Every finding on record at Rock Canyon Respiratory and Rehabilitation Center

Based on observations, record review and interviews, the facility failed to ensure three (#5, #12 and #23) of 14 residents reviewed for abuse out of 21 sample residents were kept free from abuse.Specifically, the facility failed to:-Protect Resident #5 from multiple incidents of physical abuse by Resident #8;-Protect Resident #12 from physical abuse by Resident #11; and, -Protect Resident #23 from physical abuse by Resident #11.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy and procedure, reviewed 4/23/25, was provided by the nurse supervisor on 8/6/26 at 3:30 p.m. It read in pertinent part, New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. Existing staff will receive annual education through planned in-services and as needed. Training topics include: prohibiting and preventing all forms of abuse, identifying what constitutes abuse, recognizing signs of abuse, and reporting process for abuse Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed or certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have the knowledge of the individual residents' care needs and behavioral symptoms.II. Incidents of physical abuse by Resident #8 towards Resident #5A. Incident of physical abuse on 3/1/261. Facility investigationThe facility investigation, dated 3/1/26, was received from the DON on 8/5/26 at 3:15 p.m. and revealed the following:On 3/1/26 Resident #8 and Resident #5 were in the dining room. Resident #8 was apparently speaking loudly and Resident #5 told him to shut up. Resident #8 hit Resident #5 in the stomach and grabbed his arm, leaving a scratch on Resident #5's arm. The residents were separated and assessed, and Resident #8 was placed on 15-minute checks. Resident #5 received first aid for the scratch on his arm but had no other injuries on assessment. An interview with Resident #5, undated, revealed Resident #8 hit him and grabbed his arm. An interview with Resident #8, undated, revealed he said he did not like to be told to shut up. Resident #8 confirmed he hit Resident #5. The facility substantiated the allegation of abuse. Resident #5 was monitored for any psychosocial changes, and Resident #8 had a medication review and was to work with the social services department on coping skills.An undated, blank root cause analysis form was included in the investigation.-However, the facility had not documented a root cause analysis for this incident and had left the form blank.B. Incident of physical abuse on 3/28/261. Facility investigationThe facility investigation, dated 3/28/26, was received from the DON on 8/5/26 at 3:15 p.m. and revealed the following:On 3/28/26, Resident #8 became agitated while nursing staff were attempting to administer an injection, as the resident did not like receiving injections. During the interaction, Resident #8 began swinging at staff. Resident #5 observed the incident and told Resident #8 to knock it off, and Resident #8 then slapped Resident #5 on the hand. The residents were separated and assessed with no injuries noted. Interviews conducted with staff and other residents revealed Resident #8 was swinging his arms and accidentally hit Resident #5. The allegation of abuse was unsubstantiated, as Resident #8 did hit Resident #5 but it was determined not to be intentional. Resident #5 was monitored for psychosocial changes, and Resident #8 was not to receive insulin any injections when around other residents.A root cause analysis, undated, revealed the facility determined the root cause of the incident on 3/28/26 was because Resident #8 hated shots.A risk management report for Resident #8, dated 3/28/26, revealed Resident #8 was yelling in the dining room. Several certified nurse aides (CNAs) and one nurse ran to the dining room and saw Resident #8 hit Resident #5 in the arm while he was getting coffee. Resident #8 was removed from the dining room and was cursing and attempting to strike out at the staff members.A risk management report for Resident #5, dated 3/28/26, revealed Resident #5 was in the dining room getting a cup of coffee when Resident #8 hit him with a closed fist. Resident #5 said he did not do anything to Resident #8 but said he was okay. An interview with a resident who witnessed the incident, dated 3/28/26, revealed Resident #8 was upset about getting a shot, swung his arm at the staff members and hit Resident #5.An interview with LPN #5, dated 3/28/26, revealed she was getting ready to give Resident #8 his insulin shot when he started yelling and swinging his arms. Resident #5 was in the vicinity and told Resident #8 to stop, and Resident #8 struck Resident #5 in his arm/hand.C. Incident of physical abuse on 5/17/261. Facility investigationThe facility investigation, dated 5/17/26, was received from the DON on 8/5/26 at 3:15 p.m. and revealed the following:The facility investigation, dated 5/17/26, was received from the DON on 8/5/26 at 3:15 p.m. and revealed the following:On 5/17/26 Resident #5 was walking to get coffee and inadvertently walked too close to Resident #8. Resident #8 reached up and grabbed Resident #5's arm, which resulted in a scratch when Resident #5 pulled his arm back. Both Resident #8 and Resident #5 tried to swing at each other but missed. The residents were separated, assessed and placed on 15- minute checks. The facility substantiated the allegation of abuse. The facility follow-up included reminding Resident #5 to respect others' personal space, and finding alternate placement for Resident #8An interview with Resident #5 on 5/17/26 revealed he was walking to get a cup of coffee when Resident #8 grabbed his arm. Resident #5 said he pulled his arm back and swung at Resident #8 but missed.Resident #8 was interviewed on 5/17/26 and said he did not know what happened. Resident #8 said he was at his table eating when someone (Resident #5) walked by him so Resident #8 grabbed him and got his arm.A root cause analysis, undated, revealed Resident #5 walked too close to Resident #8's wheelchair which caused Resident #8 to grab Resident #5's arm. Resident #5 had no sense of personal space.D. Resident #8 (assailant)a. Resident statusResident #8, age [AGE], was admitted on [DATE] and discharged to another facility on 6/23/26. According to the June 2026 CPO, diagnoses included severe vascular dementia with psychotic disturbance, cerebral infarction (stroke) and aphasia. The 6/23/26 MDS assessment revealed the resident was severely cognitively impaired and was unable to complete a BIMS assessment. The resident required partial to maximal assistance from staff for most ADLs.The assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others during the assessment lookback period.b. Resident representative interviewResident #8's representative was interviewed on 8/6/26 at 8:34 a.m. The resident's representative said Resident #8 had dementia and behavioral issues. The resident's representative said said Resident #8 became aggressive whenever people were in his face. The resident's representative said Resident #8 could not speak or express himself so he became easily frustrated. The resident's representative said Resident #8 did have a few issues with other residents but was cool for the most part.c. Record reviewThe behavior care plan, revised 5/18/26, revealed Resident #8 had the potential for behavior problems. Resident #8 had a history of choosing not to take his medications, striking out at staff, cursing at staff, making threatening statements or gestures and at times attempted to hit others. Pertinent interventions included offering the resident a snack or activity of choice, approaching him in a calm manner, anticipating and meeting his needs and administering medications as ordered.A progress note, dated 1/10/26 at 1:01 a.m., revealed Resident #8 was yelling for several hours and agitated.A progress note, dated 1/11/26 at 2:35 a.m., revealed Resident #8 was refusing care and attempting to hit staff with a closed fist.A progress note, dated 2/21/26 at 1:18 p.m., revealed Resident #8 was having physical and verbal behaviors towards others. Staff continued to work with Resident #8 one-to-one.A physician's note, dated 2/28/26 at 10:58 a.m., revealed Resident #8 had previously been transferred from one facility to another due to his history of severe vascular dementia with psychotic disturbance. Resident #8 had a history of verbal and physical aggression and medication noncompliance.A progress note, dated 3/1/26 at 6:00 p.m., revealed while in the dining room Resident #8 was yelling out hey repeatedly. Resident #8 had just been served dinner. Resident #5 asked Resident #8 to be quiet and cursed at him. When Resident #5 went to walk past Resident #8, Resident #8 punched Resident #5 in the stomach, grabbed his hand and scratched it. Resident #8 was removed from the area as he could not be calmed down.A progress note, dated 3/7/26 at 12:30 p.m., revealed Resident #8 was refusing to let staff check his blood sugar or administer insulin. Resident #8 was striking out at staff and was difficult to redirect. Resident #8 was striking out at staff and cursing at staff and others. Resident #8 was receiving one-to-one observation and distractions from staff. The note revealed the social services department would be contacted regarding his case.A progress note, dated 3/13/26 at 12:34 p.m., revealed Resident #8 was sitting in his wheelchair by the front door when a visitor attempted to enter. Resident #8 became verbally abusive and was cursing and raising his hand. A staff member attempted to move Resident #8 away from the front door and the resident attempted to strike out at them. The social worker was informed.A progress note, dated 3/28/26 at 11:57 a.m., revealed staff observed Resident #8 hit Resident #5 with a closed fist on the right arm. Resident #8 was removed from the dining room and was cursing and attempting to strike out at staff. Resident #8's physician ordered lab work for the resident and Resident #8 was verbally abusive and raised his fist at the phlebotomist.Resident #8's Kardex revealed the following psychosocial interventions:-Offer to sit and talk with the resident in a quiet place;-Offer the resident a snack of choice;-Offer the resident an activity of choice; and,Medication review and possible referral to psychiatry.-The Kardex did not list any potential triggers for Resident #8's behaviors and did not list interventions specific to the resident himself.E. Resident #5 (victim)a. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the August 2026 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), schizophrenia, depression, anxiety, dementia and cognitive communication deficits. The 7/13/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required setup or cleanup assistance from staff for all ADLs.The assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others during the assessment lookback period.b. Record reviewA change in condition form, dated 3/1/26 at 6:00 p.m, revealed Resident #5 was assessed and found to have a new skin wound or ulcer. Resident #5 had a small, 0.5 centimeter (cm) scratch on the back of his left hand.A change in condition form, dated 5/17/26 at 4:00 p.m, revealed Resident #5 was assessed and a new skin wound or ulcer was identified, which was documented as a scratch to Resident #5's left inner arm with no open areas or bleeding.F. Staff interviewsLPN #3 was interviewed on 8/6/26 at 11:27 a.m. LPN #3 said Resident #8 was volatile, assertive and aggressive initially but became calmer over time. LPN #3 said Resident #8 was nonverbal and required extensive assistance from nursing staff. LPN #3 said she had to call Resident #8's family a lot because of his behaviors. LPN #3 said Resident #8's behaviors would happen frequently after his family left because he wanted to go home. LPN #3 said she knew Resident #8 had some triggers but couldn't remember what they were. LPN #3 said she knew of times where other residents would agitate Resident #8 so she talked to the other residents about being more understanding and giving Resident #8 grace. LPN said Resident #8's behaviors were totally random, and said one minute he would be your best friend and the next minute he would not like you. LPN #3 said to redirect Resident #8 the nursing staff went slow and let him reorient. LPN said the nursing staff knew to stay out of arm's range until Resident #8 was reoriented. LPN said Resident #8's behaviors were more physical and were mostly directed at staff, but LPN said she knew of one incident where he reached out and grabbed another resident. LPN said she could not remember what interventions worked to redirect Resident #8 but said they would have been in his care plan or kardex.The SSD was interviewed on 8/6/26 at 3:09 p.m. The SSD said Resident #8 did not like when staff performed cares for him, and said providing cares or medications would set Resident #8 off. The SSD said once Resident #8 became more familiar with the nursing staff and other residents he was more comfortable. The SSD said Resident #8 have physical behaviors directed at staff which mostly stemmed around receiving his insulin shot, and said he would cuss at people sometimes. The SSD said Resident #8's triggers were mostly around his medications or insulin. The SSD said Resident #8 was redirectable with interventions including taking him to a quiet place, snacks, activities, or working with specific staff.The DON was interviewed on 8/6/26 at 3:35 p.m. The DON said Resident #8 was very apprehensive about being in the facility. The DON said Resident #8 had diabetes and did not like needles, so there were times where a nurse would prepare to give him his insulin shot and Resident #8 would go ballistic at staff. The DON said Resident #5 was protective of the staff, so he one time ran over to get Resident #8 to stop yelling at the staff. The DON said on 3/28/26 Resident #8 was not going after Resident #5, but it was unintentional contact stemming from the situation. The DON said once Resident #8 got adjusted to the facility he was fine, and could be redirected after a while. The DON said the SSD put residents' triggers and interventions in their care plan and Kardex.-However, Resident #8 did not have any triggers or person-centered interventions listed in his care plan or Kardex.The NHA was interviewed on 8/6/26 at 4:50 p.m. The NHA said he had done an extensive root cause analysis on Resident #5 a few months prior, as the facility identified he was involved in nearly all of their physical or verbal abuse incidents as a victim. The NHA said they identified that Resident #5 was very protective over the staff and wanted to help them if another resident was upset with the staff or was yelling at them, and would assert himself into the situation. The NHA said the facility provided education to the nursing staff to ensure Resident #5 was not in the area when a resident began having behaviors, or to take the resident into a private area if Resident #5 was nearby to prevent him from jumping into the situation.-However, the incidents of physical abuse between Resident #8 and Resident #5 on 3/1/26 and 5/17/26 did not stem from any interactions between Resident #8 and the nursing staff.IV. Incidents of physical abuse by Resident #11A. Incident of physical abuse between Resident #11 and Resident #12 on 4/6/261. Facility investigationThe facility investigation, dated 4/6/26, was received from the director of nursing (DON) on 8/5/26 at 3:15 p.m. and revealed the following:On 4/6/26 Resident #12 was walking down the hallway when he passed Resident #11, who was sitting on her walker in the middle of the hallway. Resident #11 reached out and grabbed Resident #12's hand and hit his hand, and Resident #12 became startled and slapped Resident #11 in the face. The residents were separated and assessed with no injuries noted, and neurological checks were initiated for Resident #11. Both residents were placed on 15-minute checks. Neither resident could recall the event when interviewed. The allegation of abuse was substantiated as it was witnessed by a staff member. The facility's follow-up included monitoring Resident #11 for psychosocial changes, and doing a medication review and more frequent checks on Resident #12.A root cause analysis, undated, revealed the root cause of the incident on 3/1/26 was both residents had dementia.2. Resident #11a. Resident statusResident #11, age [AGE], was admitted on [DATE]. According to the August 2026 computerized physician's orders (CPO), diagnoses included metabolic encephalopathy (swelling of the brain caused by metabolic changes), altered mental status and unspecified symptoms and signs involving cognitive function and awareness.The 7/8/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) assessment score of 10 out of 15. The resident required setup to touching assistance from staff for activities of daily living (ADL).The assessment documented the resident did not have other behavioral symptoms not directed toward others, and had physical and verbal behaviors directed toward others on one to three days during the assessment lookback period.b. Record reviewThe behavior care plan, revised 8/5/26 (during the survey process), revealed Resident #11 had a potential behavior problem. Resident #11 at times became agitated and had attempted to hit staff, curse at staff, rummage through trash cans or take glasses off of staff members' faces. Resident #11 at times would become upset when others were in her room or personal space. Pertinent interventions included evaluation and treatment from a psychiatrist, anticipating and meeting the resident's needs, approaching the resident in a calm manner and placing a stop sign on the resident's door. An intervention to redirect residents out of Resident #11's room as needed was added on 8/5/26 (during the survey process).A social services care plan, revised 7/11/26, revealed Resident #11 was at times resistive to care and could become combative with staff, attempt to strike out and at times attempted to use her walker to hit staff members. Resident #11's triggers included when people used profanities and noted Resident #11 was very territorial over her room. Pertinent interventions included giving the resident a clear explanation of all care activities prior to and during each contact.Review of Resident #11's August 2026 CPO revealed the following physician's order:Monitor episodes of striking out at others each shift, ordered 6/25/26.-Review of Resident #11's electronic medical record (EMR) did not reveal any behavioral monitoring initiated prior to 6/25/26.A progress note, dated 1/14/26 at 5:19 a.m., revealed Resident #11 was sitting on the floor after a behavioral episode in which she repeatedly attempted to strike staff. Resident #11 began telling another resident as he passed that she would punch him too.A progress note, dated 3/21/26 at 9:30 a.m., revealed Resident #11 became angry with an unidentified staff member and hit him in the arm while he was providing meal assistance for another resident. Resident #11 was able to be redirected without further incident.A progress note, dated 4/6/26 at 6:38 p.m., revealed Resident #11 was sitting on her walking in the living room when Resident #12 walked past her. Resident #11 grabbed and hit Resident #12's right hand. Staff attempted to separate the residents but Resident #12 punched Resident #11 in the face. Resident #11 was assessed and found to be at baseline, and neurological checks were initiated.Review of the behavior monitoring task, from 7/7/26 to 8/6/26, did not reveal any behavior tracking documentation for Resident #11.Resident #11's Kardex (a nursing reference tool), revealed the following psychosocial interventions:-Redirect others out of the resident's room;-Place a stop sign in the resident's doorway as she chooses; and,-Provide frequent checks to anticipate needs.-The Kardex did not list any potential triggers for Resident #11's behaviors and did not list interventions for deescalation.A trigger and intervention task in Resident #11's EMR revealed Resident #11's triggers included when others were in her room, others taking her belongings, and when it was too loud. Interventions included offering the resident a quiet place, offering to take Resident #11 outside on a walk, offering the resident a snack of choice including cookies, and offering to play music for the resident.-However, these triggers and interventions were not available in Resident #11's Kardex or care plan.3. Resident #12a. Resident statusResident #12, age [AGE], was admitted on [DATE] and passed away on 5/31/26. According to the May 2026 CPO, diagnoses included dementia without behavioral disturbance, cognitive communication deficits and muscle weakness.The 4/27/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. The resident was dependent on staff for most ADLs.The assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others during the assessment lookback period.b. Record reviewThe behavior care plan, revised 6/2/26, revealed Resident #12 had a potential for a behavior problem. Resident #12 would at times yell at staff and threaten them, and raise his cane in a threatening manner towards staff. Pertinent interventions included anticipating and meeting the resident's needs, using interventions including taking away his cane when needed, offering to take the resident for a walk, offering the snack of choice and offering a quiet place.B. Incident of physical abuse by Resident #11 towards Resident #23 on 6/16/261. Facility investigationThe facility investigation, dated 6/16/26, was received from the DON on 8/5/26 at 3:15 p.m. and revealed the following:On 6/16/26 Resident #23 wandered into Resident #11's room. Resident #11 then slapped Resident #23 on the face and told her to get out. The residents were separated, redirected and assessed. Resident #23 had bruising to her left eyebrow and abrasions on both sides of the bridge of her nose. Psychosocial monitoring was initiated for Resident #23. A medication review with a psychiatrist was initiated for Resident #11, and a stop sign was placed on her door to keep any other residents from wandering into her room. The investigation substantiated the allegation of abuse.The investigation documented a risk assessment for Resident #23, dated 6/16/26, revealed the resident was able to reenact being punched but was unable to explain what happened between her and Resident #11.The investigation documented a risk assessment for Resident #11, dated 6/16/26, revealed nursing staff heard a female resident scream, and when staff entered Resident #11's room she told the staff and Resident #23 to get out of her room, and said she already hit her (Resident #23) once. A stop sign was placed on Resident #11's door to warn other residents she did not like people coming into her room.2. Resident #23 (victim)a. Resident statusResident #23, age [AGE], was admitted on [DATE]. According to the August 2026 CPO, diagnoses included dementia with behavioral disturbance, generalized anxiety, depression and wandering.The 6/1/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. The resident required partial to moderate assistance from staff for most ADLs.The assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others during the assessment lookback period.b. Record reviewA change in condition form, dated 6/16/26, revealed Resident #23 was assessed for a change in condition after she was hit in the face by another resident (Resident #11). Resident #23 had bilateral superficial abrasions to the bridge of her nose and her left eyebrow was bruised and swollen.C. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 8/6/26 at 11:44 a.m. CNA #5 said she had seen Resident #11 try to throw her walker at staff, and said Resident #11 had mostly physical behaviors. CNA #5 said she had heard Resident #11 had been physically aggressive. CNA #5 said she did not know Resident #11's triggers. CNA #5 said there was a sign behind a door in the nurse's station with all of the residents' triggers and interventions listed, but said she had not had a chance to look at it yet. CNA #5 said she also thought Resident #11's triggers and interventions were listed in her Kardex. CNA #5 said she had not yet had a chance to read Resident #11's Kardex to see what interventions worked for her or see what her triggers were.CNA #6 was interviewed on 8/6/26 at 1:17 p.m. CNA #6 said Resident #11 did not have any behaviors that she knew of. CNA #6 said residents' behaviors, interventions and triggers were listed in a sign behind a door in the nurse's station and on the residents' Kardexes. LPN #4 was interviewed on 8/6/26 at 1:45 p.m. LPN #4 said she usually worked in another unit but picked up shifts on the memory care unit a few times per month. LPN #4 said she had not had any behavioral issues with Resident #11 and had not heard about any issues or behavioral incidents with her. LPN #4 said no one told her whenever a behavioral incident occurred and said she stayed out of the loop. LPN #4 said she could tell when Resident #11 was getting antsy, and said the resident paced back and forth or yelled about people staying out of her room. LPN #4 said she knew in those times to park her medication cart down by Resident #11's room to keep people away from it. LPN #4 said Resident #11's triggers were mostly about herself and her things and said Resident #11 did not like people in her space or in her room. LPN #4 said Resident #11 was usually very easily redirected just by talking to her and asking if she wanted a snack or to go outside. LPN #4 said she was not sure if Resident #11 had any triggers or interventions documented in her care plan or Kardex, but said that was usually where that information would go. LPN #4 said she was not sure if Resident #11 had any behavior monitoring in place or if the nurses or CNAs would do that. LPN #4 said behavior monitoring was usually documented in the CNAs' tasks.The social services director (SSD) was interviewed on 8/6/26 at 3:09 p.m. The SSD said Resident #11 did not love other people being in her personal space, going into her room or being in her bubble. The SSD said Resident #11 could become verbally or at times physically aggressive with staff, but could be redirected. The SSD said the facility had offered Resident #11 a stop sign for her door so people would not go into her personal space, and said she was being seen by a psychiatrist. The SSD said Resident #11's behaviors were sporadic. The SSD said Resident #11 could be easily redirected and liked to go outside, listen to music, or have quiet space.The SSD said she documented residents' triggers and interventions in their care plans and their Kardexes so the CNAs would have access to them. The SSD said she also placed that information on a sign in the door behind the nurse's station so staff members without EMR access, such as housekeeping staff, could review them. The SSD said she asked the nursing staff to look at residents' care plans and Kardexes frequently and whenever they were updated. The SSD said she also verbally communicated with the nursing staff whenever any changes to the care plan or Kardex were made.The DON was interviewed on 8/6/26 at 3:35 p.m. The DON said Resident #11 was good if she was left alone, but was triggered by people coming into her room. The DON said the facility had put a stop sign on Resident #11's door, provided her with a private room, changed her medications, and put a vinyl cover on one of the other doors in the hallway to discourage other residents from wandering down that end of the hallway. The DON said they had a few residents in Resident #11's unit that wandered or got turned around on the way to their rooms.The DON said you could tell when Resident #11 was getting worked up, so the staff would go on a walk with her or talk to her one-to-one. The DON said there was a list of interventions at the nurse's station and said nursing staff could write in new interventions which worked for them which would then be added to their care plan by the SSD.The DON said they performed behavior monitoring if a resident was on antipsychotic or antidepressant medications, but otherwise charted by exception in the resident's progress notes. The DON said nurses would message her if a resident was having any increase in behaviors, and said the administration reviewed progress notes Monday through Friday in their clinical meetings each morning.The DON said the SSD checked in with staff once a month and made sure new employees knew to look at the residents' Kardexes and care plans. The DON said older employees did not think to relay information about the residents' Kardexes or care plans to new employees. The DON said reading the Kardex might help staff take better care of residents. The DON said her expectation would be for her staff to review residents' Kardexes or care plans at least within their first week of working at the facility, and said she may add that information to their online training or orientation.

Based on observations, record review and interviews, the facility failed to ensure one (#7) of eight residents reviewed for abuse out of 13 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #7 from physical abuse by Resident #6. Findings include:I. Facility investigationThe facility investigation, dated 7/11/25, was provided by the DON on 10/14/25 at 12:44 p.m. The investigation revealed the following:On 7/11/25 Resident #6 was attempting to take food from a female resident (Resident #7). The female resident told Resident #6 to stop and Resident #6 hit the female resident. This incident occurred on the secured unit. The residents were separated and Resident #6 was given a new plate of food. Staff sat with Resident #6 until he was done with his meal and calmed down. Resident #7 was assessed and did not have any noted injuries. Neither resident was able to recall the incident.Interviews with facility staff members revealed Resident #6 approached Resident #7 and grabbed some of her food. Resident #7 yelled at Resident #6, and he hit her.A root cause analysis of the incident revealed Resident #6 attempted to take Resident #7's food, Resident #7 told him not to, and Resident #6 hit her as a result. Resident #6 did not have his meal yet and was hungry. The root causes of the incident were determined to be Resident #6's hunger, and Resident #6's dementia not allowing for the cognition that Resident #7's food was not his own.The investigation documented Resident #7 did not have a history of behaviors and did not have a behavior care plan. The investigation indicated Resident #7 had not been involved in any other occurrences.The investigation documented Resident #6 had a history of behaviors, including becoming aggressive, pushing furniture around the dining room and being resistant to care. The resident's care plan included interventions which documented the resident could become physically aggressive and was not easily redirectable.The investigation concluded the incident of physical abuse was found to have happened as it was witnessed. Facility actions included updating Resident #6's plan of care, including adding an intervention which specified when Resident #6 was taken to his seat in the dining room, the staff would immediately provide him with his meal. II. Resident #6 (assailant)A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, restlessness and agitation, unspecified symptoms and signs involving cognitive functions and awareness, wandering, and anxiety disorder.The 7/21/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and was unable to complete a brief interview for mental status (BIMS) assessment. The resident was dependent on staff assistance for most activities of daily living (ADL), and required setup or cleanup assistance from staff for eating.The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others during the assessment look-back period.B. ObservationsOn 10/13/25 at 11:37 a.m. Resident #6 approached an unidentified female resident. Resident #6 held her hand, and the residents smiled at each other. Resident #6 then reached with his other hand and tried to take a cup the female resident was holding. The female resident pulled away from Resident #6 and told him no and that the cup was hers. Two staff members were standing within a few feet of the residents as this occurred. When the female resident told Resident #6 the cup was hers, a nursing staff member then began redirecting Resident #6 away from the female resident. The staff member assisted Resident #6 into a seat in a separate part of the dining area.At 11:42 a.m. another unidentified resident was assisted by a staff member into the a separate part of the dining area and seated at a table away from Resident #6. The staff member then left the dining area to continue assisting other residents.At 12:04 p.m. Resident #6 stood up from his seat and began pacing in the lower dining area. A staff member entered the lower dining area and redirected Resident #6 back to his seat. Resident #6 began slapping the table and stopped after a few beats.At 12:08 p.m. Resident #6 began slapping his hands on the table again. A nursing staff member delivered Resident #6's meal tray to him and another staff member began to assist the resident with eating. Both staff members left the lower dining area to help continue passing trays shortly thereafter. At 12:42 p.m. Resident #6 finished his meal and was assisted from the dining area into the common area by a nursing staff member. Resident #6 tried several times to take food from trays left unattended from the lunch meal service and was repeatedly redirected by the staff member.C. Resident representative interviewResident #6's representative was interviewed on 10/13/25 at 11:07 a.m. The resident's representative said he knew of an incident in which Resident #6 tried to take food off of someone's plate and the other resident hit him, and said the incident was Resident #6's fault. The resident's representative said the facility had changed the order in which meals were served so Resident #6 would receive his meal first in order to avoid another incident of that nature. The representative said Resident #6 liked to wander around the facility and grab things.D. Record reviewThe behavior care plan, revised 7/16/25, revealed Resident #6 had the potential for a behavior problem. Resident #6 at times became physically aggressive and would hit, strike out, pound on or shake doors, push furniture items and flip them over. Resident #6 was not easily redirected at times. Pertinent interventions included assisting Resident #6 with meals, taking him to his seat and immediately providing him with his meal tray. Additional interventions included offering frequent toileting, snacks or drinks, offering to go on a walk, or redirecting Resident #6 back to his room as needed.-The behavior care plan did not document the resident's identified trigger of resistance or argument when he tried to grab things from other residents.The nutrition care plan, revised 7/17/25, revealed Resident #6 had a potential nutritional problem due to his dementia diagnosis and wandering during meals. Resident #6 had a history of taking other residents' food. Pertinent interventions included staff redirecting Resident #6 when he picked food off of other residents' plates, initiated 5/1/25.A interdisciplinary team (IDT) note, dated 5/1/25 at 10:29 a.m., revealed Resident #6 had a witnessed fall on 4/30/25 at 5:30 p.m. in the dining room. Resident #6 was in the dining room trying to pick food off of another resident's plate, but his feet got caught in another resident's wheelchair footrests, which resulted in Resident #6 losing his balance. Resident #6 fell on his bottom on the floor and acquired a skin tear to his right elbow. Risk factors included poor safety awareness, impulsivity, dementia, and wandering. Interventions added after the incident included staff assisting Resident #6 with ambulation through congested areas when he allowed.A progress note, dated 7/11/25 at 2:13 p.m., revealed Resident #6 attempted to take food from another resident's (Resident #7) plate, and when the other resident refused to give Resident #6 her plate, Resident #6 hit the other resident with a closed fist on the side of her head. Resident #6 was redirected by staff away from the other resident and back to his food. The resident's representative, DON, and physician were notified.Review of Resident #6's June 2025 treatment administration record (TAR) from 6/1/25 through 6/30/25 revealed an order for behavior monitoring for aggressive behaviors, including hitting and kicking. The TAR documented Resident #6 had episodes of aggressive behavior on 6/9/25, 6/16/25, and 6/17/25.III. Resident #7 (victim)A. Resident statusResident #7, age greater than 85, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included dementia and cognitive communication defects.The 9/24/25 MDS assessment revealed the resident was severely cognitively impaired and could not complete the BIMS assessment. The resident required staff supervision or touching assistance for most ADLs.The MDS assessment documented the resident did not have physical or verbal behaviors directedat others or other behavioral symptoms not directed toward others.B. Record reviewThe cognition care plan, revised 7/15/24, revealed Resident #7 was at risk for impaired cognitive function or impaired thought processes due to cognitive deficits from her dementia diagnosis. Pertinent interventions included staff frequently checking on Resident #7 and anticipating her needs.A progress note, dated 7/11/25 at 2:24 p.m., revealed Resident #7 was sitting at the dining table eating her lunch when another resident (Resident #6) attempted to take her plate from her. Resident #7 refused to let the other resident take her food, and the other resident struck Resident #7 in the head. No injuries were noted on Resident #7's skin assessment. When asked what happened, Resident #7 could not recall the event. Resident #7 denied any pain or injuries. Resident #7's representative, physician and the DON were notified.C. Resident's representative interviewResident #7's representative was interviewed on 10/13/25 at 11:10 a.m. The resident's representative said Resident #7 had not had any issues with any other residents that she was aware of. The representative said Resident #7 did not like when people came up to her and tried to take her items from her, and would yell at people when that occurred.IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/14/25 at 9:28 a.m. LPN #1 said Resident #6 wandered the secured unit, so the staff had to keep an eye on him to keep him from going outside. LPN #1 said Resident #6 tried to take food and drinks away from other residents, but the staff were able to redirect him. LPN #1 said Resident #6 was not aggressive, and did not try to hit or kick. LPN #1 said all of the residents in the secured unit had issues with other residents, so the staff just had to redirect the residents whenever issues came up and offer them food, drinks and toileting.Activities assistant (AA) #1 was interviewed on 10/14/25 at 10:00 a.m. AA #1 said Resident #6 wandered and tried to take food and items from other residents, but was able to be directed. AA #1 said the facility staff served Resident #6 first during meals to keep him occupied. AA #1 said the staff sometimes gave Resident #6 an empty bowl before meals just so the resident would be distracted. AA #1 said Resident #6 did not have any aggressive behaviors and never hit or kicked. Certified nurse aide (CNA) #4 was interviewed on 10/14/25 at 11:45 a.m. CNA #4 said Resident #6 tended to wander around the unit and liked to grab food and plates in the dining room. CNA #4 said the nursing staff usually tried to assist him to the dining room and serve him his meal last, so the other residents would have more of a chance to eat before Resident #6 began wandering around and grabbing items. CNA #4 said Resident #6 did not have any aggressive behaviors and was only aggressive if he was provoked. CNA #4 said Resident #6 became mean if he grabbed something from another resident and they did not let the item go or tried to argue back to him. CNA #4 said Resident #6 was easily redirectable with food. CNA #4 said she and the other CNAs knew where everyone needed to be seated in the dining room in order to prevent conflicts, as she knew of another resident who was very protective over his food and would threaten to hit people with his cane.The MDS coordinator (MDSC) was interviewed on 10/14/25 at 2:03 p.m. The MDSC said Resident #6's behaviors fluctuated. The MDSC said Resident #6 would occasionally escalate to hitting or pushing, but was generally calm. The MDSC said Resident #6 occasionally wandered and would grab things from other residents. The MDSC said Resident #6 had previously had an incident with another resident in which the other resident hit Resident #6 when he tried to grab his food, but that was several months prior. The MDSC said Resident #6 was sometimes aggressive with redirection and could be difficult to redirect. The MDSC said Resident #6 could be redirected with food or being offered walks outside. The MDSC said the staff tried to serve Resident #6 whenever he arrived at the dining room in order to keep him occupied.The DON was interviewed on 10/14/25 at 2:30 p.m. The DON said for the incident on 7/11/25, Resident #6 walked into the dining room and tried to take food off of Resident #7's plate. Resident #6 walked around and grabbed items, and was mostly nonverbal. The DON said Resident #6 did not get aggressive very often, but could be difficult to redirect and could become upset. The DON said Resident #6 had not had any altercations with any other residents prior to the incident with Resident #7. The DON said Resident #6 was supposed to be fed immediately whenever he entered the dining room. The DON said she could not tell the staff to bring him into the dining room first or last, as they could not force the resident to go to the dining room at a specific time. The DON said the facility staff watched out for Resident #6 and made sure he had his food. The DON said they had not had any other incidents involving Resident #6 since 7/11/25. The DON said Resident #6 was redirectable with food, walking outside and using a calm voice. The DON said Resident #6 escalated quickly if staff did not use a calm tone with him. The DON said she did not see any triggers for Resident #6's behaviors documented in his electronic medical record (EMR), only how he could be redirected.V. Facility follow-upA written statement from the MDSC, dated 10/15/25, was provided via email by the DON on 10/17/25 at 2:16 p.m. The statement revealed on 10/13/25 at 12:00 p.m. the MDSC was present in the lower dining room during lunch time waiting for lunch to be delivered and assisting with meal management. Resident #6 was sitting calmly and still with a subdued affect. While waiting for his food, Resident #6 began to tap lightly with an open hand on the table in a drumming motion for approximately ten seconds. Resident #6 did not appear agitated. Resident #6 remained in a sitting position.-However, Resident #6 slapped his hands on the table in two different instances and had been pacing in the lower dining room prior to this episode (see observations above).

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident bathrooms; -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff performed appropriate hand hygiene; and, -Ensure individual glucometers were cleaned properly. Findings include: I. Housekeeping failures A. Professional reference According to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection. (July 2021); pages113:104-114, retrieved on 6/10/25 from https://pubmed.ncbi.nlm.nih.gov/33744383/, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures (5/4/23) was retrieved on 5/26/25 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails; -IV (intravenous) poles; -sink handles; -bedside tables; -counters; -edges of privacy curtains; -patient monitoring equipment (keyboards, control panels); -call bells; and, -door knobs. According to the CDC's Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 5/26/25 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. B. Facility policy and procedure The Routine and Disinfecting Resident Rooms policy and procedure, revised May 2024, was provided by the nursing home administrator (NHA) on 6/5/25 at 2:30 p.m. It read in pertinent part, It is the policy of the facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Cleaning considerations included: dry cleaning procedures will be conducted before wet procedures; clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty; clean from top to bottom (bring dirt from high levels down to the floor levels); and,clean from front to back areas. Consistent surface cleaning and disinfection will be conducted with the detailed focus on high touch areas to include:tToilet flush handles, bed rails, tray tables, call buttons, TV (television) remote, telephones, toilet seats, monitor control panels, touch screens and cables, residence chairs, IV (intravenous) poles, blood pressure cuffs, sinks and faucets, light switches, door knobs and levers. The Hand Hygiene policy and procedure, revised January 2025, was provided by the NHA on 6/5/25 at 2:30 p.m. It read in pertinent part, It is the policy of the facility to clean hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. Hand washing is generally considered the most important single procedure for preventing nosocomial infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. Although antiseptics and other hand washing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the hand washing technique followed. C. Observations During a continuous observation on 6/5/25, beginning at 9:53 a.m. and ending at 10:47 a.m., the following was observed: Housekeeper (HK) #1 pushed the cleaning cart to room number #9. She removed the bleach germicidal cleaner from the cart. She sprayed the faucet, the counter, the sink, the ABHR dispenser, the towel dispenser and the trash cans. She placed the spray bottle back onto the cart and removed the broom and swept the room. At 10:02 a.m. she removed a wet rag from the cleaning solution and wiped down the items she had previously sprayed. She removed her gloves and put on clean gloves, without performing hand hygiene. She removed the mop from the mop bucket and placed the wet floor sign in the doorway and mopped the floor. She returned the mop to the mop bucket on the cleaning cart and removed her gloves. room [ROOM NUMBER] and room [ROOM NUMBER] had a shared bathroom and she said she would clean the bathroom when she cleaned room [ROOM NUMBER]. Without performing hand hygiene, she put on clean gloves and pushed the cleaning cart to the housekeeping closet to empty and replace her cleaning solutions including the mop water. -HK #1 failed to disinfect high touch areas such as the bed remotes, the call lights,the light switches, over the bed table and night stand. -HK #1 failed to perform hand hygiene after removing her gloves and putting on new gloves and after exiting the residents' room. At 10:21 a.m HK #1 pushed the cleaning cart to room [ROOM NUMBER] and put on clean gloves, without performing hand hygiene. She removed the disinfectant spray bottle from the cart and sprayed the toilet tank, the grab bars, inside and outside the toilet bowl and emptied the trash. She returned the spray bottle back to the cart and retrieved the toilet bowl cleaner. She poured the toilet cleaner into the toilet, placed the cleaner back on the cart and removed the toilet brush. She scrubbed the inside of the toilet bowl and under the rim. She dipped the toilet brush into the toilet water and scrubbed feces off the bottom of the seat and flushed the toilet. She placed the toilet brush back into its holder and returned it to the cleaning cart. She removed her gloves and put on clean gloves, without performing hand hygiene. At 10:25 a.m. HK #1 removed two wet rags from the cart and used the pink rag to wipe the handrails in the bathroom, the toilet tank, the lid and the inside of the lid. She used a blue rag to wipe the seat, under the seat and the rim. She removed her gloves, used ABHR and put on clean gloves. -HK#1 did not clean the base of the toilet and used the toilet brush outside of the toilet bowl. At 10:27 a.m. HK #1 removed the disinfectant spray from the cart and sprayed the faucet, the sink, the ABHR dispenser and the paper towel dispenser. She placed the spray bottle back onto the cleaning cart, removed a spray bottle with glass cleaner and cleaned the mirror. At 10:30 a.m. HK #1 removed an orange rag from the cart and wiped the ABHR dispenser, the paper towel dispenser, the counter, the faucet and the sink. She placed the soil rag into a bag on the cleaning cart and removed her gloves. She put on clean gloves and placed trash bags into the trash cans. She removed the broom from the cleaning cart and swept the room. She removed her gloves and put on clean gloves. She removed the mop from the mop bucket and mopped the room. She removed her gloves and used ABHR and pushed her cleaning cart to room [ROOM NUMBER]. -HK #1 failed to disinfect high touch areas such as the bed remotes, the call lights, the light switches, over the bed table and night stand. -HK #1 failed to perform hand hygiene after removing her gloves and putting on new gloves. D. Staff interviews HK #1 was interviewed on 6/5/25 at 10:47 a.m. through a translator. HK #1 said she had hand hygiene education when she recently started working at the facility. She said she was supposed to use ABHR or wash her hands after removing gloves and putting on clean gloves. She said prior to working at the facility, she worked at a restaurant and she got into the bad habit of not performing hand hygiene when she changed her gloves. She said high touch areas should be cleaned daily and that she would come back and clean them after cleaning the room at the end of the day. She said she would clean the night stand, bedside table and dresser sometimes when she cleaned the room. She said she did not like touching the resident items when they were not in the room. She said she used the toilet brush on the underside of the seat because there was a small amount of feces on it. She said she did not know she was not supposed to use the toilet brush outside of the toilet bowl. She said she did not document which rooms she needed to come back to to clean high touch areas and just remembered which rooms she needed to come back too. She said she would start cleaning the rooms and the high touch areas at the same time instead of coming back at a later time. The house keeping and laundry manager (HKM) was interviewed on 6/5/25 at 1:16 p.m. The HKM said hand hygiene education was provided upon hire and was discussed on a regular basis. She said after removing gloves the staff member should always perform hand hygiene before putting clean gloves on. She said the housekeepers should change their gloves after cleaning the bathroom and after cleaning the room. She said the housekeepers should perform hand hygiene when they change their gloves either by washing their hands or using ABHR. She said high touch areas should be cleaned daily when cleaning the room. She said high touch areas included the light switches, call lights, door handles, over bed tables, nightstands, dressers, remotes and handrails. She said the toilet brush should only be used inside the toilet bowl and no other part of the toilet. She said she would immediately provide education to the housekeeping staff and to HK #1 on the correct room cleaning procedure and hand hygiene. The director of nursing (DON) was interviewed on 6/5/25 at 2:36 p.m. The DON said hand hygiene should be performed whenever there was a glove change. She said high touch areas should be cleaned daily and the toilet brush should not be used outside of the toilet bowl. II. Glucometer failures A. Manufacturer guidelines According to Arkray USA, Inc., Arkray Technical Brief cleaning and Disinfecting the Assure Prism multi Blood Glucose Monitoring System (September 2024), retrieved on 6/12/25 from,. https://arkrayusa.com/diabetes-management/professional-healthcare-products/assure/assure-prism-multi/. Each time the cleaning and disinfecting procedure is performed, two wipes are needed; one wipe to clean the meter and a second wipe to disinfect the meter. Wipe the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from the meter. Repeat the above steps with a new towelette to disinfect the meter. Meter surfaces must remain wet according to contact times listed in the wipe manufacturer's instructions. Once complete, wipe the meter dry. According to the PDI. Sani-Cloth Bleach Germicidal Disposable Wipe instructions (2025). Retrieved on 6/12/25 from https://pdihc.com/products/envhttps://pdihc.com/products/environment-of-care/sani-cloth-bleach-germicidal-disposable-wipe/ironment-of-care/sani-cloth-bleach-germicidal-disposable-wipe/. Although efficacy at one minute contact time for HIV (AIDS virus) and HCV (hepatitis C virus) has shown to be adequate, this time is not sufficient for all organisms listed on this label. Therefore a four minute wet contact time must be used for tuberculosis (TB) and pathogenic fungi. Effective against 52 microorganisms in four minutes. B. Observations On 6/4/25 at 8:35 a.m. registered nurse (RN) #2 removed Resident #122's designated glucometer from the medication cart. RN #2 approached Resident #122 in the common area and obtained her morning blood glucose. He returned to the medication cart with the glucometer and disposed of the lancet and test strip. He then wiped the glucometer with one Sani Cloth Bleach Germicidal wipes and immediately placed it in the resident's labeled glucometer container and returned it to the medication cart. -However, according to the manufacturer guidelines RN #2 should have used a total of two wipes and allowed the glucometer to remain wet for four minutes total disinfection time (see manufacturer guidelines above). C. Staff interviews RN #2 was interviewed on 6/4/25 at 8:45 a.m. RN #2 said glucometers should be wiped before and after use. He said the glucometer should be allowed to dry for two minutes. -However, according to the manufacturer guidelines, the glucometer should stay wet for four minutes (see manufacturer guidelines above). The clinical nurse resource was interviewed on 6/4/25 at 8:45 a.m. The clinical nurse resource said that glucometers should be cleaned according to manufacturer recommended contact disinfection times and that it should be kept wet for three minutes after use. She said she would provide education to the nurses. The infection preventionist (IP) was interviewed on 6/5/25 at 1:42 p.m. The IP said glucometers should be cleaned according to the manufacturer recommendations and the recommended contact disinfection times.

Based on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for one (#122) of five residents out of 43 sample residents. Specifically, the facility failed to ensure Resident #122, who was on antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements) did not worsen. Findings include: I. Professional reference According to the National Institute of Health (NIH) National Library of Medicine's Impact of A Pharmacist-Driven Tardive Dyskinesia Screening Process (7/16/21), retrieved on 6/10/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC8287863/#s1, According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), tardive dyskinesia (TD) is defined as involuntary movements generally of the tongue, lower face, jaw, torso, and extremities that are developed from the use of antipsychotics. These movements can either be choreiform (rapid and jerky) or athetoid (slow, snakelike, and writhing). Tardive dyskinesia (TD) is defined as involuntary movements that can develop with prolonged antipsychotic use. Several studies have investigated risk factors that may be associated with tardive dyskinesia, including age, sex, and long-term antipsychotic use. II. Facility policy and procedure The Chemical Restraints and Psychotropic Medication Management policy and procedure, revised April 2025, was provided by the director of nursing (DON) on 6/5/25 at 3:51 p.m. It read in pertinent part, The licensed nurse shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors, and related side effects prior to verification of admission orders with the attending physician. The facility's interdisciplinary team (IDT) will review to ensure monitoring for adverse consequences and effectiveness of medications are in place. Tardive dyskinesia is abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected. III. Resident #122 A. Resident status Resident #122, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician order (CPO), diagnoses included schizoaffective disorder (a mental health condition characterized by a combination of symptoms of schizophrenia - a disconnection from reality and a mood disorder like depression or mania), bipolar disorder, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, chronic kidney disease and wandering. The 4/10/25 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. She required partial assistance with showering, dressing and personal hygiene. The MDS assessment revealed the resident had received antipsychotic medications during the seven day assessment look back period. B. Observations On 6/2/25, during a continuous observation beginning at 10:25 a.m. and ending at 11:44 a.m., the following was observed: At 10:43 a.m. Resident #122 was walking throughout the common area of the secured unit. Resident #122 was observed constantly smacking her lips together while she walked around. At 11:25 a.m. Resident #122 was still in the common area and continued constantly smacking her lips together. On 6/3/25, during a continuous observation beginning at 10:06 a.m. and ending at 12:23 p.m., the following was observed: From 10:31 a.m. to 11:40 a.m, Resident #122 walked from different chairs in the common area to the women's hallway. From 11:40 a.m. to 12:23 p.m., Resident #122 was observed in the main dining room in the secured unit. Resident #122 was observed constantly smacking her lips together at 10:06 a.m., at 10:59 a.m., and at 11:47 a.m. On 6/4/25, during a continuous observation beginning at 11:14 a.m. and ending at 1:15 p.m., the following was observed: At 11:14 a.m. Resident #122 was sitting in a chair in the common area. The resident was observed constantly smacking her lips together. At 12:30 p.m. Resident #122 was sitting in a chair closest to the television. The resident was observed constantly smacking her lips together. C. Record review The antipsychotic medication care plan, initiated and revised on 4/5/25, revealed Resident #122 received an antipsychotic medication. Interventions included documenting episodes of behavior, documenting non-pharmacological interventions, documenting side effects, including tardive dyskinesia, completing an Abnormal Involuntary Movement Scale (AIMS) assessment quarterly and monitoring episodes of physical and verbal aggression. The 4/4/25 AIMS assessment documented the resident had a low risk of movement disorder. The assessment revealed the resident had no facial and oral movements, no extremity movements, no trunk (neck, shoulder, and hip) movements and no severity of abnormal movement and no incapacitation due to abnormal movements. -However, according to staff interviews, Resident #122 had been exhibiting signs of tardive dyskinesia since her admission to the facility on 4/4/25 (see interviews below). Review of Resident #122's June 2025 CPO revealed the following physician's orders related to antipsychotic medications: Olanzapine 10 milligrams (mg). Give one tablet at bedtime for behavior, ordered 4/4/25 and discontinued 5/16/25. Olanzapine 7.5 mg. Give 7.5 mg by mouth at bedtime related to schizoaffective disorder, ordered 5/16/25. Quetiapine fumarate 25 mg. Give one tablet in the afternoon for behavior, ordered 4/4/25. Quetiapine fumarate 300 mg. Give two tablets by mouth at bedtime for schizoaffective disorder, ordered 4/5/25. Monitor episodes of side effects: drowsiness, dry mouth, blurred vision, constipation, less common side effects: edema, extra pyramidal symptoms, urinary retention, stiff or tight muscles, restlessness, rare side effects: tardive dyskinesia, ordered 4/4/25. Monitor episodes: physical and verbal aggression, side effects: drowsiness, dry mouth, blurred vision, constipation, less common side effects: edema, extra pyramidal symptoms, urinary retention, stiff or tight muscles, restlessness, rare side effects: tardive dyskinesia, ordered 4/5/25. Review of Resident #122's April 2025, May 2025 and June 2025 medication administration records (MAR) and treatment administration records (TAR), from 4/5/25 through 6/4/25, revealed there was no documentation to indicate the resident was exhibiting symptoms of tardive dyskinesia on 4/6/25, 4/825 through 4/12/25, 4/17/25 through 4/30/25 and 5/1/25 through 6/4/25. -However, according to staff interviews, Resident #122 had been exhibiting signs of tardive dyskinesia since her admission to the facility on 4/4/25 (see interviews below). The 5/21/25 physician's note revealed Resident #122 was seen by the physician for paranoid schizophrenia. The note indicated the resident continued on a gradual dose reduction (GDR) process of her psychotropic medications over time. The resident continued on two antipsychotic medications and the plan was to continue the GDR process. The most recent GDR was done five days prior. -Review of Resident #122's progress notes, from 4/4/25 to 6/4/25, failed to reveal documentation to indicate the resident was exhibiting symptoms of tardive dyskinesia or that the physician was notified if the resident was exhibiting symptoms of tardive dyskinesia. -However, according to staff interviews, Resident #122 had been exhibiting signs of tardive dyskinesia since her admission to the facility on 4/4/25 (see interviews below). -A review of Resident #122's electronic medical record (EMR) did not reveal any documentation to indicate the resident was being seen by a psychiatric or behavioral health consultant related to her diagnosis or her tardive dyskinesia. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 6/4/25 at 3:57 p.m. RN #2 said he was familiar with Resident #122. He said when a resident had a side effect from a psychotropic medication, he documented the side effect in the resident's TAR. He said Resident #122 smacked her lips because she had tardive dyskinesia. He said she had had symptoms of tardive dyskinesia since she was admitted . Licensed practical nurse (LPN) #2 was interviewed on 6/5/25 at 10:42 a.m. LPN #2 said an AIMS assessment was completed quarterly or every six months when a resident was on antipsychotic medications. He said he documented if a side effect from a psychotropic medication was observed in the MAR and TAR in the resident's chart. He said he was familiar with Resident #122. During the interview, Resident #122 walked into the secured unit, and she was observed to be constantly smacking her lips together. LPN #2 said her behavior of lip smacking was a symptom of tardive dyskinesia. The DON was interviewed on 6/5/25 at 1:30 p.m. The DON said AIMS assessments should be completed every six months or once a quarter for residents on antipsychotic medications. The DON said it was the responsibility of nursing staff to complete the assessments. She said once an antipsychotic medication's side effect was identified, it should be discussed and addressed with the physician or the psychiatrist and documented in the resident's medical record. The DON said it was important to monitor for side effects of psychotropic medications because the side effects could get worse and could affect the resident's quality of life. The DON said she was familiar with Resident #122. She said the resident had had symptoms of tardive dyskinesia since she was admitted to the facility. She said she did not know if there was a referral made to psychiatry for Resident #122 or if the resident's physician had noticed the tardive dyskinesia. The DON said she could not diagnose what caused the tardive dyskinesia. The DON said Resident #122 was on two antipsychotic medications so that could have caused the resident's tardive dyskinesia. The social services director (SSD) was interviewed on 6/5/25 at 2:10 p.m. The SSD said she was familiar with Resident #122. She said the resident had been seen by an outside psychiatrist since she was admitted to the facility. The SSD said she had not received the psychiatrist's records regarding the visits with Resident #122. The SSD said she had noticed the resident's tardive dyskinesia since she was initially admitted . She said when she saw a side effect, such as tardive dyskinesia, she told the psychiatrist or the resident's physician. The SSD said she did not tell Resident #122's physician or psychiatrist. V. Facility follow-up The DON provided psychiatry progress notes for Resident #122 via email on 6/6/25 at 1:44 p.m., after the survey exit. The notes revealed Resident #122 was seen by the psychiatrist on 4/14/25, following her 4/4/25 admission to the facility. The 4/14/25 psychiatry progress notes revealed documentation that the resident's psychomotor activity was normal, there were no abnormal movements observed, there was no psychomotor retardation and there was no psychomotor agitation. -However, the nursing staff identified Resident #122 had tardive dyskinesia and failed to report the side effects to the physician (see interviews above).

Based on observations, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in ROM for one (#33) of three residents reviewed for restorative services out of 43 sample residents. Specifically, the facility failed to ensure Resident #33's bilateral hand contracture soft splints were applied for contracture management per physician's order. Findings include: I. Facility policy and procedure The Restorative Care Program Overview policy and procedure, revised May 2018, was provided by the director of nursing (DON) on 6/5/25 at 2:30 p.m. It read in pertinent part, Provide direct nursing care services that will maintain optimum physical and mental health for the resident and meet his medical treatment needs. II. Resident #33 A. Resident status Resident #33, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included anoxic brain damage (brain damage caused by a lack of oxygen) and contractures of bilateral upper and lower extremities. The 5/5/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) could not be conducted. He was dependent with bed mobility, transfers, personal hygiene and toileting. The MDS assessment indicated Resident #33 was in a persistent vegetative state with no discernable consciousness. The MDS assessment indicated Resident #33 had received passive ROM and active ROM on six days, with no splint or brace assistance, during the seven day look back assessment period. B. Observations On 6/3/25 at 9:56 a.m. Resident #33 was in his room in bed. His hands were on his chest with all five digits on both hands folded inward toward the palm. He did not have soft splints in his hands. One soft splint was sitting on Resident #33's chest. On 6/3/25 at 11:16 a.m. Resident #33 was sitting up in his wheelchair. His hands were on his chest with all five digits on both hands folded inward toward the palm. He did not have soft splints in his hands. On 6/4/25 at 10:15 a.m. Resident #33 was in his room in bed. His hands were on his chest with all five digits on both hands folded inward toward the palm. He did not have a soft splint in his hands. On 6/5/25 at 9:20 a.m. Resident #33 was in his room in his wheelchair. His hands were on his chest with all five digits on both hands folded inward toward the palm. He did not have soft splints in his hands. Certified nurse aide (CNA) #1 pulled a soft splint from under the pillow under his head and a second soft splint from the bedside table table and placed both soft splints into Resident #33's hands without difficulty. C. Record review The restorative program care plan, initiated 10/22/24, indicated Resident #33 was immobile and had contractures. Interventions included monitoring/documenting/reporting to the physician signs/symptoms of contractures worsening, nursing rehabilitation program with passive ROM to bilateral upper extremities, providing supportive care with mobility and therapy referral as ordered. -A review of Resident #33's comprehensive care plan did not reveal personalized interventions for checking for the placement of the resident's soft hand splints. The June 2025 CPO revealed a physician's order for Resident #33 to utilize bilateral resting hand splints as tolerated. Check placement for fit and signs of breakdown every shift, ordered 2/15/25. A review of the CNA task documentation, from 5/23/25 to 6/5/25, related to providing passive ROM to Resident #33's hands, wrists, elbow and shoulders and applying hand protectors revealed the following: Fifteen minutes of passive ROM was provided to Resident #33 one time on 5/23/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/25, 6/1/25, 6/3/25, 6/4/25 and 6/5/25. -There was no documentation to indicate whether or not the resident received passive ROM on 5/26/25, 5/27/25 and 6/2/25. -The documentation did not indicate if Resident #33's hand protectors were applied and checked for fit. A facility training inservice sign in sheet, dated 3/20/25, was provided by the assistant director of nursing (ADON ) on 6/5/25 at 10:30 a.m. The training provided to staff was for positioning Resident #33 daily with bolsters in between his elbows, applying his hand protectors, conducting skin assessments and getting the resident up on Tuesdays and Thursdays. -However, observations revealed staff did not consistently apply Resident #33's hand protectors (see observations above). III. Staff interviews CNA #1 was interviewed on 6/5/25 at 9:18 a.m. CNA #1 said the nursing staff would put Resident #33's soft hand splints in his hands in the morning, if he would let them. She said staff would additionally put bolsters under his elbows. She said sometimes the resident's hands were pretty tight and it was difficult to apply the splints. She said sometimes he was able to maneuver the hand splints out of his hands. She said CNAs would document the application of the splints in the resident's electronic medical record. Registered nurse (RN) #3 was interviewed on 6/5/25 at 9:40 a.m. RN #3 said the facility's restorative nurse aide had recently stepped down from the position and it had been falling onto the CNAs to place splints and provide passive ROM to residents. See said the therapy department had now been overseeing the restorative program. The physical therapist (PT) was interviewed on 6/5/25 at 10:00 a.m. The PT said there currently was not a restorative nurse aide in the facility and they had been slowly transitioning the residents that needed a maintenance restorative program under the domain of the therapy department. He said the therapists had been working with the CNAs on how to place splints and provide passive ROM to residents. The rehabilitation resource was interviewed on 6/5/25 at 11:30 a.m. The rehabilitation resource said Resident #33 had a history of refusing his soft splints to his hands but the facility needed to do a better job of documenting his splints and his refusals on the care plan.

Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#15) of six residents reviewed for medication errors of 43 sample residents. Specifically, the facility failed to ensure that Resident #15 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration Findings include: I. Professional reference According to the Humalog Kwikpen manufacturer guidelines, last updated July 2023, retrieved on 6/12/25 from https://uspl.lilly.com/humalog/humalog.html#ug1 on 6/12/25 included the following recommendations, Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensuring that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle in until it stops, and 0 is seen in the dose window. Hold the dos knob in and count to 5 slowly. You should see insulin at the tip of the needle. II. Resident #15 A. Resident status Resident #15, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2025 computerized physician orders (CPO), the diagnoses included hypertension and diabetes. The 3/12/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent with toileting, required set up/clean up assistance with eating, supervision with personal hygiene, transfers and was independent with bed mobility. B. Observations On 6/4/25 at 11:15 a.m. licensed practical nurse (LPN) #3 checked Resident #15's insulin order of Humalog 8 units to be administered at the lunchtime meal. She obtained her labeled Humalog insulin pen. She then dialed in two units and pushed on the cartridge. She then placed a disposable needle on the pen and dialed in 8 units into the pen. She then entered Resident #15's room and administered the insulin into the resident's abdomen. -LPN #3 failed to prime the insulin pen prior to administering it to Resident #15. III. Staff interviews LPN #3 was interviewed on 6/4/25 at 11:20 a.m. LPN #3 said the insulin pens could be primed before the needle was placed on the cartridge. She said insulin pens needed to be primed so that the resident would get the correct dose of insulin. -However, according to the manufacturer recommendations the needle needed to be placed on the cartridge prior to priming the insulin pen. The director of nursing (DON) was interviewed on 6/4/25 at 11:23 a.m. The DON said the needle needed to be on the cartridge before it was primed so that the air could be flushed out of the needle and the resident received the correct dose of insulin. She said the insulin did not go anywhere if there was no needle on the syringe. She said she would follow up with LPN #3 and provide education on the correct way to prime the pen.

Based on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the residents' environment for two (#119 and #120) of seven residents reviewed out of 43 sample residents. Specifically, the facility failed to ensure Resident #119 and Resident #120's call lights were within reach when the residents were in bed. Findings include: I. Facility policy and procedure The Call Light/Bell policy and procedure, revised January 2025, was received from the director of nursing (DON) on 6/5/25 at 3:15 p.m. It read in pertinent part, It is the policy of this facility to provide the resident with a means of communication with nursing staff and ensure the safety of residents. Leave the resident comfortable and safe. Place the call device within the resident's reach before leaving the room. II. Resident #119 A. Resident status Resident #119, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included metabolic encephalopathy (a brain disorder that occurs when problems with the body's metabolism lead to brain dysfunction), osteoarthritis, dementia and unsteadiness on feet. The 5/19/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. The resident required substantial to maximal assistance for most activities of daily living (ADL). B. Resident interview and observations Resident #119 was interviewed on 6/2/25 at 2:09 p.m. Resident #119 said her call light was far away from her bed. Resident #119 said there had been a few instances in which she had her roommate use her call light to get assistance from the nursing staff, as Resident #119 had not been able to reach her call light. Resident #119 said she had spoken with the facility staff about her call light being too far away from her bed but did not want to make a fuss. Resident #119 was sitting in her wheelchair, her call light was plugged into a call light receptacle on the wall approximately four feet away from the left side of her bed. On 6/3/25 at 10:19 a.m. Resident #119 was lying in her bed and her call light was on the floor under a chair, approximately three feet away from the resident. Resident #119 said she could not reach her call light. Certified nurse aide (CNA) #2 entered Resident #119's room and removed the resident's breakfast from her over-bed table. -CNA #2 did not move Resident #119's call light so it was within the resident's reach. On 6/4/25 at 9:21 a.m. Resident #119 was lying in bed. Resident #119's call light was clipped to the top of her bed above her head. Resident #119's call light cord was stretched out from the wall completely without any slack. C. Record review The ADL care plan, revised 2/19/25, revealed Resident #119 had ADL performance deficits due to weakness and arthritis. The care plan documented Resident #119 required one to two staff members to assist with toilet use, transfers, bed mobility, bathing and eating. The pressure ulcer care plan, revised 2/19/25, revealed Resident #119 was at risk for pressure ulcer development. Pertinent interventions included keeping Resident #119's call light within reach. III. Resident #120 A. Resident status Resident #120, age [AGE], was admitted on [DATE]. According to the June 2025 CPO, diagnoses included cerebral infarction (stroke), repeated falls, muscle wasting and fracture of the right femur (thigh). The 5/19/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of eight out of 15. The resident required substantial to maximal assistance for most ADL. B. Resident interview and observations Resident #120 was interviewed on 6/4/25 at 1:12 p.m. Resident #120 said he often had a hard time reaching his call light. Resident #120 said he had told his nurse about not being able to reach his call light, and the nurse told him she was working with maintenance to get another call light cord. Resident #120 was lying in bed with his call light cord clipped to the top of his bed with over a foot of space between the resident's head and the call light. Resident #120's call light was plugged into a receptacle directly behind the resident's bed. Resident #120 attempted to reach for his call light but could not grasp it. On 6/5/25 at 9:18 a.m. Resident #120 was lying in bed with his call light cord clipped to his bed underneath his pillow. C. Record review The ADL care plan, revised 3/4/25, revealed Resident #119 had ADL performance deficits due to weakness, stroke and right hip fracture. The care plan documented Resident #119 required one to two staff members to assist with toilet use, transfers, bed mobility, bathing and eating. The pressure ulcer care plan, revised 3/4/25, revealed Resident #120 was at risk for pressure ulcer development. Pertinent interventions included keeping Resident #120's call light within reach. IV. Staff interviews CNA #2 was interviewed on 6/4/25 at 4:15 p.m. CNA #2 said she clipped the residents' call light cords to their beds so if they had mobility issues they could easily reach them. CNA #2 said Resident #119's call light cord was not long enough to clip to her bed, so she laid it across her over-bed tray and placed the resident's belongings on the cord so it would not fall off. CNA #3 was interviewed on 6/5/25 at 9:42 a.m. CNA #3 said Resident #119's call light was placed on her side table so she could see it. CNA #3 said Resident #119 was able to reach her call light and use it when it was on her side table. CNA #3 said Resident #120 was able to reach his call light when it was placed behind him. CNA #3 said Resident #120's call light was placed behind him due to the location of his bed. The social services director (SSD) was interviewed on 6/5/25 at 10:53 a.m. The SSD said she had never received any grievances from Resident #119 or Resident #120 regarding call lights. The SSD said she had not heard about any issues with the residents' call light cord lengths, but she would talk to Resident #120 and Resident #119 and ensure their call lights were long enough and within reach. Licensed practical nurse (LPN) #1 was interviewed on 6/5/25 at 10:58 a.m. LPN #1 said she preferred when the nursing staff clipped residents' call lights to their bed so they could reach them. LPN #1 said Resident #119 could sometimes reach her call light if it was on her side table, but was unable to reach it other times. LPN #1 said Resident #119 preferred to have her call light near her in bed. LPN #1 said Resident #119 needed help with getting out of bed and incontinence care. LPN #1 said Resident #119 never mentioned to her that her call light cord was too short. LPN #1 said Resident #120 could reach and use his call light when it was positioned above his head. -However, observations Revealed Resident #120 was unable to reach his call light when it was clipped to the bed sheets above his head (see observations above). LPN #1 said Resident #120 used his call light to get help with getting out of bed or when he needed tissues. LPN #1 said Resident #120 occasionally lost his call light cord under his blanket or behind his bed. The DON was interviewed on 6/5/25 at 11:53 a.m. The DON said when residents were in bed their call light should be within reach by being clipped on their bed, pillow or gown. The DON said she had not heard about any issues with Resident #119 or Resident #120's call light cord length but would look into the issue.

Based on observations, record review and interviews, the facility failed to ensure one (#53) of five residents out of 43 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to ensure the physician's orders for Resident #53 contained the appropriate dose of the medication that was to be administered to the resident. Findings include: I. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 6/11/25 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Incorrect dosage is a prevalent modality of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct medication and the patient's identity is verified, without first checking to ensure it is the correct strength for the patient. According to the NIH, National Library of Medicine, hydrocortisone cream 1% cream (May 2025), retrieved on 6/11/25 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9987165c-1a0f-dd57-e053-2a95a90ae735, Apply to the affected area not more than three to four times a day. According to the NIH, National Library of Medicine, miconazole nitrate 2% cream, (June 2024), retrieved on 6/11/25 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e66191a6-0c3c-7319-e053-2a95a90aae84, Clean the affected area and dry thoroughly. Apply a thin layer of the product over the affected area twice daily (morning and night) or as directed by a healthcare professional. II. Facility policy and procedure The Medication Administration policy and procedure, revised 10/1/23, was provided by the director of nursing (DON) on 6/5/25 at 3:51 p.m. It read in pertinent part, Five rights: right resident, right drug, right dosage, right route, right time are applied for each medication being administered. III. Resident #53 A. Resident status Resident #53, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician order (CPO), diagnoses included vascular dementia, hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction affecting the left non dominant side, type 2 diabetes mellitus and mesothelioma (a rare and aggressive cancer that develops in the lining of certain tissues). The 3/24/25 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and his cognitive skills for daily decision making were severely impaired. He was dependent on staff assistance for eating, oral hygiene, toileting, showering, dressing and personal hygiene. The MDS assessment revealed the resident received applications of ointments and medications other than to his feet. B. Observation On 6/4/25 at 1:00 p.m. Resident #53 was sitting in his Broda chair in the hallway next to his room. His abdomen was exposed and there were multiple red spots across his abdomen. C. Record review Review of the June 2025 CPO revealed Resident #53 had the following physician's order: Wound care: Rash to the body. Mix prednisone cream and antifungal cream and apply every shift to the affected body area until resolved. Every shift for rash, ordered 5/19/25. -The physician's order did not include a dose or measurement to direct the nursing staff how much cream to apply to the affected areas with each administration of the medicated treatment. IV. Staff interviews The hospice registered nurse (HRN) was interviewed on 6/3/25 at 3:18 p.m. The HRN said Resident #53 had had skin issues the last couple of months. She said he had a rash on his trunk, his back, his arm and in his arm pits. She said the rash was due to heat. She said when the resident was hot and sweated, the rash was worse. She said the facility recently changed the resident's skin treatment plan. She reviewed the physician's order and she said the order was confusing because she said she did not know how much antifungal cream and how much steroid cream to put on the affected areas. She said if she was the nurse providing the skin care, she would call the physician to clarify how much to use of each cream. Registered nurse (RN) #2 was interviewed on 6/4/25 at 3:57 p.m. RN #2 said he was familiar with Resident #53. He said he provided skin care for the resident's rash today (6/4/25). During the interview, RN #2 went to the treatment cart and displayed the two creams he applied to Resident #53' affected areas. The two creams RN #2 displayed were hydrocortisone cream 1% cream (steroid cream) and miconazole nitrate 2% cream (antifungal cream). He said he measured 4 centimeters (cm) of each cream and mixed the cream in a plastic cup (approximately one ounce) before he applied the cream to the resident's affected areas. He said Resident #53 had a rash on his hands, his chest, his stomach and on his back. He said he determined to use four cm of each cream based on his nursing judgement. Licensed practical nurse (LPN) #2 was interviewed on 6/5/25 at 10:52 a.m. LPN #2 said he was familiar with Resident #53. He said he provided skin care for the resident's rash today (6/5/25). He said he applied a thin layer of a steroid cream and a thin layer of antifungal cream to the resident's affected areas. LPN #2 said he used as much as possible of the steroid cream and the antifungal cream to cover the body areas affected. He said the resident had a rash on his whole body but mostly on his upper torso. He said the facility tried everything from ointments, to creams to antibiotics, to resolve the resident's rash. LPN #2 said the current plan was to provide the resident with a daily shower, apply the two creams, keep him as dry as possible and provide the skin treatment. He said he determined to use a thin layer of cream based on best nursing practice. The DON was interviewed on 6/5/25 at 1:35 p.m. She said some of the key components of a prescription were the right route, the right resident and the right frequency. She said if the physician left a component out of the prescription, such as the amount to administer, the nurse should contact the physician to clarify the order prior to administering the medication. She said she was not aware Resident #53's prescription creams did not say how much for the nurse to administer. She said the nurses should have clarified how much to use with each administration with the physician.

Based on record review and interviews, the facility failed to ensure one (#1) of one resident was free from mental anguish out of three sample residents. Resident #1 was admitted to the facility on [DATE] for long term care with a diagnosis of diagnoses included developmental disabilities, dementia, depression, anxiety, schizophrenia (mental illness), myocardial infarction (heart attack), nicotine dependence, hypertension (high blood pressure), coronary heart disease and chronic obstructive pulmonary (lung) disease (COPD). On 12/7/24, the facility staff noticed Resident #1 had a pipe used to smoke methamphetamines. The nursing home administrator (NHA) approached Resident #1 in order to find out where the resident was purchasing the drugs. The NHA asked Resident #1 if he could observe the resident purchase drugs to determine who was selling the drugs within the facility. Resident #1 told the NHA that he did not have any money. The NHA provided Resident #1 with $20 to purchase methamphetamines, so he could determine who was selling the drugs. The NHA watched Resident #1 approach Resident #2 and purchase methamphetamines. The NHA confiscated the drugs and the pipe from Resident #1. The NHA notified the police of the incident. Resident #1 suffered mental anguish from the drug buying incident the NHA arranged. Resident #1 reported he felt he needed to purchase the drugs to prove to the NHA that he was not a drug dealer. Resident #1 said he was afraid and the incident made him feel uncomfortable. Resident #1 said he was staying in his room longer as he was afraid he was going to get kicked out of the facility or arrested. Findings include: I. Facility policy and procedure The Abuse Prevention and Reporting policy, revised August 2024, was provided by the director of nursing (DON) on 4/3/25 at 4:57 p.m. It read in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, neglect, and exploitation. Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, or other individuals. All allegations of abuse are investigated. 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 abuse will immediately report to the charge nurse. The staff member will intervene to ensure the resident is safe during the investigation. The staff member will notify the administrator or designee immediately. The staff member will report suspicion of a crime against a resident. Social services will provide ongoing support and counseling to the resident and other residents as needed. The administrator will complete the investigation and implement corrective action based on the investigation findings. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included developmental disabilities, dementia, depression, anxiety, schizophrenia , myocardial infarction , nicotine dependence, hypertension , coronary heart disease and COPD. The 1/3/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent with activities of daily living. B. Resident interview Resident #1 was interviewed on 4/3/25 at 2:15 p.m. Resident #1 said the nursing home administrator (NHA) approached him and said a staff member saw him outside the facility with a pipe used for drugs. Resident #1 said he told the NHA the pipe was not his. Resident #1 said he told the NHA that another resident, Resident #2, sold drugs from inside the facility. Resident #1 said the NHA wanted to know which resident sold the drugs. Resident #1 said when he told the NHA, the NHA asked him if he would return and buy drugs from Resident #2. Resident #1 said he told the NHA that he did not have any money to buy drugs. Resident #1 said the NHA called him a drug user and drug dealer. Resident #1 said the NHA said he would provide him with money to purchase the drugs from Resident #2. Resident #1 said the NHA wanted to watch Resident #2 purchase drugs. Resident #1 said he agreed to the deal to prove to the NHA he was not a drug dealer. Resident #1 said the NHA gave him two ten-dollar bills and they went to Resident 2's room. Resident #1 said he entered Resident #2's room and purchased the drugs. Resident #1 said he was unaware when the NHA entered the room and said the NHA took the drugs. Resident #1 said he told the NHA he had used drugs and was a drug runner for Resident #2. Resident #1 said after the drug incident the NHA and the DON told him he could not enter the unit where Resident #2 resided. Resident #1 said that it upset him because he had friends who were residents there, and he enjoyed visiting and participating in bingo and other activities with those friends. Resident #1 said he felt bad because he considered Resident #2 a friend and was scared about her being arrested. Resident #1 said before the drug purchase, no staff member reviewed with him what could happen during and after the drug purchase. He repeated that he participated in the set-up just to prove to the NHA he was not the drug dealer. Resident #1 said he cooperated with the police investigation because he thought he did not do anything wrong. Resident #1 said he thought he would not get into trouble because he bought the drugs for the NHA and not for another resident. Resident #1 said the officer told him if Resident #2 was arrested, he and the NHA would also be charged because they participated in the drug-buying set-up. Resident #1 said he was scared and fearful of the police because he would be charged. Resident #1 said he was afraid that the NHA would discharge him from the facility Resident #1 said he had since talked with the NHA to see if things were good because he felt scared. Resident #1 said none of the facility staff helped him determine if he was at risk with the police, so he reported the investigation to his sister. Resident #1 said he told her he wanted to resume counseling services with his preferred provider. Resident #1 said that he felt bad and afraid after the incident. He said that he stayed in bed longer because he was scared of the police and felt bad for what happened to Resident #2. Resident #1 said he had received counseling at the facility. He said he was unhappy with the service because the provider talked to him about breaking the facility rules with drugs. He said the meetings were held in common areas instead of in a private location. Resident #1 said he wanted to return to a prior counselor because he wanted to talk in a different environment. Resident #1 said he still felt upset that he was used in a drug set-up. He said he still had some fear he would be arrested and discharged from the facility. He said he still heard nursing and therapy staff refer to him as a drug dealer. He said he enjoyed living in the facility. C. Resident #1's family interview Resident #1's sister was interviewed by telephone on 4/3/25 at 5:32 p.m. She said she was not informed on 12/7/25 that her brother had been involved in a drug investigation and that he had reported he used methamphetamine. The sister said she was notified of the drug purchase in mid-January 2025, when Resident #1 spoke to her about being afraid of a nurse and said he was upset that the staff called him a drug dealer. The sister said Resident #1 told her he wanted to change mental health providers because he was uncomfortable talking about his concerns in the facility. The sister said Resident #1 was still upset that he was used to buy drugs and told her he was still afraid of having to discharge from the facility. The sister said the resident was still upset that the staff called him a drug dealer. D. Facility investigation The facility investigation regarding Resident #1 was requested from the DON on 4/3/25. The DON said there was no documentation for the investigation related to the drug purchase incident. E. Care plan review The cognitive impairment care plan, revised 2/16/24, revealed the resident was at risk for cognitive function or impaired thought process related to intellectual disability and schizophrenia. Pertinent interventions included administering medications as ordered, communicating with the family/caregivers regarding the residents capacity as needed, giving step-by-step instructions to support cognitive function, monitoring for changes in cognitive function and reporting to the physician as needed and to provide psychosocial support through social services as needed. F. Record review An undated notification that was sent to the police by the NHA was provided by the DON on 4/3/25 at 11:15 a.m. It read in pertinent part, Earlier today, Resident #1 was found with a methamphetamine pipe in his room. The NHA immediately notified the police, who came to investigate (However, the police came to investigate two days after the incident on 2/9/24). During the conversation with Resident #1 he disclosed he had been receiving drugs from another resident (Resident #2). To address this issue, the NHA and the DON accompanied Resident #1 the next time he attempted to purchase drugs. This led to the identification of the resident involved in selling, who was caught in the act. The police confiscated the drugs and the ombudsman was notified. Resident #1 cooperated with law enforcement. Resident #1 was no longer able to visit the unit where Resident #2 resided. At this time, no further issues had been noted, but the facility would continue to monitor closely. The note was signed by the NHA. The local police department investigation report, dated 12/9/24, was provided by the police department. It read in pertinent part, The report documented on 12/9/24 at approximately 12:53 p.m., the officer was dispatched to the facility on a narcotics violation (two days after the incident). Upon arrival, the NHA was contacted and said there was a drug problem inside the facility. The NHA said he found out who he believed was supplying the drugs. The NHA said he observed a male (Resident #1) who had a pipe used for drugs in his possession. The NHA had Resident #1 tell him where he got the drugs. The NHA reported to the officer he conducted a sting operation with Resident #1 and went to where Resident #1 said he got the drugs from. The NHA identified another resident (Resident #2) as the one who was supplying the drugs. The NHA reported to the officer he gave Resident #1 $20 to buy methamphetamine from Resident #2. The NHA said that he stood outside of the room in a spot where Resident #2 could not see him, when Resident #1 bought methamphetamine from Resident #2. The police report read the NHA gave what appeared to be methamphetamine and a pipe used to smoke methamphetamine to the officer. The officer took pictures of the items and the items were confiscated. The police report read the NHA told the officer he believed Resident #2's son was a drug dealer and he brought the drugs to the resident to sell. The police report read the NHA reported Resident #2 used Resident #1 as a runner to deliver drugs to another resident, and the NHA reported he believed that resident had $40 worth of methamphetamine from the suspected resident/supplier and had attempted to locate the drugs but had not found the drugs. The police report revealed the police officer contacted Resident #1, who was developmentally delayed. Resident #1 told the officer he had received drugs from Resident #2 at least 12 times and that he also brought the drugs to another resident. The police report revealed Resident #1 told the officer that Resident #2 gave him methamphetamine for delivering the drugs to the other resident. The police report revealed Resident #1 reported he was the go-between man for the suspected supplier. Resident #1 told the officer he suspected Resident #2 kept the drugs in a drawer. The clinical record review did not reveal progress notes, assessments, or physician notifications related to Resident #1's involvement in a drug investigation. III. Staff interviews The DON was interviewed on 4/3/25 at 11:06 a.m. The DON said she was aware of the drug set-up investigation completed by the NHA. The DON said the staff had suspected Resident #2 had been dealing drugs but had been unable to catch the resident in the act. The DON said she was aware that the NHA met with Resident #2 after he completed the drug purchase set-up. The DON said the NHA issued Resident #2 a 30-day discharge notice because the NHA observed her provide methamphetamine to Resident #1. The social services director (SSD) was interviewed on 4/3/25 at 1:40 p.m. She said she coordinated the change in mental health counselors for Resident #1. She said she was unaware of why Resident #1 wanted to change providers. The SSD said she was aware Resident #1 had bought illegal substances and was found with a drug pipe. She said she checked on Resident #1 occasionally and he had not reported concerns to her. The NHA was interviewed on 4/3/25 at 2:15 p.m. He said he wrote and sent the message on 12/7/24, the day of the occurrence, to the police and the ombudsman. The NHA said this document was sent by email and was used to report the occurrence (see staff notification above). The NHA was interviewed again on 4/3/25 at 3:15 p.m. The NHA said he had suspected there was a drug problem in the facility. The NHA said the staff had been talking about drugs being used in the facility but had not heard that from any residents. The NHA said after an employee reported she saw Resident #1 with a drug pipe, he responded by investigating the situation. The NHA said he went to Resident #1's room and found a drug pipe. The NHA said he spoke with Resident #1, who told him that he got drugs from Resident #2. The NHA said Resident #1 said he also delivered drugs to another resident in the facility. The NHA said he asked Resident #1, if he could go with him the next time he went to get drugs. The NHA said Resident #1 told him he could go to Resident #2 to get drugs but needed money. The NHA said he provided Resident #1 with $20 and he went with Resident #1 to buy the drugs. The NHA said he confiscated the drugs during the purchase and notified the police. The NHA said he kept the drugs in his office to give to the police. The NHA said he knew Resident #1 was developmentally delayed, but did not abuse Resident #1 in any way. -However, Resident #1 suffered mental anguish and fear from the drug buying incident that was set up by the NHA. The NHA said Resident #1 agreed to help and participate in the drug purchase and said he felt it was the opposite of abuse. The NHA said he successfully identified the drug dealer and stopped drugs from reaching residents. He said by doing that, he prevented drug overdoses and deaths. The NHA said that after the investigation, he notified the facility's legal department about the situation. The NHA said the legal department's feedback was that they approved and told him he did a great job. The NHA said he did not have investigation documents because there was nothing to investigate. The NHA said after discovering and confirming that illegal drugs were in the facility, he did not interview other residents or staff members. He said he interviewed Resident #1 and Resident #2 and identified the parties that were involved. The NHA said there was no reason to go further with interviewing other residents.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one (#20) of four residents reviewed for accident hazards out of 29 sample residents. Resident #20, who had severely impaired daily decision-making skills, was admitted on [DATE]. The facility determined the resident to be at risk for falls upon her admission and implemented a care plan with generalized fall risk interventions that were not individualized for Resident #20. Resident #20 sustained falls with minor injuries on 5/3/24, 5/10/24 and 5/16/24. Per interviews during the survey (from 7/12/24 to 7/16/24), the facility added fall interventions following each of the falls, however, the facility failed to update the interventions on the resident's care plan or ensure staff were consistently implementing the identified fall interventions for the resident. The facility additionally did not evaluate the fall interventions to determine if the interventions were effective. On 7/8/24, Resident #20 sustained another fall, which resulted in the resident being transferred to the hospital for further evaluation, where it was discovered that she had sustained a fractured nose from the fall. Observations during the survey revealed the resident was not always wearing appropriate footwear (non-skid socks or shoes), as had been identified as a fall intervention. Additionally, the resident did not have a call light in her room, despite one of the fall interventions instructing staff to ensure the call light was within reach of the resident. Due to the facility's failures to identify and consistently implement individualized person-centered fall interventions, and update the resident's care plan with new fall interventions that were identified, Resident #20 sustained four falls within a three month period between 4/25/24 and 7/8/24, with the last fall on 7/8/24 resulting in a fracture to the resident's nose. Findings include: I. Facility Policy The Falls Monitoring and Management policy, undated, was provided by the director of nursing (DON) on 7/10/24 at 5:28 p.m. The policy read in pertinent part, Residents are assessed and evaluated to identify risks for injury due to falls. Residents receive necessary treatment and monitoring after a fall and interventions are implemented to minimize risks for injury due to falls. II. Resident status Resident #20, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies, cognitive communication deficit and diabetes. The 5/1/24 minimum data set (MDS) assessment revealed the resident was rarely/never understood and had short-term and long-term memory problems and her daily decision-making was severely impaired. She was dependent on staff for personal hygiene, dressing, bathing, toileting and oral hygiene. She also needed setup and clean-up for meals. She was dependent on staff for bed mobility, and needed supervision or touching assistance for walking and sitting to standing, while needing substantial assistance with transferring from chair to bed and bed to chair. She was frequently incontinent of bladder and always incontinent of bowel. III. Observations On 7/10/24 at 11:00 a.m., Resident #20 was observed getting up from her chair and beginning to walk. The brakes on the resident's wheelchair were not locked. The resident's representative was in the room and asked for the resident to sit down. The resident did not sit back down until she was encouraged to sit back down. She did have non-slip socks on. On 7/11/24 at 11:35 a.m., the resident was sitting in her wheelchair. She was self propelling with her feet. -Resident #20 had socks on her feet, however they were not non-slip socks. Certified nurse aide (CNA) #3 said the resident was at risk for falls and staff needed to ensure she had proper footwear on, which would be non-slip socks or shoes. On 7/11/24 at 2:00 p.m. Resident #20's room was observed. -There was no call light in the resident's room, however, ensuring the call light was within reach was one of the resident's care planned fall interventions (see record review below). On 7/12/24 at approximately 5:00 p.m. the resident was sitting in her wheelchair. -Resident #20 had socks on her feet, however, they were not non-slip socks. CNA #2 was interviewed on 7/12/24 at approximately 5:00 p.m. CNA #2 said the resident was at risk for falls and staff needed to ensure she had proper footwear on, which would be non-slip socks or shoes. IV. Resident representative interview Resident #20's representative was interviewed on 7/10/24 at 11:41 a.m. The representative said Resident #20 had resided at the facility since April 2024. She said since the resident had resided at the facility, she had fallen four times. She said Resident #20 fractured her nose during her most recent fall on 7/8/24. The representative said the resident had been at risk for falling prior to her admission to the facility and the facility was aware of the resident's fall history. She said the resident was not always toileted timely and that could be a contributing factor to the falls. The representative said the facility had just placed a lipped mattress on the resident's bed after the fall on 7/8/24. The representative said the Resident #20 was not on a walking program, but she frequently would stand up and try to walk on her own. -The lipped mattress was not added to Resident #20's care plan. V. Record review The fall care plan, initiated on 4/29/24, identified Resident #20 was at risk for falls related to the resident's confusion and impaired safety awareness. Pertinent interventions included to ensure the call light was within reach, resident to wear proper footwear when ambulating or wheeling in wheelchair and to maintain a clear pathway. -There were no interventions added to the resident's care plan following the resident's falls on 5/3/24, 5/10/24, 5/16/24 or 7/8/24. The Kardex (a tool utilized for providing consistent care for residents), dated 7/12/24, documented the safety interventions which in place for Resident #20 were to provide frequent checks and ensure the resident was wearing appropriate footwear when walking or wheeling her wheelchair. Review of Resident #20's fall risk assessments revealed the following: -On 4/25/24, Resident #20's fall risk score was documented as an eight, which indicated she was a medium fall risk; -On 5/3/24 Resident #20's fall risk score was documented as a 13, which indicted she was a high fall risk; -On 5/11/24 Resident #20's fall risk score was documented as a 13, which indicted she was a high fall risk; -On 5/16/24 Resident #20's fall risk score was documented as a nine, which indicted she was a medium fall risk; and, -On 7/8/24 Resident #20's fall risk score was documented as a 13, which indicted she was a high fall risk. -Resident #20 was incorrectly assessed as a medium hall risk on 5/16/24 despite the resident sustaining falls on 5/3/24, 5/10/24 and 5/16/24. A. Fall #1 The 5/3/24 fall investigation documented Resident #20 fell on [DATE] and was found laying on her right side in the hall. The resident sustained a large hematoma (an injury which causes blood to pool under the skin) forming on the back right side of her head. The investigation documented the resident was confused, drowsy, incontinent and ambulating without assistance. The investigation further documented the predisposing psychological factors were confusion, drowsy, incontinence and impaired memory. The predisposing situation factors were ambulating without assistance and being a wanderer. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 5/3/24 at 5:18 a.m. documented the registered nurse (RN) heard a loud thud and noted the resident laying on the floor on her right side. The resident had been walking in the hallway. A CNA was walking toward the resident with the resident's wheelchair when the fall occurred.The RN assessed the resident and found a large hematoma forming on the back right side of her head. The resident was assisted up into a waiting wheelchair and brought to the nurses station. Neurological checks were started on the resident. The 5/3/24 post fall interdisciplinary team (IDT) note documented the resident was found on the floor. She could not explain what happened. The note documented more frequent checks were to be provided when the resident was in her room. -However, the intervention for more frequent checks was not added to the resident's care plan. B. Fall #2 The 5/10/24 fall investigation documented the resident was refusing to sit down and Resident #20 was found laying on the floor on her right side in the common area living room. She had a small one millimeter (mm) by two mm bruise to her eye and a bruise on her leg. The investigation documented the resident was ambulating without assistance. The investigation further documented the predisposing psychological factors were confusion, gait imbalance, recent change in medication and impaired memory The predisposing situation factor was ambulating without assistance. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 5/11/24 at 1:03 a.m. documented the resident fell on [DATE]. The resident had been refusing to go to her room or sit in her wheelchair and was wide awake. The resident was on the other side of a wall. A RN who was nearby heard a noise and went to assess. Resident #20 was found laying in front of her wheelchair on her right side on the floor. The RN assessed the resident and found bruises on the resident's right lateral eye orbit, left side of her face near the temple area and her right lower leg. The resident was alert and able to follow simple directions. The resident was assisted to stand by a CNA and the RN, placed into her wheelchair and positioned within view of the nurses station. Neurological checks were started on the resident. -Review of Resident #20's electronic medical record (EMR) revealed there was no documentation to indicate the IDT reviewed the resident's 5/10/24 fall or that new fall interventions were implemented. C. Fall #3 The 5/16/24 fall investigation documented the resident slid to the floor from her wheelchair. The resident did not sustain any injuries. The investigation documented the predisposing psychological factor was confusion. The predisposing situation factor was she was a wanderer. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 5/16/24 at 8:25 p.m. documented Resident #20 was in the front entrance hallway of the facility and was observed sliding from her wheelchair to the floor in a seated position and then laying herself flat on her back. There were no injuries observed and neurological checks and vital signs were initiated. The 5/17/24 post fall IDT note documented the resident slid from her chair near the front door. Frequent checks and an occupational therapy wheelchair evaluation were documented as prior fall interventions. The new fall intervention added was for the occupational therapist to screen for adding dycem (a non-slip material used under wheelchair cushions) to the resident's wheelchair. -However, the interventions for frequent checks and dycem to the wheelchair were not added to the resident's care plan. D. Fall #4 The 7/8/24 fall investigation documented Resident #20 was face down on the floor bleeding from her nose and the right side of her head. The resident was sent to the emergency department. The resident had facial grimacing. The fall happened in the hallway. The investigation documented the predisposing psychological factors were gait imbalance, impaired memory and confusion. The predisposing situation factor was she was a wanderer. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 7/8/24 at 11:33 p.m. documented the resident was observed on the floor face down bleeding from the bridge of her nose and the right side of her head. She had bruising and swelling noted to her face and her pupils were unequal. The resident was sent to the hospital for further evaluation and treatment. A nurse progress note dated 7/9/24 at 3:33 a.m. documented the resident had returned from the hospital. A nurse progress note dated 7/9/24 at 3:48 a.m. documented the resident had a fractured nose with swelling and bruising noted. The 7/8/24 post fall IDT note documented the resident had been found in her room laying on the floor with a fractured nose. The prior interventions listed were for occupational therapy to screen for wheelchair safety and dycem and frequent checks. The current new intervention was to lay the resident down when she appeared fatigued. -However, none of the interventions were added to the resident's care plan. VI. Staff interviews RN #1 was interviewed on 7/12/24 at 11:30 a.m. RN #1 said the resident had memory impairments and dementia. He said the resident could walk with assistance but she was not on a walking program. RN #1 said the resident's dementia was worse later in the day and the interventions the facility used to keep her safe were keeping an eye on her and ensuring she was wearing proper footwear. -However, observations during the survey revealed the resident was not consistently wearing non-slip socks or shoes (see observations above). The DON was interviewed on 7/12/24 at 3:42 p.m. The DON said residents were assessed for fall interventions upon admission, quarterly and after each fall. She said the falls were to be analyzed the day of or the day after a fall in the facility's morning meetings and as a IDT they talked about what interventions had worked to prevent falls and which ones had not. The DON said the IDT came up with new interventions and implemented them after the falls. The DON said Resident #20 was found laying on her right side on 5/3/24 and that she had a hematoma on her head. She said they implemented frequent checks. -However, the intervention was not added to the resident's care plan. The DON said the resident fell on [DATE] in front of her wheelchair. She said she received a laceration on her eye. She said that the resident's representative did not want to move her room. She said the occupational therapist screened for a new wheelchair. However, she said the resident's family did not wish to change the chair. -However, the intervention was not added to the resident's care plan and there was no documentation the resident's family had declined a room move or a new wheelchair for the resident. The DON said Resident #20 fell on [DATE] when she slid to the floor onto her back. She said dycem was placed in the wheelchair under the cushion. -However, the intervention was not added to the resident's care plan. The DON said the resident fell on [DATE] and was sent to the emergency department for evaluation and treatment. She said Resident #20 had a fractured nose. The MDS coordinator (MDSC) was interviewed on 7/12/24 at approximately 6:00 p.m. The MDSC said she completed the MDS assessments and also the residents' care plans. She said the fall intervention for Resident #20 to have her call light within reach was not an appropriate intervention for the resident because she did not have a call light in her room.

Based on record review and interviews, the facility failed to ensure two (#23 and #1) of nine residents reviewed for weight loss out of 29 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being Resident #23, admitted at nutritional risk and lost 14 pounds in six weeks. While nutritional interventions were initiated on admission (supplements three times a day) and again when a significant weight loss was identified on 6/20/24 (fortified foods), observations revealed the facility failed to promote the resident's nutritional status by encouraging, cueing and assisting the resident at mealtime, documenting his intake of snack and supplement, and addressing his agitation in the dining room at mealtime. No new interventions were considered when the resident continued to lose weight. Additionally, the facility failed to weigh Resident #1 upon admission to create a baseline to assess the resident's weight and nutritional status. Findings include: I. Facility policy and procedure The Weights policy, revised May 2017, was provided by registered dietitian consultant (RDC) #1 on 7/12/24 at 12:20 p.m. It read in pertinent part, It is the policy of this facility to obtain an accurate weight as part of the resident's assessment upon admission and at least monthly thereafter. Nursing will be responsible for the initial determination of each individual's weight. Admission weights will be obtained. This will be included in the admission process and documented in the medical record. If hospital weight is entered, it should be listed as'type of scale used. ' The facility is responsible for obtaining correct weights on a regular basis, and for keeping accurate records. This includes having adequate weight scales, lift scales and/or wheelchair scales as needed. Erroneous (incorrect) weights may be struck out when determined inaccurate. Reweighs may be requested if a discrepancy is presumed or if a significant weight change is noted to assure accuracy of the weight. Individuals with unplanned significant or severe weight loss may receive nutrition interventions to prevent further weight loss, stabilize weight and/or assist to regain weight as appropriate. II. Resident #23 A. Resident status Resident #23, age 84, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included senile degeneration of the brain, anxiety, hyperglycemia (high blood sugar), protein-calorie malnutrition, dysphagia oropharyngeal phase (difficulty swallowing), muscle weakness, muscle wasting and atrophy multiple sites (partial or complete wasting of the muscles). The 5/28/24 minimum data set (MDS) assessment revealed the resident was rarely or never understood through staff assessment. The resident had short-term and long-term memory deficits and was severely impaired in daily decision-making through staff assessment. The resident required set up and clean up assistance for meals and was dependent for all other activities of daily living (ADL). The assessment revealed the resident had complaints of difficulty or pain of swallowing, was on a mechanically altered diet and showed none or had unknown weight loss or weight gain. B. Observations On 7/9/24 at approximately 5:06 p.m., an unidentified staff member served Resident #23 dinner. Resident #23 was able to eat approximately 25% of his dinner and drink 100% of his beverages. -Resident #23 was not encouraged, cued or assisted by staff. -No alternates, refills or seconds were offered to Resident #23 before he was assisted out of the dining room. On 7/10/24 at approximately 12:05 p.m. Resident #23 was served his lunch meal. He was eating his lunch with no issues. -Resident #23 was not encouraged, cued or assisted by staff. At approximately 12:15 p.m. Resident #23 accidentally knocked his plate over the side of the table which spilled his plate of food down the front of himself and onto the floor. Resident #23 had consumed less than 25% of his meal. The resident was assisted out of the dining room and into the common area. -The resident was not offered a new meal after his lunch spilled on the ground. C. Record Review The nutrition care plan, dated 5/23/24, revealed the resident had a nutritional problem related to the diagnoses of dementia and hyperglycemia. The care plan documented the resident was malnourished and had a history of weight loss based on hospitalization s prior to admission to the skilled nursing facility. Pertinent interventions included honoring his right to make dietary choices, monitoring and reporting signs and symptoms of decreased appetite and unexpected weight loss to the physician, monitoring weekly weights for four weeks, monitoring intake and the registered dietitian (RD) would monitor the resident's ongoing nutritional status. -Resident #23's care plan did not identify weight loss was expected for the resident and there were no updates made to the care plan when significant weight loss was identified (see record review below). The July 2024 CPO revealed the resident had a physician's order to receive MedPass 2.0 (nutritional supplement) 120 ml (millileters) three times a day, ordered 5/24/24. The June 2024 and July 2024 medication administration records (MAR) revealed that MedPass 2.0 120 ml was being given to the resident three times a day and the resident was consistently consuming 100% of the supplement. -However, the amount of the supplement was not increased or another nutritional supplement added when the resident continued to lose weight until 6/25/24 when the RD added fortified foods. Resident #23's weights were documented in the resident's electronic medical record (EMR) as follows: -On 5/22/24, the resident weighed 153.5 lbs; -On 6/5/24, the resident weighed 150 lbs; -On 6/13/24, the resident weighed 147.5 lbs; -On 6/20/24, the resident weighed 142 lbs; -On 6/24/24, the resident weighed 140.5 lbs; and, -On 7/1/24, the resident weighed 139.0 lbs. -The resident lost 14.5 lbs (9.5%) from 5/22/24 to 7/1/24, in 40 days, which was considered significant. The 5/23/24 mini nutritional assessment (MNA) score was a six, which indicated that he was malnourished upon admission. The 5/24/24 admission nutritional assessment documented the resident's weight was 153.5 lbs upon admission. It documented his mini nutritional assessment risk score was a six, which indicated the resident was malnourished. The RD documented the resident was consuming 75-100% of most meals. The RD recommended starting 120 ml MedPass 2.0 three times a day, which would provide 720 calories and 30 grams protein per day. The assessment documented the RD would continue to monitor and follow up as needed. The 6/25/24 RD progress note documented the RD spoke to the resident's representative about the resident's weight loss and recommended fortified meals to help reduce further weight loss. The resident's representative agreed with the intervention. The 6/25/24 nutrition at risk committee documented the resident's current weight was 140.5 lbs. The committee reviewed the resident's weight loss, which was down 13 lbs from the admission weight. The committee determined the resident's weight loss might have been related to fluctuating intake at meals and the disease progression. The resident's representative said the resident enjoyed peanut butter and honey. The note documented the recommendation was to assist the resident at meals to help reduce further weight loss. The physician was notified of the weight loss and was requested to evaluate for a possible appetite stimulant. The 7/1/24 progress note revealed the resident was placed on hospice with the diagnosis of senile degeneration of the brain. A review of Resident #23's intake meal record on 7/11/24 at 11:37 a.m., revealed the amount the resident had consumed of his meals from 6/12/24 to 7/11/24 was as follows: -25% of meals on 23 occasions; -50% of meals on 21 occasions; -75% of meals on 12 occasions; -100% of meals on 28 occasions; - refusal noted one time; and, - no documentation on two occasions. A decline in the resident's meal intakes was noted between 7/5/24 and 7/11/24, following the resident's admission to hospice. D. Staff interviews Registered nurse (RN) #1 was interviewed on 7/11/24 at 4:00 p.m. RN #1 said Resident #23 should have been given another meal when he had spilled his first one. He said the resident was able to feed himself. RN #1 said Resident #23 required encouragement and oversight with eating. RN #1 said the certified nurse aides (CNA) were responsible for documenting the amount each resident consumed at meals. CNA #3 was interviewed on 7/12/24 at 11:45 a.m. CNA #3 said snacks were offered to the residents throughout the day. She said if a resident did not like something (snacks or meals), the staff would go and get them what they wanted. CNA #3 said the CNAs would chart how much each resident ate after the resident was finished eating. The dietary manager (DM) was interviewed on 7/12/24 at approximately 10:00 a.m. The DM said the satellite kitchen in the secured area had extra pureed food. The DM said the staff should have offered Resident #23 a new meal after he spilled his food. RDC #2 was interviewed on 7/12/24 at approximately 2:00 p.m. RDC #2 said Resident #23 had first experienced a three pound weight loss. She said because the resident did not have a significant weight loss, the facility did not implement a new intervention since he was already on the prescribed health shake upon admission. She said, on 6/20/24, the resident had experienced a significant weight loss. She said after the resident triggered for significant weight loss, the interdisciplinary team (IDT) began reviewing the resident in the nutrition at risk meetings. RDC #2 said the RD assessed the resident's nutritional status, spoke with the resident's family and observed the resident at lunch on 6/25/24. She said the RD spoke with the resident's representative about the fortified meal program and recommended fortified foods to help combat the resident's weight loss. RDC #2 said the resident often had increased agitation at meal times. She said the noise and amount of activity may have contributed to the agitation. She said the resident began hospice services on 7/1/24 with the diagnosis of senile degeneration of the brain. 48412 III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the July 2024 computerized physician order (CPO), diagnoses included hemiplegia (paralysis on one half of the body), hemiparesis (muscle weakness on one half of the body) following a cerebral infarction (stroke) affecting right non-dominant side, quadriplegia (paralysis of all four limbs), tracheostomy status (opening from the outside of the windpipe to help oxygen reach the lungs), dysphagia oropharyngeal phase (inability to swallow food or fluids) and gastrostomy status (artificial opening to the stomach). The 5/2/24 minimum data set (MDS) assessment revealed the resident was unable to be understood and unable to participate in the brief interview for mental status (BIMS). The MDS assessment indicated the resident had no memory problems through staff assessment. The assessment documented Resident #1 had lost five percent or more of his body weight in the previous month or 10% or more of his body weight in the previous six months and he was not on a prescribed weight loss regimen. The assessment documented Resident #1 had a feeding tube and 100% of his nutrients were received through the feeding tube. B. Record review Resident #1's weights were documented in the resident's EMR as follows: On 2/22/24, Resident #1 weighed 103 lbs, this was struck out as an incorrect weight on 2/23/24. On 2/23/24, it was documented that Resident #1 weighed 152 lbs, which was obtained during his hospital stay. On 3/13/24, Resident #1's weight was 152 lbs, via the Hoyer scale (mechanical lift). On 3/28/24, Resident #1's weight was 104.5 lbs, via the Hoyer scale. Resident #1's nutritional care plan, revised 3/4/24, documented the resident had a nutritional problem or potential for a nutritional problem referring to his diagnoses. Interventions implemented were to provide the resident with Nutren 2.0 (tube feeding formula) at 35 milliliters (ml) an hour for 24 hours a day, enteral support regimen as ordered by the physician, staff monitoring for signs of intolerance to the tube feedings, staff monitoring for muscle wasting and significant weight loss and staff providing the resident his diet as ordered of nothing by mouth. Resident #1's tube feeding care plan, revised 3/6/24, documented the resident was dependent on tube feedings and water flushes and needed the RD to evaluate his needs quarterly and as needed to provide recommendations for changes to the tube feeding regimen. Review of nutritional assessments and IDT notes revealed the facility continued to use the resident's hospital weight and failed to weigh the resident to create a baseline for nutritional assessment until 3/28/24, 36 days after he was admitted to the facility, even though the RD requested the facility to obtain a weight on 2/23/24, in order to determine the correct amount of tube feeding the resident should be receiving (see RD nutritional summary below). The 2/23/24 nutritional summary documented Resident #1's hospital weight was entered into the facility's EMR. The RD requested for the facility to obtain a weight because the resident's weight history was undetermined. The 3/27/24 nutrition at risk meeting note documented the reason the resident was reviewed by the IDT was to adjust the resident's enteral feeding. The note documented Resident #1 weighed 152 lbs and often requested to have his feeding turned off because the resident felt full. The RD followed up with the resident and Resident #1 said the feedings caused the resident to feel full and made the resident nauseous. The resident said he had thrown up and the RD confirmed this in his chart. The RD spoke with the resident's family that the current feeding regimen was not enough to meet Resident #1's nutritional needs. The RD requested a follow-up weight and anticipated a weight decline because of a decrease in calories and a potential erroneous weight at the facility. The RD recalculated Resident #1's nutritional needs based on the resident's weight at home and adjusted the feeding regimen to match the weight of 103 lbs. C. Staff interviews The RD was interviewed on 7/11/24 at 10:14 a.m. The RD said the nursing staff weighed the residents upon admission. He said the facility preferred not to use the hospital weight because the facility was unsure if the weight was accurate. He said if a resident who received nutrition via a feeding tube experienced weight loss, he asked the nursing staff to re-weigh the resident to ensure the weight was accurate. The RD said when he noticed Resident #1 had lost weight he called the resident's family and the family said the resident typically weighed around 105 lbs and the family said the resident did not weigh 152 lbs. The RD said he questioned Resident #1's initial weight entered into the EMR, but the resident's weight was never confirmed. Registered dietitian consultant (RDC) #1 and RDC #2 were interviewed together on 7/12/24 at 10:19 a.m. RDC #1 said she and RDC #2 were dietary resources for the facility when help was needed. She said the hospital weight was not supposed to be entered into the resident's chart and the resident needed to be weighed on the facility's scale. RDC #1 said it was important to have an accurate weight because the facility needed to be able to provide the resident with the correct amount of calories he needed since he had a feeding tube. She said she and RDC #2 investigated any resident who experienced any type of weight loss. RDC #1 said the facility had documentation that Resident #1's family said the resident never weighed over 120 lbs and the facility knew the weight was incorrect. RDC #1 said the 152 lbs weight needed to be struck out as it was incorrect. She said the weight had not been struck out. She said when the resident was admitted to the facility, the hospital weight of 152 lbs was entered into Resident #1's EMR. RDC #1 said the resident's weight was documented as 103 lbs. She said the following day, on 2/23/24, the former RD struck out the 103 lbs and re-entered the 152 lbs as the resident's current weight. She said the current RD documented in the resident EMR that Resident #1's admitting weight was incorrect. She said the RD entered a progress note that indicated the weight of 152 lbs was incorrect should have been disregarded. The director of nursing (DON) was interviewed on 7/12/24 at 3:17 p.m. The DON said she had spoken to the staff member who documented Resident #1's admitting weight at 152 lbs. She said the staff member informed the DON she did not physically weigh the resident. The DON said the staff member who entered Resident #1's weight did not normally weigh residents The DON said the facility planned to have one staff member responsible for documenting the weights so someone was keeping track of any weight changes.

Based on observations, record review, and interviews the facility failed to ensure residents with percutaneous endoscopic gastrostomy (PEG) tubes received treatment and services to prevent complications for eight (#10, #25, #13, #15, #12, #14, #16 and #11) of nine residents reviewed for tube feeding management out of 29 sample residents. Specifically, the facility failed to: -Label Resident #10, Resident #25, Resident #13, Resident #15, Resident #12, Resident #14, Resident #16 and Resident #11's tube feeding containers with the residents' names, room number, date, start time, formula type, feeding rate and nurse initials; -Provide Residents #10, Resident #12, Resident #14, Resident #15, Resident #16 and Resident #25, with the prescribed formula as written in the computerized physician orders (CPO); -Provide Residents #10, Resident #25 and Resident #13 with water flushes at the prescribed rate as written in the CPO; and, -Ensure the feeding pumps were calibrated for Residents #13, Resident #15, Resident #12, Resident #14 and Resident #11. Findings include: I. Facility policy and procedure The Gastrostomy policy and procedure, dated March 2024, was provided by the director of nursing (DON) on 7/10/24 at 10:35 a.m. It read in pertinent part, Administer enteral feedings per prescriber orders. -The policy did not include how the formula bottle/bag should be labeled according to professional standards. The DON provided an undated resource poster that was typically hung in their medication room on 7/11/24 at 12:45 p.m. that indicated Jevity 1.2 could be substituted with Fibersource HN. The Food and Nutrition Services: Enteral Nutrition policy, dated August 2021, was provided by the registered dietitian consultant (RDC) on 7/12/24 at 10:17 a.m. The policy read in pertinent part, Nursing will administer enteral feeding per orders. Nursing will utilize formulary substitution sheets when the product is not readily available. Nursing will consult RD (registered dietitian) if the comparable formula (using substitution sheet) is not available. II. Professional reference Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), pages 2270-2277. Retrieved on 7/24/25. It read in pertinent part, Prior to administration, check the prescription for type of feeding, rate of infusion, and frequency of feeding. Label the container with the patient's name, room number, date, start time, formula type, feeding rate, and nurse initials. According to the Fibersource HN nutrition label, retrieved on 7/10/24 from https://www.nestlemedicalhub.com/products/fibersource-hn, Fibersource HN has 300 calories per 250 milliliters (ml) and 13.5 grams protein per 250 ml. According to the Jevity 1.2 nutrition label, retrieved on 7/10/24 from https://www.abbottnutrition.com/our-products/jevity-1_2-cal, Jevity 1.2 has 285 calories per 237 ml and 13.2 grams protein per 237 ml. According to the Jevity 1.5 nutrition label, retrieved on 7/25/24 from https://www.abbottnutrition.com/our-products/jevity-1_5-cal, Jevity 1.5 has 355 calories per 237 ml and 15.1 grams protein per 273 ml. III. Resident #10 A. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status (surgical opening into the stomach for nutrition support), anoxic brain damage (lack of oxygen to the brain), chronic respiratory failure, disorders of diaphragm (muscle in the chest), disorders of electrolyte fluid imbalance, gastro-esophageal reflux disorder (GERD) and dependence on respirator (ventilator) status. The 5/27/24 minimum data set (MDS) assessment revealed the resident was in a persistent vegetative state with no discernible consciousness. The resident was dependent on two staff members for all activities of daily living (ADL). The assessment revealed the resident had a feeding tube. B. Observations On 7/9/24 at 6:10 p.m., the resident's feeding tube was connected to the tube feeding pump which was infusing Jevity 1.5 (tube feeding formula) at 83 ml per hour. The tube feeding pump automated water flush was programmed at 83 ml every two hours. -The CPO revealed the resident was supposed to receive Fibersource HN at 83 ml per hour, however, the resident was receiving Jevity 1.5, which was not an equivalent formula to Fibersource HN. -The tube feeding formula container did not have the time the formula was hung or the nurses'initials. On 7/10/24 at 9:30 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 83 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 83 ml per hour, however, the resident was receiving Jevity 1.5. On 7/10/24 at 5:51 p.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 83 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 83 ml per hour, however, the resident was receiving Jevity 1.5. On 7/11/24 at 9:17 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 83 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 83 ml per hour, however, the resident was receiving Jevity 1.5. C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: Fibersource HN at 83 ml per hour for 20 hours via PEG tube, ordered 5/20/24. Free water flush every shift a 83 ml water auto flush every 20 hours via enteral support while feeding is running, ordered 4/29/24. -The physician's order indicated the resident was to receive 83 ml of water per day. However, the nutritional assessment indicated to provide 83 ml of water every two hours for 20 hours. The 5/21/24 nutritional summary documented the resident's nutritional needs were met with the enteral nutrition order of Fibersource HN at 83 ml per hour for 20 hours which the resident was observed not to be receiving. The free water was an auto flush of 83 ml every two hours while enteral feed was running. The 7/11/24 (during the survey) nutritional assessment documented due to shortage of Fibersource HN formula, Jevity 1.2 was used for substitution. -However, observations revealed the resident was receiving Jevity 1.5. IV. Resident #25 A. Resident status Resident #25, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status, constipation, hyperkalemia (high potassium levels in the body), amyotrophic lateral scoliosis (ALS) and dependence on respirator status. The 7/8/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. B. Observations On 7/10/24 at 9:30 a.m., the resident's feeding tube was connected to the tube feeding pump which was infusing Jevity 1.5 (tube feed formula) at 72 ml per hour. The water flush on the tube feeding pump was programmed at 72 ml every two hours. The formula type was identified by the manufacturer label on the bottle. -The CPO revealed the resident was supposed to receive Fibersource HN at 72 ml per hour, however, the resident was receiving Jevity 1.5. -Additionally, the CPO revealed the resident was supposed to receive 80 ml of water every two hours. On 7/10/24 at 5:51 p.m., the resident's feeding tube was connected to the tube feeding pump which was infusing Jevity 1.5 at 72 ml per hour. The tube feeding pump automated water flush was programmed at 72 ml every two hours. -The CPO revealed the resident was supposed to receive Fibersource HN at 72 ml per hour, however, the resident was receiving Jevity 1.5. -Additionally, the CPO revealed the resident was supposed to receive 80 ml of water every two hours. On 7/11/24 at 9:17 a.m., the resident's feeding tube was connected to the tube feeding pump which was infusing Jevity 1.5 at 72 ml per hour. The tube feeding pump automated water flush was programmed at 72 ml every two hours. On 7/11/24 at 9:30 a.m. (during the survey), licensed practical nurse (LPN) #3 adjusted the rate of the water on the feeding pump to match the ordered rate of 80 ml every 2 hours (see interview below). C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: Fibersource HN at 72 ml per hour for 20 hours via PEG tube, ordered 5/21/24. 80 ml free water flush every two hours via enteral support while the tube feeding was running, ordered 6/14/24. May substitute Jevity 1.2 for Fibersource HN at 72 ml per hour for 20 hours via peg tube, ordered 7/11/24 (during the survey). -However, observations revealed the resident was receiving Jevity 1.5. The 7/3/24 nutritional summary documented the enteral nutrition order as Fibersource HN at 72 ml per hour for 20 hours. The free water was an auto flush 80 ml every two hours while enteral feed was running. D. Staff interviews LPN #3 was interviewed on 7/11/24 at 9:17 p.m. LPN #3 said Resident #25 was being administered Jevity 1.5. LPN #3 said Resident #25 was receiving 72 ml of water every two hours instead of 80 ml of water every two hours. LPN #3 said she recently started working at the facility. She said she knew the physician's orders for Fibersource HN were incorrect but, as a nurse, she did not question the physician's orders. She said the physician's order indicated to administer Fibersource HN, however the facility had been administering Jevity 1.5. She said a staff communication was sent on 5/29/24 by the director of staff development (DSD). She said the communication advised that Jevity would replace Fibersource HN during back order. She said the communication did not indicate which Jevity formula to utilize. V. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status, GERD protein calorie malnutrition, hyper/hyposmolality, hyper/hyponatremia (high and low levels of sodium in the body), constipation and dependence on respirator status. The 5/20/24 MDS assessment revealed that the resident was rarely/never understood through staff assessment. The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. B. Observations On 7/9/24 at 6:10 p.m., Resident # 13 was lying in bed. The resident's feeding tube was connected to a feeding tube pump. The automated water flush was programmed at 115 ml every two hours. -However, the nutrition assessment indicated the resident needed 110 ml every two hours for 20 hours. -The container of tube feeding formula was not dated or initialed by the licensed nurse. On 7/10/24 at 9:30 a.m., the resident's feeding tube was connected to the tube feeding pump. An automated water flush was programmed at 115 ml every two hours. -However, the nutrition assessment indicated the resident needed 110 ml every two hours for 20 hours. On 7/10/24 at 5:51 p.m., the resident's feeding tube was connected to the tube feeding pump. Nutren 2.0 (tube feed formula) at 65 ml per hour with an automated water flush programmed at 115 ml every two hours. -However, the nutrition assessment indicated the resident needed 110 ml every two hours for 20 hours. -The tube feed formula container was not dated. On 7/11/24 at 9:17 a.m., Resident #13 was lying in bed. The resident's feeding tube was connected to a feeding tube pump and was infusing Nutren 2.0 at a rate of 65 ml per hour. -The container was not dated with the time it was hung for administration or initialed by the administrating nurse. On 7/11/24 at 9:27 a.m., Resident #13 was lying in bed with Nutren 2.0 infusing at 65 ml per hour. The water auto flush was programmed at a rate of 115 ml every two hours. -However, the nutrition assessment indicated the resident needed 110 ml every two hours for 20 hours. -The tube feed formula container and the bag that contained the water flushes was not dated with the time it was hung on the pump to be administered or initialed with the administering nurse's signature. -The resident's tube feeding pump in Resident #13's room did not have a sticker indicating the pump had received annual calibration. C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: Nutren 2.0 at 65 ml per hour for 20 hours via PEG tube, ordered 5/21/24. 110 ml free water flush every two hours via enteral support while the tube feeding was running, ordered 3/22/24. 70 ml free water flush every two hours via enteral support while the tube feeding was running ordered 7/11/24 (during the survey). The 5/21/24 nutritional summary documented the enteral nutrition order as Nutren 2.0 at 65 ml per hour for 20 hours. The free water was an auto flush 110 ml every two hours while the enteral feed was running. -The physician's order indicated the resident was to receive 110 ml of water every two hours, however, observations revealed the resident was receiving 115 ml of water every two hours. D. Staff interviews LPN #3 was interviewed on 7/11/24 at 9:27 a.m. LPN #3 said the resident was receiving Nutren 2.0 formula through the feeding tube. LPN #3 confirmed the formula container was not dated or initialed. LPN #3 said the formula container was not labeled with the time it was hung to be administered or initialed. LPN #3 said Resident #13's water flush was running at 115 ml instead of the physician's order of 110 ml every two hours (see observations above). VI. Resident #15 A. Resident status Resident #15, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status, type II diabetes mellitus, hyposmolality (low levels of nutrients, proteins and electrolytes in the blood), hyponatremia, anemia (low blood levels), vitamin D deficiency, cerebral infarction (stroke) and dependence on respirator status. The 5/6/24 MDS assessment revealed the resident had severe cognitive impairments with a mental status score of six out of 15. The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. B. Observations On 7/9/24 at 6:10 p.m., Resident #15 was lying in bed. The resident's feeding tube was connected to a feeding tube pump. The pump was infusing Jevity 1.5 at a rate of 90 ml per hour. The water flush bag was not labeled. -The CPO revealed the resident was supposed to receive Fibersource HN at 90 ml per hour, however, the resident was receiving Jevity 1.5, which was not an equivalent formula to Fibersource HN. -The tube feed formula container was not dated with the time or date it was hung on the pump to be administered or initialed with the administering nurse's signature. On 7/10/24 at 9:30 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 90 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 90 ml per hour, however, the resident was receiving Jevity 1.5, which was not an equivalent formula to Fibersource HN. On 7/10/24 at 5:51 p.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 90 ml per hour -The CPO revealed the resident was supposed to receive Fibersource HN at 90 ml per hour, however, the resident was receiving Jevity 1.5. On 7/11/24 at 9:17 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 90 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 90 ml per hour, however, the resident was receiving Jevity 1.5. -On 7/12/24 at 2:51 p.m. The tube feeding pump in Resident #15's room did not have a sticker indicating the pump had received annual calibration. C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: Fibersource HN at 90 ml per hour for 20 hours via PEG tube, ordered 5/21/24. 90 ml free water flush every two hours via enteral support while the tube feeding was running, ordered 6/14/24. The 4/30/24 nutritional summary documented the enteral nutrition order as Fibersource HN at 90 ml per hour for 20 hours. The free water was an auto flush of 90 ml every two hours while the enteral feed was running. VII. Resident #12 A. Resident status Resident #12, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status, GERD, gastroparesis (decreased stomach movement), traumatic brain injury, and dependence on respirator status. The 6/24/24 MDS assessment revealed the resident was rarely/never understood through staff assessment. The resident was in a persistent vegetative state with no discernible consciousness The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. B. Observations On 7/9/24 at 6:10 p.m., Resident # 12 was lying in bed. The resident's feeding tube was connected to a feeding tube pump. The pump was infusing Jevity 1.5 at a rate of 68 ml per hour. The automated water flush was programmed at 100 ml every two hours. -The CPO revealed the resident was supposed to receive Fibersource HN at 68 ml per hour, however, the resident was receiving Jevity 1.5. -The tube feed formula container was not dated with the time it was hung on the pump to be administered or initialed with the administering nurse's signature. On 7/10/24 at 9:30 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 at 68 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 68 ml per hour, however, the resident was receiving Jevity 1.5. On 7/10/24 at 5:51 p.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 68 ml per hour. On 7/11/24 at 9:17 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 68 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 68 ml per hour, however, the resident was receiving Jevity 1.5. On 7/11/24 at 9:27 a.m., Resident #12 was lying in bed and Jevity 1.5 was infusing at 68 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 68 ml per hour, however, the resident was receiving Jevity 1.5. -On 7/12/24 at 2:51 p.m. the tube feeding pump in Resident #12's room did not have a sticker indicating the pump had received annual calibration. C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: Fibersource HN at 68 ml per hour for 20 hours via PEG tube, ordered 6/25/24. 100 ml free water flush every two hours via enteral support while the tube feeding was running, ordered 6/14/24. May substitute Jevity 1.2 for Fibersource HN at 68 ml per hour for 20 hours via PEG tube, ordered 7/11/24 (during the survey). -However, observations revealed the resident was receiving Jevity 1.5. D. Staff interviews LPN #3 was interviewed on 7/11/24 at 9:27 a.m. LPN #3 said Resident #12 was being administered Jevity 1.5 at 68 ml per hour. She said the physician's order indicated to administer Fibersource HN. VIII. Resident #14 A. Resident status Resident #14, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status, GERD, constipation, anoxic brain injury and dependence on respirator status. The 6/17/24 MDS assessment revealed the resident was rarely/never understood through staff interview. The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. B. Observations On 7/9/24 at 6:10 p.m., the resident's feeding tube was connected to the tube feeding pump which was infusing Jevity 1.5 at 72 ml per hour. -The tube feed formula container was not dated with the time it was hung on the pump to be administered. On 7/10/24 at 9:30 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 72 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 72 ml per hour, however, the resident was receiving Jevity 1.5. On 7/10/24 at 5:51 p.m., Jevity 1.5 was infusing at 72 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 72 ml per hour, however, the resident was receiving Jevity 1.5. On 7/11/24 at 9:17 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 72 ml per hour with an automated water flush programmed at 72 ml every two hours. -The CPO revealed the resident was supposed to receive Fibersource HN at 72 ml per hour, however, the resident was receiving Jevity 1.5. -The water flush bag was not labeled with the time or date it was hung on the pump to be administered or initialed by the administrating nurse. On 7/12/24 at 2:51 p.m. the resident's feeding tube was connected to the tube feeding pump. Fibersource HN was infused at 72 ml per hour. -On 7/12/24 at 2:51 p.m. the tube feeding pump in Resident #14's room did not have a sticker indicating the pump had received annual calibration. C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: Fibersource HN at 72 ml per hour for 20 hours via PEG tube, ordered 5/21/24. 72 ml free water flush every two hours via enteral support while the tube feeding was running, ordered 4/9/24. May substitute Jevity 1.2 for Fibersource HN at 72 ml per hour for 20 hours via PEG tube, ordered 7/11/24 (during the survey). -However, observations revealed the resident was receiving Jevity 1.5. The 6/11/24 nutritional summary documented the enteral nutrition order as Fibersource HN at 72 ml per hour for 20 hours. The free water was an auto flush of 72 ml every two hours while the enteral feed was running. VIII. Resident #16 A. Resident status Resident #16, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status, protein-calorie malnutrition, anemia, constipation, GERD, traumatic brain injury and dependence on respirator status. The 4/29/24 minimum data set (MDS) assessment revealed the resident was in a persistent vegetative state with no discernible consciousness. The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. B. Observations On 7/9/24 at 6:10 p.m., the resident's feeding tube was connected to the tube feeding pump which was infusing Jevity 1.5 at 105 ml per hour. The tube feed formula container had the name of the formula, however, was not timed when hung, and failed to have the nurses' initials. -The tube feed formula container bag was not labeled with the time it was hung on the pump to be administered or initialed by the administrating nurse. On 7/10/24 at 9:30 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 at 105 ml per hour. with an automated water flush programmed at 100 ml every two hours. -The CPO revealed the resident was supposed to receive Fibersource HN at 105 ml per hour, however, the resident was receiving Jevity 1.5. On 7/10/24 at 5:51 p.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 infused at 105 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 105 ml per hour, however, the resident was receiving Jevity 1.5. On 7/11/24 at 9:17 a.m., the resident's feeding tube was connected to the tube feeding pump. Jevity 1.5 was infusing at 105 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 105 ml per hour, however, the resident was receiving Jevity 1.5. On 7/11/24 at 9:27 a.m., Jevity 1.5 was running through the pump at 105 ml per hour. -The CPO revealed the resident was supposed to receive Fibersource HN at 105 ml per hour, however, the resident was receiving Jevity 1.5. The tube feeding pump serial number: C14113939 had a sticker validating that annual calibration was required in March 2025. C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: Fibersource HN at 105 ml per hour for 20 hours via PEG tube, ordered 2/20/24. 100 ml free water flush every two hours via enteral support while the tube feeding was running, ordered 2/20/24. May substitute Jevity 1.5 for Fibersource HN at 105 ml per hour for 20 hours via PEG tube, ordered 7/11/24 (during the survey). May substitute Jevity 1.2 for Fibersource HN at 105 ml per hour for 20 hours via PEG tube, ordered 7/11/24 (during the survey). The 4/23/24 nutritional summary documented the enteral nutrition order as Fibersource HN at 105 ml per hour for 20 hours. The free water was an auto flush of 100 ml every two hours while the enteral feed was running. D. Staff interviews LPN #3 was interviewed 7/11/24 at 9:27 a.m. LPN #3 said Resident #16 was receiving Jevity 1.5 at 105 ml per hour. She said the physician's order indicated to administer Fibersource HN at 105 ml per hour. X. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted to the facility on [DATE]. According to the July 2024 CPO, diagnoses included gastrostomy status, GERD, type II diabetes mellitus with hypoglycemia, chronic idiopathic constipation, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, aphasia following cerebral infarction, iron deficiency anemia and dependence on respirator status. The 6/3/24 MDS assessment revealed the resident was rarely/never understood through staff interview. The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. B. Observations On 7/9/2024 at 6:10 p.m., [NAME] Farms Peptide 1.5 (tube feed formula) was being administered at 59 ml per hour. -The tube feed formula container bag had the formula type written on the bag, however, the writing was illegible. The container was not labeled with the time it was hung on the pump to be administered or initialed by the administrating nurse. On 7/10/24 at 5:51 p.m., the resident's feeding tube was connected to the tube feeding pump. [NAME] Farm Peptide 1.5 was infused at 59 ml per hour with an automated water flush programmed at 100 ml every two hours. -On 7/12/24 at 2:51 p.m., the tube feeding pump in Resident #11's room did not have a sticker indicating the pump had received annual calibration. C. Record Review The July 2024 CPO revealed the following physician's order related to the resident's nutritional needs: [NAME] Farms Peptide 1.5 at 59 mla per hour for 20 hours via PEG tube, ordered 5/20/24. 100 ml free water flush every two hours via enteral support while the tube feeding was running, ordered 1/28/24. The 5/28/24 nutritional summary documented the enteral nutrition order as [NAME] Farms Peptide 1.5 at 59 ml per hour for 20 hours. The free water was an auto flush of 100 ml water every two hours for 20 hours while the enteral feed was running. XI. Additional record review The nursing communication memo written by director staff development (DSD), dated 5/29/24 at 2:37 p.m., documented in pertinent part, The manufacturer of Fibersource tube feeding is back-ordered. They sent Jevity and can be used in its place. -The nursing communication memo did not indicate which Jevity formula to use. On 7/12/24 at 3:45 p.m., the director of nursing (DON) provided a print out from a website called MedWrench. The print out read in pertinent part, A series of tests can be performed to verify pump performance. It is recommended that the evaluation procedure be run at least once per year. XII. Additional staff interviews Registered nurse (RN) #2 was interviewed on 7/9/2024 at 6:25 p.m. RN #2 said the tubing on a feeding tube pump must be changed every 24 hours. She said she changed them on the nightshift as her first task upon shift change. RN #2 said she wrote the resident's initials, date, and her first initial on each tube feed bottle. She said it was not important to label tube feeding formula bags or containers because the formula was used quickly. RN #2 She said that many of the residents in her assigned hallway had tube feeding sets that were not properly labeled related to a hectic shift the previous night. RN #2 observed Resident #15's infusing tube feed had no writing on the formula or water bag. RN #2 stated she had not hung it. She said the day shift hung it. She said the previous night shift had been extremely busy. The registered dietitian (RD) was interviewed via telephone on 7/11/24 at 10:14 a.m. The RD said when a resident was admitted to the facility he reviewed their medical record to determine which tube feeding formula they had been receiving prior to admission. The RD said he interviewed the residents and their representatives to determine the previous enteral feed regimens. The RD said he entered tube feeding related orders and the physician signed them. The RD said the physician's orders needed to be followed. The RD said there was communication with upper management and the nursing staff any time changes with the tube feeding orders had been made. The RD said Fibersource HN had been on backorder since May 2024. The RD said Jevity was being used as a temporary replacement for Fibersource HN. The RD said he was unaware that the physician's orders did not match the tube feeding formula that was hung for the residents. The RD said an incorrect auto water flush could cause a resident to become overhydrated, dehydrated, or to develop an electrolyte imbalance. The RD said he reviewed tube feed related orders with the expectation that the orders would not be altered by other staff members. The DON was interviewed on 7/11/24 at 11:29 a.m. The DON said she was not responsible for managing the tube feedings for the residents. She said the director of staff development (DSD) was responsible for ordering all tube feed formulas. The DON said the communication written by the DSD was not a valid physician's order and the actual orders should have been rewritten. She said the physician's order needed to match the tube feed formula that was infusing. She said the registered nurse supervisor (RNS) verified that the formulas that were infused through the tube feeding pumps matched the physician's orders. She said the RNS had been unable to complete the checks because he had been covering night shifts. The DON said different formula substitutions would not always run at the same rate, related to the caloric and nutritional content. She said the water flushes might also be altered in relation to tube feed formula. She said effects of incorrect formula or water intake could cause issues for residents from dehydration to fluid overload. The DON said the tube feeding for all the samples was not labeled improperly. The DON said she did not initial a formula bag when she hung th[TRUNCATED]

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 quality of life and quality of care. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) policy, revised 1/2022, was provided by the director of nursing (DON) on 7/12/24 at 6:23 p.m. The policy documented in pertinent part, The purpose of the QAPI plan and processes is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individuals' highest practicable physical, mental and social well-being. The committee will meet at least quarterly or more often as the facility deems necessary. The committee will maintain a record of the fates of all meetings and the names and titles of those attending each meeting. Committee functions include QAPI plan, identifying and prioritizing performance improvement plans (PIPs), implementing actions to correct quality issues and monitoring to ensure the corrective action implemented is being sustained. II. Repeat deficiencies Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies. F919 Resident call system During a recertification survey on 3/21/24, F919 was cited at an E level, no actual harm with potential for more than minimal harm that is not immediate jeopardy, pattern. During an abbreviated survey on 7/12/24, F919 was cited at an E level, no actual harm with potential for more than minimal harm that is not immediate jeopardy, pattern. F677 ADL (activities of daily living) Care Provided for Dependent Residents During a recertification survey on 12/15/22, F677 was cited at a D level, no actual harm with potential for more than minimal harm that is not immediate jeopardy, isolated. During an abbreviated survey on 8/10/23, F677 was cited at an E level, no actual harm with potential for more than minimal harm that is not immediate jeopardy, pattern. During an abbreviated survey on 9/11/23, F677 was cited at a D level, no actual harm with potential for more than minimal harm that is not immediate jeopardy, isolated. During an abbreviated survey on 7/12/24, F677 was cited at an E level, no actual harm with potential for more than minimal harm that is not immediate jeopardy, pattern. III. Cross-referenced citations Cross-reference F692: The facility failed to ensure residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. This failure resulted in actual harm with a severe weight loss and a G level citation, actual harm that is not immediate jeopardy, isolated. Cross-reference F693: The facility failed to administer tube feedings and water flushes accurately and according to physician orders. The facility failed to update physician orders when the tube feeding formula was on backorder and verbally informed staff to use a comparable tube feeding formula. This failure resulted in substandard care being provided to the residents due to eight out of eight residents having the incorrect formula administered. Cross-reference F677: The facility failed to provide activities of daily living (ADL) care to dependent residents. Cross-reference F689: The facility failed to implement effective interventions to prevent falls and bruises. Cross reference F919: The facility failed to install and maintain a working call light system. IV. Interviews The nursing home administrator (NHA) was interviewed on 7/12/24 at 5:52 p.m. The NHA said the interdisciplinary team (IDT) met once a month for QAPI. He said the QAPI team used the fishbone diagram (a tool used to identify root causes of a problem) once a specific area was identified as a concern. He said the facility had a spreadsheet to document each specific concern area identified. The NHA said the QAPI team discussed certain concerns if a grievance was filed about it. The NHA said tube feedings were not on the QAPI teams' areas of identified concerns within the past 90 days. The NHA said the registered dietician entered the residents' order for tube feedings and the nursing staff followed the orders. The NHA said he was unsure if the clinical staff were not hanging the formula bags correctly, however, he said the facility clearly did not have an effective process to ensure resident tube feedings were being appropriately monitored and managed. The NHA said falls was a topic covered in every QAPI meeting, which included discussion about interventions and active falls. The NHA said weight loss was discussed as part of the facility's nutritional program and the QAPI team investigated if the weight loss was desired or not and how to correct the problem. The NHA said he felt the registered dietician consultant needed to provide training to the facility to ensure everyone was on the same page regarding management of weight loss. The NHA said the facility would be following up on how to proceed with the concern regarding the lack of an appropriate call light system in the memory care secure unit.

Based on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for six (#10, #16, #14, #6, #24 and #9) of 13 residents reviewed for ADLs out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #10, #16 and #14 received timely repositioning and toileting/incontinence care while in bed; -Ensure Resident #6 and #24 received timely repositioning and toileting/incontinence care; and, -Ensure Resident #9 received assistance with meals. Findings include: I. Professional reference According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 1214 read in pertinent part, Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort, damage to superficial nerves and blood vessels, and contractures. II. Facility policy The Activity of Daily Living/Maintain Abilities policy and procedure, revised October 2022, was provided by the director of nursing (DON) on 7/10/24 at 5:28 p.m. It documented in pertinent part, Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff. ADLs will be care planned to reflect the resident specific needs The Activities of Daily Living (ADL) policy, undated, was provided by the DON on 7/12/24 at 11:45 a.m. It documented in pertinent part, Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care, transfer and ambulation, toileting, eating, to include meals and snacks. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. III. Failure to ensure timely repositioning in bed and toileting/incontinence care for Resident #10, #16 and #14 A. Resident #10 1. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included anoxic brain damage, persistent vegetative state, muscle wasting and atrophy, contracture of muscle (right ankle and foot), contracture (right elbow, left elbow, right wrist, left wrist), swan-neck deformity of (right fingers, left fingers), chronic respiratory failure, and dependence on respirator (ventilator) status. The 5/27/24 minimum data set (MDS) assessment revealed the resident was in a persistent vegetative state with no discernible consciousness and was unable to complete a brief interview for mental status (BIMS). The resident was dependent on two staff members for all ADLs. 2. Observations During a continuous observation on 7/10/24, beginning at 10:37 a.m. and ending at 1:12 p.m., the following observations were made: At 10:55 a.m. Resident #10 was lying in bed, positioned with his right arm off-loaded by a wedge cushion. At 12:03 p.m. licensed practical nurse (LPN) #2 entered the resident's room. LPN #2 completed a medication administration for the resident and then left the room. Resident #2 was not repositioned. At 12:24 p.m. Resident #10 remained lying in the same position in bed, positioned with his right arm off-loaded by the wedge cushion. At 12:55 p.m., two staff members entered the resident's room. The staff members performed incontinence care with the resident's roommate, however, Resident #10 was not repositioned. -Resident #10 was not repositioned or provided toileting/incontinence care during the two hour and 18 minute continuous observation. 3. Record Review Review of the Kardex (a tool utilized for providing consistent care for residents) for Resident #10 revealed the resident required the total participation of two staff members to reposition and turn in bed. The resident was to be repositioned at least every two hours Resident #10's ADL care plan, revised 3/7/24, revealed the resident was totally dependent for all ADLs related to his vegetative state. Interventions included total staff participation of two staff members to reposition and turn the resident in bed. B.Resident # 16 1. Resident status Resident #16, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included traumatic brain injury and dependence on respirator (ventilator) status. The 4/29/24 MDS assessment revealed the resident was in a persistent vegetative state with no discernible consciousness and was unable to complete a BIMS. The resident was dependent on two staff members for all ADLs. The assessment revealed the resident had a feeding tube. 2. Observations During a continuous observation on 7/10/24, beginning at 10:37 a.m. and ending at 1:12 p.m., the following observations were made: At 10:55 a.m. Resident #16 was lying in bed turned to the right side with his left arm and left hip off-loaded by wedge cushions. The resident's heel protector boots rested next to his feet on the right hand side of the bed and his heels were not off-loaded. The resident was wearing only a brief. Resident #16's left leg and left hip were covered by a flat sheet. The resident's door was open to the hallway. At 12:03 p.m. LPN #2 entered the room and provided care to Resident #16's roommate. Neither resident was repositioned. Resident #16 remained in just a brief with his left leg covered by a sheet. The resident's left hip had become exposed. At 12:24 p.m. Resident #16 remained in the same position. The wedge cushions placed to off-load the resident's weight remained on the resident's left side. The resident's heels were laying on the mattress next to his heel protector boots. The resident was wearing only a brief with just his left leg covered by a sheet and the resident's door was open fully. At 12:45 p.m. a respiratory therapist (RT) entered Resident #16's room. The RT performed tracheostomy care and suctioning with the resident and exited the room at 12:49 p.m. The resident remained in the same position with his left leg partially covered by the sheet. At 12:55 p.m. two staff members entered the resident's room and performed incontinence care with Resident #16. The resident was repositioned with the wedge cushions on the right side of his body and he was covered with a sheet and no longer exposed. -However, Resident #16's heel protector boots remained next to his feet on the right hand side of the bed and the resident's heels were not off-loaded. -Resident #16 was not repositioned or provided toileting/incontinence care for two hours and 18 minutes during the continuous observation. 3. Record Review Review or the Kardex for Resident #16 revealed the resident required the assistance of one to two staff members. -The Kardex did not document how frequently the resident should be repositioned. Resident #16's ADL care plan, revised 2/20/24 revealed the resident needed assistance to turn/reposition and his heels were to be floated as the resident tolerated. C. Resident # 14 1. Resident status Resident #14, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included need for assistance with personal care, anoxic brain injury, quadriplegia, contracture of muscle (right ankle and foot), contracture (left shoulder, left elbow, left wrist, right elbow, right wrist, right hand), muscle wasting and atrophy, and dependence on respirator (ventilator) status. The 6/17/24 MDS assessment revealed the resident was rarely/never understood and was unable to complete a BIMS. The resident was dependent on two staff members for all ADLs. 2. Observations During a continuous observation on 7/10/24, beginning at 10:37 a.m. and ending at 1:12 p.m., the following observations were made: At 11:03 a.m. Resident #14 was lying in bed, positioned with his left arm off-loaded with a pillow. At 11:12 a.m. Resident #14's family member was observed adjusting the positioning of the resident's feet and the bed linens. At 12:14 p.m. LPN #2 entered the resident's room. LPN #2 administered medications to the resident and exited the room at 12:19 p.m. Resident #14 was not repositioned and remained lying in bed with the pillow under his left arm. -Resident #14 was not repositioned or provided toileting/incontinence care during the two hour and 18 minute continuous observation. 3. Record Review Review of the Kardex for Resident #14 revealed the resident was totally dependent on two staff members for repositioning and turning in bed. The resident's heels were to be floated as tolerated or he was to wear pressure relieving boots as tolerated. Review of Resident #14's ADL care plan, revised 2/20/24, revealed the resident was totally dependent on two staff members for repositioning and turning in bed and his heels were to be floated as tolerated. D. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 7/10/24 at 1:12 p.m. CNA #7 said Resident #14 and Resident #16 were to be repositioned and toileted or changed every two hours and more frequently if needed. CNA #1 was interviewed on 7/10/24 at 1:17 p.m. CNA #1 said residents were repositioned and toileted or changed every two hours CNA #1 said he provided care for Resident #10 and Resident #16. He said he checked the residents every two hours. He said some residents were checked more frequently if they required more frequent incontinence care. CNA #6 was interviewed on 7/12/24 at 10:48 a.m. CNA #6 said dependent residents should be turned/repositioned every two hours. He said staff was not always able to reposition residents every two hours. CNA #6 said his current shift required him to complete eight showers during his shift. He said when a resident was being showered, it required one CNA to be off the floor while the CNA was in the shower room. CNA #6 said some dependent residents were difficult to reposition related to their contractures or preferred position. Physical therapist assistant (PTA) #1 was interviewed on 7/12/24 at 10:56 a.m. PTA #1 said each resident received an individualized evaluation which included recommendations for positioning PTA #1 said the recommendations could be restorative, preventative, or maintenance measures. 51163 IV. Failure to ensure timely repositioning and toileting/incontinence care for Resident #6 and #24 A. Resident #6 1. Resident status Resident #6, age 84, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included hemiplegia and hemiparesis (conditions that cause weakness or paralysis on one side of the body) following cerebral infarction (type of stroke) affecting left non-dominant side, vascular dementia unspecified severity, senile degeneration of brain not elsewhere classified, benign prostatic hyperplasia (increased cell production in a normal tissue or organ) without lower urinary tract symptoms. The 4/22/24 MDS assessment revealed the resident was rarely or never understood, had short-term and long-term memory problems and his daily decision making was severely impaired. He was dependent on staff for personal hygiene, dressing, bathing and toileting and needed substantial or maximal assistance for oral hygiene. He needed setup and clean-up for meals and he was dependent on staff for wheelchair and bed mobility. 2. Observations During a continuous observation on 7/10/24, beginning at 9:35 a.m. and ending at 1:30 p.m., the following observations were made: At 9:35 a.m. Resident #6 was in the common area with a group of other residents and activities assistant (AA) #1 who were hitting and throwing a large ball. Resident #6 was tilted in his wheelchair at approximately a 45 degree angle and he was leaning to his left side. At 10:25 a.m. the resident continued to participate in the activity. There were no changes to his positioning. At 11:54 a.m. Resident #6 was assisted into the dining room for lunch by a CNA. -The CNA positioned the resident's wheelchair at approximately a 90 degree angle at the table, however, the resident was not repositioned in the wheelchair and continued to lean to his left side. -Resident #6 was not offered toileting or incontinence care prior to being taken to the dining room for lunch. -At 12:35 p.m., after eating lunch, Resident #6 was assisted back to the common area by a CNA. -The CNA positioned the resident's wheelchair at approximately a 45 degree angle, however, the resident was not repositioned in the wheelchair and continued to lean to his left side. -Resident #6 was not offered toileting or incontinence care prior to being taken back to the common area after lunch. At 1:06 p.m. the resident was heard asking an unknown CNA to lay down because he had urinated himself. At 1:11 p.m. the resident was assisted to his room and assisted by two staff members to lay down in bed and have his brief changed. -Resident #6 was not repositioned or provided toileting/incontinence care during the three hour and 36 minute continuous observation. 3. Record review Resident #6's ADL care plan, initiated 8/13/23, revealed the resident had ADL self care performance deficits due to lack of safety awareness, end stage dementia and impaired mobility. The care plan indicated that the resident was dependent on one to two staff members with toilet use, transfers to and from wheelchair, bathing, bed mobility, personal hygiene, oral care and dressing. The care plan further revealed Resident #6 was at risk for bowel and bladder incontinence. Pertinent interventions included checking the resident as required for incontinence. B. Resident #24 1. Resident status Resident #24, age 70, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included other sequelae of cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, cerebrovascular disease (condition affecting blood flow and blood vessels in the brain and spinal cord) unspecified, unspecified dementia, abnormal posture, muscle weakness generalized, contracture of left elbow, and contracture of muscle left upper arm. The 6/17/24 MDS assessment revealed the resident had a severe cognitive impairment with a BIMS score of seven out of 15. He was dependent on staff assistance with oral hygiene, toileting, bathing, dressing upper and lower body, putting on footwear, personal hygiene, transfers to and from his wheelchair and bed mobility. He needed supervision or touching assistance with eating. 2. Observations During a continuous observation on 7/10/24, beginning at 9:35 a.m. and ending at 1:30 p.m., the following observations were made: At 9:35 a.m. Resident #24 was in the common area with a group of other residents and AA #1 who were hitting and throwing a large ball. Resident #24 was tilted in his wheelchair at approximately a 45 degree angle and was not actively participating in the activity. At 10:25 a.m, Resident #24 remained in the common area in his wheelchair in the same position. -At 11:57 a.m. the resident was assisted to the dining room for lunch by a CNA. -The CNA positioned the resident's wheelchair at approximately a 90 degree angle at the table, however, the resident was not repositioned in the wheelchair. -Resident #24 was not offered toileting or incontinence care prior to being taken to the dining room for lunch. At 12:40 p.m., after eating lunch, Resident #24 was assisted back to the common area by a CNA. The resident was sliding down in his wheelchair. -The CNA positioned the resident's wheelchair at approximately a 45 degree angle, however, the resident was not repositioned in the wheelchair despite the resident noticeably sliding down in his wheelchair. -Resident #24 was not offered toileting or incontinence care prior to being taken back to the common area after lunch. - At approximately 12:45 p.m. Resident #24 was wheeled to his room to be provided with incontinence care. At 1:01 p.m. the resident was transferred to bed and provided with incontinence care. -Resident #24 was not repositioned or provided toileting/incontinence care during the three hour and 26 minute continuous observation. 3. Record review Resident #24's ADL care plan, initiated 10/6/23, revealed the resident had an ADL care performance deficit due to his weakness and left sided deficits due to his cerebrovascular accident. The care plan indicated the resident was dependent on one to two staff members with toilet use, transfers to and from the wheelchair, bathing, bed mobility, personal hygiene, oral care, and dressing. The care plan further revealed Resident #24 was at risk for bowel and bladder incontinence. Pertinent interventions included checking the resident as required for incontinence. C. Staff interviews LPN (licensed practical nurse) #1 was interviewed on 7/10/24 at 12:45 p.m. LPN #1 said residents should be toileted every two to three hours and should be toileted before going to lunch. She said residents should be repositioned every two hours. LPN #1 said Resident #6 and Resident #24 were incontinent and were at risk for skin issues. CNA #3 was interviewed on 7/10/24 at approximately 1:20 p.m. CNA #3 said Resident #6 should be checked for incontinence every two hours unless he asked to be changed more frequently. She said the resident could reposition himself in his wheelchair. -However, observations revealed the resident did not attempt to reposition himself (see observations above). CNA #5 said residents should be repositioned and have their briefs checked for incontinence every two hours. She said Resident #6 and Resident #24 were incontinent. V. Failure to ensure Resident #9 received assistance with meals A. Resident #9 1. Resident status Resident #9, age 82, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included Alzheimer's disease, cognitive communication deficit and need for assistance with personal care. The 5/1/24 MDS assessment revealed the resident was rarely or never understood through staff assessment. She had short-term and long-term memory deficits and was severely impaired in daily decision-making through staff assessment. She required set up and clean up assistance for meals and was dependent on staff for all other ADLs. 2. Observations On 7/9/24 at 5:10 p.m. Resident #9 was assisted to the dining room. The resident was served her meal which consisted of four chicken nuggets, french fries and four apricot halves. She instantly picked up a french fry to eat. At 5:13 p.m. Resident #9 stood up and ate half an apricot half. She then proceeded to leave the table. -No staff members attempted to redirect the resident back to the table as she walked away from the dining room or offer the resident a hand held food item to take with her while she walked. At 5:15 p.m. the resident returned to the dining room. She took her plate of chicken nuggets and french fries with her as she left the dining room again. At 5:19 p.m. Resident #9 was walking the hall and had blankets in her arms. She did not have the food plate with her and the plate of food was not in sight in the hallway. At approximately 5:30 p.m. an unidentified CNA passed the resident walking in the hallway. The unidentified CNA asked another CNA if Resident #9 had eaten. The other CNA said the resident had eaten. -However, Resident #9 had not eaten (see observations above). On 7/10/24 at 8:35 a.m. Resident #9 was sitting at a dining room table with her meal in front of her. The resident was sleeping. At 8:45 a.m. the resident continued to sit at the table asleep. She had not touched her food. -No staff members attempted to wake the resident up or provide encouragement for her to eat. -On 7/10/24 at 11:00 a.m. Resident #9's plate of chicken nuggets and french fries from the dinner meal on 7/9/24 were found in another resident's drawer. The plate still contained the four chicken nuggets and french fries. 3. Record review Resident #9's nutrition care, initiated 4/26/24, revealed the resident had a nutritional problem. Pertinent interventions were to provide the diet as ordered. Resident #9's ADL care plan revealed the resident required set up and supervision with eating. The 5/2/24 initial nutritional evaluation documented the resident ate in the dining room and required set up assistance with her meal. B. Staff interviews Registered nurse (RN) #1 was interviewed on 7/11/24 at 4:00 p.m. RN #1 said Resident #9 was able to feed herself but she needed to receive cueing and encouragement to eat. RN #1 said the resident did get up and leave the table but she should be encouraged to come back to the dining room and she should be provided a hand held food to take with her if she would not come back to the dining room. The dietary manager (DM) was interviewed on 7/12/24 at 10:00 a.m. The DM said the kitchen had bread and other items and a hand held sandwich could be made for Resident #9 to take with her when she was walking. CNA #3 was interviewed 7/12/24 at 11:45 a.m. CNA #3 said residents who needed meal assistance could vary each day and she observed the dining room to see which residents needed assistance. The registered dietitian (RD) was interviewed on 7/12/24 at 2:00 p.m. The RD said Resident #9 would benefit from a hand held meal because she tended to walk around during meals. She said the resident should always be offered an alternative if she was not eating.

Based on observations, record review and interviews the facility failed to adequately equip the residents to call for staff for two (#8 and #24) of three residents out of 29 sample residents and to provide a working call light system in the shower facilities. Specifically, the facility failed to: -Provide a working call light for Resident #24 and Resident #8; and, -Have a functioning call light system in the women's and men's shower areas. Findings include: I. Facility policy and procedure The Call Light/Bell policy and procedure, revised May 2007, was provided by the director of nursing (DON) on 7/12/24 at 11:54 a.m. It revealed in pertinent part, It is the policy of this facility to provide the residents a means of communication with nursing staff. II. Resident #24 A. Resident status Resident #24, age 70, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side (limited or no movement of the resident's dominant side), cerebrovascular disease unspecified, unspecified dementia, abnormal posture, muscle weakness generalized, contracture of left elbow and contracture of muscle left upper arm. The 6/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He was dependent on staff for oral hygiene, toileting, bathing, dressing upper and lower body, putting on footwear, personal hygiene, transfers and bed mobility. He required supervision or touching assistance with eating. B. Resident interview and observations On 7/9/24 at approximately 5:15 p m., Resident #24 was lying in his bed. His room was at the end of the hallway. Resident #24 was yelling for help and did not have a call light. On 7/10/24 at approximately 12:45 p.m. licensed practical nurse (LPN) #1 and certified nurse aide (CNA) #5 assisted Resident #24 with transferring from his wheelchair to the bed. Resident #24 did not have a call light in his room. On 7/12/24 at approximately 5:00 p.m. the resident had a yellow service bell. The resident had it on his chest. He said he was happy to have a call bell, however, he said when he rang it, the staff did not answer him. C. Record review The 4/11/24 call system assessment documented #24 was unable to demonstrate using a call bell. D. Staff interviews CNA #5 was interviewed on 7/10/24 at approximately 1:15 p.m. CNA #5 said Resident #24 was able to make his needs known. She said none of the residents who resided on the memory care unit had a call light. CNA #4 was interviewed on 7/11/24 at 9:30 a.m. CNA #4 said Resident #24 was not able to use a call light to make his needs known due to his forgetfulness. He said Resident #24 would be at risk for safety issues such as strangulation due to not understanding what it was for and playing with the long cord. The social services director (SSD) was interviewed on 7/11/24 at approximately 3:00 p.m. The SSD said she had recently taken over the call bell assessments. She said the assessments consisted of explaining and showing the call bell procedure to the resident. She said she would ask the resident to demonstrate the call bell procedure. She said if the resident could demonstrate the call bell procedure they left the call bell in their room. She said Resident #24 was unable to use the call bell on the last assessment but that she would reassess Resident #24 later that day (7/11/24). The social service director (SSD) was interviewed again on 7/11/24 at 4:04 p.m. The SSD said the resident was reassessed and it was determined Resident #24 could use a call bell. She said she gave the resident a yellow service bell (see above observations). III. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, other amnesia (difficulty speaking), muscle weakness, contracture right knee, contracture left knee and rheumatoid arthritis (pain in the joints). The 5/8/24 MDS assessment revealed Resident #8 had moderate cognitive impairments with a BIMS score of eight out of 15. The MDS assessment revealed she had limited range of motion in both lower and upper extremities. Resident #8 was dependent on staff for eating, oral hygiene, toileting, showering, dressing lower and upper body, personal hygiene and bed mobility. B. Observations On 7/10/24 at 12:20 p.m. Resident #8 was in the dining room, another resident began to eat Resident #8's cake. Resident #8 told the other resident to stop eating her cake. On 7/11/24 at 12:00 p.m., the resident was at the medication cart. Registered nurse (RN) #1 was asking her medical questions and she was able to answer appropriately. C. Resident interview Resident #8 was interviewed on 7/12/24 at 3:00 p.m. Resident #8 said she was glad to have a call bell. She said she was able to use it when she needed to call for staff. D. Record review The 5/21/24 call system assessment documented Resident #8 was unable to demonstrate using a call bell. E. Staff interviews The SSD was interviewed on 7/11/24 at approximately 3:00 p.m. The SSD said Resident #8 scored an eight on her most recent BIMS assessment. She said because the resident scored an eight on the assessment, the SSD determined the resident was unable to use the call bell. The SSD said she would reassess the resident later in the day. The SSD was interviewed again on 7/11/24 at 4:04 p.m. The SSD said she reassessed the resident and determined the resident was able to use a call bell. She said she gave the resident a bell. IV. Shower rooms A. Observations and interviews On 7/10/24 at approximately 2:30 p.m., the men's and women's shower rooms on the memory care unit did not have a working call light system. There was a small red button on the men's side of the shower room which read emergency. However, when pushed, the red button did nothing. CNA #2 was interviewed on 7/10/24 at approximately 2:30 p.m. CNA #2 said the shower room call light initiated a light on a panel that was located across from the nurse's station. She tested the red button and the light on the panel did not light up. She said the facility did not have a different system in place to call for assistance. The maintenance supervisor (MS) was interviewed on 7/11/24 at 2:43 p.m. The MS said he had worked at the facility for four years. He said during that time there had never been call lights in the shower rooms on the memory care unit. He said the red button in the shower room was from an old call light system that no longer functioned. The MS was interviewed again on 7/11/24 at 3:15 p.m. The MS said he was able to put call lights into the shower rooms (on 7/11/24).

Based on observations, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for two (#16 and #28) of two residents reviewed for respect and dignity out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #16 had privacy when he slept in a brief; and, -Ensure Resident #28 was dressed appropriately and not exposed in the dining room. Findings include: I. Facility policy and procedure The Resident Rights Dignity and Respect policy, revised November 2023, was provided by the director of nursing (DON) on 7/12/24 at 11:45 a.m. It read in pertinent part, It is the policy of this facility that all residents be treated with kindness, dignity and respect. Residents will be appropriately dressed in clean clothes arranged comfortably on their persons, and well groomed. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by. Violations of the resident's right to dignity and respect should be promptly reported to the DON and/or the administrator. II. Resident #16 A. Resident status Resident #16, age less than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included personal history of a traumatic brain injury, dependence on respirator and persistent vegetative state (disordered state of consciousness). The 5/1/24 minimum data set (MDS) assessment revealed the resident was unable to be understood and unable to participate in the brief interview for mental status (BIMS) for a cognitive score. The MDS assessment indicated Resident #16 had a memory problem and was severely impaired through staff assessment. Resident #16 was dependent upon staff for all activities of daily living (ADLs). B. Observations During a continuous observation on 7/10/24, beginning at 10:55 a.m. and ending at 12:55 p.m., the following was observed: At 10:55 a.m. Resident #16 was lying in bed wearing a brief. The resident's brief and the entire right side of his body was exposed and the resident's bedroom door was completely open. At 12:03 p.m. licensed practical nurse (LPN) #2 entered Resident #16's room and administered his medication through his feeding tube. There was a sheet that covered Resident #16's left leg exposing the rest of his body and his brief. -LPN #2 did not cover Resident #16 and left the room at 12:07 p.m. The resident's door was left completely open. At 12:45 p.m. an unidentified respiratory therapist (RT) entered Resident #16's room. The unidentified RT suctioned the resident's tracheostomy. The RT exited the room at 12:49 p.m. and left the resident's room without covering the resident. The RT left the resident's door completely open. At 12:55 p.m. a staff member entered Resident #16's room and provided incontinence care. The staff member covered Resident #16 with a sheet when he left the room. -However, the facility failed to cover the resident for two hours. The resident's door was left open and he was exposed to individuals who passed by in the hallway. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/10/24 at 1:17 p.m. CNA #1 said after a resident was changed or repositioned the staff covered the resident with a sheet or their clothing. CNA #1 said if the resident refused to be covered the staff closed the door or pulled the privacy curtain. The DON was interviewed on 7/12/24 at 3:17 p.m. The DON said if a resident wanted to lay in their bed in their underwear or a brief the staff respected the resident's wishes. She said the staff needed to close the bedroom door or pull the privacy curtain if they chose to lay in bed without clothing. The DON said she was not sure why the staff left Resident #16 exposed. She said the staff should have covered Resident #16's legs, closed the door or pulled the privacy curtain to prevent Resident #16 from being exposed to individuals passing by his room. III. Resident #28 A. Resident status Resident #28, age 69, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included morbid obesity due to excessive calories, undifferentiated schizophrenia (a psychotic disorder that was a subtype of schizophrenia with a broad range of symptoms), muscle weakness and abnormal posture. The 4/17/24 MDS assessment revealed Resident #28 was cognitively intact with a BIMS score of 13 out of 15. Resident #28 had no impairment to his upper or lower extremities and used a wheelchair. It indicated the resident refused care offered. B. Observations On 7/10/24 at 12:37 p.m. Resident #28 was in the main dining room in his wheelchair. His shirt was raised over his stomach just below his chest and his pants were down low which exposed his intergluteal cleft to the residents and staff in the dining room. -No staff members offered to adjust the resident's clothing so the resident was not exposed in the dining room. On 7/11/24 at 12:21 p.m. Resident #28 was in the main dining room in his wheelchair wearing the same clothes from 7/10/24. His shirt was raised over his stomach just below his chest and his pants were down low which exposed his intergluteal cleft to the residents and staff in the dining room. -No staff members offered to adjust the resident's clothing so the resident was not exposed in the dining room. On 7/12/24 at 5:04 p.m. Resident #28 was in the main dining room in his wheelchair wearing the same clothes from 7/10/24. His shirt was raised over his stomach just below his chest and his pants were down low which exposed his intergluteal cleft to the residents and staff in the dining room. -No staff members offered to adjust the resident's clothing so the resident was not exposed in the dining room. C. Resident interview A resident, who wished to remain anonymous, was interviewed on 7/10/24 at 3:00 p.m. The resident said when the weather was hot the staff often placed residents in their wheelchairs with only a brief and shirt or just a brief on in the dining room. The resident said a lot of residents walked around exposed and Resident #28 often had his clothes not positioned properly to prevent exposure. D. Staff interviews The DON was interviewed on 7/12/24 at 3:17 p.m. The DON said Resident #28 often sat in the dining room partially exposed because he was a bigger resident and his clothes did not fit well. She said the staff encouraged him to fix his clothing placement or offered to help him, but the resident often refused. The DON said the facility offered to purchase the resident bigger clothes and Resident #28 refused. -However, staff were not observed offering to reposition Resident #28's clothing so he was not exposed in the dining room during the survey (see observations above). The DON said she had not heard of any concerns from residents regarding other residents being exposed during meal times. The DON said she understood why it was a concern.

Based on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for three (#3, #22 and #59) out of four residents reviewed out of 47 sample residents. Specifically, the facility failed to: -Ensure the medical orders for scope of treatment (MOST) form had complete and accurate documentation of who obtained verbal consent from legal decision makers; and, -Ensure timely follow up was completed with a signature from the resident's legal representative. Findings include: I. Facility policy and procedure The Advanced Directives policy and procedure, reviewed [DATE], was provided by the director of nursing (DON) on [DATE] at 6:05 p.m. It read in pertinent part, The resident or responsible party will be asked to fill out and sign a MOST form upon admission indicating their wishes in the event of a health emergency. The resident and/or legal representative shall sign and date the form acknowledging that the options were reviewed and understood. Such documentation shall be maintained in each resident's record. The form will also be signed by the resident's medical provider. Any resident who does not have a signed order or advance directive will be treated as a full code until the order is signed by the resident/responsible party and the provider. II. Resident #3 A. Resident status Resident #3, age 84, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included vascular dementia, diabetes mellitus and hypertension (high blood pressure). The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of one out of 15. He was dependent with personal hygiene, transfers, toileting, required substantial/maximal assistance with bed mobility and set up assistance with eating. B. Record review The MOST form, dated [DATE] and reviewed on [DATE], revealed the resident wished to receive CPR (cardiopulmonary resuscitation). -The form did not have a mandatory patient or legal decision maker signature. The form had a hand written verbal consent from POA (power of attorney) along the margin without any corresponding signatures of who obtained the verbal consent. III. Resident #22 A. Resident status Resident #22, age 72, was admitted on [DATE]. According to the [DATE] CPO, the diagnoses included Alzheimer's disease and diabetes mellitus. The [DATE] MDS assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. He rarely ever made decisions regarding daily life. He was dependent with toileting, personal hygiene, bed mobility, transfers and required set up assistance for eating. B. Record review The MOST form, dated [DATE] and reviewed [DATE], revealed the resident wish of no CPR with comfort focused treatment and no artificial nutrition by tube. -The form did not have a mandatory patient or legal decision maker signature. The consent had handwritten verbal consent from POA without corresponding signatures of who obtained verbal consent. IV. Resident #59 A. Resident status Resident #59, age 85, was admitted on [DATE]. According to the [DATE] CPO, the diagnoses included cervical fracture, cerebral infarction (stroke) and dementia. The 2//,d+[DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief BIMS score of 3 out of 15. He was dependent with personal hygiene, bed mobility, transfers, toileting and required set up assistance with eating. B. Record review The MOST form, dated [DATE] and reviewed [DATE], revealed the resident wish of CPR with selective treatment and short term nutrition by tube. -The form did not have a mandatory patient or legal decision maker signature. The consent had handwritten verbal consent from daughter and resident without corresponding signatures of who obtained verbal consent. V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 11:30 a.m. She said the nurse completed the MOST forms upon admission. She said if the resident was not able to sign their consent the legal decision maker or POA would sign the form. She said if the legal decision maker was not available to sign the form she said a verbal consent was obtained and the sure signed the form. She said only one nurse needed to sign the form. She said the MOST forms were forwarded to medical records for completion and uploaded into the electronic medical record. The medical records specialist (MRS) was interviewed on [DATE] at 11:35 a.m. She said she ensured the physician signed the MOST forms. She said if there were other missing signatures including from the resident or the legal decision maker she would notify the nursing staff. She said she did not know if verbal consents required two signatures until a formal signature from the legal decision maker or POA could be obtained. The social work consultant (SSC) was interviewed on [DATE] at 9:17 a.m. She said the admitting nurse completed the MOST form upon the resident's admission into the facility. She said during the care conferences MOST forms were reviewed at that time. The recommended practice during the care conference was to make sure the MOST forms were complete and accurately filled out. She said when a verbal consent was obtained for a MOST form two staff members needed to witness the verbal consent and then follow up with their signatures on the form. She said there seemed to be a gap in practice in ensuring those signatures were completed and reviewed during the quarterly care conferences.

Based on observations, record review and interviews, the facility failed to store, prepare and serve food in a sanitary manner in one of two kitchens. Specifically, the facility failed to ensure dish room sanitation was maintained to eliminate harborage conditions for pests in the secure unit kitchen. Finding include: I. Professional reference The Colorado Retail Food Regulations, effective 3/16/24, were retrieved 3/25/24 from https://cdphe.colorado.gov/environment/food-regulations. The regulations revealed in pertinent part, Physical facilities shall be cleaned as often as necessary to keep them clean. Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by routinely inspecting incoming shipments of food and supplies; routinely inspecting the premises for evidence of pests; and eliminating harborage conditions. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests. II. Facility policy and procedure The Kitchen Sanitation and Cleaning policy and procedure, revised August 2021, was provided by the dietary manager (DM) on 3/21/24 at 12:30 p.m. The policy revealed in pertinent part, Cleaning should be performed before, during and after food preparation. Each user must properly clean and sanitize the kitchen after their shift and ensure the kitchen is ready for the next user. Floors should be swept and cleaned at the end of your shift. All custodial brushes and equipment must be in good repair. Dirtied walls should be washed with hot soapy water, wiped with clean towels, sanitized and wiped again with clean towels. III. Observations Lunch service was observed and a kitchen walk through was conducted in the secure unit on 3/20/24 from 11:50 a.m. to 12:30 p.m. Observations in the kitchen revealed a cleaning list was not posted or utilized and the facility failed to maintain in good condition and keep the floor and walls under the dish machine clean to prevent pest harborage. The dish machine in the secure unit kitchen was flanked by dish tables on both sides that connected in a 90 degree angle in the corner of the kitchen. The tile walls behind and under the dish machine tables were splattered with brown spots and small pieces of debris. A layer of black dirt and grime with pieces of debris and food crumbs was on the floor under the dish machine and both dish machine tables and extended to the walls. The black vinyl cove base (baseboard) under the clean dish table pulled away from the wall at its top edge in two spaces, approximately one inch long each. An undated pest glue trap approximately three inches long was on the floor under the clean side dish table with approximately 20 small roaches inside. There were two dead and dried roach carcasses next to the pest glue trap on the floor. The black vinyl cove base under the dirty side dish table was completely separated from the wall and when pulled away from the wall half an inch there were two live cockroaches behind the cove base. IV. Staff interviews The DM was interviewed on 3/20/24 at 3:30 p.m. The DM said she was working on a cleaning list for the kitchen but did not have a cleaning list currently in use. The DM said staff cleaned the kitchen floors daily but have not specifically cleaned under the dish machine. The DM said the pest control company came to the facility for scheduled maintenance visits and made additional visits and if the facility called the company. The DM said staff wrote pest sightings in a pest control log and then informed maintenance. The DM said she would add the walls and floor under the dish machine to the cleaning list as an area to be cleaned on a regular basis and deep cleaned. The maintenance supervisor (MS) was interviewed on 3/20/24 at 3:45 p.m. The MS said the pest control company came to the facility on a regular schedule for maintenance. The MS said the pest control company put the pest sticky traps in the area most likely to harbor pests such as under the dish machine. The MS said he was unsure how long the pest sticky trap had been under the dish machine.

Based on observations, interviews, and record review, the facility failed to provide a clean, comfortable and homelike environment for 27 of 27 residents in two of two hallways on the secure unit and one of eight residents reviewed on the rehabiliation unit. Specifically, the facility failed to: -Ensure resident rooms were in good repair, blinds were maintained and doors in good condition; -Ensure common areas and the dining room such as walls and baseboards were cleaned and maintained in good repair in the secure unit; -Ensure resident rooms and closet space was labeled appropriately; and, -Ensure resident common area furniture was in good condition. Findings include: I. Observation of the secured unit On 3/17/24 an initial tour was conducted in the secure unit from between 3:00 p.m. and 4:30 p.m. The secure unit consisted of two hallways with resident living areas where 27 residents occupied 17 rooms and were connected by a main hallway with a common area, dining room and the main entrance from outside to the secure unit itself. The following conditions were observed in common areas and resident rooms during the initial walkthrough and throughout survey from 3/17/24 to 3/21/24. Resident hallways and common areas: -The hallway baseboards throughout the facility had multiple areas of peeling paint and pieces of the wood chipped away. Flakes of dried, chipped paint one-fourth to one-half inch in size were scattered in the hallways in front of resident rooms on the women's hallway. -Numerous splatters of white paint were present on the hallway floors. -Adjacent hallway corners were scuffed, uneven and were missing fragments that exposed layers of gray, yellow and white paint. -There were six long pink drip stains that ran down the wall from the handrail to the wood baseboard near the men's hallway. -Multiple brown splatters covered an area approximately two feet long and six inches high on the wall above the baseboard near the women's hallway. -A large piece of paint approximately two by three inches was peeling from the door frame of room number five. -A square inch of yellow colored splatter was visible on the wall outside the shower room. -The men's and women's hallways were devoid of any wall decoration. -A handrail approximately twelve inches long on the women's hallway was connected to the wall by two brackets with two screws each. One of the bracket's screws were not secured to the wall and the handrail lifted approximately one inch when moved. -A light brown chair in the common area was cracked and the surface of the chair's headrest worn away so it was black instead of light brown. Residents sat in the chair throughout the survey. -A corner of the metal baseboard heater in the dining room was bent and protruding. The bent corner was under a dining room chair and near residents' feet while resident dined in the dining room. -A grass patio space outside the front entrance of the secure unit building and was accessed freely by secure unit residents through the front doors. The front doors opened to a small outdoor concrete patio that residents and staff passed through during the day. There were eight cigarette butts on the concrete patio 3/18/24 to 3/21/24. Next to the cigarette butts were numerous black burn marks on the concrete, and approximately four feet above the cigarette butts on the brick wall of the building entrance. Staff were observed entering and exiting the front doors of the building numerous times throughout the survey. On 3/20/24 residents participated in a staff led activity on the grass patio space next to the front doors with the cigarette butts still on the concrete patio. Resident rooms: -The doors to the residents' rooms had clear pieces of tape stuck to the doors, multiple spots of leftover tape residue and numerous scuff marks and scratches. -Room number four had a window with a set of blinds that had approximately a dozen missing end pieces near the braided ladders of the blinds. -room [ROOM NUMBER] had two windows each with a set of blinds. Both sets of blinds have multiple bent and broken pieces as well as missing ends of the blinds. -room [ROOM NUMBER] had two name labels taped to the door, one was laminated yellow paper and the other was laminated orange paper, both approximately two by six inches wide. Multiple other resident rooms had no resident name signs of any kind. -room [ROOM NUMBER] had a yellow two inch by two inch post it note taped to the door and written in red marker was #20 and the resident's first name. The yellow paper was taped to the door with a four inch long piece of clear tape. room [ROOM NUMBER] on the secure unit: -The four drawer dresser had a drawer with a missing handle. -The closet shelf had a name written on it with black marker and another name attached by a yellow label with white letters. -room [ROOM NUMBER] had two windows with blinds in each window. Both sets of blinds have missing ends. II. Resident interviews and additional observation The resident in room [ROOM NUMBER] of the secure unit was interviewed on 3/17/24 at 3:30 p.m. He said his dresser and bed (in room [ROOM NUMBER]) were old. Resident #111 said he did not know who the people were whose names were written on his closet shelf, but he thought one of them used to live in room [ROOM NUMBER] and had passed away. Resident #111 said he was unsure how long the handle on his dresser was broken and would like his blinds fixed. The resident in room [ROOM NUMBER]W was interviewed on 3/18/24 at 11:00 a.m. Resident #53 said he wished his blinds were fixed because his room was not dark even with the blinds closed. The missing sections of the blinds still let light in his room. -On 3/18/24 room number nine on the rehabilitation unit was observed at 11:00 a.m. to have seven missing ends of the window blinds. III. Staff interviews The maintenance supervisor (MS) was interviewed on 3/20/24 at 1:30 p.m. The MS said facility staff could put a maintenance request into TELS (electronic maintenance request system) to let him know that the blinds in residents' rooms needed repair. The MS said that it was preferable that closet shelves in resident rooms did not have resident names written on them but staff should instead use a label maker. The MS said he would repaint the shelf in room [ROOM NUMBER] on the secure unit to cover the name written in black marker. The MS said the burn marks on the front wall of the building and pavement were likely done by staff smoking and should be cleaned. He said any facility staff could all clean the interior walls and he would see if the housekeeping staff could clean them. The MS said the facility should be getting new chairs and the items were taken off the walls for the remodel a couple weeks prior. On 3/20/24 at 2:33 p.m. the nursing home administrator (NHA) came in through the front door of the secure unit and passed by the cigarette butts on the ground. The NHA said he did not see the cigarette butts at the front door when he entered the building and said he would clean them up. The NHA immediately turned and went to the front door of the secured unit and cleaned the cigarette butts from the front entrance. Certified nurse aide (CNA) #1 was interviewed on 3/20/24 at 2:35 p.m. CNA #1 said she usually asked other staff to put a maintenance request for blinds in TELS but the staff told her the residents would just pull the blinds down. CNA #1 said she had not put a work order into the TELS system herself. CNA #1 said she was unsure who was responsible for putting the resident's name on their closet shelf. CNA #1 said all staff regardless of position could clean the spills off the walls. The assistant director of nursing (ADON) #1 was interviewed on 3/21/24 at 10:30 a.m. The ADON said the resident in room [ROOM NUMBER] on the secure unit did not let people in his room when he first arrived so staff were unable to label his closet. ADON #1 said staff were able to place maintenance requests for blinds in TELS and then maintenance staff could then follow up. DON #1 said she was unaware staff told CNA #1 residents would just pull the blinds down again when she noticed the blinds needed repair. ADON #1 said she was unaware there were cigarette butts at the front entrance of the secure unit but cleaning in the facility was the responsibility of all staff. IV. Facility follow up The MS provided a follow up on 3/20/24 at 2:00 p.m. he asked a housekeeping staff member to clean the drips and splatters on the secure unit walls and that she would let him know if the walls were not cleanable and needed to be painted. The MS pushed in the protruding corner of the baseboard heater so it was flush with the rest of the unit and no longer a hazard.

Based on record review, observations and staff interviews, the facility failed to ensure the call light system was functioning properly in its entirety. Specifically, the facility failed to ensure all 27 residents on the secure unit had access to a functioning call light system. Findings include: I. Facility policy The Call Light/Bell policy, revised May 2023, was provided by the director of nursing (DON) on 3/21/24 at 10:00 a.m. The policy revealed in pertinent part, It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: Answer the call light/bell within a reasonable time. Turn off the call light/bell. Listen to the resident's request/need. Respond to the request. If the item is not available or you are unable to assist, explain the resident and notify the charge nurse for further instructions. Leave the resident comfortable. Place the call device within the resident's reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor. II. Facility layout and initial observations The secure unit consisted of two resident hallways that housed 27 residents and connected to a main hallway that contained the main entrance, common area and nurses station. On 3/19/24 at 11:15 a.m call lights in room [ROOM NUMBER] were observed: There was a call light button over a bed in room [ROOM NUMBER] and no call light in the bathroom of room [ROOM NUMBER]. Each resident room in the secure unit had a light over their door in the facility hallway. Two of the lights were painted over so the light was not visible under the paint. No lights were turned on over the resident's doors during the survey for the following dates and times: 3/17/24 from 3:00 p.m. to 6:00 p.m., 3/18/24 to 3/20/24 from 9:00 a.m. to 5:00 p.m, and 3/21/24 from 9:00 a.m. to 12:30 p.m. III. Resident #111 A. Resident status Resident #111, age 65, was initially admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), fracture of the fourth vertebrae, encephalopathy (change in brain function), epilepsy, high blood pressure, muscle weakness, history of traumatic brain injury and disorientation. The 1/2/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15 with no behaviors. The resident needed staff set-up assistance with bathing, dressing, using the toilet, and eating, and all transfers, including toileting and tub/shower. B. Resident interview and observations Resident #111 was interviewed on 3/17/24 at 3:00 p.m. Resident #111 said the call light system above his bed and in his bathroom did not work and the call lights did not go anywhere. Resident #111 said he could push the button on the call light in the bathroom or pull the call light cord. The call light system was observed on 3/17/24 at 12:59 p.m. in Resident #111's room. The call light for the bed was non-functional. The call light for the bathroom activated inside the bathroom when pushed by showing a red light on the call button, but did not activate the light over Resident #111's door or activate a notification system at the nurses station. Resident #111's room was at the end of a hallway farthest from the nurses station and common area of the secure unit. An unidentified certified nurse aide (CNA) aide approached Resident #111's room at 3:07 p.m. The CNA said the staff performed 15 minute checks on the residents in the secure unit because the call light system was not used and did not work. -A review of Resident #111's electronic medical record revealed 15 minute checks were not documented or recorded in his electronic medical record. C. Record review Resident #111's care plan for activities of daily living (ADLs) for self-care performance deficit related to weakness, cognitive deficits, seizures and history of traumatic brain injury was initiated on 12/29/23. Pertinent interventions encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use the bell to call for assistance and that Resident #111 required the assistance of 1-2 staff members for transfers, bed mobility, toilet use and showers. -Resident #111's care plan did not encourage staff to ensure the resident's call light was functional or include a care plan or intervention for scheduled resident monitoring. The care plan failed to provide alternatives for Resident #111 since the call system did not function. IV. Staff interviews The maintenance supervisor (MS) was interviewed on 3/20/24 at 1:30 p.m. The MS said the call light system on the secure unit was not functional primarily because the residents were unable to use it. The MS was not sure how long or when the facility stopped using the call light system. The MS said the call light over the beds were part of the defunct call system and not in use, and the call light in Resident #111's bathroom was part of a wireless call light system used on the rehabilitation unit but the call light did not alert anywhere. Certified nurse aide (CNA) #1 was interviewed on 3/20/24 at 2:35 p.m. CNA #1 said she was not aware Resident #111 had a call light in his bathroom or that Resident #111 had an intervention on this care plan to encourage him to use a call light. The minimum data set (MDS) coordinator for the secure unit was interviewed on 3/20/24 at 2:40 p.m. She said the care plan intervention for Resident #111's call light encouragement was a standard intervention that was added to all residents' care plans in the secure unit. The staffing development coordinator (SDC) was interviewed on 3/20/24 at 2:41 p.m. The SDC said residents in the secure unit were evaluated upon admission for appropriate use of the call light but it was possible that not all of them were uploaded into the electronic medical record. Assistant director of nursing (ADON) #1 was interviewed on 3/21/24 at 10:30 a.m. ADON #1 said if Resident #111 fell in his bathroom, the staff on the secure unit would hear the fall and get to the resident timely so that Resident #111 would not have to wait until staff completed their 15 minute rounds to find him. V. Facility follow up The nursing home administrator (NHA) provided the Call Light/Bell Secured Unit Policy, revised October 2014, on 3/22/24 at 2:28 PM. The policy read in pertinent part, It is the policy of this facility to provide the resident a means of communication with nursing staff. Residents on the secure unit will be assumed to need to have their needs and wants anticipated by staff. Staff is selected to round on residents regularly to ensure all needs are met. Residents with moderate to severe cognitive impairment are unable to utilize a call light system appropriately. Further, resident with moderate to severe cognitive impairment are unable to be taught to use a call light system and presence of call lights in the room present risk related to entanglement, uniting the call light for harm to self or other and an infection control risk. If a resident is unable to use the call light, keep all cords out of the resident's reach to keep residents safe from getting tangled on the cord. Facility to provide frequent checks to anticipate resident needs due to the inability to use the call-light system and potential for injury by getting tangled in the call light cord. -However, Resident #111 had a call light with a pull cord in his bathroom and was able to explain the call light function. Staff were notified on 3/17/24 the call button in the bathroom was pushed and the call light remained in Resident #111's bathroom throughout the survey process. The facility provided two call light assessments for Resident #111 on 3/22/24. The assessments were completed on 12/28/23 and 3/21/24 (the last day of survey). The call light assessment documented the resident was unable to demonstrate how to use the call light button. -However, there was no additional documentation provided as to whether the call light with the attached cord remained in Resident #111's room or updates to Resident #111's care plan.

Based on interviews and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for for one (#1) of three residents reviewed for dental care out of five sample residents. The facility failed to provide emergency dental services for Resident #1. Resident #1's family was visiting on 4/16/23. The family notified the licensed nurse on duty of a broken, dark tooth, pain, discoloration and swelling to the resident's right lower jaw and neck.The family member said it was weeks before he was seen by a dentist, and the facility just kept giving him antibiotics. The resident received oral and intravenous (IV) antibiotics between 4/18/23 and 5/25/23 for repeat swelling and pain to the jaw. He was not seen by a dentist until 5/3/23, more than two weeks after he was observed with pain and swelling to his right jaw and neck. The dentist documented on 5/3/23, Resident #1 needed a root canal (dental procedure needed when the soft tissue or pulp inside the tooth becomes infected leading to severe toothache, tooth becomes darker, swollen painful gums and abscess if not treated). The resident was discharged to the hospital on 6/5/23, he had not had a root canal or been scheduled for one. Additionally, antibiotics were not initially started until two days after the resident developed signs of infection. Findings include: I. Facility policy and procedure The Dental Services policy, dated January 2020, was provided by the director of nursing (DON) on 9/11/23 at 4:57 p.m. It revealed, in pertinent part, It is the policy of this facility, in accordance with residents' needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. The Social Services Director maintains contact information for providers of dental services that are available to facility residents at a nominal cost. II. Resident status Resident #1, age 70, was admitted on [DATE], readmitted on [DATE] and discharged from the facility to the hospital on 6/5/23. According to the August 2023 computerized physician orders (CPO), diagnoses included hypothermia (dangerously low body temperature) with shock, acute respiratory failure and metabolic encephalopathy (problem of the brain due to chemical imbalance in blood). The 5/17/23 minimum data set (MDS) assessment revealed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) with a score of 14 out of 15. He was totally dependent on two staff to assist with bed mobility, transfers, dressing, toileting and personal hygiene. He had a tracheostomy and was on a mechanical ventilator with oxygen. The assessment documented the resident had mouth or facial pain and discomfort. He had received intravenous medications while at the facility. III. Interviews Resident #1's family was visiting the resident on 4/16/23 and observed discoloration and swelling to the resident's right lower jaw extending down his neck. The family member said the entire right lower jaw and neck were swollen and the resident complained of pain when the family member lightly touched his neck. The family said she could see a broken dark tooth in his lower right jaw. The family member notified the nurse on duty. The family said the nurse became angry and abruptly said she would call the physician for an x-ray. The x-ray showed no bone abnormality and there were no new orders on 4/16/23. The family member said it would be weeks before Resident #1 was actually seen by a dentist, and in the meantime the facility had just kept giving him antibiotics. Social worker (SW) #1 was interviewed on 9/11/23 at 9:39 a.m. She said social services handled ancillary services such as dental services. SW #1 said she was assigned to Resident #1. She said she was not notified of the resident's dental issue on 4/16/23. SW #1 said she discovered the resident had pain and swelling in his jaw and neck when she was reviewing progress notes on 4/19/23. She said the facility had no formal process for notifying her of emergent dental needs. SW #1 said emergency dental services could probably be provided within a week through the visiting dentist, but not 24 hours. She asked if it was a requirement that the resident receive dental services in 24 hours. She said she would have to send them to the emergency room (ER) because the visiting dentist probably would not come out in 24 hours. SW #1 acknowledged there were no dentists in the ER. She said she scheduled an appointment for Resident #1 with the visiting dentist for 4/26/23. However, the dentist had a scheduling problem and did not come on 4/26/23 (see below). The resident was treated with oral and IV medications for repeated swelling, redness and pain to his right jaw and neck. SW #1 provided a note from a dentist dated 5/3/23, more than two weeks after he developed pain and swelling to his jaw and neck. The dentist note recommended a root canal. -The resident was discharged to the hospital on 6/5/23. He had not had a root canal. SW #1 said she had not been able to schedule the procedure due to insurance issues. IV. Record review On 4/16/23 at 10:13 a change of condition report documented the resident had swelling along the right mandible (lower jaw). The report documented the family was at bedside, the physician was notified and ordered an x-ray of the face and jaw. -There was no further description of the jaw or neck by the nurse, or of the broken tooth the family observed. On 4/16/23 at 5:59 p.m. the nurse notes documented the x-ray was normal and there were no new orders. On 4/17/23 the nurse practitioner (NP) documented the resident's face had developed redness and swelling. She documented the area was hot to touch and hard. The NP documented the area probably had an abscess or was an odontogenic (infection of teeth and or tissues). -There was no description of his mouth or broken tooth. The NP ordered two antibiotics, Linezolid Oral Tablet, 600 mg (milligrams) via PEG (percutaneous endoscopic gastrostomy) feeding tube two times a day for skin infection for 10 Days. The NP documented this antibiotic was given in case the infection was MRSA (methicillin resistant staphylococcus aureus). Additionally, she ordered Augmentin antibiotic 875-125 MG, one tablet via PEG tube two times per day for odontogenic infection for 10 days. The April 2023 medication administration record (MAR) documented the antibiotics were not started until the following day 4/18/23, two days after the family notified the facility of the signs of infection to Resident #1's tooth, jaw, and neck. On 4/19/23 at 10:27 a.m. SW #1 documented the resident was referred to the dental provider for swelling in his lower jaw, three days after his facial and neck swelling was observed. On 4/19/23 at 3:43 p.m. the nurse's notes documented the dentist would come for an emergency visit on 4/26/23 (10 days after the resident developed emergent dental concerns). Additionally, the Augmentin was increased to four times per day. On 4/26/23 at 10:50 a.m. the resident's physician documented the jaw and neck had improved, and the dentist would be out to evaluate the resident that day. On 4/26/23 at 2:07 p.m. the nurse notes documented the dentist would be here today for possible tooth extractions, and the resident and the resident's niece were notified. On 4/27/23 at 10:46 a.m. the nurse documented the social worker said the dentist would see the resident on 5/3/23. SW #1 provided an email she sent to the dentist on 4/27/23 at 9:49 a.m., when the dentist did not show up to see the resident on 4/26/23. The dentist said she had not added the emergency to her phone and therefore missed it. She said would come to see Resident #1 on 5/3/23. On 5/10/23 at 11:38 a.m. the NP documented the redness and swelling had returned to the residents face and neck on the right side. The NP ordered IV antibiotics, Unasyn IV every six hours for seven days total. On 5/10/23 at 1:00 p.m. the nursing notes documented the resident's face on the right side and jaw were swollen again and tender to touch. At 3:00 p.m. the nurse documented the resident and his medical power of attorney would like to do antibiotics through the PEG tube. The Augmentin was restarted twice per day via the PEG tube. On 5/15/23 at 11:23 the resident's swelling was worse. The Augmentin was discontinued and the Unasyn 3 g (grams) IV every 6 hours for 7 days until seen by a dental surgeon was ordered. On 5/17/23 3:51 a.m. the nursing note documented the swelling was better but the resident was having pain. He was medicated for pain. On 5/18/23 4:19 a.m. the nursing note documented the swelling was diminished to the resident's right jaw, but the resident was having pain. He was medicated for pain. On 5/22/23 at 8:04 a.m. the NP documented the resident was supposed to come off IV antibiotics today but due to significant swelling the IV antibiotics would be continued for three more days. 5/25/23 at 11:15 a.m. the NP documented the the resident would complete the IV antibiotic today, and the jaw swelling was better. -There were no further progress notes related to the resident's jaw or follow up appointment with the oral surgeon. On 6/1/23 at 9:23 a.m. SW #1 documented she had spoken to the resident's insurance company and the insurance would be transferred from the office in the city the resident previously resided in to the office of his current address at the nursing home. -This was the first social service follow up note since the initial note on 4/19/23 at 10:27 a.m. On 6/5/23 at 7:34 a.m. the nursing progress notes documented the resident was transferred to the hospital with altered mental status and a low blood pressure. V. Facility follow-up The facility provided a note from the medical director (MD) on 9/12/23, after the survey. The note, undated, documented in pertinent part, The dental delay did not have any impact on the resident health as the infection resolved with interventions in place. This had no impact on the resident eating as he was NPO (nothing by mouth) and meeting nutritional needs through enteral feeds. There was no harm related to dental appointments being rescheduled and the provider was monitoring the situation closely with resolution of the infection obtained in house. -However, emergency dental services were required to be provided. Placing the resident on antibiotics repeatedly by the primary physician did not meet this requirement. Additionally, the resident was not initially started on antibiotics for two days after his symptoms began, a dentist recommended increasing the amount of antibiotics three days later via telephone, but he was not seen by a dentist for two weeks after he developed symptoms. He suffered repeated swelling and pain and needed repeat treatments with antibiotics. Furthermore, the facility never followed up and scheduled the resident with an oral surgeon.

Based on record review and interviews, the facility failed to ensure one (#5) of three residents reviewed out of five sample residents received respiratory care consistent with professional standards of practice. Resident #5 was admitted to the hospital from home on 6/28/23 with pneumonia. While at the hospital a tracheostomy was placed and the resident was placed on a mechanical ventilator (machine that breathes for you, ensures large enough breaths are taken). During the last week of the resident's hospitalization he was weaned from a ventilator down to a bi-level positive airway pressure (BIPAP, helps keep the airway open with positive pressure and gives more oxygen to the lungs, a person breathes on their own). The facility admitted the resident on 8/4/23. The facility placed him back on a mechanical ventilator. Facility records were requested that documented the resident was being weaned off the ventilator. The facility provided one respiratory note that was written during the survey and documented the resident was tolerating trach shield trials (a process of masking the tracheostomy and providing oxygen but no assistance with breathing) a few times per week for 20 minutes to four hours. However, the resident's hospital notes documented the resident was tolerating a BIPAP and trach shield trials up to five hours. The resident and his representative were interviewed which revealed the resident was not being weaned off the ventilator. The resident and resident representative expressed concern that since he had been on the ventilator at the facility for over a month, he would not be able to wean off successfully. Discharge orders from the hospital did not include mechanical ventilator orders. The facility admission orders did not include mechanical ventilator orders, tracheostomy care or suctioning orders until four days after the resident was admitted to the facility. Findings include: I. Facility policy and procedure The Mechanical Ventilator policy and procedure was requested on 9/11/23 at 4:30 p.m. and not received by the end of the survey 9/11/23 or within 24 hours after the survey exit. A protocol titled Mechanical Ventilation Weaning with Decrease of Settings, undated, was received from respiratory therapist (RT) #1 on 9/11/23 at 2:01 p.m. The protocol documented in pertinent part, daily evaluation, do not wean if systolic blood pressure is less than 90 mmhg (millimeters mercury), the pulse is less than 50 or greater than 130 sustained, BPM (beats per minute). Weaning, chart baseline on all parameters every two hours, weaning to continue 24 hours around the clock. II. Resident #5 A. Resident status Resident #5, under age 65, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO) diagnoses included amyotrophic lateral sclerosis (ALS, nervous system disease where nerve cells breakdown which reduces function of muscles). The 8/4/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score (BIMS) with a score of 14 of 15. He required extensive two person assistance with bed mobility. He required extensive two person assistance with transfers, dressing and personal hygiene. According to the assessment, the resident was only transferred and toileted one to two times and required extensive one person assistance with transfers and extensive one person assistance with toileting. The assessment documented the resident was on a mechanical ventilator with tracheostomy and oxygen and he had no shortness of breath. II. Interviews and record review The resident's representative was interviewed on 9/6/23 at 3:16 p.m. She said Resident #5 had initially been on a mechanical ventilator at the hospital. She said during the last two weeks the hospital had weaned the resident off the mechanical ventilator on to a BIPAP because he was able to breathe spontaneously on his own. She said when he was discharged from the hospital the resident's son was present. The emergency medical services (EMS) staff could not use the BIPAP in their vehicle, so they used an Ambu bag to provide supportive oxygen and positive pressure ventilation. However, when he arrived at the facility the respiratory staff placed him on a mechanical ventilator. The resident's representative said she had spoken to the director of respiratory therapy (DRT) several times including on 8/31/23 at the care conference without resolution (cross-reference F585 grievances). The DRT informed the resident representative that when he saw the resident at the hospital he was on a BIPAP with a back up. He told her this was the same as a ventilator. However, the resident representative said the facility's assessment was two weeks before Resident #5 was discharged from the hospital to the facility. She said the resident had been making progress at the hospital with just a BIPAP. The resident's representative said she and Resident #5 were aware that he had a progressive neurological disease. However, she said that did not excuse the facility's lack of care and treatment resulting in the resident becoming more dependent on a mechanical ventilator. He was up and walking in the hospital with just a BIPAP (see hospital notes). She said since admission to the facility he was in bed most of the time and on a mechanical ventilator full time. The resident's representative said the hospital records indicated he was weaned to just the BIPAP portion of the machine during the last week of hospitalization and breathing spontaneously on his own. The resident's representative expressed concern that Resident #5 was not able to get off the mechanical ventilator since the facility had placed it on him since his admission on 8/4/23. She said the respiratory staff were supposed to be working with the resident on trach shields (a process of masking the tracheostomy and providing oxygen but no assistance with breathing). However, this was not occurring consistently. The DRT was interviewed via telephone on 9/11/23 at 1:52 p.m. He said if the resident came to the facility on a ventilator then that was continued at the facility. He said all residents come with orders for respiratory therapy (RT) to evaluate and treat. The DRT said residents were given more or less support based on their needs per the facility protocol. He said the facility was attempting to wean the resident off the full time ventilator. The DRT said the hospital BIPAP system also has a back up which functions as a ventilator and therefore it was the same as the facility ventilator. -However, the hospital records the last week before the resident discharged did not indicate the resident needed the backup ventilator. He was using the BIPAP and ambulating. The DRT said the facility was attempting to wean the resident using trach shields off the ventilator. The RT notes from admission to present related to weaning the resident off the ventilator were requested. Only one note related to weaning was received (see below). RT #1 was interviewed on 9/11/23 at 2:01 p.m. She said she reviewed the hospital notes and the notes did indicate the resident was only using the BIPAP. She said she did not know why he was put on a mechanical ventilator when he admitted . RT #1 said she had reviewed his physician orders, and did not find orders for the mechanical ventilator or orders regarding his tracheostomy until 8/8/23. III. Additional record review A record containing hospital notes labeled referral in the resident's facility medical record was reviewed. According to a hospital document History of Present Illness, Resident #5 had been living at home with his sister before admission. He was diagnosed with ALS in February 2023. He was on room air and ambulated with a walker at home. Resident #5 went to the hospital on 6/28/23 due to shortness of breath. He was diagnosed with pneumonia and sent to the intensive care unit (ICU). He had a tracheostomy placed and was on a mechanical ventilator as of 6/29/23. Hospital progress notes were reviewed and further documented: On 7/7/23 the hospital documented the resident was tolerating trach shields for three hours. On 7/10/23 the hospital notes documented the resident was tolerating trach shields for five hours and had participated in therapy five days per week for one to three hours. He was still on the ventilator. On 7/16/23 at 7:00 a.m. the nursing notes documented the resident was resting in bed with a ventilator via tracheostomy. At 7:20 a.m. the nursing notes documented the resident was placed on BIPAP per respiratory therapy. At 10:00 a.m. the nurses notes documented the physician was at bedside and said to plan to keep Resident #5 on BIPAP if he continues to tolerate it. On 7/17/23 at 11:11 a.m. the hospital nursing notes documented the nurse had placed a trach shield and taken the resident for a walk. The nursing note documented the resident tolerated the walk fine. On 7/20/23 at 7:09 p.m. the nursing notes documented the resident was on BIPAP and his vital signs were stable. On 7/25/23 at 10:05 a.m. the physician notes documented the resident was medically stable to leave the ICU and tolerating trach shield trials and was on a BIPAP. From 7/21/23 to 8/1/23 the nurse notes documented the resident remained on BIPAP and his vital signs were stable. The 8/3/23 at 6:30 a.m. the nurse notes documented the resident was maintaining oxygen saturation levels above 90% on BIPAP. The facility admission orders on 8/4/23 revealed there was an order for respiratory therapy to evaluate and treat as indicated. There were no orders for a mechanical ventilator, oxygen, tracheostomy care, tracheostomy size, monitoring or suctioning of the tracheostomy until 8/8/23, four days after the resident was admitted to the facility. The facility nursing admission note dated 8/4/23 at 11:15 p.m. documented the resident was alert and oriented to person, place and time. His lungs were clear, he had no cough. Oxygen was administered at 16 liters per minute via tracheostomy. The note documented the resident was on a mechanical ventilator. The resident had a tracheostomy and required suctioning. The RT records from admission to the facility 8/4/23 to 9/11/23 were received from RT #1 on 9/11/23 at 2:01 p.m. The RT notes for 8/4/23 to 8/8/23, 8/30 to 9/1/23 and 9/6/23 during the survey were received. No other notes were provided. The RT notes from 8/4/23 to 9/1/23 did not include any documentation regarding weaning the resident off the ventilator. The RT note on 9/6/23, during the survey, documented the resident has been able to tolerate TS (trach shield) trials roughly a few times per week for 20 minutes to four hours. -There was no information regarding what days the trials were done, how many times a trial was done, what the resident's vital signs were before or after the trials or why the trial ended at 20 minutes of the four hour mark. VI. Facility follow-up On 9/13/23, two days after the survey exit on 9/11/23, the facility provided an undated note from a pulmonologist. The note documented in pertinent part, patients have a standing order to maintain current ventilatory support at the time of discharge and to migrate them to management protocols in place at the facility.

Based on record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening and infection of a pressure injury for two (#1 and #3) of four residents with pressure injuries out of five sample residents. Resident #1 admitted to the facility on [DATE] with intact skin. Resident #1 developed pressure injuries at the facility to his sacrum, left shoulder and right buttock. He had multiple comorbidities including a history of cardiogenic shock (heart not pumping enough blood to organs) and chronic respiratory failure, rhabdomyolysis (muscle tissue breakdown) and diabetes mellitus. He was at high risk for pressure injuries. The facility failed to initiate treatment when the sacral wound was first found on [DATE] for three days until [DATE]. The treatment administration records from [DATE] to [DATE] documented the wound care to his sacral, shoulder and right buttock wounds was held on multiple dates. The facility discussed the sacral wound with the wound doctor and documented the sacral wound was probably a Kennedy ulcer (terminal ulcer that may develop possibly indicating impending death) on [DATE]. However, there was no documentation that was discussed with the resident or the resident's representative to determine if aggressive treatment was desired. The decision to aggressively treat the wounds or seek acute care, regardless of risk factors or rationale for developing or worsening should have been discussed with the resident and/or his representative. His sacral wound became almost three times larger between [DATE] and [DATE] with a large amount of drainage. His wound was described by the facility as having a foul odor on [DATE]. There was no documentation the resident or his family were notified. He was sent to the hospital on [DATE] with altered mental status and hypotension. The resident's wounds were diagnosed as infected and he was septic. He underwent surgical treatment of the wounds, intravenous (IV) antibiotics and extensive wound care. He passed away 10 days later. His hospital death discharge summary listed his infected wounds and pneumonia as his final diagnoses. Resident #3 was admitted with a stage three pressure injury to his sacrum on [DATE]. On [DATE] at 4:03 p.m. the nursing note documented the resident fell out of bed, face down and hit his head causing a laceration. At 11:22 p.m. the nursing notes documented the resident began jerking, was less responsive with sluggish pupils and a high blood pressure (BP) of ,d+[DATE] (normal 130s/80s). The resident was sent to the hospital. He was admitted for sepsis infection to his sacral wound. The hospital notes documented the wound had pus coming from it, his temperature was 101 (normal for this resident 97.3 to 98.3). degrees fahrenheit and the resident had severe sepsis of his chronic sacral wound. His head computed tomography (CT, x-ray with cross sections) was normal. The resident was readmitted to the facility on [DATE], however there was no assessment of the wound until [DATE] or treatment of the sacral wound documented until [DATE]. Additionally, the resident was observed on an air mattress during the survey which was set for someone weighing 320 lbs (pounds). The resident weighed 233 lbs as of [DATE]. The air mattress was overinflated. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on [DATE], Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin and Wound Monitoring and Management policy, revised [DATE], was received from the director of nursing (DON) on [DATE] at 4:57 p.m. The policy documented in pertinent part, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and a resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Current evidence documents that, in certain circumstances, the development of pressure injury is an unavoidable occurrence. In accordance with the guidance issued by the National Pressure Ulcer Advisory Panel ([DATE]), the facility recognizes that an 'unavoidable' pressure injury is one that developed even though the provider evaluated the individual's clinical condition and pressure injury risk factors; defined and implemented interventions that are consistent with individual needs goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Facility nursing staff will identify and document in the resident's clinical records, the condition and pressure injury risk factors related to the development of unavoidable pressure injury. This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout the assessment process for developing a comprehensive plan of care. A licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented on the Initial Admission Record. A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not be limited to: measuring the skin injury, staging the skin injury when the cause is pressure, describing the nature of the injury, describing the location of the skin alteration, describing the characteristics of the skin alteration. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's order. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to the resident and or responsible party. Monitoring, daily via medication administration (MAR) and treatment administration records (TAR), weekly via the Skin Weekly Committee, inspection on showering, weekly skin check by a licensed nurse. III. Resident #1 A. Resident status Resident #1, age 70, was admitted on [DATE], readmitted on [DATE] and discharged from the facility to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included hypothermia (dangerously low body temperature) with respiratory failure and shock, and metabolic encephalopathy (problem of the brain due to chemical imbalance in blood). The [DATE] minimum data set (MDS) assessment revealed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) with a score of 14 out of 15. He was totally dependent on two staff to assist with bed mobility, transfers, dressing, toileting and personal hygiene. He had a tracheostomy and was on a mechanical ventilator with oxygen. The assessment documented the resident had two stage 3 pressure injuries. He was on a pressure reducing device in bed and he was not on a turning or repositioning program. The assessment documented the resident did not have application of wound dressing. B. Resident representative interview The resident's representative was interviewed on [DATE] at 2:19 p.m. She said she had not been aware of the resident's deteriorating wound until she got a panicked call from the nurse on [DATE], and the nurse said they were sending Resident #1 to the hospital. The representative reviewed the calls on her phone. The representative had no record of a call from the facility on [DATE]. She said she spoke to nurse, she thought it was licensed practical nurse (LPN) #1, on [DATE] and [DATE]. LPN #1 said each time the wounds were looking good. She was not notified of the deterioration of the wounds. The representative said Resident #1 was not on hospice or comfort care and was not dying. She said she was familiar with the term Kennedy ulcer. The representative said the facility should have notified her so a decision could have been made on treatment options. C. Record review The resident had a medical orders for scope of treatment (MOST) form dated [DATE], signed by the resident [DATE] and the physician [DATE], documenting he wanted full CPR (cardiopulmonary resuscitation) if needed and full treatment to prolong life by all means, including transfer to the hospital and intensive care unit (ICU). The resident was not on comfort care, palliative care or hospice. On [DATE] at 5:21 p.m. the nursing admission assessment documented the resident admitted with intact skin. The only note was regarding a healed surgical incision to the back of his neck. He was placed on a pressure redistributing overlay. On [DATE] at 3:30 p.m. the nursing notes documented the resident was sent to the hospital with altered mental status. On [DATE] at 1:25 p.m. the nursing admission assessment documented the resident's skin was intact except for being dry with three small scabs to the right ankle. On [DATE] at 10:57 a.m. the nurse practitioner (NP) documented the resident had been admitted to the hospital [DATE] with septic shock due to lung infection. On [DATE] at 7:14 p.m. the resident was sent to the hospital with abdominal distension and vomiting. On [DATE] at 1:15 p.m. the facility nursing admission documented the resident had an open area 7.0 centimeter (cm) in length by 0.5 cm width to his left inner thigh and an 0.5 cm by 0.5 cm red area to his scrotum. On [DATE] a non pressure wound report documented the resident had an abrasion to the back of the left thigh, with an onset of [DATE]. The wound was 0.3 cm by 0.15 cm. On [DATE] the nursing notes documented the resident had altered mental status and was sent to the hospital. On [DATE] at 11:34 a.m. the nursing admission note documented the resident had a 1.0 cm by 2.0 cm red area on the back of his right thigh. -There were no pressure injuries or wounds documented. There were no treatment orders until [DATE] (see below). On [DATE] at 3:11 a.m. the weekly skin evaluation documented monitor red area back of leg. -There was no further description of which leg or the size of the red area. On [DATE] at 5:26 a.m. (the same day) the weekly skin evaluation documented the resident's skin was intact. On [DATE] at 2:39 a.m. the weekly skin evaluation documented the resident had three pressure injuries. One to the rear left thigh 0.4 cm by 0.6 cm, stage 2. One to the sacrum 5 cm by 1 cm, stage 3. One to the right gluteal fold 4 cm by 3.5 cm stage 3. The evaluation said the resident would see the wound doctor on [DATE]. -There was no documentation the physician or family were notified. The [DATE] CPO was reviewed and revealed there were no treatment orders until [DATE], three days after the wounds were discovered (see below). On [DATE] at 10:27 a.m. the weekly pressure ulcer assessment documented: -Left rear thigh was 0.4 cm by 0.6 cm, no depth, no drainage or odor, 100% epithelialization (new epidermis outer skin layer), stage 2. -The sacrum was 5 cm by 1 cm, no depth, no drainage or odor, wound bed pink, 50% epithelialization, 50% granulation (new connective tissue), stage 3. -The right buttock was 4 cm by 3.5 cm, no depth with scant serosanguineous (contains blood and serum) drainage, the wound bed had slough (dead cells in wound, white or yellow material in wound bed) stage 3. The wound physician notes on [DATE] documented the above measurements and ordered to clean the wounds with normal saline and apply barrier cream twice daily and as needed for all wounds. On [DATE] at 10:22 p.m. a change of condition evaluation documented the resident had moisture associated skin damage (MASD) to the right and left buttock. On [DATE] at 4:53 a.m. the weekly skin evaluation documented the wounds to the sacrum and back of right thigh were intact (the wound on [DATE] as the left thigh). -There was no further documentation. On [DATE] at 3:45 p.m. the weekly pressure ulcer assessment documented: -Left rear thigh was resolved. -The sacrum was larger, 8.5 cm by 6.5 cm, no depth, with a small amount of serosanguinous drainage, no odor, the wound bed had granulation and the wound edges were macerated (softening and breaking down of skin related to moisture), stage 3. -The right buttock was smaller, 3.5 cm by 2 cm, no depth, with a small amount of serosanguinous drainage, no odor, the wound bed had granulation and the wound edges were macerated, stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. The wound physician notes on [DATE] documented the above measurements and ordered to clean the wounds with normal saline and apply barrier cream twice daily and as needed for both wounds. On [DATE] at 10:53 a.m. the weekly pressure ulcer assessment documented, -The sacrum was 7.5 cm by 6.5 cm, by 0.2 cm depth, with a small amount of serosanguinous drainage, no odor, the wound bed had non granulating tissue and the wound edges were macerated, stage 3. The treatment changed to Medihoney and foam dressing daily and as needed. -The right buttock was smaller, 2.1 cm by 4.2 cm, no depth, with a small amount of serosanguinous drainage, no odor, the wound bed was black and brown eschar (necrotic tissue) and the treatment was changed to Medihoney and foam dressing daily and as needed.The wound was a stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound MD documented the same measurements and ordered to clean the wounds with normal saline and apply honey and cover with foam dressing daily and as needed for both wounds. On [DATE] at 10:37 a.m. the weekly pressure ulcer assessment documented: The sacrum was 9.5 cm by 10.5 cm, by no depth, with a moderate amount of serosanguinous drainage, no odor, the wound bed had black and brown eschar and the wound edges were macerated, the surrounding skin was red, stage 3. The treatment changed to barrier cream to wound edges, Medihoney and abdominal dressing daily and as needed. -The right buttock was larger, 4.4 cm by 2.7 cm, no depth, with a moderate amount of serosanguinous drainage, no odor, the wound bed was black and brown eschar and the treatment was changed to barrier cream to wound edge, Medihoney and foam dressing daily and as needed. The wound was stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound physician documented the above measurements and ordered to clean the wounds with normal saline, protect the wound edge with barrier cream, and apply honey and cover with abdominal dressing, twice daily and as needed for both wounds. On [DATE] at 1:18 p.m. the weekly pressure ulcer assessment documented: The sacrum wound had improved and was 4.5 cm by 5 cm, by no depth, with a small amount of serosanguinous drainage, no odor, the wound bed had black and brown eschar and the wound edges were macerated, the surrounding skin was red, stage 3. The treatment was unchanged. -The right buttock was improved, 4.1 cm by 2.5 cm, no depth, with a small amount of serous (clear to yellow fluid) drainage, no odor, the wound bed had granulation tissue and the treatment was unchanged. The wound was stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound physician documented the above measurements and ordered to clean the wounds with normal saline, protect the wound edge with barrier cream, and apply honey and cover with abdominal dressing, daily and as needed for both wounds. On [DATE] at 2:04 p.m. the weekly pressure ulcer assessment documented: The sacrum wound had deteriorated and was 12 cm by 10 cm, by no depth, with large copious amounts of serosanguinous drainage, moderate odor, the wound bed had black and brown eschar, stage 3. The wound was debrided (removal of dead tissue with scalpel). The wound was packed with gauze soaked in Dakins (antiseptic). -The right buttock was improved, 3 cm by 2.7 cm, no depth, with a moderate amount of serosanguineous, no odor, the wound bed had granulation tissue and the treatment was unchanged. The wound was stage 3. The nurse documented the wound physician said the sacrum could be a Kennedy ulcer (pressure injury identified when a person is terminal). All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound physician documented the above measurements and ordered to clean the wounds with normal saline, protect the wound edge with barrier cream, and apply honey and cover with abdominal dressing, daily and as needed for both wounds. The wound physician documented the wounds were debrided, the length and width of each wound remained the same. The depth of the sacrum wound after debridement was 0.3 cm. The depth of the right buttock wound was 0.1 cm. On [DATE] at 2:49 p.m., the wound physician signed a Wound Tracker form documenting the sacral wound was probably a Kennedy ulcer. On [DATE] at 3:32 p.m. the nursing progress notes documented a late entry, that a call was placed to the resident's family about his wound deterioration and a return call was pending. -There was no further documentation of family or resident notification of the deteriorating wound. -The resident representative had no record of a call from the facility on [DATE] (see below). On [DATE] at 2:41 a.m. a change of condition assessment documented the resident had shearing to the back of the left shoulder. There was no further description. The MD was notified and the resident was notified. Wound care orders were obtained on [DATE] for bacitracin and an island dressing every shift and as needed. On [DATE] at 1:54 a.m. the weekly skin evaluation documented the sacrum wound was stage 4 and had a foul odor. -There was no documentation of the right buttock or left shoulder. On [DATE] at 7:38 a.m. a change of condition report documented the resident was unresponsive with a blank stare, labored breathing and a low blood pressure of ,d+[DATE]. It further documented he had a new skin condition, changes to a wound and his skin color was jaundice (yellow due to build up of bilirubin with the liver not functioning). The treatment administration records (TAR) were reviewed for [DATE], [DATE] and [DATE] and revealed the following: [DATE] Wound care to sacrum and left posterior thigh, dated [DATE], clean with wound cleanser pat dry, apply skin prep to peri wound and apply barrier cream every shift. The facility had two shifts, day shift and night shift. The order was written three days after the wound was found on [DATE]. The wound care orders for the sacrum and posterior left thigh were documented as 2 hold on the night shift [DATE], [DATE] and [DATE]. A number 2 indicated the treatment was held, see progress notes. -However, there were no progress notes for the sacrum on those dates. Orders for wound care to the right thigh, dated [DATE], were documented as 2 hold on the night shift ,d+[DATE] to ,d+[DATE], ,d+[DATE] to ,d+[DATE], and ,d+[DATE] to [DATE]. The orders for barrier cream to the buttocks and peri area every shift, dated [DATE], were documented as 2 hold, see progress notes on the night shift on ,d+[DATE] to ,d+[DATE], ,d+[DATE] to ,d+[DATE], and ,d+[DATE] to [DATE]. [DATE] The wound care orders for the sacrum and right buttock were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE]. On [DATE] and [DATE] the TAR was blank for the night shift wound care. -There were no progress notes for the sacrum on those dates. The orders for barrier cream to the buttocks and peri area were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE]. On [DATE] and [DATE] the TAR was blank for the night shift barrier cream. [DATE] The orders for wound care to the left shoulder, right buttock and sacrum were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE]. The orders for barrier cream to the buttocks and peri area were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE]. -There were no progress notes for the dates documented that the wound care was held. The skin integrity, potential or actual skin impairment care plan initiated [DATE] was reviewed. The care plan had interventions: air mattress, keep skin clean and dry, use lotion and avoid scratching. The skin impairment, abrasion of the left thigh care plan initiated [DATE], documented to follow protocol: monitor the location and size, report abnormalities to the physician and avoid scratching. The pressure ulcer care plan actual or potential, initiated [DATE], documented administered treatment as ordered: air mattress, assess and monitor wounds, report decline to physician, call light in reach, daily body checks, monitor nutritional status. The pressure ulcer stage 3 to the sacrum care plan, initiated [DATE], documented administer treatment as ordered, assess wound for healing, encourage turning and repositioning, monitor and report changes to the physician, notify nurse of new area of skin breakdown, weekly head to toe skin assessment. The pressure ulcer stage 3 to the right buttock care plan, initiated [DATE], documented administer treatment as ordered, assess wound for healing, inform resident and family of new area of skin breakdown. The hospital records dated [DATE] documented the nursing facility staff said the resident's wounds were looking more infected and that the resident was usually able to communicate, but had been confused lately and was hypotensive (low blood pressure). The ER records documented the resident was hypotensive, hypoglycemic (low blood sugar), anemic (low red blood cells), hypothermic, with altered mental status and a large sacral wound. The ER notes documented the medical durable power of attorney (MDPOA) confirmed the resident's full code status and understood his condition was life threatening. On [DATE] a pelvic CT revealed a large sacral wound with evidence of early osteomyelitis. The notes documented the resident was in shock due to sepsis or hemorrhagic (due to blood loss). The blood loss was documented as most likely chronic blood loss due to the extensive sacral wound. On [DATE] the hospital measured the sacral wound at 8.1 cm by 18.9 cm by 4.6 cm. The left back wound was 7.1 cm by 6.4 cm by 2.1 cm. The right ischial wound was measured at 6.7 cm by 6.5 cm by 0.1 cm. The left ischial wound, not documented in the nursing facility record, was measured at 6.7 cm by 6.5 cm by 0.1 cm. The resident had MASD with draining open areas to the lower abdomen and front of the left thigh near his groin. The resident received IV antibiotics and was followed by the infectious disease physician. On [DATE] at 10:28 a.m. the hospital nursing notes documented the resident's representative provided photos of the coccyx (tailbone near sacrum) with what the nurse described as a skin tear for [DATE]. The resident representative expressed concern with the wound care at the nursing facility. Adult protective services (APS) was notified by the hospital. On [DATE] the surgical records documented the stage 4 wound to the sacrum and stage 3 wound to the left back were surgically debrided. The record documented the left back wound and sacral wound had extensive amounts of necrotic tissue with a foul odor. A wound vac (machine to pull out fluids, stimulate new tissue) was placed on the left back wound. On [DATE] the right ischial wound was smaller and was measured at 5 cm by 5 cm by 0.1 cm. The left ischial wound, not documented in the nursing facility record, was measured at 7.5 cm by 7 cm by 6.5 cm by 0.1 cm. On [DATE] the sacral wound was smaller at 7.8 cm by 16 cm by 7.6 cm depth (debrided [DATE]). The left back wound was 7.1 cm by 6.4 cm by 2.1 cm. On [DATE] the surgeon spoke with the family and recommended debride of the left back again per the advice of the infectious disease physician. The family declined further treatment. The resident's code status was changed, he was removed from the ventilator and passed away on [DATE]. On [DATE] the hospital discharge summary documented the resident was admitted with altered mental status and hypotension likely due to septic shock with pneumonia and bacteremia (bacteria in the blood). The shoulder and sacrum wound were considered the cause of the bacteremia. He had early signs of osteomyelitis. The final diagnoses in pertinent part: septic shock due pneumonia, infected sacral decubitus ulcer, osteomyelitis, hemorrhagic shock with anemia of blood loss. On [DATE] at 4:11 p.m. the DON provided a document titled QAPI (quality assurance and performance improvement), dated [DATE], related to hospital concern of wound management for Resident #1. The document reviewed the resident's wounds and interventions. The review documented the facility felt the wound was unavoidable and recommended talking to the rounding wound nurse about keeping the family updated. -There was no documentation or review of the left shoulder wound. There was no review of the missing treatments documented as a 2 on the TAR. The facility documented the wound was unavoidable, probably a Kennedy ulcer. The review did not include any information related to evaluating wound care technique. There were no names or signatures on the QAPI document. VI. Resident #3 A. Resident status Resident #3, under age 65, was admitted on [DATE]. According to the [DATE] CPO diagnoses included interstitial lung disease, fibrotic phenotype (fibrous changes in lungs affecting lung function), unstageable sacral pressure injury, anxiety and depression. The [DATE] MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 of 15. He was totally dependent on extensive two person staff assistance for bed mobility, dressing, and personal hygiene. Transfers and toileting were documented as only having occurred one to two times, requiring extensive two person staff assistance. The assessment documented the resident had no behavioral concerns and did not refuse care. He had an unstageable wound and was not on a turning or repositioning program. B. Record review The nursing admission assessment dated [DATE] documented the resident had an unstageable wound to the sacrum measuring 3.6 cm by 3.4 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 6 cm by 10 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 8.5 cm by 10 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 6.5 cm by 9 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 7 cm by 8 cm by 0.5 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 8 cm by 8 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 7.5 cm by 7.6 cm by 2 cm. On [DATE] at 4:03 p.m. the nursing notes documented at the resident fell out of bed face down, and hit his head causing a laceration. At 11:22 p.m. the nursing notes documented the resident began jerking, was less responsive with sluggish pupils and a high blood pressure (BP) of ,d+[DATE]. The resident was sent to the hospital. Hospital records dated [DATE] documented the resident was admitted for sepsis infection to his sacral wound. The hospital notes documented the wound had pus coming from it, his temperature was 101 degrees fahrenheit and the resident had severe sepsis of his chronic sacral wound. His head CT (computed tomography, x-ray with cross sections) was normal. H[TRUNCATED]

Based on record review, observations, and interviews, the facility failed to create an environment that protected two (#37 and #124) of six residents reviewed for abuse out of 38 sample residents. Resident #69, with moderate cognitive impairment, exhibited inappropriate sexual behavior toward one resident (#37) who had severe cognitive impairment. Resident #37 was sexually abused on 8/6/22 by Resident #69. In response to the 8/6/22 incident, the facility temporarily moved Resident #69 to another unit and provided one-on-one staff supervision for six days. Resident #69 returned to his original unit and 15 minute checks were instituted from 8/13/22 to 8/19/22. Supervision was changed to 30 minute checks between 8/20/22 and 8/31/22. The resident was returned to 15 minute checks on 8/31/22 however, this level of supervision was ineffective in protecting female residents on the unit from Resident #69's inappropriate sexual advances. Following the sexual abuse that occurred on 8/6/22, Resident #69 attempted to bring Resident #37 and other female residents to his room on 8/14/22, 8/21/22, 8/23/22, 9/5/22, and 9/8/22. On 10/3/22, Resident #69 removed Resident #37's pants and attempted to touch her vagina while the two residents were in the front lobby. They were separated by staff, however Resident #69 attempted to take Resident #37 to his room approximately five minutes later. The facility's failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to inappropriate sexual behavior by Resident #69 made serious harm likely if the situation was not immediately corrected. In addition, the facility failed to protect Resident #124 from physical abuse by Resident #123. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Resident #69, with moderate cognitive impairment, exhibited inappropriate sexual behavior toward one Resident (#37), who had severe cognitive impairment on multiple occasions. Resident #37 digitally penetrated Resident #69 in his room on 8/6/22. On 10/3/22, Resident #69 pulled Resident #37's pants down in the lobby and attempted to put his hand in the resident's vagina. Documentation revealed Resident #69 also attempted to take other female residents to his room or enter their rooms on multiple occasions. The facility's failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to inappropriate sexual behavior by Resident #69 made serious harm likely if the situation was not immediately corrected. On 12/14/22 at 4:05 p.m., the nursing home administrator (NHA) was notified the facility's failure created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 12/15/22 at 2:45 p.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: Immediate Action: Resident #69 remained on the secured unit and the facility initiated one-to-one (1:1) supervision on 12/14/22 at 4:00 p.m. All employees that provided 1:1 supervision to Resident #69 were trained by the staff development coordinator (SDC) in regards to identifying escalating behaviors and indicators of psychosocial distress. This training initiated on 12/14/22 at 4:00 p.m., and would continue until complete on or before 12/22/22. Facility staff to assist in providing 1:1 supervision starting on 12/14/22 at 4:00 p.m. Employees will be trained prior to providing services in regards to Resident #69's escalating behaviors and indicators. Education will include interventions to assist in resident care and education will be provided by RN (registered nurse) and/or social services (SS). Resident #69-care-plan-updated on 12/14/22 to reflect 1:1. Pharmacist completed a medication review for Resident #69 on 12/14/22. Medical Director completed a chart review on Resident #69 on 12/14/22. Designated Psychiatrist, scheduled to assess and evaluate Resident #69 on 12/16/22. Resident #37 was assessed by social services on 12/14/22, and showed no signs or symptoms of distress or psychosocial harm and was provided with additional psychosocial support. Resident #69 will be evaluated monthly during the psychotropic committee meeting. The IDT completed a sexual intimacy capacity for consent assessment, on Resident #69 and Resident #37. Resident care plan updated with results of assessment. This was completed by IDT on 12/14/22. Systematic changes: Facility initiated all staff education on specific interventions for Resident #69. This education was initiated on 12/14/22, and all staff will be completed prior to beginning their assigned shift. All education will be completed on or by 12/22/22. Resident #69 and Resident #37 will be evaluated by counseling services on 12/16/22. Identification of residents' affected or likely to be affected: All female residents on the secured unit are at risk to be affected. Completed observations of all residents on the secured unit on 12/14/22 to identify if any residents show signs of psychosocial distress and agitation. Observations completed by SDC. No issues identified from the audit. Actions to Prevent Occurrences/Recurrences: All staff to be educated on how to identify aggressive and unwanted sexual behaviors and intervene as needed. Staff education to be provided by either SS (social services), and/or RN. All education to be provided to staff prior to direct care with the resident. All staff to be educated in person by 12/22/22. If staff are out of town, they will be educated prior to returning to their scheduled shifts. Education listed below was initiated on 12/14/22 at 4:00 p.m. The education was initiated 12/14/22 at 1600 (4:00 p.m.). Facility educated on results of intimacy assessments for Resident #69 and Resident #37 to all staff currently working. Monitoring: Social services, RN, or designee to observe the secured unit every shift for five days starting 12/14/22 until 12/18/22 to monitor female residents for psychosocial distress or behaviors outside of their baseline. The secured unit observation audit was initiated on 12/14/22 during day shift and completed by SDC/ RN. If no issues identified with every shift observation for five days, will decrease audit to five times weekly on various shifts for 12 weeks. This will determine if 1:1 supervision for Resident #69 is effective. In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. C. Removal of immediate jeopardy On 12/15/22 at 3:35 p.m. the NHA was notified that based on review of the facility plan, the immediate jeopardy situation had been removed. However, deficient practice remained at a scope and severity of G, harm that was isolated. II. Facility policy The Abuse policy, modified October 2022, was received from the director of nursing (DON) on 11/28/22 at 9:47 a.m. It read in pertinent part: It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated. Procedures: When an incident or suspected incident of abuse or neglect is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. A licensed nurse will examine the resident upon receiving reports of alleged physical or sexual abuse and will record findings in the resident's medical record The investigation will consist of at least the following: A review of the completed Complaint Report; An interview with the person (s) reporting the incident; Interviews with any witnesses to the incident; An interview with the resident if possible; A review of the resident's medical record; An interview with staff members working on/in the unit where alleged incident took place if applicable; Interviews with the resident's roommate, family members, and visitors if applicable; A review of all circumstances surrounding the incident. All phases of the investigation will be kept confidential in accordance with the facility's policies governing the confidentiality of medical records and privilege of quality assurance/ quality improvement programs. The Administrator will keep the resident or his/her representative informed of the progress of the investigation as necessary. The summary of the investigation will be recorded and attached to the report. The Administrator would report such allegations to the State Licensing Agency as necessary, health department within (24) hours and police department within (2) hours as necessary with the results of the completion of the investigation. The Administrator or designee will complete a copy of the Resident Abuse Investigation Report Form within five (5) working days of the reported incident. III. Failure to create an environment that protected Resident #37 from sexual abuse by Resident #69. A. Resident #37 (victim) 1. Resident status Resident #37, age 80, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included chronic respiratory failure, dementia, anxiety, and history of falls. According to the 11/7/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had no behaviors. She required extensive assistance for bed mobility, transfers, grooming and toilet use. 2. Record review The care plan, initiated 9/25/2020 and revised 10/17/22, identified the resident was at risk for elopement/wandering related to dementia. Interventions included distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. -Resident #37 did not have a person-centered care plan or interventions to evaluate the effectiveness of the interventions to protect her from the potential risk for sexual abuse. Incident 8/6/22 The nurse documented the following, I and another coworker were in the dining room and the housekeeper came in to the dining room asking for the Resident #37. She stated she and the nurse could hear crying and screaming. She was saying 'please let me up, help me up' so I got up and went to look for her at this time. The nurse located her in Resident #69's room. We removed him from his room. Resident #37 was lying in his bed crying. He removed her brief had it was thrown on the other side of the room. He was touching her with his fingers in her vagina the nurse examined her with my help. She was really red and had some blood. We removed her from the room. Took her to her room and cleaned her up and put her in her bed. The nurse documented the following, The housekeeper and this nurse were looking for Resident #37. She was looking for Resident #37 and she was missing. I went down the girl's hall and the housekeeper was going down the men's hall when we heard 'HELP, HELP me up.' Resident #69's room was the first room we entered to check to see if someone had fallen. What we found was Resident #69 standing with the side of his bed and Resident #37 was lying in his bed. Her adult pad had been taken off and thrown on the other side of the bed. Resident #37 was screaming 'Let me Up' and crying. Resident #69 had his fingers or his hand in her vagina plunging it in and out (thrusting). When Resident #69 saw me and immediately left the room, wiping his hand on his shirt. The housekeeper and I immediately went to Resident #37 comforting her and assessing her. No injuries could be seen. The housekeeper and certified nurse aide (CNA) helped Resident #37 stood and placed her in a wheelchair. We then took her to her room and further assessed her. My director of nursing (DON) was notified, police and families called. Incident on 10/3/22 Nursing log note dated 10/3/22 at 6:45 p.m., documented in part: This nurse observed Resident #69 had pulled Resident #37 pants down in the lobby and was attempting to put his hand in the resident's vagina. When approached by this nurse and asked the resident to stop and let him know what he was doing was inappropriate. Resident #69 responded 'I am not doing anything you (expletive). Resident #37 was separated from this resident and taken to the other side of the lobby. Approximately five minutes later resident was attempting to take Resident #37 to his room, this nurse intervened and took Resident #37 to her room and again let the resident know this was inappropriate behavior. Resident #69 responded 'What are you talking about?' and walked off and sat down in a chair in the lobby. Fifteen minute checks implemented for the resident. No other incidents occurred during the night. Social service log note dated 10/4/22 at 12:12 p.m., documented in part: This writer met with the resident and explained the importance of keeping his hands to himself, he stated he did not know what this writer was talking about. He expressed understanding. Spoke with staff and they stated he has been keeping to himself and has been pleasant and has had appropriate interactions with other residents. Will continue to follow up with resident. B. Resident #69 (assailant) 1. Resident status Resident #69, age 83, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included fracture of the left femur, Alzheimer's, diabetes, dementia, and depression. According to the 9/5/22 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. 2. Record review The care plan, initiated 9/6/19 and revised 9/12/22, identified the resident had potential for a mood & behavior problem related to dementia and Alzheimer's disease, insomnia, and history of alcohol abuse. The resident was at risk for irritability, social withdrawal, flat affect, increased depression and difficulty sleeping. He at times becomes agitated and has shown aggressiveness to other residents. He at times will become territorial of the recliner in the day hall area and doesn't want others to sit on certain chairs. He will at times ask others to move out of the recliner so he can sit there. At times the resident will invite female residents into his room. At times resident becomes agitated when asked to take a shower. At times resident will attempt to clean his own BM (bowel movement) and will wipe it on inappropriate things (for example: the curtain in his room, hand rails outside) At times resident makes inappropriate sexual comments/gestures towards females Triggers include: overstimulation, loud noises. Interventions include document behaviors, and resident response to interventions. If reasonable, discuss behavior. Explain/reinforce why inviting the female resident to his room was inappropriate and/or unacceptable. The social service director (SSD) log note dated 8/6/22 at 3:46 p.m. documented in part: this writer met with a resident in the lobby area, asked the resident if he recalled the earlier incident. He stated he did not know what this writer was talking about. This writer asked the resident if he was hungry and if he had dinner. He stated no, that he had not had dinner. Offered him a peanut butter and jelly sandwich and a cup of milk. He stated he would like that and I brought a resident a sandwich and milk. He thanked this writer. Will continue to follow up. The SSD log note dated 8/8/22 at 3:44 p.m. documented in part: This writer met with the resident once he arrived back at the secured unit. He stated he was fine and he was going to his room to take a nap. He does not appear to recall a resident to resident altercation. He has not exhibited any current mood or behaviors. Will continue to follow up. The nurse log note 8/6/22 at 5:33 p.m., documented in pertinent part: a female resident was missing from the common area. As we were looking for her, someone heard help me up. Resident #69 was found to have a female resident in his room, she was laying on his bed and he was standing over her with his fingers in her vagina, finger thrusting vigorously. The resident's shirt was found to have blood on it and it was taken for evidence. The director of nursing (DON), police, family, and provider were notified. Resident shirt found to have blood on it and it was taken for evidence. Nurse log note dated 8/14/22 at 11:43 p.m. documented in part: Resident continues on 15 min (minute) checks. Resident made an attempt to grab and stop Resident #37 while she was passing by this resident in her wheelchair after dinner. When approached by this nurse, the resident denied trying to do anything yelling at this nurse to leave him alone. Later in the evening at this time the resident came out to the lobby and attempted to grab another female resident by the hand to go to his room. The female resident resisted and he let go of her after this nurse intervened and asked him what he was doing. He stated 'nothing' then retreated to his room. Nurse log note dated 8/21/22 at 4:58 p.m., documented in part: observed resident has made some sexual comments to female residents as they were passing by this resident such as 'you get laid in my bed, and you'll get paid.' The resident also attempted to grab one of the female residents. This writer intervened & separated them immediately. Reoriented & redirected resident. Given peanut butter sandwich & a cup of juice. The resident was eating supper at this time. Nurse log note dated 8/23/22 at 1:23 p.m., documented in part: resident continues on 30 minute checks talking to a few ladies trying to talk them into going into his room with him. Nurse note dated 9/5/22 at 6:10 p.m., documented in part: resident attempted one time to pull a female resident into his room. The two were separated and Resident #69 was instructed that this was inappropriate. He denied the incident. Nurse note dated 9/8/22 at 2:57 p.m., documented in part: resident needed redirection after attempting to take female resident into his room. Female resident removed from room. On 12/14/22 at 10:20 a.m., a written request for the investigation for the incident on 10/3/22 was (documented in Resident #37's record, see above) given to NHA. IV. Staff interviews Housekeeping (HSK) #2 was interviewed on 11/30/22 at 8:28 a.m. She said, About two to three months ago we had a missing female resident. I and another nurse heard someone yelling out but we couldn't figure out where the screaming was coming from. We walked the women's side of the unit and then to the men's side. This was where I heard screaming coming from Resident #69's room. She said, I opened the door and found Resident #37 lying down in the bed with Resident #69 standing over her with his fingers in her private area. She said Resident #69 wiped his hand on his shirt and then he left the room. Licensed practical nurse (LPN) #2 was interviewed on 11/30/22 at 8:44 a.m. She said Resident #69 liked to go into female rooms. She said she did not really know the specifics of the incident on 8/6/22 but Resident #69 was placed on one-to-one supervision. She said Resident #69 had been okay. Certified nurse aide (CNA) #3 was interviewed on 11/30/22 at 8:57 a.m. She said she was new to the secured unit. She said she was not familiar with Resident #69 and did not know anything about his history. CNA #4 was interviewed on 11/30/22 at 9:08 a.m. She said she was familiar with the incident on 8/6/22 but did not really know the details. She said Resident #69 was sent to the long term care side for some time after the incident. She said, I just monitor him and redirect him but he has not had any of the behaviors lately. The nursing home administrator (NHA) was interviewed on 11/30/22 at 9:16 a.m. He said he was the abuse coordinator for the facility. He said the staff had found Resident #37 in Resident #69's room on 8/6/22. He said she was partially naked from the waist down and he had his hands in her vagina. He said they were immediately separated and all necessary parties contacted. He said the investigation was inconclusive because they could not define if the sexual act was consensual or non-consensual. He said neither resident was interviewable. He said all care plans were updated to address Residents #69 and Resident #37's behaviors. He said, I wouldn't classify her yelling out for help as a sign of non-consensual as she had a history of yelling out. He said, I would have to review the investigation further. CNA #4 was interviewed on 11/30/22 at 9:43 a.m. She said Resident #69 was pretty quiet and he has recently kept to himself. She said he would sit in the chair in the common area and then go back to his bed and sleep. She said she did hear he was moved across the street after the incident but did not really know much more about that. She said, I was not told of any interventions for Resident #69 or Resident #37. The social service director was interviewed on 11/30/22 at 9:53 a.m. She said the incident was reported to her and she was informed to ensure all residents were safe. She said staff had found Resident #37 in Resident #69's bed and he was touching her inappropriately. She said, I spent some time with Resident #37 but she appeared to be at her baseline. She said facility had moved Resident #69 over to the long term side of the facility and I continue to monitor him. She said she would provide documentation regarding the interaction with Resident #37 and Resident #69. -However, the documentation was not provided by the SSD. The MDS coordinator was interviewed on 11/30/22 at 11:55 a.m. She said she was familiar with Resident #69. She said she Resident #69 liked to be on his own and he would visit her office. She said, I remember hearing about the incident on 8/6/22 and the facility had to separate the residents. We updated their care plans but I do not know what or if there were any interventions in place for Resident #69. HSK #1 was interviewed on 11/30/22 at 12:12 p.m. She said, Resident #69 was caught molesting one of the female residents in his bed and he was touching her inappropriately. She said Resident #37 was screaming help, help! The NHA and DON were interviewed on 12/1/22 at 12:49 p.m. The NHA said the incident on 8/6/22 was unsubstantiated as both residents had a history of wandering into other residents' rooms. He said the reason for it being unsubstantiated was due to the facility not determining if the sexual contact was consensual or non-consensual. Resident #37 yelling out and calling for help could not be determined as non-consensual as the staff discussed before she had a history of yelling out. He said, Law enforcement found it unsubstantiated as well. The DON said, Resident #37 had a good idea but when the good idea went south it was clear it was not a good idea at the time. She said the facility could not distinguish if the blood on Resident #69 was his or Resident #37. She said, I cannot conclusively say that blood came from Resident #37 as there were no injuries. The NHA said, all of our policies and procedures were followed in a timely manner. He said Resident #69 was transferred for three to four days to long term care to ensure the safety of the residents on the secure unit. A Pueblo police officer was interviewed on 12/6/22 at 12:44 p.m. He said he was the investigating officer for the incident on 8/6/22. He said his investigation was passed on to the special victims units as an open ongoing investigation, which may result in filing of charges. He said he reviewed the file and it was pending for formal charges. He said at this point it was still listed as an open investigation. The nurse practitioner was interviewed on 12/14/22 at 11:47 a.m. She said she was familiar with Resident #37 and Resident #69. She said she was familiar with the incident of 8/6/22. She said she had examined both residents approximately two days after the incident. She said she did not observe any marks or wounds to Resident #37's private area. She said she had not completed a genital exam of Resident #37 as she did not have a nurse to assist during a genital exam. She said she had not been informed of blood being found on Resident #37's vagina on 8/6/22. She reviewed her notes and said she did not find any communication from the facility in reference to vaginal bleeding. She said, If I would have been given that information I would have completed a genital exam on Resident #37. She said she did a physical exam and a skin assessment on Resident #69 with no issues or concerns. She said Resident #69 did not have any scratches or wounds anywhere on him. She said she was not aware of the incident on 10/3/22. She said, If I was informed I would have written a note. The NHA was interviewed again on 12/14/22 at 2:00 p.m. The NHA stated he did not have the key to the filing cabinet which contained the soft investigation files. He said the DON was the only staff member who had a key to the cabinet and she was out of the facility. The NHA stated the facility investigated the incident on 10/3/22 but no contact was made by Resident #69 and staff intervened before contact was made. The NHA stated, it could not be proven that Resident #69 pulled down Resident #37's pants as she had a history of stripping down in the facility. -However, the progress note had documented the nurse observed Resident #69 pulling down Resident #37's pants and attempting to touch her vagina. V. Resident to resident physical altercation between Resident #124 and #123 A. Resident's #124 (victim) 1. Resident status Resident #124, age 86, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included dementia, anxiety, and altered mental state. According to the 11/7/22 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. 2. Record review The care plan, initiated 11/4/22 and revised 11/7/22, identified the resident was involved in a resident-to-resident altercation and received skin tears to bilateral arms. Interventions include avoiding scratching her hands and body parts from excessive moisture. Keep fingernails short and encourage good nutrition and hydration in order to promote healthier skin. Monitor and document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, and maceration. Nurse note dated 11/12/22 at 10:55 p.m. documented in part, resident taken out of room to nursing station. The resident had two skin tears on each forearm. Each wound was cleaned with wound cleaner and four by four (gauze), dried, iodine applied, steri strips applied and covered with band aid. Resident taken out of (from his room to another room) for tonight. The supervisor called the police department, and the on-call medical doctor on the non-urgent line called. Nurse noted dated 11/13/22 at 9:34 a.m. documented in part, No fearful episode noted. No negative behaviors noted. No further resident to resident altercations noted. No distress noted. Provided wound treatment as physician ordered. The SSD note date 11/16/22 at 12:56 p.m. documented in part, this writer sat with Resident #124 out in the day hall area as she was pleasant and did not appear in distress and did not appear to be expressing any fear. She was smiling and watching television. No current concern at this time. The SSD note date 11/14/22 at 10:53 a.m. documented in part, This writer sat with Resident #124 out in the day hall area, she was pleasant and smiling. She did not appear to recall the resident to resident altercation when she was asked about it. She did not appear in any distress and was not expressing any current fear. B, Resident #123 (assailant) 1. Resident status Resident #123, age 75, was admitted on [DATE] and passed away 11/18/22. According to the November 2022 computerized physician orders (CPO), diagnoses included senile degeneration of the brain, dementia, cognitive communication deficit, anxiety, and depression. According to the 11/7/22 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The resident had wandering behaviors, which may put others at risk. She required supervision for bed mobility, transfers, grooming and toilet use. 2. Record review The care plan, initiated 11/4/22 and revised 11/7/22, identified the resident had potential for a behavior problem. At times she becomes physically aggressive with staff, attempting to bite them. Interventions include administering medications as ordered. Monitor and document for side effects and effectiveness. If reasonable, discuss behavior. Explain and reinforce why behavior was inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from the situation and take to alternate locations as needed. Residents placed on one-on-one observation until behavior was under control. The SSD note dated 11/12/22 at 11:33 p.m. documented in part, The resident was found on the floor kneeling next to another resident's bed across the room. The other resident standing up behind this resident holding arms. This resident with blood on hands and under fingernails. The resident was removed from the room. The SSD note dated 11/14/22 at 2:23 p.m. documented in part, This writer attempted to meet with a resident to discuss a resident to resident altercation, she just stared at this writer. Offered her a drink and she drank water. She was not willing to have a conversation. Met with staff resident no current behaviors at this time. VI. Staff interview Licensed practical nurse (LPN) #2 was interviewed on 11/30/22 at 8:44 a.m. She said there was an altercation where Resident #123 scratched Resident #124 on her arms. She said Resident #124 wounds continue to be monitored with no problems. The social service director (SSD) was interviewed on 11/30/22 at 9:53. a.m. She said Resident #123 and #124 did have a resident to resident altercation. She said Resident #123 grabbed Resident #124's arm and made it bleed. She said they were separated immediately and moved. She said the facility was monitoring both residents and had them on 15 minute checks. She said Resident #124 appeared to be doing fine. The NHA and DON were interviewed on 12/1/22 at 12:49 p.m. The NHA said the incident was unsubstantiated as there were no injuries. The DON said the resident to resident altercation did happen but it was unsubstantiated as the facility could not find intent as each one of the residents' involved were at their baseline. She said Resident #123 had passed away on 11/18/22 of natural causes. -However, the incident should have been substantiated due to Resident #123 grabbing Resident #124 willfully and causing her arm to bleed.

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) of three out of seven sample residents. Specifically, the facility failed to ensure a registered nurse (RN) #1 correctly transcribed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on 5/18/22, and several hours after the administration of the medication the resident became unresponsive while away from the facility and was transported to a local hospital. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/27/22 to 6/28/22, resulting in the deficiency being cited as past noncompliance with a correction date of 6/23/22. I. Professional reference Saunders Nursing Drug Handbook 2020, Kizior, R. J. and Hodgson, K.J., St. Louis Missouri 2020, revealed the following pharmaceutical information: -page (pp). 276-278 read in part: [MEDICATION(S)] (Clonaril, [MEDICATION(S)], [MEDICATION(S)]). Clinical classification-antipsychotic. Uses: Management of severely ill [CONDITION(S)] patients who fail to respond to other antipsychotic therapy. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Off label treatments, [CONDITION(S)] disorder, [CONDITION(S)] disorder obsessive-compulsive disorder and agitation to Alzheimer's dementia. Black box alert significant risk of life-threatening agranulocytosis (decline in white blood cells), increased risk of potentially fatal cardiovascular events, particular [CONDITION(S)], in elderly patients with dementia related [CONDITION(S)]. May cause severe [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and dose dependent seizures. Precautions/caution in patients with: history of seizures, cardiovascular disease, respiratory or renal impairments; and patients at risk of aspiration pneumonia, [CONDITION(S)], bowel obstruction, visual disturbances and diabetes. Avoid using it for patients with dementia. Side effects: Frequent drowsiness, salivation, [CONDITION(S)], dizziness and constipation. Occasional: [CONDITION(S)] headache, tremors, [CONDITION(S)], diaphoresis, dry mouth nausea, visual disturbances, nightmares, restlessness, agitation, hypertension and abdominal distress. Monitor blood pressure, pulse, white blood cell count and supervise for suicidal risk during early therapy. II. Facility policy and procedure The Medication Errors policy and procedure, revised November 2017, was provided by the director of nursing (DON) on 6/28/22 at 4:30 p.m. It read in pertinent part: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. III. Resident #1 A. Resident status Resident #1, age under 65, was admitted to the facility on [DATE]. According to the May 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/18/22 minimum data set (MDS) assessment revealed the resident had short term memory problems, and her cognitive skills for daily decision making were severely impaired. She required extensive assistance of one staff member with mobility and activities of daily living (ADLs). She did not have any behaviors or rejections of care. B. Record review A review of the resident's May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] tablet 75 mg (miligram) by mouth one time a day for [CONDITION(S)] for seven days, ordered 5/17/22 with a start date of 5/18/22. -[MEDICATION(S)] tablet 100 mg by mouth one time a day for [CONDITION(S)] until 5/25/22, ordered 5/17/22 with a start date of 5/18/22. A review of the resident's nursing progress notes revealed the following progress notes: 5/18/22: Received call from (name of outside provider) stating that (the) resident was transported from (name of outside provider) to (local hospital) as resident had gone unresponsive while at (name of outside provider). (Outside provider) notified family of resident. Prior to leaving to (name of outside provider), resident was alert and at baseline walking around. Resident ate breakfast and was sitting in living room prior to leaving. 5/19/22: Transcription error reviewed by IDT (interdisciplinary team) and recommendation made for education with the Nurse that entered (the) order incorrectly. No abuse/neglect suspected. A review of the hospital records from 5/18/22 revealed the following ICU (intensive care unit) progress note: This is a (age) woman with a history of [CONDITION(S)] and depression who presents from her (name of facility) after being found unresponsive. Unable to obtain any history from the patient as she is unresponsive. Per report from someone at the facility, the patient likely received double her dose of [MEDICATION(S)]. Patient has cognitive impairment at baseline and does have a history of catatonia (abnormality of movement and behavior arising from a disturbed mental state) but she normally is awake and answers questions. On arrival to the ER (emergency room ) the patient was hypotensive (low blood pressure) and hypoxemic (low oxygen levels). VBG (venous blood gas) revealed severe respiratory acidosis (failure of ventilation and accumulation of carbon [MEDICATION(S)]) with pH 7.09. She was put on a [CONDITION(S)] (bilevel positive airway pressure). The patient has paperwork indicating comfort measures only. Her medical decision-maker is present at bedside when I evaluated the patient in the ER, she said that she decided to change goals of care to selective treatment today. Patient was admitted to the ICU in shock on pressors (medicines to tighten blood vessels and raise blood pressure). C. Facility investigation On 5/18/22 the facility began an investigation of the incident immediately upon learning of the medication error. The investigation revealed RN #1 had made a transcription error for the resident's [MEDICATION(S)]. The investigation revealed the order was for the resident to receive 75 milligrams (mg) of [MEDICATION(S)] for seven days, and then increase the dose to [MEDICATION(S)] 100 mg indefinitely. The order as written read: 4/27/22 recommending starting [MEDICATION(S)] 25 mg (miligram), titrating 25 mg weekly to a goal of 100 mg daily. The facility investigation determined RN #1 had entered the order so that both doses (75 mg and 100 mg) started on the same day, therefore the resident was given 175 mg of [MEDICATION(S)] on 5/18/22 instead of the physician ordered 75 mg. IV. Facility actions The facility took action immediately after the medication error to identify any other potential areas of concern and prevent any recurrence. On 5/19/22 upon identification of the error, RN #1 was provided education by the director of nursing (DON) regarding correctly entering physician orders, and verification the orders have been correctly entered. Each nurse working in the facility was provided verbal education on 5/19/22 and 5/20/22 regarding correctly entering physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An audit was completed of all of RN #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility wide audit was completed on 5/19/22 and 5/20/22 to ensure no additional physician order [MEDICAL RECORD OR PHYSICIAN ORDER] An additional facility education occurred on 6/23/22 with all facility nurses regarding obtaining orders from prescribers, entering the order into the resident electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Starting 5/20/22, the facility began auditing each new order to ensure the order had been entered correctly. V. Interviews The DON was interviewed on 6/27/22 at 1:19 p.m. She said the facility became aware of the medication error the day of the order due to the resident being sent to the hospital directly from an appointment with her provider. The DON said it was determined RN #1 had made a transcription error, and due to that error the resident received more than double her prescribed dose of [MEDICATION(S)]. The DON said she had provided the education to RN #1 following the incident, and RN #1 has not worked in the facility since. The DON said the facility had always gone over new physician orders, but they had now begun to look closer for duplicate orders, and start and end dates. The assistant director of nursing (ADON) was interviewed on 6/27/22 at 1:33 p.m. She said she was the nurse who had given Resident #1 the incorrect dose of [MEDICATION(S)]. She said she did double check the order, and just assumed the physician was titrating the dose for the resident. The ADON said she was not alarmed about the resident getting 175 mg of [MEDICATION(S)], as they had several residents that received double that dose, twice daily. The ADON said the resident was at her baseline when she left for her provider's office. The medical director was interviewed on 6/27/22 at 2:00 p.m. He said he had completed a chart review for Resident #1 following the medication error. The MD said that although a medication error was never desired, he did not feel the error contributed to the residents decline. The MD said the maximum dose of [MEDICATION(S)] was 900 mg, and the resident had not even come close to getting that amount.

Based on interviews and record review, the facility failed to ensure residents on one out of two neighborhoods had the right to a dignified existence. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely to include four (#2, #3, #5 and #6) of six sample residents out of 26 residents living in the neighborhood. The feeling of dehumanization, and treated in an undignified manner is evidenced by the residents' interviews. Resident #6 who was totally dependent on staff said, frequently I'm wet till 4:00 a.m. and sometimes they don't even check on me the whole night. Resident #2 who was dependent on staff said, it made her feel she was not important. She said it really bothered her to sit in a dirty brief for a long period of time to the point she had to call her family at night and asked to call the facility's main number and ask for help. Resident #5 who was dependent on staff stated she felt disrespected and neglected. Resident #3 who was an extensive assist with toileting, had waited an hour when a CNA came into her room. Resident #3 said, I peed all over myself and soaked the bed wet with urine. I apologized to the CNA and I felt degraded. Findings include: I. Facility policy and procedure The Nursing Services-Staffing policy, undated, was provided by the Executive Director (ED) on 5/18/21 at 2:00 p.m., read in part: It is the policy of this facility to provide adequate staffing to meet the needs of the residents population. The facility maintains adequate staff on each shift to assure that the resident's needs are met. Inquiries concerning staffing should be referred to the Director of Nursing Services and/or to the administrator. II. Residents' status and interviews A. Resident #6 Resident #6, age 76, was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 4/16/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. She required extensive assistance of two plus staff with bed mobility and transfers, extensive assistance of one staff with dressing, and was totally dependent on staff with toilet use and personal hygiene. The resident had a [CONDITION(S)] and was always incontinent of urine. Resident #6 was interviewed on 4/27/21 at 1:00 p.m. She said in the past few months staffing went downhill. She said there are nights with one CNA (certified nurse aide) in the whole house. She said last year CNAs did rounds every two hours at night and currently they don't do it. She said frequently I'm wet till 4:00 a.m. and sometimes they don't even check on me the whole night. B. Resident #2 Resident #2, age 81, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/18/21 MDS assessment revealed intact cognition with BIMS score 13 out of 15. She had no hallucinations, delusions or rejection of care behavior. She required extensive assistance of two staff with bed mobility and toilet use, and was totally dependent on two staff with transfers. She was totally dependent on one staff with dressing, and one staff extensive assist with personal hygiene. She was always incontinent of urine and bowel. She received a mechanically altered diet. She was administered daily antipsychotic, antianxiety and antidepressant medications. Resident #2 was interviewed on 4/27/21 at 12:45 p.m. She said frequently she had been waiting for staff for longer than an hour after she turned the call light on, to change her soaked depend. She said she cannot feel when she needs to void (urinate) and her depend was wet frequently. She said she does not use the toilet or the bedside commode because she needed two staff to transfer and there were no two CNAs available most of the time to assist her. She said nights are the worst with one or two CNAs trying to help all of the residents. She said she had to call her family often to complain about the poor care she was receiving. C. Resident #5 Resident #5, age 66, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/8/21 MDS assessment revealed intact cognition with a BIMS score 15 out of 15, no hallucinations, delusions or rejection of care behavior. She was totally dependent of two staff with bed mobility, transfers, dressing and toilet use. She required extensive assistance of two staff with personal hygiene. She was always incontinent of urine. She received an antianxiety, antidepressant, anticoagulant, and diuretic medications daily. Resident #5 was interviewed on 4/27/21 at 1:35 p.m. She said she was the resident council president. She said all residents in the facility suffered from severe staff shortage. She said she required two to three staff to reposition her in bed and with transfers from bed to a wheelchair (motorized wheelchair). She said she frequently was sitting in a puddle of urine for as long as five hours. She stated she felt disrespected and neglected. She said on average it takes CNAs two hours to respond to a call light. She said last weekend she was confined to her bed because there was not enough staff in the facility to help with transferring her to the wheelchair. She said when she turned her call light on, a registered nurse came and told her they were short of staff and she needed to stay in bed. D. Resident #3 Resident #3, age 86, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/16/21 MDS assessment revealed intact cognition with a BIMS score 15 out of 15. She required extensive assistance of two staff with bed mobility, transfers, dressing, extensive assist of one with toilet use and personal hygiene, supervision with eating. She was occasionally incontinent of urine. Resident #3 was interviewed on 5/18/21 at 10:00 a.m. She stated facility staffing had really gone downhill. She said she was aware that a few nursing staff left and there were no new staff coming in. She said her call light took anywhere from half an hour to two hours to be answered, depending on the time of day or night and which staff were working. She stated last night she turned her call light on at 6:40 p.m. because she needed to go to the bathroom. She said a CNA came to her room at 7:45 p.m. She stated I peed all over myself and soaked the bed wet with urine. She said I apologized to the CNA and I felt degraded. Further Resident #3 stated they cut my showers on Mondays. She said for the past three weeks she was getting her showers one time a week, on Thursdays. III. Resident Council meeting Minutes -The 2/17/21 resident council meeting minutes review revealed several residents complained about staff did not provide incontinence care and did not change soiled clothing in timely manner. Staff deactivated (turned off) call lights without addressing residents' needs. Staff declined to assist a resident with transfer from bed to a wheelchair for St Valentine's party. -The 4/14/21 resident council meeting minutes review revealed residents complained about staff being slow with answering call lights. The staff development coordinator (SDC) told the residents that call lights should be answered within 3-5 (three to five) minutes. The Resident Council Concern Forms were provided by the activities director (AD) on 5/18/21 at approximately 10:00 a.m. The documentation revealed in parts, Nursing and social services will be informed of the situation . with the Final Result, Social services was aware of this situation and working on this concern .ADON (assistant director of nursing) discussed and reminded staff on customer service protocols . IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/27/21 at 12:00 p.m. She said there were not enough nursing staff in the facility to provide care for all of the residents in a timely manner. She said she felt very sorry for the residents when they had to wait a long period of time to get cleaned up and have their clothes and bed sheets changed. She said most residents required two staff with transfers. She said she was asked to work extra hours every shift. She said nights and weekends in the past months were the worst with one or two CNAs and two nurses providing care for over 60 residents on this unit. Registered nurse (RN) #1 was interviewed on 5/17/21 at 8:30 p.m. She said the facility could use more staff. She said a while back there were three nurses and three CNAs at night working 12 hours shifts. She said she was aware that one night shift nurse was off and a few CNAs left, resigned. She said it was hard for two CNAs to provide care for 67 residents on this unit with most residents requiring two staff assistance. She said nurses were frequently helping CNAs with transfers and incontinence care for the residents. CNA #2 was interviewed on 5/17/21 at 8:40 p.m. She said the facility experienced nursing staff shortage for quite some time. She said she worked 12 hours day shift and was asked to work extra few hours the night shift. She said she had been asked almost daily to work extra hours. The executive director (ED) was interviewed on 5/18/21 at 11:00 a.m. He said the facility was in the process of interviewing more staff to hire. The director of nursing (DON) was not available for an interview.

Based on record review and interviews, the facility failed to provide the care and services to prevent the development and worsening of a pressure injury for one (#1) of three residents reviewed out of five sample residents. The facility failed to implement interventions upon admission when the resident was identified as a high risk for skin integrity problems. When the resident was seen by the wound physician, recommendations were not implemented from the wound physician in a timely manner. When the wound had progressed from a moisture associated skin disorder to a pressure ulcer, new interventions were not assessed and implemented to prevent the pressure ulcer from worsening. Furthermore, the dietary department did not implement interventions timely to help promote healing of the pressure ulcer when it was identified as worsening. Due to the facility failures, the resident wound had progressed from moisture associated skin disorder (MASD) on admission of 6/17/2020 to an inhouse acquired Stage 3 pressure ulcer on 7/21/2020, causing the resident pain. She was sent to the hospital on [DATE], while at the hospital the wound was documented as a Stage 4 as of 7/27/2020. Findings include: I. Professional reference According to the National Pressure Inquiry Advisory Panel, retrieved 9/10/2020 from https://npiap.com/page/PressureInjuryStages, pressure injury stages were defined as follows: Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. II. Facility policy and procedure The Pressure Ulcer Skin Monitoring and Management policy and procedure, last revised 9/2/2020, provided by the facility on 9/2/2020, included in pertinent part, In order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement approaches as appropriate and consistent with the resident's care plan. If moisture associated skin disorder (MASD) is identified upon admission an air mattress should be placed within 48 hours and a referral made to the wound physician. Preventative measures should continue, such as: pressure reduction, continence care, mobility, nutrition and hydration management. Re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is not healing or showing improvement. III. Resident status Resident #1, younger than 65, was admitted to the facility on [DATE] and discharged on [DATE] to the hospital. According to the July 2020 computerized physician orders [REDACTED]. The 6/21/2020 minimum data set (MDS) assessment documented the resident had no cognitive impairment according to the brief interview for mental status (BIMS) score of 15 out of 15. The resident exhibited no behaviors toward others and did not reject care. She required extensive assistance of staff for all activities of daily living (ADL) including transfers, toileting, bed mobility and personal hygiene. The resident was at risk for pressure injuries. IV. Resident interview Resident #1 was interviewed by telephone on 8/5/2020 at 11:10 a.m. She said her pressure injury developed at the facility two weeks after she was admitted . She said that she was left for extended periods of time without being changed or repositioned. She said often when she requested staff change her; staff would tell her they would come back or they were short staffed and she would need to wait. She said, she told the staff, it is not my choice to be like this, it really hurts my pride and I asked for help and you can ' t even help me. V. Record review The 6/17/2020 Initial Admission Record revealed the resident had moisture associated skin disorder (MASD) to her sacrum measuring 4 centimeters (cm) by 4.5 cm. The 6/17/2020 Braden Scale for Predicting Pressure Sore Risk revealed the resident was at a moderate risk with a score of 13. The care plan, initiated 6/18/2020, revealed the resident had actual impairment to her skin integrity, MASD. Interventions included: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; -Encourage good nutrition and hydration in order to promote healthier skin; -Keep skin clean and dry. Use lotion on dry skin; and, -Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. -The care plan did not include interventions, such as an air mattress, mentioned in the facility's policy for preventing pressure injuries for a resident admitted with MASD (see above). The June 2020 CPO revealed orders upon admission included: -Pressure reducing mattress per facility protocol, ordered 6/18/2020. However, the mattress type was not appropriate for this resident. Furthermore an air mattress was not implemented until 7/16/2020 (see July CPO below) which was not given to the resident for another 48 hours (see director of nursing interview below). The 6/19/2020 Nutritional Summary progress note by the registered dietitian (RD), the resident was malnourished and agreed to a house shake twice a day and prostat (liquid protein) daily to provide 1,440 calories (kcal) and 60 grams (g) of protein. These recommendations were ordered by the physician on 6/21/2020. A 6/23/2020 skin/wound note revealed initial wound rounds were completed with the wound physician. It indicated the resident had MASD to her sacrum, measuring 4 cm by 4.5 cm with 100% [MEDICATION NAME] (healthy) tissue to the wound bed. The recommendation was for the area to be cleansed often and barrier cream applied twice a day, skin was to be kept clean and dry and the resident was to be on a pressure reducing mattress. The 6/23/2020 wound tracker form completed by the wound physician revealed the top portion of the assessment reviewing vitals, causes for delayed healing, preventative measures, falls, procedures was left incomplete. Review of the other body systems, such as cardiovascular, respiratory, musculoskeletal, neurological, abdomen, eyes/nose/throat, and orientation was done. It identified the MASD to the sacrum as measuring 4 x 4.5 x 0.1 with 100% [MEDICATION NAME] tissue, minimal drainage and healthy periwound. Treatment was barrier cream twice a day. The physician orders [REDACTED]. The 6/24/2020 weekly skin evaluation documented the resident's skin is warm dry and intact other than noted wounds (no other wounds were noted in the document) treatment in place. Review of the record revealed no weekly skin evaluation was completed for the week of 6/26/2020 to 7/4/2020. The 6/30/2020 wound tracker form completed by the wound physician revealed the top portion of the assessment was incomplete including review of the body systems. It identified the MASD to the sacrum as measuring 5.5 cm by 6 cm with an undetermined depth. It indicated the wound bed had 10% granulation (healing) tissue, 40% eschar (dry,dead tissue) and 50% [MEDICATION NAME] tissue with a moderate amount of bloody drainage and a healthy periwound. The progression of the wound was documented worse. Treatment was honey with a foam dressing. -This treatment was not processed as an order. The 7/1/2020 skin/wound note revealed wound rounds were completed with the wound physician and the MASD to the sacrum was worse however the treatment was to cleanse the wound often and apply barrier cream twice a day, keep skin clean and dry and a pressure reducing mattress. -This treatment did not match the treatment recommendation made by the wound physician on 6/30/2020 (see above). A 7/4/2020 nursing progress note revealed the wound to the sacrum needed to be assessed by the wound team. It indicated the area was cleaned and thick barrier cream was applied with a foam dressing and the resident was being repositioned every two hours with a wedge. -This treatment did not match the current physician orders [REDACTED]. The 7/7/2020 wound tracker form completed by the wound physician revealed the top portion of the assessment was incomplete including a review of the body systems. It identified the MASD to the sacrum as measuring 4 cm by 3 cm by 0.1 cm with 10% granulation tissue and 90% slough (dead tissue) in the wound bed with a moderate amount of drainage and the periwound was red. It indicated the subcutaneous tissue (the innermost layer of skin) was debrided (removal of dead tissue). The progression of the wound was not documented. The treatment was honey with alginate and a foam dressing daily. The July 2020 physician orders [REDACTED]. The 7/8/2020 daily skilled note revealed a pressure reducing device for the resident's chair was being used to maintain skin integrity, along with a turning and repositioning program. It indicated the resident was cooperative with the treatment. -These interventions were not added to the resident's care plan. The 7/8/2020 weekly skin evaluation was incomplete. It documented the resident had wounds on the buttocks, sacrum, abdomen. The wounds to her ankles were healed. It indicated the resident tolerated wound care well. It did not provide the specific location of the wounds, the type of wounds, the measurements of the wounds or the stage of the wounds. -This indicated the resident had the ability to heal and the wounds were avoidable. According to 7/8/2020 nursing progress notes, the RD recommended discontinuation of the residents supplements due to the high vitamin D and calcium content since the resident's laboratory results showed an elevated calcium level. -The note did not address the resident's wounds or the need for supplementation to assist with wound healing or an alternate source to promote healing. The 7/9/2020 skin/wound progress note revealed the progression of the wound was stable and added an intervention to reposition often as the resident tolerated. The July 2020 CPO revealed the house shakes and liquid protein were discontinued on 7/8/2020 however no alternative supplements to aid in wound healing were ordered at that time. According to the July 2020 treatment administration record (TAR), the treatment ordered for the MASD to the sacrum was blank on 7/12/2020, indicating it was not done. The 7/13/2020 daily skilled note revealed the resident was having pain originating from the sacral wound, rated 7-10 and described it as a burning ache. It indicated repositioning, pressure relief and rest were non-pharmacological interventions used. The note also identified the wound to the sacrum as a pressure wound and interventions were a pressure relief mattress and cushion and turning every two hours or more for relief. The 7/14/2020 wound tracker form completed by the wound physician revealed the top portion of the form was incomplete including a review of the body systems. It identified a pressure wound to the sacrum measuring 5.2 cm by 6 cm by an undetermined depth with 10% granulation tissue and 90% eschar in the wound bed with minimal drainage and a healthy periwound. It indicated the wound was debrided to the subcutaneous tissue. The progression of the wound was not documented. Treatment was honey and foam daily. The 7/14/2020 skin/wound progress note revealed the etiology of the wound was classified as MASD (even though the wound physician classified it as pressure) and the progression of the wound was worse. The 7/15/2020 weekly skin evaluation was incomplete. It documented the resident had wounds on the buttocks, sacrum, abdomen. The wounds on her ankles were healed. It indicated the resident tolerated wound care well. It did not provide the specific location of the wounds, the type of wounds, the measurements of the wounds or the stage of the wounds. On 7/16/2020, the July 2020 CPO was updated to include the following: -Air mattress for sacral pressure ulcer; -Juven (supplement) mix one packet with eight to ten ounces of water or juice two times a day for wound healing; and, -Nepro (supplement) one carton one time a day for wound healing. -However the air mattress did not specify if it was a standard air mattress or alternating pressure amd/or moisture reducing to help the residents wounds heal and prevent further breakdown. The July 2020 Medication Administration Record [REDACTED]. The 7/15/2020 daily skilled note revealed the resident was having pain originating from the sacral wound, rated 7-10 and described it as a burning ache. It indicated repositioning, pressure relief and rest were non-pharmacological interventions used. According to the July 2020 TAR, the treatment ordered for the MASD to the sacrum was blank on 7/20/2020, indicating it was not done. The 7/21/2020 wound tracker form revealed the top portion of the form was incomplete including a review of the body systems. It identified wound #2 to the sacrum measuring 4.5 cm by 7 cm with a 1.5 cm depth with moderate drainage and a healthy periwound. No description of the wound bed was documented and the etiology (such as pressure or MASD) was not documented. It indicated the wound was debrided to the muscle. The progression of the wound was documented as worse. Treatment was honey, calcium alginate and a foam dressing daily. The 7/21/2020 skin/wound progress note revealed the etiology of the wound was classified as MASD/pressure. The wound bed was described as 10% granulation tissue with 90% eschar with a moderate amount of bloody drainage. It documented the progression of the wound was worse and was debrided. The 7/21/2020 weekly skin evaluation revealed the resident had a stage 3 pressure ulcer to the sacrum that measured 4.5 cm by 7 cm by 1.5 cm. The 7/21/2020 daily skilled note revealed the resident was having pain originating from the sacrum wound rated 7-10 and described as dull aching. It indicated non-pharmacological interventions, such as: the resident being repositioned every two hours or more using wedges, off-loading and rest, were used. The 7/21/2020 nursing progress note revealed wound rounds were completed and the area to the sacrum had progressively gotten worse despite ongoing interventions and being followed by a wound care specialist. It indicated the resident was on two different dietary supplements to help with wound healing and had been placed on an air mattress. The resident was being repositioned as tolerated and placed in her wheelchair multiple times a day as the resident allowed. The 7/23/2020 daily skilled note revealed the resident was having pain originating, in part, from the wounds on her coccyx rated 6-10 and described as sharp pain. It indicated the pain rating decreased after wound care and repositioning as well as medication management. The note also revealed the resident had chills, clammy skin and a low grade fever throughout the shift. The resident's care plan was updated on 7/23/2020 to include a stage 3 pressure ulcer to the sacrum. Interventions included: -Administer medications and treatments as ordered. Monitor/document for side effects and effectiveness; -Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document the status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician; -Call light within reach; -Encourage fluid intake and assist to keep skin hydrated; -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -If the resident refuses treatment, meet with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. The care plan did not include interventions such as the air mattress to the bed, a pressure reducing device for the chair, a turning and repositioning program for off-loading pressure, a consultation with the registered dietitian for nutritional recommendations or the assessment and recommendations of the wound physician. A 7/24/2020 change of condition was done related to the resident having a fever and altered mental status. The July 2020 CPO was updated on 7/24/2020 with an order to send the resident to the emergency department for evaluation and treatment for [REDACTED]. The 7/27/2020 hospital wound note documented the resident had a Stage 4 pressure ulcer to her sacrum. VI. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/5/2020 at 5:11 p.m. She said that she had provided care to Resident #1, however, she had been on vacation for two weeks during the time that her MASD developed into a pressure injury. She said that when she left for vacation, the MASD was small and by the time she returned to work, two weeks later, it was huge. She said that when she was working with the resident, she would reposition her every two hours which was standard. She said she did not know how it could have gotten that bad. The assistant director of nursing (ADON) #1 was interviewed on 8/28/2020 at 3:25 p.m. She said Resident #1 was admitted to the facility with surgical wounds to her right foot and shin, an abdominal wound from the removal of her feeding tube and MASD to her sacrum. She said they were putting barrier cream on the MASD when she first arrived and it was stable. She said she went on vacation and when she returned, it turned into an open wound. She said at that point she got the resident an air mattress and tried to encourage the resident to reposition but she refused frequently. She said the resident was put on supplements as soon as her skin issues arose but they had to be changed related to sodium issues. She said the resident was seen weekly by the wound physician and dietary was involved. Licensed practical nurse (LPN) #1 was interviewed on 9/2/2020 at 3:40 p.m. He said he did wound treatments as ordered on a daily basis. He said physician orders [REDACTED]. He said a physician order [REDACTED]. He said physician orders [REDACTED]. He said the Braden assessment was used to identify a resident's risk for skin breakdown. He said the Braden assessment was done upon admission and quarterly. He said weekly skin assessments were completed in shower days and when a resident was being changed. He said the CNAs would report any changes or abnormalities in the skin they observe while providing care. Registered nurse (RN) #1 was interviewed on 9/2/2020 at 3:51 p.m. He said physician orders [REDACTED]. He said there was no reason an order should be started seven days after it was received. He said it was important to initiate physician orders [REDACTED]. He said the Braden scale assessment was done upon admission and quarterly. He said the Braden scale assessment was used to determine a resident's risk for skin breakdown due to the level of movement, how moist the skin was, and their nutritional status. He said the CNAs report to the nurse any abnormalities observed while providing shower and incontinence care. He said the nurse then conducted a skin assessment to determine if there was an issue. He said CNAs should be repositioning residents every two hours when they do their rounds. He said he saw the CNAs doing their rounds and supervised them. CNA #2 was interviewed on 9/2/2020 at 4:00 p.m. She said any abnormality on the skin observed while providing care to residents was to be reported to the nurse. She said the CNAs looked for redness, skin tears, skin breakdown, and bruises while providing resident care including peri-care. She said a skin assessment was completed upon admission when the resident was put into bed after arrival. She said she repositioned residents every two hours when she completed her rounds. She said wedges and pillows were used to help reposition residents. She said the CNAs could find positioning guidance on the computer and from the nurse. The DON and the clinical resource consultant (CRC) were interviewed on 9/3/2020 at 4:00 p.m. They confirmed the wound physician recommendations made on 6/30/2020 were not put into place until 7/7/2020. They said the expectation was for the staff to change and use the correct order immediately. The CRC said they had identified this as a problem in June 2020 so they started a process of reviewing the orders to ensure they were being changed immediately. The DON said the hole in the TAR for 7/12/2020 was probably because the nurse that was rounding that day did not sign off on the treatment because that was when the physician wound had done rounds. (According to the record, the physician saw the resident on 7/14/2020). The DON said she knew the treatment for 7/20/2020 was done because there was a treatment note in the progress notes. (No treatment note was found or provided for this date). The DON and CRC said the facility continued to offer repositioning and supplements and added boots to prevent her heels from breaking down but the resident was very non-compliant. They said they were not able to get the air mattress until 7/16/2020 (although it was ordered on [DATE]) because there was a delay in getting the mattress from the company due to COVID-19. They said there were therapy interventions as well that they tried, however, they did not provide documentation of these attempted interventions. The DON and CRC said it would have been useful if nursing staff had documented all the times the resident refused repositioning due to the resident's documentation not reflective that she refused repositioning. The DON and CRC confirmed when you reviewed the resident's record it only reflected a few times the resident refused care.

Based on observations, record review and interviews, the facility failed to provide medically related social services to one (#1) of four residents reviewed for psychosocial wellbeing of six sample residents. Specifically, the facility failed to identify and address distress that affected Resident #1's mental and psychosocial well-being. The facility's failure to sufficiently address abusive behavior by another resident resulted in an increase in anxiety and feelings of anger and fearfulness for Resident #1. Cross reference F600, freedom from abuse. Findings include: [NAME] Resident status Resident #1, age 72, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) 2020 computerized physicians orders (CPO), [DIAGNOSES REDACTED]. The 11/27/19 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no identified behaviors or rejections of care during the assessment period. B. Resident and family interviews Resident #1 was interviewed on 1/29/2020 at 2:56 p.m. She said she was concerned with Resident #2. She said she had problems sleeping at night because she was afraid Resident #2 would come to her room. She explained that Resident #2 made rude comments and inappropriate gestures in the dining room at meals such as rubbing his nipples and calling out her name. She said the behavior made her afraid because she thought he might try to come to her room. She said she felt vulnerable at night but thought she could protect herself during the day. She said she knew in her head (gesturing to her temple) that he could not get to her at night, but felt it here (gesturing to her heart) that he had the potential to get her at night. Resident #1 said took her anywhere from a day to a week to feel safe again in her room at night after Resident #2 displayed these behaviors. She said she had to change the route she took to leave the dining room because Resident #2 tried to grab her in the dining room multiple times. She said she changed her whole routine and would sit with a friend until after Resident #2 left the dining room. Resident #1 said she reported Resident #2's actions and her feelings to everyone including staff She said she knew certain nurses would would keep Resident #2 away from her hall; however, she became fearful when other nurses were on duty and did not feel she would be protected. She said she could not sleep at night because she was fearful. Resident #1 said she reported Resident #2's behavior to the director of nursing (DON). The DON told her the staff had received training on Resident #2 but she said she was hesitant to believe it. She said knowing Resident #2 was in a wheelchair gave her a tiny bit of reassurance, but she was still afraid at night when he acted out in the dining room. A family member of Resident #1 was interviewed on 1/29/2020 at 5:20 p.m. The family member said Resident #1's behavior had changed. She said Resident #1 was more concerned, scared, and defensive. The family member said Resident #1 reported she was afraid Resident #2 would come into her room at night The family member said Resident #1 called her and told her about Resident #2's inappropriate behavior in the dining room and was feeling upset. The family member said she went to the facility and talked to the social services (SS #1) staff. The family member said she was present when Resident #1 gave SS #1 specific examples of Resident #2's behavior in the dining room. SS #1 told the family she was not previously aware of Resident #2's behaviors. The family member said SS #1 asked Resident #1 if she was uncomfortable and she responded yes. Resident #1 said she felt unsafe at night and afraid Resident #2 would go into her room at night and get her. Resident #5 was interviewed on 1/29/2020 at 4:35 p.m. She said she had been friends with Resident #1 for awhile and ate with her at meals. Resident #5 said Resident #2 lifted up his shirt and played with his nipples and as he called out to Resident #1. She said Resident #1 became increasingly upset, angry and was uncomfortable all the time. Resident #5 said Resident #1's demeanor was worse whenever Resident #2 acted out. She said he tried to do it when staff were not in the dining room but she said staff were aware of Resident #2's behavior. Resident #5 said Resident #2's behavior had a noticeable negative effect on Resident #1's emotions. C. Record review 1. Care plan Resident #1's care plan, initiated 8/23/18 and revised on 12/3/19, identified the resident had the potential for a psychosocial well-being problem related to anxiety. Interventions included allowing time to answer questions and to verbalize feelings, perceptions, and fears. The care plan did not include goals and approaches to address Resident #1's psychosocial wellbeing after she became fearful at night and had changes in her demeanor as a result of being targeted repeatedly by Resident #2 in the dining room. 2. Concern form A Concern and Problem Resolution form was completed on 12/24/19. The form documented Resident #1 found Resident #2's behavior toward her to be bothersome. The form described Resident #2's behavior as making faces and trying to get her attention in the dining room and noted Resident #1 felt uncomfortable at night. No further description of Resident #2's behavior or of Resident #1's response was included on the form. 3. Progress notes A social services note written on 12/24/19 at 9:57 a.m. documented, Note Text: Spoke with Ombudsman today in regard to resident concern. Social services spoke with resident's daughter today and resident concerns have been addressed. Will continue to follow up, as needed. The note did not identify what the concern was related to. A social services note written on 12/27/19 at 9:17 a.m. documented, Social worker met with resident, resident stated she had no questions or concerns at this time. Resident also stated she feel(s) as though her recent concerns have been resolved. The PN failed to identify the specific concerns. The facility failed to identify and address distress that affected a resident's mental and psychosocial well-being. D. Staff interviews The nursing home administrator (NHA), DON, and SS #1 were interviewed on 1/29/2020 at 4:53 p.m. The NHA said a concern form was completed on 12/24/19 when the facility became aware of Resident #1's concerns. The NHA said the facility was not aware of the extent to which Resident #1 was affected by Resident #2's behavior. The DON said Resident #2 was known to stare at various residents in the dining room and she redirected him when she saw it. SS #1 said she checked in with Resident #1 frequently and Resident #1 did not expressed fear toward Resident #2 during her visits. The NHA said the facility would immediately initiate an investigation for verbal/mental abuse. CNA #1 was interviewed on 1/30/2020 at 8:03 a.m. She said she knew Resident #2 had the potential to be inappropriate. She said she knew Resident #1 was very uncomfortable around Resident #2. She said all the staff knew. CNA #2 was interviewed on 1/30/2020 at 8:10 a.m. She said Resident #2 would pull up his shirt and play with his nipples in the dining room and call out Resident #1's name. She said when he displayed the behavior, the staff would ask him to put his top down and he would stop. She said Resident #1 had told all the staff about Resident #2's behavior. She said everyone knew about it. CNA #3 was interviewed on 1/30/2020 at 8:15 a.m. She said she's heard about Resident #2 being inappropriate to Resident #1. She said all the staff knew. She said Resident #1 had told everyone when Resident #2 acted out. Dietary aide (DA) #1 was interviewed on 1/30/2020 at 8:20 a.m. She said Resident #2 was inappropriate to everyone in the dining room. She said he would pull up his shirt all the time and play with himself and call out Resident #1's name as well as various staff names. She said he had pulled out his genitals and played with himself in the dining room. She said he had also defecated in the dining room. She said the staff knew about it. Licensed practical nurse (LPN) #1 was interviewed on 1/30/2020 at 8:05 a.m. She said she had noticed a change in the resident's demeanor. She said Resident #1 stays in her room more often and was very concerned where Resident #2 was. She said she reassured the resident she would not let Resident #2 down the hallway near her door. She said that helps a bit, but does not take away all the anxiety toward Resident #2. SS #1 was interviewed on 1/30/2020 at 1:48 p.m. She said she had no idea until Resident #1's family member came in on 12/24/19 that the problem with Resident #2 was as severe as it was. She said she would have addressed the issue instantly if Resident #1 had expressed any fear when she had interviewed her. She said the day the family member came by Resident #1 had expressed she felt uncomfortable at night. SS #1 said she reassured Resident #1 that the facility had nursing staff on 24 hours a day and no one would let Resident #2 go down her hall. She said she was not aware of the dining room incidents. SS#1 said there should have been a care plan to identify the fears and concerns Resident #1 had about Resident #2 with interventions it help her feel safer and more in control of what was happening. She said she did not know why staff had not informed her of the frequency of Resident #2's behavior. E. Follow-up Resident #1 was interviewed with the NHA on 1/30/2020 at 12:10 p.m. Resident #1 said she would get upset right after Resident #2 was inappropriate to her and it could take from a day to a week for her to get over it. She said she understood in her head that he's immobile, but she still dwelled at night on the Resident #2's behavior toward, especially if he had acted out that day. She said she was afraid Resident #2 would come into her room at night when she was vulnerable. She said she felt like she was being punished. She said she knew in her head she was not, but she was uncomfortable and upset. She told the NHA she felt safe during the day, but at night she was fearful of Resident #2 trying to get into her room. She said she felt like Resident #2 was tormenting her. F. Failure Review of the clinical record and interviews with residents, family and staff revealed the facility was aware of Resident #1's concerns over Resident #2's behavior. Resident #1 experienced increasing anxiety, the onset of fearfulness and anger as well as changes to her daily routines and sleep as a result of being targeted by Resident #2. The facility failed to prevent Resident #2's behavior which resulted in an ongoing emotional response by Resident #1. The facility failed to address Resident #1's emotional distress through care planned support or counseling provided in and/or outside of the facility.

Based on record review and interviews, the facility failed to provide behavior health services for two (#2 and #4) of five residents reviewed for behaviors out of six sample residents. Specifically, the facility failed to: -Effectively address ongoing incidents of inappropriate sexual behavior for Resident #2; and -Develop a plan to prevent Resident #4 from frequently defecating in inappropriate locations. The failure to provide effective behavior health services led to ongoing incidents of verbal/mental abuse by Resident #2 toward Resident #1, resulting in psychosocial harm. Cross reference F600, freedom from abuse. Findings include: I. Resident #2 [NAME] Resident status Resident #2, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 12/10/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident did not experience hallucinations or delusions but exhibited physical behavior symptoms and refusal of care one to three days during the seven day assessment period. He received daily antipsychotic medications. B. Report of incidents A Concern and Problem Resolution form was completed on 12/24/19. The form documented Resident #1 found Resident #2's behavior toward her to be bothersome. The form described Resident #2's behavior as making faces and trying to get her attention in the dining room and noted Resident #1 felt uncomfortable at night. No further description of Resident #2's behavior or of Resident #1's response was included on the form. Resident #1 was interviewed on 1/29/2020 at 2:56 p.m. Resident #1 said Resident #2 made rude and inappropriate gestures and comments on multiple occasions when the two residents were in the dining room. Resident #1 said Resident #2 pulled up his shirt and rubbed his nipples while calling out her name. Resident #1 also said Resident #2 tried to grab her as she left the dining room. Resident #1 said Resident #2 used to have a room near hers but he was moved to another hall. She said moving Resident #2 did nothing to stop the behaviors he was having in the dining room. Resident #1 said she was still fearful Resident #2 would come to her room at night to get her when she was vulnerable. She said the most recent behavior from Resident #2 occurred within the last month. Resident #5, a friend and tablemate to Resident #1, was interviewed on 1/29/2020 at 4:35 p.m. Resident #5 said she observed Resident #2 lift up his shirt and play with his nipples in the dining room as he called out to Resident #1. Resident #5 said Resident #2 did this on multiple occasions. She said he tried to do it when staff were not in the dining room but she said staff were aware of Resident #2's behavior. Resident #5 said Resident #2's behavior had a noticeable negative effect on Resident #1's emotions. C. Record review 1. Physician orders The (MONTH) 2020 CPO included orders for: - [MEDICATION NAME] (a mood stabilizer) 500mg three times each day for [MEDICAL CONDITION] disorder, current episode mixed, severe, without psychotic features, start date 12/3/19; and, - Vraylar (an atypical antipsychotic medication) 3mg at bedtime for [MEDICAL CONDITION] related to sexual behaviors, start date 12/20/19. The CPO also included orders for behavior monitoring each shift: - Target behaviors for [MEDICATION NAME] included episodes [MEDICAL CONDITION] delusions of sexual fantasies or withdrawn in room .If TB (target behaviors) or SE (side effects) are noted, a nurse's note must be made to include NPI (non-pharmacological interventions) and effectiveness. - Target behaviors for Vraylar included manic sexual behaviors such as inserting objects into body orifices (rectum/penis) and/or rubbing his nipples inappropriately when staff provides care .If TB or SE are noted, a nurse's note must be made to include NPI and effectiveness. 2. Care plans The care plan for potential mood problem was initiated on 12/19/18. - The goal was to have improved mood state, calmer appearance, signs or symptoms of depression, anxiety or sadness. - Interventions included administer medications as ordered, monitor/document for side effects and effectiveness; assist to identify strengths, positive coping skills and reinforce these; behavior health consult as needed. - Interventions were last revised on 12/19/18. The care plan for potential behavior problems related to [MEDICAL CONDITION] disorder and hyper-sexuality, initiated 1/15/15, identified the resident, at times, made accusatory statements toward staff. He often asked staff to do tasks around his peri area that he was capable of doing himself. The resident enjoyed watching pornography but sometimes left his privacy curtain open. He was incontinent and did not allow staff to assist him at times. He made inappropriate sexual comments to staff. He often masterbated and asked staff to clean him up. He had a history of [REDACTED]. He chose to wear soiled pants and at times had his gluteal crease uncovered and his pants worn low. The resident also smeared feces on himself and the bed. - The goals were to not exhibit grandiosity, narcissism, depression or crying out; and, decreased sexual behaviors toward staff. - Interventions included administer medications as ordered; monitor/document for side effects and effectiveness; anticipate and meet needs; assist to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately; intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed; and, observe for side effects of medication. - Goals were revised on 12/18/19. A revision to interventions on 12/2/19 was limited to documenting behaviors and response to interventions. No additional revisions were made in response to ongoing behaviors. The care plan for inappropriate sexual behavior, initiated 11/15/19, identified the resident demonstrating inappropriate sexual behaviors in the hallway and other common areas in front of staff/other residents. The resident exposed his chest and rubbed his chest/nipples in front of staff and other residents while making sexual references. He also tried to touch staff inappropriately when giving him care. - The goal was to have fewer episodes of sexually inappropriate behavior. - Interventions included analyze key times, places, circumstances, triggers and what de-escalates behavior, document; attempt to redirect resident as allowed; and, document observed behavior and attempted interventions. - The goal was revised on 12/20/19. No additional revisions were made to specifically address the resident's behaviors. A care plan for [MEDICATION NAME] use was initiated 4/6/16. - Interventions included administer medications as ordered, monitor/document side effects and effectiveness (revised 4/7/17); consult with pharmacy, physician to consider gradual dose reduction when appropriate, revised (6/13/17); monitor/record occurrence for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression toward staff/others) and document (revised 6/13/17); NPI to include back rub, redirection, speak to/approach in calm manner, reposition, offer snacks/fluids/milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities and provide reassurance (revised 4/22/19). - Interventions were last revised on 4/22/19. A care plan for [MEDICATION NAME] use was initiated 3/12/15 and revised 10/12/17. Target behavior is audio hallucinations. If TB or SE are noted a nurse's note must be made to include NPI, effectiveness and intensity of behavior. - Interventions included behavior monitoring every shift (revised 2/1/16); check blood glucose per physician order [REDACTED]. - Interventions were last revised on 4/22/19. - [MEDICATION NAME] was discontinued on 12/23/19. A care plan for [MEDICATION NAME] use included the same interventions listed above and was last revised on 4/22/19. - [MEDICATION NAME] was discontinued on 12/23/19 . The care plan did not identify target behaviors or include goals and approaches for the resident's use of Vraylar. 3. Behavior documentation November 2019 Progress notes revealed: - On 11/14/19, the resident smeared feces on himself and in his room. He made inappropriate comments to staff and was unable to be redirected. He received re-education about hygiene, infection control and making inappropriate comments to others. - On 11/15/19, the resident was observed walking down the hallway with no clothing on his lower extremities. He was resistive to redirection. He continually made rude sexual comments to female staff and could not be redirected. - On 11/15/19, the resident was seated in the main dining room for supper. He yelled out to a CNA (certified nurse aide) that she had extremely large breasts and pulled up his shirt and started twisting his nipples. When asked to stop, he replied, This makes me feel good when I look at other residents and staff breasts and playing with my breast. He left the room stating, I'm going to my room where I can make myself feel better. -On 11/15/19, the resident smeared feces on himself. He attempted to touch staff during hygiene care. He was provided one-to-one (1:1) and social services was notified. - An 11/15/19 note documented social services staff met with the resident to talk about his behavior. He said he was doing fine and did not want to discuss it. - On 11/20/19, the resident continued to touch and comment in an inappropriate sexual/perverted manner despite education, encouragement and distraction. He was not redirectable. - The resident continued to be sexually inappropriate on 11/21/19. - On 11/22/19, the resident yelled out staff names and spoke inappropriately to staff in the dining room. The resident was provided 1:1 and told to stop and apologize or leave the room. Social services was informed. - The resident continued to make sexually inappropriate comments to staff on 11/23/19. He was redirected and received 1:1 with poor results. - The resident continued to have inappropriate behaviors such as grabbing female staff members in inappropriate ways and places on 11/24/19. - On 11/24/19, the resident smeared feces on the table and wall in the dining room. He continued to make inappropriate remarks and tried to touch staff. He said They like it when he was redirected. - On 11/25/19, the resident continued to have inappropriate behaviors offending other residents and staff. All necessary notifications previously made. Resident will continue to be redirected. - The resident continued to be sexually inappropriate with staff on 11/26/19. He attempted to reach out and grab staff and was unable to be redirected. - On 11/26/19, the resident continued to have inappropriate sexual behaviors toward staff and another resident. - The resident was moved to another room on another hallway on 11/27/19. - On 11/28/19, the resident continued to be sexually inappropriate toward staff. He pinched his nipples and touched female staff. Police were contacted and the resident was taken to hospital for a mental health evaluation. December 2019 Nurses' notes revealed: - The resident was readmitted to the facility from the hospital on [DATE]. - A 12/2/19 social services note documented the resident was referred to a behavior health provider. - On 12/3/19, the resident ripped his television off the wall and threw other objects around his room and into the hallway. He was laughing and talking nonsensically. He was provided 1:1 and helped to get into bed. - A 12/5/19 social services note documented the referral was declined by the behavior health provider as they were unable to meet resident's needs. - The resident continued to be verbally sexually inappropriate with female staff on 12/5/19. He was redirected several times and social services was notified of continued behavior. - A 12/11/19 social services note documented the resident's referral was declined by an inpatient behavior health provider as they feel resident does not meet criteria. - On 12/14/19, the resident attempted to grab and kiss a nurse. When redirected, he stated Where is the nurse with the large breasts? - On 12/20/19, the psychiatrist recommended discontinuing [MEDICATION NAME] and starting Vraylar for increase in sexual behaviors and previously prescribed medication being ineffective for behaviors. - On 12/21/19, the resident continued to talk to female staff inappropriately. He also continued to pull up his shirt and play with his nipples in the lobby area. He was confronted and provided 1:1 with poor results. A message was left for social services. - A 12/24/19 social services note documented the resident was put on frequent checks as needed (this was not a care planned approach and not otherwise described). - Two episodes of talking sexual toward female aides while changing and showering occurred on 12/27/19. Behavior tracking included on the MAR indicated [REDACTED] - for [MEDICATION NAME] use, two episodes of self-isolation and/or complaints of sadness occurred on 12/21/19. - for [MEDICATION NAME] use, three episodes on 12/13/19, three episodes on 12/14/19, continuous behaviors on 12/21/19, four episodes on 12/22/19 and one episode on 12/27/19 [MEDICAL CONDITION] delusions of sexual fantasies. - for Vraylar use, one episode of manic sexual behaviors, inserting objects into body orifices (see physician orders [REDACTED]. January 2020 Nurses' notes revealed: - The resident smeared feces on himself and then touched his nipples as the aide gave him a shower on 1/1/2020. He was redirected. - The resident displayed sexual behavior, pinching his nipples during a shower on 1/4/2020. He was redirected after many attempts. - Two episodes of inappropriate sexual comments toward one particular CNA occurred on 1/7/2020. He was redirected. - A medication administration note for the use of Vraylar and [MEDICATION NAME] completed on 1/8/2020 revealed the resident continued to make sexually inappropriate remarks toward staff and rub his nipples and genitalia while female staff provided care. The resident received verbal redirection on inappropriateness to which he expressed understanding and apologized to the nurse. Continued to have same behavior with CNAs shortly thereafter. - The resident was found masterbating at the nurses' station on 1/10/2020. The MAR indicated [REDACTED]. Target behaviors for [MEDICATION NAME] included episodes [MEDICAL CONDITION] delusions of sexual fantasies. Target behaviors for Vraylar included manic sexual behaviors, inserting objects into body orifices (see physician orders [REDACTED]. - The MAR for both [MEDICATION NAME] and Vraylar use revealed multiple episodes occurred on the evening of 1/7/2020 and during the day on 1/8/2020. C. Resident observation and interview Resident #2 was interviewed on 1/30/2020 at 3:10 p.m. The resident was seated in a wheelchair as he moved the length of the hallway to his room which was located near the end. He stood and transferred himself from the chair to his bed and asked for a CNA to help him adjust the bed. The resident said he knew staff and other residents were upset with him but he just can't help it. He said I get excited when I see some of the staff with large breasts, and I just want to do things to them I shouldn't explain (which he later described as giving oral sex to a female). The resident admitted he was also excited by Resident #1 but knew it would not be social accepted to act out his feelings toward her or any of the other staff. D. Staff interviews CNA #1 was interviewed on 1/30/2020 at 8:03 a.m. The CNA said she was aware Resident #2's behavior made Resident #1 uncomfortable. She said she believed all of the staff were aware. CNA #2 was interviewed on 1/30/2020 at 8:10 a.m. The said Resident #2 pulled up his shirt and played with his nipples in the dining room while calling out Resident #1's name on multiple occasions. The CNA said Resident #1 told numerous staff about Resident #2's behavior. She said Resident #2 usually complied when told to stop. Dietary aide (DA) #1 was interviewed on 1/30/2020 at 8:20 a.m. She said Resident #2 was inappropriate to everyone in the dining room. She said he pulled up his shirt and played with himself all of the time. The DA said Resident #2 called out Resident #1's name and staff names when he touched himself in the dining room.She said Resident #2 also pulled out his genitals and played with himself in the dining room. She said all of the staff were aware of Resident #2's behavior. CNA #6 was interviewed on 1/30/2020 at 3:05 p.m. The CNA said Resident #2 targeted her sometimes and made inappropriate sexual comments to her. She said sometimes she was unable to provide care because of his behavior and had to get a male CNA to assist or take over. The CNA said she always reported the resident's behavior to the nurse. Licensed practical nurse (LPN) #2 was interviewed on 1/30/2020 at 3:35 p.m. The LPN said the resident frequently displayed inappropriate behavior. The LPN said the resident was difficult to redirect and often times was not compliant. The LPN said staff reported the resident's behavior to social services staff (SS #1) so she could talk with him when his inappropriate sexual behavior could not be stopped. SS #1 was interviewed on 1/30/2020 at 4:05 p.m. SS #1 said the resident had multiple behaviors of concern. She said he was non-compliant with care at times and made sexually inappropriate comments to staff. SS #1 said she was made aware of Resident #2's behavior toward Resident #1 during a meeting with Resident #1 and her family. SS #1 said she was not aware of the frequency of behaviors directed by Resident #2 toward Resident #1. She said she met often with Resident #2 to counsel him about his behaviors and just realized he might find the meetings reinforcing. SS #1 said the resident was referred for behavior health services but was declined care as he was not believed to be appropriate for these services. She said she needed to look at the care plan to see what interventions were identified but acknowledged that individualized approaches were more likely to address his behavior. She said the IDT (interdisciplinary team) needed to work with the resident's physician, psychiatrist and therapist to get their input in developing and implementing interventions. SS #1 agreed the effectiveness of interventions should be evaluated and revised when necessary, with input from the IDT and professionals working with the resident. The director of nursing (DON) was interviewed on 1/30/2020 at 4:22 p.m. The DON said she would ensure the IDT developed individualized interventions for staff to use to address the resident's behavior toward staff and toward other residents. She said the team would engage in an active process of evaluating and revising interventions to protect others from Resident #2's inappropriate expressions and gestures. She said staff would ensure Resident #1 was protected from Resident #2's behavior. E. Failures Review of the resident's clinical record and interviews with residents and staff revealed the facility attempted to address the resident's behavior through medication management and referrals to outside emergency and behavior service providers. However: - The facility did not identify individualized interventions to address the resident's behavior on a day by day basis. - When comparing progress notes with the MAR, behavior tracking was not always consistent and did not always describe the NPI used to address the situation. - Resident #2's behavior toward Resident #1 (see resident interviews and staff interviews) was not consistently tracked and, with the exception of moving Resident #2 to another room, was not addressed through a process of revising and implementing new interventions. - The facility did not evaluate the effectiveness of interventions used by staff in order to determine the most favorable approaches to use in preventing Resident #2's unacceptable behavior. - Resident #2's inappropriate behavior, especially in the dining room, was left unmanaged and resulted in significant feelings of distress for Resident #1. -The facility failed to address Resident #2's behavior and implement a plan to protect Resident #1 and other residents until 1/30/2020, after the survey was initiated. II. Resident #4 [NAME] Resident status Resident #4, age 64, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/20/19 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score of 12 out of 15. He had no identified behaviors of concern and did not reject care during the assessment period. The resident was frequently incontinent of bowel but did not have a toilet retraining program. B. Record review The care plan, initiated 7/11/17 and revised 12/24/19, identified the resident had occasional bowel/bladder incontinence related to confusion. Interventions included check as required for incontinence; wash, rinse and dry perineum; and, change clothing as needed (PRN) after incontinence episodes. The care plan, initiated 10/30/19 and revised 12/24/19, identified target behaviors for [MEDICAL CONDITION] medication such as having bowel movements outside or in inappropriate receptacles (trashcan, sink). Interventions included administer medications as ordered and monitor and document for side effects and effectiveness. The care plan failed to address frequent defecation in inappropriate locations and did not include interventions to address the resident's behavior. The psychiatrist's provider note dated 10/29/19 documented, He has been having some behaviors of defecating in the sink and trash can. When I spoke with the patient about this he did deny this behavior. I did counsel the patient on the importance of avoiding this behavior. The electronic Medication Administration Record [REDACTED]. Progress notes included: - On 1/16/2020 at 2:13 a.m., Resident had multiple bowel movements (BMs) on floor through hall 2 and around nurses station in front of the rock wall. -On 1/15/2020 at 5:20 a.m., Resident noted to be using inappropriate receptacles to defecate in, room sink. Residents educated without positive response. A review of nurses' notes and behavior tracking revealed the facility failed to monitor and address the resident's frequent defecating incidents (see interviews below). No further documentation by staff about the behavior was completed. C. Interviews Housekeeping staff (HK) #1 was interviewed on 1/30/2020 at 7:45 a.m. HK #1 said Resident #4 had BMs in inappropriate places everyday to every other day. She said she found BM in his sink, trash can, walls and his bed. She said the resident also defecated in the hallway. The HK said she told the CNAs but, because they were often too busy, she just cleaned it up. She said the problem might come from his [MEDICAL CONDITION], but thought he also chose to defecate in the trash can or down the hall. CNA #1 was interviewed on 1/30/2020 at 8:03 a.m. She said sometimes the resident defecated in his pants and either did not care or did not notice. She said he left a trail of feces behind him as he walked down the hall. The CNA said the only place she was unable to document the BMs as a behavior but could only document incidents as toileting or incontinence. The CNA said she reported the incidents to the nurse and cleaned up the messes whenever they occurred CNA #2 was interviewed on 1/30/2020 at 8:10 a.m. She said the resident had a BM between every day and every other day. The CNA said defecating in the hallway seemed less frequent but only because he defecated in his trash can more often. She said the resident refused to wear attends (briefs). The CNA said she reported incidents to the nurse and cleaned him whenever the resident had a BM. She said she charted the incidents under incontinence/toileting and not as a behavior. The CNA said she thought nursing and administration was aware of the issue because he had so many instances of defecating in inappropriate locations. CNA #3 was interviewed on 1/30/2020 at 8:15 a.m. The CNA said she encouraged the resident to wear attends but he always refused. She said she asked the resident to go to his room to clean up whenever he had a defecation incident. She said he was very agreeable to go to his room. The CNA said she informed the nurse of every BM that was not in the toilet. Dietary aide (DA) #1 was interviewed on 1/30/2020 at 8:20 a.m. She said the resident had defecated in the dining room on multiple occasions. The DA said she reported it to the CNAs and the nurses so they could clean it up. LPN #1 was interviewed on 1/30/2020 at 8:05 a.m. She said the resident defecated in the hallway, in the dining room and all over his room. She said he defecated in his sink and in the trash can and had also had feces on the walls and bed in his room. The LPN said she charted incidents in his record when reported. The DON was interviewed on 1/30/2020 at 3:08 p.m. She said she was not aware Resident #4 defecated in inappropriate places as frequently as he did. The DON said she did not know why staff were not reporting the volume of incidents that needed to be cleaned up by staff or the additional hygiene care he received. She said she would talk with staff to encourage better communication to address his needs. The DON said there should be a care plan to address the resident's behavior and interventions to help him defecate in appropriate receptacles. The DON said the behavior should be tracked to help develop and revise interventions as needed.

Based on record review and interviews, the facility failed to ensure one (#1) of four residents reviewed for abuse out of six sample residents was protected from abuse. Specifically, the facility failed to protect Resident #1 from mental/verbal abuse by Resident #2. The facility's failure to protect Resident #1 from abuse resulted in an increase in anger, anxiety and feelings of fearfulness in direct response to Resident #2's behavior. Cross reference F740, behavior health services. Cross reference F745, medically related social services. Findings include: I. Resident status [NAME] Resident #1 Resident #1, age 72, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 11/27/19 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no identified behaviors or rejections of care during the assessment period. B. Resident #2 Resident #2, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2020 CPO, pertinent [DIAGNOSES REDACTED]. The 12/10/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. The resident did not experience hallucinations or delusions but exhibited physical behavior symptoms and refusal of care one to three days during the seven day assessment period. He received daily antipsychotic medications. II. Resident and family interviews Resident #1 was interviewed on 1/29/2020 at 2:56 p.m. She said she was concerned with Resident #2. She said she had problems sleeping at night because she was afraid Resident #2 would come to her room. She explained that Resident #2 made rude comments and inappropriate gestures in the dining room at meals such as rubbing his nipples and calling out her name. She said the behavior made her afraid because she thought he might try to come to her room. She said she felt vulnerable at night but thought she could protect herself during the day. She said she knew in her head (gesturing to her temple) that he could not get to her at night, but felt it here (gesturing to her heart) that he had the potential to get her at night. Resident #1 said took her anywhere from a day to a week to feel safe again in her room at night after Resident #2 displayed these behaviors. She said she had to change the route she took to leave the dining room because Resident #2 tried to grab her in the dining room multiple times. She said she changed her whole routine and would sit with a friend until after Resident #2 left the dining room. Resident #1 said she reported Resident #2's actions and her feelings to everyone including staff She said she knew certain nurses would would keep Resident #2 away from her hall; however, she became fearful when other nurses were on duty and did not feel she would be protected. She said she could not sleep at night because she was fearful. Resident #1 said she reported Resident #2's behavior to the director of nursing (DON). The DON told her the staff had received training on Resident #2 but she said she was hesitant to believe it. She said knowing Resident #2 was in a wheelchair gave her a tiny bit of reassurance, but she was still afraid at night when he acted out in the dining room. A family member of Resident #1 was interviewed on 1/29/2020 at 5:20 p.m. The family member said Resident #1's behavior had changed. She said Resident #1 was more concerned, scared, and defensive. The family member said Resident #1 reported she was afraid Resident #2 would come into her room at night The family member said Resident #1 called her and told her about Resident #2's inappropriate behavior in the dining room and was feeling upset. The family member said she went to the facility and talked to the social services (SS #1) staff. The family member said she was present when Resident #1 gave SS #1 specific examples of Resident #2's behavior in the dining room. SS #1 told the family she was not previously aware of Resident #2's behaviors. The family member said SS #1 asked Resident #1 if she was uncomfortable and she responded yes. Resident #1 said she felt unsafe at night and afraid Resident #2 would go into her room at night and get her. Resident #5 was interviewed on 1/29/2020 at 4:35 p.m. She said she had been friends with Resident #1 for awhile and ate with her at meals. Resident #5 said Resident #2 lifted up his shirt and played with his nipples and as he called out to Resident #1. She said Resident #1 became increasingly upset, angry and was uncomfortable all the time. Resident #5 said Resident #1's demeanor was worse whenever Resident #2 acted out. She said he tried to do it when staff were not in the dining room but she said staff were aware of Resident #2's behavior. Resident #5 said Resident #2's behavior had a noticeable negative effect on Resident #1's emotions. III. Record review [NAME] Care plan Resident #1's care plan, initiated 8/23/18 and revised on 12/3/19, identified the resident had the potential for a psychosocial well-being problem related to anxiety. Interventions included allowing time to answer questions and to verbalize feelings, perceptions, and fears. The care plan did not include goals and approaches to address Resident #1's psychosocial wellbeing after she became fearful at night and had changes in her demeanor as a result of being targeted repeatedly by Resident #2 in the dining room. B. Concern form A Concern and Problem Resolution form was completed on 12/24/19. The form documented Resident #1 found Resident #2's behavior toward her to be bothersome. The form described Resident #2's behavior as making faces and trying to get her attention in the dining room and noted Resident #1 felt uncomfortable at night. No further description of Resident #2's behavior or of Resident #1's response was included on the form. C. Progress notes A social services note written on 12/24/19 at 9:57 a.m. documented, Note Text: Spoke with Ombudsman today in regard to resident concern. Social services spoke with resident's daughter today and resident concerns have been addressed. Will continue to follow up, as needed. The note did not identify what the concern was related to. A social services note written on 12/27/19 at 9:17 a.m. documented, Social worker met with resident, resident stated she had no questions or concerns at this time. Resident also stated she feel(s) as though her recent concerns have been resolved. The PN failed to identify the specific concerns. IV. Staff interviews The nursing home administrator (NHA), DON, and SS #1 were interviewed on 1/29/2020 at 4:53 p.m. The NHA said a concern form was completed on 12/24/19 when the facility became aware of Resident #1's concerns. The NHA said the facility was not aware of the extent to which Resident #1 was affected by Resident #2's behavior. The DON said Resident #2 was known stare at various residents in the dining room and she redirected him when she saw it. SS #1 said she checked in with Resident #1 frequently and Resident #1 did not expressed fear toward Resident #2 during her visits. The NHA said the facility would immediately initiate an investigation for verbal/mental abuse. CNA #1 was interviewed on 1/30/2020 at 8:03 a.m. She said she knew Resident #2 had the potential to be inappropriate. She said she knew Resident #1 was very uncomfortable around Resident #2. She said all the staff knew. CNA #2 was interviewed on 1/30/2020 at 8:10 a.m. She said Resident #2 would pull up his shirt and play with his nipples in the dining room and call out Resident #1's name. She said when he displayed the behavior, the staff would ask him to put his top down and he would stop. She said Resident #1 had told all the staff about Resident #2's behavior. She said everyone knew about it. CNA #3 was interviewed on 1/30/2020 at 8:15 a.m. She said she's heard about Resident #2 being inappropriate to Resident #1. She said all the staff knew. She said Resident #1 had told everyone when Resident #2 acted out. Dietary aide (DA) #1 was interviewed on 1/30/2020 at 8:20 a.m. She said Resident #2 was inappropriate to everyone in the dining room. She said he would pull up his shirt all the time and play with himself and call out Resident #1's name as well as various staff names. She said he had pulled out his genitals and played with himself in the dining room. She said he had also defecated in the dining room. She said the staff knew about it. Licensed practical nurse (LPN) #1 was interviewed on 1/30/2020 at 8:05 a.m. She said she had noticed a change in the resident's demeanor. She said Resident #1 stays in her room more often and was very concerned where Resident #2 was. She said she reassured the resident she would not let Resident #2 down the hallway near her door. She said that helps a bit, but does not take away all the anxiety toward Resident #2. SS #1 was interviewed on 1/30/2020 at 1:48 p.m. She said she had no idea until Resident #1's family member came in on 12/24/19 that the problem with Resident #2 was as severe as it was. She said she would have addressed the issue instantly if Resident #1 had expressed any fear when she had interviewed her. She said the day the family member came by Resident #1 had expressed she felt uncomfortable at night. SS #1 said she reassured Resident #1 that the facility had nursing staff on 24 hours a day and no one would let Resident #2 go down her hall. She said she was not aware of the dining room incidents. SS#1 said there should have been a care plan to identify the fears and concerns Resident #1 had about Resident #2 with interventions it help her feel safer and more in control of what was happening. She said she did not know why staff had not informed her of the frequency of Resident #2's behavior. V. Follow-up Resident #1 was interviewed with the NHA on 1/30/2020 at 12:10 p.m. Resident #1 said she would get upset right after Resident #2 was inappropriate to her and it could take from a day to a week for her to get over it. She said she understood in her head that he's immobile, but she still dwelled at night on the Resident #2's behavior toward, especially if he had acted out that day. She said she was afraid Resident #2 would come into her room at night when she was vulnerable. She said she felt like she was being punished. She said she knew in her head she was not, but she was uncomfortable and upset. She told the NHA she felt safe during the day, but at night she was fearful of Resident #2 trying to get into her room. She said she felt like Resident #2 was tormenting her. The NHA reminded her there were respiratory therapists (RTs) on duty 24 hours a day and asked her if it could help put her at ease. She said she knew it sounded like she was contradicting herself, but she again said she felt safe during the day. She said she felt safe at night until Resident #2 acted out and then she would be fearful at night again. The NHA reassured her that she was safe and offered to have someone stop in and talk to her. VI. Failures Review of the clinical record and interviews with residents, family and staff revealed facility staff were aware of Resident #2's behavior. The facility failed to protect Resident #1 from being targeted by Resident #2's sexually inappropriate comments and gestures. The verbal/mental abuse directed at Resident #1 resulted in an increase in anxiety, the onset of fearfulness and anger, and changes to her daily routines and sleep. The facility failed to develop a plan to protect Resident #1 and other residents from further abuse by Resident #2 until 1/30/2020, after the survey was initiated.

Based on record review and interview, the facility failed to ensure three (#44, #45 and #70) of five residents reviewed for dementia care of 39 residents, that resided in the secure unit, out of 56 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The facility's failure to protect Resident #44, #45 and #70 and the residents involved with the altercations caused harm to Resident #271, #31 and #55. The facility's failure to address repeated behavioral issues for Resident #44, #45 and #70 created an environment where abuse (resident to resident altercations) persisted. The continued resident to resident altercations revealed they did not assess each resident for the appropriate level of stimulation. Because this assessment was not completed they were not able to identify and implement appropriate interventions to provide the level of stimulation to meet each residents individual needs. Cross-reference F600-free from resident-to-resident altercations. Findings include: The Dementia Care Guideline policy, undated, was provided by the executive director (ED) on 11/12/19 at 9:30 a.m. It read, in pertinent part, -The secured unit is designed to meet the needs and ensure the safety of individuals with Alzehimer's, dementia, [MEDICAL CONDITION], psychiatric and behavioral diagnoses. The secured unit is designed to provide a holistic approach to ensure the safety and well-being of the resident. A team approach is used so that the staff is able to work collaboratively with families to meet the diverse needs of the families and residents. -Efforts to maintain an appropriate level of stimulation are most important. Each individual will be able to tolerate different levels of stimulation. They may, at times, be taxed beyond their individual capacities. Should that happen, the person might experience considerable anxiety and irritability. After observation and monitoring of the resident, the amount of stimulation will be catered to their individual needs. II. Resident census and conditions The 11/6/19 resident census and condition form documented 125 total residents with 69 residents (55%) with dementia and 22 residents (22%) with a psychiatric diagnosis. The facility had a secured unit with 39 residents. III. Resident-to-resident altercations involving Resident #44 [NAME] Resident status Resident #44, age 82, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/19/19 minimum data set (MDS) assessment revealed the resident had short and long-term memory impairment and severe impairment for daily decision making. He did not exhibit any behaviors and required supervision from staff for most activities of daily living (ADLs). B. 9/25/19 1. Resident #45 status Resident #45, age 81, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/21/19 MDS assessment revealed the resident had severe cognitive impairment according to the brief interview for mental status (BIMS) score of three out of 15. She did not exhibit any behaviors and required extensive assistance from staff for most ADLs. 2. Resident altercation The 9/25/19 nurse progress note documented Resident #45 was yelling at Resident #44 in the hallway by the nurse's station. Resident #44 punched Resident #45 on left side of her face, she fell on the floor on her bottom and hit her back against the wall. A head to toe assessment was completed with no apparent injury to both residents. Resident #45 was given as needed Tylenol for pain and neuro checks were initiated that were within normal limits. Staff took Resident #44 to his room. -There was no interdisciplinary team (IDT) review of the incident documented in Resident #44's electronic medical record (EMR). There were no interventions put in place to prevent recurrence implemented by the IDT. C. 10/15/19 1. Resident altercation The 10/15/19 nurse progress note documented that a certified nurse aide (CNA) reported that Resident #44 threw coffee at Resident #45's chest in the lower dining room during dinner time. Resident #45 attacked Resident #44 and left a scratch on his right forearm. Resident #44 had two open areas on his right forearm and wound treatment was provided. Resident #45 did not have injury from the coffee being thrown at her. The staff separated the Resident #44 and Resident #45. -There was no IDT review of the incident documented in Resident #44 and Resident #45's EMR and interventions put in place to prevent recurrence. D. 10/20/19 1. Resident status Resident #271, age 89, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/5/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of five out of 15. He did not exhibit any behaviors and required limited assistance from staff for most ADLs. 2. Resident altercation The 10/20/19 nurse progress note documented Resident #271 had told the CNA that Resident #44 had knocked or pushed him down onto the floor in his room. Resident #271 had a skin tear to his left elbow and a small bruise on his left knee when the nurse assessed for injuries and wound care was provided. -Implemented after this altercation was activities staff provided one-to-one visits with Resident #44 and a binder was made for him that included pictures, cards, and items he could review. -The psychiatrist assessed the resident on 10/23/19 and [MEDICATION NAME] (antipsychotic medication) 0.25 milligrams (mg) two times a day was ordered due to his dementia with behavioral disturbance. E. 10/27/19 1. Resident status Resident #70, age 73, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/30/19 MDS assessment revealed the resident had short and long-term memory impairment and severe impairment for daily decision making. He did not exhibit any behaviors and required supervision from staff for most ADLs. 2. Resident altercation The 10/27/19 nurse progress note documented the staff heard yelling from the hallway where Resident #44 and Resident #70 swinging at each other. Resident #44 and Resident #70 were separated by staff. Resident #44 had a small skin tear under his right eye with scant blood and treatment was provided. -The facility implemented frequent checks every 15 minutes for three days. F. Record Review 1. Behavior documentation The 9/7/19 behavior care plan documented the resident was physically aggressive towards staff, he attempted to push other residents in their wheelchairs and took silverware from the dining room and placed it in his pocket. The goal was for him to have fewer episodes of behaviors. Pertinent interventions were administered medication as ordered, anticipate and meet his needs, approach in a calm manner, intervene as necessary to protect the rights and safety of others by approaching in a calm manner, divert attention and remove from location, medication review and psych consult as needed, offer resident to look at his binder created by activities and to offer activities of choice when agitated. -The interventions added to his care plan were a psych review added on 10/20/19 and for staff to review his binder with him when agitated added on 10/28/19. The (MONTH) 2019 behavior monitoring documented no episodes of behaviors. -Previous to the resident starting [MEDICATION NAME] medication on 10/23/19 his behaviors of being aggressive toward residents and staff were not being monitored. The (MONTH) 2019 behavior monitoring documented one episode of behavior on 11/1/19 of either striking out at others with objects, resistive to care, aggressive, or spitting. 2. Physician documentation The 7/20/19 history and physical documented the resident had no behaviors and his dementia was stable and non-progressive. The 10/13/19 physician progress notes [REDACTED]. The 10/23/19 psychiatrist progress note documented the resident had many movements of agitation and often would strike out at staff when performing cares. The resident had multiple altercations with other residents. The resident did not understand the concept of personal space and often had to be redirected. -The psychiatrist recommended the resident stat [MEDICATION NAME] 0.25 mg twice a day to improve his quality of life in order for him to be less agitated and aggressive. 3. Activity documentation The 9/17/19 activity admission evaluation documented the resident liked games, exercise groups/sports, music/singing, walking indoors, watching television, boating/fishing/hunting, parties, cat/dog visits and conversing. The one-to-one visits were not beneficial since he could not tolerate the 15 minute minimum requirement. The resident became agitated quickly and was unable to be rediretable. The 10/21/19 activity progress note documented that the resident would have one-on-one visits three times weekly. The activity staff provided a binder with different pictures, cards and daily news. IV. Resident-to-resident altercations involving Resident #45 Previous to the resident altercation on 11/10/19, Resident was involved with two altercations with Resident #45 on 9/25/19 and 10/20/19 (see above). [NAME] 11/10/19 1. Resident status Resident #31, age 93, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/19/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of five out of 15. She had verbal behavior symptoms towards others and required extensive assistance from staff for most ADLs. 2. Resident altercation The 11/10/19 nurse progress note documented that during the dinner meal at 4:30 p.m. Resident #31 and Resident #45 started yelling at each other. Resident #45 then stood up from the dinner table and grabbed Resident #31's left arm. CNA separated the residents. Resident #31 had a small skin tear on her left arm from the incident. -Implemented on 11/12/19 by the IDT were for the activity department were not to complete their charting before dinner time and keep the resident engaged in programs while waiting for the dinner meal to begin (see interview below). B. Record review 1. Behavior documentation The 9/11/19 behavior care plan documented the resident enjoyed walking with her roommate around the facility, she cussed and yelled at others and she could be aggressive towards others. Pertinent interventions were to administer medications as ordered, anticipate and meet her needs, approach in a calm manner, intervene as necessary to protect the rights and safety of others and offer activities of choice. The September, (MONTH) and (MONTH) 2019 behavior tracking documented target behaviors for her use of [MEDICATION NAME] were physical and verbal aggression towards others. -Resident #45 had no behaviors of physical and verbal aggression towards others during the months of September, (MONTH) and (MONTH) 2019. 2. Physician documentation The 7/10/19 and 10/22/19 physician progress notes [REDACTED]. 3. Activity documentation The 9/16/19 activity admission evaluation documented she liked exercise groups/sports, drawing/painting, music/singing, spiritual/religious, watching television, parties, cat/dog visits and conversing. The 11/11/19 annual activity evaluation documented the resident enjoyed attending food socials, manicures, church services, coloring, exercise and puppy visits. She liked sitting in the front room while watching television while observing her surroundings and ambulating around the unit. Resident #45 did get upset at times but was easily directable back to her room or with food. V. Resident-to-resident altercations involving Resident #70 [NAME] 10/22/19 1. Resident status Resident #55, age 86, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/25/19 MDS assessment revealed the resident had short and long-term memory impairment and severe impairment for daily decision making. He did not exhibit any behaviors and required extensive assistance from staff for most ADLs. 2. Resident altercation The 10/22/19 nurse progress note documented tha Resident #55 and Resident #70 were fighting during a group therapy program held in the living room. Resident #70 had no injury. Resident #55 had multiple scratches on his right face and right forearm. The nurse provided wound treatment and Resident #55 denied pain or discomfort. -There was no IDT review of the incident documented in Resident #55 and Resident #70's EMR and no interventions put in place to prevent recurrence. The resident had a subsequent resident-to-resident altercation with Resident #44 on 10/27/19 (see above). B. Record Review 1. Behavior documentation The 9/6/19 behavior care plan documented the resident had a history of [REDACTED]. Pertinent interventions were to administer medications as ordered, anticipate and meet his needs, approach in a calm manner, medication management by the psychiatrist, document behaviors and interventions, intervene as necessary to protect the rights and safety of residents and offer activities of choice. The September, (MONTH) and (MONTH) 2019 behavior tracking documented to monitor target behaviors of physical aggression towards others, refusals of care, volatile mood and threatening towards others. -Resident #55 did not have any documented behaviors for September, (MONTH) and (MONTH) 2019. 2. Physician documentation The 7/20/19 history and physical documented the resident had his behavior under control but had some aggressive behaviors towards staff and other residents. The 10/13/19 physician progress notes [REDACTED]. 3. Activity documentation The 9/17/19 activity admission evaluation documented he liked puzzles, drawing/painting, exercise groups/sports, music/singing, spiritual/religious events, walking/wheeling outdoors, watching television, gardening/plants, conversing, visits with cats and dogs and parties. The resident enjoyed watching television in the front room and watching his surroundings and had behaviors including striking at staff and residents for no reason. VI. Staff interviews The assistant director of nursing (ADON) #2 and minimum data set coordinator (MDSC) were interviewed on 11/7/19 at 11:28 p.m. The ADON said she started about two months previous and she was the nurse manager in charge of the secured and rehabilitation unit. She said the interdisciplinary team met during the week and reviewed incidents and change of conditions, falls and resident altercations. She said when a resident altercation occurred in the secured unit, the residents were immediately separated by staff. She said the nurse on shift completed an incident report to initiate the investigation, provided treatment if needed and notify nursing management or administration, the police, physician and responsible parties. She said the investigation was completed by herself or management, where staff were interviewed about what occurred, what might have precipitated the incident like if a resident was agitated and then it was reviewed with the ED or director of nursing (DON). She said the nursing staff monitored the residents for at least three days post altercation to ensure there were no psychological changes like fear and provided treatments if needed. She said the IDT implemented interventions that were appropriate based on the conclusion of the investigation. She said some interventions included lab draws to help detect an acute medical change, one-to-one activities and frequent checks. She said any new interventions put in place would be care planned and staff educated on the new interventions put in place to prevent reoccurrence. She said when the IDT reviewed an incident a progress note was documented in the resident's EMR of what happened and interventions put into place. The MDSC and ADON said Resident #44 had resident altercations with other residents in the secured unit. They said the first incident that occurred with Resident #44 was with Resident #45 when he punched her in the face and she fell on to her bottom. They said the residents were immediately separated after the altercation occurred. They said after the altercations, the staff in the unit tried to keep Resident #44 and #45 separate, but both residents were ambulatory and wandered throughout the unit. They said the staff offered diversional activities to all the residents in the secured unit to prevent altercations. They said there was no IDT review of the altercation between Resident #44 and #45 in the EMR and that no additional interventions were added to prevent reoccurrence. They said an additional altercation occurred on 10/15/19 between Resident #44 and #45 while in the dining room. They said Resident #44 threw coffee at Resident #45's chest and then she scratched Resident #44 for throwing the coffee at her. They said Resident #45 did not have a burn from the coffee, but Resident #44 had scratches on his right forearm. They said the IDT informally reviewed the incident and decided the residents should not sit at the same table. They said the information was not documented in Resident #44 and #45's EMR or care plan for them to sit in separate dining rooms. They said they could not stop Resident #44 and #45 from sitting together in the dining room if they chose to sit by each other. They said the altercation that occurred on 10/20/19 they could not substantiate that Resident #44 had pushed Resident #271 in his room. They said staff interviews determined that a CNA had documented that Resident #271 was yelling for help to get Resident #44 away from him and that Resident #44 was in his room when he was yelling for help. They said after the incident, the psychiatrist had saw Resident #44 due to his resident altercations and aggressiveness and had ordered [MEDICATION NAME] 0.25 mg twice a day. They said the altercation that occurred on 10/27/19 between Resident #44 and Resident #70, happened in the hallway. They said IDT had talked about interventions of medication review with psych consult, offering him a binder with pictures and one-to-one activities. They said they updated Resident #44's care plan with the interventions put into place by the IDT. They said they implemented frequent checks for a few days to make sure Resident #44 did not have an additional resident altercation. They said the resident altercation with Resident #55 and Resident #70 had occurred during a group therapy activity. They said Resident #55 had multiple scratches on his face and right forearm. They said IDT had not reviewed this incident and implement measures to prevent future occurrence. The ED was interviewed on 11/7/19 at 12:59 p.m. He said many of the residents in the secured unit had behavioral issues and required ongoing assessment. He said the psychiatrist came in every other week to review the residents with increasing aggressive behaviors to ensure their [MEDICAL CONDITION] medications were effective and what other interventions were required. He said it was the facility's priority to keep the residents safe in the secured unit and would review and implement measures. The director of clinical services (DCS) was interviewed on 11/7/19 at 1:28 p.m. She said the facility implement one-to-one supervision for Resident #44 due to the multiple resident altercations that occured to prevent future occurrence. She said the IDT, in the meantime, would discuss and document measures on how to keep the residents safe in the secured unit from altercations. She said they were going to train the staff that worked in the secure unit about the measures the facility was implementing. Licensed practical nurse (LPN) #3 was interviewed on 11/10/19 at 2:30 p.m. She said she worked the day shift in the secured unit from 6:00 a.m. to 2:00 p.m. She said there were a few residents that were aggressive in the unit which caused resident-to-resident altercations. She said she educated the certified nurse aide staff on how to take care of the combative residents and appropriate strategies to calm the residents if agitated. She said if a resident altercation occurred, the staff immediately separate the two residents involved. She said she would complete an assessment for injury and would notify the appropriate personnel like the physician, responsible parties and ADON #2. She said Resident #44 had aggressive behaviors towards both staff and residents which consisted of pushing, kicking and biting. She said the psychiatrist came to see him and added Ripserdal on 10/23/19 due to his aggressive behaviors. She said she was aware of some of the resident altercations with Resident #44 but not all had occurred on her shift. She said the facility tried to redirect him when he was agitated to calm him down to avoid an altercation. She said Resident #70 had aggressive behaviors of hitting. She said he had a resident altercation with Resident #55 during a group therapy activity. She said since then the staff ensured Resident #55 and Resident #70 did not sit next to each other during activities and in the dining room for meals. She said Resident #45 had behaviors of being aggressive and she yelled and could become physical. She said when she was agitated she screamed so the staff knew to calm and redirect her before an altercation occurred. She said if a resident continued to bother her then she became physical. She said she did not do well with previous female roommates and became aggressive toward them but her current roommate had worked out well for her. The activities assistant (AA) was interviewed on 11/10/19 at 2:41 p.m. She said she provided activity programs in the secured unit. She said she provided a variety of programs like manicures, ring toss, daily chronicles, sensory boards and balloon toss. She said she individualized activity programs based on the resident likes and interests. She said there were a few residents that did not do well with group activities due to them requiring low stimulation and being aggressive but she was not able to determine which residents required one-to-one visits. She said the activity director decided which residents required one-to-one visits and she was currently on vacation. She said during one-to-one visit she talked with residents in their rooms, read, listened to music or gave them hand massages. She said one-to-one visits were typically three times a week for 15 minutes. She said Resident #44 had a binder to read and keep him occupied that included pictures and paperwork relating to the air force, hunting and fishing and daily chronicles. She said the staff were to show him the binder when he was agitated which helped calm him. She said he did better with low stimulation activities and individual programs so he was recently added to the one-to-one activity visits on 10/20/19 and that it had been beneficial to him. She said Resident #45 liked activity programming that had low stimulation and individualized since she had agitation while being in groups. She said she participated in manicures, balloon toss in her room and nursery rhymes being read to her. She said she did like to be alone and in her room most of the time. She said she was not on the one-to-one activity programs because the activity director had not added her to the list. She said Resident #70 liked balloon toss and to have conversations about his life. She said he preferred more one-to-one activity programming since he could get agitated in a group setting. She said he was not included on the list of residents to have one-to-one programming because the activity director had not added him. The social services director (SSD), social worker (SW) #2, ED and DCS were interviewed on 11/11/19 at 4:20 p.m. They said Resident #44 had been admitted to the hospital for a psychiatric hold. They said the staff would meet with the case manager to devise strategies for his aggressive behaviors and ensure the staff were trained before he returned. They said when he returned to the facility, they were going to have one-to-one supervision provided by the staff until IDT reviewed and determined it was not necessary. They said therapy was going to assess him for a restorative referral, provide him headphones to listen to music, and place coloring pages into his binder for him to color. They said the psychiatrist planned to continue to follow the resident when he returned to the facility. They said they were going to review him in the [MEDICAL CONDITION] meeting held monthly for a minimum of six months to address his behavior. They said Resident #70 often grunted when he was agitated. They said they were going to ensure all staff were aware of this sign to redirect him from other residents to de-escalate his aggressiveness. They said he enjoyed going outside for walks so they were going to add that to his restorative program. He likes to communicate on paper so the staff will ensure he had writing utensils in order to convey his thoughts because he could get frustrated if people did not understand him. They said the psychiatrist would review his medications and behaviors to ensure he was on the appropriate plan of care. They said he was added to the one-to-one activity program list since he did desire low stimulation and individual activities. They said they were going to provide Resident #45 with one-to-one activity programming since she desired low stimulation and individual programs. The IDT implemented having activities during the time the residents were waiting for their dinner meal to help alleviate their boredom and lessen behaviors. They said previously the activity department was charting during the time before dinner when the residents behaviors seem to escalate. They said they had provided comprehensive treatment and services to the residents residing in the secured unit because the psychiatrist was involved with the residents that had behaviors and ensured they had the appropriate regimen. They said that they provided additional training to the staff in the secured unit on how to manage behaviors especially with the residents that were aggressive, like approaches to calm the residents when agitated and intervene before a resident altercation arose. They said they provided specialized activity programming to the residents in the secured unit by having full time activity assistants to provide group activities geared towards those residents with dementia and one-to-one programs. They said moving forward the IDT team will review residents with any new behaviors, changes to their behavior and ensure they were implementing measures to keep the residents safe in the secured unit. They said the residents continued to be reviewed quarterly in the [MEDICAL CONDITION] meetings and if a resident needed to be reviewed more often then the IDT would ensure they were reviewed. They said they would in-service all staff on documenting behaviors in order for the IDT to determine trends of when the behavior occurred and in order for the resident to be effectively reviewed by the [MEDICAL CONDITION] committee. They said they were working with the activity department to make sure they were a part of the IDT and reviewing the resident's programming more often if they did not do well with group activities or required low stimulation. They said they had recently merged two buildings, one with the secured unit and one with their rehabilitation and respiratory unit in (MONTH) and since the merge they had not had a coordinated effort with the management staff in the secured unit and the management staff in the rehabilitation and respiratory unit. They said moving forward all management staff would comprehensively work together. The medical director (MD) was interviewed on 11/12/19 at 4:00 p.m. He said he had been the medical director at the facility for many years. He said he was often at the facility to meet with the administrator and attended quality assurance and [MEDICAL CONDITION] meetings monthly. He said during the [MEDICAL CONDITION] meeting the pharmacist, social services, administration and nursing where present and 25 to 30 residents were reviewed at a time. He said at a minimum, residents who received [MEDICAL CONDITION] medication were reviewed quarterly but some residents required to be reviewed more often. He said the quality assurance committee reviewed resident altercations in the past but he did not recall any recent incidents. He said the facility monitored the recommendations made in the quality assurance and [MEDICAL CONDITION] committees and involved the psychiatrist if needed to make recommendations for the residents that had behaviors like aggression. He said the facility was responsible to bring behavioral concerns to the committee's attention regarding the secured unit residents. This included an increase in behaviors and resident altercations.

Based on observations, record review, and interviews, the facility failed to provide the necessary referrals for mental health for one (#34) of one resident reviewed for psychosocial well-being out of 30 residents. Resident #34 was admitted to the facility following a traumatic car accident in which he lost his wife and father-in-law, as well as his independence due to a spinal cord injury. The facility failed to identify, monitor and timely provide supports to address the resident's multiple losses, such as through the implementation of a person-centered care plan and timely referral for mental health services. The resident became tearful during interview and expressed feelings of loss, guilt, and mental and physical pain. (Cross reference F697). Findings include: I. Resident #34 and facility response A. Resident status Resident #34, under the age of 65, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The [DATE] admission 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 had mild depression with the resident scoring seven out of 27 on the patient health questionnaire (PHQ-9) B.Record review 1. Physician orders The (MONTH) (YEAR) CPO included orders to: -Administer [MEDICATION NAME] HCI tablet 100 mg, give one tablet orally two times a day for depression. Do not crush. The start date was [DATE]. This order was to clarify the existing order for the medication to include Do not crush. 2. Care plan The care plan, initiated [DATE], identified the resident had the potential for adjustment issues due to admission. Interventions included: encourage ongoing family involvement; invite family to attend special events, activities and meals; encourage participation in conversation with staff and other residents daily; introduce to other residents with similar backgrounds and interests; and encourage and facilitate interactions. The care plan, initiated [DATE] and revised [DATE], identified the resident was at risk for depression related to injury and adjustment to placement. Interventions included administering medications as ordered; monitor and document for side effects and effectiveness; discuss with family and caregivers any concerns, fears, or issues regarding health or other subjects; monitor and document to nurse, physician any signs or symptoms of depression including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing negative statements, repetitive anxious or health related complaints and tearfulness. The care plan, initiated [DATE] (during survey), identified the resident used an antidepressant. Interventions included: give antidepressant medications as ordered; monitor and document for side effects and effectiveness; side effects included: dry mouth, dry eyes, constipation, [MEDICAL CONDITIONS], sedation, drowsiness, blurred vision, muscle tremor, agitation, rash and weight loss or weight gain; monitor and document and report to the physician signs and symptoms of depression unaltered by antidepressant meds; sad irritable, anger, never satisfied, crying, shame, worthlessness, guilt, [MEDICAL CONDITION], negative mood or comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, not enjoy usual activities, changes in cognition, changes in weight or appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety and constant reassurance; observe for signs and symptoms of: confusion, mood change, change in normal behavior, hallucinations, delusions, social isolation, suicidal ideation, withdrawal, decline in ability to help with or do activities of daily living, continence, cognitive function, fecal impaction, no voiding, shuffle gait, rigid muscles; difficulty ambulating, balance problems, accidents, dizziness, [MEDICAL CONDITION] or falls, movement problems, tremors, diarrhea, , muscle cramps and nausea and vomiting. The care plan, initiated [DATE] (last day of survey), identified the resident had a psychosocial wellbeing problem related to lack of acceptance of current condition as evidenced by repetitive health and non-health concerns. Interventions included assist, encourage and support to set realistic goals; increase communication between resident, family and caregivers about care and living environment; explain all procedures and treatments, medications, results of labs or tests, condition, all changes, rules and options; initiate referrals as needed or increase social relationships including family dynamic repair; and provide opportunities for family to participate in care. The Kardex directed staff to Monitor/document/report to MD prn ongoing s/sx (signs and symptoms) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideation, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. The care plans, identified the resident used an antidepressant and the resident had a psychosocial wellbeing problem related to lack of acceptance of current condition as evidenced by repetitive health and non-health concerns was not initiated prior to survey and was not person centered. The interventions are not specific for the resident. The resident is not able to walk, shuffle gait, difficulty ambulating and balance problems do not pertain to the resident. II. Failure in response A. Resident interviews and observations [DATE] -The resident was reclined on the bed in his room at 10:09 a.m. He said he was new to the hall, he was moved about a week or so ago into the room from another hall. The resident said he had been in a car accident and that was why he was in his current condition. He became tearful when disclosed his father in law and wife had died after the car accident. He said the tire blew and he could not control the car. He said he woke up under the steering wheel and airbag. He said he would never be normal. The resident said he was taking an antidepressant daily. He reported he felt guilty and did not know why the tire blew. The resident said he was not receiving any type of counseling. He said he did not know who the social services person was in the facility. [DATE] -At 4:39 p.m., the resident was in his room. He said he had good days and bad days. He said his sister lived out of state and could not visit as often as they would like. He said his grandmother visited on weekends when she did not have to work. The resident started crying and said he did not know why he let the tire blow and he wished the accident did not happen. He said he will never walk again and will have to live with the PEG tube, [MEDICAL CONDITION] and catheter for the rest of his life. The resident said he missed his wife, he had pictures near his bed of his wife and children, and he pointed to it. [DATE] -The resident was reclined on the bed in his room at 9:18 a.m. He said he was going on an activity with the residents out of the facility. He said the staff was going to get him dressed and ready to go. The resident became tearful and said he was scared to go out in public because of the tubes. He did not want people to stare at him. He said he did not know if he was able to make it for the whole day and what if they did not want to take him back. He said he felt like he was a burden to everyone at the facility because he could not take care of himself. B. Record review 1. Social services notes A social services noted written on [DATE] read: His cognition is good, and he has depression and anxiety. No further documentation from social services was in the residents chart until the referral note on [DATE]. A social services noted written on [DATE] read: Submitted referral for resident to see Senior Counseling. A social services noted written on [DATE] read: PASRR (sic) currently on [MEDICATION NAME] 100mg twice a day for depression. Follow up next Quarter [DATE] noted to be completed. The facility failed to submit a referral for counseling timely. The resident was admitted to the facility on [DATE]. He was discharged [DATE] and readmitted [DATE]. The referral was submitted six weeks after readmission on [DATE]. The facility failed to address the resident's history of substance abuse, grief and loss, his loss of independence and identity and chronic pain. 3. physician progress notes [REDACTED]. I had seen this patient upon admission and his history is very tragic. Today the patient reported two symptoms: depression going on since the last few months. [MEDICAL CONDITION] since the last few months. The patient reported that he has been depressed and feeling very hopeless. He denied being suicidal. He also reported having severe [MEDICAL CONDITION]. As far as his depression goes, I would like to start him on [MEDICATION NAME] 20mg once a day. The physician addressed the resident's depression by prescribing another antidepressant medication. No order for a referral was written on [DATE]. 4. Nurses' progress notes A nurses' note written on [DATE] read: Resident reports an overwhelming feeling of sadness r/t (related to) multiple losses he has experienced over the past few months. States he can't help feeling that the MVA that caused his injury and resulted in his father in laws death was his fault as well as feels responsible for his wife's death. Resident provided time to voice his feelings and reassurance provided. Requesting additional medication to assist with depression. Will report in am. Resident reported that being able to verbalize his feelings was helpful and expressing interest in counseling. III. Staff interviews Certified nurse aide (CNA) #2 was interviewed on [DATE] at 1:11 p.m. She said she did not know of interventions when a resident presented as depressed. She said she talked to the residents, asked what they needed. She said she tried to take their mind off of sadness or whatever was bothering them by talking about something they liked. The CNA said Resident #34 was sad recently, he was crying because it was his deceased wife's birthday. She said she offered a hug, talked about other things other than his wife. She said she did not know what else to offer him. The CNA said she reported to the nurse and she did not know what the nurse did after she reported to her. She did not think the resident was seeing a counselor or therapist for depression. LPN #4 was interviewed on [DATE] at 1:30 p.m. She said she talked to residents when they appeared to be depressed, sad or anxious. She said sometimes the residents needed to talk to someone else, the social worker, a priest or a counselor. She said a lot of residents talked to her. She said she let them talk and she listened and sometimes that seemed to help. She said she would ask for help from the social worker or director of nursing (DON) if the resident appeared to be in distress and she was not able to offer more. The LPN said the resident had days when he was sad. She said he told her one day he was angry with God, because his wife died . She said she offered comfort, listened to him and reassured him, it was okay for him to be angry. She said she did not report the conversation to social services. The social services director (SSD) was interviewed on [DATE] at 2:00 p.m. She said there were different assessments to identify when a resident was depressed. She said she completed the PHQ 9 or the general depression scale (GDR). She said she relied on feedback from staff who worked with the residents too. She said if the was PHQ-9 score was above 10 she looked at PASARR to see if changes were required. She said she would make a referral to the counseling group or the contracted psychiatrist when a resident's mood changed or behaviors were displayed. The SSD did not know how long the referral process was after she contacted the counseling group or psychiatrist to be seen. The SSD said she had not spent time with the resident since assuming the SSD position. She said when she was the receptionist she had a little bit of contact with him. She said a referral was sent to the counseling on [DATE] for him. She confirmed the order was written on [DATE] and did not know why the referral was not submitted until five days later. She also did not know why the physician did not write an order when the assessments were completed, she said she did not complete the assessments for the residents. She said the DON said she wanted to refer him to the counselor because she thought the resident was feeling guilty. The SSD said the referrals should be sent immediately to the counseling group. She was unable to find the fax to the counseling group. She provided it and said she just faxed it. The SSD said she had to ask the DON and NHA if there were any possible risks to the resident. She reported the DON and NHA felt the resident was being monitored by the doctor. They would report any changes the resident had to be addressed. They thought communication with the family was important and could ask family if needed for additional support. The DON was interviewed in the presence of the NHA on [DATE] at 2:56 p.m. She said the physician had talked with the resident and he added another antidepressant to the resident's medication regime and wrote an order for [REDACTED]. She said the facility was responsible to care and treat the resident holistically to include mental health and mood improvement. She said the resident displayed some behaviors such as: he cussed at staff, cussed at his former roommate, refused stuff and at times was withdrawn and did not want to socialize. She said the risk to the resident was possibly his depression could worsen, weight loss, further withdrawal and could lead to failure to thrive. She said the SSD should have completed assessments to ensure the referrals were sent to the appropriate sources timely.

Based on observation, record review, and staff and family interview, the facility failed to prevent development of pressure ulcers and promote healing of pressure ulcers for two (#84 and #100) of three residents reviewed of 32 sample residents. Specifically, the facility failed to: - Identify risk factors, communicate changes, provide ordered treatment modalities, implement and monitor effectiveness of individualized interventions, and revise interventions as appropriate to prevent a pressure ulcer for resident #84 and to promote healing. - Reposition resident #100 per professional standards to reduce the risk of pressure ulcers. These failures contributed to resident #84 developing a stage four pressure ulcer. The findings included: 1. Facility Policy and Procedure The Pressure Ulcer Management Protocol policy and procedure, revised 1/15, revealed the following interventions should be used for pressure ulcer prevention: - Pressure relief devices should be used based on nursing and therapy assessments. - Reposition the resident every one to two hours while in bed and chair. - Initiate dietary interventions with particular attention to protein, vitamin C, fluid intake, and nutritional supplements as indicated. - Provide resident education, for example, weight shifting in bed, self-turning if capable, active assistive range of motion (ROM). - Provide assistive devices and/or techniques to facilitate independent/dependent resident movement. The Care and treatment of [REDACTED]. Resident assessment, identify risk factors such as: - Impaired/decreased mobility and decreased functional ability. - Impaired diffuse or localized blood flow. - Resident refusal of some aspects of care and treatment. - Cognitive impairment. - Nutritional risks. Prevention: - Stabilize, reduce, or remove underlying risk, monitor impact of interventions, and modify interventions as appropriate. - Provide support surfaces and pressure relieving devices. - Maintain or improve nutrition and hydration status. 2. Professional References According to the Agency for Healthcare Research and Quality article titled, Pressure Ulcer Prevention and Treatment Protocol, 2012, guideline.gov/content.aspx?id= &search=cleaning+wound#Section420 <http://www.guideline.gov/content.aspx?id= &search=cleaning+wound>, Immobility is the most significant risk factor for pressure ulcer development. Patients have greater intensity of pressure over the bony prominences when sitting in a chair, because there is less distribution of weight. Along with increased weight over the bony prominences, there is a tendency for the body to slide in a downward motion, causing shearing and destruction of the soft tissue over the bony prominences. A sitting position includes sitting in bed with head elevation greater than 30 degrees, a cardiac chair, recliner or wheelchair. When in this position, it is important for the patient to shift weight every 15 minutes if he/she is able to do so independently. This includes small shifts of weight such as pushing up on their arms, raising or lowering their head slightly to redistribute the weight, or lifting from side to side. If the patient is unable to shift weight independently, his/her position should be changed by care providers on an hourly basis. 3. Resident #84 Resident #84, age 75, was admitted on [DATE] and re-admitted on [DATE]. According to the 3/16 computerized physician orders [REDACTED]. According to the 2/9/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance of two persons with bed mobility, toilet use, and transfers. A stage two wound was present upon admission. A pressure relieving device was on the bed, and nutrition and hydration interventions were in place to manage skin problems. The resident did not refuse cares during the assessment period. a. Resident Observation On 3/10/16 at 11:59 a.m., the resident received a bowl of fruit and 240 milliliters (ml) of milk for lunch. He ate all of the fruit and drank the milk. According to the meal intake documentation, he consumed 76 to (-) 100 percent (%) of lunch. However, according to Guidelines for Percentage of Meal Intake provided by the registered dietitian (RD) on 3/15/16 (see below), the resident only consumed 25% of his noon meal. On 3/10/16 at 3:47 p.m., the wound care physician (WMD) assessed and measured pressure ulcers located on the resident's right calf and right heel. He said the calf wound could have been related to floating the resident's heels, and suggested to the wound nurse to obtain different boots to relieve pressure to the calf area. He proceeded to demonstrate the wound on the right calf matched the contour of the boot, thus causing pressure to the area. The wound on the right calf was observed with black and yellow necrotic tissue. No drainage or odor was noted. The wound on the right heel had thick black necrotic tissue attached to the wound. No drainage or odor was noted. (See also WMD wound documentation below) On 3/14/16, through continuous observation from 7:00 a.m. through 1:00 p.m., the resident received breakfast at 8:35 a.m., which included a bowl of oatmeal and a glass of orange juice. -At 9:00 a.m., accompanied by the physical therapy assistant (PTA), boots were observed to the resident's bilateral feet. Both feet were also resting on a pillow. The PTA said the boots were not multi-podus boots (see PTA interview below for further detail on boots). -At 12:45 p.m. the resident received his lunch which included a large bowl of ambrosia salad and 240 ml of milk. He ate and drank all of both meals. No snacks were offered or encouraged between breakfast and lunch. According to the meal intake documentation, he ate 75 - 100% of breakfast and received tube feeding for lunch. However, the resident did not have a feeding tube in place and according to Guidelines for Percentage of Meal Intake, provided by the registered dietitian on 3/14/16, the resident's actual intake was 30% for breakfast and 35% for lunch (see below). -During this continuous observation (7:00 a.m. through 1:00 p.m.), staff was not observed to encourage or assist the resident to reposition. On 3/15/16 at 7:20 a.m., the resident was lying in bed. He had a boot on his left foot only and his legs were propped up on a pillow. The resident's right calf was resting on the pillow. The resident said he was very happy with his care and said he refused to use an air mattress. b. Record Review Care Plan: (1) The pressure ulcer care plan, initiated 4/15/15 and revised on 8/10/15, revealed the resident had a pressure ulcer to his buttocks and heels related to immobility. The goal read the pressure ulcer would show signs of healing and remain free from infection. The interventions included: -Administer treatments as ordered and monitor effectiveness. -Administer medications as ordered and monitor for side effects and effectiveness. The stage four pressure ulcer on the resident's right calf was not identified on the care plan. The care plan failed to identify individualized interventions or new interventions after the ulcer increased to a stage four (see below). (2) The skin care plan, initiated 8/14/15 and revised on 3/3/16, revealed the resident was at risk for further skin breakdown related to a history of pressure areas, incontinence, depression, impaired mobility, [MEDICAL CONDITION], and [MEDICAL CONDITION]. On 1/28/16, it indicated the resident had developed a new cluster of wounds on his coccyx. The approaches included the following: - Therapy evaluation and treatment per physician orders. - Encourage good nutrition and hydration in order to promote healthier skin. - Identify and document potential causative factors and eliminate or resolve when possible. - Keep the resident's skin clean and dry. - The resident was to be followed by the wound care physician. The care plan failed to identify the stage four pressure ulcer on the resident's right calf and did not identify individualized interventions related to the wound to promote healing. (3) The activity of daily living (ADL) care plan, initiated 8/13/15 and revised on 8/14/15, revealed the resident required extensive assistance with cares. The care plan failed to identify the need for assistance with bed mobility or repositioning and it did not address the resident's history of refusal of care as reported by staff (see below). (4) The nutrition care plan, initiated on 6/30/15 and revised on 2/5/16, revealed the resident had an alteration in nutrition as evidenced by a history of insidious weight loss related to suboptimal caloric intake. It indicated he had a wound with poor adherence to the wound care regimen. The interventions included to provide a fortified diet and monitor and record food intake at each meal. Supplements were to be provided as ordered and staff was to report if he was not consuming them. physician progress notes [REDACTED].>The 12/10/15 PPN revealed the resident had a [DIAGNOSES REDACTED]. It read, Poor blood flow leads to poor healing of pressure ulcerations. Physician Computerized Orders (CPO): The 3/16 CPO revealed the following orders related to wound care and prevention: - 6/22/15, Administer nutritional support, 30 ml by mouth three times daily. - 6/22/15, Administer Juven, one packet in water or juice by mouth two times daily. - 11/24/15, Administer Mighty shake, 180 ml by mouth at bedtime. - 3/9/16, Cleanse stage four pressure ulcer to right posterior calf with wound cleanser, pat dry, and apply hyrdrogel impregnated gauze and cover with petroleum gauze. Cover with a dry dressing and secure with kerlix. Change the dressing daily and as needed (PRN). - 11/12/15, Apply multi-podus boots to bilateral lower legs every shift. - 11/12/15, Float the resident's heels while in bed. Wound Care Documentation - Worsening of pressure wound on right calf: The 2/18/16, 5:22 p.m. skin/wound progress note read the WMD had assessed the resident. The resident had a stage two wound to his right posterior calf which measured 7.0 centimeters (cm) by (x) 1.2 cm. It was documented to continue the use of multi-podus boots. The 2/25/16, 6:46 p.m. skin/wound progress note revealed the wound measured 6.0 cm x 0.5 cm. The wound bed had red and pink granulation tissue and a small amount of serous drainage was noted. There was no stage indicated in the note. It read the current treatment would be continued along with an air mattress and multi-podus boots. No air mattress was on the resident's bed as he refused. The 3/4/16, 4:39 p.m. skin/wound progress note revealed the wound to the right posterior calf was a stage four and measured 7.0 cm x 2.5 cm x 0.5 cm. The wound bed was red with blood noted from the edges of the wound. Visible bone noted to center of wound bed. The current treatment was to be continued multi-podus boots were to be on at all times and continue the use of an air mattress on the bed. The resident did not have multi-podus boots on and he had refused to use an air mattress. The 3/10/16, 7:18 p.m. skin/wound progress note revealed the WMD had assessed the resident (see observations above). The wound to the right posterior calf was unstageable due to necrotic tissue. The site measured 7.5 cm x 1.2 cm. The note read to have physical therapy evaluate the resident for different pressure relieving boots and to obtain laboratory tests to rule out osteo[DIAGNOSES REDACTED]. Nutritional Assessment: The 2/8/16 quarterly nutritional evaluation, completed by the dietary manager, revealed the resident's weight was 129 pounds. He was below ideal body weight but his weight had been stable over the past six months. It indicated his meal intake averaged between 75 - 100 % and his fluid intake was adequate. The meal intake average was inaccurate due to the fact the resident had not been receiving full meals (see observations above). The resident was not assessed by the registered dietitian (RD) for nutritional needs after the wound on his right calf increased to a stage four pressure ulcer. (See RD interview below) On 3/14/16, the registered dietitian provided a form titled Guidelines for Percentage of Meal Intake. The form revealed a chart on how to record the food consumption of each resident. It revealed the following guidelines: Breakfast: - 40% egg or breakfast entrée - 20% cereal - 15% toast - 15% milk - 10% juice Lunch: - 30% meat - 20% starch - 15% milk - 10% soup or salad - 10% dessert - 10% vegetable - 5% bread and butter Skilled Therapy On 3/14/16 at 9:30 a.m., the PTA provided a company description of the boot which had been applied since 11/12/15 and was currently being used by the resident. It revealed the boot was a heel protector boot and not a multi-podus boot. It read the boot was used to help relieve pressure on the heels. The boots would completely off-load the heels and redistribute the pressure away from the heels. c. Staff Interviews The WMD was interviewed on 3/10/16 at 3:47 p.m. He said the resident had refused to use an air mattress despite encouragement and education. He said the right calf ulcer could be related to floating his heels. He assessed the wound in relation to the boot the resident had been wearing and said the wound did match to the contour of the boot. He gave a verbal order to the wound care nurse to have therapy evaluate the resident for different boots. The PTA was interviewed on 3/14/16 at 9:00 a.m. He said he had spoken with the wound care nurse and they had looked through the supply book and could not find a different boot. He said they jointly decided to continue the same boots but to elevate the resident's legs on a pillow. He verified the boots currently being used on the resident's lower feet were not multi-podus boots. He said he was not aware the WMD had indicated the right calf wound matched the contour of the boot. He then decided to remove the boot to the right foot and use only a pillow for the right leg to elevate the heels. As a result, the resident's right calf lay on the pillow; it was not being off loaded. Certified nurse aide (CNA) #17 was interviewed on 3/14/16 at 3:00 p.m. She said the resident should be encouraged and assisted to reposition every two hours. She would report to the nurse if the resident refused. The RD was interviewed on 3/14/16 at 3:07 p.m. She said the staff should not have charted the resident had eaten 75 - 100 % when a full meal was not provided. She said she was not aware the resident was not being offered a full meal as he chooses his own meals. She provided and explained a form titled Guidelines for Percentage of Meal Intake (see above). She said she would start in-servicing the staff immediately on how to chart meal intake. She verified the resident did not consistently receive fortified foods based on what he ordered. She said the resident did receive supplements, but she had not looked at the intake of them lately. She was not aware the resident had a stage four wound on his right calf. CNA #10 was interviewed on 3/15/16 at 7:30 a.m. She said staff had reported that the resident would refuse to reposition but she was usually able to get him to. She said she would report to the nurse when he did refuse to reposition. Licensed practical nurse (LPN) #2 was interviewed on 3/15/16 at 7:40 a.m. She said the resident would refuse to reposition at times but the CNAs were supposed to report this to her. She said she was usually able to get the resident to reposition. The director of nursing (DON) was interviewed on 3/15/16 at 8:15 a.m. She said the resident's care plan should have included the stage four wound and individualized interventions to promote healing and to prevent further breakdown. She said she was not aware the resident did not have multi-podus boots. She said she expected staff to reposition the resident at least every two hours and to off-load the pressure areas as ordered. 4. Resident #100 Resident #100, age 86, was admitted on [DATE]. According to the 3/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 1/15/16 MDS assessment, the resident was severely cognitively impaired with a BIMS score of three. She required extensive assistance of two persons with bed mobility, transfers, toilet use, personal hygiene, and she was non-ambulatory. The resident was incontinent of bowel and bladder. a. Resident Observations On 3/9/16 at 11:20 a.m., the resident was continuously observed in the dining room sitting in a geri chair. She was taken to the foyer area after the noon meal where she stayed until 2:31 p.m. when two CNAs assisted her to bed. On 3/10/16 at 11:30 a.m., the resident was sitting in a geri chair at the dining room table. Through continuous observation, she remained in the geri chair without repositioning or toileting assistance until 4:11 p.m. when she was taken to the dining room and placed at the dining room table for dinner. On 3/14/16 at 7:00 a.m., continuous observations of the resident revealed she was in the dining room in the geri chair, then wheeled to the foyer area after breakfast. After breakfast, she was taken to an activity in the dining room at 9:06 a.m. where she stayed until lunch was served. At 12:21 p.m. she was assisted to bed. b. Record Review The skin care plan, initiated 1/28/16 and revised on 3/9/16, revealed the resident had the potential for impaired skin integrity related to immobility, weakness, and deconditioning. The goal read she would be free from injury. The potential for pressure ulcer development was not addressed in the goal or interventions. The pain care plan, initiated on 1/8/16 and revised on 2/5/16, indicated the resident was to be repositioned for comfort. Review of the comprehensive care plan revealed an ADL care plan had not been developed and the resident's repositioning needs were not addressed. CNA Kardex (communication tool): The CNA kardex, updated and provided by the DON on 3/15/16 at 8:02 a.m., failed to indicate the resident's need for repositioning assistance. c. Staff and Family Interviews The resident's responsible party was interviewed on 3/14/16 at 11:30 a.m. She said she found the resident in the geri chair every time she came to visit. CNA #10 was interviewed on 3/15/16 at 7:30 a.m. She said the resident should be assisted to reposition at least every two hours. LPN #2 was interviewed on 3/15/16 at 7:40 a.m. She said the resident should be repositioned at least every two hours. She said nursing staff was responsible for updating the CNA kardexes and it should include repositioning needs. The DON was interviewed on 3/15/16 at 8:15 a.m. she said the resident should be repositioned at least every two hours. She said she expected the repositioning needs of the resident to be on the care plan to direct staff appropriately.