Every finding on record at Rock Creek Rehabilitation and Healthcare Center

Based on observations, record review, and interviews the facility failed to ensure two (#25 and #35) of eight out of 24 sample residents were kept free from abuse.Specifically, the facility failed to: -Protect Resident #25 from verbal abuse from Resident #3 on 12/15/25 and 12/21/25, which caused psychosocial distress for Resident #25; and,-Protect Resident #35 from verbal abuse from Resident #3 on 12/23/25 and 12/31/25, which caused Resident #35 to become tearful after both incidents. Resident #3, who was admitted to the facility on [DATE] and readmitted on [DATE], was known to have verbally aggressive behaviors toward others and had been involved in verbal altercations with other residents.On 12/15/25 Resident #3 verbally abused Resident #25 in the dining room by yelling foul language, making threatening comments and moving aggressively toward Resident #25. The facility placed both residents on 15-minute checks and educated staff regarding de-escalation techniques. However, six days later, on 12/21/25, Resident #3 again approached Resident #25 in the dining room, calling him names and threatening to kick his (expletive word).Record review and interviews during the survey revealed Resident #25 became fearful, nervous and emotionally distressed following the repeated verbal abuse incidents from Resident #3.Due to the facility's failure to protect Resident #25 from verbal abuse from Resident #3, Resident #25 sustained psychosocial distress, which included sleep disturbances, fear of Resident #3, avoidance of the dining room and decreased social and activity participation.Additionally, following the second incident with Resident #25, the facility implemented an intervention for staff to escort Resident #3 to and from the dining room. However, on 12/23/25 and again on 12/31/25, Resident #3 was verbally abusive toward Resident #35 in the dining room when he passed by her, causing Resident #35 to become tearful after each incident. Observations during the survey revealed Resident #3 was not consistently escorted to and from the dining room (see observations below). Findings include: I. Facility policy and procedure The Abuse Prevention Program policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 5/18/26 at 12:08 p.m. It read in pertinent part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. II. Incidents of verbal abuse between Resident #25 and Resident #3 on 12/15/25 and 12/21/25 A. Facility investigation on 12/15/25 The facility's abuse investigation, dated 12/15/25, documented that at approximately 5:40 p.m. on 12/15/25 Resident #25 and Resident #3 were in the dining room eating dinner when a verbal altercation occurred. Resident #3 was walking out of the dining room and Resident #25 looked at Resident #3, which triggered Resident #3 and Resident #3 began yelling foul language at Resident #25. The situation escalated and both residents started yelling at each other. During the altercation, both residents held silverware in a threatening manner. There was no physical contact between the residents during the altercation. The facility staff separated both residents prior to notifying law enforcement. They provided Resident #25 with emotional support. Resident #25 was interviewed and said he would avoid Resident #3. Resident #3 was interviewed and said he did not remember the verbal altercation. The investigation revealed facility staff did not observe changes in Resident #25's behavior following the incident and he remained at baseline. The investigation revealed that five other residents were interviewed and they did not report any ongoing safety concerns. The interventions implemented after the incident for both residents included continued 15-minute checks, adjusting Resident #3's medications and educating staff regarding de-escalation techniques. The investigation documented that the facility substantiated that the allegation of resident-to-resident verbal abuse occurred. B. Facility investigation on 12/21/25 The facility's abuse investigation, dated 12/22/25, revealed that on 12/21/25 at 5:35 p.m. a verbal altercation occurred in the dining room between Resident #25 and #3. Resident #3 walked into the dining room to eat dinner and said to Resident #25 he was a fat (expletive word) and that he was going to kick his (expletive word). Resident #25 yelled back at Resident #3 using foul language. An unknown registered nurse (RN) entered the dining room, separated the residents, ensured the safety of the residents and contacted law enforcement. At that time, both residents denied feeling fearful. The investigation revealed both residents were already on 15-minute checks prior to the altercation. Due to the occurrence, Resident #3 was escorted to and from meals. The following morning, Resident #25 said he could not ignore it anymore because Resident #3 kept coming for him and would not leave him alone. Resident #25 said he would slit Resident #3's throat if he came for him again. Staff educated Resident #25 that the statement was inappropriate and he said he understood. The facility staff provided emotional support to Resident #25. The investigation revealed that Resident #3 was interviewed and said Resident #25 started the altercation and he was not going to let him talk to him that way. The interventions put into place after the incident included continued 15-minute checks, keeping the residents separated, escorting Resident #3 to and from meals and educating staff regarding de-escalation techniques specific to Resident #3. -However, Resident #3 was already on 15-minute checks and educating staff on de-escalation techniques had already been documented as an intervention following the 12/15/25 verbal abuse incident with Resident #25 (see above). Cross-reference F610 for failure to correct an alleged violation. The investigation documented that the facility substantiated that the allegation of resident-to-resident verbal abuse occurred. C. Resident #25 - victim and assailant 1. Resident status Resident #25, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included schizophrenia, depressive episodes and unsteadiness on feet. The 1/1/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial assistance with bathing, dressing and needed supervision assistance with eating and personal hygiene. The MDS assessment revealed the resident did not display physical or verbal behaviors directed towards others during the assessment look-back period. 2. Resident interview Resident #25 was interviewed on 5/20/26 at 9:53 a.m. Resident #25 said he remembered the incidents with Resident #3 in the dining room that occurred in December 2025. Resident #25 said he had been sitting down enjoying his dinner meal when Resident #3 became upset. Resident #25 said residents could not look at Resident #3 because it triggered him. Resident #25 said Resident #3 yelled at him and started moving toward him. Resident #25 said he became scared because Resident #3 was a big guy and was acting erratically. Resident #25 said staff stopped Resident #3 before he reached him. Resident #25 said Resident #3 yelled foul language at him and said (expletive word) you. Resident #25 said he felt nervous and had an eerie feeling when Resident #3 became erratic. Resident #25 said he continued to feel worried, upset and uncomfortable around Resident #3 following the incidents. Resident #25 said the incidents affected his sleep because he thought Resident #3 would come to his room and hurt him. Resident #25 said he continued to think about the incidents, although not as much as before. Resident #25 said he currently felt safe in the facility. Resident #25 said the incidents affected his meals because it was hard for him to go to the dining room due to fear Resident #3 would blow up again. Resident #25 said the incidents also affected his participation in activities because he remained scared of Resident #3 even though Resident #3 did not attend activities. Resident #25 said staff did not talk with him about his concerns or how he felt after the incidents. Resident #25 said he spoke with his counselor, but the facility ignored the incidents and brushed them under the table. Resident #25 said staff did not take residents' concerns about Resident #3 seriously. Resident #25 said Resident #3 bullied other residents and residents were scared of him. Resident #25 said staff should do more to prevent future incidents with Resident #3. 3. Record review The behavior care plan, initiated 6/2/25 and revised 4/27/26, documented Resident #25 had behaviors related to wandering into other residents' rooms, mocking other residents and engaging in verbal altercations with another resident. The care plan revealed the resident believed another resident was out to get him and said if the other resident came at him again, he would stab him with a fork. The care plan revealed the resident brought up race in an inappropriate manner and discussed rape in the dining room, which upset other residents. The care plan revealed these behaviors were related to the resident's delusions and hallucinations. Pertinent interventions included non-pharmacological interventions, such as approaching the resident in a calm manner, redirecting the resident when exhibiting behaviors and re-approaching the resident after de-escalation. Additional interventions included educating the resident regarding appropriate conversations with others, educating the resident it was not appropriate to target others and monitoring behavior episodes to determine the underlying cause, including the location, time of day, persons involved and situations. The 12/16/25 nursing progress note revealed Resident #25 was involved in a verbal altercation with Resident #3. Resident #3 yelled foul language toward Resident #25 which upset Resident #25. Staff redirected and separated both residents. The 12/21/25 nursing progress note revealed Resident #25 was involved in a verbal altercation with Resident #3 in the dining room. Resident #3 yelled foul language toward Resident #25 and both residents began yelling at each other. Staff intervened and separated both residents. D. Resident #3 - assailant and victim 1. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 CPO, diagnoses included dementia with behavioral disturbance and depressive disorder. The 3/10/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. He required partial assistance with bathing, dressing, and personal hygiene, and required supervision assistance with eating and toileting. The MDS assessment revealed the resident displayed verbal behaviors directed towards others during the assessment look-back period. 2. Record review The dementia and behavioral care plan, initiated 5/17/22 and revised 2/3/26, revealed Resident #3 had verbally aggressive behaviors toward others and used threatening gestures. Pertinent interventions included approaching the resident in a calm manner, redirecting the resident when exhibiting behaviors and re-approaching after de-escalation, monitoring and documenting episodes of inappropriate behaviors, and providing non-pharmacological behavior interventions such as calm approach, positive reassurance, one-on-one interactions and a quiet environment. -The care plan failed to identify the interventions for 15-minute checks and to have staff escort the resident to and from the dining room for meals. The 12/16/25 nursing progress note revealed Resident #3 was involved in a verbal altercation with Resident #25. Resident #3 yelled foul language toward Resident #25 which upset Resident #25. Staff redirected and separated both residents. The 12/21/25 nursing progress note revealed Resident #3 was involved in a verbal altercation with Resident #25 in the dining room. Resident #3 yelled foul language toward Resident #25 and both residents began yelling at each other. Staff intervened and separated both residents. E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/19/26 at 2:57 p.m. LPN #1 said she would separate residents involved in resident-to-resident verbal altercation, notify the management team, complete a witness statement, and implement interventions to prevent further occurrences. LPN #1 said interventions for residents with known abusive behaviors included redirecting the resident, providing education, notifying the physician for possible medication changes and involving the social services director (SSD) to speak with the resident. LPN #1 said Resident #3 was supposed to be escorted in and out of the dining room and was not supposed to sit near Resident #25 following the incidents December 2025. LPN #1 said Resident #3 had behavioral monitoring in place prior to the incidents in December 2025, which was tracked on the medication administration record (MAR). LPN #1 said staff were expected to provide education, explain situations to the resident, maintain a consistent routine and ensure the residents sat in different areas of the dining room. LPN #1 said after the first incident between Resident #3 and Resident #25 on 12/15/25, the facility implemented 15-minute monitoring checks for Resident #3 for an extended period of time. LPN #1 said staff also remained with Resident #3 during meal times to help prevent additional incidents. The NHA was interviewed on 5/19/26 at 5:40 p.m. The NHA said the facility was responsible for doing the best they could to protect residents from abuse. The NHA said staff received education regarding how to respond to residents with known abusive behaviors. The NHA said that after the first incident between Resident #3 and Resident #25 on 12/15/25, the facility had several conversations with Resident #3 regarding having appropriate conversations with other residents. The NHA said Resident #3 would sometimes talk about being a fighter as part of his personality. The NHA said the facility contacted Resident #3's nephew and asked him to take the resident out for rides as an intervention to help calm the resident. The NHA said the facility offered both residents the option to sit in the private dining area with other residents they got along with so they would not feel isolated from others. The NHA said both residents declined those interventions. The NHA said Resident #25 was doing fine after the incidents and continued to follow with behavioral health services to discuss concerns and behaviors. The NHA said the SSD and the activity director (AD) completed follow-up visits with Resident #25 to ensure his well-being. RN #2 was interviewed on 5/20/26 at 10:30 a.m. RN #2 said resident-to-resident verbal abuse should be reported immediately to all appropriate parties, including the physician, the family and the NHA. RN #2 said staff would ensure resident safety by separating the residents involved and initiating 15-minute checks, one-on-one supervision, distraction techniques and using a calm approach. RN #2 said Resident #3 did not respond well when staff talked to the resident like the resident was being blamed. RN #2 said staff should speak to Resident #3 in a calm and softer tone of voice and avoid an accusatory approach. RN #2 said Resident #3 did not do well with male residents. RN #2 said Resident #3 became agitated when people stared at him. RN #2 said interventions for Resident #3, prior to the incidents in December 2025, included encouraging him to verbalize concerns, using a calm approach and reaching out to behavioral health services. RN #2 said the facility reached out to behavioral health services, but Resident #3 refused to speak with behavioral health staff. RN #2 said she remembered speaking with Resident #25 in January 2026 regarding Resident #3's verbal altercations. RN #2 said Resident #25 told her he was not afraid of Resident #3. RN #2 said she could not find documentation of that conversation in the resident's electronic medical record (EMR). The SSD and the NHA were interviewed together on 5/20/26 at 11:15 a.m. The SSD said if she witnessed abuse, she would report it to the NHA and would document interviews with residents. The SSD said she obtained statements from the victim and the assailant. The SSD said she did not interview staff members. The SSD said the care team determined interventions to prevent reoccurrence of incidents. The NHA said she and the director of nursing (DON) interviewed staff members. The SSD said the crisis team was contacted if deemed necessary. The SSD said residents with behaviors were followed closely by social services. The SSD said resident behaviors were monitored through alert charting. The SSD said Resident #3's wife passed away several years ago in December and that triggered him. The SSD said Resident #25 had diagnoses including schizophrenia. The SSD said Resident #25 was not necessarily afraid of Resident #3, but was afraid of what his own actions might be. The SSD said Resident #25 was encouraged not to engage in conversations with Resident #3 and was moved to a different hallway. The NHA said Resident #25 felt targeted and had a history of delusions involving people attacking him while he lived in the community. The SSD said Resident #25 visited his outside counselor once weekly, saw a peer counselor at the facility weekly and talked with a psychiatrist monthly. The SSD said they did not complete a psychosocial assessment with Resident #25 following the verbal abuse incidents. The SSD said post-traumatic stress disorder (PTSD) assessments were completed at admission and during quarterly and annual assessments. The NHA said the facility relied on peer counseling notes and facility observations to implement interventions. The SSD said interventions implemented following the verbal abuse incidents included moving Resident #25 to a different hallway. The SSD said Resident #3 was offered a private dining room. The SSD said Resident #25 was also offered a private dining room. The SSD said they had many conversations with Resident #25 to comfort him and reassured him that he was safe. The SSD said staff reassured Resident #25 that no one could hurt him. The SSD said Resident #25 was observed looking through the window and required reassurance regarding his safety. The NHA said staff encouraged Resident #25 to listen to music and provided him with headphones. The SSD said Resident #25 avoided going to the dining room for meals for approximately three days and ate meals in his room following the 12/21/25 incident. The SSD said there was no documentation indicating whether Resident #25 later returned to eating in the dining room consistently. The SSD said Resident #25 had the choice whether to go to the dining room and the interventions, including 15-minute checks, medication management for Resident #3 and staff interventions were not effective in preventing another verbal altercation between the residents (on 12/21/25). The NHA said Resident #25 had an increase in his Patient Health Questionnaire (PHQ-9 - a tool utilized to determine a resident's level of depression) score following the incidents in December 2025. The NHA said Resident #25 had previously been upset regarding delays related to his surgery and dietary restrictions. The NHA said those concerns may also have contributed to the increase in the resident's PHQ-9 score. LPN #2 was interviewed on 5/20/26 at 1:01 p.m. LPN #2 said that following the incidents between Resident #25 and Resident #3 in December 2025, Resident #25 met with his behavioral health counselor. LPN #2 said Resident #25 told the behavioral health counselor that he was afraid of Resident #3 during that visit. LPN #2 said that after Resident #25 returned from behavioral health appointments, nursing staff reviewed the behavioral health assessment notes. LPN #2 said she remembered asking Resident #25 whether he was afraid of Resident #3 after reviewing the behavioral health note. LPN #2 said Resident #25 told her he was no longer afraid of Resident #3. LPN #2 said Resident #25 had not reported sleep issues to staff or concerns that Resident #3 would try to enter his room. LPN #2 said Resident #25 continued attending meals in the dining room as usual and did not attend meals less frequently following the incidents. The AD was interviewed on 5/20/26 at 2:58 p.m. The AD said she had worked at the facility for two years. The AD said she participated in interdisciplinary team (IDT) meetings that occurred once weekly. The AD said Resident #25 attended group activities and socialized with staff and residents when he felt well. The AD said her notes dated 3/11/26 indicated Resident #25 was not participating in activities as often due to surgery, but still attended activities a few times per week. The AD said Resident #25 enjoyed outings, socializing and music and staff encouraged him to attend more group activities. The AD said within the last few months, she noticed that Resident #25 had become less active and was not coming out of his room as often. The AD said Resident #25 previously came to speak with her one-on-one consistently, but had not done so recently because he had been hospitalized for surgery and had undergone two knee surgeries. The AD said Resident #25 mentioned that Resident #3 had bothered him in December 2025. The AD said Resident #25 told her he did not want to attend bingo because he was afraid of Resident #3. The AD said she reassured Resident #25 that Resident #3 did not attend bingo. The AD said Resident #25 sometimes attended bingo activities and sometimes declined to attend following the incidents with Resident #3 in December 2025. The AD said she attempted to encourage Resident #25 to attend activities when he reported being tired and sometimes Resident #25 would make excuses not to attend. The AD said she informed the IDT that Resident #25 was not participating in activities and was not as active as he had previously been. The AD said Resident #25 previously attended chapel services regularly, but now only attended approximately half of the time and required encouragement to participate. The AD said Resident #25 attended chapel services approximately three to four times per month. III. Incidents of verbal abuse towards Resident #35 by Resident #3 on 12/23/25 and 12/31/25 A. Facility investigation on 12/23/25 Review of the 12/23/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/23/25 in the dining room when Resident #3 passed Resident #35 and called the resident an inappropriate name. An unknown staff member witness said they saw Resident #35 talking to dietary staff and the resident crying when Resident #3 called Resident #35 a big (expletive) baby and said All you do is cry. When interviewed by the facility, Resident #35 began to cry and said Resident #3 was calling her names. She was escorted out of the dining room away from Resident #3. When the facility spoke to Resident #3, he became disruptive, disrespectful and was cursing at staff. He stated he was aware he made nasty comments and stated to staff that he did not feel it was wrong and he did not regret it. He stated he could do whatever he wanted. Staff stayed with Resident #3 until he agreed to leave the dining room. Five residents were interviewed and denied having had issues with Resident #3 being verbally aggressive towards them. Staff interviews were not conducted. Both residents were placed on frequent 15-minute checks. The residents' responsible parties, the police, and the physicians were notified. The facility substantiated the verbal abuse. -However, Resident #3 was already on 15-minute checks following the verbal abuse incident with Resident #25 on 12/21/25 (see above). -Additionally, after the 12/21/25 incident with Resident #25, Resident #3 was supposed to be escorted to and from the dining room as an intervention to prevent further verbal abuse incidents (see above). Cross-reference F610 for failure to correct an alleged violation. B. Facility investigation on 12/31/25 Review of the 12/31/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/31/25 in the dining room when Resident #3 began mocking and making fun of Resident #35. The investigation did not reveal what was said between Resident #3 and Resident #35. When interviewed by facility staff Resident #35 again began to cry and said Resident #3 was making fun of her. She was escorted out of the dining room. When staff spoke to Resident #3 he began yelling at the nurse and refused to leave the dining room. Five residents were interviewed and denied having had verbal altercations with Resident #3 or that they were fearful of him. The investigation did not include staff interviews. Both residents were placed on frequent 15-minute checks. The residents' responsible parties, the police, and the physicians were notified. The facility substantiated the verbal abuse. C. Resident #3 (assailant) 1. Resident observation On 5/17/26 at 5:00 p.m. Resident #3 was observed entering the dining room unescorted by a staff member. -However, following the verbal abuse incidents in December 2025, interventions included Resident #3 was to be escorted in and out of the dining room and was to sit in an area that would not trigger negative behaviors (see investigations above). 2. Resident interview Resident #3 was interviewed on 5/19/26 at 4:00 p.m. Resident #3 he did not recall having any negative interactions with Resident #35 on 12/23/25 and 12/31/25. 3. Record review -Review of Resident #3's dementia and behavioral care plan, initiated 5/17/22 and revised 2/3/26, did not include the interventions implemented to prevent further verbal abuse incidents (see investigations above). D. Resident #35 (victim) 1. Resident status Resident #35, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 CPO, diagnoses included morbid obesity due to excess calories, unspecified intellectual disabilities, depression and seizures. The 4/7/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The MDS assessment indicated the resident did not have behaviors that impacted others. The MDS assessment indicated the resident felt down, depressed, or hopeless, and had little interest or pleasure in doing things for two to six days during the assessment look-back period. 2. Resident interview Resident #35 was interviewed on 5/17/26 at 3:00 p.m. Resident #35 said Resident #3 would call her names that made her cry several times. She said she was not afraid of him but she stayed away from him, especially in the dining room. She said where she now sat in the dining room, her back was toward him so she did not have to look at him. She said he was not a nice man and yelled quite a bit. 3. Record review Review of the communication care plan, initiated 10/3/14 and revised 5/16/24, revealed Resident #35 had limited verbal ability but used smiling, hugging, and holding hands with staff as a form of communication and validation. Interventions included for staff to be aware that this was her form of communication, but due to low cognitive function she would also swing from happiness to sadness as a way of communication and getting her needs met. Review of the vulnerability care plan, initiated 3/13/24 and revised 10/23/25, revealed Resident #35 was at risk of being easily influenced by other residents to the detriment of her own care and wellbeing. Interventions included that the resident needed to be monitored when visiting with residents in their rooms or at daily activities. The resident was vulnerable and should be protected from others who used her to express their own wants or needs. Review of the behavior/trauma care plan, initiated 1/11/16 and revised 4/22/25, revealed Resident #35 had a history of sexual abuse from childhood. She would at times exhibit verbal aggression, self isolation, crying and sadness. Interventions included allowing the resident time to vent and express herself and cry, offering reassurance and attempting to find out what triggered the episode and having the resident removed from the present situation and taken to a private quiet area. Review of the at-risk for abuse care plan, initiated 8/7/25 and revised on 9/30/25, revealed Resident #35 was at risk for abuse related to a diagnosis of intellectual disabilities. The resident could become upset if other residents made derogatory remarks at her. Interventions included assessing the resident regularly and as needed for signs of abuse, investigating any concern or change in functional or mental status as those could be a sign of abuse and observing for and reporting any changes in mental status caused by situational stressors. -The care plan failed to identify the episodes of verbal aggression by Resident #3 towards Resident #35 on 12/23/25 and 12/31/25 (see facility investigations above) and the interventions implemented to prevent further verbal abuse incidents. A review of Resident #35's EMR, from 12/23/25 to 12/31/25, revealed the following; Review of the December 2025 behavior monitoring documentation revealed Resident #35 had three episodes of crying and sadness on 12/23/25, the date of the first verbal abuse incident with Resident #3. The 12/23/25 nurse progress note revealed Resident #35 was sitting in the dining room when Resident #3 entered the dining room and passed Resident #35's table. Resident #3 told Resident #35You are a big (expletive) baby, all you do is cry. When staff intervened, Resident #3 became disrespectful and unable to be redirected and began cursing at staff and refusing to leave the dining room. Staff stayed with him until he agreed to leave the dining room. Resident #3 said he knew he made the comment because he could do what he wanted. After the incident, Resident #35 was tearful. -Review of Resident #35's EMR failed to reveal documentation of the incident with Resident #3 on 12/31/25. -Further review of Resident #35's EMR revealed no social services involvement or documentation entries related to the two verbal abuse incidents in December 2025 between Resident #3 and Resident #35. E. Staff interviews LPN #1 was interviewed on 5/19/26 at 10:15 a.m. LPN #1 said she witnessed the verbal incidents between Resident #35 and Resident #3 (on 12/23/25 and 12/31/25. She said Resident #3 had mocked Resident #35 and when Resident #35 told Resident #3 to be quiet, he called her a fat (expletive). She said Resident #35 came to nursing staff and complained about Resident #3 because he was calling her names. She said there had not been any recent incidents between the two residents that she knew of and Resident #35 was not afraid of Resident #3 and would try to stand up for herself. LPN #1 said since the incidents in December 2025, Resident #35 had moved to a different table in the dining room to not be in close proximity to Resident #3. She said any form of abuse, whether it was resident-to-resident or staff-to-resident,

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition;-Maintain the ice machine in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated and discarded within appropriate use-by timeframes.Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. (6-501.12) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (4-601.11) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11) The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment. (6-501.114)B. ObservationsThe initial tour of the kitchen was completed on 5/17/26 at 1:05 p.m., and revealed the following: -There was food debris and grease buildup on the floor beneath the steam table and oven area in the kitchen.-There were three unopened butter cups underneath the steam table.-There was dark brown residue, unidentified debris buildup and dirt accumulation underneath the steam table and near the wheels.C. Staff interviewsThe food service supervisor (FSS) was interviewed on 5/19/26 at 1:33 p.m. The FSS said the dietary completed sweeping daily at the end of each meal. The FSS said dietary aides took turns cleaning and staff knew their responsibilities based on the kitchen duty schedule. The FSS said the staff performed spot sweeping and the staff swept and mopped the kitchen after each meal and each night and he reminded them again during the survey. The FSS said failure to keep the kitchen clean could lead to rodents, mold and odors.Dietary aide #2 was interviewed on 5/19/26 at 1:40 p.m. Dietary aide #2 said staff swept the kitchen floors after every meal, including the dish room and the dining room. Dietary aide #2 said the cook was responsible for cleaning the kitchen floors.Dietary aide #3 was interviewed on 5/19/26 at 3:30 p.m. Dietary aide #3 said she followed daily cleaning tasks, swept the floors after each meal and mopped daily.II. Failure to maintain the ice machine in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. (4-601.11) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11)B. ObservationsThe initial tour of the kitchen was completed on 5/17/26 at 1:05 p.m., and revealed the following: The ice machine had dirt and debris buildup that was gray in color on the upper interior portion of the ice dispensing opening and on the interior surface near the top of the door. A second observation of the kitchen was conducted on 5/19/26 at 1:20 p.m. Observations identified the same concerns as identified on 5/17/26 during the initial tour. C. Staff interviewsThe dietary manager (DM) was interviewed on 5/19/26 at 1:26 p.m. The DM said the dietary staff cleaned the ice machine weekly and reported any dirt, debris or maintenance concerns to the FSS. The DM said the dietary staff notified maintenance if there were major issues. The DM said dirt and debris could come into contact with the ice, contaminate the ice and cause residents to become sick.The FSS was interviewed on 5/19/26 at 1:33 p.m. The FSS said dietary aides were responsible for cleaning the ice machine every Wednesday. The FSS said he did not think they cleaned the ice machine the previous Wednesday because gray lint buildup was present on the interior surfaces of the ice machine. The FSS said the ice machine was sanitized monthly by either him or maintenance staff. The FSS said if maintenance staff could not sanitize the ice machine, he cleaned it. The FSS said he sanitized the ice machine on 4/28/26.Dietary aide #2 was interviewed on 5/19/26 at 1:40 p.m. Dietary aide#2 said she would notify the FSS if she observed dirt or debris buildup in the ice machine. Dietary aide #2 said she would ask the FSS before cleaning the ice machine and would clean it if the FSS approved. Dietary aide #2 said cleaning kitchen equipment was everyone's responsibility.Dietary aide #3 was interviewed on 5/19/26 at 3:30 p.m. Dietary aide #3 said the ice machine was cleaned weekly and the staff member assigned to duty cleaned it. Dietary aide #3 said she received initial food safety and kitchen sanitation training during orientation and attended monthly in-service training.The maintenance director was interviewed on 5/20/26 at 5:07 p.m. The maintenance director said maintenance staff sanitized the ice machine monthly and dietary staff cleaned it daily. The maintenance director said the filter contained a gauge that alerted staff when replacement was needed. The maintenance director said the ice machine was last sanitized in April 2026 and was due for cleaning again this month. The maintenance director said staff cleaned the entire ice machine during the monthly sanitizing process.III. Failure to properly label, cover and discard expired food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location and, where it is not exposed to splash, dust, or other contamination. (3-305.11) Working containers holding food or food ingredients that are removed from their original packages for use in the food establishment shall be identified with the common name of the food. (3-302.12) Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. (3-501.17) A food specified in 3-501.17(A) or (B) shall be discarded if it exceeds the temperature and time combination specified, is in a container or package that does not bear a date or day, or is inappropriately marked with a date or day that exceeds the temperature and time combination. (3-501.18)B. ObservationsThe initial tour of the kitchen was completed on 5/17/26 at 1:05 p.m., and revealed the following: -A tray containing 10 individual portions of banana pudding cake was observed in the walk-in refrigerator without a protective covering, wrapping or label.There were multiple food items and drinks observed in the dining room refrigerator beyond their use-by or discard dates. -One opened container of thickened cranberry cocktail was dated 4/30/26;-One container of cranberry juice had a use-by date of 5/15/26;-One container of orange juice had a use-by date of 5/16/26;-Six containers of cantaloupe were dated 5/11/26;-Ten cups of Jello were dated 5/5/26;-Seven cups of butterscotch pudding were dated 5/14/26; and,-One pitcher containing a beverage was observed stored in the refrigerator without a label or date.-The thickened cranberry, cantaloupe, Jello and butterscotch pudding dates did not indicate if it was a preparation date or use by date.During dinner observation on 5/17/26, the following was observed:At 5:20 p.m. dietary aide #1 filled Resident #30's pitcher with cranberry beverage and returned the pitcher to the refrigerator after filling it.At 5:23 p.m. dietary aide #1 removed Resident #30's pitcher from the refrigerator and placed it on the meal tray cart for delivery to Resident #30.C. Staff interviewsThe FSS was interviewed on 5/19/26 at 1:23 p.m. The FSS said dietary aide #1 prepared the banana pudding the night before. The FSS said dietary aide #1 forgot to wrap and date the dessert because he started working at the facility approximately two weeks ago. The FSS said dietary aide #2 provided training to dietary aide #1. The FSS said he expected staff to label and date food items to prevent contamination.The FSS and the DM were interviewed together on 5/19/26 at 1:33 p.m. The FSS said he used a reference sheet to determine how long food items remained safe and how they should be labeled. The FSS said cantaloupe cups were good for five days and the containers of cantaloupe should have been discarded on 5/16/26. The FSS said he did not know how long Jello remained good once prepared and said he would look it up online. The FSS said pudding was good for two days and the containers of pudding in the refrigerator should have been discarded on 5/16/26. The FSS said the 4/30/26 date on the thickened cranberry cocktail container was the received date. The FSS said the thickened cranberry cocktail was good for seven days and should have been discarded after seven days. The FSS said he discarded the expired food items. The DM said unlabeled food items could not be properly monitored for safety because staff would not know how old the items were. The DM services said unwrapped food items could become contaminated and cause illness.Dietary aide #2 was interviewed on 5/19/26 at 1:40 p.m. Dietary aide #2 said she labeled prepared drinks with the date the item was prepared. Dietary aide #2 said, for example, orange juice remained good for three days and she labeled the container with a three-day discard date.Dietary aide #3 was interviewed on 5/19/26 at 3:30 p.m. Dietary aide #3 said she covered and dated food and dessert items immediately after preparation. Dietary aide #3 said the staff member who prepared the item was responsible for labeling and dating it. Dietary aide #3 said if she observed an unlabeled item, she would ask staff when the item was prepared and if she could not determine when it was made, she would discard the item for safety reasons. Dietary aide #3 said she checked dates on food items to identify expired FSS and discarded items after three days. Dietary aide #3 said she would discard Jello if it became watery, even if the item had not expired.

Based on record review and interviews, the facility failed to take appropriate corrective actions, as a result of abuse investigations, for four of nine abuse allegations. Specifically, the facility failed to take appropriate corrective action following the investigations of four verbal abuse incidents by Resident #3 towards Resident #25 on 12/15/25 and 12/21/25, and Resident #35 on 12/23/25 and 12/31/25, to ensure that verbal abuse did not recur.Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised 9/22, was provided by the nursing home administrator (NHA) on 5/21/26 at 11:32 a.m. It read in pertinent part, All allegations are thoroughly investigated. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The individual conducting the investigation reviews the documentation as evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, observes the alleged victim, interviews the person reporting the incident, interviews any witnesses, interview the resident, interview staff members, interview the staff member who had contact with the resident, reviews all events leading up to the alleged incident and documents the investigation completely and thoroughly. II. Incidents of verbal abuse between Resident #25 and Resident #3 on 12/15/25 and 12/21/25 The investigations of the resident-to-resident altercations between Resident #25 and Resident #3 on 12/15/25 and 12/21/25 were provided by the NHA on 5/18/26 at approximately 2:00 p.m. A. 12/15/25 facility investigation The facility's abuse investigation, dated 12/15/25, documented that at approximately 5:40 p.m. Resident #25 and #3 were in the dining room eating dinner when a verbal altercation occurred. Resident #3 was walking out of the dining room and Resident #25 looked at Resident #3, which triggered Resident #3 and Resident #3 began yelling foul language at Resident #25. The situation escalated and both residents started yelling at each other. During the altercation, both residents held silverware in a threatening manner. There was no physical contact between the residents during the altercation. The facility staff separated both residents prior to notifying law enforcement. They provided Resident #25 with emotional support. Resident #25 was interviewed and said he would avoid Resident #3. Resident #3 was interviewed and said he did not remember the verbal altercation. The investigation revealed facility staff did not observe changes in Resident #25's behavior following the incident and he remained at baseline. The investigation revealed that five other residents were interviewed and they did not report any ongoing safety concerns.The investigation documented that the facility substantiated that the allegation of resident-to-resident verbal abuse occurred.The interventions implemented after the incident for both residents included continued 15-minute checks, adjusting Resident #3's medications and educating staff regarding de-escalation techniques.-However, the investigation failed to reveal documentation of the education provided to staff regarding de-escalation techniques as a corrective action in order to prevent a recurrence of verbal abuse.Cross-reference F600 for failure to keep residents free from abuse.B. 12/21/25 facility investigationThe facility's abuse investigation, dated 12/22/25, revealed that on 12/21/25 at 5:35 p.m. a verbal altercation occurred in the dining room between Resident #25 and #3. Resident #3 walked into the dining room to eat dinner and said to Resident #25 he was a fat (expletive word) and that he was going to kick his (expletive word). Resident #25 yelled back at Resident #3 using foul language. An unknown registered nurse (RN) entered the dining room, separated the residents, ensured the safety of the residents and contacted law enforcement. At that time, both residents denied feeling fearful.The investigation revealed both residents were already on 15-minute checks prior to the altercation. Due to the occurrence, Resident #3 was escorted to and from meals.The following morning, Resident #25 said he could not ignore it anymore because Resident #3 kept coming for him and would not leave him alone. Resident #25 said he would slit Resident #3's throat if he came for him again. Staff educated Resident #25 that the statement was inappropriate and he said he understood. The facility staff provided emotional support to Resident #25.The investigation revealed that Resident #3 was interviewed and said Resident #25 started the altercation and he was not going to let him talk to him that way.The investigation documented that the facility substantiated that the allegation of resident-to-resident verbal abuse occurred.The interventions put into place after the incident included continued 15-minute checks, keeping the residents separated, escorting Resident #3 to and from meals and educating staff regarding de-escalation techniques specific to Resident #3.-However, Resident #3 was already on 15-minute checks and educating staff on de-escalation techniques had already been documented as an intervention following the 12/15/25 verbal abuse incident with Resident #25 (see above). The 12/15/25 interventions proved to be ineffective in preventing the second verbal abuse incident between Resident #3 and Resident #25 on 12/21/25.-Additionally, the facility failed to determine an appropriate corrective action following the 12/15/25 and 12/21/25 verbal abuse incidents with Resident #25 in order to prevent a third occurrence of verbal abuse involving Resident #3 (towards Resident #35 -see below). III. Incidents of verbal abuse between Resident #35 and Resident #3 on 12/23/25 and 12/31/25The investigations of the resident-to-resident altercations between Resident #35 and Resident #3 on 12/23/25 and 12/31/25 were provided by the NHA on 5/18/26 at approximately 2:00 p.m. A. 12/23/25 facility investigationThe facility's investigation report revealed that on 12/23/25 at 12:18 p.m. Resident #3 was escorted with a nurse to the back of the dining room to a single table. Resident #3 sat for a short time by himself with the kitchen staff. Resident #3 called Resident #35 a big (expletive) baby and told Resident #35 All you do is cry. Resident #3 mumbled to himself and staff asked Resident #3 to stop. When Resident #3 did not stop, the charge nurse and the director of nursing (DON) went to the dining room to talk to the resident. Resident #3 was not respectful or redirectable. Resident #3 continued to be disruptive in the dining room, swearing at staff and making comments and refusing to leave the dining room, eat in his room, keep his comments to himself and be kind to others. Staff stayed with Resident #3 until he agreed to leave and go to his room. Resident #35 cried when Resident #3 cursed at her. The facility substantiated the verbal abuse.Cross-reference F600 for failure to keep residents free from abuse.Interventions implemented after the incident included placing both residents on 15-minute checks, moving them to a separate hallway, and offering behavioral health services. Additional interventions included assisting Resident #3 to and from the dining room, additional observation while in the dining room, offering meals in the private dining room, offering extra behavioral health visits during the holidays as his behaviors may be due to depression due to missing his spouse, medications adjusted and recent gradual dose reduction (GDR). -However, 15-minute checks, assisting Resident #3 to and from the dining room and medication adjustments were implemented following the 12/21/25 incident with Resident #25 (see above), before the 12/23/25 incident with Resident #35. -There was no documentation behavioral health services were offered to Resident #3 until 1/28/26, more than 30 days after the incident. -The investigation failed to reveal documentation of education provided to staff regarding the interventions implemented, including additional observations while in the dining room and offering meals in the private dining room. -A review of Resident #3's electronic medical record (EMR) revealed there was no documentation to offer meals to the resident in the private dining room.-The facility failed to determine an appropriate corrective action following the 12/15/25 and 12/21/25 verbal abuse incidents with Resident #25, and the 12/23/25 verbal abuse incident with Resident #35, which resulted in a fourth verbal abuse incident involving Resident #3 (again towards Resident #35) seven days later (see below).B. 12/31/25 facility investigationReview of the 12/31/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/31/25 in the dining room when Resident #3 began mocking and making fun of Resident #35. The investigation did not reveal what was said between Resident #3 and Resident #35. When interviewed by facility staff Resident #35 again began to cry and said Resident #3 was making fun of her. She was escorted out of the dining room. When staff spoke to Resident #3 he began yelling at the nurse and refused to leave the dining room.Five residents were interviewed and denied having had verbal altercations with Resident #3 or that they were fearful of him. The investigation did not include staff interviews. Both residents were placed on frequent 15-minute checks. The residents' responsible parties, the police, and the physicians were notified.The facility substantiated the verbal abuse.-The facility identified and substantiated four incidents of verbal abuse involving Resident #3. However, the facility failed to identify appropriate corrective actions to prevent further incidents of verbal abuse involving Resident #3. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 5/19/26 at 2:17 p.m. LPN #2 said she reported abuse to the NHA. LPN #2 said she should report abuse as soon as the residents were determined to be safe. She said once abuse was reported, an investigation was started by the nurse and then the NHA and the DON completed the investigation. LPN #2 said she started the investigation by writing what happened, notifying the physician, the police and the resident's representative. LPN #2 said she knew what interventions were put into place by verbal communication. LPN #2 said there was a communication section in the facility's electronic records system for nurses to read at the start of their shift. LPN #2 said she was not sure if certified nurse aides (CNA) or other departments had access to the communication section. LPN #2 said she was not educated on resident-specific interventions to prevent resident-to-resident altercations, but there was online training that reviewed different interventions for the staff to try.The interim DON was interviewed on 5/20/26 at 3:15pm. The interim DON said abuse should be reported to the NHA as soon as possible. She said once abuse was reported, the nurse should start an incident file including what was done to keep the residents safe, notifying the physician, the resident's representative, the NHA and the DON. The interim DON said there should be a statement obtained from the assailant, the victim and any witnesses. The interim DON said there should be documentation of the statements obtained. The interim DON said the interventions to keep the resident safe should be documented in the resident's care plan and Kardex (an abbreviated care plan). The interim DON said the interviews should have a date, time and signature of who completed the interviews and the statements. She said the statements should be by the assailant, the victim or the witness if possible and it should have the date and the time when the statements were obtained. The interim DON said when she was a DON, she would complete the staff interviews and she interviewed whoever was working including nursing, dietary staff and housekeeping. She said she used the incident report to document initial interventions to keep all pertinent information in one place. The interim DON said there should be an interdisciplinary team (IDT) discussion the following day after the alleged abuse to determine what additional interventions should be in place. She said she did that so the residents' care plans were updated at the same time. The interim DON said she started working at the facility on 5/17/26, and she was not very familiar with the incidents involving Resident #3. The interim DON said she reviewed the incident reports for the verbal abuse incidents between Resident #25 and Resident #3 on 12/15/25 and 12/21/25 and the verbal abuse incidents between Resident #35 and Resident #3 on 12/23/25 and 12/31/25. She said the investigation was not thorough because it was not clear on what interviews were completed, what statements were obtained or how staff were educated on the interventions to keep the residents safe and to prevent a recurrence. The NHA was interviewed on 5/19/26 at 5:05 p.m. The NHA said staff reported abuse to the NHA. The NHA said staff should report abuse as soon as the residents were determined to be safe. She said once abuse was reported, an investigation was started by the nurse and then the NHA and the DON completed the investigation. The NHA said the nurse was responsible for documenting what happened, notifying the physician, the police and the resident's representative. The NHA said staff knew what interventions were put into place by verbal communication and. The NHA said nurses had access to a communication section in their electronic records system for nurses to read at the start of their shift. The NHA said CNAs or other departments did not have access to the communication section and a paper communication binder was used for educating CNAs. The NHA said investigating an alleged abuse was divided between the DON and herself. She said sometimes the SSD helped as well. The NHA said the questions asked were standard depending on the type of abuse. The NHA said if the type of abuse was verbal, there was a standard set of questions to ask staff and residents. The NHA said staff were interviewed who worked in the unit, were familiar with the resident and included housekeeping and dietary staff. The NHA said the unit nurses determined the initial intervention.The NHA said she did not know if she had access to the electronic records for the communication page to show how nurses were educated. The NHA said she would look to see how CNAs were educated. The NHA was interviewed a second time on 5/20/26 at 9:30 a.m. The NHA said she was unable to locate the electronic records for the communication page to show how the nurses were educated. The NHA said the interventions should be care planned and said the care plans for Resident #25, Resident #35 and Resident #3 could use improvement to reflect the interventions that were put into place after the resident-to-resident altercations in December 2025.

Based on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for one (#7) of five residents out of 24 sample residents. Specifically, the facility failed to ensure Resident #7, who was receiving an antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements that can be caused by taking antipsychotic medications) 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 5/26/26 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 Psychotropic Medication Use policy and procedure, revised February 2025, was provided by the nursing home administrator (NHA) on ) on 5/21/26 at 11:32 a.m. It read in pertinent part, Residents are monitored for adverse consequences associated with psychotropic medications, including neurologic effects such as agitation, distress, extrapyramidal symptoms, neuroleptic malignant syndrome, Parkinsonism, tardive dyskinesia and cerebrovascular events. If a psychotropic medication is identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication should be discontinued. If the medication is not discontinued, the rationale for this decision must be documented.III. Resident #7A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders, diagnosis included type 1 diabetes mellitus with ketoacidosis, mild cognitive impairment, bipolar disorder and hypertension. The 3/11/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He used a cane. He required supervision with eating, oral hygiene, toileting, showering and personal hygiene.The MDS assessment revealed the resident had received antipsychotic medications during the seven-day assessment look-back period. B. Resident interview and observation Resident #7 was interviewed on 5/18/26 at 10:08 a.m. During the interview, Resident #7 was smacking his lips. At the end of the interview, Resident #7 said he had noticed his lips smacking over the last couple of months. He said it was annoying when his lips smacked and the facility did not tell him what they were doing to help him not smack his lips. C. Record review The psychotropic and anticonvulsant care plan, initiated on 5/21/25 and revised on 6/28/25, revealed Resident #7 took psychotropic medications related to his bipolar disorder. Interventions included monitoring for behaviors, administering medications per physician orders, and observing closely for side effects of quetiapine, including extrapyramidal symptoms (EPS), such as tremors, restlessness, and involuntary movement of mouth or tongue and periodically complete the AIMS (abnormal involuntary movement scale) evaluation for EPS. Review of Resident #7's 4/28/26 AIMS assessment revealed a score of 13, indicating the resident's movements were clear, prominent and widespread. The assessment revealed the resident had moderate facial and oral movements around his lips and perioral area, such as smacking, around his jaw, such as biting and mouth opening and around his tongue. His lower legs were moderate movements, such as foot tapping. The assessment revealed the resident was aware of mild distress. -However, according to record review and interviews, Resident #7 had been exhibiting signs of tardive dyskinesia prior to 4/28/26 (see interviews and record review below). Review of Resident #7's May 2026 CPO revealed the following physician's orders related to antipsychotic medications: Depakote extended release (ER) 500 milligrams (mg) tablet. Take two tablets by mouth at bedtime for bipolar disorder, ordered 12/6/25. Seroquel 25 mg tablet. Take three tablets by mouth at bedtime, ordered 12/9/25. Haldol 1mg. Take one tablet by mouth every eight hours as needed for agitation related to bipolar mania for 14 days, ordered 5/18/26. Monitor the following agitation behaviors. Takes Haldol as needed every shift for 14 days, ordered 5/18/26. Monitor the following behaviors related to Seroquel: agitation, increase in complaints, elopement, delusions, aggressions, ordered 9/25/25. Observe closely for side effects of Seroquel, including dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, EPS symptoms, every shift, ordered 4/28/25. Review of Resident #7's electronic medical record (EMR) revealed nursing staff observed the resident's lip smacking on 3/11/26, 3/17/26, 3/26/26, 4/15/26, 5/4/26 and 5/18/26. -However, according to staff interviews and record review, Resident #7's physician was not notified that the resident was exhibiting symptoms of tardive dyskinesia. -A review of Resident #7's EMR did not reveal any documentation to indicate the resident had not been seen by a psychiatrist or behavioral health consultant related to his diagnosis or his tardive dyskinesia since 3/18/26.IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 5/19/26 at 2:17 p.m. LPN #2 said she was familiar with Resident #7. She said when Resident #7 had a side effect from a psychotropic medication, she documented the side effect on the resident's treatment administration record (TAR) and as a progress note. LPN #2 said she had not seen Resident #7 smack his lips for a while. LPN #2 said she thought he smacked his lips when he took Haldol. LPN #2 said an AIMS assessment was completed quarterly when a resident was on antipsychotic medications. She said the assessment determined if the resident exhibited signs of tardive dyskinesia. LPN #2 said the assessment was done on the computer and if the resident's score indicated signs of tardive dyskinesis, she was not sure what the next step was. LPN #2 said she thought the director of nursing (DON) reviewed all AIMS assessments. LPN #2 said if she noticed tardive dyskinesia, she would document it on the TAR and notify the physician. She said the physician was notified because the physician could look at the resident's medications to see if there were any recommendations to change the resident's medications. The interim DON was interviewed on 5/20/26 at 3:15pm. She said an AIMS assessment was completed at admission, when a resident started a new antipsychotic medication and every six months. The interim DON said an AIMS assessment was completed to monitor for adverse reactions from antipsychotic medications. She said if a resident scored high, the physician was notified to see if a medication should be slowly titrated before starting a new medication. The interim DON said if a nurse noticed a side effect from a psychotropic medication, the nurse should notify the physician so the physician could assess and determine the best recommendation to reduce the adverse effects. She said nurses should document side effects observed and the physician notification as a progress note. The interim DON said she started working at the facility on 5/17/26 and she was not familiar with Resident #7. She said she would look into the resident's medical record. V. Facility follow upOn 5/20/26 at 4:28 p.m. the interim DON completed a new AIMS assessment for Resident #7 which revealed the resident scored a two. The interim DON said despite the resident's AIMS score being lower, the nurses who observed the lip smacking on 3/11/26, 3/17/26, 3/26/26, 4/15/26, 5/4/26 and 5/18/26 should have notified the physician about the symptoms.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation for one (#22) of one resident reviewed for a safe and orderly discharge out of 24 sample residents.Specifically, the facility failed to ensure a written bed hold notice was provided to Resident #22 and/or her representative at the time of the resident's transfer to the hospital.Findings include:I. Facility policy and procedureThe Bed-Holds and Returns policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 11:57 a.m. It read in pertinent part, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to the residents/representatives explain in detail: the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (forMedicaid residents); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy. The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. Residents who seek to return to the facility within the bed-hold period defined in the state plan are allowed to return to their previous room, if available. Residents who seek to return to the facility after the state bed-hold period has expired are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident still requires the services provided by the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.II. Resident #22A. Resident statusResident #22, age greater than 65, was admitted on [DATE], readmitted on [DATE] and transferred to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), mild intermittent asthma, acute upper respiratory infection and respiratory syncytial virus (RSV).The [DATE] minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had no impairment of her upper or lower extremities and used a wheelchair for mobility. She required partial to moderate staff assistance with activities of daily living (ADL). B. Record reviewReview of Resident #22's [DATE] CPO revealed a physician's order, dated [DATE], to transfer the resident to the emergency room for evaluation and treatment of low oxygen saturation, cough, and shortness of breath. The [DATE] at 11:00 a.m. nursing progress note revealed Resident #22 was experiencing increased cough, shortness of breath and she was in respiratory distress. She was transported to the hospital for evaluation.Review of Resident #22's electronic medical record (EMR) profile revealed she was her own responsible party. -Review of Resident #22's EMR revealed no documentation to indicate Resident #22 and/or her representative were provided with a written bed hold notice at the time of the resident's transfer to the hospital on [DATE].III. Staff interviewsRegistered nurse (RN) #1 was interviewed on [DATE] at 2:00 p.m. RN #1 said Resident #22 was transferred to the hospital around lunch time on [DATE] for respiratory distress. She said the resident had several instances in the past where she had to be transported to the hospital for respiratory issues and the most recent occurrence was in [DATE]. She said she did not know that a bed hold form had to be completed with the resident prior to her being transported to the hospital. She said she had not been made aware of the form and did not know what was required on the form.The social services director (SSD) was interviewed on [DATE] 8:25 a.m. The SSD said it was her responsibility to complete a bed hold form when a resident required a transfer to the hospital. She said the resident or their responsible party were to sign the form that indicated they understood the bed hold policy. She said Resident #22 was her own responsible party and she did not complete a bed hold form with the resident when she was transferred to the hospital (on [DATE]). She said at the time of Resident #22's transfer, getting the bed hold form signed did not cross her mind, and she did not notify the facility's frequent visitor of the transfer. She said she had not implemented a good process for completion of the bed hold form for the long-term care residents when they required a hospital transfer. The frequent visitor was interviewed on [DATE] at 8:47 a.m. The frequent visitor said he was not notified that Resident #22 had been transferred to the hospital on [DATE]. He said he received notices when a resident was discharged home, but he was not normally notified of hospital transfers unless there was a reportable incident associated with the transfer.

Based on observations, record review and interviews, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for one (#10) of two residents out of 24 sample residents.Specifically, the facility failed to maintain, clean, sanitize and properly store Resident #10's nebulizer machine (breathing treatment device) and mask.Findings include:I. Resident #10A. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (chronic lung disease), dependence on supplemental oxygen, and hypertension (high blood pressure).The 3/3/26 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. The MDS assessment documented the resident used continuous oxygen therapy.B. Resident interview and observationsResident #10 was interviewed on 5/17/26 at 3:20 p.m. Resident #10 said he did not know how often staff cleaned his nebulizer mask.Resident #10's nebulizer machine was observed on the television stand in the resident's room. The nebulizer mask had visible brown residue buildup inside it.On 5/18/26 at 2:35 p.m. Resident #10's nebulizer machine remained on the television stand in the resident's room. The nebulizer mask had not been cleaned. The mask had visible brown residue buildup inside it and was greasy. Resident #10 said he did not know whether staff cleaned the nebulizer equipment after use.C. Record reviewA review of Resident #10's May 2026 CPO revealed the following physician's order:-Albuterol Sulfate nebulization solution (2.5 milligrams/3 milliliters) 0.083%, one vial inhale orally via nebulizer, ordered on 5/6/26.-However, there were no physician's orders for cleaning, sanitizing or storing the nebulizer equipment.Resident #10's respiratory care plan, initiated 2/27/26, revealed Resident #10 had an impaired respiratory status. Pertinent interventions included administering medications as ordered, monitoring for signs and symptoms of respiratory distress and reporting to the physician, monitoring lung sounds for wheezing or crackles as needed, providing oxygen as needed when the resident exhibited signs and symptoms of difficulty breathing and treatments as ordered by the physician.-The care plan failed to include interventions related to cleaning, sanitizing or storing the resident's nebulizer equipment.II. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 5/19/26 at 9:43 a.m. CNA #3 said nurses were responsible for sanitizing nebulizer equipment. CNA #3 said nebulizer equipment was usually taken apart and cleaned between treatments. CNA #3 said brown residue buildup inside a nebulizer mask was not sanitary. CNA #3 said if a resident's respiratory equipment was dirty, she would notify the nurse and obtain new equipment.Licensed practical nurse (LPN) #1 was interviewed on 5/19/26 at 9:54 a.m. LPN #1 said nurses were responsible for rinsing nebulizer equipment. LPN #1 said nebulizer equipment should be rinsed, taken apart and allowed to air dry after breathing treatments. LPN #1 said the night shift changed the nebulizer tubing and masks and provided a new one. LPN #1 said visible residue buildup inside nebulizer masks created a risk that the resident could inhale contaminants. LPN #1 said Resident #10's nebulizer treatment was ordered every six hours as needed and the resident's last breathing treatment was administered on 5/5/26, during the night shift. LPN #1 said staff should discard nebulizer equipment with visible buildup or contamination and obtain new equipment.The nursing home administrator (NHA) was interviewed on 5/19/26 at 10:55 a.m. The NHA said oxygen tubing changes were documented, however nebulizer equipment cleaning was not documented. The NHA said nursing staff received infection control training through SNF (skilled nursing facility) Clinic as needed. The NHA said respiratory equipment with visible buildup should be replaced because it was important for infection control. The NHA said nurses were responsible for ensuring nebulizer equipment remained clean and sanitary after each use. The NHA said Resident #10's nebulizer mask should have been discarded and replaced with a new mask.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#37) of one resident reviewed for pain out of 24 sample residents. Specifically, the facility failed to:-Ensure a thorough pain assessment was completed that identified Resident #37's history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident's quality of life; -Identify Resident #37's goals for pain management and the resident's acceptable level of pain; -Ensure Resident #37's location of pain was consistently identified when administering pain medication to the resident; and, -Ensure Resident #37's pain medication was administered as ordered and needed, based on the resident's observed status.Findings include: I. Facility policy and procedure The Pain Assessment and Management policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 5/21/26 at 11:32 a.m. It read in pertinent part, Pain assessments should include the resident's pain history and prior treatments, including pharmacological and non-pharmacological interventions. The assessment should identify whether the pain is acute, subacute, or chronic and evaluate pain characteristics such as location, intensity, description, pattern, frequency, timing, and duration. The assessment should also address the impact of pain on function, mobility, mood, sleep, and quality of life; factors that worsen or relieve pain; associated symptoms; history of opioid use disorder; current medical conditions and medications; and the resident's pain management goals and satisfaction with pain control. When establishing a pain medication regimen, considerations include starting with lower doses and increasing as needed, administering medications routinely rather than only as needed, combining long-acting medications with as needed medications for breakthrough pain, using non-narcotic and narcotic analgesics together when appropriate, and implementing measures to reduce or prevent adverse medication effects, such as bowel regimens for opioid-related constipation.II. Resident #37A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included Parkinson's disease, Lewy body neurocognitive disorder with dementia and behavioral disturbances (progressive brain disease caused by abnormal protein clumps that damage nerve cells), anxiety, depression, type 2 diabetes, hypertension, lumbar radiculopathy and sciatica (irritation or compression of nerve root in the lower spine and radiating leg pain caused by sciatic nerve), tremors, encephalopathy (damage to the brain) and history of lumbar compression fracture (vertebrae in lower spin collapses often due to osteoporosis or trauma). The 4/23/26 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. The assessment revealed Resident #37 had a pain medication regimen and did not receive as needed pain medications. The assessment revealed non-medication interventions were provided to the resident. The assessment section indicating the pain frequency, the effect on daily activities, the numeric scale and pain intensity was not completed. B. Observations During a continuous observation on 5/17/26, beginning at 4:30 p.m. and ending at 5:52 p.m., the following observations were made in the facility's dining room: Resident #37 was observed at a dining room table close to the door to the outside. An unknown staff member was assisting the resident with eating her meal. Prior to the meal, the resident was observed biting her clothing protector. No staff members tried to redirect the resident from biting her clothing protector. During a continuous observation on 5/18/26, beginning at 2:22 p.m. and ending at 4:25 p.m., the following observations were made: From 2:22 p.m. to 4:10 p.m. Resident #37 was observed lying on her back in her bed. Resident #37 was observed leaning to the left side of the bed and her back was not touching the bed. At 3:21 p.m. certified nurse aide (CNA) #2 told licensed practical nurse (LPN) #2 that Resident #37 kept trying to crawl out of her bed and was trying to hold on to the left side of her mattress. From 4:10 p.m. to 4:25 p.m. Resident #37 was observed in her high back wheelchair in her room and the hallway in front of her room. At 4:12 p.m. Resident #37 was observed with her left leg shaking more than her right leg. At 4:23 p.m. Resident #37 was observed with her right hand trying to hold the toes on her right foot. On 5/19/26 at approximately 1:52 p.m. Resident #37 was observed in her high back wheelchair in the hallway in front of her room. Resident #37 was observed biting her shirt and lifting her shirt up. CNA #2 told Resident #37 to stop biting her shirt and assisted the resident to lower her shirt. At 1:53 p.m. Resident #37 stopped biting her shirt and started to bite her lips. CNA #2 went to LPN #2 and said Resident #37 was in pain. LPN #2 came over and assessed the resident for pain. CNA #2 said she thought Resident #37 bit her clothes because she was in pain. As CNA #2 talked about Resident #37's pain, Resident #37 leaned forward to touch and hold the toes on her left foot. CNA #2 said Resident #37's legs did not always shake but today, 5/19/26, the resident's legs were more shaky than usual. C. Record Review Resident #37's pain care plan, initiated 7/28/25 and revised 7/29/25, revealed the resident had the potential for acute and chronic pain. She was able to verbalize she was in pain. If she had pain, she became restless and was at risk for falls. She had a stable fracture to her thoracic (T) 3 and T4 vertebrae (middle back), chronic fracture to her T8 vertebra and a stable fracture to her lumbar (L)1 vertebra (lower back) and a sternal fracture (thoracic and lumbar spine fractures on the mid-back and lower back region, breastbone). Interventions included administering medications per physician orders and monitoring for effectiveness, determining what the resident's optimal pain level was for day-to-day function, ensuring the resident's fentanyl patch (pain patch) was in a location, monitoring for any changes in usual activities, monitoring for changes in behavior that may be indicators of pain, monitoring for changes in mood that may be indicators of pain, monitoring for changes in sleep patterns, monitoring for verbal and non-verbal signs and symptoms relating to pain, offering non-pharmacological interventions to relieve pain and providing rest periods to prompt relief, sleep and relaxation. -The care plan did not identify the resident's goal for pain management and acceptable level of pain. Resident #37's behavior care plan, initiated 4/20/23 and revised 8/12/25, revealed the resident had a behavior of constantly chewing on the neck of her shirt and blanket. Staff tried to redirect her, but she continued. Interventions included assessing and anticipating the resident's needs, assessing the resident's understanding of the situation, encouraging as much participation and interaction by the resident during care activities and offering non-pharmacological behavior interventions prior to behavior medication administration. The 1/8/26 pain assessment revealed Resident #37 did not have evidence of pain and the FACES pain rating scale (a self-reported assessment tool that uses a series of six facial expressions to measure pain intensity) was used. Pharmacological interventions included administering acetaminophen, Sombra and fentanyl patches for pain management. -However, the prior non-pharmacological interventions section of the assessment was not completed, the pharmacological interventions section failed to indicate the use of tramadol, the resident's acceptable pain level was not completed and the pain location section failed to indicate the resident's leg pain. The 4/8/26 pain assessment revealed Resident #37 expressed complaints of back and leg pain at times. The resident was unable to communicate the intensity of her pain. The pharmacological interventions section indicated the resident used gabapentin and Tylenol. The pain location section, including the pain duration and frequency of pain revealed the resident had pain in her upper to mid-vertebrae. Relieving factors included position changes and medication. -However, the prior non-pharmacological interventions section was not completed, the pharmacological interventions section failed to indicate the use of a fentanyl patch, tramadol, Sombra gel and acetaminophen suppositories, the pain location section failed to indicate the resident's leg pain and the resident's acceptable pain level section was not completed. Review of Resident #37's May 2026 CPO revealed the following physician's orders: Fentanyl transdermal patch 72-hour 12 microgram (mcg)/hour. Apply one patch transdermally in the morning every three days for pain, ordered 10/3/25. Gabapentin 300 milligrams (mg) capsule. Take one capsule by mouth in the afternoon for painful legs, ordered 11/15/24. Acetaminophen 500 mg tablet. Take two tablets three times a day by mouth for back pain, ordered 7/1/24 and discontinued 2/24/26. Acetaminophen 500 mg tablet. Take two tablets by mouth every eight hours as needed for pain control, ordered 2/24/26.Acetaminophen 650 mg suppository. Insert one suppository rectally every six hours as needed for pain. Do not exceed three grams of acetaminophen in 24 hours, ordered 7/28/25. Sombra natural pain relieving external gel 3%. Apply to legs, feet and back topically every four hours as needed for pain, ordered 11/15/24. Tramadol 50 mg tablet. Take one tablet by mouth every six hours as needed for pain, ordered 1/27/26. Check fentanyl patch placement every shift, ordered 8/26/25. Document pain every shift two times a day for pain, ordered 2/6/23. Observe closely for side effects of opioid medication use, ordered 10/3/25. Offer non-pharmacological pain interventions prior to pain medication administration. Non-pharmacological interventions include repositioning, pillows for support, cold compress and massage. Complete two times a day, ordered 3/19/24. -Review of Resident #37's EMR did not reveal documentation indicating if the non-pharmacological interventions were effective or what interventions were attempted for the resident's pain relief. Review of Resident #37's medication administration records (MAR) from February 2026 to May 2026 revealed the following as needed pain medications were administered: Tramadol 50 mg was administered on 2/1/26, 2/2/26, 2/3/26, 2/8/26, twice on 2/13/26, 2/20/26, 2/24/26, 2/26/26, 2/27/26, 3/4/26, twice on 3/15/26, 3/24/26, 4/13/26, 5/4/26, 5/11/26 and 5/12/26. Acetaminophen 500 mg was administered on 4/17/26, 5/4/26 and 5/10/26 -However, there was no documentation indicating where the resident's pain was located when the tramadol 50 mg or the acetaminophen 500 mg was administered to the resident.III. Staff interviews CNA #2 was interviewed on 5/19/26 at 1:52 p.m. CNA #2 said she was familiar with Resident #37. She said she thought Resident #37 bit her clothes because she was in pain. She said it was hard for Resident #37 to communicate when she was in pain. CNA #2 said she was not sure why Resident #37 bent forward to touch and hold her feet when she was in her wheelchair. CNA #2 said she must be uncomfortable but she was not sure why. CNA #2 said she told the nurse when she noticed the resident was uncomfortable. LPN #2 was interviewed on 5/20/26 at 5:52 p.m. LPN #2 said a pain assessment included if the resident had pain, using the Pain Assessment in Advanced Dementia (PAINAD )scale (an observational tool used by healthcare providers and caregivers to assess pain in patients with advanced dementia or severe cognitive impairments who cannot verbally communicate), what the resident's acceptable level of pain was, where the pain was located, what non-pharmacological and pharmacological interventions were used and if the interventions were effective. LPN #2 said when pain medications were used as needed, the nurse found out where the resident had pain, tried non-pharmacological interventions first and if that was not effective, to offer an as needed pain medication to the resident. LPN #2 said she followed up with the resident to see if the pain medication was effective. LPN #2 said the location of pain should be documented on the MAR and she entered a progress note with a thorough explanation of the pain. LPN #2 said when a resident had multiple as needed pain medications and the resident was unable to communicate, she used the PAINAD and used her judgment on what medication to use based on the resident's level of pain. LPN #2 said she was familiar with Resident #37. She said she thought the resident's pain management goal was to have a pain level of zero and be comfortable. LPN #2 said Resident #37 had pain in her lower legs in the afternoon and had pain in her back. She said she knew Resident #37 had pain because she would vocalize pain, and demonstrate facial grimacing, biting, and grabbing or reaching out for things. LPN #2 said she used the stronger as needed pain medications, such as tramadol when Resident #37's pain level was high based on the PAINAD scale. The interim director of nursing (DON) was interviewed on 5/20/26 at 3:15pm. The interim DON said a pain assessment covered the resident's pain history, the pain impact on the resident's life, the resident's pain management goal, the acceptable level of pain and the location of pain. The interim DON said the assessment helped determine what interventions to use to help manage the resident's pain. She said the assessment helped to determine if the pain medications were controlled in order to ensure a better quality of life for the resident. The interim DON said when administering as needed pain medications, a nurse should assess the resident to see if there was facial grimacing, guarding and what the nurse was actually seeing from the resident. The interim DON said the location of pain should be documented in a progress note and on the MAR. She said the nurse should attempt a non-pharmacological pain intervention and if the non-pharmacological intervention was ineffective, the pain medication could be attempted. The interim DON said it was hard for nurses to determine which pain medication to administer when residents had multiple pain medications ordered as needed. The interim DON said the physician should direct which pain medication should be administered. The interim DON said she started working in the facility on 5/17/26 and she was not familiar with Resident #37. She said she would review the residents' pain medication regimen and pain assessment.

Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well being for one (#3) of seven residents out of 24 sample residents. Specifically, the facility failed to identify Resident #3's history of depression to monitor and provide ongoing assessment to determine whether the care approaches met the emotional and psychosocial needs of the resident.Findings include: I. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and depressive disorder.The 3/10/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. He required partial assistance with bathing, dressing, and personal hygiene, and required supervision assistance with eating and toileting.The MDS assessment revealed the resident displayed verbal behaviors directed towards others during the assessment look-back period.The MDS assessment revealed the resident had depression based on the patient health questionnaire-9 (PHQ-9), a standardized, 9-question self-report tool used by healthcare providers to screen, diagnose, and measure the severity of depression.) Resident #3 reported he felt little interest or pleasure in doing things every day (12 to 14 days), felt down, depressed and hopeless every days, had trouble fall asleep or sleeping too much on seven to 11 days, felt tired or having little energy on two to six days, had a poor appetite or overeating on 12 to 14 days and felt bad about himself on two to six days during the assessment look-back period. The assessment revealed the resident took an antipsychotic medication and an antidepressant medication. The assessment revealed a gradual dose reduction was not attempted and was not documented as clinically contraindicated. B. Resident observations and interview On 5/17/26 at 3:00 p.m. Resident #3 was in his room. The room was dark with no lights on and the blinds closed. Certified nurse aide (CNA) #2 went into his room and spoke Spanish to the resident. On 5/17/26 at 5:01 p.m. Resident #3 was in the dining room. Resident #3 sat by himself in the corner of the dining room and did not engage with other residents.On 5/18/26 at 9:55 a.m. Resident #3 was lying in his bed and had his television turned on. The room was dark with no lights on and the blinds closed. Resident #3 said he stayed in his room most of the day and he did not like to participate in any facility activities. He said he liked to stay in his room because the other residents did not have the same interests as him. On 5/18/26 at 2:35 p.m. Resident #3 was in his room. The room was dark with no lights on and the blinds closed. CNA #2 went into his room and asked him if he wanted to attend the resident council meeting. Resident #3 said no. C. Record reviewThe dementia and behavioral care plan, initiated 5/17/22 and revised 2/3/26, revealed Resident #3 had verbally aggressive behaviors towards others and used threatening gestures. Pertinent interventions included approaching the resident in a calm manner, redirecting the resident when exhibiting behaviors and re-approaching after de-escalation, monitoring and documenting episodes of inappropriate behaviors, and providing non-pharmacological behavior interventions such as calm approach, positive reassurance, one-on-one interactions and a quiet environment.The psychotropic medication care plan, initiated 3/7/22 and revised 6/16/25, revealed Resident #3 was medicated daily with a psychotropic medication due to depression and self isolation. Interventions included monitoring for behaviors for Seroquel treatment, including calling out, offering non-pharmacological interventions for noted behaviors, such as calm approach, positive reassurance, one-on-one and quiet environment, encouraging resident to verbalize his feelings, establishing a consistent daily routine, and monitoring for side effects of antipsychotics and antidepressants. Monitoring for target behavior and documenting; monitoring for isolation throughout shift for Lexapro, providing psychiatry consult as needed, providing distraction and diversional activities and responding to concerns and feelingsThe depression care plan, initiated 5/17/22 and revised 10/6/25, revealed Resident #3 was at risk for alteration in psychosocial well-being related to depression and at times would self-isolate in his room. Interventions included allowing the resident to express his feelings, encouraging alternative communication opportunities with visitors, encouraging and providing activities of interest, monitoring for changes in psychosocial changes, notifying the physician of changes in mental status, offering behavioral services and talking with a therapist, PHQ-9 assessment quarterly and as needed. The 5/25/25 psychiatry behavioral health note revealed the facility was to encourage Resident #3 to attend activities by using a slightly more proactive approach, such as going into his room and saying It is time to go to dinner or It is time to attend whatever activity is about to occur rather than asking if he would like to go to dinner or to an activity. The facility was to respect the resident if he declined or refused.-However a review of Resident #3's EMR did not reflect the recommended intervention. The 12/9/25 social services director (SSD) note revealed an assessment was completed for Resident #3 on 12/9/25. Resident #3's advance directives were do not resuscitate with comfort focused treatment and no artificial nutrition. Resident #3 had an acute hospitalization for chronic obstructive pulmonary disease, depression, dementia, psychotic disturbance, mood disturbance, anxiety and other specified depressive episodes. Resident #3 was on Lexapro (an antidepressant medication) 20 milligrams (mg) daily in the morning for depressive episodes and Seroquel (an antipsychotic medication) 25 mg twice a day for verbal aggression. The facility would continue to monitor the resident for changes in mood and behaviors. Resident #3 could make his needs known and did leave his room more frequently and was eating in the dining room. He sat in the lobby and talked with others occasionally. The resident's family was involved with his care and attended care conferences by phone. The SSD continued to monitor the resident's mood status. The SSD would encourage positive behaviors, continue the current plan of care and provide social emotional support as tolerated. Review of Resident #3's PHQ-9 assessments revealed the following:The 9/18/25 PHQ-9 assessment revealed Resident #3 scored a nine out of 27, indicating the resident had mild depression.The 12/10/25 PHQ-9 assessment revealed Resident #3 scored a 14 out of 27, indicating the resident had moderate depression, which had increased since his previous PHQ-9 assessment.The 3/10/26 PHQ 9 assessment revealed the resident scored a 13 out of 27, indicating the resident continued to have moderate depression. -A review of Resident #3's EMR did not reveal any documentation that addressed the resident's PHQ-9 score and what follow up, interventions or services were offered to the resident. Review of Resident #3's May 2026 CPO revealed the following physician's orders: Escitalopram 20 mg (Lexapro, an antidepressant medication). Take one tablet in the morning, ordered 12/24/25. Seroquel 25 mg (an antipsychotic medication). Take one tablet three times a day for verbal aggression, ordered 1/14/26. Behavior monitoring for verbal outbursts throughout shift twice a day for behavior monitoring, ordered 6/14/22. Monitor for behaviors for Seroquel, including negative statements every shift, ordered 6/4/25.Monitor for adverse side effects of antipsychotic medications, ordered 5/10/24. Monitor for side effects of Lexapro, ordered 10/9/25.Monitor for isolation throughout shift for Lexapro every shift for behavior monitoring, ordered 8/29/24. Offer non-pharmacological interventions for noted behaviors. Interventions included calm approach, positive reassurance, one-on-one and quiet environment. Complete twice a day. Document Y for yes interventions attempted prior to medication administration and N for no interventions not attempted prior to medication administration, ordered 7/1/24. Escort in and out of the dining room for meals attending three times a day for behavior, ordered 12/22/25.-However, this intervention was not being implemented consistently by staff, which resulted in four verbal abuse incidents with other residents.Cross-reference F600 for failure to keep residents free from abuse. -A review of Resident #3's medication administration records (MAR) and treatment administration records (TAR), from 12/1/25 to 5/20/26, revealed the resident exhibited behaviors and interventions that were not consistently offered and documented if interventions were effective. II. Staff interviews CNA #2 was interviewed on 5/19/26 at 1:52 p.m. CNA #2 said interventions for residents who had behaviors were documented on shift report. CNA #2 said if she saw a resident had a behavior that required an intervention, she told the nurse and the nurse charted the behavior. She said some residents had an option for her to chart if she saw a behavior and when she could chart the behavior, she documented what behavior she saw, what intervention was used and if the intervention was effective. CNA #2 said she was familiar with Resident #3. She said one effective intervention to de-escalate Resident #3 was to speak Spanish to him. CNA #2 said Resident #3 spoke Spanish and he was in a good mood when they spoke Spanish together. CNA #2 said she tried to make jokes in Spanish to keep his mood positive. CNA #2 said the facility could identify better interventions for Resident #3's behavior. She said he was in a lot of resident-to-resident altercations and he was blamed for most of the altercations. CNA #2 said if the facility staff approached him differently, instead of blaming him for the altercations, but seeking to understand what happened from his standpoint, Resident #3 would be in a different spot. Licensed practical nurse (LPN) #2 was interviewed on 5/19/26 at 2:17 p.m. LPN #2 said interventions for residents who had behaviors were documented in a couple of different ways. She said if nursing needed to monitor post resident-to-resident altercation, there was alert charting where the nurse was responsible for documenting what they saw during their shift. LPN #2 said the alert charting was free form and the nurse could chart whatever they saw. LPN #2 said when a resident was first admitted , she tried to learn the resident's behaviors and what escalated the resident and what de-escalated the resident. LPN #2 said she knew what interventions worked to de-escalate a resident by trying one approach and if it upset the resident, then she did not try that approach again. LPN #2 said if she saw a behavior, she documented it as a progress note and wrote what intervention was used and if the intervention was effective. LPN #2 said she was familiar with Resident #3. LPN #2 said interventions to de-escalate Resident #3 included encouraging him to stay away from residents he did not like, calling his family to come in and talk to him to calm him down and removing him from the situation. LPN #2 said she learned first hand to not approach Resident #3 in a way that suggested he was to blame for resident-to-resident altercations. She said Resident #3 escalated when she and other staff members approached him in a way that suggested he was to blame. The nursing home administrator (NHA) was interviewed on 5/19/26 at 5:05 p.m. The NHA said staff knew what interventions were put in place by verbal communication. The NHA said nurses had access to a communication section in their electronic records system for nurses to read at the start of their shift. The NHA said CNAs or other departments did not have access to the communication section and a paper communication binder was used for educating CNAs. The NHA was interviewed a second time on 5/20/26 at 9:30 a.m. The NHA said she was unable to locate the electronic records for the communication page to show how the nurses were educated on interventions for Resident #3's behaviors. The NHA said the interventions should be care planned and said the care plans for Resident #3 could use improvement to reflect the interventions put into place after the resident-to-resident altercations. The SSD and the NHA were interviewed together on 5/20/26 at 12:07 p.m. The SSD said she and the corporate social services director were responsible for completing PHQ-9 assessments with residents. The SSD said the PHQ-9 assessment measured the resident's level of depression. She said the PHQ-9 assessment was completed at admission, quarterly and as needed. The NHA said anyone who triggered for depression was reviewed by the interdisciplinary team (IDT) in a monthly meeting. The NHA and the SSD said the SSD documented what occurred while the PHQ 9 was completed with the resident as a progress note. The NHA said the IDT reviewed the PHQ 9 to see if there were interventions, review medications and add activities as needed. The SSD said if a resident's PHQ 9 score increased from one quarter to another, she documented the conversation as a progress note and she offered behavioral health services to the resident. The NHA said the facility looked to see why the resident's PHQ-9 assessment score increased. The NHA said maybe the resident's score increased because of a recent death, an anniversary of a death or the resident was sad because of the season. The SSD said she was responsible for coordinating behavioral health services for residents. The SSD said she was responsible for implementing interventions recommended by behavioral health services. The SSD said when residents came back from an outpatient behavioral health services appointment, nursing was responsible for reviewing the consult form. The SSD said she knew what interventions were recommended by behavioral health services through the IDT.The NHA said the director of nursing (DON) reviewed the consult form and collaborated with the IDT to implement any recommendations. The NHA said interventions were documented in the resident's chart in their care plans, verbal report and a paper communication sheet. The SSD and the NHA said they were familiar with Resident #3. The SSD said Resident #3 had depression. During the interview, the SSD looked in Resident #3's chart to see who completed Resident #3's PHQ 9 and she was unable to find documentation of a progress note indicating why Resident #3's PHQ 9 increased from the September PHQ 9 assessment to the December 2025 PHQ assessment. The NHA said Resident #3's PHQ 9 may have increased because December was the month of the anniversary of the resident's spouse's death.-However, there was no documentation to indicate why Resident #3's PHQ-9 assessment score increased and what additional interventions were offered. The SSD and the NHA said they were not aware behavioral health services recommended for staff to not ask Resident #3 to attend activities but to tell him it was time to go to an activity. The SSD and the NHA said if behavioral health services recommended the intervention, it should be in the resident's care plan and staff should follow the intervention.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards received adequate supervision out of four sample residents.Resident #1, who was dependent on facility staff for wheelchair mobility, sustained a fall from her wheelchair on [DATE], which resulted in a cervical spine fracture.During the facility's investigation of the fall, it was discovered that staff failed to attach the foot pedals to Resident #1's wheelchair. As a result, Resident #1 was unable to rest her feet on the foot pedals while being transported. On [DATE], while Resident #1 was being transported from the dining room to her room, Resident #1 caught her foot/feet on the rug, fell forward out of the wheelchair, and hit her head on the floor as she fell.Due to the facility's failure to ensure staff used wheelchair safety equipment/foot pedals, Resident #1 sustained a fall on [DATE], which resulted in a cervical (C1) spine fracture. Specifically, the facility failed to ensure staff transported residents in their wheelchairs with the foot pedals in place, which resulted in a fall for Resident #1 where she sustained a C1 spine fracture.Findings include:Record review and interviews confirmed the facility corrected the deficient practice before the onsite investigation on [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE].I. Incident on [DATE]Resident #1, who was dependent on facility staff for wheelchair mobility, sustained a fall from her wheelchair on [DATE], which resulted in a cervical spine fracture.During the facility's investigation of the fall, it was discovered that staff failed to attach the foot pedals to Resident #1's wheelchair. As a result, Resident #1 was unable to rest her feet on the foot pedals while being transported. On [DATE], while Resident #1 was being transported from the dining room to her room, Resident #1 caught her foot/feet on the rug, fell forward out of the wheelchair, and hit her head on the floor as she fell.Due to the facility's failure to ensure staff used wheelchair safety equipment/foot pedals, Resident #1 sustained a fall on [DATE], which resulted in a cervical (C1) spine fracture. II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #1The correction action plan implemented by the facility in response to Resident #1's fall on [DATE] was provided by the director of nursing (DON) on [DATE] at 4:10 p.m. The corrective action plan included documentation that all facility nursing staff were educated on [DATE] on the facility's wheelchair safety procedure and the wheelchair policy and procedure. The education included instructions that all residents who required staff assistance for wheelchair mobility must have foot pedals in place. The corrective action plan identified that the facility ensured an adequate supply of foot pedals was available when needed.B. Systemic changesStaff were educated on [DATE] to ensure residents that required staff assistance for wheelchair mobility were required to have foot pedals on their wheelchairs. Staff were educated foot pedals must be used during transportation. C. MonitoringThe interdisciplinary team (IDT) was responsible for reviewing all fall occurrences and occurrences that involved facility equipment, including wheelchairs. The maintenance inspection and repair logbook documentation, dated [DATE], revealed the facility inspected all manual wheelchairs for damaged or missing components such as, hand grips, brakes, casters, wheels, seats and leg rests. The work history monthly report for [DATE] to [DATE] documented the wheelchair inspections that were completed. III. Facility policy and procedureThe Wheelchair policy and procedure, undated, was provided by the DON on [DATE] at 12:14 p.m. It revealed in pertinent part, To safely push a wheelchair, you must communicate with the user and take special precautions for obstacles like ramps and curbs.Check the equipment. Ensure the wheelchair is in good working order. Check that all parts are securely attached. Footrests significantly enhance safety for older adults in wheelchairs by preventing their feet and legs from draping, which could cause them to catch on the ground, get caught under the wheels, or even get pulled out of the wheelchair entirely. Keeping the feet elevated and supported on the footrests ensures that there is sufficient ground clearance, preventing the footplate from hitting obstacles or catching on the ground, which can cause the wheelchair to tip.IV. Facility Investigation of incident on [DATE]On [DATE], the facility investigated Resident #1's fall. The facility investigation revealed that on [DATE] at 9:00 a.m., while a staff member was transporting Resident #1 in a manual wheelchair, Resident #1 caught her foot on the carpeted floor and fell to the floor. Resident #1 struck her head on the floor and staff observed a laceration and a hematoma (bruising and swelling) on her forehead. Resident #1 had a bruise on her left hand. Resident #1 had a blood pressure reading of 190/108 millimeters of mercury (mmHg). The nurse immediately placed a foot shelf on Resident #1's wheelchair, completed neurocognitive assessments, and notified appropriate parties, including the physician. Resident # 1 was transferred to the emergency department for an evaluation.The facility interviewed all staff on duty who were involved in care for the resident on the day of the fall.The staff member who witnessed the occurrence provided a written incident statement that revealed Resident #1 was assisted from the dining room to her room and was often assisted without foot pedals and Resident #1 had previously been able to lift her feet when requested while she pushed her in the wheelchair. The statement revealed Resident #1 sat in her chair as usual, but the resident leaned forward and landed on the floor. Inspection of Resident #1's wheelchair revealed the foot pedals were not attached to her wheelchair and therefore Resident #1 was unable to keep her feet off the floor while being transported by a staff member. The investigation documented the nurse on duty immediately attached foot pedals to Resident #1's wheelchair.The investigation revealed that a registered nurse (RN) completed a post-fall assessment, and Resident #1 was able to move all her extremities, had no facial grimacing, and had a laceration on her forehead with a bruise forming on the backs of her right and left hands. The assessment documented that Resident #1 had no changes in her cognitive status.The investigation revealed Resident #1 was transferred to a hospital for higher-level care for a C1 spine fracture. The family declined surgical care and placed Resident #1 on hospice care and Resident #1 passed away on [DATE].The facility investigation revealed that the facility followed policy, procedure, and manufacturer guidelines for wheelchair use, and the staff member involved had been adequately trained in using the equipment.V. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. Resident #1 did not return to the facility and expired on [DATE] while in hospice care. According to the [DATE] computerized physician orders (CPO), diagnoses included high blood pressure, diabetes mellitus and Alzheimer's disease.The [DATE] minimum data sets (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily living (ADL). Resident #1 did not walk and was dependent on staff for mobility with a manual wheelchair. B. Record reviewResident #1's fall prevention care plan, revised [DATE], revealed Resident #1 was at risk for falls. The pertinent fall prevention interventions included placing a sign for Resident #1 to call for assistance and placing anti-tippers on Resident #1's wheelchair to prevent tipping backwards ([DATE]).A fall occurrence progress note, dated [DATE] at 9:00 a.m., revealed Resident #1 was being pushed in a manual wheelchair to her room when her foot caught on the carpet and she fell out of the wheelchair onto the floor. Resident #1 hit her head and sustained a laceration surrounded by a hematoma to the middle of the upper forehead at her hairline. Resident #1 was unable to follow commands, and the nurse completed passive range of motion for all major joints while Resident #1 was on the floor. Vital signs were normal except for the blood pressure measurement of 190/108 millimeters of mercury (mmHg). Resident #1's statement on what was being attempted when the fall occurred was that her wheelchair did not have a footrest or foot pedals, and her feet were dragging on the floor. The evaluation revealed Resident #1's representative, the physician, the DON, and the nursing home administrator (NHA) were notified regarding the fall. The progress note did not include the time of notification or response from those notified. The record review revealed there were no new CPOs given at the time of the initial fall notification. -Review of Resident #1's vital signs following the fall revealed the resident's blood pressure readings remained high for over four hours after the fall before the facility notified the physician for a physician's order to address the high blood pressure.Cross reference F684 for failing to notify the physician of high blood pressure readings.A nurse progress note, dated [DATE] at 3:00 pm., revealed Resident #1's representative and power of attorney (POA) were informed regarding Resident #1's fall and insisted Resident #1 be transferred to the hospital emergency department for evaluation. The RN documentation revealed the RN did due diligence and educated the family member there were no signs of serious injury or neurological damage after the fall. The POA was also informed Resident #1 had high blood pressure and had a new order for medication to control high blood pressure. The manager on duty returned to the facility to transport Resident #1 to the emergency department. Resident #1 was changed and prepped for transfer to the emergency department. -A review of Resident #1's electronic medical record (EMR) did not reveal a time or assessment status of Resident #1 left for the emergency department.The hospital progress notes, dated [DATE], revealed Resident #1's representative was notified at 3:00 p.m. that Resident #1 had fallen in the morning. The representative went to visit the resident at the facility and found Resident #1 was not at her baseline and said Resident #1 was holding her left arm and was uncomfortable. Resident #1 arrived at the hospital by facility transport van. Resident #1's blood pressure at 5:50 p.m. at the emergency department was 208/115.The hospital Xray report for left arm pain, dated [DATE], revealed Resident #1 had a mild superior subluxation (joint dislocation) of the elbow and an age undetermined of the radial neck (elbow). The hospital computerized tomography (CT) scan of the cervical spine, dated [DATE], revealed Resident #1 had a type 2 dens/odontoid fracture with displacement of the dens/odontoid and anterior ring by 5 millimeters (mm). Fracture lines were seen through the posterior ring of C1 in two places.Resident #1 was diagnosed on [DATE] at the emergency department with a C1 spine fracture, closed head injury, wedging of the thoracic spine, and left radial head/neck impacted fracture. A rigid cervical collar was placed on Resident #1, and a splint was placed on the left upper extremity. Resident #1's representative was informed of the diagnoses and the decision was made to transfer Resident #1 to a higher level of care for appropriate specialty management with neurosurgery capability. Resident #1 was transferred in fair condition on [DATE] via rotor flight transport.VI. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on [DATE] at 2:30 p.m. CNA #1 said she frequently used wheelchairs and assisted residents with mobility inside the facility. CNA #1 said she received education and training on safe wheelchairs and equipment in her CNA training, and also a few weeks ago. CNA #1 said wheelchair foot pedals were used to lift the resident's feet off the floor and were adjustable to help position the leg and foot placement of each resident. CNA #1 said staff were educated not to remove foot pedals from wheelchairs until the residents were checked off and able to maneuver themselves independently. CNA #1 said that when foot pedals were missing from a wheelchair and were needed, staff would look around the facility, in closets or storage rooms, to locate the required appropriate wheelchair equipment. CNA #1 said she was unsure how to determine if the wheelchair equipment in use was as ordered or evaluated. She said she continued mobility equipment use based on what was in each resident's room, and if the equipment was not appropriate or adequate, she would talk to the floor nurse.RN #1 was interviewed on [DATE] at 2:52 p.m. RN #1 said that after a resident fell in the facility, the facility policy required the RN on duty to complete a post-fall assessment. The RN said the nurse should try not to move the resident until a head-to-toe assessment was completed and the nurse determined it was safe to move the resident. The RN said after the resident was assisted to their bed, the facility policy required close monitoring for three days. The RN said the monitoring intervals started frequently, every 15 minutes, and then went to every 30 minutes, then every four hours, then every eight hours, and then once per shift. The RN said that after the resident assessment was completed, the RN was responsible for notifying the physician and family, and documenting the fall occurrence, notifying the physician, and documenting if the physician gave new orders. The RN said the physician could be informed by voicemail or directly. The RN said a nurse did not always need a physician's order to call 911 and would base the decision to call 911 on nursing judgment and education. The RN said the decision to move a resident after a fall where the resident hit their head would depend on assessment and judgment. The RN said a high blood pressure reading after a fall could be evidence of pain, but the RN should call the physician if the resident's blood pressure was rising after a head injury.The director of rehabilitation (DOR) was interviewed on [DATE] at 3:06 p.m. The DOR said wheelchair assessments were completed by the occupational therapist (OT). The DOR said residents were assessed for mobility status when they were admitted to the facility. The DOR said if the OT determined the resident required a wheelchair for mobility, the facility provided a wheelchair for the resident's use. The DOR said the maintenance department was responsible for inspecting wheelchair equipment for safety and providing wheelchair maintenance. The DOR said Resident #1 did not have a wheelchair assessment that determined whether or not foot pedals were required for Resident #1. The DOR said nursing staff would know from the residents' EMR or care plan what equipment was needed for each resident and how the nursing staff would be aware of changes in equipment required, such as when a resident had a change in status and required different equipment. The DOR said if a wheelchair assessment was not available, nursing staff were able to screen residents and get a general idea of what equipment was required for resident care.The DON and the nursing home administrator in training were interviewed together on [DATE] at 3:15 p.m. The DON said after Resident #1 fell, nursing staff followed policy and completed neurological assessments and notified the physician. The DON said post-fall assessments included a complete body assessment and measuring vital signs. The DON said the purpose of frequent assessments was to closely monitor residents so that nursing staff could identify concerning changes in assessment and implement interventions and notify the physician if necessary. The DON said the neurological assessments were completed after an unwitnessed fall or anytime a resident had a head strike. The DON said the neurological assessments included looking at skin for trauma or new deformities, pain, acting abnormally, and changes in vital signs. The DON said the neurological assessments completed on [DATE] did not reveal a change in Resident #1's normal status, and Resident #1 was monitored appropriately. The DON said Resident #1 had no signs of serious injury, moved all major joints, and did not grimace or hold her head. The DON said that when the family requested Resident #1 to be evaluated at the hospital, the facility manager on duty transported Resident #1 in the facility van because the nurse assessment documented Resident #1 was stable and had no indicators for ambulance transport.The DON said the interdisciplinary team (IDT) reviewed the [DATE] fall and discussed that nursing staff would receive education on the use of foot pedals with wheelchairs. The DON said there had not been additional occurrences or injuries that involved wheelchairs since [DATE].

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for acute changes in condition out of four sample residents.Specifically, the facility failed to timely notify the physician and intervene to treat high blood pressure for Resident #1.Findings include:I. Professional reference The article Hypertensive crisis: What are the symptoms? (2024) was retrieved on [DATE] from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/hypertensive-crisis/faq-20058491?cjdata=MXxOfDB8WXww&cjevent=765460d1cfad11f082c907180a1cb829&cm_mmc=CJ-_-100357191-_-5250933-_-Evergreen+Link+for+Mayo+Clinic+Diet&utm_source=cj&utm_content=100357191&utm_capaign=3-months read in pertinent part; A hypertensive crisis is a sudden, severe increase in blood pressure. The blood pressure reading is 180/120 millimeters of mercury (mmHg) or greater. A hypertensive crisis is a medical emergency. It can lead to a heart attack, stroke, or other life-threatening health problems. See emergency medical help for anyone with these blood pressure numbers. Call 911 or emergency medical services if your blood pressure is 180/120 mmHg or greater and you have chest pain, shortness of breath, or symptoms of stroke. Stroke symptoms include:-numbness or tingling;-loss of feeling in the face, arm, or leg;-trouble walking;-trouble speaking; and,-changes in vision.II. Facility policy and procedureThe Change in a Resident's Condition or Status policy, undated, was received from the director of nursing (DON) on [DATE] at 12:10 p.m. It read in pertinent part, Our facility promptly notifies the resident, the physician, and the resident representative of changes in the resident's medical status. The nurse will notify the physician when there has been a(n): -accident or incident involving the resident;-significant change in the resident's physical condition; and/or,-need to transfer the resident to a hospital. A significant change of condition is a major decline in the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the physician, the nurse will gather relevant information for the physician, including information prompted by the interactive communication form. The nurse will record in the resident's medical record information relative to changes in the resident's medical status.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. Resident #1 did not return to the facility and expired on [DATE] while in hospice care. According to the [DATE] computerized physician orders (CPO), diagnoses included hypertension, diabetes mellitus and Alzheimer's disease.The [DATE] minimum data set (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily living (ADL). Resident #1 did not walk and was dependent on staff for mobility with a manual wheelchair. B. Record reviewResident #1's fall prevention care plan, revised [DATE], revealed Resident #1 was at risk for falls. The pertinent fall prevention interventions included placing a sign for Resident #1 to call for assistance, and placing anti-tipper devices on Resident #1's wheelchair to prevent tipping backwards ([DATE]).A fall occurrence progress note, dated [DATE] at 9:00 a.m., revealed Resident #1 was being pushed in a manual wheelchair to her room. The resident's foot caught on the carpet and she fell out of the wheelchair onto the floor. Resident #1 hit her head and sustained a laceration surrounded by a hematoma (bruising and swelling) to the middle of the upper forehead at her hairline. Resident #1 was unable to follow commands, and the nurse completed passive range of motion for all major joints while Resident #1 was on the floor. Vital signs were normal except for the resident's blood pressure measurement of 190/108 millimeters of mercury (mmHg). Resident #1's statement on what was being attempted when the fall occurred was that her wheelchair did not have a footrest or foot pedals and her feet were dragging on the floor. The evaluation revealed Resident #1's representative, the physician, the DON, and the nursing home administrator (NHA) were notified regarding the fall. The record review revealed there were no new physician's orders given at the time of the initial fall notification.Review of Resident #1's post-fall neurological assessments revealed the following:On [DATE] at 9:00 a.m. the resident had a normal level of consciousness, abnormal speech/aphasia(impaired speech) and no hand grasps. Vital signs: blood pressure 139/106 mmHg, heart rate 90 beats per minute (bpm) and respiration rate was 18 per minute.On [DATE] at 9:15 a.m. the resident had a normal level of consciousness, abnormal speech/aphasia and no hand grasps. Vital signs: blood pressure 190/108 mmHg, heart rate 77 bpm, respirations 18 per minute.On [DATE] at 9:30 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 191/90 mmHg, heart rate 89 bpm, respirations 15 per minute.On [DATE] at 9:45 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 187/94, heart rate 82 bpm, respirations 16 per minute.On [DATE] at 10:15 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 190/98, heart rate 80 bpm, respirations 15 per minute.On [DATE] at 10:45 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 184/86 mmHg, heart rate 78 bpm, respirations 15 per minute.On [DATE] at 11:15 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 187/91 mmHg, heart rate 82, respirations 16 per minute.On [DATE] at 11:45 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 194/96 mmHg, heart rate 77 bpm, respirations 15 per minute.On [DATE] at 12:45 p.m. the resident had a normal level of consciousness, normal speech and equal hand grasps. Vital signs: blood pressure 186/82, heart rate 73, respirations 15 per minute.On [DATE] at 1:45 p.m. the resident had a normal level of consciousness, normal speech and equal hand grasps. Vital signs: blood pressure 184/81 mmHg, heart rate 81 bpm, respirations 15 per minute.A CPO, dated [DATE] at 1:32 p.m., was initiated for hydralazine 25 mg by mouth every eight hours as needed for high blood pressure with a systolic reading of greater than 180. The medication was not administered.-However, Resident #1's blood pressure had remained high for over four hours after the fall before the facility notified the physician.A nurse progress note, dated [DATE] at 1:56 p.m., revealed Resident #1's blood pressure did not recover in four hours following her fall. Resident #1's blood pressure remained in the 180s range. The nurse contacted the physician regarding the fall and high blood pressure readings and the physician gave a new order for hydralazine 25 mg every eight hours as needed for a systolic blood pressure reading greater than 180. A nurse progress note, dated [DATE] at 3:00 pm., revealed Resident #1's representative and power of attorney (POA) were informed regarding Resident #1's fall and insisted Resident #1 be transferred to the hospital emergency department for evaluation. The registered nurse (RN) documentation revealed the RN did due diligence and educated the family members there were no signs of serious injury or neurological damage after the fall. The POA was informed Resident #1 had high blood pressure and had a new order for medication to control the high blood pressure. The manager on duty returned to the facility to transport Resident #1 to the emergency department. Resident #1 was changed and prepped for transfer to the emergency department. The RN documented the blood pressure had normalized by the afternoon without using the hydralazine. The hospital progress notes, dated [DATE], revealed Resident #1's representative was notified at 3:00 p.m. that Resident #1 had fallen in the morning. The representative went to visit the resident at the facility and found Resident #1 was not at her baseline. The representative said Resident #1 was holding her left arm and was uncomfortable. Resident #1 arrived at the hospital by facility transport van. Resident #1's blood pressure at 5:50 p.m. at the emergency department was 208/115.IV. Staff interviewsRN #1 was interviewed on [DATE] at 2:52 p.m. RN #1 said after a resident had a fall, it was the facility's policy to have the resident assessed by a registered nurse. RN #1 said the assessment included a measurement of vital signs, including blood pressure. RN #1 said the post-fall assessments were documented in the resident's electronic medical record (EMR) and also on the facility's neurological assessment form, if the fall was unwitnessed, or if the resident struck their head while falling. RN #1 said when a resident had high blood pressure, it was the nursing standard to recheck the blood pressure to verify the result. RN #1 said if the reading were high, it would indicate the resident had a heart issue or maybe elevated pain. RN #1 said if a resident had continuous high blood pressure after about three minutes, she would contact the physician and report the resident's condition. RN #1 said it was not a good idea to monitor high blood pressure for hours without a physician's awareness and orders. RN #1 said the facility had medication to lower blood pressure in the facility's emergency medication supply, and a nurse could access the medication without delay after a physician's order was initiated.The DON and the nursing home administrator in training were interviewed together on [DATE] at 3:15 p.m. The DON said after Resident #1 fell, nursing staff followed policy and completed neurological assessments and notified the physician. The DON said post-fall assessments included a complete body assessment and measuring vital signs. The DON said the purpose of frequent assessments was to closely monitor residents so that nursing staff could identify concerning changes in assessment and implement interventions and notify the physician if necessary. The DON said the neurological assessments were completed after an unwitnessed fall or anytime a resident hit their head. The DON said the neurological assessments included looking at skin for trauma or new deformities, pain, acting abnormally and changes in vital signs. The DON said Resident #1 had a history of high blood pressure and had fluctuations in blood pressure before the [DATE] fall, but had not previously required new medications to lower blood pressure. The DON said the neurological assessments completed on [DATE] did not reveal a change in Resident #1's normal status, and Resident #1 was monitored appropriately. The DON said Resident #1 had no signs of serious injury, moved all major joints, and did not grimace or hold her head. The DON said that when the family requested Resident #1 to be evaluated at the hospital, the facility's manager on duty transported Resident #1 in the facility van because the nurse assessment documented Resident #1 was stable and had no indicators for ambulance transport.

Based on record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for maintaining resident health records out of four sample residents.Specifically, the facility failed to ensure physicians' progress notes for Resident #1 were available in the electronic medical record (EMR).Findings include:I. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 6/8/25. According to the June 2025 computerized physician orders (CPO), diagnoses included high blood pressure, diabetes mellitus and Alzheimer's disease.The 5/8/25 minimum data set (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily living (ADL). Resident #1 did not walk and was dependent on staff for mobility with a manual wheelchair. B. Record reviewRecord review revealed there were no physician's progress notes in Resident #1's EMR after 1/15/25. As a result, physician's records were unavailable for review during the survey. II. Staff interviewsThe director of nursing (DON) and the nursing home administrator in training were interviewed together on 10/14/25 at 3:15 p.m. The DON said she was unable to locate the physician's progress notes in Resident #1's EMR after 1/15/25. The DON said the previous physician documented in a system separate from the facility's EMR. The DON said that she was able to contact the former physician and request records as needed, and the documents would be available either late evening or on 10/15/25. The DON said the facility obtained physician services from a new provider in July 2025, and the facility had been working with the new provider to ensure documentation was available in residents' EMRs.

Based on observations, interviews and record review, the facility failed to ensure the environment was free of accidents and hazards for two (#16 and #4) of four residents reviewed for falls out of 17 sample residents. Resident #16, who was at high risk for falls, sustained 17 falls from 9/4/23 to 1/31/24. The facility failed to ensure fall interventions were implemented after each fall and implement effective interventions when they were added. The resident, who required maximum assistance with toileting according to her care plan, often fell trying to go to the bathroom. Due to the facility's failures to implement effective interventions, Resident #16 had a major injury on 1/9/24 when she fell trying to go to the bathroom which required hospital treatment for a head laceration where she had two staples. Observations during the survey from 2/5/24 to 2/8/24 revealed the facility had not consistently implemented fall interventions. In addition, the facility failed to ensure fall interventions were utilized consistently for Resident #4. Findings include: I. Resident #16 A. Resident status Resident #16, age 89, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and diabetes. The 10/2/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment and was unable to complete a brief interview for mental status (BIMS). The resident had behaviors of delusions and wandering. She used a wheelchair for mobility and required maximum staff assistance with transfers and ambulation. It indicated the resident had two or more falls since the prior assessment. B. Observations On 2/5/24 at 10:46 a.m. Resident #16 was observed in her bed. The bed was not in the lowest position and the resident did not have a fall mat next to her bed. No positioning device was observed in the resident's wheelchair (indicated as an intervention, see below). On 2/6/24 at 1:15 p.m. Resident #16 was observed propelling herself down the hallway towards her room. There were no staff present in the resident's hallway. When the resident approached the door, she locked her brakes and stood up. Her nasal cannula was still in her nose and her oxygen concentrator was still attached to the back of her wheelchair. The resident attempted to walk into her room but she was attached to the wheelchair via her oxygen tubing. The resident eventually removed her cannula and started to walk inside her room and towards her bathroom. At 1:21 p.m., a certified nurse aide (CNA) walking past the hallway noticed the resident's wheelchair in the hallway and came into the resident's room to assist. No positioning device was observed in the resident's wheelchair. C. Record review The fall care plan, initiated on 7/27/22, revealed the resident had a history of falls and used an assistive device. Interventions initiated 7/27/22 included providing a therapy evaluation as indicated, call light within reach, bed in low position, and side rails up while the resident was in bed. Interventions initiated 10/13/22 included call light and personal items within reach, and educating the resident on using the call light. Interventions initiated 3/20/23 included providing a call light with a longer cord to reach the recliner and offer non skid socks. Interventions initiated 7/26/23 included non slip matting added to the resident's recliner and non skid strips by the bed and recliner. Interventions initiated 1/10/24 included fall mat by bed and lipped mattress. -The fall care plan interventions did not include frequent checks or anticipating toileting needs. The resident fell 17 times between 9/4/23 and 1/31/24 and the care plan did not reflect additions to interventions or modifications in response. The activities of daily living (ADL) care plan, revised on 1/10/24 revealed the resident required limited to total assistance with her activities of daily living. The resident did not acknowledge her limitations or use her call light for assistance. The resident required maximum assistance with transfers and toileting. -The CNA tasks (abbreviated care plan) did not reveal fall interventions. The February 2024 CPO revealed the following physician orders: Non skid strips in front of the recliner and bed. Non skid strips on recliner cushion- ordered on 3/23/23; Physical therapy to evaluate for vertigo related to falls and complaints of dizziness- ordered on 9/7/23; Send resident for magnetic resonance imaging (MRI) for confusion with new onset of gait disturbance- ordered on 9/12/23; Buspirone (antianxiety) 10 MG- give two times daily for anxiety- ordered on 2/2/24; and, Fall mat placed when in bed- ordered on 2/7/24 (during survey). -No orders for fall mats, positioning devices, or alarms were located prior to the survey. The fall incident report dated 9/4/23 to 1/31/24 revealed: 1. Fall incident 9/4/23 According to the 9/4/23 interdisciplinary (IDT) fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had taken her oxygen off and she could not recall how she fell . No injuries were observed. The interventions included decreasing a medication the resident complained made her feel dizzy. 2. Fall incident 9/7/23 According to the 9/7/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had become dizzy. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance. 3. Fall incident 9/14/23 According to the 9/14/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she fell while trying to go to the bathroom. She complained of pain in her hip. No injuries were observed. The interventions included making frequent rounds on the resident. 4. Fall incident 9/19/23 According to the 9/19/23 IDT fall incident report, the resident sustained a witnessed fall while taking herself to the bathroom in her room. The staff said the resident was not wearing her oxygen or her shoes. No injuries were observed. -It did not include any new interventions. 5. Fall incident 9/25/23 According to the 9/25/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she fell while trying to go to the bathroom. A skin tear to her finger was observed. -It did not include any new interventions. 6. Fall incident 10/1/23 According to the 10/1/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident was unable to explain why she fell . No injuries were observed. -It did not include any new interventions. 7. Fall incident 10/2/23 According to the 10/2/23 IDT fall incident report, the resident sustained an unwitnessed fall. The resident said she had slipped and fallen. No injuries were observed. -The interventions included encouraging the resident to utilize the call light to ask for assistance. 8. Fall incident 10/3/23 According to the 10/3/23 IDT fall incident report, the resident sustained an unwitnessed fall while trying to get up. The resident was confused and disorientated. Bruises to the right elbow and left elbow were observed The intervention indicated the nursing home administrator had ordered bed and chair alarms. -However, the nurse was unable to find any within the facility. 9. Fall incident 10/17/23 According to the 10/17/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had slipped and fallen. A bruise was observed on the resident's posterior right forearm. -It did not include any new interventions. 10. Fall incident 11/5/23 According to the 11/5/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident had been incontinent in her bed and slipped. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance and implement a fall mat. 11. Fall incident 11/19/23 According to the 11/19/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. No injuries were observed. -It did not include any new interventions. 12. Fall incident 11/20/23 According to the 11/20/23 IDT fall incident report, the resident sustained a witnessed fall when her legs buckled. The resident said she was trying to get up to get into her wheelchair. No injuries were observed. -It did not include any new interventions. 13. Fall incident 12/19/23 According to the 12/19/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. No injuries were observed. -It did not include any new interventions. 14. Fall incident 12/27/23 According to the 12/27/23 IDT fall incident report, the resident sustained a witnessed fall at 8:06 a.m. when she slid out of her bed. The resident said she was trying to put her shoes on. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance. 15. Fall incident 12/27/23 According to the 12/27/23 IDT fall incident report, the resident sustained an unwitnessed fall at 5:01 p.m. while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. No injuries were observed. -It did not include any new interventions. 16. Fall incident 1/9/24 According to the 1/9/24 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. The resident was observed with blood on her face, a laceration to the top of her scalp, and a skin tear to her right forearm. The resident was sent out to the hospital. The resident received two staples at the hospital and was returned to the facility. The fall intervention indicated a wheelchair positioning device was requested by the power of attorney (POA). 17. Fall incident 1/31/24 According to the 1/31/24 IDT fall incident report, the resident sustained an unwitnessed fall while trying to get into her bed. The resident said she was trying to go to bed. Redness was observed to the resident's right anterior ankle. The intervention included encouraging the resident to utilize the call light to ask for assistance. D. Staff interviews CNA #3 was interviewed on 2/5/24 at 1:30 p.m. CNA #3 said Resident #16 was a high fall risk and had fall interventions when in bed keeping her bed in the lowest position and using a fall mat. The resident did not have interventions of frequent checks or routine toileting. Licensed practical nurse (LPN) #3 was interviewed on 2/6/24 at 10:35 a.m. LPN #3 said Resident #16 had behaviors of impatience and impulsivity. The resident was at a high fall risk and the interventions were to utilize a fall mat when she was in bed, check on the resident frequently, and toilet the resident before and after meals. The resident frequently fell when attempting to toilet herself and did not remember how to use the call light. The director of nursing (DON) was interviewed on 2/7/24 at 10:22 a.m. She said the facility evaluated a resident's circumstances after a fall and made recommendations for fall interventions based on the circumstances and resident status. Fall interventions were updated in the care plan and the CNA tasks. The DON did not know the resident's fall interventions. She was recently put on anti anxiety medication to decrease anxiety to reduce falls. The DON stated the facility had not identified any recurring theme to the resident's falls and she was not aware the resident had been trying to toilet herself before the majority of the falls. The nurse practitioner (NP) was interviewed on 2/8/24 at 11:00 a.m. Resident #16 had fall interventions of a low bed and occupational therapy as needed. The NP had put the resident onto comfort care because it appeared she was declining but the resident had recently returned to her baseline. The resident was at risk for falls related to manipulative behaviors. The resident would throw herself on the floor for attention. The NP said there was a staff member who stayed in the hallway to monitor the resident and sometimes the nurses took the resident to the nurses station to be monitored. 31820 II. Resident #4 A. Resident status Resident #4, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 CPO, diagnoses included muscle weakness, spondylolisthesis lumbar region (occurs when one vertebra in the spinal column becomes fractured and the spine slips out of place, usually in the lumbar area) and osteoarthritis. The 11/9/23 MDS assessment revealed the resident's mental status was not impaired with a (BIMS score of 13 out of 15. She had no behaviors or rejections of care. B. Observations Resident #4 was in her bed on 2/5/24 at 10:45 a.m. The fall mat was tucked in between the headboard of the bed and the wall and her wheelchair was next to her bed. Resident #4 was in her bed on 2/6/24 at 2:45 p.m. The fall mat was not next to her bed and her wheelchair was placed next to her bed. C. Record review The care plan, initiated 2/28/22 and revised on 11/16/23, identified the potential for falls related to a history of falls, unsteady gait, and the use of an assistive device. Interventions included to have the fall mat by the bed when Resident #4 was in bed. Review of Resident #4's electronic medical record revealed the resident sustained two falls in January 2024. D. Interviews CNA #1 was interviewed on 2/6/24 at 2:50 p.m. She said Resident #4's fall mat was only used at night. She said the resident preferred the fall mat only at night. LPN #1 was interviewed on 2/6/24 at 2:55 p.m. She said Resident #4's fall mat was only for night. She said during the day the fall mat was a trip hazard. She said the resident preferred to not have the mat by her bed during the day. She said the resident preferred the wheelchair be placed next to the bed during the day. The DON was interviewed on 2/7/24 at 10:01 a.m. She said the fall mat needed to be next to the bed every time the resident was in bed. She said she was not aware the mat was only being used at night. She said with the resident's history of falls, the mat needed to be utilized every time she was laying in bed. She said the wheelchair next to the bed could cause more injury if there was a fall. She said she would provide education to the staff.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for six of 22 resident rooms in two hallways. Specifically, the facility failed to ensure blinds were intact in six resident rooms. Findings include: I. Environmental tour and interview The environmental tour was completed with the nursing home administrator (NHA) and the maintenance director (MTCE) on 2/8/24 at 9:03 a.m. The following items were found: Resident rooms #2, #4, #31, #33, #35 and #37 had broken blinds covering the windows. The NHA said prior to the ongoing change of ownership the facility was only ordering a few items at a time. She said the blinds may have been ordered previously and the facility was waiting for the delivery. She said it was important for the residents' privacy to have intact blinds. II. Record review The December 2023 resident council meeting minutes documented the facility had informed the residents they were going to get estimates to replace the blinds. III. Facility follow up The NHA provided an order receipt for the blinds dated 2/6/24, during the survey.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning staff, laundry and housekeeping. Findings include: I. Facility policy and procedure The Grievance policy, which was undated, was provided by the nursing home administrator (NHA) on 2/7/24 at 11:05 a.m. It read it pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance. The resident, or person filing the grievance on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and any actions that will be taken to correct any identified problems. II. Resident interviews Resident #13 was interviewed on 2/5/24 at 10:46 a.m. She said the facility did not follow up on grievances brought up in the resident council meetings. She said she had brought up grievances regarding call lights and staffing but the facility had not followed up with a resolution. The resident council president, Resident #3, was interviewed on 2/6/24 at 3:13 p.m. She said the resident council had brought up grievances regarding call lights, staffing shortages and rooms not getting cleaned enough. Resident #3 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting. If it was an individual grievance the department head would follow up with the individual resident. If it was a group grievance a resolution was not brought back to the next resident council meeting by the facility. III. Record review A review of the resident council meeting minutes dated 11/8/23 revealed group grievances concerning beds not being made, not enough staff in the facility, one CNA's attitude and residents getting other residents' clothes returned from the laundry department. A review of the resident council meeting minutes dated 12/13/23 revealed group grievances concerning resident rooms not getting cleaned. A review of the resident council meeting minutes dated 1/10/24 revealed group grievances regarding the facility needing more certified nurse aides (CNA). -There was no documentation in any of the resident council minutes to indicate resolutions were discussed with the resident council members for the grievances brought up at the 11/8/23, 12/13/3 or 1/10/24 resident council meetings. Resident council generated grievances for November 2023, December 2023 and January2024 were requested from the NHA on 2/7/24 at 2:51 p.m. Individual grievances for Resident #13 and Resident #3 were also requested at that time. -The NHA responded via email on 2/7/24 at 3:35 p.m. that there were no grievances for Resident #13 or Resident #3 or the concerns from the resident council meetings. IV. Staff interviews The social services consultant (SSC) was interviewed on 2/7/24 at 2:00 p.m. The SSC said the facility had hired a social services director (SSD) who started a few days before the survey. The SSC was filling in as the director from September 2023 until January 2024. He said resident council grievances should be handled the same as individual grievances. A grievance form should be completed and a resolution should be brought back to the council by the next meeting. He said he would look for resident council grievances. The NHA was interviewed on 2/8/24 at 9:46 a.m. The NHA said the social services department handled resident council grievances and the SSD was the grievance official. A grievance needed to be filled out on a grievance form and then the form was given to the department responsible for the resolution. A resolution should be brought back to the next resident council meeting for the group grievances. If it was an individual grievance, a follow up should be completed within 24-48 hours. -There were no grievances from the resident council meetings provided by the end of the survey on 2/8/24.

Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility failed to have a RN on duty for eight consecutive hours on a consistent basis from 11/1/23 to 2/5/24. Findings include: I. Record review Review of the nursing schedule from 11/1/23 to 2/5/24 revealed the following: -In November 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month; -In December 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month; -In January 2024, the facility did not have a RN on duty for eight consecutive hours on four days during the month; and, -In February 2024, from 2/1/24 to 2/5/24, the facility did not have a RN on duty for eight consecutive hours for one day. II. Staff interview The director of nursing (DON) was interviewed on 2/7/24 at 10:26 a.m. She said she was not aware of the federal requirement regarding the need for a RN for eight consecutive hours seven days a week. She said going forward she would do her best to meet the federal requirement for the safety of the residents.

Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for four (#13, #3, #16 and #20) of five residents reviewed for vaccinations of 17 sample residents. Specifically, the facility failed to ensure Residents #13, #3, #16 and #20 were offered and/or received pneumococcal immunization. Findings include: Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), Pneumococcal Vaccine Recommendations website, revised 9/21/23, retrieved on 2/13/24 from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html read in pertinent part, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. According to the CDC Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2023, retrieved on 3/27/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part, The pneumococcal vaccine was to be administered to immunocompetent adults aged [AGE] years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23. For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals aged 19-[AGE] years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23. II. Resident #13 Resident #13, age 78, was admitted on [DATE]. The medical record revealed the resident declined the influenza vaccination on 12/6/23 and her pneumococcal vaccination was not up-to-date. The minimum data set (MDS) assessment dated [DATE] indicated the resident had refused the influenza vaccine and the pneumococcal vaccine. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. III. Resident #3 Resident #3, age 79, was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination on 11/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated [DATE] indicated the resident had received the influenza vaccine and had not been offered the pneumococcal vaccine. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. IV. Resident #16 Resident #16, age 89, was admitted on [DATE]. The medical record revealed the resident declined the influenza vaccination on 11/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated [DATE] revealed the section pertaining to vaccines had not been completed. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Resident #20 Resident #20, age 77, was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination on 10/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated [DATE] indicated the resident had received the influenza vaccine and had declined the pneumococcal vaccine. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Staff interviews The nursing home administrator (NHA) was interviewed on 2/8/24 at 9:46 a.m. She said she did not know if the facility had documentation of pneumococcal vaccines being offered to the residents. The NHA would have to look for the records. The infection preventionist (IP) was responsible for the tracking but was not available for interview during the survey. The nurse practitioner (NP) was interviewed on 2/8/24 at 11:00 a.m. She said the residents should be offered the pneumococcal vaccine when they enter the facility if there was no record of the vaccine being given. Proof of the vaccine being offered or refused with education should be in the resident's medical record at the facility. -There was no pneumococcal vaccine documentation provided by the exit on 2/8/24.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for one (#13) out of 17 sample residents. Specifically, the facility failed to ensure the discharge planning process focused on Resident #13's discharge goals. Findings include: I. Resident #13 A. Resident status Resident #13, age 78, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and developmental disorder of scholastic skills (learning disability). The 1/11/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She used a wheelchair for mobility and required substantial staff assistance with transfers, toileting, showering, and dressing. The section about discharge planning and goals revealed the resident had not been interviewed but had been interviewable. The legal representative was interviewed and there were no plans for discharge. B. Resident interview The resident was interviewed on 2/5/24 at 10:46 a.m. She said the facility would not let her leave and she did not know why. No one had explained to her why she was unable to leave and she did not want to live in the facility anymore. The resident became emotional and could not further articulate where she wanted to be discharged . C. Record review The resident had a medical durable power of attorney for assistance with medical decisions dated 11/16/02. -There were no documents in the resident's medical record showing the resident was unable to make decisions. The comprehensive care plan, revised 1/11/21, revealed the resident required extensive assistance with bathing and toileting. The resident required limited to set up assistance with mobility, dressing and personal hygiene. The resident or family expressed a preference to remain in long term care at the facility. The resident at times made statements of wanting to return to the community. Interventions included to assess the resident on comprehensive assessments for discharge planning. A review of progress notes dated 10/1/23 to 2/6/24 failed to reveal concerns regarding discharge planning. Certified nurse aide (CNA) tasks (abbreviated care plan) revealed a task for discharge planning initiated on 4/24/23. It indicated if the resident made statements regarding wanting to return to the community, staff were to listen and validate the resident's concerns. Staff were to explain to the resident a discharge plan home was unrealistic and it was imperative she remain in 24 hour care. II. Staff interviews The social services consultant (SSC) was interviewed on 2/7/24 at 2:00 p.m. The SSC said the facility had hired a social services director who started a few days before the survey. The SSC was filling in as the director from September 2023 until January 2024. The social worker was responsible for assisting residents with discharge planning. If a resident consistently brought up wanting to discharge and there were efforts made to assist the resident with discharge planning, the care plan should be updated to reflect. The SSC said the resident's family wanted her to remain in long term care but Resident #13 was able to make her own decisions. The resident had told the SSC she had a friend who she could live with but did not have contact information. The SSC said if the resident provided him with contact information, he would have followed up with her friends to discuss if a discharge plan was feasible. He could not recall exactly when he had these conversations with the resident. The SSC said he would look for documentation of the discharge planning conversations. The SSC was interviewed on 2/8/24 at 9:45 a.m. He said he just checked in with the resident this morning regarding discharge planning. He said the resident would let him know when she was ready to discharge but currently did not have a formulated plan. He was not able to find documentation of prior conversations. The NHA was interviewed on 2/8/24 at 9:46 a.m. She said there had not been conversations with the resident regarding discharge planning. The resident would become anxious and conversations regarding discharge would have done the resident more harm than good. The conversations consisted of redirecting the resident to another topic or an activity. The NHA said she would look to see if there were any care conference notes regarding discharge conversations with the resident. -There was no additional documentation provided by the time of exit on 2/8/24.

Based on observations, record review and interviews, the facility failed to ensure residents received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable for one (#23) of two residents reviewed for mobility out of 17 sample residents. Specifically, the facility failed to ensure a carrot contracture prevention device was placed according to physician orders for Resident #23. Findings include: I. Resident #23 A. Resident status Resident #23, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included muscle weakness and Parkinson's disease. The 11/15/23 minimum data set (MDS) assessment revealed the resident's mental status was severely impaired. The assessment did not identify functional limitations in the upper extremities. B. Observations Resident #23 was in her room on 2/5/23 at 9:53 a.m. with no carrot splint in her hand. Resident #23 was in her room on 2/6/23 at 9:30 a.m. with no carrot splint in her hand. C. Record review The care plan, initiated 2/23/23 and revised on 1/15/24, identified the resident was at risk for skin tears and bruises. Interventions included an orange carrot palm protector to the left hand, on in the morning and off at noon. Check skin before and after application. -The resident did not have a care plan focus that addressed the contracture of the resident's left hand. Review of the February 2024 CPO revealed the following physician order: Place orange carrot in left hand in morning upon awakening and remove at midday. Check for red areas or skin breakdown two times a day for contracture. The occupational therapy (OT) note dated 12/10/23 documented Resident #23 was tolerating wearing the left hand carrot splint. The OT discharge summary note dated 12/14/23 documented Resident #23 was wearing the left hand carrot splint in the palm to reduce the risk of skin breakdown. -There was no documentation in the resident's electronic medical record (EMR) to indicate Resident #23 was refusing to wear the carrot splint. D. Interviews Certified nurse aide (CNA) #2 was interviewed on 2/6/24 at 9:50 a.m. CNA #2 said Resident #23 often pulled the carrot out of her hand. She said she would report it to the nurse who would attempt to replace the carrot three times. After the third time, the carrot would be put away. She said the nurse was the person responsible for placing the carrot. She said the resident only wore the device in the mornings. Licensed practical nurse (LPN) #1 was interviewed on 2/6/24 at 10:00 a.m. LPN #1 said the carrot would be placed in Resident #23's left hand in the morning and taken out at 12:00 p.m. She said the resident did not like the carrot and would pull it out. She said after three attempts she would stop trying to replace the carrot in the resident's hand and put it away. She said if the resident refused to let her put the carrot in her hand she would not force her to wear it. The director of nursing (DON) was interviewed on 2/7/24 at 10:01 a.m. The DON said the nurses were to put the carrot in Resident #23's left hand in the morning and remove it at lunch. She said when the carrot was applied the nurses were to assess her skin for any breakdown. She said the resident did remove the carrot by herself. She said if an aide found the carrot they were to give it to the nurse for her to reapply the carrot. She said if the resident removed it repeatedly or refused to wear it, there should be a nurse note documented so the team would know the resident was refusing to wear the device. She said the resident was not getting the benefits of contracture prevention when the carrot was not put in her left hand consistently She said she would talk to the staff about documenting the resident's refusals of the carrot and report the refusals to the provider and the therapist.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #3 (hired on 10/20/15), CNA #4 (hired on 6/16/93) and CNA #5 (hired on 10/1/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 2/7/24 at 10:30 a.m. She said she could not locate the performance reviews for CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure best care was being delivered to the residents.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication rooms. Specifically, the facility failed to date a multi use vial of tuberculin when opened. Findings include: I. Professional reference According to the Tubersol package insert, retrieved 2/12/24 from: https://www.fda.gov/media/74866/download, A vial of Tubersol which has been entered and in use for 30 days should be discarded. II. Observation and interview The medication room was reviewed on 2/6/24 at 1:15 p.m. An opened multi use vial of Tubersol was in the refrigerator. -There was no date on the vial to indicate when the medication was opened. Licensed practical nurse (LPN) #1 said she did not know when the vial was opened. She said it should have been dated when opened for the safety of the residents. III. Additional interview The director of nursing (DON) was interviewed on 2/6/24 at 3:30 p.m. She said Tubersol was good for 30 days after opening. She said the vial should have been dated when opened to make sure the medication was safe for residents.

Based on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development and worsening of pressure injuries for one (#3) of three residents reviewed for pressure injuries out of five sample residents. Record review and interviews revealed the facility had multiple systemic failures in its management of pressure injuries. These included the failure to timely assess and monitor for pressure injuries, prevent the development and worsening of Resident #3's avoidable pressure injuries, and effectively educate the clinical staff on the use and monitoring of contracture devices. Resident #3, diagnosed with enteropathic arthropathies ([CONDITION(S)] arthritis) of her right hand and a contracture of her right hand, developed two avoidable stage 2 pressure injuries to her right middle and index fingers on 5/12/21, which progressed to two stage 4 pressure injuries on 5/17/21, five days later. The resident required evaluation by a wound care specialist and an orthopedic surgeon, was diagnosed with [CONDITION(S)] (inflammation of bone caused by infection) in the wounds and was transferred to a hospital for surgical amputation of her two fingers on 5/21/21. The facility did not ensure the medical device used to treat her contracture was repositioned on an individualized schedule, based on her risk factors, to minimize tissue damage, or consistently monitored for signs of rubbing to prevent skin breakdown. Although the resident developed two stage 4 pressure injuries, the facility did not develop or complete a performance improvement plan or implement prevention measures to prevent this from happening again to other residents. The facility's failure to properly educate the clinical staff on the use and placement of contracture devices, and prevent, assess and monitor residents for pressure injuries created an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Resident #3, diagnosed with enteropathic arthropathies and a contracture of her right hand, developed two avoidable stage 2 pressure injuries to her right middle and index fingers on 5/12/21, which progressed to two stage 4 pressure injuries on 5/17/21, five days later. The resident required evaluation by a wound care specialist and an orthopedic surgeon was diagnosed with [CONDITION(S)] in the wounds and was transferred to a hospital for surgical amputation of her two fingers on 5/21/21. The facility did not ensure the medical device used to treat her contracture was repositioned on an individualized schedule, based on her risk factors, to minimize tissue damage, or consistently monitored for signs of rubbing to prevent skin breakdown. After the resident developed the two stage 4 pressure injuries, the facility did not develop or complete a performance improvement plan or implement prevention measures to prevent this from happening again to other residents. The facility's failure to properly educate the clinical staff on the use and placement of contracture devices, and prevent, assess and monitor residents for pressure injuries created an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. On 6/4/21 at 1:20 p.m., the nursing home administrator (NHA) and the director of nurses (DON) were notified that the findings above created a situation of immediate jeopardy for serious harm. B. Plan to remove immediate jeopardy On 6/4/21 at 6:12 p.m., the facility submitted the following plan to remove the immediate jeopardy situation: -As of June 4, 2021, carrot therapy (contracture prevention device) discontinued for all residents until proper education could be provided. -Nurses completed the skin assessments for all residents with devices prior to application and upon removal of the device and DON placed the documentation on the MAR (medication administration record) for nursing to sign off. DON will complete education with nursing staff on June 8, 2021 and as they arrive before their next scheduled shift, regarding facility expectations for wound documentation. -Education to be completed upon hire, annually, and PRN (as needed). -Upon admission of all residents, the nurse will complete the Point Click Care (resident charting program) admission assessment and Braden Scale (tool to measure pressure injury risk). Any issues identified on admission will be addressed and have interventions implemented as appropriate by the IDT (interdisciplinary) team within three business days from admission. -IDT will review daily orders for wound care treatment to ensure appropriate treatment is implemented. -If a new pressure injury is identified during the weekly skin assessment, the registered nurse (RN) will complete Point Click Care wound evaluation flow sheet, Multiple Weeks Wound Evaluation Flowsheet, weekly and PRN until two weeks after resolution date. -DON or designee will complete wound rounds weekly, and ensure documentation is inputted into the medical record weekly beginning the week of June 7, 2021. -DON will complete pressure wound dressing observations and complete chart review twice a week for one month, then weekly for two months. Wound documentation for two residents will be audited to ensure orders are in place and being followed as written, that documentation is consistent throughout the chart, and identified concerns are addressed with staff PRN. -NHA or designee to complete monthly review of three residents with pressure wounds documentation to ensure it is consistent with documentation with the wound physician, and the physician was being contacted PRN for the wound. Identified concerns to be addressed with DON or designee. -Facility-wide audit of all residents completed by licensed nurses by June 4, 2021 for baseline of skin concerns in the facility. No new concerns identified. -DON implemented residents with a stageable wound will have daily charting completed by the day shift licensed nurse. -Education will be provided by the therapy department to all licensed nursing staff on proper placement of contracture devices prior to initiating therapy for all new orders beginning on June 4, 2021. -The facility's wound care provider who was contracted for wound care management will provide education to all licensed nurses by June 18, 2021. -DON will educate all licensed staff to assess and document skin conditions prior to applying the device and upon removal prior to working their next shift. -Wound nurse/therapy staff/or designee will assess and review all current pressure relieving devices (such as mattresses, wheelchair cushions, etc.) used to ensure their appropriateness by June 8, 2021, and continue weekly for three months, and monthly for six months. DON/NHA will monitor audits and ensure assessments are completed each month. -Residents with a stageable wound will be reviewed by the medical director on June 7, 2021, and monthly during the QA (quality assurance) meeting. -Education provided to all staff regarding pressure ulcers, risk factors, as well as preventative interventions will be completed by June 8th, 2021, upon hire, and annually. -Residents have weekly skin assessments performed by a licensed nurse. DON or designee will review assessment findings twice weekly for three months and then weekly. -Braden scale will be completed upon admission, quarterly, and as needed. The MDS (minimum data set) coordinator/wound care nurse will complete an audit of the findings weekly. C. Removal of immediate jeopardy On 6/4/21 at 6:15 p.m., the NHA was informed that the facility's plan to remove the immediate jeopardy was accepted. Based on the review of the facility's plan to address systemic issues in pressure injury management, the immediate jeopardy situation was removed. However, deficient practice remained at G level, isolated actual harm. II. Resident #3-Failure to prevent pressure injuries and ensure they did not worsen A. Resident #3 status Resident #3, over the age of 85, was admitted to the facility 6/9/17. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/27/21 minimum data set (MDS) assessment revealed the resident had short and long-term memory problems and was severely cognitively impaired. She had no behavioral problems, [CONDITION(S)], or rejection of care. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She was at risk of developing pressure injuries and had one stage 1 unhealed pressure injury. She had pressure reducing devices for her chair and bed, was on a turning program and received pressure injury care. She received occupational therapy for a total of 57 minutes in the seven-day look back period. A restorative nursing program was performed seven of the last seven days that included splint or brace assistance. B. Resident representative interview The resident's representative was interviewed on 6/2/21 at 5:10 p.m., who was also the resident's medical durable power of attorney (MDPOA). She said approximately six to nine months ago, Resident #3's arthritis in her hands turned into contractures and described it as her hand locks up. She said her right hand had locked up into a fist, so the facility informed her they were going to try physical therapy to treat it, but it did not get any better. Then the facility tried something called a carrot that they put in her hand to try to help open it up. She said she received a phone call from the facility on 5/12/21, and was informed the resident had developed pressure ulcers to her right hand, and the physician wanted to send her out to an orthopedic surgeon for an evaluation. She agreed to this, and the surgeon saw the resident on 5/19/21, who determined blood work needed to be completed. She said she was informed by licensed practical nurse (LPN) #1 that the wound had some type of infection and they were really worried about her becoming septic. She said the facility arranged for an emergency staffing meeting the next day that included the orthopedic surgeon, and he said he did not think he could save those two fingers because her bone was exposed. She stated, My concern initially was how it could get this bad this quickly? She said she thought there was some way this could have been prevented, and was worried about putting the resident through surgery at her age. C. Record review The Prevention of Pressure Injuries policy and procedure, dated April 2020, was provided by the NHA on 6/4/21 at 6:25 p.m. The facility staff were to assess residents on admission (within eight hours) for existing pressure injury risk factors and repeat the risk assessment weekly and upon any changes in condition. They were to use a standardized pressure injury-screening tool to determine and document risk factors, and supplement the use of a risk assessment tool with assessment of additional risk factors. Residents with or at risk of pressure injuries should be repositioned on an individualized schedule, as determined by the interdisciplinary team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Remind and encourage residents to change positions. For device-related pressure injuries: -Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. -Monitor regularly for comfort and signs of pressure-related injury. -For prevention measures associated with specific devices, consult current clinical practice guidelines. Evaluate report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. The Braden Scale Observation/Assessment (for predicting pressure sore risk), dated 3/30/21, revealed a score of 17, which indicated the resident was at risk for the development of pressure injuries. According to the scoring key: a score of 25-18 indicated at risk, 13-14 moderate risk, and 12 or below high risk. The care plan, initiated 6/15/17 and revised on 3/29/21, identified Resident #3 had limited physical mobility related to right hand contracture. The goal was she would remain free of complications related to the immobility. The approaches included: invite her to activity programs that encouraged activity and physical mobility, such as exercise group. She used a wheelchair for locomotion around the facility with assistance of one staff member. Provide gentle range of motion as tolerated with daily care. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Physical therapy (PT) and occupational therapy (OT) referrals as ordered, PRN (as needed). Resident to use a therapy carrot during the day and off at night (initiated 3/29/21). The manufacturer's instructions for use of the therapy carrot, dated 2021, included the following directions for application: There are two methods of application: A) manual placement and B) insertion using the placement wand. Depending on the severity of the contracture, the therapy carrot could be inserted at either the index finger or the little finger. Pull the therapy carrot into the hand to the greatest diameter comfortable for the patient. Note which number is visible at the index and at the little finger. These numbers will be used to track progress and to ensure consistency of placement. Or, use the placement wand by threading the loop at the end of the carrot through the eye of the placement wand and gently slide the placement wand and the attached therapy carrot through the patient's clenched fist. Continue to pull gently until resistance was felt. The patient should not experience pain. Once the therapy carrot has been positioned in the hand, note which number is visible at the little finger or at the index finger. You will track progress by observing an increase in the number visible when the therapy carrot was correctly placed. When comfortably placed, the device could be safely worn for several hours at a time. It is imperative that you establish a wearing schedule and that the skin is consistently monitored for signs of rubbing. Discontinue use if redness appears. 1. 1/2/21 through 3/20/21 - Occupational therapy (OT) notes and ineffective training on the importance and placement of the therapy carrot and other contracture prevention interventions for Resident #3. On 1/2/21, a referral was made for skilled occupational therapy services to address Resident #3's right hand contracture. Her hand had become visibly edematous and she tended to keep it in a fisted position and reported pain with gentle passive range of motion. Recommendations included a trial of a palm guard and/or therapy carrot with progression to a resting hand splint. On 1/8/21, an OT treatment encounter note documented skilled therapy to include therapy carrot application and education to hall staff and DON. The COTA (certified occupational therapy assistant) educated staff and DON on need for daily application to progress extension of digits in patient's right hand and to decrease pain. On 1/9/21, an OT treatment encounter note documented resident was not wearing therapy carrot when COTA entered the room for session and staff explained resident removed it herself at times. On 1/15/21, an OT treatment encounter note documented the COTA educated nursing caregivers with 75% understanding with need for continued education being displayed. On 1/30/21, an OT treatment encounter note documented the resident had the therapy carrot in her right hand at the beginning of the session, but it was in backward (with small end between first and second digits) and was in only minimally. Therapy was provided and the therapy carrot was applied for level 4 to show past her fifth digit. -No education was provided to staff at that time to address the incorrect placement. On 2/1/21, an OT treatment encounter note documented the DON was informed of the need for another therapy carrot to be ordered for a backup if the patient's therapy carrot was misplaced by staff. On 2/3/21, an OT treatment encounter note documented a finger contracture cushion was being used on Resident #3's right hand, while they waited the arrival of the new therapy carrot. The COTA documented education provided to the hall nurse and CNA staff on the application of the finger contracture cushion. On 2/8/21, an OT treatment encounter note documented the finger contracture cushion was misplaced, per the hall staff. The DON was notified and educated on the need for therapy carrot due to swelling. On 2/20/21, an OT treatment encounter note documented Resident #3 did not have a rolled washcloth in her right palm at the beginning of the session. A rolled washcloth was placed in the space of the palm/curled digits with care taken to extend the washcloth through the first web space. The therapy staff provided the CNA and nursing staff with education regarding the importance of, and techniques for, placing the rolled washcloth in her palm throughout the day and night to keep fingernails from digging into the palm and reduce moisture in the palm and between digits for improved skin integrity. On 2/27/21, an OT treatment encounter note documented at the beginning of the session, Resident #3 had her right hand fisted in her lap and no washcloth was available in her bedroom. A CNA retrieved one upon request and the therapy staff provided the CNA and nursing staff with hands-on education and training regarding the importance of, and techniques for, consistent orthotic application. On 3/6/21, an OT treatment encounter note documented; For the first time since patient arrived on caseload, her orthotic (rolled washcloth at this point) was in her right hand when therapy approached for session. (The resident started OT services on 1/2/21). On 3/8/21, an OT treatment encounter note documented the hall staff were educated on the need for a hand towel to be rolled up and placed in the resident's right hand throughout the day. On 3/13/21, an OT treatment encounter note documented when resident had been wearing her rolled washcloth in her right hand prior to treatment sessions, her digits range further, easier, and with less pain. However, staff have demonstrated inconsistent follow-through with rolled washcloth placement resulting in limited progress toward goals. Resident continued to demonstrate decreased right hand strength, stamina, range of motion and coordination. Resident was unable to use her right hand functionally. Continued skilled OT services were medically necessary because she was not yet at her prior level of function and was not likely to attain that functional status without further intervention. Lack of further intervention would put the resident at risk of non-healing pressure injury and decreased quality of life. On 3/20/21, an OT treatment encounter note documented a green (large) therapy carrot was in the patient's hand at the beginning of the session. Therapy staff provided a lidded box in the resident's room for storage of the carrot when not in use to help prevent lost equipment, and the box was labeled with the resident's name and hand carrot. 2. 1/5/21 to 5/17/21-Wounds developed and worsened-failure to complete timely weekly skin assessments and adequately assess placement of therapy carrot use to prevent avoidable pressure injury The June 2021 CPO included the following order: Apply therapy carrot to palm of right hand following every meal and leave in place as tolerated. Maintain therapy carrot in right palm throughout night as tolerated. The order was started on 1/5/21. The May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation indicated staff were applying the therapy carrot as scheduled, but there was no indication the device was regularly removed after it was applied to consistently monitor for signs of rubbing. Further, there was no documentation to indicate the number where the carrot was placed at the index or little finger, to track positioning or progress. The DON provided an On the Spot Education form on 6/4/21 at 10:15 a.m. The topic of the training was Therapy Carrot, and no additional information about the content of the training was included. The training was provided by the physical therapy assistant (PTA) on 10/30/2020 and was attended by four certified nurse aides (CNA) and one restorative CNA. There was no education provided to any clinical nursing staff members or any additional CNAs in the facility as of 6/4/21. A progress note, dated 5/12/21, documented a nurse identified two new stage 2 pressure injuries to the right hand. Resident's hand is contracted and fingers fit very snug together. The MD, NHA, DON, and MDPOA were notified of the new wounds. The pressure injuries were cleansed with wound cleanser, patted dry, and triple antibiotic ointment was applied. Pieces of foam were placed in between the fingers and the hand was wrapped with Kerlix gauze. The dressing was to be changed daily and PRN until it healed. The routine Weekly Skin Review documentation was reviewed from 3/30/21 through 5/24/21 and revealed the following: -4/6/21, completed -4/18/21, completed, 12 days since last Weekly Skin Review -4/21/21, completed -5/1/21, completed, 10 days since last Weekly Skin Review -5/15/21, completed, 14 days since last Weekly Skin Review. New skin alterations identified that included the following: 5/12/21 = right hand inside of pointer finger 1.2 (cm) x 1.4 (cm), stage 2 pressure injuries, and right hand inside of middle finger by pointer finger 0.8 (cm) x 0.4 (cm) stage 2 pressure ulcer. -5/17/21, completed, and the facility changed to a new form to track the pressure injuries, which was titled, Wound Evaluation Flow Sheet Multiple Weeks. The form documented the wound round findings showed the two pressure injuries had increased in size and both were measured at 2.0 cm length x 2.0 cm width x 0.2 cm depth for the pointer finger, and 1.0 cm length x 1.5 cm width x 0.2 cm depth for the middle finger, and progressed to stage 4. The additional descriptions documented the pressure injuries developed with pressure from the fingers sitting so close together with very bony fingers on the resident. The exudate (fluid) was sanguineous and thick, and the wound bed was 100% granulation with [CONDITION(S)]. The May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -The documentation indicated staff were applying the therapy carrot as scheduled, but there was no indication the device was regularly removed after it was applied to consistently monitor for signs of rubbing. Further, there was no documentation to indicate the number where the carrot was placed at the index or little finger, to track positioning or progress. 3. 5/18/21 through 5/21/21 - Orthopedic surgery consultation and surgical amputation of two fingers A progress note on 5/18/21 documented lab work and blood cultures were obtained to rule out [CONDITION(S)] (infection in the bone). A progress note on 5/19/21 at 11:55 a.m., written by the facility's wound nurse (WDN), documented Resident #3 was sent out to the wound care clinic to have the two stage 4 pressure injuries assessed and a recommendation was made for her to be evaluated by an orthopedic surgeon. A progress note on 5/19/21 at 4:00 p.m., written by the WDN, documented the resident had a tele-health consultation completed with the orthopedic surgeon, resident, MDPOA, and interdisciplinary team (IDT). The surgeon was able to visualize the injuries with assistance from staff, and recommended amputation of the second and third digits due to the nature of the wounds. The MDPOA was upset with the news of amputation, however understands the risks related to [CONDITION(S)] and outcomes of untreated [CONDITION(S)]. The surgery plan would be communicated to the facility staff in the next 24-48 hours. A progress note on 5/21/21 documented the resident was transferred to a local hospital for surgery scheduled at 2:00 p.m. that day. She returned to the facility at 6:25 p.m. with an ace wrap in place over her right hand. Her pinky finger and ring finger were exposed, and the index and middle finger were amputated. She appeared comfortable and the dressing was to remain in place until the post-operative appointment on 6/3/21. The care plan, initiated 5/21/21 and revised 5/27/21, identified Resident #3 had two digits on her right hand amputated (pointer finger and middle finger) related to stage 4 pressure injuries and contractures to the right hand. The goal was she would remain free from complications. The approaches included to encourage her to not allow the surgical arm to dangle below waist level, monitor and assess dressings as directed by the surgeon, and follow up with the surgeon for abnormal findings, monitor and assess her pain every shift and treat as ordered, obtain and follow orders for pain management, and the surgeon to provide orders for wound care. III. Staff interviews LPN #2 was interviewed on 6/2/21 at 4:30 p.m., and said she had cared for Resident #3 at times in the past when she had orders for the therapy carrot device to be placed. She said she had not received any education on how to place the contracture device properly. CNA #4 was interviewed on 6/2/21 at 5:30 p.m., and said she did not routinely care for Resident #3, but she was her CNA that evening. She said she had not received any education on how to place the therapy carrot device in her right hand. The DON was interviewed on 6/2/21 at 5:43 p.m., and she said Resident #3 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident was receiving Sombra (topical pain relieving gel) for the arthritis and they had referred her to therapy services for range of motion to her right hand contracture on 1/2/21. She said on 1/5/21, a therapy carrot was ordered to maintain in her right palm throughout the night as tolerated. The resident would take it out at times on her own, but more recently she was compliant with it. The DON said the nurses documented when they applied the therapy carrot on the MAR, but did not check it for proper placement throughout the day after it was applied. She said the therapy carrot went missing in February 2021, so they had therapy evaluate her again and a new order was initiated to place a rolled washcloth in the palm of her hand day and night. The DON said she did not know what caused the stage 2 pressure ulcer and would have to look for a clinical note with that information. The NHA joined the interview at 5:53 p.m., she explained as Resident #3's contracted hand, fingers were opening up, and releasing, the pressure between her fingers increased, and her own fingers caused the pressure. She said the facility had set up a conference call with their corporate team at a future date to look at implementing a program where residents under part B could be seen by therapy staff once per week. She said that way, therapy staff would be more involved in checking the placement of their splints. However, this had not been implemented. She clarified that currently, the nursing staff checked the placement of contracture devices when they were placed, and when they were removed, but not consistently throughout the day in between those times. She said she thought skin checks were being completed by nurses, but would have to look at the documentation to verify that. The NHA said the facility planned to implement education for the nursing and CNA staff for the proper use and placement of contracture prevention devices, but had not been started yet. The NHA said the facility had not created an action plan or performance improvement plan after the stage 4 pressure injuries were identified to evaluate their pressure ulcer prevention program or prevent it from happening to other residents. The COTA was interviewed on 6/2/21 at 6:16 p.m., and said he had worked at the facility for approximately two years and frequently worked with Resident #3. He said he thought the pressure injuries to her right hand were preventable and could have been avoided. When he first started seeing her in March 2021, he did a lot of static stretching and warm packs for her right hand and fingers, and initiated the use of the therapy carrot. He said he had used it in the past with other residents and did not have any problems with it. He demonstrated how the carrot should be placed properly in a resident's hand, how it should be measured, and how the fingers would gradually open up. He said they facility had some success with it with Resident #3, and then it got misplaced. The COTA said he did on-the-spot education with staff with a couple of CNAs on how to put the therapy carrot in her hand properly, and the DON had the documentation for that. The COTA said approximately three weeks ago, a nurse informed him that Resident #3 had stage 4 pressure injuries with bone exposed. He said he believed the therapy carrot could have caused the pressure injuries because of the finger adduction (squeezing together) when the therapy carrot caused her fingers to open up more, and became tighter. He explained her ultimate goal was to get her on a splint, hopefully get some mobility, and use out of her right hand. The COTA said he thought maybe further training on skin assessments was needed for the clinical nursing staff, and stated he could have done a better job with training CNAs to look at her skin. He said he was not informed when the resident developed the stage 2 pressure injuries, and first learned about her skin breakdown after they had progressed to stage 4. The COTA said the therapy carrot was discontinued on all residents after they identified the pressure injuries on Resident #3, until further education for himself and the CNAs could be completed on things to watch for. He said the last training he had provided to the staff was on bed mobility and transfers, but none with the therapy carrot. He said he wanted to talk to the medical director to see if therapy carrots would still be used, and was really shocked that Resident #3's fingers had to be amputated. The medical director (MD) was interviewed on 6/2/21 at 6:38 p.m. He explained by trying to open up Resident #3's right hand contracture, pressure was placed on other parts of the fingers that they just did not see. He said as her fingers were opening up, that pressure on her fingers was what they concluded caused the pressure injuries. He said by the time they identified the pressure wounds, it was on such a thin part of the fingers, that the pressure injuries went straight to the bone quickly. He clarified this resulted in presumed [CONDITION(S)], and the only definitive way to diagnose [CONDITION(S)] was to do an MRI (magnetic resonance imaging), but Resident #3 would not sit through that long enough to conduct the test. He explained that once there was exposure to bone of any ulcers or wounds, you have to assume it was [CONDITION(S)]. The lab work showed her [CONDITION(S)] markers were elevated, and after reviewing the facts with the surgeon, without hesitation, her fingers needed to come off. The MD said once hand contractures started opening up after using therapy devices, the staff might have to do more frequent assessments every

Based on observation, interview and record review, the facility failed to ensure one (#5) of six sample residents and three (#7, #8, and #14) supplemental sample residents received the necessary care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. Specifically: (1) The facility failed to assess, monitor, communicate and address changes in resident #8's abrasion in a timely manner, contributing to the development of a stasis ulcer,[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus), [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED], and resident pain. (2) The facility failed to ensure resident #7 who were receiving [MEDICATION NAME], an anticoagulant, was appropriately managed and monitored per physician's orders [REDACTED]. In addition, antibiotics were not administered in a timely manner. (3) The facility failed to ensure a safe transport (facility van had mechanical failure) from the hospital to the facility for resident #5 after a surgical procedure resulting in necessary, temporary accommodations for resident #5. The resident went without his ordered narcotic pain medications resulting in increase pain. (4) The facility failed to assess and monitor resident #14 when doing self blood glucose testing. The findings include: 1. Resident #8 - Wound and Pain Management Medical record review revealed resident #8, [AGE] years old, was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The resident returned from the hospital during the onsite investigation on 10/26/10. The most recent Minimum Data Set (MDS), dated [DATE], revealed the resident had short-term memory problems and was moderately impaired in the daily skills needed for daily decision-making. The MDS coded the resident as needing the assistance of a staff member in all activities of daily living except eating and with toilet use. The resident was continent of bowel and bladder, was 63 inches tall and weighed 159 pounds. According to the MDS, the resident had no pressure or stasis ulcers. The care plan, last updated on 8/26/10, indicated the resident went to [MEDICAL TREATMENT] three times a week, was at risk for pressures sores, and was at risk for nutritional deficit, impaired skin integrity and pain/discomfort. a. Left (L) ankle wound According to the nurse's note documented on 5/22/10 at 9:00 a.m., the resident stated she scraped her left ankle on the bed frame while climbing out of bed. The nurse documented the area measured 0.5 x 1.0 cm and was treated daily with Hydrogel and a foam spot dressing until healed per physician's orders [REDACTED]. The 6/10 Treatment Administration Record (TAR) indicated that the treatment, dated 5/22/10, was to apply [MEDICATION NAME] and foam dressing to the left outer ankle daily. However, there was no documentation this was being done on any day in June. On 5/27/10, there was a new order for two ounces of Prostat (protein supplement) to be given daily for 30 days. Review of the 6/10 Medication Administration Record (MAR) and the (TAR) revealed no evidence that Prostat was given as ordered. On 5/29/10, the order was changed to, "Clean area on L ankle, pat dry, apply Silver [MEDICATION NAME] 1% (sulfa derivative topical antibacterial). Cover w (with) non adhering dsg (dressing). Wrap with Kerlix gauze bid (twice a day)." On 6/10/10, a nurse documented the "Abrasion to L ankle developed into an ulcer. ...Wound nurse to follow. ..." On 6/24/10, "a follow-up entry", two weeks after the initial documentation (6/10/10) that the wound nurse was to visit, a nurse documented the wound nurse (name of wound nurse) saw patient on 6/22/2010). New orders obtained. ..." On 6/28/10, almost a month after the abrasion occurred, the treatment was changed to cleansing the left ankle wound with normal saline and pat dry. The area around the wound was then to be prepped with skin prep, the wound bed treated with Santyl (an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level) and then cover with oil [MEDICATION NAME] gauze which was then covered with foam. This dressing was to be changed daily. The weekly skin/wound log was requested from the Director of Wellness (DOW) on 10/26/10 and again on 10/27/10. Only the skin/wound logs with dates beginning on 8/4/10 until 9/29/10 were received from the DOW on 10/27/10 at 6:30 p.m. The weekly skin/wound rounds report revealed: -On 8/4/10, the area was classified as an abrasion. (The choices included skin tear, abrasion, rash, [MEDICAL CONDITION] ulcer, burn, open lesion, surgical wound, pressure ulcer, arterial, diabetic neuropathic, and other.) The measurements were documented as 1.25 x 1 cm. -On 8/11/10, the measurements were documented as 1.0 x 1.0 cm. b. Pain at wound site According to the Pain Flow Sheet, the resident was experiencing pain with the left ankle wound. -The documentation revealed the resident received one tablet of [MEDICATION NAME] 5/500 mg on 6/5/10 at 3:40 a.m. and again on 6/25/10 at 1:30 a.m. S/he also received Tylenol 650 mg on 6/25/10 at 12:30 p.m. and again on 6/30/10 at 7:30 p.m. The medications were documented as given for pain in the ankle wound. -The resident was also receiving routine [MEDICATION NAME] 5/500 mg, three times a day, scheduled at 8:00 a.m., at 6:00 p.m. and at 10:00 p.m. (ordered 6/2/10). Neither any nurses' notes documented in 7/10, nor the 7/10 MAR and TAR were received as requested on 10/27/10 from the facility before exit. Therefore, review of the 7/10 TAR could not be completed to ensure the treatment was done as ordered, and if and when pain medications were given. c. Decline in status - Wound Worsening, Pain Increasing, and Mental Status Changes On 8/16/10 at 3:30 a.m., the resident was found on the floor in her room without apparent injuries. At 9:00 a.m., the resident was complaining of weakness, dizziness, and fatigue. At 4:30 p.m., the resident was described as "lethargic." The resident was also being treated with dressing changes on bath days to open areas on the right and left buttock. On 8/18/10, the physician ordered the [MEDICATION NAME] be reduced to a half tablet in the a.m. and a half tablet at bedtime and to report the use of as needed Tylenol on 8/20/10. On 8/24/10, the measurements of the left ankle wound were documented as 1.0 x 1.4 cm. Conflicting information about the "pressure sore" including measurements, description, and if the wound had an odor were found in the nurses' notes documented on 8/23 and 8/24/10. -A nurse documented on 8/23/10 at 8:30 a.m., "Pressure wound on L ankle was evaluated today. Wound bed measures 1.5 x 1.75 cm. Bed is covered with yellow slough. Edges are red and appear soft and macerated. Posterior wound edges have a small, excoriated area, 0.2 cm. Dressing applied by (name of nurse) LPN (Licensed Practical Nurse) Will continue to monitor. No pain or odor reported." -The same nurse documented on 8/24/10 at 11:45 a.m., "Pressure wound on L ankle was evaluated by (name of wound nurse) R.N. wound nurse. Wound bed measures 1.0 x 1.4 cm. It is covered with yellow slough. Edges are inflamed, mildly [MEDICAL CONDITION]. The wound bed has an odor. Wound nurse (consultant) recommends oral abax (antibiotic). (Name of physician) notified, ordered L ankle x-ray to rule out osteo[DIAGNOSES REDACTED]. ..." -Documentation by the wound nurse consultant, dated 8/24/10, indicated the wound was a full thickness wound located on the left lateral malleolus and the etiology was "friction and sheer." The wound nurse documented there was no tunneling or undermining; however, there "was minimal exudates, [MEDICAL CONDITION] drainage with a PUSH score of 8." Professional Reference Use of the PUSH Tool to Measure Venous Ulcer Healing VOLUME: 51. Issue Number: 5. author: Catherine R. Ratliff, PhD, APRN-BC, CWOCN; George T. Rodeheaver, PhD. "Wound assessment is critical to monitoring the effectiveness of treatment in chronic wounds. Accurate and comprehensive wound assessment depends on meticulous and consistent clinical observations and quantitative measurements. Regular assessments quantify and document progress and guide further treatment decisions. Terminology describing wound assessment is not standardized, nor has consensus been reached on the most appropriate wound healing parameters to monitor. In clinical practice, regular wound assessment using the same technique is the only way to monitor healing outcomes. A tool to assess the healing progress of a venous ulcer over time is lacking. The Pressure Ulcer Scale for Healing (PUSH) tool was introduced in 1997 by the National Pressure Ulcer Advisory Panel (NPUAP) to monitor the healing of Stage II through Stage IV pressure ulcers. 1 The PUSH tool consists of three parameters: length x width; exudate amount (none, light, moderate, and heavy); and tissue type (necrotic tissue, slough, granulation tissue, [MEDICATION NAME] tissue, and closed). Each parameter is scored and the sum of the scores yields a total wound score. Scores range from 0 (healed) to 17 (worst possible score). Observation of the changes in the direction and magnitude of the score over time indicates whether the wound is healing. Because the PUSH tool involves only three parameters, it is quick and easy to use. The tool and instructions for use are available from the NPUAP website, www.npuap.org.2 " According to the nurse's notes and the 8/10 MAR, the resident was receiving [MEDICATION NAME] 5/500 mg routinely at 8:00 a.m. 6:00 p.m. and at 10:00 p.m. for pain. In addition, the resident received a tablet of [MEDICATION NAME] 5/500 mg on 8/2 at midnight, 8/4 at 4:00 a.m., 8/6 at 1:25 a.m., 8/7 at 3:00 a.m. for leg pain with no relief, on 8/24 at midnight, on 8/25 at 12:15 a.m., and on 8/29/10 at 3:00 a.m. The nurses did not specify where the pain was located on 8/2, 8/4, 8/6, 8/24 and 8/25/10. The resident also received 650 mg of Tylenol on 8/7 at 3:30 a.m., 8/19 at 2:10 a.m. (effectiveness not documented), on 8/24 at 4:20 p.m., and on 8/28/10 at 3:30 p.m. for leg pain. In addition, despite the ankle wound getting larger, draining purulent exudate and described as red and swollen, the dressing change ordered (on 6/28/10), two months earlier was changed from daily to bath days (Mondays and Thursdays) on 8/16/10. According to the telephone orders, the physician on 8/26/10 ordered, Keflex 250 mg orally three times a day for seven days. On 8/27/10, the ordered x-ray of the left ankle was completed (as ordered on [DATE]) to rule out osteo[DIAGNOSES REDACTED]. The findings were, "consistent with erosions of the first distal phalanx volar aspect and the fifth metatarsal head. These would be consistent with osteo[DIAGNOSES REDACTED] in the proper context. There is however profound osteopenia which compromises the exam. Correlate with bone scan as indicated." There was no evidence of further testing (bone scan) completed. There was no evidence of a wound culture being done. The 9/01/10 Weekly Skin/Wound Rounds reports revealed the documented measurements of the wound as 3 x 2 cm. On 9/6/10, a nurse documented the "wound on the resident's ankle appears to be still infected. Wound bed measured 2 cm x 1.5 cm, with surrounding area reddened and tender to touch. Tenderness and pain extend to upper calf. (Name of physician) was notified, ordered [MEDICATION NAME] 500 mg po q day x 10 days, consult with vascular specialist (name of specialist) and wound consult with (name of a different wound consultant)." On 9/08/10, the measurements were documented as 1.5 x 1.2 cm. On 9/11/10 at 10:29 a.m., a nurse documented the resident stated, "ankle hurt throughout night but is not hurting as bad in am." On 9/12/10 at 1:18 p.m., the resident stated according to the nurse's note, the "ankle was throbbing in middle of night. Ankle and foot are swollen and hurting in a.m." The nurse also documented the resident stated, "it is not as sore as yesterday." The nurse continued to document that the scheduled pain medications were given and the pain had decreased later in the a.m. On 9/15/10, the measurements (per Weekly Skin/Wound Rounds form) were documented as 3 x 2 cm. According to nurse's notes documented on 9/15/10, the resident complained of more pain and the wound appeared "with more redness." According to the nurse's note documented on 9/21/10, the resident missed an appointment with the physician and when the MPOA (medical durable power of attorney) was informed of this, relayed her concern of the resident's pain and infection in the left ankle. The nurse documented the "resident not able to tolerate contact with leg; wound is foul-smelling." The physician was notified and the resident was sent to the ER (emergency room ) on 9/22/10. The nurse documented that an [MEDICATION NAME] dressing was applied and needed to be changed on 9/23/10. "No osteo[DIAGNOSES REDACTED] noted in ER." On 9/28/10, the resident was described as "lethargic," "confused all day," "chewing on her O2 cord," and "mumbling and not making sense." According to a nurse's note, the resident had a consult with a physician assistant (PA) on 9/28/10. The nurse documented the wound's dressing was now to be changed daily (instead of only on bath days) and the resident was to see the wound nurse on 10/20/10. The treatment for [REDACTED]." On 9/29/10, the measurements were documented as 3.5 x 2 cm. There was no further evidence of the wound description, drainage or odor. On 9/30/10 at 2:00 p.m., the nurse documented the resident had been with "increased confusion and somnolence. Family concerned about her confusion and non-responsiveness." The physician was notified and ordered to hold the [MEDICATION NAME] for seven days and to give Tylenol 650 mg instead in the am and at HS. On 10/4/10 at 3:35 a.m., a nurse documented the resident had no relief from the leg pain after Tylenol 650 mg was administered. The physician then ordered one time dose of one half tablet of [MEDICATION NAME] 5/500 mg. On 10/5/10, Keflex 500 mg was ordered for seven days to be given twice a day. On 10/9/10, a nurse documented at 10:09 a.m. the ankle wound had a "foul smell" to it when the bandage removed. Wound is growing and has a yellowish slough in the middle with dark red skin surrounding wound. ..." The resident was documented as very confused on 10/9/10 at 8:30 p.m. At 12:47 p.m. on 10/10/10, the resident was "still lethargic in a.m. mumbling and slurring words. ...Res. states she has some pain in ankle but not bad. ..." On 10/11/10, the resident was documented as "having hallucinations in the am and mumbling incoherent (ly). ..." On 10/12/10 at 3:26 p.m., a nurse documented the resident was "still lethargic." The nurse also documented the "Ankle sore still has a small odor to it and resident states it hurts." On 10/15/10 at 2:07 p.m., a nurse documented the night nurse reported the resident was talking to her/his son who was not present. The nurse also documented the left ankle sore was still odorous, and the area around the ankle was red and tender. At 10:00 a.m., the same day a nurse documented the resident's appointment with the wound nurse had been rescheduled for 11/3 in order to see first a vascular specialist. There was no evidence that the facility contacted the physician about the continued confusion. There was no evidence the facility tested the resident's blood sugar to see if it was in acceptable parameters. On 10/15/10 at 9:55 p.m., the medical director wrote orders to schedule Tylenol 325 mg twice a day and to discontinue the [MEDICATION NAME]. The medical director also ordered a dermatology consult- biopsy ulcer of the left ankle. On 10/16/10 at 3:01 p.m., the nurse documented the resident "was confused all day." On 10/17/10, a nurse documented the resident did not respond verbally or follow verbal commands. The resident was sent to the hospital at 12:02 p.m. that same day (at family's insistence-see interview below). On 10/26/10, the resident returned from the hospital with a wound vac in the left ankle wound. According to the hospital discharge summary report, dated 10/26/10, the resident [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED] in the ankle wound. 2. Interviews On 10/26/10 at 8 p.m., a family member was interviewed. The family member stated the family was unaware the ankle wound was so severe until another family member insisted upon seeing the wound. The family member stated the wound was deep and smelled of rotten flesh. The family member stated it was then the family insisted the resident be sent to the hospital. The family member also stated that the resident had so much pain from the wound that she was given [MEDICATION NAME] all the time and then she became groggy. The family went on to say that the resident had an appointment with a wound consultant; however, she never made that appointment. On 10/27/10 at 4:52 p.m., the Director of Wellness (DOW) was interviewed. The DOW stated the wound was not a pressure sore as the facility nurses documented; rather, it was a stasis ulcer. The DOW confirmed the wound started as an abrasion several months ago and she felt the facility did everything they thought they needed to do, including doing a vascular study and ruling out osteo[DIAGNOSES REDACTED]. When asked about the treatments to the wound, she stated the physician wanted wet to dry. On 10/27/10 at 6:00 p.m., resident #8 was interviewed. She stated when staff changed the dressing around the wound vac (since her return from the hospital), she cried with pain. When asked if the staff had given her pain medication, she replied, "Not until after the dressing change." Another family member was interviewed on 11/ 2/10 at approximately 10:32 a.m. She stated the facility would call with treatment changes and when the resident fell ; however, she said she never realized the seriousness of the wound until another family member was allowed to actually see the wound. She did say she had concerns with the facility transportation system and appointments for her mother that were cancelled because of van problems or van scheduling. The family member stated the family had to transport the resident in their car which they did on 10/26/10 when she returned from the hospital, which was extremely uncomfortable for the resident. 3. Resident #7 - [MEDICATION NAME] Management Medical record review revealed resident #7, [AGE] years old, was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. a. Resident status The most resent MDS, dated [DATE], revealed the resident had short-term memory impairments and had modified independence with the cognitive skills needed in daily decision-making. The resident was independent in all activities of daily living and had no behaviors. The resident was coded as usually continent of bowel and continent of bladder. The resident was 66 inches tall and weighed 176 pounds according to the MDS. Review of the resident's care plan, dated 8/29/10, indicated the resident had potential for abnormal bleeding or hemorrhage because of anticoagulant usage. The goals were listed as: -Resident will be free from signs and symptoms of abnormal bleeding through the next review date (90 days was handwritten in). -Resident's PT and INR values will be maintained within the therapeutic range, as determined by their physician through the next review date (90 days was handwritten in). -Resident currently attends the [MEDICATION NAME] clinic (on Tuesdays) and is also checked at the facility (7/19/10). -Keep INR between 3.0 and 3.5 (8/26/10). Approaches included: -Administer anticoagulant as currently prescribed by the resident's physician. -Monitor for and report to nurse any of the following s/s (signs and symptoms) bleeding: Bleeding gums, nose bleeds, unusual bruising, tarry, black stools, and pink or discolored urine. -Report to the physician any S/S abnormal bleeding or hemorrhage, and -Educate resident/responsible party on benefits and potential risks of anticoagulant drug use. Review of the 8/10 MAR revealed the resident was receiving 5 mg of [MEDICATION NAME] on Monday, Wednesday, Friday, Saturday and Sunday and 2.5 mg on Tuesday and Thursday. b. Failure to consistently ensure resident #7's [MEDICATION NAME], an anticoagulant, was appropriately managed and monitored per physician's orders [REDACTED]. According to the PT/INR flow sheet, the INR was documented as 3.1 on 7/27/10 with no change in dosage. According to the copies of the 8/10 MAR received from the facility, there was no documentation any [MEDICATION NAME] was given on 8/1 and 8/2/10. On 8/3/10, the INR was documented as 1.3. The new orders included to give one dose of [MEDICATION NAME] 10 mg po 8/3/10 only and to give [MEDICATION NAME] 5 mg daily and to recheck the INR again on 8/5/10. The INR was documented as 1.6 on 8/5/10. The physician's orders [REDACTED]. The INR on 8/10 was documented as 2.4. The orders were then to give 10 mg of [MEDICATION NAME] on 8/10/10 and then to continue with the same dose as previous (5 mg every day except Sundays when 7.5 mg was to be given) and to recheck the INR on 8/16/10 at the clinic. The INR was documented as 2.6 on 8/16 and the orders were to continue the same dose and to recheck the INR on 8/23. The INR was documented on 8/23 as 2.3. The orders were to give 5 mg of [MEDICATION NAME] every day except 7.5 mg on Wednesday and Sunday. The copies of the 8/10 MAR requested and received from the facility did not show that any [MEDICATION NAME] was given after 8/23/10. The telephone order (TO) was to recheck the INR on 8/31 at the clinic. The documented INR on 8/31 was 3.2. The 8/31 TO was to continue the same dose of [MEDICATION NAME] every day except 7.5 mg on Wednesday and Sunday and to recheck the INR on 9/7/10. Review of the 9/10 MAR revealed two entries of [MEDICATION NAME] revealing that 7.5 mg of [MEDICATION NAME] was documented as given on 9/1/10 (Wednesday) and that an additional 2.5 mg of [MEDICATION NAME] (a total of 10 mg was given). On Thursday, Friday, Saturday, and Monday, 5 mg were documented as given as ordered with 7.5 mg documented as given on Sunday. On Tuesday, 9/7/10, the INR was elevated and documented as 5.4. The [MEDICATION NAME] was to be held on 9/7/10, 2.5 mg was to be given on 9/8/10, and then the INR was to be rechecked on 9/9/10, which was documented as done. The INR was documented as 3.1 and the same dose (5 mg of [MEDICATION NAME] every day except 7.5 mg on Wednesday and Sunday) was to continue. The INR was to be recheck on 9/14/10 at the clinic. On 9/14/10, the INR was documented 3.0 and the current dose continued with the next INR to be drawn on 9/21/10 at the facility. The 9/21 INR was 4.3 and was reported to the clinic with orders to hold the [MEDICATION NAME] on 9/21/10 and resume on 9/22/10 and recheck the INR on 9/24/10. A note in the nurse's note documented the facility did not draw the INR on 9/24/10 ("d/t not written in the MARS") as ordered; however, it was drawn on 9/25/10 (2.8). The INR was to be rechecked on 9/28/10 at the clinic. The nurse's note documented on 9/28/10 (Tuesday) that the resident missed the appointment at the clinic. The clinic gave orders to check the INR at the facility and report the results to the clinic. The 9/28/10 INR results were documented as 3.4 and the current dose was ordered to be continued with the INR to be rechecked on 10/5/10. The clinic INR results of 10/5/10 were documented as 3.9. The clinic orders were to "Hold 2.5 mg dose on 10/5/10 then to continue with 5 mg daily except on Wednesday and Saturday when 7.5 mg was to be given and to recheck the INR at the clinic on 10/12." According to the 10/10 MAR, there were initials in the 10/5 (Tuesday) dated square that one tablet 5mg of [MEDICATION NAME] was given. However, there was a hand written entry above the dated initialed square that 2.5 mg was held. On 10/6/10, a clarification order was written to withhold 2.5 mg of [MEDICATION NAME] for 10/5 and to resume the current dose (5 mg daily except on Wednesday and Saturday when 7.5 mg was to be given). The 10/12 INR was documented as 4.4 and the orders were to hold [MEDICATION NAME] that day and then resume the current dosage and recheck the INR on 10/15/10. The [MEDICATION NAME] was held on 10/12 and 7.5 mg was given on 10/13 as ordered and 5 mg on 10/14/10. On 10/15/10, the INR was documented as 3.9. The clinic ordered 2.5 mg to be given on 10/15 and then to resume the current dose and to recheck the INR on 10/19 at the clinic. c. Failure to administer antibiotics timely The resident was bitten by the facility bird and went to the physician on 10/19. [MEDICATION NAME] 875 mg (an antibiotic) was ordered on [DATE]; however, it was not started until 10/21/10, two days later. d. Interviews A family member was interviewed on 10/26/10 from 1:30 p.m. until approximately 5:00 p.m. The family member stated the resident was to attend the [MEDICATION NAME] clinic on Tuesdays; however, the facility would forget to take her or the van was not available. The family member continued that she felt she needed to check on the resident's INR almost daily to make sure the facility was doing the INRs and/or giving the ordered doses of [MEDICATION NAME] correctly. 4. Resident #5 - Pain Management a. Policy The facility's policy for "Pain Management" was requested and received on 9/23/10 from the Director of Wellness (DOW). According to the policy, "Residents will receive pain management based upon their individual needs." The purpose of the policy was stated as, "To ensure comfort for Residents and manage pain." Under procedure were the following: 1. Staff assesses the presence of pain upon admission, on discharge, at each of assessment intervals, and/or self-reporting of pain. 2. The pain assessment tool will be utilized. 3. Based on the assessment, work with the resident's family and physician to develop an approach to pain management which may include both Pharmacological and behavioral components area 4. Document interventions and outcomes on the resident service and health plans using intensity scale to record pain levels, prior to and after interventions. 5. Reassess at least every 72 hours to determine effectiveness, comfort and the need for continuance and/or change of medication. 6. Training was provided by the licensed nurse or designee regarding pain management. b. Resident #5 Medical record review revealed resident #5, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], revealed the resident had no memory impairments and was independent in the cognitive skills for daily decision-making. The resident was independent in all activities of daily living and coded as continent of bowel and continent of bladder. The resident was 59 inches tall and weighed 83 pounds. The comprehensive care plan, last updated on 8/2/10, revealed the resident was care planned for pain. Some of the approaches listed were: -Administer medications as ordered, and -Monitor the resident for signs and symptoms of pain c. Record review Review of the medical record revealed the resident had the removal of hardware from the left hip and returned to the facility on [DATE]. According to interviews the resident was discharged from an area hospital on [DATE], and was to be transported back to the facility by the facility's van. However, the facility's van had mechanical problems and the resident spent the night at a sister facility without his post surgical narcotic medications which were unavailable due to the holiday week-end. Review of the sister facility's documentation of the overnight visit verified that Tylenol was the only pain medication given even though the hospital discharge orders revealed orders for a [MEDICATION NAME]. d. Interviews The resident was interviewed on 10/26/10 at 4:30 p.m. He stated he remembered the trip back from the hospital and spending the night in an unfamiliar place. He stated he remembered he had a lot of pain and only received Tylenol. "I won't go back." A family member interviewed on 10/27/10 at approximately 11:00 a.m., stated the resident had a lot of pain and needed to reposition frequently in the van. The family member stated the needed narcotic pain medications were not available to the resident during his overnight stay at the sister facility. She stated the resident was quiet (does not voice his concerns) in unfamiliar situations and she was not allowed to spend the night with her relative. 5. Resident #14 - Failure of Assessment and Monitoring of Self Monitoring of Blood Sugars. Medical record review revealed resident #14, [AGE] years old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE], revealed the resident had short-term memory impairments and had modified independence in the cognitive skills used in daily decision making. The resident was independent in all activities in daily living, was continent of bowel and bladder, was 65 inches tall and weighed 239 pounds. a. Record review Review of the 10/10 Computerized physician's orders [REDACTED]. In addition, the resident was on a sliding scale for [MEDICATION NAME] insulin. The orders indicated the resident received 8 units sub-Q three times a day after meals of [MEDICATION NAME] 100 units/ml and received 53 units of [MEDICATION NAME] 100 units/ml sub-Q at bedtime. Review of physician orders [REDACTED]. Review of the care plan revealed no indication of self-monitoring of blood sugars. Further review of the medical record revealed no assessment of self testing of blood sugars. There was no documentation that the facility had provided any education or instruction in self-testing of blood sugars. b. Observations On 10/28/10 at approximately 12:19 p.m., resident #14 was observed to walk up to the medication cart, insert a test strip in the glucometer and use a lancet to prick his finger. He then was observed to test the first drop of blood he obtained and announced that his blood sugar was 230. The nurse assigned to the medication cart was observed (with another nurse) taking vitals on a resident seated in the hallway near the medication room and the front lobby. There was no attempt to stop the resident when he tested the blood sugar, other than the nurse stated, "You can't wait for me?" The nurse was not observed to retest the resident blood sugar level. On 10/28/10 at approximately 2:00 p.m., the DOW stated the resident had not been assessed to do his own blood sugars. The DOW added the resident had never previously attempted to test his blood sugar.

Based on observation, staff and physician interview and record review, the facility failed to provide adequate pressure ulcer prevention and management for three of 13 sample residents (#1, #7, #8). Specifically, the facility failed to consistently accurately assess, monitor, implement interventions and provide adequate pressure ulcer prevention and management for these residents. These failures contributed to resident #7 developing a Stage III pressure ulcer that required surgical intervention and ongoing treatment. This pressure ulcer remained unresolved through the survey; nine months from the date of onset. The findings include: 1. Resident #7 Resident #7, an [AGE] year-old male, was originally admitted to the facility on [DATE] and readmitted on [DATE], after a hospitalization for a condition unrelated to his pressure ulcers. His [DIAGNOSES REDACTED]. Review of resident #7's record was initiated at 9:02 a.m. on 4/20/10. The Minimum Data Set assessment dated [DATE], revealed resident #7 had no memory loss and modified independence in cognitive skills for daily decision-making, required assistance with transfers, dressing, hygiene and bathing, used wheelchair for mobility, was incontinent of bladder and had one stage III pressure ulcer. a. Observation and interview At 2:11 p.m. on 4/19/10, resident #7 was observed sitting on the side of his bed while a Registered Nurse (RN) was applying a dressing to his right heel. -The RN stated resident #7 had undergone an I&D (irrigation and debridement - surgical intervention) about a month ago to the pressure ulcer on his heel. -Resident #7's bed was not a pressure-reducing mattress and the nurse did not apply any sort of protective boot after she changed his dressing; rather, the nurse applied a pair of white socks with a knitted-type slipper over the resident's foot. An observation of the room contents and bathroom revealed no heel boots in sight. Resident #7 participated in the group interview at 10:30 a.m. on 4/20/10. He was observed to have socks with knitted-type slippers on both feet that were resting on the footrest of his wheelchair. He was not wearing heel protective boots. On 4/20/10 at 4:11 p.m. resident #7 was observed in the hallway sitting in his electric wheelchair. He wore no shoes or protective boots and both of his feet, including his heels, were resting on the footrest of his wheelchair. He was not wearing heel protective boots. At 10:35 a.m. on 4/22/10, resident #7's pressure ulcer was observed during a dressing change performed by an RN. The wound was clean with no apparent drainage present. There was no evidence of infection. The granulating tissue formed jagged edges around the circumference of the wound. Resident #7 said, "It's finally healing up . . . No, it doesn't hurt . . . My doctor told me that maybe next week I can wear regular shoes again." b. Record Review The Admission Nursing assessment dated [DATE] assessed resident #7's skin condition and noted "multiple bruises" and a surgical incision which was attributed to "gallbladder surgery." There was no documentation to indicate that resident #7 had skin issues on his heels upon admission to the facility. He was full-weight bearing and used a walker to ambulate. The Dehydration/Skin Assessment, dated 6/24/09, indicated resident #7's skin condition was assessed as "turgor adequate, skin moist." There were no "pressure ulcers present or H/O (history of)." On the Braden Scale - For Predicting Pressure Sore Risk with assessment date 6/24/09, resident #7 was scored 20, which meant he was low risk to acquire pressure ulcers where a "Total score of 12 or less represents HIGH RISK." His most recent Braden Scale on 2/28/10, scored him with an 18 (mild risk). Although assessed at low-mild risk to develop pressure ulcers, the resident developed Stage III pressure ulcers (see details below). According to the undated Colorado Foundation for Medical Care's "Classifications of Pressure Ulcers" pocket-guide, Stage III pressure ulcers are "Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue." Upon admission, resident #7's "Interim Plan of Care", dated 6/24/09, failed to complete the Skin Integrity section and preventive skin care was not addressed. The "Risk for Pressure Ulcer" care plan, initially dated 9/21/09, read "Resident is at risk for developing a pressure ulcer related to Braden Scale score of 15 (mild risk) on 12/6/09 and score of 18 on 2/23/10, decreased mobility and incontinence." -Hand written was "area on coccyx intact and red" - no date and area on right heel intact and red - again not dated. Also written in was "use of heel boots while in wheel chair" - no date. -The approaches included "complete weekly skin assessment, report changes in skin status to physician, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care, monitor lab results as ordered and report abnormal results to physician." -Also included in the approaches were "pressure reduction mattress, Roho air cushion, float heels in bed (heel boots), provide incontinence care after incontinence episodes, 10/1/09 1 can of Glucerna at lunch, 11/30/09 D/C Glucerna in one month, 1/20/09 1 oz. Prostat BID, 3/10/10 4 oz. juice BID." -Interventions on the care plan read, 3/23/10 "Debrided by MD. Wound healing. Continue to float heels." On 7/9/09, the Daily Skilled Nurses Notes first mentioned the condition of resident #7's heels. The description stated, "Non-blanchable bilateral dark purple areas to heels. Left heel dry skin, all areas intact." There was no documentation of notification of the physician, the Director of Nursing (DON), or the family member of this finding. On 7/10/09, the Daily Skilled Nurses Notes documented, "Resident has bilateral non-blanchable areas on right and left heels, intact no drainage. Apply heel protectors while in bed, allow feet to float, instruct CNA's (certified nurse aides) to reposition frequently." The instruction to reposition "frequently" failed to include specific measurable frequency, such as every two hours or four times per shift. There was no documentation that resident #7 was repositioned or reminded to reposition himself. Resident #7's Nurses Notes, Wound Care Skin Integrity Evaluation Forms (completed by the wound nurse consultant), Weekly Skin Assessments, Physician Faxes and Telephone Orders sheets and Wound/Skin Healing Records were reviewed from 7/10/09 until date of survey, 4/20/10. These records documented the deterioration in skin integrity, the multiple assessments and myriad treatments provided for resident #7 to treat his right heel wound. Almost without exception, the wound nurse consultant would order (co-signed by the physician), "Keep heel protectors on at all times" There was a physician's orders [REDACTED]." This was transcribed on the MAR as an FYI (for your information) and not as an order. During an interview with the new DON at 1:00 p.m. on 4/20/10 she confirmed this finding and remarked, "I checked on the MAR and it (the order to float heels) was an FYI . . . it should have been transcribed as an order. . . the nurses should have caught that . . . Yes we do have 24-hour chart checks by our nurses." Resident #7's MARs for the last six months were reviewed. There was no documentation on the MARs that the nursing staff had routinely monitored whether or not the resident's heels had been floated with heel boots in order to prevent further skin breakdown. Review of the Daily Skilled Nurse's Notes and then Nurse's Notes from 7/9/09 to 4/20/10, also documented infrequent, inconsistent application of the physician orders [REDACTED]. c. Interviews Resident Interview: Resident #7 was interviewed at 2:22 p.m. on 4/21/10. Regarding his pressure sore, he related, "First I got a sore foot. How? . . . I was almost paralyzed from that spider bite when I first came in. I could not move . . . I don't remember if they turned me or not. I think I had an air mattress for a while but some girl (Resident #7 was unable to remember who) wanted it so she took it away . . ." When asked if the CNAs kept his heels from touching the mattress when he was in bed, resident #7 replied, "Most of the time I think they do with a pillow or two . . . of course, I don't know when I'm sleeping . . . once in a while they had me wear those boots . . . I'm not sure where they are." Physician Interview: At 12:28 p.m. on 4/22/10 the facility's Medical Director was interviewed. He stated, "Residents with pressure ulcers are discussed routinely during the monthly QA (quality assurance) meetings with the IDT (interdisciplinary team). We talk about nutrition, pressure relief, overlap mattresses, cushions . . . My contribution has been in educating staff and other docs . . . I recall, in his (resident #7's) case, (the facility's DON) got (a wound care nurse) involved in his care." Staff Interviews: On 4/20/10 at 1:00 p.m., the Director of Nursing (DON) (until 4/19/10), the Nursing Home Administrator (NHA), the corporate clinical consultant and the new DON (as of 4/19/10) were interviewed. -When asked to explain the process for assessment, intervention determination and implementation for prevention of pressure ulcers, the prior DON replied, "Usually we determine what the ulcer is (stasis or pressure) . . . We do an incident report, fax the MD (doctor) and get orders . . . We have a certified wound nurse who comes from Denver . . . she's contracted and comes on Thursdays, she writes the recommendations and we fax them to the MD for approval and she takes care of ordering the treatment supplies (for pressure ulcers.)" -The NHA stated, "We had a wound nurse until recently . . . she was to do weekly measurements and assessment . . . part of the reason we terminated her was that things weren't being followed up . . . then we had a couple of nurses doing it (wound care) and then (the Staff Development Coordinator) was covering it." -The new DON related, "The plan is, I'll be doing the measuring and QA piece and start tracking them and provide a weekly report to the regional directors." During this interview, the former DON also stated, "Not long after he (resident #7) came in, he was wheelchair bound and not moving much. We discovered bilateral heel ulcers and one of them resolved (on 11/6/09 according to the Wound Healing Record) and we're still treating the other one . . . " The new DON added, "Actually, I believe the nurse (that was terminated) was staging them incorrectly . . . If the wound is covered with thick black eschar it should be considered unstageable." -The corporate clinical consultant stated, "When admitted , we follow their skin assessments and perform Braden Scale assessment once a month for the first month. The DON submits a weekly report from which a report is generated every month. That report generates a graph to assist in identifying educational needs and provides tracking." -The NHA explained, "When identified, they (pressure ulcers) are reported to the nurse and an incident form is completed . . . the presence of pressure ulcers is also reported in our morning meetings as well. We have really come a long way with wounds; staff have received more education about staging and pressure relief . . . We have also introduced new barrier and peri-care products and have started applying lotion to heels of the feet . . . Also we've recently [MEDICATION NAME] protein powder, increased the number of health shakes and Magic cups as well. We follow all wound progression in our monthly QA meeting." d. Policy and Procedure The facility's "Nursing: Pressure Ulcer Program", dated 12/27/05, was submitted for review at 3:05 p.m. on 4/20/10 by the corporate clinical consultant. The policy reads in pertinent part: Policy: Individuals who are admitted to the facility without a pressure ulcer will have preventative measures to prevent pressure ulcer development. Individuals who develop pressure ulcers due to an unavoidable clinical condition, or are admitted with a pressure ulcer will receive appropriate care and services to promote healing and to prevent additional ulcers. Purpose: To maintain skin integrity toward the highest practicable quality of life. Procedure: Prevention of Pressure Ulcers: Upon admission - 1. Determine Risk: Assess the individual's pressure ulcer risk by using the Braden Pressure Ulcer Scale. 2. Assess Skin: Conduct a thorough skin assessment and document on the Skin Assessment Form . . . 3. Care Plan: Start an acute care plan for any skin problems noted. 4. Make appropriate referrals: . . . notify physician, make referral to Restorative Department . . . make a referral to the Registered Dietician. 5. If an ulcer is present, begin the Daily Monitoring Sheet . . . 6. Comprehensive Care Plan: The interdisciplinary team will create a comprehensive skin care plan . . . treatment of [REDACTED]. When a pressure ulcer is present: 1. Complete a comprehensive assessment (Document on the Weekly Pressure Ulcer Healing Assessment) . . . 2. Care Plan: Develop an interdisciplinary plan of care utilizing the Pressure Ulcer or Skin Problem Template. 3. Treatment: Provide dressing and treatments as ordered by the physician and per the plan of care, document on the Daily Monitoring Sheet . . . 4. Weekly Documentation of the Pressure Ulcer should be done on the Weekly Pressure Ulcer Healing Assessment during wound rounds with the wound nurse or the DON . . . 5. Report any worsening in pressure ulcer conditions to the Physician." The facility failed to timely and consistently intervene to prevent resident #7 from developing a Stage III pressure ulcer on his heel and once the ulcer developed implement planned and ordered measures to promote healing. 2. Resident #8 Resident #8, an [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of resident #8's record was initiated at 2:50 p.m. on 4/20/10. The admission Minimum Data Set assessment, dated 1/8/10, revealed resident #8 had both short- and long-term memory loss and modified independence in cognitive skills for daily decision-making, required assistance with transfers (manual lift), dressing, hygiene and bathing, used wheelchair propelled by others for mobility, was incontinent of bowel and bladder and had no pressure ulcers. a. Observations At 8:45 a.m. on 4/20/10, resident #8 was observed sitting in her wheelchair in her room. She had white socks on her feet and they were resting against the footplate attached to her wheelchair. She was not wearing foam boots to relieve heel pressure. On 4/20/10 at 2:50 p.m. resident #8 was observed lying supine (on her back) on top of her peripheral-defining mattress. Her eyes were closed and she was snoring lightly. There was one pillow under her legs, positioned at mid-calf; her feet extended beyond the edge of the pillow and both heels were resting directly on the bed. She did not have foam boots on. Later, on 4/20/10 at 6:10 p.m., resident #8 was observed sitting in her wheelchair in the dining room. She did not have foam boots on and her heels were resting on the footplate on her wheelchair. The following morning (4/21/10), resident #8 was observed again in her wheelchair in the dining room. She was wearing socks; her heels were resting on the footplate on her wheelchair. b. Record Review In resident #8's History and Physical (from the hospital) and dated 12/22/09, the physician included an assessment of the resident's skin, "Without breakdown or rashes. There are senescent (age-related) changes . . ." The Admission Nursing assessment dated [DATE] assessed resident #8's skin condition and noted "multiple bruises." There was no documentation to indicate that resident #8 had skin issues on her heels upon admission to the facility. On the Braden Scale - For Predicting Pressure Sore Risk with assessment date 12/25/09, resident #8 was scored 16 which meant she was at mild risk to acquire pressure ulcers where a "Total score of 12 or less represents HIGH RISK." Her most recent Braden Scale on 4/1/10, scored her with a 16 (mild risk). Although resident #8 was assessed to be at mild risk to develop pressure ulcers, she developed a Stage II pressure ulcer on her heel (see details below). According to the undated Colorado Foundation for Medical Care's "Classifications of Pressure Ulcers" pocket-guide, Stage II pressure ulcers are, "Partial-thickness skin loss involving the epidermis or dermis. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater." The "Risk for Pressure Ulcer" care plan, initially dated 1/5/10, stated "Resident is at risk for developing a pressure ulcer related to Braden Scale score of 16 (mild risk) on 12/25/09 and score of 15 on 4/1/10, decreased mobility, nutritional status and incontinence." -Hand written was "Left heel with eschar." - no date and "Left heel with slough." again not dated. Also written in was "foam boots bilat to relieve pressure" and float heels/off load at all times" - no date. -The approaches included "complete weekly skin assessment, report changes in skin status to physician, monitor lab results as ordered and report abnormal results to physician provide diet as ordered and monitor nutritional status, assist PRN to reposition/shift weight, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care, provide pressure relieving or reduction device, pommel positioning foam cushion and wound care as ordered." -Also included in the approaches were "float heels when in bed, wound care as ordered, minimize pressure over boney prominences, provide incontinence care after incontinence episodes, 8 oz. can of Glucerna BID, 3/25/10 1 oz. Prostat QD (every day), multivitamins, menu [MEDICATION NAME] protocol." Interventions on the care plan stated, 3/23/10, "Eschar with slough present, eschar about to come off of wound. Nurse recommendations to MD." and 3/24/10, "Received wound care orders." The Nurses Notes revealed the first mention of the condition of resident #8's heels on 1/11/10 at 6:30 p.m., "A blister 4.5X4.5cm, was found on resident's left heel by CNA this afternoon. Blister is fluid-filled and clear, with a smaller dark area in the center, measuring 1.5X1.5 cm. The area was painful to touch. Skin-Prep was applied o the heel. Foam boots to be worn to prevent pressure. (Doctor) was informed by fax and orders were requested for treatment and foam boots. Daughter was notified by phone . . ." On 1/13/10 at 10:05 a.m. Nurse's Notes documented, "IDT (interdisciplinary team) review. Resident to wear foam boots at all times. Reasonable to conclude that blister occurred from weight of foot resting on bed and/or foot pedals." The first Wound/Skin Healing Record was dated 1/21/10 and resident #8's heel ulcer was staged a Stage II. The most current Nurses Notes relating to wound care were dated 4/17/10 at 1:00 p.m. "Dressing changed to L heel; small amount of yellow slough remains, no signs of infection. Wound improving. Resident voiced no pain during dressing change. Will continue to monitor. " Resident #8's Nurses Notes, Wound Care Skin Integrity Evaluation Forms (completed by the wound nurse consultant), Weekly Skin Assessments, Physician Faxes and Telephone Orders sheets and Wound/Skin Healing Records were reviewed from 1/11/10 until date of survey, 4/20/10. These records documented the appearance of skin integrity compromise on 1/11/10, the assessments and treatments provided for resident #8 to treat her right heel wound. A Physician's Telephone Order sheet dated 1/13/10 at 1:00 p.m. included the relevant orders: "1. Sure-prep to blister on L heel Q day. 2. Foam boots bilaterally to relieve pressure from heels . . ." The April 2010 Computerized Physicians Orders (undated) included "Apply heel protectors to bilateral feet while res. is in bed only." As with resident #7, this order for heel protectors was transcribed on the MAR as an FYI (for your information) and not as an order. A CNA who routinely cared for resident #8 was interviewed at 9:55 a.m. on 4/22/10. She stated that she placed two pillows under resident #8's legs and "you have to make sure her heels aren't touching the bed or in her wheelchair touching the foot rest." There was no documentation that staff was routinely/consistently applying foam boots to protect resident #8's heels from developing other pressure ulcers or exacerbation of her present one. The record was void of anticipatory interventions to prevent resident #8 from developing pressure ulcers initially. 3. Resident #1 Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident status Minimum Data Set (MDS): According to the MDS dated [DATE], resident #1 had short- and long-term memory problems, modified independence for daily decision-making, needed limited assistance of one or two persons with bed mobility, transfers, and dressing, was independent with eating, had a fall within the past 30 days, coded not to have pain, required total assistance with toileting, and continent of bowel and bladder. Braden Scale: Review of the Braden Scale-For Predicting Pressure Sore Risk, documented resident #1 was scored on 2/10/10 with a score of 15, a total score of 12 or less represented high risk. The Braden Scale score for resident #1 on 3/11/10 was 17. Care Plan: The care plan for Risk For Pressure Ulcer, dated 3/8/10, and last updated on 4/1/10, documented in part as follows: Problem - Resident is at risk for developing a pressure ulcer related to decreased mobility, nutritional status, [MEDICAL CONDITION], weakness, and chronic pain. Goal - Resident will have intact skin, free of redness, blisters, or discoloration over a bony prominence through the next 90 days. Approaches - Complete weekly skin assessment, report changes in skin status to physician, notify nurse immediately of new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care, provide pressure relieving or reduction mattress. b. Record Review - left heel ulcer According to the nurses note on 3/18/10 at 2:00 p.m., the resident had blister 3 x 3 cm, on her left heel, skin intact, blister is soft and mushy. On 3/19/10, per nurses note, communication to the physician, left heel of her foot 3 cm x 3 cm blister, apply skin prep every day to blister and float heels at all times. Care plan: The care plan for Pressure Ulcer, dated 3/23/10 and last updated on 4/16/10, documented: Resident has pressure ulcer on left heel that is unstageable related to immobility, nutritional status, low [MEDICATION NAME], and [MEDICAL CONDITION]. Goal - Pressure ulcer will heal, decrease in size, be free of infection through 6/23/10. Approaches - Consult and make referral for screening with PT/OT (physical therapy and occupational therapy) and wound nurse, multipodus boots on except when bathing, heel/elbow protectors, fortified milk 8 oz twice per day. Physician orders: Review of physician orders [REDACTED]. -On 3/22/10 physician phone order, non weight bearing except PT referral to (name ) (clinic), wound nurse. -On 3/22/10 per physician FAX, the facility wound nurse notification to the physician documented, resident has new pressure ulcer on her foot. May we have order to off load heels at all times except during PT and to wear foam boot with no socks. Physician response: no weight bearing except PT and referral to (name/clinic) wound nurse. -On 3/23/10 per physician communication form (FAX) resident #1, intact blister on left heel, 4.1 cm x 3.8 cm, pressure ulcer, facility protocol skin prep while intact, hydrogel and foam dressing after rupture every day while healing. -On 3/24/10 per physician phone order, apply skin prep daily to left heel while intact. -On 3/29/10 physician order, may have foam decompression dressing with Kerlix dressing. -On 4/14/10 a physician phone order for multipodus boots prn (as needed). -On 4/15/10 a physician order [REDACTED]. Discontinue PP Novdertor boots. Weekly skin assessments and wound/skin healing records: -On 3/19/10 (weekly skin assessment), left heel intact with blister, soft boot in place, heel off load. -On 3/22/10, (wound/skin healing record) unstageable 4.1 cm x 3.8 cm blister on left heel, date notified dietary 3/22/10, date notified family 3/22/10, date notified physician 3/23/10. (but see above, indicating physician notification 3/22/10). -On 3/26/10, (weekly skin assessment) left heel blister intact, off loaded with boot in place. There was no description of the wound. -On 4/1/10, (wound/skin healing record) left heel unstageable, 4.0 cm x 4.4 cm with black/brown eschar, no odor, no exudate. -On 4/2/10, (weekly skin assessment) left heel unstageable. There was no further description of the wound or the size of the wound. -On 4/9/10, (weekly skin assessment) left heel unstageable. There was no further description of the wound or the size of the wound. - On 4/16/10, (wound/skin healing record) left heel unstageable, 3.5 cm x 4.5 cm, with black/brown eschar, no odor, no exudate. c. Observations On 4/19/10 at approximately 2:00 p.m., resident #1 was observed in her room sitting in her wheelchair. The wheelchair pedals were on the wheelchair and the resident's feet were half way out of her multipodus boots, hanging between the pedals. The resident's feet were in a turned position. -The CNA came into the room and was asked about the position of the resident's feet (twisted and out of her multipodus boots). The CNA said the resident can move her feet about and she somehow gets the Velcro on the multipodus boots loose. -The CNA said she had already repositioned and reapplied the boots about five times that day. On 4/21/10 at 8:30 a.m. resident #1 was in her room in bed. She was on her back and her feet were turned to the right in her multipodus boots. The outside of her left foot had a reddened area, where the multipodus boot pressed against her foot. -The staff nurse was observed while she provided wound care. The nurse said she did not size or stage the resident's wound, stating the wound nurse did one time each week. -Observations revealed the left heel had black eschar greater than the size of a half dollar coin, no drainage, and no odor. The left outer edge of her foot was red where the boot was not on in proper position and had been pressing against her left outer foot just prior to the dressing change. d. Interview On 4/20/10 at 5:00 p.m. during a group meeting with the NHA, DON, (the DON was also the facility Wound Nurse), Director of Wellness (DOW) and the facility Regional Consultants, the facility provided a summarized timeline of resident #1's pressure ulcer. On 4/22/10 at 1:00 p.m., during a meeting with the DON, she expressed that the resident #1 was on a pressure reduction mattress, the same mattress that is provided to all residents. -The DON said the resident was not placed on an air mattress because she could turn herself a little. She said resident #1 was not on a turning schedule. When asked if the resident could turn over and reposition herself with the multipodus boots on, the DON said she was not sure how far over resident #1 could turn herself. -The DON was asked what had caused the resident to get the heel blister. The DON stated she was not sure of the cause but she (resident #1) likes to sleep on her back. Copies of the consult notes from the (Clinic) wound nurse, ordered by the physician on 3/22/10, were requested during the above interview with the DON. At the time of exit (4/22/10) no copies had been provided.

Based on observation, record review, and resident and staff interview, the facility failed to provide adequate supervision and assistance devices to prevent falls and accidents, and failed to ensure the environment was as free of accident hazards as possible for five of 13 sample residents (#1, #5, #8, #10, #13). Specifically, the facility failed to: - Provide supervision and assistive devices to prevent repeat falls and injuries for residents #1 and #5. These failures contributed to resident #5 suffering multiple falls, a fractured pelvis, a laceration to the back of her head, and severe pain. The facility further failed to: - Provide safe assistance with transfers for residents #10 and #8. - Provide supervision to prevent elopement for resident #13. - Ensure water temperatures were safe in resident rooms and common areas. The findings included: A. Falls Policy Procedure The facility's "Falls and Fall Risk, Managing" policy/procedure, revised [DATE], read in part: "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling...To ensure the safety and well-being of the residents. - The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. - Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication is suspected as a possible cause of a resident's falling, the initial intervention might be to taper or stop that medication. - If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. - If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. - Staff will identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED]." 1. Resident #5 Failure to provide supervision and safety devices to prevent falls with injury Resident #5, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses, per the client [DIAGNOSES REDACTED]. a. Resident status According to her [DATE] Minimum Data Set (MDS): -The resident had short-term memory problems and modified cognitive independence. Mood and behavioral symptoms included altered perception, mental function varied throughout the day, persistent anger, sad/pained/worried facial expressions, tearfulness, and reduced social interaction; symptoms were present but easily altered. -The resident needed limited, one-person physical assistance with transfers, ambulation, dressing, toilet use, hygiene, and bathing. -The resident was taking antipsychotic, antidepressant, and diuretic medications. She had edema, was continent of bowel, and frequently incontinent of bladder. -The resident required partial physical support to balance while standing. She had fallen within the past 30 days and within the past ,[DATE] days, and had a hip fracture within the last 180 days. Medical record review revealed resident #5 was admitted after having fallen at home. Upon admission to the facility, she was assessed at high risk for falls on [DATE] (a score of 10 or more indicated high risk). The undated cover sheet on resident #5's comprehensive care plan identified her "cautions" as "episode of dizziness, fall, hypertensive episodes, edema to LE (lower extremities)." Her care plan for "falls" initiated [DATE] and revised on [DATE] and [DATE], identified her fall risk score as "10" on [DATE] and "21" on [DATE], related to cognitive impairment, right ischial ramus fracture, antipsychotic, diuretic, antidepressant, front wheel walker, and "resident attempting to become more independent." -Approaches included: fall risk screen, report falls to physician and responsible party, observe for side effects of medications (gait disturbance, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness, change in mental status), call light within reach, area free of clutter, provide/monitor use of walker/cane, remind resident and reinforce safety awareness when rising from a lying position, educate/remind resident to request assistance prior to ambulation, and appropriate footwear. -Additional approaches and dates added were: "[DATE] Encourage resident to use call light and wait for assist when needed; [DATE] sentry alarm while in w/c (wheelchair) for poor safety awareness and in bed, ,[DATE] refuses to work with therapy, [DATE] provide non-skid socks (discontinued), [DATE] provide non-skid socks as edema allows." Observations of resident #5 on ,[DATE], ,[DATE], ,[DATE] and [DATE] revealed she spent most of her time in her room alone, watching television. At 9 a.m. on [DATE], she was observed sitting in her wheelchair, leaning forward with her head resting on a pillow on her bed. Her tab alarm, attached to the back of her wheelchair, was stretched taut. Asked if she was okay and if she needed anything, she said no, she was having a bad day and wanted to be alone. (See resident interview below.) b. Multiple falls after admission, increased risk factors, injury Review of nurses' notes, investigative reports, and a hospital report revealed the resident experienced several falls after her admission to the facility. -On [DATE] at 12:25 a.m., resident #5 was found sitting on the floor next to her bed with her legs in front of her, stated she was trying to go to the bathroom. No injuries were noted. -On [DATE] at 10 a.m., she was found on her knees on the floor in her room, complained of dizziness, said she stumbled, did not call for help or use her walker. No injuries were noted. However, later that day she was noted to continue walking in her room without assist. She was noted as being encouraged to "ring for help." -On [DATE] she was found on the floor at 5:30 p.m. next to her wheelchair. A family member reported the resident went to sit in a wheelchair and missed it, going to the floor. The resident said she was trying to find the bathroom. No injuries were noted. She was reminded to use her call light for assist. -On [DATE] at 11:30 p.m., she "slipped off of her glider chair onto the floor landing on her bottom. Resident stated she was reaching for her shirt when this happened. Fall assessment done...Resident's representative requests that something be done to keep chair from sliding on floor but expressed no other concerns at this time." No injuries were noted. The resident's care plan did not mention her glider chair, or that anything was done to prevent it from sliding on the floor and causing additional falls. IDT (interdisciplinary team) notes the following day recommended educating the resident "about calling for help when she needs something. Will obtain a reacher for resident." During ,[DATE], resident #5 was repeatedly documented as having "increased anxiety with delusional/paranoid behavior." Her physician ordered Seroquel 25 mg at bedtime daily for one week, then increase to 25 mg twice daily. A urinalysis (UA) was also ordered, with no new orders after the culture was received. The resident was noted as "anxious, weepy and delusional" on [DATE], but the nurse noted her mood was "more stable." -On [DATE] at 2 p.m., the resident stated "she fell during the night after getting up, landing on her right side. She reported fall to a certified nurse aide (CNA) and asked her 'not to tell anyone." She was "confused and depressed, refusing to wear her oxygen, and stating she 'wants to die.'" The physician was notified and ordered Wellbutrin 100 mg twice daily for depression. No injuries were noted from the fall. The resident was noted to continue "to have episodes of intense, delusional anxiety, but she is more easily redirected." On ,[DATE] and [DATE], she was noted as "delusional and agitated." -On [DATE] at 6:50 p.m., the resident was found on the floor on her buttocks. No injuries were noted, and she was "unsure how she fell ." She was wearing shoes, doing "pm care by sink." -On [DATE] at 12:30 p.m., she "fell while attempting to move a rolling table in her room and turning toward her reclining chair. She cried out when she fell ; CNAs heard her and ran to room. She was sitting on the floor on her buttocks...She complains of pain to (right) lower back and hips, cried out when lifted from floor. She had full range of motion in (right) leg, however she complained of pain when walking and was unable to take more than ,[DATE] steps. Order received from (physician) to send her to (local emergency room ) for X-rays and evaluation...POA expressed concern that (resident) has fallen twice in 2 days." At 7 p.m., the nurse noted she received notification that the resident's "pelvis has a small fracture, to be treated with pain control and PT (physical therapy)...Seroquel was reduced to 25 mg (orally every) day due to possible influence on resident's equilibrium." The resident was also diagnosed with [REDACTED]." -On [DATE] the resident was noted to complain of "severe pain" in her right hip, which continued into [DATE], "significant pain" on [DATE]. Her physician ordered a Sentry alarm while in her wheelchair due to history of falls and poor safety awareness, and an order for [REDACTED]. -On [DATE], she "still has pain while standing, walking, or transferring to toilet, but it is not as severe as it was yesterday." The resident was treated with pain medication, with some resistance to the medication noted at times. -On [DATE] at 4:45 p.m., the resident was found sitting on the floor beside her bed, legs extended in front of her. She said she slid to the floor after attempting to reach for her wheelchair. The call light was within reach, but she had not used it. There was no documentation of injury, but she complained of pain to her buttocks the next day. A [DATE] IDT note stated the fall was "related to non-skid socks - will evaluate this, provide socks @ all times." The investigative report dated [DATE] noted the fall was a result of "no gripper socks (non-skid). Will evaluate this & provide socks @ all times." -On [DATE] at 11 p.m., the resident was found on the floor at the foot of her bed with "blood noted to the floor under her foot board, also to the back of her head & nightgown. 2.5 cm lac(eration) to back of resident's head...CNA stated she had just assisted resident to bed a few minutes prior to resident being FOF (found on floor). Resident stated she was trying to turn her TV off and slipped. Resident did have slipper socks on. Call light was within reach." An IDT note on [DATE] documented the fall was a "result of unsteady gait." It was noted the Sentry alarm was working and the resident was wearing non-skid socks. No further interventions were noted. -On [DATE] at 3:08 a.m., the resident was "found on all fours crawling on the floor in her room." She was confused and denied falling. No injuries were noted. The investigative report noted the resident had removed the clip for her Sentry alarm; an additional note documented, "pressure alarm, now knows how to remove clip from Sentry alarm." -On [DATE] at 8 p.m. she was found lying on the floor beside her recliner, confused about where she was. Her chair was "turned over behind her. She said she was trying to get out of chair when she fell ." An IDT review dated [DATE] noted, "Staff spoke with POA, she has ordered easy lift chair - glider in room and previous lock placed on glider combines to prohibit glider from gliding - pressure alarm in bed & chair - Reasonable to conclude fall (related to increase) in Seroquel - will continue to monitor and (follow up) in ,[DATE] days." The investigative report noted, "Resident...reminded not to transfer without assistance. Recliner to be replaced with a more solid chair." It was further noted the resident's care plan "needs to be updated to accommodate increased mobility...Replace sliding recliner with a more stable chair. PT evaluation. Monitor for increased dizziness, drowsiness or confusion due to Seroquel increase. If possible, move resident closer to Wellness Center for closer monitoring, as she believes she is more capable of transferring and movement than she actually is." c. Interviews Resident #5 was interviewed in her room at 2:15 p.m. on [DATE]. The resident's room was located at the far end of the hall away from the nursing department offices. The resident said she liked having a room to herself. When asked about the cause of her falls, and if staff assisted her as needed, she said, "They're never around...I don't know what to do about that." Resident #5 said she had been told to use her call light for assistance, but asked, "Why can't they look at the time I'd like to go to bed?" Asked if there were problems that led to her falls, she said, "These (linoleum) floors are so slippery." On [DATE] at 9:30 a.m., the Nursing Home Administrator, Director of Wellness, nursing management team and two corporate consultants were interviewed about the resident's falls and asked for information on what the facility had done to identify her risks and prevent falls. They said they could provide IDT notes, as they always scheduled review for a follow-up date where IDT would "come back and review" a resident's falls and make recommendations for future fall prevention. When the resident's two falls related to her glider were discussed, the management team responded that resident #5 was "very attached to her glider," but they had removed it, and her POA was "getting her a lift chair." On [DATE] at 4:30 p.m., the Social Services Director was interviewed regarding resident #5's quality of life. She said when the resident was admitted from home "She was falling a lot, not taking her meds, so she moved here. She was fine, but then she got paranoid...(and) delusional...We're encouraging her to get out (of her room) more...We do talk to her about what's going on. It must be horrible for her. She's starting to experience dementia and she may realize that...She's changed quite a bit - she's become more distant...I think once her medication kicks in, hopefully she'll be happier. She seems to be getting better already. We want her happy, and not to be out of it." A certified nurse aide (CNA) who provided care for resident #5 was interviewed at 3 p.m. on [DATE]. The CNA said they checked on residents every hour to ensure their supervision, toileting, fluid and hydration needs were met. On [DATE] at 5:55 p.m., two corporate consultants provided additional information regarding follow-up on resident #5's falls. They reviewed copies of the reports detailed above, and interventions recommended by IDT. -They said that as of [DATE], the resident was undergoing "lots of changes with Lasix, refusing to keep her feet up." -They said PT was started on ,[DATE], the Sentry alarm on ,[DATE], skid socks on at all times on ,[DATE], and a new PT order for six weeks, on ,[DATE] an IDT review reviewed their recommendations for socks, alarms which were on and in place, then the resident was found on the floor on experienced falls on ,[DATE] and [DATE]. -When asked about monitoring and supervision to prevent falls and accidents, when the facility was aware the resident was admitted after having fallen at home, had poor safety awareness and did not use her call light, they pointed out the every-hour-on-the-hour monitoring system the facility had initiated after the resident's [DATE] fall. However, the resident had fallen and broken her pelvis halfway between a one-hour observation period. Also (see CNA interview above), the one-hour observation periods were not above and beyond what a CNA said was typically provided for residents on the Aspen Hall where resident #5 resided. Other than the information contained in the report above, no further evidence of tracking and trending or monitoring and supervision was provided. The Medical Director was interviewed by phone at 12:30 p.m. on [DATE]. He said he had reviewed protocols with the facility to prevent falls and accidents, and mentioned hipsters as an intervention to prevent fractures. The former Director of Nursing (the new DON had started in her position on [DATE], the day the survey began) was interviewed at 1:15 p.m. on [DATE]. When asked if they had attempted the use of hipsters for resident #5, she said she did not ask the resident about hipsters and did not consider them. In summary, the staff was aware resident #5 had a history of [REDACTED]. However, they did not implement effective measures to prevent and respond to her falls to prevent further falls. -Review of the findings above revealed the facility did not consistently update the resident's care plan after she experienced falls, did not track and trend the times (mealtimes, afternoons, evenings, late night) and circumstances (looking for the bathroom, arising unassisted to do something she needed) surrounding her falls. -Review of the findings above revealed the facility did not timely implement fall prevention with self transfers. Alarms were not implemented until after her eighth fall when she sustained a fractured pelvis. Non-skid socks were not implemented until after her ninth fall. -Review of the findings above revealed the facility did not care plan her glider (furniture) being the cause of two falls or document when it was removed. -Review of the findings and staff interviews revealed the facility further failed to provide increased monitoring related to the resident's agitation, depression, delusions and her failure to use her call light for assistance. -Review of the findings revealed the facility failed to update the resident's care plan when they discovered she knew how to disengage her alarm. -Review of the findings revealed that moving her closer to the Wellness Center was recommended by IDT; however, the resident remained in her room at the far end of the hall. -Finally, review of the findings revealed that although the resident was on diuretics and was frequently incontinent, and record review revealed she had refused Lasix because of urinary frequency, there was no evidence the facility developed a toileting plan to help meet her needs and prevent that issue as a fall risk. The resident experienced 11 falls, two significant injuries, and severe pain after her pelvic fracture. 2. Resident #1 Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], resident #1 had short- and long-term memory problems, modified independence for daily decision-making, needed limited assistance of one or two persons with bed mobility, transfers, and dressing, was independent with eating, had a fall within the past 30 days, coded not to have pain, required total assistance with toileting, and continent of bowel and bladder. a. Record Review - fall and injury risks - facility response Admission information: The Admission Nursing assessment dated [DATE], documented functional status partial weight bearing, use wheelchair only/refusing walker, needs two person assistance with transfers. Review of the hospital admission history and physical dated [DATE], resident #1 was admitted to the hospital after a fall. The hospital history report documented in part; this is the 3rd straight fall within the year, she allegedly hit her head, she has fallen twice within the past 2 weeks, she is on coumadin anticoagulation therapy therefore high potential of a hemorrhagic cerebral event. Fall risk assessment: The facility Fall Risk assessment dated [DATE], scored resident #1 with a score of 11, a total score of, 10 or greater represents high risk. Care Plan: The care plan for falls dated [DATE], documented as follows: Problem - At risk for falls related to disease process/senile dementia, muscle weakness, use of assistive devices/wheelchair. -Goal - Resident will not sustain a fall related injury, by utilizing fall precautions, through next 90 days. -Approaches - Use fall risk screen to identify risk factors, report falls to physician and responsible party, bed raised/lowered per OT (occupational therapy) evaluation on [DATE], additional approaches on [DATE] monitor for increased confusion and pressure alarm while in bed due to poor safety awareness, on [DATE] sentry alarm while in wheelchair for poor safety awareness and risk of fall. b. Incidents and interventions after admission On [DATE] at 4:50 a.m., documentation per nurses notes read, in part that two staff CNA's were assisting resident #1 up out of bed to the bathroom. The resident began to slide out of bed and CNA's were unable to stop her from sliding and assisted the resident to the floor. Resident was unable to bend her legs and back, will monitor for increased stiffness. On [DATE] at 10:15 a.m. consulted with OT for evaluation of bed height for resident to make transferring to and from bed easier and more safe. On [DATE] the facility Incident/Accident Report Form documented in part: immediate action taken to provide safety, the resident was lifted off the floor with assistance of mechanical EZ Lift and three staff persons, non-slip socks in place. Resident currently attending therapies to increase strength. Review of the medical records revealed safety measures put into place included: On [DATE], pressure alarm to bed for poor safety awareness. On [DATE], orders for OT evaluation of bed for safety. On [DATE], Sentry alarm to wheelchair for poor safety awareness and risk of falling. On [DATE], order for PT to evaluate wheelchair for positioning. There were no interventions regarding increasing resident supervision, given her coumadin/anticoagulation therapy. By observation during the survey (,[DATE] - [DATE]), resident #1 was in room 11, the last room on the left side of the hallway, furthest away from the nurses station. c. Interview On [DATE] at 5:40 p.m. during a group meeting with the Nursing Home Administrator (NHA), Director of Nurses (DON), Director of Wellness (DOW), they were interviewed about fall prevention measures related to resident #1. The NHA expressed that the facility has a daily stand up meeting and following that the Interdisciplinary Team does a review of falls and does follow ups. The OT evaluated the resident's bed for proper positioning of height for safety with transfers. The DON expressed they had not put the resident on a low bed or put a fall mat next to her bed because her previous falls had been when she was up using her walker and not from the bed, and the resident was able to make her needs known. But see above; the incident [DATE] was during a transfer from bed. B. Transfers 1. During the group interview with eight residents at 10:30 a.m. on [DATE], the subject of transfer assistance was broached. The residents made the following comments: -"I use a walker and don't need help." -"They never use one of those belts on me when they're helping me go from my wheelchair to bed." -"Sometimes they do (use the gait/transfer belt) and sometimes they don't . . . I feel safer when they do." -"I'm lucky, I don't need 'em to help me." -"I fell out of bed once and they got me up from the floor by putting their hands under my arms and pulled me up . . . when my roommate fell , they got some kind of lift thing to help him up." 2. Resident #10 Resident #10, a 95-plus-year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to her activities of daily living (ADL) care plan, dated [DATE], she needed two-person transfer assistance. According to her [DATE] MDS, she was totally dependent for transfers by two or more staff. At 5:45 p.m. on [DATE], resident #10 was at the dining room table and asked to go back to her room. A CNA took resident #10 in her wheelchair back to her room, and was observed to transfer her without assistance and without using a gait belt, by grasping her around the waist. The resident cried out that the CNA was "killing" her during the transfer, and was quiet after being seated in her recliner. On [DATE] at 9:30 a.m., the NHA, DON, nursing management team and corporate consultants were notified of the observation above. On [DATE] at 10:50 a.m., the former DON was notified of the observation and asked if nursing management staff did observations and monitoring to ensure residents received safe transfer assistance. She said, "We don't do formal observations of staff transfer technique." The CNA was interviewed at 3 p.m. on [DATE], and acknowledged that s/he "should have used a gait belt on her that night" during the transfer. The CNA said typically s/he would have used a gait belt. 3. Resident #8 Resident #8, an [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. a. Resident status Review of resident #8's record was initiated at 2:50 p.m. on [DATE]. The admission Minimum Data Set assessment, dated [DATE], revealed resident #8 had both short- and long-term memory loss and modified independence in cognitive skills for daily decision-making, required assistance with transfers (manual lift), dressing, hygiene and bathing, used wheelchair propelled by others for mobility and was incontinent of bowel and bladder. According to her activities of daily living (ADL) care plan, dated [DATE], she required one to two-person transfer assistance. According to her [DATE] MDS, she needed extensive assistance with transfers. b. Observations At 4:50 p.m. on [DATE], resident #8 was observed lying on her bed. Two CNAs approached her and advised her that she needed to get up to go to dinner. One of the CNAs placed the resident's arms around her neck and the CNA placed her arms under the resident's arms and lifted. Simultaneously, the other CNA grasped the back of the resident's slacks and pulled her up and they both pivoted the resident into her wheelchair. Neither of the CNAs used a gait belt during this transfer. During the transfer, resident #8 asked, "You won't drop me will ya?" c. Staff interview At 11:25 a.m. on [DATE] a CNA was interviewed. She stated, "When do I use the gait belt? . . . Well, some of them need more standby assist than others and sometime they (residents) are weaker than other times. It just depends." D. Elopement Resident #13 Resident #13, (closed record) an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13 expired in the facility on [DATE]. a. Record Review - elopement risk Review of resident #13's closed record was initiated at 11:47 a.m. on [DATE]. Her Minimum Data Set assessment revealed that she was severely impaired in cognitive skills for daily decision-making, wandered, required supervision or minimal for all activities of daily living and was incontinent of bowel and bladder. A fax to resident #13's physician, dated [DATE], read: "Resident continues to elope facility frequently throughout the day. Can we get an order for [REDACTED].?" The physician agreed, signing the order on [DATE]. A copy of the resident's elopement care plan was requested during an interview with the former DON and NHA at 1:10 p.m. on [DATE]. The care plan was not submitted by the facility for review prior to exit [DATE]. b. Elopement [DATE] Nurses' Notes dated [DATE] at 10:00 a.m. documented, "Resident found outside, behind building, lying in the snow. She was shivering, pale, tachypnea (breathing rapidly). Resident was brought inside, clothing removed, wrapped in warm blankets. Staff members attempted to warm her. 02 Sats (oxygen saturation levels) in mid-70's on supplemental oxygen. Tympanic (through the ear canal) temperature was 93 degrees. Blood pressure could not be obtained. Skin was pink where snow had made contact. (Doctor) was notified; gave orders to send resident to ER. Son was notified. Said he would go to ER. Report called to (Nurse) in ER. Resident left at 10:30 via ambulance. A Physician's Telephone Order dated [DATE] at 10:30 read, "Send resident to ER (Hospital) for evaluation and treatment. Dx: Hypothermia." The hospital's Discharge Summary dated [DATE] included the following pertinent information: "Admission: [DATE] Discharge:[DATE] Admitting Diagnoses: [REDACTED]. 2. Hydration 3. Alzheimer's disease - moderate to severe . . . Hospital Course: This is a pleasant 80 yo (year old) . . female who has been living in (Facility) who was found down and outside, collapsed in below freezing temperature for approximately ,[DATE] minutes estimated. She was observed inside the nursing home at approximately 9:30 and then was discovered at approximately 10:00 a.m. . . .EMS was dispatched. Patient was brought to the ER. Initial reports of hypothermia were reported but patient's core temperature was 97.1 degrees Fahrenheit rectal . . . The patient had an uneventful hospital stay . . ." Resident #13 returned to the facility on [DATE]. An Incident/Accident Report form relating to the events of [DATE] was reviewed. The report indicated: - "Incident was not witnessed" - "Resident exited building through a back door and fell in the snow." - "Administrator ordered new alarm system, code activated to prevent residents from exiting building without an alarm sounding." - "New alarm system installed [DATE]." Added [DATE]: "Initial IDT review. Found outside laying on right side in the snow. Resident had been on every 15-minute checks (substantiated by documentation) and resident found approximately 20 min after last check. Resident had exited the building through the far exit door and into contained courtyard. Investigation (illegible) due to c/o from residents that regular alarm was disturbing. A new alarm system for all exits at end of hall was ordered that same day." c. Interview During an interview with the NHA and the former DON, at 3:16 p.m. on [DATE], the NHA stated, "(Resident #13) liked to walk . . . she walked a specific route . . . She was on 15-minute checks . . . so we discovered she was missing . . . (Registered Nurse) realized that (Resident #13) was not in eyesight . . . She was wearing her wander guard . . . Yes, the alarm sounded (on the door through which resident exited) but it was set on low . . . light chime, because the residents on that hall had complained that it was too loud every time a CNA went out that door to empty the trash . . . We immediately ordered a new alarm system." The former DON related that she had "accompanied resident #13 to the hospital in the ambulance and stayed with her for a couple of hours." The former DON also stated that she thought she remembered the temperature as "being in the 20's . . . Her clothes? She was wearing shoes and socks, long pants, short-sleeved shirt and no coat." Although the facility had 15-minute checks in place for frequent observation of resident #13, the facility failed to ensure supervision, in the form of the elopement detection alarm-system, was operating effectively to alert staff to resident'