and occupational therapy as ordered, -Encourage participation to ability, -Set-up, cue and assist as needed, and -Tube feedings as ordered. The resident was also care planned for impaired skin integrity as evidenced by the [MEDICAL CONDITION], diarrhea, and urinary incontinence. The goal was the skin would remain intact. Some of the approaches listed included: -Pressure redistributing mattress and/or w/c (wheelchair) cushioning, -Use draw sheet for bed mobility to prevent friction and shearing, -Weekly skin checks, -Promote adequate nutrition and hygiene, -Report signs of infection, -Incontinent care as needed, -If complaints of pain during treatment, stop treatment, medicate and treat when comfortable, -RD (Registered Dietitian) Re-consult as needed, -Turn and reposition every 2 hours and as needed, -Treatment as ordered, and -Weekly wound monitoring. 2. Resident Status after Admission - Skin breakdown Per care plan: Review of the resident care plan for impaired skin integrity (see above) revealed skin breakdown shortly after admission with the following planned interventions. Specifically: -A handwritten, undated comment read, "Darken spot to sacral area." -Another handwritten comment dated [DATE], ten days after the resident's admission, was added that read, "Reddened area (illegible)." -Another handwritten comment dated [DATE], two weeks after the resident's admission, read "Stage II open area to sacral area." -Another handwritten comment dated [DATE] read "unstageable wound to coccyx." Orders: On [DATE], the physician wrote an order to "cleanse the open areas to sacral area with wound cleanser, apply skin prep around the wound, and apply [MEDICATION NAME] Plus 2 x 2.75 dressing. Apply Triad cream to buttock and lower thighs, and reddened area." The order instructed staff to clean only the soiled cream and reapply, however, not to cleanse the cream off. Skin Assessments: The [DATE] skin report indicated the sacral area was red and there was a wound dressing in place. The [DATE] skin assessment indicated the reddened areas were healing and there were no new skin issues. The [DATE] skin assessment indicated the wound was healing and on [DATE], documentation indicated there were no new skin issues. (There were no further skin assessments found for review.) Per Pressure Ulcer Wound Log: The pressure ulcer wound log received from the Director of Nursing (DON) on [DATE] at 10:28 a.m., revealed the wound's measurements as follows: -On [DATE] there were two identified areas, one on the right and one on the left sacral area. The right area measured 0.3 x 0.2 x UTD (undetermined depth). The left area measured 0.2 x 0.1 x UTD. -On [DATE] the right area measured 0.4 x 0.2 x <0.1. The left area measured 0.3 x 0.2 x <0. -On [DATE] the wounds evolved into one wound measuring 4.0 x 4.7 x UDT. -On [DATE] the wound treatment ordered was to "Cleanse wound with wound cleanser, apply Santyl to eschar/sluff and cover with foam dressing." There was no evidence that the wound was measured again until two weeks later on [DATE], when the wound measured 4.0 x 4.4 x UTD and wound had exudates and an odor. -On [DATE], the measurements were documented as 4.2 x 4.1 x 1.0 cm. The resident was seen by a wound specialist on [DATE]. The wound measurements per the wound clinic were documented as "Stage 4 - 4.2 x 4.7 x 1.0 with undermining." -On [DATE], the wound measured 4.1 x 4.4 x 1.0 cm. -On [DATE], the wound measurements were documented as 4.0 x 4.3 x 1.0 with 50% slough and 50% granulation tissue. -On [DATE], the wound measurements were documented as 3.4 x 4.0 x 0.8 with 25% slough and 75% granulation tissue. -On [DATE], the wound measurements completed by wound specialist revealed the wound as "3.0 x 3.7 x 0.6 with undermining of 1.5 at 6 o'clock. Stage 4." 3. Facility Failures a. Monitoring Failure See above; lack of documentation after [DATE] until [DATE] as the wound worsened. b. Nutritional Failures The NPUAP (National Pressure Ulcer Advisory Panel) and EPUAP (European Pressure Ulcer Advisory Panel) have published the following nutrition guidelines for the treatment of [REDACTED]. The complete report can be access at:<http://www.npuap.org/Final_Quick_Treatment_for_web_2010.pdf> Nutrition Recommendations for treatment of [REDACTED]. Screen and assess nutritional status for each individual with a pressure ulcer at admission and with each condition change - and/or when progress toward pressure ulcer closure is not observed. 1.1. Refer all individuals with a pressure ulcer to the dietitian for early assessment of and intervention for nutritional problems. 1.2. Assess weight status for each individual to determine weight history and significant weight loss from usual body weight (> 5% change in 30 days or > 10% in 180 days). . . .1.4. Assess the adequacy of total nutrient intake (food, fluid, oral supplements, enteral/[MEDICATION NAME] feedings). 2. Provide sufficient calories. 2.1. Provide ,[DATE] kcalories/kg body weight for individuals under stress with a pressure ulcer. Adjust formula based on weight loss, weight gain, or level of obesity. Individuals who are underweight or who have had significant unintentional weight loss may need additional kcalories to cease weight loss and/or regain lost weight. 2.2. Revise and modify (liberalize) dietary restrictions when limitations result in decreased food and fluid intake. These adjustments are to be managed by a dietitian or medical professional. . . .3. Provide adequate protein for positive nitrogen balance for an individual with a pressure ulcer. 3.1. Offer 1.25 to 1.5 grams protein/kg body weight daily for an individual with a pressure ulcer when compatible with goals of care, and reassess as condition changes. 3.2. Assess renal function to ensure that high levels of protein are appropriate for the individual. 4. Provide and encourage adequate daily fluid intake for hydration. . . .5. Provide adequate vitamins and minerals. . . . 5.2. Offer vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected." The admission orders [REDACTED]. In addition, Acidophilus one tablet twice a day was ordered per G tube. Daily weights were also ordered. [MEDICATION NAME] HN is a nutritionally complete, high-calorie liquid food designed to meet the increased protein and calorie needs of stressed patients and patients who required low volume feedings. The Registered Dietitian (RD) completed the nutritional evaluation on [DATE], when the resident was first admitted using the current documented weight of 140 pounds (63 kg) and when the resident's "skin condition was intact." The resident's calculated calorie needs were estimated at 1900 a day (using 30 Kcal/kg), her protein needs were estimated as 75 gm/day (based on 1.2 gm/kg) and her fluid needs were estimated as 1900 ml/day (based on 30 ml/kg). The [MEDICATION NAME] HN would supply 840 ml, 1680 kcal and 70 gm per day. The [MEDICATION NAME] HN supplied 2 calories per ml. The fluid flush of 60 ml before and after each [MEDICATION NAME] would supply 1280 ml plus free water of 579 and with medication pass, fluid total would be 1859 ml per day. However, due to diarrhea, the tube feeding was decreased to 1 can 2CAL HN 240 ml four times a day (960 ml/day) with water flushes on [DATE]. On [DATE], the RD recommended 1 can 2CAL HN 240 ml every six hours or 960 ml per day. On [DATE], the RD questioned the documented admission weight of 140 and calculated the resident's daily needs based on the resident's current weight of 124 pounds or 56 kg. She also increased the daily protein need to 79.6 gm/day ("related to pressure ulcer.") The RD then recommended Liquid protein 30 ml daily and Floraster 30 ml bid (twice a day) per the Peg tube for added protein and for wound healing. The Acidophilus was discontinued. Floraster is a [MEDICATION NAME] supplement that helps keep intestines functioning well. Review of the ,[DATE] MAR (Medication Administration Record) revealed documentation that despite Floraster being ordered twice a day and scheduled to be given upon arising and in the evening for wound healing, Floraster was not given on ,[DATE], was only given daily on ,[DATE] through ,[DATE], and then was given as ordered on ,[DATE]-,[DATE]. There was no evidence that Floraster was given as ordered in June. On [DATE], the tube feeding was changed to 2CAL HN at 52 ml per hour times 20 hours continuous or 1040 cc/day. On [DATE] the resident was admitted to Hospice and the tube feeding was changed to [MEDICATION NAME] 1.5 (calories 1.5 ca/ml) at 57 cc/hr times 20 hours with fluid flush at 55 cc/hr times 20 hours. According to documentation on the MAR, the tube feeding was to start at 10:00 a.m. and stop 20 hours later at 6:00 a.m. Despite this order change, the ,[DATE] CPO incorrectly indicated the [DEVICE] feeding was "2 Cal HN 210 cc can [MEDICATION NAME] qid" (four times a day) with 160 cc of water flush before and after each feeding. In a phone interview with the RD on [DATE] at approximately 2:30 p.m., she explained that the water and the feeding were infused at the same time. She added that in 20 hours the resident should receive 1140 cc of [MEDICATION NAME] (and 1710 calories). She also stated that she had found out the staff were stopping the feedings to complete activities of daily living. The ADON (Assistant Director of Nursing) per phone interview on [DATE] at 7:00 a.m., stated the facility uses one liter (1000 cc/ml) feeding bags. The ADON stated the staff would add another bag, when asked about the resident receiving 1140cc in the 20 hours and the bag holding only 1000 cc. The resident's pre-[MEDICATION NAME] (a distinct marker for protein synthesis) on [DATE] was low at 14.2 (reference range 17XXX,[DATE].0) per the RD notes. On [DATE], the pre-[MEDICATION NAME] had decreased to 12.7. On [DATE], the pre-[MEDICATION NAME] had increased to 17.8. The resident's admission weight was documented as 138 pounds. Per the RD notes, the resident's weight was 124 on ,[DATE] (10% weight loss one month later) and 118 on [DATE] (14.5 weight loss two months later). On [DATE], the RD questioned the admission weight and recommended Liquid protein 30 ml daily and Floraster 30 ml bid (twice a day) per the Peg tube. (See above; inconsistent, infrequent administration of Floraster.) In an interview with the Director of Nursing (DON) on [DATE] at approximately 7 a.m., she stated she would call the physician and clarify the daily weights and the issue with the Floraster. The DON also stated that the Floraster was a capsule that clogged up the feeding tube and they (facility staff) had discussed whether this was worth it for the resident. In a second interview with DON at 9:12 a.m. on [DATE], the DON stated she had called the physician and clarified that daily weights should not have been ordered and that Floraster should have been discontinued as of [DATE], since it was discussed with the physician then about clogging the tube feeding tube. However, there was no evidence of documentation of a discontinue order for daily weights and Floraster before [DATE], when the DON was asked why these orders were not being implemented. c. Care Failures (tube feeding, positioning, pain) Although the resident was care planned to have staff change her position at least every two hours, and expectations (see above) were for at least hourly position changes, observations revealed the resident's position was not consistently changed as expected. On [DATE] at 9:53 a.m., the resident was lying in bed on her left side facing the wall. -At 10:30 a.m., the resident was in the same position. -At 11:49 a.m., the resident was lying in bed facing the wall. On [DATE], the resident at 10:29 a.m. was in bed facing wall with a pillow behind her back. The tube feeding was off. The bottle was labeled [MEDICATION NAME] 1.5 and there was 200 cc left in bottle. (Only 800 cc were given instead of the 1140 cc ordered.) A water flush bottle was piggybacked into the pump system. -At 11:08 a.m., the resident was facing wall. -At 11:31 a.m., the resident was turned on her right side - facing door. -At 12:37 p.m., the resident was in bed, facing door. -At 1:35 p.m., the resident was on her left side and turned toward wall. -At 3:13 p.m., the resident was now facing the wall with a pillow behind her back and her eyes were closed. There was 850 ml left in tube feeding bag. If the feeding had begun at 10 a.m. as scheduled (see above), there should be (5 hours times 57 cc/hr or = 285 cc infused or only 715 cc left in the bag). On [DATE] at 6:52 a.m., the resident was heard moaning. The tube feeding pump read that 1091 ml (instead of the ordered 1140 cc or 57 cc per hour times 20 hr) had been given. The resident's tongue was protruding out and was dry. The resident was facing the door, her right leg was elevated on a pillow. -At 8 a.m., the resident was facing door in the same position as above. -At 10:19 a.m., the resident was turned toward wall. -At 12:16 p.m., the resident was facing the wall. She was restless; moaning and moving her shoulders. -At 12:41 p.m., the resident was observed still facing wall. -At 2:20 p.m., the resident was observed still facing the wall. -At 4:34 p.m., the resident was observed still facing wall. A pillow was behind her back, however, the resident was almost laying on her back and left side. The resident was in the same position (on her left side) over 6 hours. On [DATE] at approximately 10:26 p.m., the resident was observed lying on her left side facing the wall. The Registered Nurse (RN) was observed while she did the daily dressing change. She stated the resident had had a bath and had been given pain medication approximately an hour earlier. -The resident was observed lying on a draw sheet and was moaning and groaning. The nurse explained the procedure to the resident and did the dressing change as ordered. -The wound was clean with a yellow wound bed. The skin around the wound was red beefy in color. The wound edges appeared to have healing edges. The Stage 4 wound was not measured at this time but appeared to be approximately 3.0 cm x 3.5 cm x 0.5 cm with undermining. On [DATE] at 4:52 a.m., resident was observed lying on left side, facing the wall. The tube feeding was on at 57/ml/hour with the water piggybacked. The bottle label read started at 11:30 a.m. despite a schedule to start at 10:00 a.m., an hour and a half earlier. The resident was now lying on a bolster/scoop mattress. The resident was moaning and slapping her uncovered right leg elevated on a pillow. Another pillow was observed behind her back. The resident's eyes were open; however, the resident did not respond to verbal stimuli. -At 6:05 a.m., the resident was still heard moaning and was laying on her left side facing the wall. The tube feeding was on and there was less than 200 cc left (800 cc infused) in the container (18 and ,[DATE] hours times 57 cc/hr =1054 cc.). The resident was ordered to get 1140 cc in 20 hours. The resident's right leg was on a pillow. -At 7:28 a.m., the resident was still facing the wall. Her eyes were open and she was observed slapping her right leg. The tube feeding was off. Her right leg was elevated on a pillow. A pillow was observed behind the resident's back. -At 8:44 a.m., the resident was observed still lying on left side facing wall. She was moaning and moving her shoulders as if restless. -At 9:24 a.m., a hospice certified nurse aide (CNA) was observed in the room and stated she was to provide care to resident. The resident was observed facing the wall at this time. -At 10:28 a.m., the DON was informed of the above observations of the resident in the same position for over five hours. The DON commented that the resident begins grimacing when turned on her other side. "She can't lie on that side." She went on to say that she would check with her staff because they usually turn and change her when they begin their shift. The DON stated the resident came to them with recently healed pressure ulcers. She stated that these were reddened areas and then dark spots were noted. The DON went on to say that these spots turned into an ulcer. -At approximately 11:00 a.m., the DON and CNA were interviewed. The DON provided the CNA's electronic documentation that the resident's position had been changed two times that morning since the beginning of the CNA's shift at 6 a.m. The CNA did not comment. -At 11:19 a.m., the resident was turned toward the doorway. There was no pillow observed to the resident's back. The tube feeding pump was on. The label on the bottle read that it had started at 10:00 a.m. (as ordered.) The resident's eyes were closed and no moaning was heard. On [DATE] at 5:00 a.m., resident was lying on left side partially on her back, awake and moaning, slapping her right leg and the bed. The pump read the feeding was on and running at 57 cc/per hour. At 6:19 a.m., there was approximately 150 cc left in [MEDICATION NAME] bottle. (Only 850 cc infused instead of the ordered 1140 cc in 20 hours - 10 a.m. to 6 a.m.) The resident was observed moaning and groaning and slapping her right leg and the bed. d. Pain Interventions See above observations of the resident moaning, restless, and slapping her leg while in bed on ,[DATE], ,[DATE], and [DATE]. The resident was care planned for an alteration in level of comfort as evidenced by pain reported on a of "0 to 10 scale" with increased risks secondary to the [MEDICAL CONDITION]. -Although the facility was aware that the resident could not speak, the goals included "will voice relief from pain interventions within ,[DATE] hour from administration x 90 days, the resident will benefit from non pharmalogical interventions x 90 days, pain will not interfere with the daily routine x 90 days, pain will be reported at acceptable level to resident times 90 days, and the resident will be free from constipation related to narcotic [MEDICATION NAME] x 90 days. Some of the interventions listed: -Pain assessments per protocol, -Identify location and rate of pain prior to and after any interventions, -Medications as ordered, -Hospice evaluation as indicated, and -Attempt and document effectiveness of non pharmalogical interventions as appropriate (breathing, imagery, reposition, heat, ice). There was no Hospice care plan in the medical record. The resident's pain assessment completed on [DATE] indicated the numerical ,[DATE] pain scale (Zero meaning no pain and 10 being the worst possible pain) would be used and indicated the resident had no pain. The [DATE] admission orders [REDACTED]. On [DATE], the physician ordered [MEDICATION NAME] ,[DATE] one tablet (per G tube) every six hours as needed for pain. On [DATE], the [MEDICATION NAME] was increased to two tablets of ,[DATE] every four hours as needed for pain. On [DATE], the two tablets of [MEDICATION NAME] were scheduled every four hours per G tube. On [DATE], Hospice added [MEDICATION NAME] 20 mg/ml, to give 0.25 ml (5 mg) sublingual 30 minutes before pressure ulcer dressing change. On [DATE] this was increased to 0.5 ml via the PEG tube every hour as needed. The dressing change was ordered to be done daily. Review of the narcotic sign out sheet, revealed no evidence that [MEDICATION NAME] was given from [DATE] at 10:00 p.m. until ,[DATE] at 4:20 a.m. (7 days), from [DATE] at 2:20 p.m. until [DATE] at 1 p.m. (4 days), not given on ,[DATE], and from ,[DATE] at 1:30 a.m. until ,[DATE] (no time documented) and again until [DATE] at 2 p.m. (3 days.) Review of the ,[DATE] MAR indicated [REDACTED] -On ,[DATE] as an 8 on the day shift (7 a.m. to 7 p.m.) and a 9 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 6 on the day shift (7 a.m. to 7 p.m.) and an 8 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 4 on the day shift (7 a.m. to 7 p.m.) and a 7 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 5 on the day shift (7 a.m. to 7 p.m.) and an 8 on the evening shift (7 p.m. to 7 a.m.),On ,[DATE] as a 6 on the day shift (7 a.m. to 7 p.m.) and a 9 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 7 on the day shift (7 a.m. to 7 p.m.) and a 7 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 5 on the day shift (7 a.m. to 7 p.m.) and an 8 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 4 on the day shift (7 a.m. to 7 p.m.) and a 7 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 5 on the day shift (7 a.m. to 7 p.m.) and no documentation on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 5 on the day shift (7 a.m. to 7 p.m.) and no documentation on the evening shift (7 p.m. to 7 a.m.), and -On ,[DATE], there was no documentation on the day shift (7 a.m. to 7 p.m.) and as an 8 on the evening shift (7 p.m. to 7 a.m.) Review of the ,[DATE] MAR, the pain level was documented as using the facial pain level: -On ,[DATE] as a 6 on the day shift (7 a.m. to 7 p.m.) and a 9 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as illegible on the day shift (7 a.m. to 7 p.m.) and a 8 on the evening shift (7 p.m. to 7 a.m.), -On ,[DATE] as a 5 on the day shift (7 a.m. to 7 p.m.) and a 5 on the evening shift (7 p.m. to 7 a.m.), and -On ,[DATE] as a 5 on the day shift (7 a.m. to 7 p.m.) and a 5 on the evening shift (7 p.m. to 7 a.m.) On [DATE] at 1:47 p.m., the director of nursing (DON) was interviewed. She said the facility had determined that the resident's behaviors, treated since admission with [MEDICATION NAME], were due to pain, and the physician had discontinued the resident's [MEDICATION NAME] [DATE]. 4. Summary In summary, the resident was admitted to the facility with her skin intact but at risk for breakdown. She was dependent on staff for nutrition, care and treatment and after admission developed a stage IV pressure sore that contributed to resident pain. Per observations, the resident was not turned and repositioned as care planned or expected, had weight loss on the tube feeding, and did not consistently receive her ordered pain medications before daily dressing changes and when she expressed pain at elevated levels per facility assessments.

Based on observations, record review and interviews, the facility failed to provide residents the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with their comprehensive assessment and plan of care for one (#5) of five sample residents. Specifically: -The facility failed to accurately conduct neurological checks per policy for resident #5 after a fall. -The facility failed to adequately assess the resident for a change in condition following a fall and the resident subsequently expired approximately 12 hours later. The Findings include: The department of public health received an occurrence report filed by the facility on [DATE] of a death that occurred on [DATE]. In addition; a concern was received by the health department on [DATE], alleging the facility failed to adequately assess the resident per policy and acceptable clinical nursing standards after an unwitnessed fall with injuries. Facility policy for neurological assessment: Review of the facility's neurological (Neuro) policy read in pertinent part, "Purpose: to assure resident safety due to suspected head injury. . . assess level of consciousness, assess pupils noting reactivity, size and accommodation, assess hand grips for strength and compare right and left side for same/equal grip, assess mobility note changes from right and left side, assess for any subjective and objective signs/symptoms of pain, and assess vital signs. Neuro checks are to be completed at these intervals: -every 15 minutes times four; -every 30 minutes times four; -every 1 hour times two; -every 4 hours times two; -then, every shift to complete 72 hour assessment." Resident: Sample resident #5, [AGE] years old, was admitted to the facility on [DATE] and discharged (expired) on [DATE]. According to the ,[DATE] CPO, the resident had [DIAGNOSES REDACTED]. The significant change of condition minimum data set (MDS) assessment, dated [DATE], assessed the resident with moderate cognitive deficits scoring a 7 out of 15 on the BIMS (brief interview of mental status), needed the assistance of two or more staff persons for most activities of daily living, including transfers, required set up and oversight with eating, had poor balance during transfers and walking. The assessment also included the resident's height at 72 inches tall and weight at 236 pounds. The resident was also assessed as non-ambulatory and mobile per wheelchair, with a history of falls prior to admission and was coded as not having any falls since admission. However, record review revealed the resident had a fall on [DATE]. Review of a MDS discharge assessment, dated [DATE], documented the resident to be totally dependent of two or more staff persons for bed mobility and transfers. Review of closed record: Review of a pre-generated fall care plan with no date found when initiated, but with the last review date of [DATE], revealed the following: Problem - Potential for falls and/or injuries related to (there were no related problems documented here). Goal - Resident will remain free of falls and/or injuries thru review period. Approaches - Gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future recurrence, ensure that floors are even and free from spills or clutter ...PT to evaluate and treat as ordered or PRN, provide activities that minimize the potential for falls, ensure the resident is wearing appropriate footwear. The care plan was not updated to reflect the resident status per the fall documented on [DATE]. The most current comprehensive nursing assessment, dated [DATE], documented the resident was ambulatory per self and required occasional assistance with transfers. The resident's fall risk score was 9 which indicated a moderate risk for falls. A daily skilled nurse's note, dated [DATE] (no time when note was written), read, "Resident on incident. CNA in room with res. assisting resident to bed, res (resident) with weakness fell to knees in front of bed, assessed by this nurse, assisted to bed ... " A written incident investigation, dated [DATE] (date does not match above) at 7:30 p.m., read in pertinent part, "Immediate actions taken as follows: assessment, assisted to bed, VS (vital signs), neuro's . . . CNA assisting resident in room to transfer to bed, resident with weakness and fell to knees in front of bed." There was no evidence of a neuro assessment completed as documented in the nurse's note above. Further record review revealed a nurse's note, dated [DATE] at 1:45 p.m. The note read, "Resident has just been readmitted to the facility from an acute care hospital." Incomplete documentation after a fall on [DATE]: In reference to the concern received by the Health Department (above), review of the resident's closed clinical record revealed, a neurological assessment flow sheet (related to a fall) on [DATE] at 4:30 p.m. Review of the Neuro flow sheet revealed the facility policy was not being followed. The Neuro checks were as follows: 4:30 p.m., 4:45 p.m., 5:00 p.m., 5:15 p.m., 6:15 p.m., 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:00 p.m., 8:30 p.m., 9:00 p.m., 9:30 p.m., 10:00 p.m., 10:30 p.m., 12:30 a.m., 2:30 a.m., 4:20 a.m. (documentation revealed resident expired at 4:50 p.m. per nurse's note below). The assessment sheet had a section to document "Hand Grasp," this section was blank throughout the Neuro assessment period. The neurological assessment was inaccurate and incomplete and therefore; did not follow the facility policy. A daily skilled nurse's note, dated [DATE] (no time documented), during the night shift read in pertinent part, "Pt in bed resting quietly with even, non labored resp (respirations). Pt talks in his sleep and cooperative ... (illegible words), PICC line patent, Neuro checks, VS (vitals signs) remain stable. All Neuro's done and recorded . . . 4:50 a.m., CNA went in to do a.m. vitals and pt had passed away. Foley catheter, PICC line remains intact. Family called, physician called for (illegible word). Post mortem care done." The front of the daily skilled nurse assessment for night shift, dated [DATE], read in pertinent part, "Resident had shallow respirations." The neuro assessment flow sheet revealed the resident's last recorded vitals were recorded at 4:20 a.m. The vitals read, "Blood pressure ,[DATE], temperature 98.2, pulse 68, respirations 14." Just 15 minutes prior to the resident being found unresponsive. The written incident investigation of the above fall, dated [DATE] at 4:15 p.m., read in pertinent part, "Describe injury: skin tear to left outer distal forearm ...activity: attempting to transfer self. Incident level: minor. Immediate actions taken: Cleansed site with NS (normal saline) applied ST (skin tear). Narrative of incident: resident stated that he was attempting to transfer self from w/c (wheelchair) to bed. Witnessed by: (name of CNA) found resident on the floor; unwitnessed. Narrative of incident: resident was found by the CNA in his room on the floor, laying against the bed. CNA called the nurse. The nurse assessed resident. Resident alert awake, aware; moves all extremities without difficulty, pupils react to light accommodate and round. On palpation no c/o (complaint of) pain or discomfort noted. Assisted resident to bed x 2 person. MD notified. Family notified. Resident's mental status prior to fall alert and confused. An interdisciplinary progress note, dated [DATE] at 10:00 a.m. by the prior director of nursing, read, "Received call from coroner office requesting information. Information given." A subsequent note at 11:55 a.m. read, "(name of RN) stated coroner's office had called requesting copies of face sheet, 48 hour nurses notes, Neuro checks . . . Called coroner's office requesting written request for information be faxed to facility. Stated she was coming over and would bring written request with her." Another entry at 1:30 p.m. read, "Coroners office in info given. Will remove body at this time. Family at bedside." Autopsy Report: The (name of county) coroner's report of death, dated [DATE], following the resident's fall, documented the cause of death as, "Rib fractures and hemothorax (accumulation of blood in the pleural cavity; the space between the lungs and the walls of the chest) due to [MEDICATION NAME] trauma to the chest." The manner of death documented as: "Accident". Occurrence report: Moreover, the occurrence report, received 14 days after the incident, documented the resident had no injuries; however, during the abbreviated survey it was found through closed record review and interviews the resident presented with a bump on the forehead, skin tear to the left distal forearm and was visibly rubbing his chest and stating that his heart hurt. Interviews: On [DATE] at 7:30 p.m., a family member was interviewed per phone. The family member stated she and another family member arrived to the facility at approximately 5:,[DATE]:45 p.m. after receiving a call, that the resident had fallen. The family member stated, "We were there for approximately three hours, maybe until around 9:00 p.m. During the time we were visiting he did not seem his usual self and was lethargic." She also stated, "I noticed there was a knot on his forehead and he kept rubbing his chest the whole time." The family member went on to say, "We only saw the male certified nursing assistant (CNA) come in to the room one time to check vital signs. We never saw a nurse enter the room the entire time we were there." During an interview on [DATE] at 9:40 a.m., the interim director of nursing (IDON) stated, "If a resident had a change of condition the nurse was expected to do a head to toe assessment, complete an incident report if warranted and do 72 hour charting." She also stated, "The nurse needs to document thoroughly in the clinical record in the nurses notes." During an interview on [DATE] at 2:00 p.m., the assistant director of nursing (ADON) was asked for the facility assessment policy. The ADON responded, "We do not have one. What we have is in the admission packet, which includes a variety of assessments." She went on to say, "A comprehensive assessment was done upon admission, if the resident goes to the hospital for more than 24 hours or if a resident has a fall." On [DATE] at 2:41 p.m., an evening CNA familiar with caring for the resident was interviewed. The CNA stated during one of his rounds he went by the resident's room and saw that he was on the floor flat on his stomach with his head on the ground. The CNA stated he called out for assistance and another CNA came to help. The CNA then went to get the nurse on duty to come and assess the resident before moving him. The CNA stated the resident had a bump on his forehead but couldn't remember what side and that the resident was bleeding from his arm somewhere. The CNA stated the resident had been in his wheelchair with an overbed table in front of him before the fall occurred. The CNA stated after the nurse checked the resident he and another CNA picked the resident off the floor and placed him back in bed. The CNA stated that he lifted the resident's legs while the other CNA lifted the resident from under the arms and around the chest. The CNA stated they had placed a gait belt around the resident's rib area first, before lifting him. The CNA stated they put an ice pack on the resident's forehead and began taking vital signs every ten minutes as instructed by the nurse. The CNA stated the resident complained of being dizzy and kept rubbing his chest and saying that his heart hurt. The CNA stated he mentioned this to the nurse and she came and checked the resident and said he was ok. The CNA stated that he himself had massaged the resident's chest gently to help comfort him. The CNA stated he saw the day nurse go in and check the resident two or three times. The CNA stated the family was present the majority of the time but wasn't sure when they left. The CNA stated he remembers he kept asking the nurse if the resident was ok and she had told him he was all right. On [DATE] at 3:19 p.m., a second CNA, who assisted with the resident above, was interviewed. The second CNA stated when he came to the resident's room to do routine vital signs he saw the resident on the floor and then told his assigned CNA to go call the nurse. The second CNA stated he saw blood on the resident's forehead. The second CNA stated he was the first person to see the resident on the floor and after the assigned CNA went to get the day nurse; she came in and examined the resident by squeezing his hands and asking him if he was ok. The nurse then asked us to do the vitals. The CNA stated when he first saw the resident he was on his front, left side with his head on the floor toward the foot of the bed. The second CNA stated he and the assigned CNA lifted the resident off the floor from under his arm on each side and standing him up to place him in bed. The second CNA stated they did not use a gait belt on the resident. The second CNA stated he took the resident's vitals until 8:00 p.m. then the nurse took over. The second CNA stated the family came in after the resident's fall and that they came to see the resident almost every day. On [DATE] at 8:00 a.m., the day registered nurse (RN) assigned to the resident's care on [DATE] was interviewed. The RN stated after a resident falls, the protocol was to start Neuro checks immediately. The RN stated with Neuro checks she checks movement of extremities, level of consciousness, pain and checks to see if the resident was lethargic. The RN stated she was familiar with the resident and knew him very well. She stated the resident was in "bad shape" health wise and had a lot of complications. She verified the resident fell on her shift and she checked on him often (after the fall) but did not remember how often. She stated the resident did not complain of any pain or shortness of breath. The RN stated two CNA's found him and that one stayed with the resident while the other came to get her. The RN stated when she entered the room she thought he was laying on his left side and had a bump on the left side of his head as far as she could remember. The RN stated she asked the resident if he could move his hands and arms and he was fine. She then asked the resident how he fell and he stated he didn't know what happened he just fell . The two CNA's then put the resident back in his wheelchair. The RN stated they used a gait belt to get him off the floor and one transferred him while the other held the gait belt. The RN stated she then started vital signs every 15 minutes, then 30 minutes. She stated the aides did the vitals and she did the Neuro checks. The RN stated she just documented on the Neuro check form but not in the nurses notes. The RN stated during the interview she could not remember if the resident had a bump on the head or not (after she indicated he did above) she did not document about the bump. The RN kept stating she could not remember exactly the events that occurred as it happened awhile ago. The RN stated she had called the family after the resident fell but did not remember seeing them in the resident's room. On [DATE] at 8:43 a.m., the night RN assigned to care for the resident on [DATE] was interviewed. The RN stated if a resident falls and they hit their head Neuro checks are automatically done. The doctor and guardian are notified. The RN stated a complete assessment was then done along with monitoring vital signs. The RN stated the resident did not show any change in level of consciousness after the fall. The RN stated the resident was in bed when she started her shift. She stated she checked on him around 8:30 p.m. and that he was resting and answered questions appropriately. She stated the resident did not complain of any pain or shortness of breath. She stated she did not give him anything for pain. The RN stated during the night the resident was his normal self and that he slept during the night. She stated she thought he had a bump on his head but could not remember. The RN stated she continued to do Neuro checks throughout the night and they were all normal. She stated she went in to check on him and do his next set of Neuro's and he had just passed away quietly. The RN stated it shocked her to death when she found him dead because he was fine. The RN stated she would have noticed if he was getting worse during the night. The RN stated she did not see the family with the resident when she started her shift but had heard they had visited earlier. On [DATE] at 3:00 p.m., the nursing home administrator (NHA) was interviewed regarding the resident fall, injury and the delay in reporting the incident (fall) as an occurrence. The NHA stated he did not remember having a conversation with nursing staff or physicians at the time as to whether the incident was reportable or not. The NHA stated he could not, at the time, correlate the fall with the resident's death and had remembered hearing that another resident had fallen. The NHA was informed that review of the resident's closed record and interviews with staff did not match what was reported on the occurrence report. Specifically, the occurrence reported the resident was assessed by the nurse on duty and there were no injuries, was alert and had no complaints of pain. The NHA stated there was a lot of staff turnover and unrest occurring in the facility at that time but that resident care should not suffer for reasons of staff turnover. The seriousness of the resident's injuries was disclosed to the NHA at this time. The NHA was not aware of the seriousness of the resident's fall resulting in death. In a second interview with the NHA during the exit interview at 4:45 p.m., the NHA stated, "The reporting of the occurrence was late and the documentation just wasn't there." In conclusion, the only documentation the resident had sustained a fall during the time period alleged, was the presence of the Neuro flow sheet in the clinical record as well as the incident investigation provided by the facility when requested during the abbreviated survey. The resident's medical record and interviews with staff did not support each other. There was no further nursing documentation found for the day or night shift for the date above regarding the residents physical condition post fall. There was no completed nursing or pain assessment. Moreover, review of the Neuro flow sheet documented inconsistent Neuro assessment times.

Based on observations, record review and staff interviews, the facility failed to ensure adequate supervision to prevent accidents was provided for residents including three (#4, #6, #17) of 20 sample residents. Specifically, the facility failed to: -ensure resident #6 was transferred in a safe manner resulting in the resident sustaining a broken arm; -ensure safety devices (tab alarms) were in place as ordered for residents #4 and #17; -ensure resident #6 had her call light accessible; -ensure water temperatures were within the appropriate range to prevent burns; -ensure medication was secured and stored appropriately; -ensure plastic trash bags were safely stored to prevent them from being accessible to residents residing on the secure unit. The findings include: 1. Failure to provide safe transfers Sample resident #6, [AGE] years old, was originally admitted to the facility on [DATE] and re-admitted on [DATE] after an acute hospitalization . According to the 9/10 computerized physician's orders [REDACTED]. According to the most recent minimum data set (MDS), dated [DATE], the resident had both short and long-term memory loss and was moderately impaired with daily decision-making. The resident was dependent of staff for all activities of daily living requiring assistance of two staff persons for transfers. The resident required a mechanical lift for transfers and was coded as being a high fall risk. -Record review Review of the most recent fall assessment, dated 8/12/10, documented the resident as having severe impairment in the following nine areas: cognition, general health, mobility, transfer ability, weight bearing status, appliance use, vision, incontinence and medications. The resident had a fall risk score of 18, and a score of 15 or more indicated the resident should be included in the facility fall prevention program. Review of a care plan for impaired mobility related to [DIAGNOSES REDACTED]." The following hand written approaches (undated) in pertinent part documented, "low bed, bed bolster, floor mat next to bed, hoyer lift for all transfers x2 staff members ..." Review of a self-care deficit for ADLs (activities of daily living), revealed the resident required extensive assist related to vascular dementia, documented as created on 5/14/10 and last reviewed 9/07/10 and included the following approaches: "...place call light in reach of resident at all times, keep area free of clutter and other hazards for safety, transfer with assist of 2 staff using hoyer lift ..." Review of a fall care plan, created 5/14/10 and last reviewed 9/07/10, documented the following in pertinent part, "...ensure call light within reach and answered promptly. Encourage resident to await assistance, bed bolsters ..." Review of a nurse's note entry, dated 7/16/10 at 10:30 a.m., documented the following in pertinent part, "CNA (certified nurse aide) called this nurse into room, noted discoloration area to right upper arm with pain/swelling upon palpation ...res (resident) does not answer questions appropriately (uninterviewable) PRN (as needed) Tylenol given per [DEVICE] (gastrostomy tube) for pain. Res (resident) refuses to wear ice pack ..." Review of a nurse's note entry, dated 7/16/10 at 11:05 a.m., documented, "DON (director of nursing) and ADON (assistant director of nursing) notified of right upper arm." Review of a nurse's note entry dated 7/16/10, at 11:25 a.m., documented, "(name of physician) paged, returned call at 12:00 p.m., new order received for x-ray." Review of the x-ray report of the right humerus and shoulder, dated 7/16/10, documented the following findings in pertinent part: "...there has been interval development of a mildly impacted fracture of the surgical neck of the right humerus ..." Although review of the incident documentation (requested during the survey on 9/14/10) for above did not provide specific information regarding the full investigation, the above incident was reported to the health department as an occurrence on 7/16/10. Review of the occurrence report on 9/14/10 revealed the facility conducted an internal investigation. The investigation concluded the resident sustained [REDACTED]. The CNAs lifted and transferred the resident manually instead of using a mechanical lift as care planned. -Interviews On 9/14/10 at 9:05 a.m., the DON was interviewed regarding the above findings. The DON acknowledged the caregivers (CNAs) failed to use the mechanical lift to transfer the resident, transferred her manually (arm in arm) and that was when the fracture occurred. The DON stated the CNAs involved were individually counseled and staff was inserviced on proper transfer techniques. The DON was asked if any monitoring of the CNAs was conducted. The DON stated monitoring was done but did not have any written documentation as evidence monitoring had taken place. 2. Failure to provide a safe environment -Observations On 9/13/10 at 1:10 p.m. resident #6 was observed in her room lying in bed. The resident was interviewed and able to answer simple yes/no questions. The bed was in a low position, there was a fall mat on the floor next to the bed and bolsters (utilized to prevent a person from falling out of bed) in the bed on both sides of the resident. The resident had a supplemental tube feeding hanging on an IV pole running via a calibrated pump. The resident's bed was near the window, and her privacy curtain was pulled closed approximately two thirds of the way. Her face and upper torso were not visible from the doorway. The call light cord was wrapped around the IV pole and not within the resident's reach. Three unidentified pills were lying on the floor next to the resident's fall mat. At 1:15 p.m., the resident began experiencing severe vomiting. No staff was present in the room, the resident's call light was not within reach and the resident's upper body was not visible from the hallway. The director or nursing (DON) was observed walking down the hall. The surveyor immediately summoned the DON to assist the resident. The medication nurse assigned to care for the resident for the day also entered the room to assist. After assisting the resident, the medication nurse and the DON were informed of and observed the unidentified pills on the floor. -Interviews On 9/13/10 at 1:30 p.m. (following the above observation), the DON was interviewed regarding the above findings. The DON acknowledged the resident's call light was not within her reach. The DON stated the resident was capable of using the call light and at times called out for help. She stated staff anticipated the resident's needs. The DON stated her expectation was for the resident to have her call light accessible and within reach at all times. The DON stated she would investigate the the circumstances regarding the pills found on the floor in the resident's room. In a follow up interview with the DON later in the day at 4:20 p.m., regarding the pills, the DON identified the pills as belonging to another resident on the same unit a few rooms down on the same hallway. The DON stated it was possible the medication nurse had stopped in to check on resident #6 earlier and sat the pills down inadvertently. The DON stated nursing staff would be re-educated. 3. Failure to ensure safety devices applied as ordered a. Sample Resident #4 Sample resident #4, [AGE] years old, was admitted to the facility on [DATE]. According to the 9/10 computerized physicians order (CPO), the resident had [DIAGNOSES REDACTED]. According to the admission minimum data set (MDS), dated [DATE], the resident had both short and long-term memory loss and was moderately impaired with daily decision-making. The resident was Spanish speaking only and was able to make self understood and to understand others through an interpreter. He required limited assistance with most activities of daily living. His primary mode of mobility was per wheelchair. His balance was unsteady while standing and was at risk for falls. -Record review Review of a telephone order (T.O.), dated 2/15/10, documented the following, "DC (discontinue) tab alarm r/t (related to) pt's increased ambulatory strength with walker and independent bed mobility." Review of a T.O., dated 4/12/10, (found in the purged record) documented the following: "Anti-slide guard in w/c (wheelchair), tab alarm in w/c, bed alarm. Diagnosis: [REDACTED]. Review of a care plan for falls, created 6/23/10 and last reviewed on 7/15/10, documented the following problem: "potential for falls evidence by history of falls, fearfulness, and unsteady gait secondary to disease process." Some of the approaches were, "observe for appropriate use of equipment: i.e. walker, merry walker, w/c, keep walkways clean and clutter-free, encourage res to use call light ..." The tab alarm, anti-slide guard and bed alarm as ordered were not listed on the fall care plan. Review of a fall risk assessment, dated 7/12/10, documented the resident scored 11, a score of 7-14 indicated a moderate risk resident and a care plan was indicated. Review of the 9/10 CPO documented the following physician's orders [REDACTED]. (resident) to use tab alarm at all times while in W/C (wheelchair)." Review of the 8/10 and 9/10 treatment administration records (TAR) revealed the above order was in place, and nursing was signing for the 7 a.m.-7 p.m. and 7 p.m.-7 a.m. shifts documenting the resident had the alarm in place. Further review of the resident's clinical record on 9/15/10 revealed from the time of admission (12/18/09) to the present, 9/13/10, the resident had two unwitnessed falls out of his wheelchair on 4/12/10 and 4/30/10. Review of a CNA assignment sheet (last update unknown) was blank and documented no safety devices were in place in accordance with the physician's orders [REDACTED]. -Observations On 9/13/10 at 9:45 a.m., during the initial tour of the facility, the resident was in his room seated in his wheelchair. There was no tab alarm observed. On 9/14/10 at 8:17 a.m., at the dining room table and again at 12:40 p.m., in the dining room, the resident was observed up in his wheelchair without the tab alarm in place. -Interviews On 9/14/10 at 10:50 a.m., a CNA assigned to care for the resident was interviewed. The CNA stated he regularly cared for the resident and knew him well. The CNA stated the resident was dependent for all ADLs, and walked very little. The CNA stated the resident did not have any safety devices in place currently; but did remember the resident had a "Spanish talking" alarm when he resided on another unit. On 9/14/10 during an administrative meeting at approximately 3:15 p.m., the DON and nursing home administrator (NHA) were informed of the above findings. Both stated they could not recall the resident having an order for [REDACTED]. The NHA stated they would look for an order. At the end of the survey, the NHA provided additional copies from the resident's purged record including the 4/12/10 T.O. for the tab alarm. The NHA provided no further comment. On 9/15/10 at approximately 4:00 p.m., the DON provided the fall investigations as previously requested. The fall investigations were reviewed with the DON. The DON stated the tab alarm had not been implemented at the time of the 4/12/10 fall. Review of the 4/30/10 fall investigation documented under current interventions: "...continue care plan, slip guard in w/c, tab alarm for safety to alert staff ..." Documentation reviewed regarding the 4/30/10 fall did no reveal whether or not the resident's alarm was sounding to alert staff of the resident's attempt to get up without assistance. The DON offered no further comments regarding the observations of the resident without the tab alarm. b. Sample Resident #17 Sample resident #17, [AGE] years old, was admitted to the facility on [DATE]. According to the 9/10 CPO, the resident had [DIAGNOSES REDACTED]. According to the most recent MDS, dated [DATE], the resident had both short term and long-term memory loss and was severely impaired with daily decision-making. She was sometimes able to make herself understood and sometimes understood others. She had indicators of moods present including persistent anger with self and others that were easily altered. She was dependent on staff for activities of daily living, was mobile per wheelchair and had a history of [REDACTED]. -Record review Review of a fall care plan, created 6/21/10 and last reviewed 9/14/10, documented the following approaches, "notify physician and family of all falls/injuries, keep area free of clutter, call light in reach at all times when in room or unsupervised area ..." The following approaches (with no start date) were written in and included, "anticipate needs, w/c for mobility, low bed, fall mat, alarms in w/c, bed, lip mattress, body pillow when in bed." Review of the resident's record for the period of 10/09 through 9/13/10, documented the resident had four falls; 10/13/09, 10/17/09, 10/23/09 and 1/04/10. Two of the falls were from her wheelchair, and two were from her bed. Review of the 9/10 CPO documented the following order: "Ok to have tab alarm to W/C (wheelchair) while up. Diagnosis: [REDACTED]. Review of a fall risk assessment, dated 6/14/10, documented the resident had a score of 14, a score of 7-14 indicated a moderate risk resident and a care plan was indicated. Review of the 8/10 and 9/10 TAR revealed the above order was in place; and nursing was documenting during the 7 a.m.-7 p.m. and 7 p.m.-7 a.m. shifts that the resident had the alarm in place. Review of a CNA assignment sheet (last update unknown) documented the resident's following safety devices, "low bed/mat/tabs." -Observations On 9/14/10 at 5:08 p.m., the resident was up in her wheelchair and parked in the hallway next to the nurses' station. She did not have a tab alarm on her wheelchair. On 9/15/10 at 8:50 a.m., and 12:12 p.m., the resident was in her wheelchair in the dining room. No tab alarm was in place as ordered by the physician. -Interview On 9/15/10 at 4:30 p.m., the fall investigations were reviewed with the DON. The DON acknowledged nursing staff should have been applying safety devices. The DON stated the tab alarm could be utilized on the bed also. The DON was asked when the tab alarm was originally ordered, as the start date on the current CPO documented 10/29/09. The DON stated she would look for an order prior to the start date of 10/29/09. 4. High Hot Water Temperatures On 9/13/10 at 9:15 a.m., the initial tour of the facility was conducted. Observations in the following residents' rooms documented the following hot water temperatures: -Room #122: 121.0 degrees Farenheit (F) -Room #124: 128.8 degrees F -Room #126: 130.6 degrees F -Room #128: 130.4 degrees F -Room #403: 121.3 degrees F -Room #408: 127.0 degrees F -Room #423: 123.8 degrees F -Room #425: 124.0 degrees F -Room #428: 127.4 degrees F -Room #427: 129.1 degrees F -At 10:15 a.m., the Nursing Home Administrator (NHA) was notified of the above water temperatures. The NHA stated at 7:30 a.m., that morning, the Environmental Supervisor (ES) stated there was a leak in the boiler room and a service contractor had been notified. -At 10:20 a.m., the ES was notified of the excessive hot water temperatures. The ES stated, "no way;" the hot water had already been checked that morning and the temperatures were within normal limits. -At 10:25 a.m., the ES accompanied by the surveyor went to the boiler room. The gauge at the mixing valve read 130 degrees F. The ES stated the hot water should never reach 130 degrees F in any resident room. -At 10:32 a.m., the ES and surveyor measured hot water temperatures in four resident rooms (#126, #128, #427 and #428). Observations documented the hot water temperatures ranged between 120.7 to 122.0 degrees F. The ES and surveyor's temperature probes were within 0.5 degrees F of each other, confirmed by the ES. -At 10:46 a.m., the ES stated he would make copies of hot water temperatures for the past two months. -At 11:00 a.m., the NHA was notified of the temperature fluctuations. The NHA state she would call the service contractor about the concerns, notify all staff in the facility and have the ES continue checking the hot water temperatures throughout the facility. -At 2:00 p.m., the facility measured hot water temperatures in six (#124, #126, #128, #408, #427 and #428) resident rooms. The hot water temperatures ranged from 124.0 degrees F to 127.0 degrees F. -At 2:20 p.m., the ES stated the service contractor left the facility and notified him that the excessive hot water temperatures were probably due to a mixing valve problem. The ES stated a new mixing valve was ordered; however, it would not be delivered to the facility until tomorrow afternoon (9/14/10). -The ES stated at 8:00 p.m. on 9/14/10, the service contractor would be back at the facility, turn off the water supply, replace the mixing valve and the leaking pipe in the boiler room. The ES stated the service contractor had turned the mixing valve down 5 degrees F to reduce the potential for high hot water temperatures. -At 3:30 p.m., the NHA stated staff and residents had been notified of the hot water concerns. The NHA stated she would personally notify the night staff and nurses of the hot water concerns. The NHA stated hot water temperatures would be taken by night staff, and she would make a spread sheet of the rooms and times for the staff to document. The NHA stated staff would also take hot water temperatures in the secure unit and on hall 300 during the night. -At 5:57 p.m., the NHA took hot water temperatures in room #126: 127.6 degrees F, -At 6:10 p.m., the NHA took hot water temperatures in room #314: 130.2 degrees F, -At 6:11 p.m., the surveyor took hot water temperatures in room #107: 119.1 degrees F, -At 6:13 p.m., the surveyor took hot water temperatures in room #112: 126.7 degrees F, -At 6:15 p.m., the surveyor took hot water temperatures in room #114: 130.0 degrees F, -At 6:20 p.m., the NHA and the Director of Nursing (DON) were notified of the additional hot water concerns. The NHA stated she would continue to educate staff regarding the hot water, and would call the corporate office to ask for help regarding the fluctuation in temperatures. -The facility staff took hot water temperatures between 8:45 p.m., and 9:35 p.m., in 18 resident rooms. Hot water temperatures ranged from 116.0 degrees F to 128.0 degrees F. On 9/14/10 between 7:40 a.m., and 8:00 a.m., the NHA measured hot water temperatures in 18 resident rooms. Hot water temperatures ranged from 121.1 degrees F to 132.7 degrees F. -Between 2:05 p.m., and 2:26 p.m., facility staff measured hot water temperatures in 18 resident rooms. Hot water temperatures ranged from 117.0 degrees F to 130.0 degrees F. -Between 6:23 p.m., and 6:51 p.m., facility staff measured hot water temperatures in 18 resident rooms. Hot water temperatures ranged from 116.0 degrees F to 126.0 degrees F. -Between 7:10 p.m., and 7:25 p.m., facility staff measured hot water temperatures in 18 resident rooms. Hot water temperatures ranged from 102.0 degrees F to 110.0 degrees F. On 9/15/10 at 8:45 a.m., the NHA stated the new mixing valve had been installed and the hot water temperatures were within normal limits. The NHA stated staff will continue to monitor the hot water temperatures. The NHA stated prior to 9/13/10, the hot water temperatures had been within normal limits; the temperatures were ranging between 113-116 degrees F. The NHA provided a work order by the serviced contractor which documented a new mixing valve was installed on 9/15/10. According to the NHA, the contractor believed the repair would alleviate the fluctuating hot water temperatures. The NHA also provided copies of staff in-services on water temperatures conducted on 9/13/10, and a detailed outline/timeline of water temperature concerns dated 9/13/10. The NHA stated she was not aware of the excessive hot water temperatures until she was notified by the surveyor. 5. Failure to ensure medication cart was locked/secured a. 9/14/10 Observation Observation on 9/14/10 at approximately 10:03 a.m., revealed nurse #1 left his medication cart unlocked when he went to the sink in the nursing station to wash his hands. The cart was parked against the outer nursing station wall across from room #120. One resident was seated to the left side of the medication cart in his wheelchair, and another sat in a chair against the wall between the unit shower room and room #120. The cart was unattended for approximately one minute. In interview on 9/14/10 at approximately 10:04 a.m., nurse #1 said there was no way any resident could have opened a drawer in the medication cart without the nurse seeing this. In interview on 9/15/10 at approximately 4:40 p.m., the director of nursing said not only should the cart be locked, but also turned around so no one could access the drawers. b. 9/15/10 Observation On 9/15/10 at 4:22 p.m., observations documented an unlocked medication cart by the nurse's station on the Durango Hall. There were several residents walking in the hall at this time. The registered nurse (RN) assigned to the medication cart was at a table (charting) in the common area approximately 30 feet away from the cart. The medication cart was not visible from where the RN was sitting. The RN was immediately notified and observed/agreed the medication cart was not locked. The RN stated the medication cart should have been locked. At 4:25 p.m., the Nursing Home Administrator (NHA) was notified of the above observation. The NHA stated the cart should not have been left unlocked. At 4:45 p.m., the director of nursing (DON) stated it was her expectation nursing staff medication carts were to be locked when staff were not in direct line of sight of the cart. The DON stated it was her expectation nursing staff follow the facility policy on medication storage. At 5:30 p.m., the DON provided the facility policy on Storage of Medications (revised 4/07). The policy documented in pertinent part: Medication carts were to always remain locked unless the nurse was in front of the medication cart preparing medications or the drawers to the medication cart were in direct line of sight of the nurse. 6. Failure to safely store Rolls of Trash Bags on Secure Unit -Observations On 9/13/10 at 9:15 a.m., the initial tour of the facility was conducted. On 9/14/10 at 10:00 a.m., the environmental tour of the facility was conducted with the Environmental Supervisor (ES) in attendance. During the two tours of the facility, the following observations were documented in resident rooms on the secure unit: -Room #512: one roll of clear plastic trash bags, -Room #514: one plastic trash bag used to tie window curtains open, -Room #516: one roll of red biohazard plastic bags and two rolls of clear plastic trash bags, -Room #517: one roll of clear plastic trash bags, one plastic trash bag used to tie window curtains open, and -Room #519: one roll of clear plastic trash bags, one plastic trash bag used to tie window curtains open. -Interviews The ES stated (during the tour-see above) rolls of plastic trash bags should not be stored in resident rooms on the secure unit. On 9/15/10 at 9:00 a.m., the Nursing Home Administrator (NHA) stated rolls of plastic trash bags should not have been found in resident rooms on the secure unit. The NHA also stated the window curtains should not have been tied open with plastic trash bags.

Based on observations, record review, resident and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and adequate supervision and assistance devices to prevent accidents were provided for two (#4 and #6) of 12 sample residents and the residents who resided in room 408, bed A and room 423, bed A. Specifically, the facility failed to ensure: -Resident #6's call light button was accessible, -Resident #4's unattended medications were appropriately stored -Medicated antifungal cream was not left at the bedside table of room 423A, and -Medicated wound care dressings were not left at the bedside table in room 408A. The findings include: I. Call Light Inaccessible 1. Resident #6 Sample resident #6, who had just been admitted to the facility the morning of 11/11/10, was observed in his room. He did not yet have any available paperwork, as he was newly admitted . On 11/11/10 at 1:04 p.m., the director of nursing (DON) stated the admissions and nursing staff were still working on the resident's admission papers. On 11/11/10 between 12:50 p.m. and 1:00 p.m. during a facility tour with the maintenance manager, resident #6 was observed lying on his bed with part of his body dangling off the bed and his feet on the floor. The resident's call light button was observed to be out of reach. On 11/11/10 at 1:04 p.m., the DON and surveyor observed resident #6. The DON acknowledged that he was partially out of bed. She stated that the resident was just admitted to the facility and staff were working on his admission papers. The DON approached the resident, who stated that he wanted to lie in that position. The DON then educated the resident about the call light. She asked the resident where he wanted his call light button to be placed. The resident stated, "Right there is okay, thank you," when the DON offered to clip the call light to the residents pillow where it was accessible. On 11/11/10 at 3:00 p.m., the DON acknowledged that resident #6's call light button was inaccessible to him. The DON stated, "The call light was not accessible to (resident #6's name ...When staff checked on the resident they should have placed the call light in reach and let the resident know where it was ...The resident was very alert and responsive." II. Inappropriate Storage of Medications 1. Resident #4 Fifty-one year old sample resident #4 was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of depressive disorder, diabetes mellitus, suicide ideation, and hallucinations. The most current Minimum Data Set (MDS) assessment, dated 9/14/10, indicated the resident had no short-term or long-term memory problems. The resident was moderately impaired with cognitive skills for daily decision-making. The resident was able to understand others and was understood by others. The resident experienced sadness and pained worried expressions. The MDS indicated the resident had no behavioral problems. The resident's medical record was reviewed on 11/11/10. There was no self-administration of medication assessment available in the record. Review of the resident's care plan revealed no indication that the resident was able to administer her own medications. On 11/11/10 at 12:15 p.m., during facility tour observations with the unit Registered Nurse (RN), the resident was observed lying on her bed. During the tour, a tube of medication was observed lying on the floor close the resident's bed. The RN was observed as she picked the tube of the floor. The RN stated that the medication tube contained, "Aspirin Cream for pain relief." The resident stated, "It (medication tube) was given to me this morning. I was supposed to put it on my neck then I forgot, I fell asleep ...I put it on the table." The RN then stated she gave the tube of cream to the resident around 9:00 a.m. that morning. On 11/11/10 at 12:20 p.m., the DON was notified of the above observation. She stated, "Unless she (the resident) has physician orders [REDACTED]." 2. Room 408, Bed A On 11/11/10 between 12:50 and 1:00 p.m. during the facility tour with the maintenance manager, room 408A was observed with three tubes of "Hydrophilic wound dressing" and one tube of "Sensi-Care" (barrier cream) on top of the bedside table. On 11/11/10 at 1:04 p.m., the DON was notified of the above observation and removed all the medications at the bedside. 3. Room 423, Bed A On 11/11/10 between 12:50 and 1:00 p.m. during the facility tour with the maintenance manager, room 423A was observed with a tube of medication identified by the DON as "antifungal (Miconazole) cream," on top of the bedside table. On 11/11/10 at 1:04 p.m., the DON was notified of the above observation and removed the medication at the bedside. 4. Staff Interview On 11/11/10 at 3:00 p.m., both the nursing home administrator (NHA) and DON were interviewed at the same time. The NHA stated, "There should be no medications left at the bedside in residents' rooms unless authorized by their physician...If medications are authorized at the bedside, they should be where they are not accessible to other residents. The policy is that if medications are at bedside, they should be locked up." In that interview both the DON and NHA stated that they will continue to educate staff.