Every finding on record at Rocky Mountain Care - The Lodge

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for 4 of 36 sampled residents, a resident's skin condition was not evaluated and treated, a resident had wound care provided without orders, a resident was hospitalized and no documentation was found of the resident's change in condition, and a resident expired at the facility and no documentation could be found of the resident's change in condition. Resident identifiers: 9, 59, 61, and 62.Findings included:1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, cerebral infarction, morbid obesity, type 2 diabetes mellitus, fracture of right toe and non-pressure injury of left foot. On [DATE] at 1:09 PM, an interview was conducted with resident 9. Resident 9 stated that he skinned his toes. Resident 9 stated that sometimes the staff wrapped the toes when they bled and put salve on the wounds, and this was approximately every 3-4 days. Resident 9 stated that the wounds had never healed. Resident 9's bilateral feet were observed with open wounds on the second toe of each foot. Both toes were observed with dried blood on the wounds. Resident 9 had a physician order for WOUND CARE: Abrasion to Left Second Toe: Remove dressing. Cleanse wound. Apply skin prep to periwound. Apply hydrogel to wound bed. Cover with border dressing one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for Wound care AND as needed for Wound Care. The order was initiated on [DATE]. Resident 9's progress notes revealed the following: a. On [DATE] at 11:40 PM, the Skin Check documented, . New skin Issue. Location: Right Dorsum 2nd Digit (Second toe) Issue type: Laceration. Progress: New: new wound. Wound acquired in-house. Wound is new. Incision approximated: Yes. Closure method: Sutures. # of Sutures: 4 . Measurements not documented as part of this assessment. Reason measurements not documented as part of this assessment: unable to measure, wrapped from ER [emergency room]. b. On [DATE] at 2:31 PM, the Skin Check documented, Skin issue has not been evaluated. Location: Right Dorsum 2nd Digit (Second toe) Issue type: Laceration. Wound acquired in-house. Wound is new. c. On [DATE] at 2:46 PM, the Skin check documented, Skin issue has not been evaluated. Location: Right Dorsum 2nd Digit (Second toe) Issue type: Laceration. Wound acquired in-house. Wound is new. d. On [DATE] at 11:15 AM, the Skin Check documented, Skin issue is resolved. Location: Right Dorsum 2nd Digit (Second toe) Progress: Resolved: Wound healed and / or closed. e. On [DATE] at 12:25 PM, the Skin Check documented, New skin Issue. Location: Left Dorsum 2nd Digit (Toe). Issue type: Abrasion. Progress: Improving: overall wound characteristics improved. Wound acquired in-house. f. On [DATE] at 2:34 PM, the Nurse Note documented, Right toe assessed with purulent drainage present. Resident unsure when condition began. Wound cleansed and antiseptic applied per protocol. Provider notified; podiatry referral requested for further evaluation. g. On [DATE] at 2:37 PM, the Skin Check documented, New skin Issue. Location: Right Dorsum 1st Digit (Hallux). Issue type: Open lesion. Progress: New: new wound. Wound acquired in-house. It is unknown how long the wound has been present. Signs and symptoms of infection: Erythema/edema. Signs and symptoms of infection: Red and bleeding surface or granulation tissue. h. On [DATE] at 5:40 PM the Skin Check documented, Skin issue has not been evaluated. Location: Right Dorsum 1st Digit (Hallux). Issue type: Open lesion. Wound acquired in-house. It is unknown how long the wound has been present. i. On [DATE] at 10:09 AM, the Skin Check documented, Skin issue has not been evaluated. Location: Right Dorsum 1st Digit (Hallux). Issue type: Open lesion. Wound acquired in-house. It is unknown how long the wound has been present. On [DATE], the hospital history and physical records documented a laceration of the right little toe after resident 9 fell out of bed. The resident had a laceration repair conducted to the 1 centimeter laceration at the base of the right little toe. The repair included 4 sutures to close the laceration. It should be noted that the suture repair to the laceration was on the fifth metatarsal and not the second metatarsal as documented in the progress note. Resident 9's care plan focus area for at risk for alteration to skin integrity was initiated on [DATE]. The care plan had an intervention for weekly skin check per facility schedule and to notify the provider of any alterations for prompt/proper interventions. On [DATE] at 8:57 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was the wound care nurse. The ADON stated that nursing staff conducted weekly skin checks and she looked through those notes daily to identify any new skin issues. The ADON stated that if a concern was not on the skin check the staff would message her on tiger text and send a secure photo of the wound for her evaluation. The ADON stated that resident 9 had abrasions on his left toes and they were doing wound care with hydrogel. The ADON stated she was not aware of the right second toe's abrasion. The ADON stated that she should have been notified of the wound on the right foot so that she could evaluate it. The ADON stated that she had wound care standing orders for an abrasion and she would evaluate the wound with the provider on the next wound care day. The ADON stated that the wound on the right second toe was first identified on [DATE]. The ADON confirmed that the wound did not have wound care orders and had not been evaluated by herself or the provider. On [DATE] at 12:41 PM, a follow-up interview was conducted with the ADON. The ADON stated that she went and assessed resident 9's right foot wound. The ADON stated that she put orders in for wound care for the right foot and was waiting to hear back from the provider. The ADON stated that she assessed a wound on the second digit of resident 9's right foot. The ADON stated that she did not measure the wound, and that she typically obtained measurements but had forgotten on this occasion. The ADON stated that she cleaned the wound with wound cleaner and applied a bordered foam dressing. The ADON stated that she was waiting to hear from the provider about new orders. The ADON stated that resident 9's left foot had scattered scabbing along all of the toes of the foot. The ADON stated that she was not notified of the wound on the second toe of the right foot and she should have been informed of the wound. 2. Resident 59 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, type 2 diabetes mellitus, acquired absence of the right and left leg above the knee, infection of left amputation stump, and chronic pain.On [DATE] at 1:02 PM, an interview was conducted with resident 59. Resident 59 stated that she had pain in the right stump and that there was a wound there. Resident 59 stated that the wound was not open and they did not do a dressing change on it. Resident 59 stated that the wound on the right stump had been present for approximately 1.5 weeks. Resident 59 had a physician order for L [left] stump: Cleanse with NS [normal saline]. Apply silver alginate to wound bed. Cover with bordered dressing. every day shift every Mon, Wed , Fri . The order was initiated on [DATE]. On [DATE] at 12:15 PM the Nurse Practitioner note documented, .Infection of amputation stump, right lower extremity *: Right AKA [above the knee amputation] surgical wound previously noted as improving. No signs of infection currently noted. Continue wound care per wound team. Will defer to hospice for all medical decision making. Continue dressings per wound team orders. On [DATE], the hospice note documented, She has a stage 2 pressure ulcer on her L buttock and another unstageable pressure ulcer on her L amputation stump. On [DATE], the hospice note documented, Wound care provided during visit and tolerated without complication. The note did not document any wound locations or characteristics. On [DATE], the hospice note documented that the patient had one or more skin conditions. The note documented the wound as a Pressure Ulcer(s)/Injuries. No documentation of the location or characteristics of the wound were found. The note further documented, Patient remained focused on going outside for a smoke break and declined assessment of known wounds to her stump and buttocks despite education regarding the importance of monitoring pressure injuries. Patient verbalized refusal of wound assessment at this time. Skin is ashen and frail with irregular pigmentation. On [DATE], the hospice note documented, Patient refused wound care at this time. Notified facility nurse and stated would attempt once patient back in bed. Skin assessment reveals ashen pallor with irregular pigmentation, poor turgor, dry and warm to touch consistent with dehydration and overall decline. On [DATE], the hospice note documented, Patient decline [sic] wound care and refused to return to bed for wound assessment despite education and encouragement. On [DATE], the hospice note documented, Patient remained focused on going outside for a smoke break and declined assessment of known wounds to her stump and buttocks despite education regarding the importance of monitoring pressure injuries. Patient verbalized refusal of wound assessment at this time. Skin is ashen and frail with irregular pigmentation. On [DATE], the hospice note documented, Patient declined returning to room for wound are [sic] during visit, stating she was waiting to go smoke. Patient demonstrates poor insight and impaired judgement regarding care needs. On [DATE], the hospice note did not document any information regarding resident 59's skin condition or wounds. Resident 59's care plan for alteration to skin integrity secondary to impaired mobility was initiated on [DATE]. The care plan had an intervention for weekly skin check per facility schedule and to notify the provider of any alterations for prompt/proper interventions. On [DATE] at 11:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the licensed nurse should be conducting a skin check assessment and documenting it per the physician orders. The DON stated that resident 59 did not go to the wound clinic for wound care. On [DATE] at 11:50 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that resident 59 had a dressing on both the left and right stump and she only had orders for the left stump. RN 4 was observed providing wound care to resident 59. Resident 59 had a bordered foam dressing on her bilateral AKA stumps. RN 4 removed the dressing from the right AKA stump and stated that it did not have any drainage on the old dressing. RN 4 cleaned the right stump with a 4 x 4 gauze pad that was soaked in normal saline. RN 4 placed a new bordered foam dressing on the right stump. RN 4 stated that the right stump was newly closed. RN 4 stated that when she cleaned the right stump wound bed a scab came off and it was closed underneath. RN 4 stated that it made her believe that the wound was barely closed or was trying to break back open. RN 4 stated that she would notify the wound nurse to assess the right stump and put a treatment order in. On [DATE] at 12:49 PM, an interview was conducted with the ADON who was the facility wound care nurse. The ADON stated that hospice was in charge of resident 59's wound care. The ADON stated that prior to resident 59 going on hospice services she provided wound care for her pressure ulcer on the left stump. The ADON stated that she stopped providing resident 59 wound care recently when she was admitted to hospice services. The ADON stated that she communicated with hospice about wound care, they wrote notes with measurements and if they changed any wound care orders. The ADON stated that she did not have any recent updates from hospice about resident 59's wounds. The ADON stated that new skin conditions should be relayed to her in writing. The ADON stated that all dressings that were applied should have an order. The ADON stated that if a new wound was identified she would expect there to be an assessment documented somewhere. 3. Resident 62 was admitted to the facility on [DATE] and passed away on [DATE] with diagnoses which included Parkinson's disease without dyskinesia, dementia, protein-calorie malnutrition, epilepsy, and adult failure to thrive. A nursing progress note dated [DATE] at 3:33 PM, revealed, Residents' hospice nurse notified of condition and most recent VS [vital signs]. Residents VS were as follows: BP [blood pressure] 184/144 HR [heart rate] 88 SPO2 [oxygen] 95% T [temperature] 97.7 RR [respiratory rate] 14. Hospice nurse said to continue to give morphine and lorazepam Q [every] 1-3 hours. Will continue to monitor resident and promote comfort for resident and family. The next nursing progress note was dated [DATE] at 4:19 PM, which revealed, Residents vitals were taken and oxygen sat [saturations] at 72%. Pt [patient] has been transitioning all night and oxygen has decreased since then. Pt is stable, morphine provided every hour for comfort measures. No sign of distress noted. Will continue to monitor throughout the shift. There were no other nursing progress notes or assessments documented regarding resident 62's change in condition. There was an assessment titled Funeral Home: release of remains which was dated [DATE]. The assessment revealed resident 62's remains were released on [DATE] at 9:30 AM. On [DATE] at 10:32 AM, an interview was conducted with RN 2. RN 2 stated when a resident was passing away, the nurse documented the resident's change in condition and who was notified. RN 2 stated along with a nurse's progress note she completed a release of remains assessment when the residents' remains were released to the mortuary. On [DATE] at 2:02 PM, an interview was conducted with the DON. The DON stated when a resident was passing away, the nurse needed to document their change in condition. The DON stated nursing should have documented resident 62's declining condition, any interventions for comfort care, what medications were provided, and when the resident passed away. 4. Resident 61 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses which included encephalopathy, acute respiratory failure with hypoxia, diabetes mellitus, stage 3 ovarian cancer, and severe sepsis. A nursing progress note dated [DATE] at 7:29 PM, [Resident 61] refused NG [nasogastric] meds [medications] due to feeling N/V [nausea and vomiting]. Her daughter stated that her mom needed complete bowel rest. Wants sublingul [sic] zofran for NV. There were no further progress notes. An assessment titled Emergent Discharge summary dated [DATE], with no time revealed that ordered blood work showed a hemoglobin of 6.2 and white blood count of 13.1. Daughter [name removed] was here with her mother and went to the hospital with her. Resident was very lethargic most of this shift before going to the hospital, her daughter answered mostly for her. On [DATE] at 10:20 AM, an interview was conducted with RN 3. RN 3 stated she was an agency nurse. RN 3 stated when a resident experienced a change in condition there was an assessment that was completed in the resident's medical record. RN 3 stated the nurse needed to document in a progress note regarding the resident's condition and who was notified. On [DATE] at 10:28 AM, an interview was conducted with RN 2. RN 2 stated if a resident had a change in condition there was an assessment that was completed in the assessment of their medical record. RN 2 stated there was a good layout/timeline of the change so that when she called the provider she was able to tell the provider exactly what was going on and what was tried. RN 2 stated the provider was then able to make decisions and provide orders based on the assessment. On [DATE] at 10:49 AM, an interview was conducted with the DON. The DON stated if a resident experienced a change in condition, the nurse notified the on-call nurse manager to discuss the change of condition assessment, and notified the family and provider. The DON stated the change of condition should be passed on during the nurse to nurse report. The DON stated the change in condition should be documented and include labs or whatever the provider ordered. The DON stated there was alert and change in condition charting that should be initiated in the resident's electronic medical record. The DON stated resident 61 was transferred to the hospital and she did not know why resident 61 did not return. The DON stated nurses were expected to document when there was a change in condition and resident 61 refusing medication with nausea and vomiting was a change in condition. The DON stated the change of condition assessment and alert charting should have been completed.

Based on observation, interview, and record review, for 2 of 36 sampled residents, the facility did not provide each resident assisted nutrition to maintain acceptable parameters of nutritional status. In addition, a resident was not offered a therapeutic diet when there was a nutritional problem. Specifically, a resident who was provided a tube feeding lost a significant amount of weight when the tube feeding was discontinued for 5 days and her oral intake was not meeting her nutritional needs. This example will be cited as a harm. In addition, a resident with a high potassium was not provided low potassium foods when the dialysis center ordered it. Resident identifiers: 6 and 13. Findings included:1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, severe protein-calorie malnutrition, alcohol induced chronic pancreatitis, thyrotoxicosis, disorders of electrolyte and fluid balance, peptic ulcer, diverticulosis of intestine, irritable bowel syndrome, alcohol hepatitis without ascites, dysphagia, and abnormal levels of other serum enzymes. On 6/2/26 at 8:41 AM, an interview was conducted with resident 13. Resident 13 was observed to have a nasogastric (NG) tube in place and tube feed supplies in her room. Resident 13 was not hooked up to the tube feed and had just returned from breakfast in the main dining area. Resident 13 stated the staff did a good job but they harped on her that she was not doing enough or eating enough. Resident 13 stated that she was below weight and she tried to eat breakfast that morning. Resident 13 stated that she tried to mix it up with dry cereal instead of eggs and sausage and she felt that she did pretty well. Resident 13 stated that her tube feed usually ran all the time. A care plan Focus initiated on 5/21/26, documented [resident 13] requires a feeding tube which places them at risk for nutritional deficits and other medical complications. The interventions initiated on 5/21/26, included, Dietitian/Nutritional evaluation and treatment, as needed. Elevate head of bed at least 30 degrees while the feeding tube was running and for at least 30 minutes after. Enhanced barrier precautions. Ensure supplies, formula, and tubing are changed, as prescribed. Ensure tube placement, as prescribed. Evaluate for signs and symptoms of aspiration, and notify physicians of positive signs or symptoms. Obtain and monitor lab/diagnostic work as prescribed. Report results to the Medical Director and follow up as indicated. Tube feeding insertion site cares, as prescribed. Notify physicians with positive signs or symptoms of complications. On 5/21/26, resident 13 weighed 106.2 pounds (lbs). On 5/26/26, resident 13 weighed 101.6 lbs which was a -4.33% weight loss in five days. On 5/20/26 at 5:05 PM, an Order Note documented The order you have entered Fibersource HN [high nitrogen] Enteral Liquid Give 1080 ml [milliliters] via NJ [nasojejunal]-Tube every shift for nutrition supplement for 5 Days Run at 45mL/hr [milliliters per hour] for 24 hours. The physician order was discontinued on 5/25/26. On 5/21/26 at 1:18 AM, an Orders - Administration Note documented Fibersource HN Enteral Liquid Give 1080 ml via NJ-Tube every shift for nutrition supplement for 5 Days Run at 45mL/hr for 24 hours. notified on call nurse manager [name omitted] regarding the flush order. ordered to hold enteral feed till AM shift. It should be noted that the Fibersource was not held. On 5/21/26 at 5:28 PM, a Nutritional Evaluation documented an ideal weight range of 119 to 130 lbs. Dietary related medications included mirtazapine. Dietary intervention included recommending Med Pass three times a day for low body mass index, body weight, and low intake. It should be noted that the Med Pass was not implemented and the mirtazapine was not implemented until 5/27/26. A physician order with a start date of 5/27/26, documented Mirtazapine Oral Tablet 15 MG [milligrams] (Mirtazapine) Give 1 tablet by mouth one time a day for appetite stimulant. The order was discontinued on 5/28/26. A physician order with a start date of 5/29/26, documented Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth one time a day for appetite stimulant. On 5/30/26 at 7:00 AM, a Provider note documented . She was seen today for rehab followup visit and is concerned about losing weight. Reviewed her vitals; everything looks fine except her weight was 101.6 lbs today, down from 106.2 lbs on 5/21. Patient says she has been eating okay but does not have a really good appetite, though she does have an NG tube feeding in place. The nurse was looking for an order to continue the feeding. On 5/30/26 at 6:46 PM, an Orders - Administration Note documented Enteral Feed Order every shift Enteral: Continuous Feed: Check every 4-6 hours, prior to irrigation and PRN [as needed] (Confirm with physician regarding withholding feedings) Order does not specify rate for feeding. ADON [Assistant Director of Nursing] notified and notified provider. Still waiting on response so feed was not started today. Pt has been eating orally. On 5/31/26 at 12:35 PM, an Order Note documented The order you have entered Fibersource HN Enteral Liquid (Nutritional Supplements) Give 45 ml/hr enterally every 4 hours for Nutrition Start at 20mL/hr, titrate by 10-20mL/hr every 4 hours to goal . It should be noted that resident 13 went without the tube feeding from 5/25/26, night shift until 5/31/26 at 4:00 PM. On 5/31/26 at 3:55 PM, a Nutrition Evaluation documented . Macronutrients Feed calories 1296 kcal [kilocalorie] (27 kcal/kg [kilocalorie per kilogram]) Total protein 58 gm [grams] (1.2 gm/kg [grams per kilogram]) Total carbs [carbohydrates] 177 gm Total fat 43 gm Fluid Feed water 875 mL Water flushes 480 mL (80 mL Q4hr [every four hours]) Total fluids 1355 mL (28 mL/kg [milliliters per kilogram]) Daily needs 1350 mL (1 mL per kcal). It should be noted that the macronutrients were not calculated during the Nutrition Evaluation on 5/21/26. No additional interventions were included on 5/31/26. On 5/26/26, resident 13 weighed 101.6 lbs. On 6/1/26, resident 13 weighed 93.4 lbs which was a -8.07% weight loss in six days. It should be noted that resident 13 lost an additional 8.2 lbs since 5/26/26. On 5/21/26, resident 13 weighed 106.2 lbs. On 6/1/26, resident 13 weighed 93.4 lbs which was a -12.05% total weight loss. The Task: NUTRITION - Amount Eaten was reviewed for the time frame that resident 13 went without the tube feeding. a. On 5/25/26 at 5:30 PM, the dinner meal was refused.b. On 5/26/26 at 4:06 PM, 0-25% was eaten. At 5:31 PM and 5:36 PM, 26-50% was eaten.c. On 5/27/26 at 1:32 PM and 1:33 PM, 0-25% was eaten. At 5:00 PM, 76-100% was eaten.d. On 5/28/26 at 3:19 PM, 51-75% was eaten. At 5:23 PM, the dinner meal was refused.e. On 5/29/26 at 4:54 PM, 0-25% was eaten, 26-50% was eaten, and Resident Not Available was marked.f. On 5/30/26 at 8:00 AM, 76-100% was eaten. At 1:00 PM, 51-75% was eaten. At 5:00 PM, 26-50% was eaten.g. On 5/31/26 at 11:19 AM, 0-25%t was eaten. At 3:23 PM, resident 13 refused. On 6/4/26 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the Registered Dietitian (RD) extended the tube feed order because resident 13 kept losing weight. The DON stated if a resident was receiving Med Pass it would be documented on the Medication Administration Record. The DON stated the physician order for the tube feed was started on 5/31/26, but the new order was not scanned into the medical record and the progress note was not in by the nurse but it was by the RD. The DON stated the Med Pass physician's order was not started but she put it in today. The DON stated to ensure resident 13 was maintaining her nutritional status staff would update the physician order, resident 13's tube feeding was increased today, and staff would encourage food. The DON stated the doctor started mirtazapine to increase resident 13's appetite. The DON stated the tube feeding was more for a supplement because resident 13 could eat. The DON stated the tube feeding was stopped because the order from the hospital was completed. The DON stated the RD and the nurse should know to continue the tube feed based on the original assessment on admission. The DON stated that staff would do a trial to discontinue the tube feed and if the resident was able to eat the tube feed would be discontinued. The DON stated if the resident was not maintaining their nutritional needs the tube feed would continue. The DON stated the provider note on 5/26/26, was when the provider decided to start the mirtazapine for resident 13. On 6/4/26 at 2:50 PM, an interview was conducted with the RD. The RD stated that she was not aware that resident 13 was without the tube feed for 5 to 6 days. The RD stated when she saw resident 13 yesterday she saw a trial order for the tube feed for 5 days. The RD stated she received a phone call over the weekend from the facility that resident 13 did not have any orders and needed a tube feed and she figured that out. The RD stated that resident 13 did take food by mouth. The RD stated that yesterday she saw resident 13 and resident 13 wanted the tube feed reduced. The RD stated she spoke with resident 13 and told her that she could not reduce the tube feed but she could reevaluate the tube feed in a week. The RD stated she got a notification from the DON today that resident 13 had lost weight and needed to up the level of the tube feed so the RD increased resident 13's tube feed. The RD stated that her recommendations were communicated in the nutrition at risk (NAR) meeting and if she did not attend the meeting she would list the recommendations and email the DON. The RD stated the recommendations were also on the NAR meeting report. The RD stated that resident 13's intake was hit and miss and the RD did not want to overload resident 13 with the tube feed if she was eating. The RD stated that she did not think it was okay for resident 13 to not have her tube feed for 5 days. The RD stated that she thought that resident 13 had lost too much weight to not have the tube feed. The RD stated if the staff did not have orders for the tube feed she should have been called within 24 to 48 hours at the latest. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, dialysis, type 1 diabetes mellitus and pulmonary hypertension due to lung disease, and hypoxia. A Nutrition Evaluation was completed on 5/6/26, which revealed resident 6 had a consistent carbohydrate diet with a 1000 milliliter fluid restriction and a renal house supplement daily. Resident 6 had a high potassium on 4/29/26, of 5.3 millimoles per Liter [mmol/L] according to the evaluation. The RD documented monthly weight triggered significant loss against weight from 3/27/26. The RD documented resident 6's Weights are otherwise stable and [resident 6] continues frequent monitoring during NAR (nutrition at risk) meetings secondary to dialysis dependency. Will continue to monitor labs, no other nutrition considerations at this time. Recommend continue current POC (plan of care). A nurse's note dated 5/27/26 at 6:18 PM, Pt [patient] noted to have a critical potassium of 6.0 [mmol/L]. Pt received dialysis, which likely reduced k [potassium] level Follow up lab draw was ordered/recommended to confirm post-dialysis k level. however pt refused repeat lab draw despite ed [education] provided. Pt monitored for signs/symptoms of electrolyte imbalance. A risk verse benefit dated 6/4/25, revealed resident 6 was educated on the benefits of a carbohydrate controlled diet. There was no information regarding a renal or low potassium diet. On 6/4/26 at 2:13 PM, an interview was conducted with the Dietary Manager (DM). The DM stated resident 6 was on a liberalized renal diet but it depended on what the dialysis RD ordered. The DM was observed to check resident 6's meal ticket and it had carbohydrate controlled, regular texture, fluid restriction, and disliked melon. The DM stated the meal ticket should have if the resident required low potassium foods. On 6/4/26 at 2:28 PM, a phone interview was conducted with the RD. The RD stated she had not been able to get into contact with the RD at the dialysis center. The RD stated she used to get lab results from the dialysis RD but had not received them with the new dialysis RD. The RD stated she was not provided information that resident 6's potassium was at 6. The RD stated she thought resident 6 was on a liberal renal diet which meant the diet was somewhat restricted. The RD stated resident 6 might have a risk vs benefit signed which meant staff had chatted with the resident about what diet they were ordered and why it was helping them. The RD stated staff were still expected to offer the resident the prescribed diet and then provide them foods they requested. At 3:38 PM, a follow up interview was conducted with the RD. The RD stated she had misspoken about resident 6's diet order and the resident should be served the diet according to the physician's order. On 6/4/26 at 2:20 PM, an interview was conducted with the Assistant Director of Nursing (ADON) and the DM. The ADON stated they reviewed resident 6's nursing notes for 5/27/26, and resident 6 had a critically high potassium level and another lab draw was completed on 6/3/26, and the potassium was normal. The ADON stated resident 6 had a risk versus benefit signed in the medical record. The ADON confirmed resident 6 was on a carbohydrate controlled diet and not a renal diet. On 6/4/26 at 3:21 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated resident 6 was readmitted from the hospital on 2/25/25, with a diet order of carbohydrate control diet and not a liberalized renal diet. The RNC stated resident 6 was on a renal diet with regular consistency prior to discharging to the hospital. The RNC stated the RD and physician evaluated the need for diet changes.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine temperatures were below the required manufacture temperatures for sanitizing dishes. Findings included:On 6/1/26 at 9:45 AM, an observation was made of the dishmachine. The following temperatures were observed: [Note: All temperatures were in degrees Fahernheit.] Wash was 160 and rinse was 150 for 3 loads of dishes.Wash was 160, rinse was 150 and final rinse was 135. Wash was 160, rinse was 155 and final rinse was 140.Wash was 165, rinse was 155 and final rinse was 130The above cycles were observed to have cups, plates, domes, mugs and bowls. The items were observed to be taken from the dish machine baskets and placed with the clean dishes. On 6/1/26 at 9:55 AM, an interview was conducted with [NAME] 1. [NAME] 1 stated the wash temperature needed to be above 150, rinse above 160 and final rinse above 180. [NAME] 1 stated those temperatures were listed directly on the dishmachine.An observation was made of the dishmachine and the temperatures listed by the manufacturer for this high temperature dishmachine were wash above 150, rinse above 160 and final rinse above 180.On 6/1/26 at 10:00 AM, an interview and observation was conducted with the Dietary Manager (DM). The DM observed the dishmachine and stated the wash was 165, the rinse was 155 and the final rinse was 130. The DM stated the staff were able to put a thermometer through the dishmachine to check temperatures. The DM obtained a thermometer and stated the batteries were dead so it did not work. The DM stated the dish machine company needed to be contacted and they were going to call them. At 2:24 PM, a follow up interview was conducted with the DM. The DM stated dishes needed to be washed in the 3 compartment sink until the dish machine company was able to look at the machine. The DM stated staff should have stopped washing dishes and notified the DM when the thermometers were not reaching the temperature.

Based on interview and record review, for 3 of 36 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident's multiple sclerosis medication was not available for administration, another resident's Clonidine, Hydralazine, and Ferrous Fumarate were documented as not available for administration, and a third resident's potassium chloride, topiramate, Myrbetriq, and duloxetine were documented as not available for administration. Resident identifiers: 6, 29, and 39. Findings included: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (MS), protein calorie malnutrition, chronic pain syndrome and major depressive disorder. On 6/2/26 at 8:59 AM, an interview was conducted with resident 29. Resident 29 stated there were problems with reordering her MS medications and the scheduled dose was usually changed when medications were reordered. Resident 29 stated the nurses struggled to get her MS medication every month and it was due every 28 days. A progress note dated 3/13/26 at 11:37 PM, documented Administered Kesimpta with [name of another nurse] as second witness, no issues with administration will reorder medication so we can [sic] for next month. According to the Medication Administration Record for April 2026 Kesimpta Subcutaneous Solution Auto-injector 20 milligrams (mg)/0.4 milliliter. Inject 1 application subcutaneously every night shift every 28 days for MS. The order instructed to have 2 nurses verify and document that the shot was given. The injection was not administered on 4/7/26 because other/See Progress note. There was no documentation regarding why the medication was not administered. On 5/18/26 at 11:45 AM, the Nurse Practitioner (NP) documented .resident does take Percocet once every 28 days however has not had the medication due to an error with her insurance. Even though this has been corrected and the resident is to continue receiving her injection, the medication has not arrived and pharmacy is to be contacted to determine where the medication is.She had been without her Kesimpta (ofatumumab) for a few weeks due to an insurance issue; she anticipates restarting in May. It should be noted that the physician wrote Percocet instead of Kesimpta. On 6/4/26 at 10:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 29 was very anxious about losing control of her body and mind. The DON stated resident 29 had an injected medication for her MS. The DON stated once the medication was administered, then insurance needed to be notified so it could be approved for administration 28 days later. The DON stated her and the Assistant Director of Nursing were in charge of making sure the medications were ordered and available for administration. The DON stated resident 29 did not get the MS medication in April 2026, her and her family were informed of what was going on. The DON stated there were no other medications that could be used to substitute. The DON stated she would look into why the medication was not available. At 12:42 PM, the DON stated there was an NP progress note saying to hold the medication until May 2026. The progress note was from 5/18/26, but there was no documentation around 4/7/26, when the medication should have been administered. 2. Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included kidney transplant rejection, end stage renal disease, dependence on renal dialysis, pulmonary hypertension, congestive heart failure, and hypertension. On 2/25/25, resident 6 had an order initiated for Hydralazine Hydrochloride (HCl) Tablet 25 mg by mouth three times a day for hypertension. On 8/15/25, resident 6 had an order initiated for Clonidine HCl tablet 0.1 mg by mouth one time a day for hypertension. On 2/4/26, resident 6 had an order initiated for Ferrous Fumarate Tables 325 mg by mouth two times a day for anemia. Resident 6's May 2026 Medication Administration Record (MAR) was reviewed. Clonidine was documented as not available for administration on 5/19/26. The Hydralazine was documented as not available for administration on 5/27/26. The Ferrous Fumarate was documented as not available for administration on 5/28/26. On 6/3/26 at 10:23 AM, an interview was conducted with the DON. The DON stated that if an area on the MAR was left blank that usually meant that the medication was unavailable. The DON stated that the MAR had an option to enter a code for medications not administered or held. Per the MAR a code 11 indicated that the medication was not available for administration. The DON stated that medication refills were obtained in a refill option on the electronic medical record system or they could be faxed directly to the pharmacy. The DON stated that the nurse should send the medication refill request 7 or 8 days before the last dose so they did not run out of the medication. 3. Resident 39 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, post traumatic stress disorder, borderline personality disorder, generalized anxiety disorder, cognitive communication deficit, and depression. On 5/25/26 at 7:57 AM, an Orders - Administration Note documented Potassium Chloride ER [extended release] Oral Tablet Extended Release 20 MEQ [milliequivalent] Give 20 mEq by mouth one time a day for Supplement medication currently not available. pharmacy states medication will be delivered today. On 5/25/26 at 7:57 AM, an Orders - Administration Note documented Topiramate Oral Tablet 100 MG Give 100 mg by mouth one time a day for Migraines medication currently not available. pharmacy states medication will be delivered today. On 5/25/26 at 7:58 AM, an Orders - Administration Note documented Myrbetriq Oral Tablet Extended Release 24 Hour 25 MG Give 25 mg by mouth one time a day for OAB [over active bladder] medication currently not available. pharmacy states medication will be delivered today. On 6/2/26 at 7:38 AM, an Orders - Administration Note documented DULoxetine HCl Oral Capsule Delayed Release Sprinkle 60 MG Give 120 mg by mouth one time a day for Depression med [medication] not available, on order, provider notified. On 6/4/26 at 9:33 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated if he needed to refill a resident's medication he would remove the tab from the medication card and fax the tab to the pharmacy. RN 5 stated if it was a medication that the resident needed immediately he would pull from the facility emergency medication cart. RN 5 stated if the medication was not available in the emergency cart he would call the DON or the NP to make sure that he was not missing something.

Based on interview and record review, for 1 of 36 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported to the State Survey Agency (SSA). Specifically, the facility waited 5 days to report an allegation of abuse or neglect to the SSA, after a resident sustained a fall which resulted in a fracture. Resident identifier: 76. Findings included:Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fall with fracture, major depressive disorder, muscle weakness and osteoporosis. The facility reported on 12/31/25 to the SAA that resident 76 sustained a witnessed fall on 12/25/25. Resident 76 was transferred to the hospital where a fracture of the sacrum was identified. On 6/4/26 at 1:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility became aware of resident 76's broken sacrum on 12/25/26. The DON stated she did not know it was not reported until 12/31/25 to SSA. On 6/4/26 at 1:58 PM, an interview was conducted with the Administrator (ADM). The ADM stated it was before he started so he did not know why it was not reported to the SSA within 24 hours. The ADM stated it should have been reported on 12/25/25.

Based on observation, interview and record review, for 1 of 36 sampled residents, the facility did not provide appropriate treatments and services to maintain or improve his or her ability to carry out the activities of daily living, which included hygiene and bathing. Specifically, a resident was not provided showers and was observed to have a body odor. Resident identifier: 57. Findings included:Resident 57 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, protein-calorie malnutrition, anxiety disorder and failure to thrive. On 6/2/26 at 8:42 AM, an observation was made of resident 57. Resident 57 was in his room and was observed to have strong body odor. On 6/3/26 at 9:21 AM, an observation was made of resident 57. Resident 57 was observed to bring a meal tray to the nurses station from his room. Resident 57 was observed to have strong body odor and was in the same clothing from 6/2/26. An annual Minimum Data Set assessment dated [DATE] revealed resident 57 needed set up or clean up assistance with bathing. A care plan dated 4/15/25 revealed resident 57 had alterations in Activities of Daily Living (ADL) function secondary to muscle weakness. Interventions included ADL needs will be met each day through next review; Assist in completing ADL tasks each day; Provide dignity and respect, and encourage independence. Another care plan dated 12/28/25 revealed resident 57 displayed behavioral symptoms: refusals of care. Interventions included allow resident 57 to make choices for their care, including the choice to refuse care; Encourage participation in activities of interest; make reports to the appropriate entities; and praise resident 57 when behavior was appropriate. The Certified Nursing Assistant (CNA) tasks section of resident 57's medical record revealed showers were scheduled Tuesday, Thursday and Saturday evenings. Resident 57 was showered on 5/5/26, 5/23/26 and 5/26/26. Resident 57 refused a shower on 6/3/26. Resident 57 was not available on 5/7/26, 5/9/26, 5/14/26, 5/19/26, 5/21/26, 5/28/26 and 5/30/26. On 6/3/26 at 9:42 AM, an interview was conducted with the Restorative Nursing Aide (RNA). The RNA stated resident 57 received a shower about once a week. The RNA stated it was difficult for resident 57 to understand showers and told staff that he will take care of it when he goes home. The RNA stated if staff offered him a shower in morning he would tell them no that he would get dirty anyway. The RNA stated that staff offered showers at night and a lot of times he still refused. On 6/3/26 at 10:06 AM, an interview was conducted with CNA 1. CNA 1 stated resident 57 was independent with his showers and staff had to remind him to shower. CNA 1 stated resident 57 sometimes refused showers and then the next day he showered. CNA 1 stated if resident 57 had not showered for a few days, a male CNA would ask him to shower and sometimes he still refused. CNA 1 stated resident 57 sometimes had body odor. CNA 1 stated if he refused an evening shower then he was showered the next day. On 6/3/26 at 10:11 AM, an interview was conducted with CNA 2. CNA 2 stated resident 57 required set up assistance with showers. CNA 2 stated resident 57 refused showers or he did them on his own time. CNA 2 stated if a resident was not showered on an assigned shower day, then it was communicated in shift to shift report. CNA 2 stated resident 57 sometimes smelled and would not be surprised if he had body odor. On 6/3/26 at 10:57 AM, an interview was conducted with the Director of Nursing (DON). The DON stated a resident's shower schedule was in their tasks section of the medical record and it populated to the CNA charting. The DON stated if a resident refused a shower, then a sheet was filled out and scanned into the miscellaneous section of the medical record. The DON stated if a resident was not available for a shower that meant the resident was out with family and the shower should be rescheduled. The DON stated if a resident was cognitively impaired, staff should make multiple attempts to offer. The DON stated the CNA and nurse signed the shower sheet. The DON stated if a resident was cognitively impaired, starting to smell, they would have another staff member offer shower assistance. The DON stated she was always willing to step in and help staff get residents to shower. At 2:01 PM, the DON stated resident 57 had been going through a time where he wanted showers at night and she did not know why it was marked that resident 57 was unavailable for showers.

Based on observation, interview, and record review, for 1 of 36 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with decreased sensation in her feet utilized hot packs heated in the microwave and staff were not able to determine the temperature prior to application. Resident identifier: 29. Findings included:Resident 29 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, protein-calorie malnutrition, chronic pain syndrome and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident 29 had a Brief Interview of Mental Status score of 15 which indicated resident was cognitively intact. The MDS further revealed no acute onset of mental status change, inattention, disorganized thinking, or altered level of consciousness. On 6/2/26 at 8:59 AM, an interview was conducted with resident 29. Resident 29 stated her feet were really cold because she had restricted blood flow. Resident 29 stated that she had a heated blanket that the facility removed from her room. Resident 29 stated she had a loss of sensation in her feet but was able to feel hot and cold. Resident 29 stated her heated blanket made her quality of life better. Resident 29 stated she had hot packs that staff provided her in place of the heated blanket. An observation was made of homemade hot packs on her table. A behavioral health note dated 2/25/26 at 8:45 AM, revealed . Patient used the example of the new director coming in and taking away her heated blanket. This event triggered feelings that she did not have control, which then led into feelings of shame. These shame feelings connected with thoughts of not being a good mother, not doing enough in her life to help those around her, and then feelings of just wanting to give up. She reported not getting out of bed for several days as a result of this cycle. It was noted that this cycle is perpetuated by thinking errors. There were no notes regarding resident 29's heated blanket being taken away and another option provided to assist in warming her feet. On 6/4/26 at 10:23 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 29's feet were always cold and she wanted to use a heated blanket on them but that was not allowed. CNA 1 stated resident 29 had heat packs that she microwaved for 45 seconds to warm them up. CNA 1 stated she did not obtain a temperature of the heat packs but if she was able to touch the hot pack, then it was at the correct temperature. CNA 1 stated she asked resident 29 how the hot pack felt but she was not sure how much feeling resident 29 had in her feet. CNA 1 stated resident 29 let staff know when to remove the heat pack. On 6/4/26 at 10:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 29's feeling in her feet was minimal. The DON stated she kept several blankets and used the foot warmers that popped and did not go above a certain temperature. The DON stated she was not aware of hot packs that were being heated in the microwave. On 6/4/26 at 10:30 AM, an interview was conducted with the Administrator (ADM). The ADM stated resident 29 was not allowed to have a heated blanket and she was upset. The ADM stated in place of the heated blanket, resident 29 was offered the heat packs that can be popped to control the heat. The ADM stated the facility did not allow heating pads, heated blankets, or reusable heat packs that were warmed in the microwave. The ADM stated the concern would be knowing the temperature of the item prior to placing it on residents skin. The ADM stated the items could cause burns.

Based on interview and record review it was determined that the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 36 sampled residents, the facility did not conduct a post dialysis assessment after each dialysis session. Resident identifier: 6. Findings included:Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included kidney transplant rejection, end stage renal disease, and dependence on renal dialysis. On 6/1/26 at 10:54 AM, an interview was conducted with resident 6. Resident 6 stated that she had dialysis today and would not be back until after 4:00 PM. Resident 6 stated that she had a dialysis port on her left chest. Resident 6 stated that the port dressing was changed weekly at dialysis and she did not have any signs and symptoms of infection in the port. Resident 6's medical records were reviewed. Resident 6's physician's orders revealed the following: a. Dialysis 3 times a week on Monday, Wednesday, and Friday (MWF). The order was initiated on 6/18/25. b. Only use DRY weight (wt) from dialysis. Enter weight after every dialysis visit MWF. Convert weight from kilograms to pounds. The order was initiated on 6/16/25. c. PRE-Dialysis (Pre-Visit Form) - Ensure dialysis communication form was completed and sent with residents every dialysis day. The order was initiated on 2/26/25. d. POST-Dialysis (Post-Visit Form) - Ensure dialysis communication form was returned to the facility, progress note if needed and scanned on every dialysis day. The order was initiated on 2/26/25. e. Dialysis - Fluid Restriction - Specify fluid restriction if applicable - (1000) milliliters (mL) every shift. The order was initiated on 2/25/25. f. Dialysis: Check site for bleeding and signs or symptoms (s/sx.) of infection every shift. The order was initiated on 2/25/25. Resident 6's May 2026 Medication Administration Record (MAR) documented that the dialysis fluid restriction was maintained, the pre and post-dialysis communication form was returned, dry wt. was documented from dialysis except on 5/15/26 and 5/29/26, and port was checked for s/sx of bleeding or infection except on 5/29/26. Resident 6's dialysis communication forms were reviewed. Post dialysis assessments were not completed for each dialysis appointment. Resident 6's care plan for required hemodialysis secondary to End Stage Renal Disease was initiated on 4/15/25. Interventions identified on the care plan included a fluid restriction of 1000 mL per day, monitor dialysis port as prescribed, monitor edema or fluid overload, and monitor weights and vital signs. On 6/3/26 at 10:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurse communicated with dialysis through the dialysis communication form or they called the dialysis center directly. The DON stated that the nurse should monitor the dialysis port for signs and symptoms of an infection every shift. The DON stated that the post dialysis form should document resident 6's weights post dialysis and any medications that were administered at dialysis or any labs that the dialysis center obtained. The DON stated that the floor nurse should fill out a post dialysis assessment after each dialysis visit to monitor resident 6's condition especially with her fragile diabetes. On 6/3/26 at 1:52 PM, a follow-up interview was conducted with the DON. The DON stated that the post dialysis assessments were not completed for resident 6 and they planned to start a performance improvement plan for this.

Based on interview and record review, the facility did not ensure that the resident's drug regimen was free from any unnecessary drugs. An unnecessary drug was any drug used in excessive dose; for excessive duration; without adequate monitoring; without adequate indications for use; in the presence of adverse consequences; or any combination of the above. Specifically, for 2 out of 36 sampled residents, a resident had medications that were not administered with no documentation of the reason for omission, and insulin was held when it should have been administered per the physician ordered parameters. Additionally, a resident was administered blood pressure medications without a documented blood pressure reading. Resident identifiers: 6 and 59.Findings included:1. Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included kidney transplant rejection, end stage renal disease, dependence on renal dialysis, pulmonary hypertension, congestive heart failure, and hypertension. On 2/25/25, resident 6 had an order initiated for Hydralazine Hydrochloride (HCl) Tablet 25 milligram (mg) by mouth three times a day for hypertension. On 8/15/25, resident 6 had an order initiated for Clonidine HCl tablet 0.1 mg by mouth one time a day for hypertension. On 1/17/26, resident 6 had an order initiated for Insulin Lispro sliding scale. Inject as per sliding scale: if blood sugar was 201 - 300 = 0; 301 - 400 = 1; 401 - 499 = 2; 500+ = 3, subcutaneously before meals and at bedtime for Diabetic management. On 5/26/26, resident 6 had an order initiated for Pregabalin Capsule 50 mg by mouth one time a day for pain. Resident 6's May 2026 Medication Administration Record (MAR) was reviewed. The medication legend documented Code 9 was see progress note; and Code 4 was Blood Sugar/Vital Signs out of parameters for administration. The Clonidine was documented as a Code 9 on 5/17/26, and no documentation was found in the progress note for the reason of the medication omission. The Pregabalin was documented as a code 9 on 5/1/26 through 5/3/26, and no documentation was found in the progress note for the reason of the medication omission. The Hydralazine was documented as a Code 4 on 5/1/26 and 5/7/26, and no documentation was found of the blood pressure reading or reason for the medication hold. The Insulin Lispro was held when it should have been administered per the sliding scale on 5/11/26 (blood sugar was 204), on 5/22/26 (blood sugar was 203), and on 5/24/26 (blood sugar was 206). Additionally, the Insulin Lispro did not have any documentation on 5/27/26. On 6/3/26 at 1:53 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the Clonidine was held on 5/17/26, without a documented reason in the progress note. The DON confirmed that the Hydralazine was held on 5/1/26, without a documented blood pressure, and was held on 5/7/26, for BP of 115/97 without a documented progress note. The DON stated that the Hydralazine should have been administered on 5/7/26, and not held. The DON stated that the facility did not have any standing orders for blood pressure parameters to hold medications. The DON stated that per the current physician order the Insulin Lispro should have been administered on 5/22/26 and 5/24/26. 2. Resident 59 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, type 2 diabetes mellitus, acquired absence of the right and left leg above the knee, infection of left amputation stump, and chronic pain. On 4/12/26, resident 59 had an order initiated for Metoprolol Succinate Extended Release Tablet, Give 25 mg by mouth one time a day for rate regulation. Hold for systolic blood pressure less than 110 or a heart rate less than 60. On 4/13/26, resident 59 had an order initiated for Bumetanide Tablet 2 mg by mouth in the morning for cardiac health. Resident 59's May 2026 MAR was reviewed. The Bumetanide was documented as administered on 5/10/26, 5/11/26, and 5/29/26, without a documented blood pressure reading. The Metoprolol was documented as administered on 5/11/26, 5/16/26, and 5/29/26, without a documented blood pressure reading. On 6/3/26 at 10:23 AM, an interview was conducted with the DON. The DON stated that if an area on the MAR was left blank that usually meant that the medication was unavailable. The DON stated that the MAR had an option to enter a code for medications not administered or held. The DON stated that vital signs should be documented and it populated to the MAR. The DON stated the MAR allowed the nurse to document that the order was completed even when vital signs were not listed.

Based on interview and record review, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, a resident that had their complete blood count (CBC) and urinalysis (UA) cancelled did not have those labs redrawn. Resident identifier: 39.Findings included:Resident 39 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, post traumatic stress disorder, borderline personality disorder, generalized anxiety disorder, cognitive communication deficit, and depression. On 5/22/26 at 10:47 AM, a physician's order documented to collect a CBC, comprehensive metabolic panel, and a UA with culture and sensitivity. On 5/22/26 at 6:45 PM, a physician's order documented to re-draw the CBC. On 5/25/26 at 6:00 AM, a physician's order documented to collect a UA culture and sensitivity. The lab reports were reviewed and revealed the CBC specimen clotted and the UA was cancelled because it was never received. On 6/4/26 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was no notification from the laboratory of resident 39's UA or CBC being cancelled. The DON stated the UA and CBC were not redrawn. The DON stated when lab results were cancelled the lab called the nurses station.

Based on interview and record review it was determined the facility did not file in the resident's clinical record laboratory reports that were dated and contain the name and address of the testing laboratory. Specifically, for 2 out of 36 sampled residents, the facility did not file the resident's laboratory results in their medical records. Resident identifiers: 6, and 9.Findings included:1. Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included kidney transplant rejection, end stage renal disease, dependence on renal dialysis, pulmonary hypertension, congestive heart failure, and hypertension. Resident 6's medical records were reviewed. On 3/9/26, resident 6 had a physician order for a lipid panel and hemoglobin A1c initiated. No documentation could be found in resident 6's medical records of the laboratory results for the lipid panel and A1c. On 6/3/26 at 1:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the lipid panel and A1c reports were requested from the laboratory and she would forward the results when they were obtained. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, cerebral infarction, morbid obesity, type 2 diabetes mellitus, fracture of right toe, non-pressure injury of left foot. Resident 9's medical records were reviewed. On 10/22/25 and 10/29/25, resident 9 had a physician order for a Comprehensive Metabolic Panel (CMP) initiated. On 11/12/25, resident 9 had a physician order for a Basic Metabolic Panel (BMP) and a Hemoglobin A1c initiated. No documentation could be found of the ordered laboratory results in resident 9's medical records. On 6/2/26 at 2:44 PM, the DON emailed copies of the 11/12/25 BMP, A1C and the 10/22/25 and 10/29/25 CMP. All results had a print date of 6/2/26. None of the results were located in the resident's medical records. On 6/3/26 at 10:18 AM, an interview was conducted with the DON. The DON stated that the lab results were requested from the laboratory yesterday. The DON stated that she would get the results uploaded into the resident's medical record.

Based on interview and record review it was determined that the facility did not ensure that radiology and diagnostic services were obtained to meet the needs of its residents. Specifically, for 1 of 36 sampled residents, the facility did obtain an x-ray of the right knee when ordered by the physician. Resident identifier: 9. Findings included:Resident 9 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, cerebral infarction, morbid obesity, type 2 diabetes mellitus, fracture of right toe and non-pressure injury of left foot.Resident 9's medical records were reviewed. On 2/6/26, resident 9's physician ordered an x-ray of the left and right knee.No documentation could be found of the right knee x-ray results in resident 9's medical records. On 6/2/26 at 2:44 PM, the Director of Nursing (DON) emailed copies of the left knee x-ray. The DON was informed that the right knee x-ray results were still not available. No results for the right knee x-ray were provided.

Based on observation, interview, and record review, for 2 of 36 sampled residents, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not completed during a dressing change and the wound bed was cleaned with multiple cross swipes with the same gauze pad. Additionally, medication was placed back into a blister pack after a resident refused it. Resident identifiers: 68 and 59.Findings included: 1 . Resident 68 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis, severe sepsis with septic shock, and stage 2 pressure ulcers. On 5/30/26, an order was started for Oxycodone hydrochloride (HCL) Give 10 milligrams (mg) orally every 4 hours as needed for severe pain. On 6/4/26, at 10:09 AM, an observation was made of the medication cart for rooms 416 to 611 with Registered Nurse (RN) 1 present. The blister pack containing resident 68's Oxycodone HCl 10 mg was observed to contain 1 tablet that had been placed back in a blister cell, and the paper folded back over it. RN 1 stated that she had removed the tablet from the blister cell that morning to administer with all of resident 68's scheduled medications. RN 1 stated that when she went to administer the Oxycodone to resident 68, resident 68 stated that she did not want to take the Oxycodone at that time and preferred to wait to take it right before physical therapy. RN1 stated that because the Oxycodone was ordered as needed, and that the resident requested to take it during RN 1's shift, she placed the tablet back in the blister cell and folded the paper over the table to hold it in place. RN 1 stated that she normally would have used tape to secure it in place, but did not have any available. On 6/4/26 at 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident refused a narcotic medication that had been removed from a blister cell the nurse should dispose of it with another nurse and document it in the narcotic log. The DON stated that when a medication was placed back into a blister cell there was a risk for infection control to be compromised. Additionally, the DON stated that it was not possible to be certain the correct medication was returned to the blister cell. 2. Resident 59 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, type 2 diabetes mellitus, acquired absence of the right and left leg above the knee, infection of left amputation stump, and chronic pain. On 6/1/26 at 1:02 PM, an interview was conducted with resident 59. Resident 59 stated that she had pain in the right stump and that there was a wound there. Resident 59 stated that the wound was not open and they did not do a dressing change on it. Resident 59 stated that the wound on the right stump had been present for approximately 1.5 weeks. Resident 59 had a physician order for L [left] stump: Cleanse with NS [normal saline]. Apply silver alginate to wound bed. Cover with bordered dressing. every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday]. The order was initiated on 4/22/26. On 6/3/26 at 11:50 AM, an interview was conducted with RN 4. RN 4 stated that resident 4 had a dressing on both the left and right stump and she only had orders for the left stump. RN 4 was observed providing wound care to resident 59. RN 4 performed hand hygiene and donned a gown and gloves. Resident 59 had a bordered foam dressing on her bilateral above the knee amputation (AKA) stumps. RN 4 removed the dressing from the right and left AKA stump. RN 4 stated that the right dressing did not have any drainage on the old dressing, and the left stump dressing had serosanguinous drainage. RN 4 doffed and donned new gloves, no hand hygiene was performed. RN 4 placed a disposable chuck pad underneath resident 59's stumps. RN 4 opened a 4x4 gauze pad and placed it into a cup squirting 20 milliliters of normal saline onto the gauze pads. RN 4 cleaned the left stump wound working from the inside outward. The RN folded the gauze pad over on itself and wiped the wound bed 2 more times with the same gauze pad. RN 4 cleaned the right stump with a new 4 x 4 gauze pad that was soaked in normal saline. RN 4 doffed her gloves and new gloves were donned, no hand hygiene was performed. RN 4 placed a sheet of silver alginate in the left wound bed and covered it with a bordered foam dressing. RN 4 placed a bordered foam dressing on the right stump. RN 4 doffed the gown and gloves, and performed hand hygiene with alcohol based hand rub prior to exiting the room. RN 4 stated that the right stump was newly closed. RN 4 stated that when she cleaned the right stump wound bed a scab came off and it was closed underneath. RN 4 stated that it made her believe that the wound was barely closed or was trying to break back open. RN 4 stated that she would notify the wound nurse to assess the right stump and put a treatment order in. On 6/3/26 at 12:49 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON was the facility wound care nurse. The ADON stated that staff should perform hand hygiene before wound care, at the time of glove changes, and at the end of wound care after doffing gloves. The ADON stated anytime staff doff and don gloves they should perform hand hygiene. The ADON stated that when performing wound care staff should clean from the center of the wound working inside out to avoid introducing bacteria into the wound bed. The ADON stated that staff should obtain a new gauze pad when cleaning the same area multiple times.

Based on interview and record review, it was determined that the facility did not ensure, for 1 of 17 sampled residents, that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility did not conduct wound care orders at prescribed by the physician. Resident identifier: 2. Findings Include: 1. Resident 2 was admitted to the facility on [DATE] following surgical repair of a fractured ankle. On March 18, 2025, the surveyor completed a review of Resident 2's medical record and the following entries were observed: Resident 2 had a wound care order that started on October 24, 2024 and was discontinued on November 1, 2024. The order had instructions to complete wound care to the right ankle on Mondays, Wednesdays, and Fridays. Resident 2's Medication Administration Record (MAR) revealed that the wound care order was not completed on October 25, 2024 with a note from the nurse that stated, Resident Unavailable. Resident 2 had a wound care order that started on November 1, 2024 and was discontinued November 12, 2024. The order had instructions to complete wound care to the right foot once a day and as needed. Resident 2's MAR revealed the wound care order was not completed on November 7, 2024 with a note from the nurse that stated, Could not track down resident while they were not busy. The surveyor reviewed the facility's Wound Treatment Management Policy. The policy stated, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. On March 17, 2025, Admin 1 communicated with the surveyor via email that if the resident was unavailable for wound care, the order should be passed on to the next shift, and the physician should be notified. Follow-up actions for the missed wound care orders for Resident 2 were not carried out in accordance with the facility's policy.

Based on interview and record review, the facility did not ensure residents were free of significant medication errors. Specifically, for 1 of 17 sampled residents, multiple doses of medications, including antibiotics and insulin, were not administered as ordered by the physician. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis which included type 1 diabetes mellitus and hypertension. The surveyor reviewed Resident 9's October 2024 and November 2024 Medication Administration Record (MAR). The MAR revealed Resident 9 was scheduled to receive multiple medications, including medications for hypertension (Amlodipine and Losartain-Hydrocholorothiazide), an antibiotic (Ciprofloxacin), and insulin (Lispro and Lantus). The following medications were observed by the surveyor as not administered per the MAR: In October 2024, the resident did not receive 4 of 13 scheduled doses of Ciprofloxacin. In November 2024 the resident did not receive 3 of 30 doses of amlodipine, 5 of 30 doses of the once a day insulin lispro, 4 of 30 doses of the before meals and bedtime insulin lispro, 5 of 30 doses of Lantus, and 2 of 30 doses of losartain-hydrochlorothiazide. These medications were noted to have been unavailable, or the resident was unavailable and were not administered according to the prescribing order for the number of doses listed above. A review of the Unavailable Medications policy revealed staff should notify the physician and obtain alternative treatment orders when a medication was unavailable for administration or was not given. Follow-up actions for the missed and unavailable medications for Resident 9 were not carried out in accordance with the facility's policy. On March 17, 2025, in an email communication with Admin 1, they were unable to explain why the missed medications for Resident 9 were marked as unavailable on multiple dates in October and November 2024. Admin 1 stated that medications should not be marked as unavailable without follow-up actions.

Based on observations, interviews, record review, and facility document and policy review, the facility failed to provide supervision to prevent accidents related to elopement for 2 (Resident #59 and Resident #38) of 3 residents reviewed for elopement. Specifically, Resident #59 eloped from the facility on 02/24/2024 and was pushing their wheelchair when it was hit by a car. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 02/24/2024 at approximately 8:00 PM when Resident #59 eloped from the facility. On 03/28/2024 at 3:34 PM, the facility Executive Director (ED) was provided with the completed IJ template and notified of the existence of an IJ for accidents. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency (SSA) on 03/29/2024 at 7:13 PM. The IJ was removed on 03/29/2024 at 8:15 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of D, which was not immediate jeopardy for F689. In addition, based on observations, interviews, record review, and facility document and policy review, the facility failed to provide supervision for Resident #38. Resident #38 eloped from the facility on 06/20/2023, around 8:30 PM, when nursing staff discovered the resident was not in their room. Resident #38 was found by emergency services and brought back to the facility around 11:40 PM. Findings included: A review of a facility policy titled Elopements and Wandering Residents, revised in June 2023, revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy further indicated, 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 1. A review of Resident #59's Face Sheet revealed the facility admitted the resident on 12/11/2023 with diagnoses that included cerebral infarction (stroke), aphasia (difficulty with speech), dysphagia (difficulty understanding language), and Wernicke's encephalopathy (a neurological disorder). A review of Resident #59's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/15/2023, revealed Resident #59 did not have a Brief Interview for Mental Status (BIMS) or a Staff Assessment for Mental Status completed. The MDS indicated disorganized thinking was present continuously. The MDS indicated Resident #59 did not exhibit any wandering behavior, ambulated with a walker or wheelchair, and required supervision or touching assistance with walking. The MDS revealed no wandering/elopement alarm was used. A review of Resident #59's Care Plan revealed a Problem area with a start date of 02/20/2024, which indicated the resident was at risk for elopement related to Wernicke's encephalopathy. The Care Plan indicated the resident had exit-seeking behaviors and would kick the door off the tracks to get it open. Interventions included to ensure the departure alert system was in place and functioning properly and indicated the resident had two departure alert system devices, one on the inside of an article of clothing and one on the back of the resident's wheelchair. Further review of the interventions revealed that company vans had been moved to the back of the facility (out of sight) after an elopement attempt on 02/20/2024, elopement monitoring every 30 minutes for an elopement attempt on 02/21/2024, and one-on-one supervision for an actual elopement on 02/24/2024. A review of Resident #59's nursing Progress Notes, dated 12/17/2023 at 9:25 AM, revealed Resident #59 was found in a facility van outside the facility, and a departure alert system device was placed on the resident. A review of Resident #59's physician's Progress Notes, dated 01/09/2024 at 3:37 PM, revealed Resident #59 was severely agitated and attempting to escape from the building. A review of Resident #59's nursing Progress Notes, dated 02/20/2024 at 10:48 AM, revealed the departure alert system alerted a nurse to check outside the facility. The note revealed the front door was pushed open off the track, and Resident #59 was found attempting to get inside the facility transport vehicle. The note revealed two staff members safely brought the resident back into the facility, and all company vehicles were moved to the back of the building as an intervention. A review of Resident #59's nursing Progress Notes, dated 02/20/2024 at 1:57 PM, revealed Resident #59 attempted to leave the facility twice on that shift. The note revealed that the first time, the resident was able to be redirected at the front door; about thirty minutes later, the resident was found outside the facility. The note revealed the resident had on a departure alert system device that locked the doors, but the resident had forced the doors open. A review of Resident #59's physician's Progress Notes, dated 02/20/2024 at 3:27 PM, revealed the Medical Director (MD) found the resident outside in the cold parking lot. The MD indicated that he felt Resident #59 required a locked memory care unit for safety. A review of Resident #59's nursing Progress Notes, dated 02/24/2024 at 3:20 PM, revealed that on this date, Resident #59 had attempted to elope multiple times. A review of Resident #59's nursing Progress Notes, dated 02/24/2024 at 8:15 PM, revealed that during the night shift, Resident #59 left their room, crossed the road, and a car collided with the resident in their wheelchair. The note revealed Resident #59 was taken to the hospital, evaluated, and returned to the facility about an hour later. The note revealed that after 30 minutes, Resident #59 attempted to leave the facility again, and staff followed the resident to the front door. The note revealed the resident became very combative, but staff were able to redirect the resident. A review of a document titled Follow-Up Investigation Report, dated as submitted by the ED on 02/28/2024 at 7:15 PM, revealed camera footage was reviewed, and Resident #59 had pushed through the front door at 7:46 PM, exited the building, and walked down the parking lot. The report revealed that at 7:52 PM, the resident was pushing a wheelchair ahead of them, and the wheelchair was struck by a car. The Follow-Up Investigation Report further revealed Resident #59 had minor cuts and scrapes to their hands, with blood visible on their fingers. The report revealed the resident was sent to the local emergency room (ER) for further evaluation, and no additional injuries were identified. The report revealed the resident was placed on one-to-one continuous staff supervision upon return to the facility. During an interview on 03/26/2024 at 7:42 PM, Registered Nurse (RN) #19 stated staff needed to always keep their eyes on an elopement risk resident. RN #19 said elopement risk residents had a departure alert system device on their wrist or ankle, and some also had a device on their wheelchair. RN #19 stated that usually, when the resident would get close to the front door, an alarm would sound, and the doors would lock. She stated if any of the side doors were opened, an alarm would sound. She stated when the door alarms sounded, staff were not able to hear them. RN #19 said that on the day of the elopement, upon arrival at work, she was made aware that Resident #59 had tried to elope earlier in the day. RN #19 stated that on the night of the elopement, a certified nursing assistant (CNA) had taken Resident #59 to the bathroom, and RN #19 had gone to administer medication to another resident. RN #19 stated that when she came out of the other resident's room, she noticed Resident #59's door was open, which was unusual. RN #19 stated that she asked the aides if they had seen Resident #59, and they all said no. RN #19 stated that the aides went running down the hallway. RN #19 stated she heard the alarm, went running towards the front door, and saw police cars. RN #19 said Resident #59 had a departure alert system device placed on their wrist or ankle and on their wheelchair. RN #19 indicated Resident #59 had kicked open the front door and walked across the street, and their wheelchair was hit by a car. RN #19 stated she went out to speak with the police to give them all the information about the resident. She stated Resident #59 was taken to the hospital. RN #19 stated that after the 02/24/2024 event, there was a booklet on elopements that staff had to read and sign that explained what to do if a resident tried to elope. RN #19 said new alarms were also put in place but did not ring overhead and were still unable to be heard. RN #19 said the alarm only sounded on the 400 hall. She further stated the two-way radio walkie-talkies only said wanderer. RN #19 stated she did not think the alarms were what alerted staff that the resident was out of the building. RN #19 stated she thought when staff first realized the resident was missing, they went to the front door and realized the alarm was sounding and the resident was out of the building. During an interview on 03/26/2024 at 8:07 PM, Certified Nursing Assistant (CNA) #21 stated she was present on the night Resident #59 eloped. CNA #21 stated that she did not recall hearing any alarms sounding because she and another CNA were in resident rooms and too far from the front door. CNA #21 said after the incident on 02/24/2024, walkie-talkie radios were put in place, and Resident #59 was put on one-to-one continuous staff supervision. CNA #21 said Resident #59 already had a departure alert device in place but discovered how to push the door open. She stated that after the incident, a booklet with information on elopement was passed out for staff to read and sign. During an interview on 03/27/2024 at 8:18 AM, the CNA Coordinator stated she worked the day Resident #59 eloped. The CNA Coordinator said she was assigned one-on-one with Resident #59, and the resident spent a lot of time with her. The CNA Coordinator stated that on the day of the incident, she was off work but came to the facility due to the resident being very agitated. The CNA Coordinator stated she came in around 11:30 AM and was with the resident until around 3:30 PM. She stated Resident #59 was completely fine when she left for the day. The CNA Coordinator said she never witnessed the resident make it outside. She stated Resident #59 was always in the hall when the alarm would sound, and she would redirect the resident and spend time with the resident. During an interview on 03/26/2024 at 12:49 PM, CNA #11 stated she was not working on the day Resident #59 eloped but said the resident would take their wheelchair, put it against the door, and open the door. CNA #11 said Resident #59 had a departure alert system device, but she was not sure where it was placed. During an interview on 03/26/2024 at 1:13 PM, CNA #5 indicated if a resident was trying to elope, she would try to redirect them. CNA #5 stated if that did not work, she would try to approach the resident in a different way. CNA #5 stated that all residents who were at an elopement risk wore a departure alert system device. CNA #5 stated the device would be attached to an ankle or wheelchair. CNA #5 stated she checked residents for placement of the device to ensure there was no dangerous situation of the resident going into the street or something. During an interview on 03/26/2024 at 1:26 PM, CNA #13 stated if a resident had on a departure alert system device and got too close to the front door, an alarm would sound in the whole building. CNA #13 said she worked as a one-on-one staff member with Resident #59 for about two weeks. CNA #13 said after the elopement incident, Resident #59 had a departure alert system device attached to their clothing because the resident hated the device being on their body. CNA #13 said walkie-talkies at the nursing stations were also alarmed when one of the residents got near the door. During an interview on 03/26/2024 at 2:27 PM, Licensed Practical Nurse (LPN) #14 stated a resident that was an elopement risk would have a departure alert system device on the resident so when they got close to an exit door, the door would automatically lock. LPN #14 said that staff now had walkie-talkies that would sound since residents in the past had been able to push the doors open once they were locked. LPN #14 said they were not at work when Resident #59 eloped. LPN #14 stated Resident #59 tended to wander a lot and got frustrated because the staff could not really understand the resident. LPN #14 said Resident #59 was the reason a special alarm was put in place for when the front door got knocked off the hinges. LPN #14 stated that prior to the walkie-talkies, there was a faint alarm that staff could barely hear. During an interview on 03/26/2024 at 2:38 PM, CNA #15 stated she could not hear the front door alarm at all. During a follow-up interview on 03/26/2024 at 3:29 PM, CNA #15 stated there had only been one resident to elope since she had been at the facility. She said newly hired staff had not been told what to do when a resident eloped. CNA #15 stated the front door alarm was faint, and she had never heard the walkie-talkie sound. CNA #15 stated she was not in the facility when Resident #59 eloped. During an interview on 03/26/2024 at 2:42 PM, CNA #17 stated that elopement risk residents had a departure alert system device, and staff checked on them every two hours to make sure the device was in place. CNA #17 said if an alarm sounded at the front door, the doors would lock, and that would cue staff to check the doors and find the residents. CNA #17 stated the alarm could be heard from everywhere in the building. CNA #17 stated walkie-talkies were implemented at each nurse's station after Resident #59 eloped and said the walkie-talkies would transmit a message. CNA #17 said after the elopement, staff had to read a packet on preventive measures and other interventions for elopement. During an interview on 03/26/2024 at 3:11 PM, the Business Office Manager (BOM) stated she would hear the alarm sounding. She stated the alarm would be very loud, and she would hear it in her office and the conference room. The BOM stated she was not working during the elopement event for Resident #59 because it was on a weekend. During an interview on 03/26/2024 at 3:34 PM, CNA #16 stated the walkie-talkies' volumes were turned down at the nurses' station due to them being too loud when staff were on the phone. CNA #16 stated the walkie-talkies notified of call light activations and an elopement. During an interview on 03/26/2024 at 7:22 PM, CNA #18 stated for an elopement risk resident, she tried to distract the resident, tried to get them to go back to their room, and keep them from the doors, and completed a safety check every two hours. CNA #18 stated if a resident with a departure alert system device went to the front door, there was an alarm that sounded, and the door locked. CNA #18 said walkie-talkies were also at the nurse's station. CNA #18 said she could hear the alarms if she was at the nurse station but not if she was in a resident room. CNA #18 said she was at work the night Resident #59 eloped but was not aware of the incident until her coworkers told her about it and she saw the police. During an interview on 03/26/2024 at 8:19 PM, RN #22 stated he was not working the night Resident #59 eloped. RN #22 said the alarms were soft and could not be heard, so a louder alarm had been put in place. RN #22 also said the walkie-talkie was connected to the call light system and was supposed to alert staff to both the departure alarm system and the call lights. RN #22 indicated it worked for call light notification, but he was not sure if it was working to alert for the departure alert system. During an interview on 03/27/2024 at 8:55 AM, RN #23 stated they were not at work when Resident #59 eloped, but for elopement risk residents wearing a departure alert system device, an alarm should have sounded when the resident got close to the door. RN #23 said sometimes the alarms did not work. RN #23 stated the front door alarm could not be heard on the 600 hall. During an interview on 03/27/2024 at 10:34 AM, the Social Services Director (SSD) stated she had witnessed Resident #59 exit the building once prior to the elopement on 02/24/2024. The SSD stated that when she tried to get Resident #59 to come back into the building, the resident grabbed her by the neck. The SSD said Resident #59 stopped once she told the resident they were hurting her. The SSD said she had heard the alarm sound when the residents approached the doors. During an interview on 03/27/2024 at 12:00 PM, the MD stated Resident #59 was a severe alcoholic and was found at home after suffering a stroke. The MD said he felt Resident #59 was admitted to the facility prematurely due to the resident being severely encephalopathic and having behaviors that were out of control. The MD recalled seeing Resident #59 right outside the front door one day. He stated when he attempted to get the resident to come back inside, the resident turned around and hit him. The MD said his approach was to get the resident on medications that could stabilize the resident's moods until the resident could be moved to a more appropriate level of care. The MD stated that on the day of the elopement, the recommendation had already been made for the resident to be transferred to another facility. During an interview on 03/27/2024 at 4:23 PM, the ED stated Resident #59 came to the facility for rehabilitation but was switched to long-term care. The ED stated that sometime in January, it was apparent the resident was a wander risk. The ED stated in February, the resident started showing signs of exit-seeking. The ED stated that Resident #59 went out the door a few times. The ED stated that the staff would see the resident but had a hard time redirecting the resident. The ED stated the resident would go toward the facility vans, so as an intervention, the vans were moved to the back of the facility. He stated that the intervention worked for a few days, but then the resident tried again, and it was at that point that communication started with a memory care facility. He stated that the resident displayed more exit-seeking behaviors on the day of the 02/24/2024 incident. The ED stated the resident had gone out to the parking lot, but staff were able to get the resident in. The ED said he was not notified of the initial exiting attempts the resident had on 02/24/2024. The ED said he wished staff would have notified him so that interventions could have been put in place and the entire incident could have been avoided. The ED said the Quality Assurance and Performance Improvement (QAPI) committee initiated a four-step plan to address elopement and how it should be reported. The ED stated he felt there should have been some interventions put in place sooner based on the number of times the resident attempted to elope. The ED said there were a few times that both he and the CNA Coordinator took Resident #59 outside, and the resident never attempted to go to the road. The ED stated the CNA Coordinator was notified on the day of the incident and came in to help calm the resident down. The ED said the departure alert system was tested routinely. The ED stated he installed a new alarm to the front doors on 02/27/2024 that sounded if the doors were pushed off the hinges. He stated that when the alarm was installed, he tested it with and without a departure alert system trigger to ensure the alarm worked appropriately. The ED stated he did not do any testing with the volume of the alarms. He said the walkie-talkies were installed around the same time, maybe the same day, and were connected to the call light system. He stated when they were installed, he tested them to ensure they were functioning and sending out notifications. He stated he went to the front, activated the alarm, and then went to the nurse's station to hear it sound the wanderer alert. The ED stated he made sure the volume was turned all the way up. The ED said no staff had ever mentioned they could not hear the alarms or the walkie-talkie alerts. During an interview on 03/28/2024 at 8:47 AM, the Maintenance Director stated he tested the departure alert system alarms weekly by removing a departure alert system device from the package and taking it to the door to make sure the alarm sounded and the door locked. During an interview on 03/28/2024 at 8:58 AM, the Director of Nursing (DON) stated her expectation was for staff to let her know immediately if an elopement occurred. The DON said if staff were not able to find the resident, the police would be called. She stated once the resident was found, a full assessment would be completed, and if needed, the resident would be sent to the ER. The DON stated the MD would also be notified. The DON stated the staff would then meet as a team to discuss what interventions could be put in place to prevent an elopement from happening again. The DON said all of this would be done after the immediate needs of the resident were taken care of. The DON said she was working on the day Resident #59 eloped. She said the resident had gone out the door earlier in the day, and a CNA was able to get the resident to come back into the facility. The DON stated the CNA Coordinator came in to calm the resident and stayed for a few hours. The DON said when the incident occurred, Resident #59 was taken to the emergency room , and when the resident returned to the facility, they were immediately placed on one-to-one continuous staff supervision. The DON stated they were working on interventions prior to the elopement incident, which included placement at another facility. She further stated once she was made aware that staff could not hear the alarms, the walkie-talkies were put in place. During observations and interviews on 03/26/2024 between 4:40 PM and 5:10 PM, the walkie-talkies were tested . On the 100/200 hall, LPN #14 was at the nurses' station, and the walkie-talkies were at the desk. There was poor audible notification when the call bells were pressed. The walkie-talkies were labeled Do not remove. LPN #14 stated he could not take the walkie-talkie off the base. LPN #14 said he could only hear the walkie-talkie at the nurses' station and that he would not be able to hear the walkie-talkie if he was more than 20 feet from the nurses' station. On the 500/600 hall, CNA #5 stated the walkie-talkie was not on the unit and was with CNA #11. CNA #11 said she normally did not carry the walkie-talkie but took the walkie-talkie because of the morning meeting. CNA #11 was asked to demonstrate how the walkie-talkie was used, and CNA #11 was observed raising the volume. CNA #11 stated when the call bell was pressed, or a departure alert system was breached, a notification was heard on the walkie-talkie. A call bell was then pressed, and the walkie-talkie was very audible. CNA #11 stated the volume was kept low due to the staff meeting. An observation on the 400 hall with CNA #11 revealed a grey box that had an alarm that would be triggered if there was a departure alert system breach. CNA #11 stated the alarm would be very loud on hall 400. CNA #11 stated that due to the low census, the unit was unstaffed and had mainly independent residents on the unit. CNA #11 stated she would not be able to hear the grey box sound if she were on halls 500 or 600. During observations on 03/27/2024, between 1:19 PM and 1:33 PM, the alarms were tested with the ED. At 1:19 PM, the departure alert system alarm was initiated and could only be heard in the lobby area. At 1:21 PM, the departure alert system alarm was initiated again, and the alarms could not be heard on the 300, 500, and 600 halls; a faint alarm could be heard while standing at the nurses' station on the 100 hall. On the 300 hall, the walkie-talkie sounded wanderer. At 1:23 PM, the front door was popped off the hinges, and the alarm could only be heard on the 100 hall. At 1:25 PM, the front door was popped off the hinges again, and the alarm was heard on the 100 hall, but there was nothing on the walkie-talkie. The alarm could not be heard on the 500 hall. At 1:29 PM, the door was popped off the hinges and the alarm was heard on the 100 hall and an unintelligible talking sound was heard on the walkie-talkie. The alarm could not be heard on the 300, 500, and 600 halls. 2. A review of Resident #38's Face Sheet revealed the facility admitted the resident on 06/13/2023 with diagnoses which included metabolic encephalopathy, delirium due to known physiological condition, generalized anxiety disorder, and cognitive communication deficit. A review of Resident #38's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 06/16/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #38 had delusions and had displayed wandering behavior for one to three days during the assessment period. The MDS further revealed the resident used a wander/elopement alarm daily. A review of Resident #38's Care Plan revealed a Problem area with a start date of 06/14/2023 that indicated the resident experienced wandering by moving with no rational purpose, seemingly oblivious to needs or safety. Interventions, with a start date of 06/14/2023, directed staff to ensure the resident had an identification band in place, follow familiar routines as much as possible, redirect to conversation or activity of choice and offer to contact loved ones and provide comfort measures for basic needs when the resident begins to wander and equip resident with a device that alarms on their left wrist. An additional intervention with a start date of 03/14/2024 indicated Resident #38 had a location device on their right wrist due to frequent elopement attempts. A review of Resident #38's physician's Progress Notes, dated 06/14/2023 at 6:07 PM, revealed Resident #38 was seen by the Medical Director (MD) sitting in the front foyer. The Progress Note indicated the resident was waiting on a ride home. A review of Resident #38's physician's Progress Notes, dated 06/19/2023 at 11:33 AM, revealed Resident #38 was seen by the MD. The Progress Note indicated the resident continued to wander around the facility, triggered the alarms often, and required heavy staff involvement to prevent the resident from eloping. A review of an Initial Report, dated as submitted on 06/21/2023, revealed that on 06/20/2023 at 8:30 PM Resident #59's room was checked by a nurse and found to be empty. The report revealed that a thorough search of the facility and outside was conducted. The report revealed that facility management and emergency services was notified. The report indicated that the resident was located at 11:40 PM in the local town. A review of a document titled Follow-Up Investigation Report dated 06/28/2023 revealed camera footage was reviewed, which revealed Resident #38 exited their room at 7:50 PM on 06/20/2023. The report revealed that a visitor was seen walking into the facility around 7:55 PM and Resident #38 was observed walking out of the facility at 7:55 PM. The report revealed Resident #38 walked to the corner of the building and walked outside of the video footage view. The report indicated that the resident had an abrasion on their head and scratches on their face. A review of Resident #38's physician's Progress Notes, dated 06/21/2023 at 11:35 AM, revealed Resident #38 was seen by the MD after the resident had been returned to the facility by the police in the early morning hours. The note revealed the resident had a laceration on their head, and the Director of Nursing (DON) escorted the resident to the emergency room (ER) for further evaluation. The note revealed a computerized tomography (CT) scan of the head, and x-rays were conducted due to complaints of shoulder pain. Results were documented in the Progress Notes as negative. A review of Resident #38's nursing Progress Notes, dated 06/22/2023 at 6:35 PM, revealed a tracking device was applied to Resident #38's shoe. During an observation on 03/26/2024 at 1:08 PM, Resident #38 was observed coming out of their room with a wheelchair and their clothes. When staff asked the resident where they were going, Resident #38 said they were going home. Staff redirected the resident back to their room, and the resident put their belongings back in their room. The resident then returned and stood at the nurses' station with staff. During an observation on 03/27/2024 at 4:06 PM, Certified Nursing Assistant (CNA) #10 was observed with Resident #38. The resident was sitting in a recliner across from the nursing station. Resident #38 got up and walked toward the dining room, and CNA #10 immediately followed the resident. During an interview on 03/26/2024 at 7:22 PM, CNA #18 stated Resident #38 wandered and was often found in other rooms or in the dining room. CNA #18 stated at times it took four to five staff members to barricade the door and redirect the resident. During an interview on 03/27/2024 at 8:55 AM, Registered Nurse (RN) #23 stated there had been multiple complaints to administration about Resident #38. She stated when Resident #38 was first admitted , she begged staff not to put the resident on the 400 hall due to their behaviors. RN #23 stated the resident was put on the 400 hall anyway and the next night, the resident eloped. RN #23 stated that after the elopement, Resident #38 was moved to the 600 hall. RN #23 stated for elopement risk residents wearing a departure alert system device, an alarm should sound when the resident gets close to the door. RN #23 said sometimes the alarms did not work. RN #23 stated the front door alarm could not be heard on the 600 hall. During an interview on 03/27/2024 at 12:00 PM, the Medical Director (MD) stated he did not know much about Resident #38's history and believed the resident had a stroke and had several mental health issues and disabilities. During an interview on 03/28/2024 at 8:58 AM, the DON stated Resident #38 had been at the facility long enough that staff knew what worked for the resident and what did not. She said the most current intervention in place for Resident #38 was one-to-one continuous staff supervision in the afternoon and evening hours because the resident seemed to be fine in the morning hours. The DON stated Resident #38 had a departure alert system device and a tracking device that could be used to locate the resident with a cell phone. She stated a tracker had been used previously, but Resident #38 started taking the tracker off and hiding it, so that was when a different device was used. The DON said extensive conversations had taken place about placement in another facility, but the resident's family had refused. During an interview on 03/29/2024 at 4:38 PM, the DON stated the expectation was for a resident who may be an elopement risk to be assessed for a departure alert system device, for the family and staff to be made aware of the wandering and the placement of the departure alert system device. She stated staff needed to respond immediately if an alarm was heard. The DON said if the staff did not see the resident, they should begin searching for the resident. The DON stated if the resident got out of the facility, the staff needed to do an extensive search and notify her and the ED. The DON stated that if the resident was repeatedly exit seeking, one-to-one continuous staff supervision would be implemented until the resi[TRUNCATED]

Based on interviews, facility document review, and facility policy review, the facility failed to ensure 4 (Certified Nursing Assistant [CNA] #3, CNA #13, Nursing Assistant [NA] #26, and Licensed Practical Nurse [LPN] #27) of 6 sampled employees were provided mandatory training related to dementia management and resident abuse prevention. Findings included: A review of a Facility Assessment Tool, dated 02/17/2024 and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee on 03/14/2024, revealed, Staff training/education and competencies, The following training topics will be used to provide a [sic] level and type of support and care needed for our resident population. (this is not an inclusive list): Abuse, neglect and exploitation - training that at a minimum educates staff on- (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. A review of a facility policy titled, Training Requirements, revised in June 2023, revealed 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. The policy further indicated, 6. Training content includes, at a minimum: g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. A review of an undated CNA/NA Orientation and Annual Checklist revealed Abuse Reporting and Care of cognitively impaired residents were included on the checklist as required topics. The checklist specified, ***All education topics must be completed by return demonstration to document understanding of training given prior to signing off. A review of an undated Licensed Nurse Annual and New Hire Checklist revealed Abuse Education and Care of cognitively impaired residents were included on the checklist as required topics. The checklist specified, ***All education topics must be completed by return demonstration to document understanding of training given prior to signing off. A review of a facility document titled Employees, dated 03/28/2024, revealed the following: - CNA #3 was hired on 12/20/2023; - CNA #13 was hired on 02/08/2024; - NA #26 was hired on 01/09/2024; and - LPN #27 was hired on 12/12/2024. Review of personnel files for CNA #3, CNA #13, NA #26, and LPN #27 did not reveal any documentation of dementia management or resident abuse prevention training. During an interview on 03/29/24 02:27 PM, the Director of Nursing (DON) stated the orientation checklists were not completed for CNA #3, CNA #13, NA #26, or LPN #27. During an interview on 03/29/24 12:49 PM, LPN #27 stated that she started working at the facility in December 2023 and had not completed a dementia management or resident abuse prevention training at the facility. During an interview on 03/29/2024 at 3:48 PM, the DON stated that she expected every staff member to have a training checklist completed before they were scheduled to work on their own. During an interview on 03/29/2024 at 4:31 PM, the Executive Director (ED) stated that staff should have been trained on dementia management and abuse prevention before being assigned to work a shift without a peer partnered with them. A review of the CNA/Nursing Schedule for the timeframe from 03/24/2024 to 03/30/2024 revealed CNA #3, CNA #13, NA #26, and LPN #27 were each assigned to work various shifts during the week. During a follow-up interview on 03/29/2024 at 5:40 PM, the ED stated that the CNA Coordinator was responsible for ensuring dementia management and resident abuse prevention training was provided. The ED stated the DON was the CNA Coordinator's supervisor. During a follow-up interview on 03/29/2024 at 5:45 PM, the DON stated that the CNA Coordinator was responsible for ensuring the education was provided. The DON stated she did not have a process in place to monitor or audit the education, because she was not aware that was one of her responsibilities. During an interview on 03/29/2024 at 5:50 PM, the CNA Coordinator stated that previously, the facility had a human resources staff member that was responsible for new employee education, but they left in the fall of 2023. The CNA Coordinator said nobody informed her that she was now responsible for ensuring staff education was completed before staff were scheduled to work independently. The CNA Coordinator stated that she did not have access to the employee education records, so she did not know if they had completed their education or not.

Based on interviews, record reviews, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident (Resident #228) for 2 (Resident #48 and Resident #42) of 5 sampled residents reviewed for abuse. Findings included: A review of a facility policy titled Abuse - Prevention, Investigating and Reporting, revised on 07/01/2019, revealed, [The facility] takes steps to prevent abuse of residents. This includes abuse from staff, other residents, families or any person having contact with the resident. Every resident has the right to be free from verbal, sexual, physical and mental abuse including abuse facilitated or enabled through the use of technology, corporal punishment, exploitation, misappropriation of resident property, neglect, use of physical or chemical restraints imposed for the purpose of discipline or convenience and involuntary seclusion. A review of Resident #228's Face Sheet revealed the facility admitted the resident on 07/17/2021 with diagnoses that included Wernicke's encephalopathy (a neurological disease), alcohol dependence with alcohol-induced persisting dementia, and mood disorder due to known physiological condition. Further review revealed the facility discharged the resident on 11/21/2023. A review of Resident #228's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2023, revealed Resident #228 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had physical and verbal behaviors directed toward others for one to three days during the seven-day assessment period. The MDS revealed the resident rejected care or evaluations for one to three days during the seven-day assessment period. The MDS indicated the resident used a wheelchair. The MDS revealed the resident received antidepressant medication seven days during the seven-day assessment period. A review of Resident #228's Care Plan History revealed a Problem area, with a start date of 04/24/2023, that indicated the resident had the behavior of wandering. Interventions directed staff to remove the resident from other resident's rooms and provide comfort measures. The Care Plan History revealed a Problem area, with a start date of 02/06/2023, that indicated the resident invaded others' personal space. Interventions included staff instructions to provide one-on-one supervision as needed and redirect the resident to an activity of their choice or have a conversation of their choice. Further review revealed a Problem area, with a start date of 08/20/2021, that indicated the resident had been combative toward staff. Interventions included staff instructions to avoid overstimulation, including other physically aggressive residents. 1. A review of Resident #48's Face Sheet revealed the facility admitted the resident on 04/14/2023 with diagnoses that included vascular dementia of unspecified severity with psychotic disturbance, alcohol dependence with alcohol-induced persisting dementia, anxiety disorder due to known physiological condition, and mood disorder due to known physiological condition with depressive features. A review of Resident #48's quarterly MDS, with an ARD of 05/04/2023, revealed Resident #48 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had verbal behaviors directed toward others for one to three days during the seven-day assessment period. The MDS indicated that the resident walked once or twice during the assessment period and used a wheelchair. The MDS indicated the resident received antipsychotic, antidepressant, and antianxiety medications seven days during the seven-day assessment period. A review of Resident #48's Care Plan revealed a Problem area, with a start date of 02/28/2023, that indicated the resident had a history of wandering. Interventions included staff instructions to redirect the resident to a conversation or an activity and to remove the resident from other resident's rooms and unsafe situations. The Care Plan revealed a Problem area, with a start date of 02/28/2023, that indicated the resident had verbal behavioral symptoms directed toward others, and at times not directed toward anyone. Interventions included staff instructions to follow familiar routines. The Care Plan revealed a problem area, with a start date of 02/28/2023, that indicated the resident had physical behavior symptoms directed at others. Interventions included staff instructions to avoid power struggles with the resident and to provide one-on-one sessions as needed. Further review revealed a Problem area, with a start date of 02/28/2023, that indicated the resident had increased moods and irritation, refused care from staff, and made accusations of staff. Interventions included staff instructions to attempt to educate the resident, provide care, and document refusals. A review of an Initial Report, dated 06/14/2023, revealed nurses on the 100 hall witnessed a resident-to-resident physical abuse incident. The report indicated that Resident #228 pulled Resident #48's arm, causing Resident #48 to fall out of their wheelchair, resulting in skin tears on Resident # 48's elbow and shoulder. A review of the Follow-up Investigation Report, dated 06/20/2023, revealed that video footage of the incident was reviewed and indicated that Resident #228 was seen walking with Resident Advocate (RA)/Receptionist #30, a former employee, and waved their hand at Resident #48. The report indicated that RA/Receptionist #30 got in between the two residents. The report indicated that Resident #228 started hitting and grabbing RA/Receptionist #30, who lost their balance, which appeared to cause Resident #48 to roll out of their wheelchair. The report indicated that RA/Receptionist #30 stated that when she was walking down the hall with Resident #228, the resident was talking loudly, and Resident #48 told them to shut up and made a gesture towards Resident #228. The report indicated that RA/Receptionist #30 stated that Resident #228 pulled and pushed her trying to get to Resident #48; she thought either Resident #48 was bumped out of their wheelchair or Resident #228 pulled Resident #48's arm but was not sure. The report indicated that Registered Nurse (RN) #8 witnessed the incident. During a telephone interview on 03/26/2024 at 7:23 PM, RN #8 stated she remembered the incident but did not see the incident; she heard a commotion. She stated that no one was yelling, but she heard excited, louder voices. She stated she did not write out a witness statement and could not remember if the previous Executive Director had interviewed her. RN #8 stated that RA/Receptionist #30 was in the middle of the incident, and no other staff were in the area. She stated that the staff did not allow Resident #228 and Resident #48 to be next to one another, and she did not know why they were together at the time of the incident. She stated that a resident-to-resident altercation between residents with dementia was considered abuse. She stated verbal behaviors between Resident #228 and Resident #48 seemed to have happened before and stated that they lived on the same hall at the time of the incident. During a telephone interview on 03/27/2024 at 7:13 PM, RA/Receptionist #30 stated she witnessed the incident on 06/14/2023. She stated she was at the nurse's station on the 100 Hall, and Resident #228 approached her in their wheelchair to request help looking for their glasses. She stated that she and Resident #228 looked in the resident's room but could not find them, then she went to the nurse's station, and Resident #228 wheeled themself next to RA/Receptionist #30, and at the same time, Resident #48 was next to RA/Receptionist #30, in their wheelchair. She stated that both residents were easily agitated, and Resident #228 yelled, That's mine, that's mine. She stated Resident #48 started to yell, and Resident #228 pushed the RA/Receptionist #30 out of the way and hit her hand. She stated she lost her balance but did not fall. Per RA/Receptionist #30, Resident #228 grabbed Resident #48 by the hair and pulled them out of their wheelchair and to the floor. RA/Receptionist #30 stated both residents had yelled at each other on other occasions but had never touched one another before the incident. She stated that the previous Executive Director had interviewed her about the incident but did not think she had written a statement. 2. A review of Resident #42's Face Sheet revealed the facility admitted the resident on 04/25/2023 with diagnoses that included unspecified personality disorder, cognitive communication deficit, and benign neoplasm of meninges. A review of Resident #42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/20/2023, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had verbal behavioral symptoms toward others on one to three days during the seven-day assessment period and rejected evaluations or care every day during the seven-day assessment period. A review of Resident #42's Care Plan revealed a Problem area, with a start date of 06/16/2023, that indicated the resident resisted care provided by staff. Interventions included staff instructions to Allow resident to choose options and have control over situations when possible and to reiterate the purpose and advantages of treatment. The Care Plan revealed a Problem area, with a start date of 06/16/2023, that indicated the resident had verbal and physical behavioral symptoms directed toward others. Interventions included staff instructions to administer medications as ordered, assess whether the behavior endangered the resident or others, and avoid over-stimulation such as noise, crowding, or other physically aggressive residents. A review of a Follow-Up Investigation Report, dated 11/8/2023, revealed that on 11/02/2023 at around 11:35 AM, Resident #228 and Resident #42 got into an argument. The report indicated that Resident #228 requested to go into Resident #42's room, who denied the request. The report indicated that Resident #228 slapped Resident #42 in the face two times. The report indicated that Assistant Director of Nursing (ADON) #2 and Certified Nursing Assistant (CNA) Coordinator heard the commotion and removed the residents from the situation immediately. The report indicated that there were no injuries. The report indicated that ADON #2 and the CNA Coordinator were both interviewed, and both stated that Resident #228 pulled Resident #42's hair and slapped Resident #42 twice. A Review of Resident #228's Resident Progress Notes, dated 11/02/2023, indicated that ADON #2 witnessed Resident #228 hit Resident #42 twice in the side of the head and pulled Resident #42's hair. During an interview on 03/28/2024 at 8:14 AM, ADON #2 stated she intervened during the 11/02/2023 resident-to-resident incident. She stated she heard the residents yelling at each other, and she came out of her office and into the hallway and saw Resident #228 pulling Resident #42's hair. She stated she removed Resident #228 from the area, and a CNA took the resident back to their room. ADON #2 stated she instructed staff to monitor them and make sure they were not in the same place at the same time. ADON #2 stated the process was to separate the residents and complete an event report, which triggered nurse monitoring on the Medication Administration Record for the nurses to monitor behaviors. She stated she reported the incident and wrote a progress note. During an interview on 03/28/2024 at 10:35 AM, the CNA Coordinator stated that a physical altercation between two residents with dementia was considered abuse. She stated that the staff reported abuse to the Executive Director, and he completed the investigation. She stated Resident #228 had behaviors and they changed quickly. She stated Resident #42 was not social and stayed in their room most of the time. The CNA Coordinator stated the incident on 11/02/2023 happened outside of her office door. She stated she heard the residents yelling, and she went out to the hall. She stated Resident #228 wanted to go into Resident #42's room, who refused the request. She stated Resident #228 became agitated and thought Resident #228 pulled Resident #42's hair. She stated she did not witness what happened visually but heard it. She stated she and ADON #2 came out of their offices at the same time. The CNA Coordinator stated that she spoke to the Director of Nursing (DON) about the incident. During an interview on 03/27/2024 at 9:08 AM, the Executive Director stated he had not been able to retrieve the requested video footage of the resident-to-resident incidents because the company that managed it had not been able to find the videos.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to protect resident personal health information (PHI) for 1 (Resident #55) of 1 sampled resident reviewed for privacy and 1 (Resident #46) of 4 sampled residents reviewed for dignity. Findings included: A review of a facility policy titled Resident Room Postings, revised in June 2023, revealed, It is the policy of this facility to support a resident's right to personal privacy and confidentiality in all aspects of care and services, to include personal and medical records. The policy revealed, 1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of resident and family groups, but does not require the facility to provide private rooms for each resident. Further review of the policy revealed, 4. Resident room postings will only be allowed if the resident or resident representative request posting at the bedside (i.e. [id est, that is], instructions not to take blood pressure in the right arm) or if used as visual safety reminders. 1. A review of Resident #46's Face Sheet revealed the facility admitted the resident on 11/09/2022 with diagnoses that included unspecified dementia, bipolar disorder, anxiety disorder, pseudobulbar affect, and cognitive communication deficit. A review of Resident #46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/2024 revealed that the resident's Brief Interview for Mental Status (BIMS) and Staff Assessment for Mental Status (SAMS) were not completed. The MDS revealed that the resident sometimes understood others and responded to simple, direct communication only. A review of Resident #46's Care Plan revealed a Problem area with a start date of 02/15/2023 that indicated the resident had cognitive loss and impaired decision-making related to dementia. The Care Plan did not indicate that the resident or the responsible party approved the display of PHI in the resident's room. An observation on 03/25/2024 at 10:09 AM revealed a large whiteboard in the resident's room facing the doorway. Personal health information was written on the board, including, Please float [Resident #46's] heels, [Name] Hospice Aide, Daily weights [four resident weights listed], and Please make sure [Resident #46] is on [his/her] sling when [he/she] is in [his/her] chair. An observation on 03/25/2024 at 1:21 PM revealed Resident #46's door was open. The whiteboard and the PHI were visible from the hallway. An observation on 03/27/2024 at 1:35 PM revealed Resident #46's door was open. The whiteboard and the PHI were visible from the hallway. An observation on 03/27/2024 at 4:10 PM revealed Resident #46's door was open. The whiteboard and the PHI were visible from the hallway. During an observation and interview on 03/28/2024 at 11:07 AM, the Certified Nursing Assistant (CNA) Coordinator observed Resident #46's whiteboard from the hallway and stated the information on the board was PHI and was a HIPAA (Health Insurance Portability and Accountability Act) violation. During an observation and interview on 03/28/2024 at 11:11 AM, in the hall outside of Resident #46's room, Registered Nurse (RN) #4 stated the information on the resident's whiteboard had health information on it and was a HIPAA violation. During an observation and interview on 03/29/2024 at 11:09 PM, in the hall outside of Resident #46's room, Hospice CNA #32 stated the PHI was visible from the hallway and it should not be there because it was confidential. During an observation and interview on 03/28/2024 at 11:53 AM, in the hall outside Resident #46's room, the Director of Nursing (DON) stated there was information on the resident's whiteboard that indicated the resident's health status and that it should not be on the whiteboard. 2. A review of Resident #55's Face Sheet revealed the facility admitted the resident on 05/05/2023 with diagnoses that included peripheral vascular disease, malignant neoplasm of the brain, and secondary malignant neoplasm of an unspecified lung. A review of Resident #55's quarterly MDS with ARD of 12/08/2023 revealed Resident #55 had a SAMS that indicated the resident had moderate cognitive impairment for daily decision-making. A review of Resident #55's Care Plan revealed a Problem area with a start date of 05/06/2023 that indicated the resident had cognitive loss and dementia. The Care Plan did not indicate that the resident or the responsible party approved the display of PHI in the resident's room. An observation on 03/28/2024 at 11:21 AM revealed a white board in Resident #55's room with information written on the board that included, [Name] Hospice Aide, and [Registered Nurse (RN) #29's name] Hospice nurse. During an interview on 03/28/2024 at 11:07 AM, the CNA Coordinator stated PHI should not be visible on a whiteboard in a resident's room even if it could not be seen from the doorway. During an interview on 03/29/2024 at 11:07 AM, Hospice CNA #32 stated Resident #55's whiteboard had PHI on it and that it should not be visible. During an observation and interview on 03/28/2024 at 11:55 AM, the DON stated Resident #55's whiteboard had PHI on it, and if a visitor entered the room, they would see Resident #55's private health information. During a follow-up interview on 03/28/2024 at 12:17 PM, the DON stated that if a resident wanted their information posted, it should be included in their care plan. During an interview on 03/29/2024 at 4:34 PM, the Executive Director (ED) stated he expected no PHI to be visible in the resident's room unless desired by the resident or family.

Based on record review, interviews, and facility document and policy review, the facility failed to adequately address a grievance filed by a family member of 1 (Resident #328) of 1 sampled resident reviewed for neglect. Specifically, Resident #328's family member filed a grievance related to finding the resident lying in bowel movement and urine on the morning of 10/16/2023, and the facility was unable to provide documentation of the steps taken to investigate the concern or information regarding whether the facility was able to confirm the concern. Findings included: A review of a facility policy titled, Resident and Family Grievances, revised in June 2023, revealed, The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. The policy specified, 10. Procedure: a. This facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of a grievance. b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. i. Take any immediate actions needed to prevent further potential violations of any resident right. ii. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. c. Forward the grievance form to the Grievance Official as soon as practicable. d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance. iii. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know. e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. f. The facility will take appropriate action in accordance with State law if an alleged violation of resident's rights is confirmed by the facility or an outside entity, such as State Survey Agency, Quality Improvement Organization, or local law enforcement agency. g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concem(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. The policy identified the Social Services Director (SSD) as the Grievance Official. A review of Resident #328's Resident Face Sheet revealed the facility admitted the resident on 09/07/2023 with diagnoses that included type two diabetes mellitus, unspecified dementia, muscle weakness, unspecified lack of coordination, and need for assistance with personal care. According to the Resident Face Sheet, Resident #328 was discharged from the facility on 11/10/2023. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/10/2023, revealed Resident #328 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. According to the MDS, the resident did not reject care in the seven days prior to the assessment, was dependent on staff for toileting hygiene, and was always incontinent of urine and bowel movement. A review of Resident #328's Care Plan revealed a Problem area, with a start date of 09/09/2023, that indicated the resident was incontinent. Interventions directed staff to keep the call light in reach, assist with toileting, and to provide incontinence care after each episode of incontinence. A review of the facility's October 2023 Concern Log revealed that on 10/16/2023, Resident #328's family member found them in bed in urine. Per the Concern Log, the concern was filed by the SSD, and the concern was resolved. A review of a Concern Form, dated 10/16/2023 at 1:45 PM, revealed Resident #328's family member reported that they found the resident lying in bowel movement and urine on the morning of 10/16/2023. The Concern Form indicated the form was filled out and turned into the facility's Executive Director (ED). The section of the Concern Form addressing Concern Investigation indicated the concern was reported to the Director of Nursing (DON)/Unit Manager, and staff were educated on call light responsiveness and frequent checks. The Concern Form did not reflect any steps taken by the facility to investigate the concern and did not indicate if the concern was determined to be confirmed or not confirmed. The Complaint Form was signed by the SSD and ED on 10/17/2023. During an interview on 03/27/2024 at 05:37 PM, the ED stated that the grievance regarding Resident #328 was not fully investigated. The ED further stated the facility had not determined who the aide was assigned to care for the resident at the time of the concern and indicated it was not clear if the resident had been provided incontinence care. The ED said the concern was reported to the SSD, the SSD turned it into the ED, and the ED immediately provided in-servicing to staff. The ED acknowledged that the grievance should have been better investigated. During an interview on 03/28/2024 at 4:08 PM, the SSD stated that the grievance regarding Resident #328 was given to the ED, and the ED should have addressed the grievance with the related department. During an interview on 03/28/2024 at 6:45 PM, the DON stated if a grievance involved nursing staff, then the nursing department was supposed to be made aware so they could investigate the concern.

Based on observation, interview, and record the review it was determined the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 30 sampled residents, a resident that had a fall and complained of pain was not provided pain medication for 11 days. Resident identifier: 51. Findings included: Resident 51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 51's medical record was reviewed on 1/11/22. An Admission Minimum Data Set (MDS) assessment dated [DATE], documented resident 51 was an extensive assistance of one person for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. In addition, the MDS assessment documented that resident 51 had a Brief Interview for Mental Status (BIMS) score of 3. [Note: A BIMS score of 0 to 7 points indicates severely impaired cognition.] A care plan problem for Pain created on 11/24/21, documented [Resident 51] is at risk for pain secondary to decreased mobility and malnutrition. The goal documented [Resident 51] will have no unaddressed pain, through next review. The approaches documented Monitor pain as prescribed. and Offer non-pharmacological approaches to pain management, (massage, ice, reposition, etc.) A care plan problem for Falls created on 11/24/21, documented [Resident 51] is at risk for falls secondary to pain and decreased mobility. The goal documented [Resident 51] will have no untreated injuries r/t (related to) falls, through next review. The approaches documented Encourage the use of the call light. and Keep room free of clutter and tripping hazards. A Fall Risk assessment dated [DATE], documented resident 51 as a Moderate Fall Risk with a score of 6. On 12/10/21 at 4:45 PM, an Event Report documented Patient had an unwitnessed fall, and was found by CNAs (Certified Nursing Assistants) at 1645 (4:45 PM). Patient states that her head and tailbone hurt and that she smacked them. Started neuros, got patient into bed. New wound present on R (right) elbow. Providers and family notified. Started neuro checks and dressed the wound. The Pain Observation section documented that resident 51 had pain to the tailbone at a 2 on the pain scale of 0 to 10. Pain interventions to treat pain from fall none. On 12/13/21 at 12:05 PM, a Physical Therapy (PT) Therapy Addendum documented Note: Pt (patient) has a unwitnessed fall on Friday 12/10. This date pt is (sic) c/o (complains of) increased Left hip pain with movements and difficulty transferring to the left with weight bearing. Nursing notified. On 12/13/21 at 12:57 PM, a x-ray of the anteroposterior and lateral left hip was obtained due to pain in resident 51's left hip. On 12/13/21 at 1:42 PM, a Nurse Practitioner (NP) progress note documented [Resident 51] is Seen (sic) today after having a fall over the weekend. She has had pain in her left hip which has waxed and waned. Today she was unable to participate in therapy because [of] this pain. She is unable to answer any questions regarding the intensity or type of pain, pain is elicited with movement. On 12/14/21 at 2:06 PM, a PT Therapy Addendum documented Note: per nursing x-ray of the left hip was taken yesterday. Awaiting results, pt continues to c/o pain on LLE (left lower extremity) with any movements and with weight bearing. On 12/15/21 at 10:53 AM, a PT Therapy Progress Report documented that resident 51 experienced an unwitnessed fall on Friday 12/10/21. Resident 51 had an increased level of assistance required. Prior to resident 51's fall she had been able to ambulate 100 to 150 feet. Post fall, resident 51 was very painful to move to complete transfers. Dates of service 12/9/21 to 12/15/21. On 12/15/21 at 12:38 PM, a NP progress note documented [Resident 51] I (sic) seen today for follow-up of her [NAME] (sic) pain. Over the weekend she did have a fall, with some subsequent left hip pain. This pain has waxed and waned, the therapy report she is unable to do activities she previously was able to do. X-ray obtained, unremarkable. She has previously had a hip replacement in this leg, no obvious fractures identified, but pain continues. Will obtain CT (computed tomography) to rule out fracture. On 12/17/21 at 9:15 AM, a NP progress note documented [Resident 51] is seen today Eating breakfast. She's confused, oriented to person only. She still has not had her CT to her left hip, this has been ordered, just waiting for scheduling. Therapy reports that she continues to have pain with any movement and cannot ambulate like she had been. Weights have remained stable since discontinuing her feeding tube. Waiting on CT. On 12/17/21 at 1:52 PM, a PT Therapy Addendum documented Note: Pt continues to c/o left hip pain. Initiated static standing inside // (parallel) bars with pt lifting her LLE upon standing. When cued pt was able to put her foot down but unable to bear weight through it. Addressed with nursing ongoing concerns. On 12/20/21 at 9:52 AM, a NP progress note documented [Resident 51] is seen today after going to therapy. Therapy reports that she was able to ambulate about 15 steps today but was limited by pain. She remains confused but will smirk and call at staff as they walk by her room or her wheelchair. She appears comfortable when at rest, VSS (vital signs stable). CT hip was completed, nurse calling for results. On 12/20/21 at 4:51 PM, a nursing progress note documented CT scan results of left hip. Impression; 1: Acute nondisplaced fractures involving the left superior and inferior pubic rami with extension to the left parasymphyseal region. 2. Zone 1 left sacral ala fracture 3. Concentric thickening of the urinary bladder wall could be accentuated by underdistention. Underlying [MEDICATION(S)] is not excluded. 4 Chronic and incidental changes as above. Results sent to [name removed] NP. [Note: Resident 51's CT scan was completed and dictated on 12/17/21 at 3:39 PM. The CT scan was received at the facility on 12/20/21. The NP documented on the CT scan non weight bearing, pain management, and refer to orthopedics as soon as possible.] On 12/21/21 at 10:05 AM, a nursing progress note documented Called Emergency Contact: [name removed] and informed him of pt's ct scan results and fracture. Of plans of getting pt an orthopedic appt (appointment) and pt to be non-weight bearing. On 12/21/21 at 11:49 AM, a nursing progress note documented Provider saw pt today; Provider N.O (new order): start pt on [MEDICATION(S)] 5mg (milligrams), admin (administer) 1/2 tab (2.5mg) Q (every) 4hr (hours) prn (as needed) r/t pain; . [Note: Pain medication was ordered for resident 51 11 days after the fall.] On 12/21/21 at 12:24 PM, a NP progress note documented [Resident 51] is seen today after receiving CT hip/pelvis results. She was found to have an inferior ramus fracture, stable and nondisplaced. She reports that this is painful with any ambulating, weight bearing, or movement. Has not been taking anything for pain. Will begin [MEDICATION(S)]. Will refer to orthopedics ASAP (as soon as possible). On 12/22/21 at 12:28 PM, a NP progress note documented [Resident 51] is seen today for a followup of her superior and inferior rami fractures. She is confused, unable to report pain improvement, staff report she moves easier after medications. She is able to verbalize pain in her hip and legs. She has been eating well, weights stable. Awaiting ortho (orthopedics) referral. On 12/22/21 at 12:31 PM, a PT Therapy Progress Report documented that resident 51 had c/o increased pain in LLE with movements and weight bearing, requiring increased level of assistance and verbal cues to safely perform bed mobility tasks to prepare for transfers. Resident 51 unable to ambulate due to increased pain in LLE. Dates of service 12/16/21 to 12/22/21. On 12/22/21 at 2:14 PM, an Occupational Therapy Therapy Progress Report documented that resident 51's status was unchanged. Resident 51 continues to be slow to progress due to pelvis fractures from a recent fall, subsequent pain, and non weight bearing status. Resident 51 continues to demonstrate decreased initiation to use a toilet and incontinence. Resident 51 was non weight bearing on the LLE and pain management was being assessed at this time due to resident 51's limited out of bed activity due to pain. Dates of service 12/16/21 to 12/22/21. On 12/27/21 at 3:08 PM, a NP progress note documented [Resident 51] is seen today for a followup of her superior and inferior rami fractures. She is sitting u pin (sic) her wheelchair, confused, but appears comfortable. Taking her medication, and I have been providing pain medication to her. Until after her orthopedist appointment, which has been scheduled. She appears to be doing well, wait (sic) to remain stable, and she is eating fairly well. No acute needs at today's visit. On 12/29/21 at 10:23 AM, a NP progress note documented [Resident 51] is seen today for a followup of her superior and inferior rami fractures. She is sitting u pin (sic) her wheelchair, confused, but snarking at staff. She states she feels well, appears comfortable. She is noted to have pain with any movement, but is improving. On 12/29/21 at 2:21 PM, a PT Therapy Progress Report documented that resident 51 continues to be non weight bearing on LLE, requires extra time to complete tasks due to pain. Resident 51 was able to bridge for brief change and lower extremity dressing. Resident 51 unable to roll to either side due to pain. Dates of service 12/23/21 to 12/29/21. On 12/30/21 at 11:19 AM, a nursing progress note documented that resident 51 went to her Orthopedic appointment. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical therapy to help with overall strengthening and balance. On 1/5/22 at 10:45 AM, a PT Therapy Progress Report documented that resident 51 is slow to move and requires extra time to complete bed mobility tasks due to pain. Resident 51 was able to bridge in supine for brief changes and lower extremity dressing. Resident 51 was unable to roll to either side due to pain. Dates of service 12/30/21 to 1/5/22. On 1/12/22 at 9:30 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she heard that resident 51 was attempting to transfer when the fall happened. RN 2 stated resident 51 did not complain of pain until the next day and an x-ray was obtained. On 1/12/22 at 9:44 AM, an interview was conducted with the NP. The NP stated resident 51 admitted to the facility with a hip fracture. Resident 51 was walking again prior to the fall and was doing great. The NP stated she had ordered a x-ray after resident 51's fall. The NP stated no injuries were reported after resident 51 fell . The NP stated resident 51 fell on the weekend and when she came back to the facility she was told that resident 51 was complaining about pain. The NP stated resident 51 continued to have pain after the CT scan. The NP stated resident 51 had a substance abuse disorder and that was probably the main reason she steered away from pain medications. The NP stated as long as resident 51 stayed in bed she was fine and had no pain. The NP stated she did not want to give resident 51 an opioid without an objective cause. The NP stated she was more on the conservative side when it came to ordering opioids for residents. The NP stated resident 51 had Tylenol. [Note: A review of the December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated once the CT scan came back she ordered resident 51 pain medications and that resident 51 be non weight bearing. The NP stated that she had also ordered an orthopedic consult for resident 51. The NP stated she did not send resident 51 to the hospital because she tried to minimize send outs if it was something the facility could deal with. The NP stated she would try to do most things in house that she could to reduce strain on the resident. The NP stated the hospital was not very helpful. The NP further stated that resident 51 was not in significant pain unless she was up and moving. On 1/12/22 at 9:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 51 was monitored for a few days and a CT scan was ordered. On 1/12/22 at 10:07 AM, an interview was conducted with the Director of Rehab. The Director of Rehab stated resident 51 was to painful to participate in therapies and the staff would try to encouraged resident 51 to participate. The Director of Rehab stated resident 51 had in her mind that the pain was to much and would not try. The Director of Rehab stated that occasionally resident 51 would give an effort. On 1/12/22 at 10:12 AM, an interview was conducted with Physical Therapist Assistant (PTA) 1. PTA 1 stated she had tried to do therapy with resident 51. PTA 1 stated she had treated resident 51 as non weight bearing while the facility was waiting on the x-ray results. PTA 1 stated if resident 51 requested to get out of bed or to get up for a meal she would help her. PTA 1 stated once the pain pills were on board resident 51 would be pre medicated prior to therapies. PTA 1 stated resident 51 had a cognitive deficit. PTA 1 stated she would also help with changing resident 51's brief. Resident 51 was difficult to roll because resident 51 was very bony and painful. PTA 1 stated resident 51 could bridge to assist with changing a brief but bridging was painful and resident 51 would moan. PTA 1 stated if resident 51 was able to do the movement herself she was not as painful. Resident 51 would still complain about the pain and it would take several minutes for resident 51 to complete the activity by herself. PTA 1 stated after resident 51's follow up orthopedic appointment the order was changed to weight bearing as tolerated. PTA 1 stated she would try to work with resident 51 to get her to advance as much as tolerated but resident 51 was still pretty painful. On 1/13/22 at 9:10 AM, a follow up interview was conducted with the NP. The NP stated she could have ordered the CT scan immediately, with out delay (STAT) but scheduling at the hospital was the problem. The NP stated If ordered STAT the CT scan would still not be scheduled for days to weeks. The NP stated she had to get on scheduling to get the CT scan done the same week ordered. The NP stated the only way to get the CT scan STAT would be to send the resident to the emergency room . The NP stated she was not sure why the CT scan was not ordered STAT. The NP stated resident 51's fall was prior to the current DON and the DON at the time probably did not know how to order a CT scan. The NP stated the order probably sat on the DON's desk for a day prior to being ordered. The NP stated she felt like the CT scan was not a life threatening problem. The NP stated she wanted the CT scan for better imaging and to identify why resident 51 was having worse pain. On 1/13/22 at 1:41 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when a resident had a fall the staff should contact the doctor with any injuries, take an x-ray, and send the resident out if necessary. The ADON stated the residents family would be called and interventions would be put into place. The ADON stated if the resident had any injuries the staff would put into place interventions from the doctor and make sure the resident was comfortable. The ADON stated the resident would be sent out depending on the injury. The ADON stated a resident with a suspected injury should have a mobile x-ray ordered STAT and sent out if the doctor recommended. The ADON stated if the resident was having pain and had no existing pain medications the staff would contact the doctor. The ADON stated the staff should call the doctor for orders. The ADON also stated the ADON or DON could call the doctor. The ADON stated he would expect staff to follow up with what the doctor initially wants and make sure it was working for the resident.

Based on observation, interview and record review it was determined, for 2 of 42 sampled residents, that the facility did not ensure that the resident environment remained as free from accident hazards as was possible; and that each resident received adequate supervision and assistance to prevent accidents. Specifically, two residents had multiple falls with injuries without interventions identified and implemented. The deficient practice identified for resident 48 was found to have occurred at a harm level. Resident identifiers 48 and 58. Findings include: HARM 1. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/07/19 at 3:06 PM, an observation was made of resident 48. A bruise was observed on the resident's left cheek. Resident 48 was unable to state how she got the bruise. On 10/8/19 at approximately 3:30 PM, an observation was made of resident 48 ambulating independently up and down the 300 hallway. Resident 48 was observed wearing shoes. Resident 48 was observed at the nurse's station looking for assistance, and was calling out I need, I need. Resident 48 was unable to state the desired request due to dementia and confusion. Resident 48 was observed to ambulate towards her bedroom with Certified Nurse Assistant (CNA) 6 and CNA 9. Resident 48's skirt was observed wet in the back and a strong odor of urine was noted. An observation was made of the resident's bed in a low position and the bedside mats were observed propped up against the wall. On 10/08/19 resident 48's medical records were reviewed. Review of resident 48's Admission Minimum Data Set (MDS) Assessment with an Admission Reference Date of 4/12/19 documented the resident's functional status was a 1 person limited assistance for transferring, walking in room and walking in corridor. Resident 48 was assessed as 1 person supervision with oversight for locomotion on unit and off the unit. Resident 48 was assessed as not steady but able to stabilize without staff assistance for moving from a seated to standing position, walking, turning, moving on and off the toilet, and surface to surface transfers. Resident 48 was assessed as having no impairment with ROM (range of motion) and no mobility devices were utilized. The resident was assessed as having no history of falls during last month prior to admission, in the last 2-6 months prior to admission, or a fracture related to a fall in the last 6 months. The assessment documented the resident's cognitive status and Brief Interview for Mental Status (BIMS) summary score as 00. This score was reflective of the resident not being able to recall information or incorrect or no responses given. The Care Area Assessment (CAA) Summary documented that resident 48 had a fall care area triggered for care planning. (Note: The care plan for falls was not initiated until 5/21/19 after the resident had sustained 2 falls with injuries.) Review of resident 48's care plan revealed the following interventions: a. On 5/21/19 standard fall precautions were initiated. These included bed in low position, call light in reach, mobility support, non-slip footwear, personal items in reach, sensory aid items within reach, traffic path free of clutter, and wheels locked for transfers. b. On 5/21/19 mat to both sides of bed and intervene for unsafe behaviors effecting fall risk, were initiated. c. On 5/30/19 therapy to evaluate walker, provide cueing and education during self-ambulation, and monitor for signs and symptoms of fatigue and encourage rest as needed, and monitor pain and treat to decrease fall risk were initiated. d. On 8/10/19 frequent checks throughout night was initiated. e. On 8/16/19 ensure proper footwear, non-skid socks was initiated. f. On 8/21/19 a bed alarm was initiated. Review of resident 48's physician orders [REDACTED]. a. Fall risk assessment, initiated on 5/20/19. b. Physical Therapy (PT)/Occupational Therapy (OT) to evaluate and treat, initiated on 5/20/19. c. PT to evaluate and treat, initiated on 6/12/19. d. X-ray to skull and mandible, initiated on 8/6/19. d. Bed alarm, initiated on 8/21/19. On 5/20/19 the Fall Risk Assessment Tool documented a score of 15, medium risk of falls for resident 48. Review of resident 48's Benefit vs. Risk form documented an area of concern as fall mat at bedside on floor. The benefit identified was a decrease in risk of injury if roused from bed. The risk identified was an increased risk of tripping, falling when ambulating in the room. The form was initiated on 6/6/19. Review of resident 48's radiology report for a skull x-ray on 8/6/19 documented no acute bony abnormalities. The report stated that the resident history was a contusion of unspecified part of head. It should be noted that no documentation could be found related to an injury resulting in a contusion on or around 8/6/19. The most recent incident prior to the x-ray was on 7/16/19 with no documented injuries noted. Review of resident 48's progress notes and incident reports for falls revealed the following: a. An incident report, on 5/12/19 at 4:30 PM, documented that resident 48 was found on the floor (FOF) in the general interior of building. The report documented that pain was present in the forehead and Bilateral hip. The injuries documented were a skin tear, hematoma to forehead, and a suspected fracture. Resident 48 was sent to the Emergency Department (ED) for treatment. Resident tripped while carrying two plates of pastries from main dining RM (room). The report documented that the care plan was updated with a referral to PT/OT upon return to the facility and staff assistance with all transfers. b. On 5/17/19 at 4:38 PM, the note stated, Facility cameras reviewed to monitor falls and determine root cause and interventions. Resident is viewed ambulating into main street area. Resident goes to creamery and removes 3 items from self-serve pastry box. Resident is also noted to be holding her purse. Resident attempted to balance all three items in conjunction with purse. She drops something and attempts to pick it up, and loses balance and falls. Nurse responds to provide immediate attention within 15 seconds of occurrence, Fall protocol initiated as appropriate. Staff attend to residents immediate needs and resident remains in appropriate positioning until medical personal were able to stabilize resident R/T (related to) fracture upon a backboard. Resident has returned to facility after surgical treatment. Resident is being monitored very frequently R/T this Pain regimen reviewed and appears to be adequately treating pain. NEW INTERVENTIONS: 1.) PT/OT 2.) Low bed with mat while bed is occupied 3.) Staff assistance with transfers. Care plan updated to reflect new orders. Attempted to call (family member) X 2 with no answer. It should be noted that this progress note was referencing the fall that occurred on 5/12/19. c. On 5/18/19 at 6:17 AM, the note stated at aprox. (sic) 0345 (3:45 AM) On patient rounds CNA went to residents room and heard her bed alarm ringing and found (resident 48) on the floor on the side of her bed. She was laying flat on her back . Nurse was called into assess resident. She was conscious and alert with confusion which is patients baseline. She has severe dementia and poor safety awareness with impulsiveness. She did not have any new bruising, has old bruise to right forehead from previous fall. Neuro checks done and WNL (within normal limits) PERLA (pupils equal, reactive to light and accommodation). with strong bilateral hand grips. V/S (vital signs) as follows 146/68, p (pulse) 80 r (respirations) 18, t (temperature) 98.1. No bleeding noted. C/O (complained of) pain to right hip area. Just readmitted to facility after TKA (total knee arthroplasty) (sic) of Right hip. Dressing to area clean dry and intact. Unable to move her right leg to assess pain or ROM d/t (due to) increase c/o and s/s (signs and symptoms) of pain from fall. Stated that it hurts really bad. (Physician) called at 0355 (3:55 AM) and gave order to have her transported via ambulance to have her revaluated for any new injuries at (local hospital). (Family member) notified at 0400 (4:00 AM) and she agrees with plan to evaluate. She stated that she would meet her at the hospital. EMS (emergency medical services) notified and Ambulance, EMTs (emergency medical technicians) arrived and transferred her to the gurney and took her to (name of local hospital) via ambulance. A hard copy incident report, on 5/18/19 at 3:00 AM, documented that resident 48 was FOF in room from high/low bed. The report documented that pain was present in both hips, and the resident was sent to ED for treatment. A factor documented at the time of fall, was bed height not appropriate. Footwear documented at the time of the fall was gripper socks. The report documented immediate interventions were low bed and fall mats times 2. Interventions implemented in the care plan on 5/21/19 were standard fall precautions which included bed in low position, call light in reach, mobility support, non-skid socks, personal items in reach, sensory aid items within reach, traffic path free of clutter, and wheels locked for transfers. Additional interventions initiated at that time were fall mats to both sides of the bed and staff to intervene for unsafe behaviors. d. On 5/18/19 at 11:02 PM, the note stated, (Resident 48) received CT (computed tomography) scan at hospital which showed no injury related to her fall. A [MEDICAL CONDITION] embolism was discovered in her right upper lobe. They are planning on keeping her for observation and returning her to the facility tomorrow. e. A hard copy incident report, on 5/26/19 (time not documented), documented that resident 48 rolled out of bed in her room. The report documented no injury or pain. The footwear at the time of the fall was not documented. The report documented an immediate intervention was frequent checks and that the care plan was updated. It should be noted that the care plan did not have an intervention of frequent checks until 8/10/19. f. On 5/28/19 at 4:14 AM, the note stated, Resident had unwitnessed fall and found by CNA on mat in front of bed. Resident had no injuries upon examination. Resident put back into bed and slept through the night. Dr., ADON (Assistant Director of Nursing), and family notified. (Note: No documentation could be found of a hard copy incident report for this fall. No new interventions were identified.) g. On 5/30/19 at 3:11 PM, the note stated, Resident noted to be back to baseline of very frequent ambulation. Resident walking with four wheeled walker and using device well. Resident does continue to reach and carry items while ambulating. Therapy notified and will be providing walker evaluation and adding Walker Purse to front of walker for resident to carry items to decrease her falls risk. Resident responds well to cueing during education but does not retain long term education for call light or assistance from staff for ambulation. Staff have spoken with family regarding fall care plan. Family understands risks of continued independent ambulation, but state that the benefit of resident being able to continue per her past history of frequent ambulation will increase her independence and would like to continue with this care path. Staff will continue to provide cueing and education for safety PRN (as needed). Staff will also continue to provide therapy services for strengthening and balance as well as safe ambulation techniques. Staff providing more frequent rounding and monitoring R/T falls risk. Staff will also continue to watch resident's pain regimen and treat as intervention appropriate. Interventions implemented in the care plan on 5/30/19 were therapy to evaluate walker and provide a walker purse for front of the walker, provide cueing and education during self-ambulation, monitor pain and treatment to decrease fall risk, monitor for signs and symptoms of fatigue, and encourage rest as needed. i. A hard copy incident report, on 6/3/19 at 2:15 AM, documented that resident 48 was FOF in room. No injuries or pain were documented. Footwear documented at time of fall was gripper socks. (Note: No new interventions were identified.) j. On 6/6/19 at 3:26 AM, the note stated, resident had an unwitnessed fall at 0045 (12:45 AM). 1 inch laceration to scalp on back of residents head with hematoma. Resident taken to ER (emergency room ) via ambulance and stretcher. In ER, per nurse to nurse, resident received 7 staples and a CT scan which was normal. Resident to have staples removed in 7 days. No new orders. Resident back from ER and resting in bed with call light within reach. A hard copy incident report, on 6/6/19 at 12:45 AM, documented Resident was found on the floor after a loud noise was heard. Large hematoma to back of resident's head. 1 inch laceration to back of head. Resident 48 was sent to the ED for treatment. Footwear documented at the time of the fall was shoes. (Note: No new interventions were identified.) k. On 6/17/19 at 1:29 AM, the note stated, Resident was sitting in recliner in hallway and stood up and started to walk and fell down on the carpet landing on her left side. Did not hit head. no injuries noted. VS 96.2 14 68 145/75 92% RA (room air). Dr , DON (Director of Nursing) and family notified. A hard copy incident report, on 6/16/19 at 10:30 PM, documented a witnessed fall to floor in the hallway from a standing position. No injuries noted or pain was documented. Footwear documented at the time of the fall was gripper socks. (Note: No new interventions were identified.) l. On 6/21/19 at 4:31 AM, the note stated, Resident was sent out to ER for further evaluation of increased back pain post ground level fall. UA (urinalysis) and CT of head, cervical, lumbar, [MEDICATION NAME] and thorax were completed with no unusual findings. Resident is back in bed with bedside mat and bed alarm in place. Call light within reach. A hard copy incident report, on 6/21/19 at 2:00 AM, documented Resident was found on floor near bed. Bedside mat had been pushed aside, bed alarm removed by resident. Resident assessed for pain/injury. Increased pain noted in back and with small movement to assist off bed frame. The report documented that the type of injury was a suspected fracture. Resident 48 was sent to the ED for treatment. The report documented factors to the fall as late hour and the footwear at the time of the fall was shoes. (Note: The progress note documented that a bed alarm was initiated. However, the physician order [REDACTED]. m. On 6/21/19 at 7:29 AM, the note stated, (Staff member) from ED called to report that MD (Medical Doctor) noticed a very subtle T10 fracture and there's nothing the doctor wants to do for it, although it will cause some pain. Family notified via voice mail message. WCTM (will continue to monitor), PRN pain medication given as needed per MD orders. n. On 7/16/19 at 3:03 AM, the note stated Pt (patient) had an unwitnessed fall-Was discovered under the desk at the nurses station after loud noise was heard. Assessed pt while on the ground, had no complaints and reported no pain. Palpated head, neck, spine, and extremities- pt denies any pain or tenderness. Vital signs with in normal limits. Initiated neuro checks and reported fall to the MD. ADM (administered) 0300 (3:00 AM) Tylenol as ordered for possible pain control. Transferred pt to bed at lowest setting with fall mats in place- will continue to monitor. The hard copy incident report, on 7/16/19 at 2:15 AM, documented pt. was found behind nurse station sitting on the floor under desk after loud noise was heard by CN[NAME] pt reported no pain or injury but will continue to monitor-possibly head injury- The report documented that the footwear was NOT non-slip. The report documented immediate interventions was to conduct frequent checks during the night, and the care plan was not updated. (Note: No new interventions were identified on the care plan.) o. On 7/31/19 at 9:26 PM, the note stated, Pt found on floor, witnessed by other patients, pt fell back landed on her back with right arm behind her, pt sweaty diaphorectic (sic), vs stable, 175/69, 91 ra (sic), hr 82 even, resp (respirations) 24. Pt alert x 1 to self, unable to communicate staring blankly at staff, unable to answer questions r/t cares etc. Md notified , (family member) notified, will meet at hospital, emergent services contacted. Cognition poor, unable to process any information. Unusual for her. Large bump to right side of her head above her ear. (Note: No documentation could be found of a hard copy incident report for this fall. No new interventions were identified.) p. On 8/1/19 at 4:43 AM, the note stated, Pt returned from the ER at (local hospital) around 0020 (12:20 AM) with the (family member). Pt was AO (alert and orient) x 2. and was more stable on her feet. Pt had a UA and tested positive for candida, and a bladder infection. Pt also had a scalp hematoma from the ground level fall. Pt had a CT brain/head w/o (without) contrast and a CT spine cervical w/o contrast. New orders recived (sic) from the ER :-[MEDICATION NAME] Keflex 500 mg (milligrams) oral capsule BID (two times a day) for 7 days. [MEDICATION NAME] topical cream QID (four times a day) for 7 days PRN as needed for skin. Pt has been resting. VS are stable and WNL (within normal limits). Will continue to monitor and do VS and Neuro checks as per protocol. Interventions implemented in the care plan were frequent checks throughout the night on 8/10/19 and ensure proper footwear, non-skid socks on 8/16/19. It should be noted that non skid-socks were initially implemented on 5/21/19. q. On 8/6/19, a note stated that resident 48 had bruising of unknown origin on the frontal, sphenoid, and mandible area, and X-rays were ordered. (Note: No documentation could be found of a hard copy incident report for this injury. No new interventions were identified.) r. A hard copy incident report, on 8/16/19 at 8:20 AM, documented that resident 48 was FOF in room. No injuries or pain were documented. The footwear at the time of the fall was documented as regular socks. The physician ordered a U[NAME] (Note: No new interventions were identified.) s. On 8/20/19 at 4:45 AM, the note stated at 00:30 (12:30 AM) patient was found on the floor of her room. When the patient was asked what happened, she stated that she did not fall. She said that she was tired and wanted to lay down. Pt had no new injuries. VITALS Temp: 97.7 Resp: 16 Pulse: 58 BP (Blood Pressure): 157/78 O2: 97% on RA NEUROS L[NAME] (level of consciousness): awake and aware Movement: all 4 extremities Speech: clear Hand grasp: equal and strong Pupil reaction: brisk Pupil size: 4mm (millimeter) Interventions already in place include; Bed in low position, mat on the floor, call device within reach, encourage handrail, night light, non-slip footwear, traffic path in room free of clutter, frequent checks. Recommendations: collaborate with family in regards to setting a bed alarm A hard copy incident report, on 8/20/19 at 12:30 AM, documented that resident 48 was FOF in room. No injuries or pain were documented. Interventions implemented on 8/21/19 in the care plan was a bed alarm. On 10/08/19 at 4:29 PM, an interview was conducted with the CNA Coordinator and Licensed Practical Nurse (LPN) 1. The CNA Coordinator stated that the bruise on the resident's right cheek was from a fall that occurred approximately a month ago where the resident's entire right side of her face was bruised. LPN 1 stated that this was not a new injury but rather a resolving and healing bruise. On 10/09/19 at 9:21 AM, an interview was conducted with CNA 7. CNA 7 stated that he was also a facility Restorative Nurse Assistant (RNA) and that he worked with resident 48 in the restorative program. CNA 7 stated that he attempted to provide resident 48 with restorative services Monday through Saturday for 15 minutes a day. CNA 7 stated that he provided resident 48 with active ROM exercises and walking. CNA 7 stated with regards to resident 48's walking exercises he just visualized her ambulation, and on days that resident 48 was not observed ambulating he would try to take her on a walk. CNA 7 stated that resident 48 liked to participate in the move and groove activity that was conducted daily at 11:00 AM. CNA 7 stated that resident 48 enjoyed hitting balloons with noodles during the move and groove activity. CNA 7 stated that resident 48 had a history of [REDACTED]. CNA 7 stated that interventions for preventing resident 48 from falling were to keep the bed in a low position, place fall mats on both sides of the bed when the resident was in bed, and to check on her frequently. CNA 7 stated that resident 48 has had injuries from her falls, such as a bruise on her face. CNA 7 stated that he observed that the bruise had caused resident 48 pain because she would touch her face and groan. CNA 7 stated that on days when resident 48 seemed off balance they would try to walk with her or guide her in her ambulation. On 10/09/19 at 10:33 AM, an observation was made of resident 48 ambulating. Resident 48 was observed ambulating down the hallway wearing only one shoe on the left foot. Resident 48 was observed to be holding the right shoe. Resident 48 stated that the right foot was hurting. Resident 48's socks were observed to be mismatched and the sock located on the right foot was thicker than the left. Resident 48 was approached by the CNA Coordinator and RN 3. Both staff members asked resident 48 why she was carrying her shoe. Neither staff member attempted to assist resident 48 with her footwear. Resident 48 then proceeded to remove the other shoe and was observed ambulating in the hallway in only socks. The resident was left unattended not wearing shoes. Resident 48 stated she wanted her shoes off because they hurt her feet. Resident 48 was then observed to ambulate down the hallway unattended while holding her shoes in her hands. Resident 48 was observed ambulating into the dining room onto the vinyl flooring in her socks. On 10/09/19 at 11:08 AM, an interview was conducted with CNA 9. CNA 9 stated she had been at the facility for a month and a half. CNA 9 stated that she knew resident 48 really well and was usually assigned to her hallway. CNA 9 stated she did not know of any interventions for falls for resident 48 and that she had not had a fall since she has worked at the facility. CNA 9 stated that resident 48 just ambulated around the facility constantly. On 10/09/19 at 11:15 AM, an observation was made of resident 48 with CNA 9. Resident 48 was observed seated in the dining room with her shoes on. CNA 9 was asked to remove resident 48's shoes to observe the socks. The right foot sock was observed with no skid marks on the bottom of the foot. The left foot sock was observed applied upside down and the no skid marks were located on top of the foot. CNA 9 stated that the sock was not correctly placed on the resident's foot. On 10/09/19 at 11:26 AM, an interview was conducted with CNA 6. CNA 6 stated that the fall interventions in place for resident 48 were to have her bed in a low position, a hand rail on the bed for positioning, and a fall mat when the resident was in bed. On 10/09/19 at 1:15 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 48 had fall mats that were placed on both sides of the bed when resident 48 was in bed. CNA 3 stated that housekeeping took one of the fall mats in the morning to clean it. CNA 3 was not able to identify any other fall interventions. On 10/10/19 at 10:11 AM, an interview was conducted with the DON. The DON stated that the protocol for staff after a resident had sustained a fall was to ensure the resident's safety first, notify the physician and family, fill out an incident report, conduct a post fall evaluation, initiate neurological assessments if the fall was unwitnessed, observe the resident for 3 days post fall for late signs of injury, and to update the care plan with new interventions after each fall. The DON stated that he conducted rounds with CNAs and nurses to obtain possible interventions. The DON stated that all interventions were documented in the care plan to communicate to the staff. The DON stated that the fall protocol was patient specific and was listed on the care plan directly below standard fall precautions. The DON stated that fall interventions were re-evaluated post fall at least weekly. The DON stated that the falls were communicated during morning meetings with department heads and that staff utilize a HIPAA (Health Insurance Portability and Accountability Act) compliant text message app. The DON stated that each fall should have an incident report. The DON stated that he had been at the facility for 2 months. The DON stated that if residents were having repeated falls he would attempt to identify interventions that would be more effective. The DON stated that the interventions needed to be patient centered and would try to keep them safe regardless of the resident's cognitive status or level of confusion. The DON stated, what should we have done, tie her down? when asked about resident 48's interventions. 2. Resident 58 was admitted to the facility on [DATE]; he went out to the hospital and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 58's medical record was reviewed on 10/9/19. A review of resident 58's Medicare Admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident 58 had a Brief Interview for Mental Status score of 12 which indicated that resident 58's cognitive status was mildly impaired. Additionally, the MDS documented that resident 58 triggered as needing a fall prevention care plan. (Note: Resident 58's Falls IP[NAME] (interdisciplinary plan of care) was not initiated and fall prevention interventions were not developed until 5/17/19.) A review of resident 58's care plan revealed the following interventions: a. On 5/17/19 Morse Fall Risk Standard Precautions, Bed in low position if unattended, call light within reach, mobility support available, non-slip footwear, personal items within reach, sensory aid items within reach, traffic path in room free of clutter, wheels locked with transfers. And . Verbal education regarding importance of call light use. b. On 8/10/19 educated on asking for assistance as needed & non skin (sic) socks or shoes when out of bed. (Note: non-skid footwear was already an intervention initiated 5/17/19.) c. On 10/9/19 Staff to provide appropritely (sic) fill O2 (oxygen) tank or oxygen concentrator in the dining room. A review of resident 58's progress notes revealed that he had 8 falls since his readmission: a. A nurses' progress note on 4/5/19 Resident has had an unsteady gait since after breakfast. Lost balance and fell into the counter. Approximately 30 minutes later he got out of bed to leave the room. He was unsteady and lost balanced with his wheelchair and he was found on the ground. (Note: No fall interventions were initiated.) b. A nurses' progress note on 4/20/19 (Resident 58) was found laying on the floor, assessed for injuries and none found, tried to assist resident back to bed but he was able to crawl back to his bed. A hard copy incident report stated (Resident 58) was found laying on the floor face down in his room. Resident stated he tripped & hit his head, neck & wrist. No apparent skin injury noted. Resident stated that he was self transferring from restroom. Director of Nursing (DON) follow up: encourage call light usage prior to transfer and no self transferring. (Note: Fall interventions were not initiated until 5/17/19.) c. A nurses' progress note on 6/12/19 CNA reported patient tangled in his O2 tubing and went to a knee but did not sustain a fall or hit his head. A hard copy incident report stated Walking from bathroom back to bed pushing his concentrator and pt (patient) leg gave out and pt knee hit floor and caught himself on his bed footboard. A Medical Director (MD) progress note dated 6/14/19 stated Pt had fall and thinks he may have broken a rib on the right side lower chest. He says he does not want an xray to confirm but would like a wrap to splint the ribs. (Note: No fall interventions were initiated.) d. A nurses' progress noted on 7/27/19 States fell on floor; from bed says feet went out from under him. DON follow up: non skid socks or shoes when OOB (out of bed). (Note: No fall interventions were initiated.) e. A nurses' progress note on 7/28/19 Resident fell x2 (twice) in his room the first time he self reported a fall the second fall was witnessed by his room mate. (Note: Fall interventions initiated on 8/10/19 were duplicate interventions.) f. A nurses' progress note on 9/21/19 Patient had call light on and CNA went into room at 2200 (10:00 PM) with writer (sic). Patient was on floor next to bed. Patient stated that he went to the bathroom and when he was walking back he slipped on a blanket that had fallen off the end of his bed. Grip socks put on patient and placed call light within reach. (Note: No fall interventions were initiated.) g. A nurses' progress note on 10/7/19 Pt was using walker and was transferring to stationary chair in dining room. Cna was holding chair and pt fell to the right towards walker and hit his right side of his ear on walker and hit right elbow. Patient then fell to the floor. (Note: Fall intervention was initiated on 10/9/19.) Resident 58 refused to be interviewed. On 10/9/19 at 10:12 AM, an interview was conducted with CNA 7. CNA 7 stated that he was familiar with resident 58. CNA 7 stated that resident 58 had fallen multiple times and had refused fall mats and a low bed. CNA 7 stated that resident 58 was encouraged to use his call light for help, but that resident 58 was trying to stay independent. CNA 7 stated that staff kept an eye on resident 58 when he was out walking around the facility. CNA 7 stated that resident 58 was super independent so staff did not provide any assistance or cares to resident 58. CNA 7 stated that new interventions were communicated to staff by mouth during shift change report. CNA 7 stated the sometimes nurse management would send out a group text about new interventions. CNA 7 stated that there had been no messages about new interventions for resident 58. On 10/10/19 at 10:20 AM, an interview was conducted with the DON. The DON stated that the facility process for falls was to assess the resident and administer first aid, fill out a hard copy incident report and notify the MD and family, fill out a post fall assessment in the facility electronic charting system, and place the resident on 3 days of monitoring. The DON stated that he printed a report every morning that told him if there had been a fall, the interdisciplinary team then met that morning and updated the resident care plan and implemented interventions. The DON stated that a new intervention was implemented after every fall, and those interventions were entered into the care plan as well as sometimes entered as a physician's orders [REDACTED]. The DON stated that the interventions were re-evaluated for effectiveness after each subsequent fall. The DON stated that if the (TRUNCATED)

Based on observation, interview and record review it was determined, for 3 of 42 sample residents, that the facility did not ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, after residents developed pressure ulcers interventions and treatments were not in place to prevent the pressure ulcers from worsening. In addition, residents that were determined to be at high risk for developing pressure ulcer did not have interventions in place to prevent pressure ulcers from developing. Resident identifiers: 19, 38 and 59. Findings include: HARM: 1. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/7/19 at 9:00 AM, an observation was made of resident 38 sleeping in his bed. Resident 38 had bare feet; resident 38's feet were not floated on a pillow. On 10/7/19 at 11:07 AM, an observation was made of resident 38 pushing himself, in his wheelchair, out of his bathroom post shower. Resident 38 was observed barefoot, pushing himself backwards by his heels. Resident 38 was observed only wearing a pair of pants. Resident 38 stated he was waiting for the nurse to put a new dressing on his heel. Resident 38's right heel was observed to have an open pressure sore with some drainage. Resident 38's pressure wound was resting directly on the laminate floor. On 10/7/19 at 11:30 AM, Certified Nursing Assistant (CNA) 7 went in to check on resident 38. CNA 7 stated that the nurse would be there soon. CNA 7 stated that the nurse was looking for supplies to do resident 38's dressing change. On 10/7/19 at 11:59 AM, Registered Nurse (RN) 3 returned to do resident 38's dressing. RN 3 stated that she had been waiting for the wound nurse to come look at resident 38's heel. RN 3 stated that since the wound nurse had not come yet, she would just do the dressing now. RN 3 observed to apply resident 38's dressing to his heel. On 10/8/19 at 2:26 PM, an observation was made of resident 38. Resident 38 was observed in his wheelchair wearing his shoes, resident 38's wheelchair had no foot pedals and his heels were resting on the ground. On 10/9/19 at 12:28 PM, an observation was made of resident 38 in bed. Resident 38's right foot was elevated on a pillow; his left foot was resting on the bed. On 10/9/19 at 2:33 PM, an observation was made of resident 38 in bed; resident 38 had been observed to be in bed throughout the day. Resident 38 had a urinal at his bedside; resident 38 stated staff had been emptying it periodically. Resident 38 had a pillow under his right calf; right heel was resting heavily on the mattress as evidence by the mattress indented below his right heel. Resident 38's medical record was reviewed on 10/8/19. An Admission Minimum Data Set ((MDS) dated [DATE] documented that resident 38 was at risk for developing pressure ulcers but that his skin was intact at that time. Additional MDS documentation showed that resident 38 was a 2 person extensive assistance for bed mobility and repositioning. Further review revealed the Care Area Assessment section of the MDS documented that the facility staff addressed resident 38's pressure ulcer risk in the resident care plan. A review of resident 38's care plan revealed that resident 38's Skin Integrity IP[NAME] (interdisciplinary plan of care) was not initiated until 9/24/19, after resident 38's stage III pressure ulcer was discovered. The only two interventions listed on resident 38's care plan were Nurse to provide skin check weekly. And Staff to assist with repositioning every 2 hours and PRN. A review of the facility electronic charting system Braden Assessment score breakdown revealed that Braden score of 18 or less will indicate a patient is at risk for a pressure ulcer. A review of resident 38's Braden Assessment results revealed: a. 8/22/19 documented that resident 38's Braden Assessment score was 17. b. 8/27/19 documented that resident 38's Braden Assessment score was 16. c. 8/31/19 documented that resident 38's Braden Assessment score was 16. d. 9/1/19 documented that resident 38's Braden Assessment score was 16. e. 9/2/19 documented that resident 38's Braden Assessment score was 16. f. 9/4/19 documented that resident 38's Braden Assessment score was 14. g. 9/5/19 documented that resident 38's Braden Assessment score was 14. h. 9/16/19 documented that resident 38's Braden Assessment score was 16. i. 9/19/19 documented that resident 38's Braden Assessment score was 17. j. 9/27/19 documented that resident 38's Braden Assessment score was 17. (Note: This was after resident 38's stage III pressure ulcer was discovered.) A review of all of resident 38's nurse skin checks documented intact skin from 8/20/19 through 9/19/19. (Note: No skin checks had been documented since 9/19/19.) A review of resident 38's shower documentation revealed that resident 38 did not get a shower from 9/12/19 until 9/21/19. None of resident 38's CNA shower sheets documented skin breakdown to either of his feet. A review of the facility Turn and Reposition Detail Report documented that resident 38 was turned and repositioned every two hours or was able to position self. Resident 38's 8/30/19 MDS documented that resident 38 was not able to reposition self in bed. A review of resident 38's nurses' notes revealed: a. On 9/21/19 a nurses' note documented Bordered dressing to R (right) Heel until healed. (Note: This was the first mention of any skin issues for resident 38, there were no measurements done at that time.) b. On 9/24/19 a nurses' note documented Pt seen by wound care NP, a dressing was placed on the heel. NP reported the pt has a stage III pressure ulcer on the right heel. A new order will be placed for a daily dressing change today. (Note: The local wound care company examined resident 38 on 9/24/19 and documented Pt states that the wound and pain to his heel has been there for at least 2 weeks.) c. On 9/25/19 a nurses' note documented pressure ulcer noted to the right heel. (MD (Medical Director) 1) ordered for (local wound care company) to treat and evaluate. New orders for patient to clean wound with NS (normal saline) and pat dry. Apply hydrogel to the wound, continue to change daily. Wound measures 1.4x1.4x0.2 (centimeters). wound bed is pink with no drainage noted. the wound edges are attached and have full thickness. The surrounding skin is within normal color for this patient. (Local wound care company) will continue to follow this patient. Staff will continue to follow these orders that were approved by (MD 1). d. On 10/2/19 a nurses' note documented New order placed for tubi grip to bil (bilateral) le (lower extremities), dx (diagnosis) [MEDICAL CONDITION], monitor [MEDICAL CONDITION] q (every) shift , soft boot to right heel when in bed. PU (pressure ulcer) to r (right) heel, cleanse with ns (normal saline), pat dry, apply [MEDICATION NAME] to wound bed, cover with border foam dressing , change q 3 days and prn (as needed), notifiy (sic) md of s.s (signs and symptoms) infection or changes, chenck (sic) placement drsg (dressing) q shift. e. On 10/7/19 a nurses' note documented Patient has a right heel pressure ulcer. The wound has a pink wound bed with a scant amount of serosang (serosanguineous) drainage. The wound edges are smooth and attached. The peri wound area is within normal color for this patient. There is no foul odor of s/s (signs and symptoms) of infection. Patient stated that he had a little discomforted when the NP debreaded (sic) the wound. NP ordered that the dressing be clean with NS, pat dry, [MEDICATION NAME] with a border foam dressing. Change dressing M-W-F and PRN. The wound measures 1.2x1.2x0.1 cm . (MD 1) was notified of the new wounds and orders and he is in agreement with all of the treatments. This patient will continued to be monitored by (local wound care company). On 9/25/19 a physician's orders [REDACTED]. Clean wound with NS, pat dry, apply hydrogel to wound, cover with boarder foam gauze. (Note: This was the first wound care order entered; the wound was discovered on 9/21/19.) On 10/2/19 a physician's orders [REDACTED]. (Note: Resident 38 was observed multiple times with no boots on while in bed.) Resident 38's TAR was reviewed, which revealed no documented dressing changes until 10/8/19. On 10/8/19 at 2:26 PM, an interview was conducted with resident 38. Resident 38 stated that the staff usually put a pillow under his feet at night. Resident 38 stated that staff did not come in and reposition him. Resident 38 stated that the staff were changing his dressing to help his wound heal, stated staff were not doing anything else. Resident 38 stated that he had never worn padding or boots on his heels. Resident 38 reported that his wound was painful. Resident 38 stated that he had reported heel pain to some staff members for a while prior to them finding the wound and starting dressing changes. An Admission MDS dated [DATE], documented the resident 38 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that resident 38 was cognitively intact. On 10/8/19 at 2:39 PM, an interview was conducted with RN 1. RN 1 stated that he changed resident 38's heel dressing every day, stated that he had already changed the dressing that day. RN 1 stated that he put hydrogel on resident 38's right heel and covered it with some kind of dressing to hold the hydrogel in place, nothing specific though. RN 1 stated that he had never put a soft boot of any kind on resident 38. RN 1 stated that the only interventions that were being done for resident 38's pressure sore were the dressing changes. On 10/8/19 at 2:47 PM, an interview was conducted with CNA 8. CNA 8 stated that the CNA's did not do any interventions to help with resident 38's heel wound. CNA 8 stated he thought night shift might float resident 38's heels. CNA 8 stated day shift let the nurse know when resident 38 was out of the shower so the nurse could change resident 38's dressing. CNA 8 stated that the CNA's notified the nurses if they saw any new skin issues. CNA 8 stated that staff was not doing anything to prevent skin breakdown prior to resident 38's pressure ulcer being identified. CNA 8 stated that he had never placed any kind of padded boot to resident 38's heel. CNA 8 stated that resident 38 was alert and oriented, and just kind of does his own thing throughout the day, stated the CNA's did not reposition resident 38. (Note: the facility Turn and Reposition Detail Report documented that the CNA's repositioned resident 38 every 2 hours on 10/8/19.) On 10/8/19 at 3:31 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that she did not know what was done with Braden score results. CRN 1 stated that if a treatment was not documented on the TAR then there was no way to know if the treatment was done. CRN 1 verified that resident 38's TAR had no documentation of dressing changes to his right heel pressure ulcer. On 10/9/19 at 10:12 AM, an interview was conducted with CNA 7. CNA 7 stated that when CNA's did showers they turned the shower sheets in the CNA Coordinator. CNA 7 stated that he had not helped reposition resident 38 all morning. On 10/9/19 at 12:26 PM, a follow up interview was conducted with resident 38. Resident 38 stated that he did not reposition himself; resident 38 stated he just always lay on his back. Resident 38 stated that staff would help him reposition about 3 times a week. (Note: Verified with resident that he meant 3 times a week. The facility Turn and Reposition Detail Report documented resident 38 was able to turn and reposition himself.) Resident 38 stated that no one had helped him reposition that day. Resident 38 stated that he had been using his feet to propel himself in his wheelchair for several months, even prior to admitting to the current facility. Resident 38 stated that he never had foot pedals on his wheelchair at this facility because he used his feet to push himself around. On 10/9/19 at 12:41 PM, an interview was conducted with the Wound Nurse (WN). The WN stated that resident 38 was at risk for pressure ulcer development when he admitted related to his [DIAGNOSES REDACTED]. The WN stated that she knew the floor nurses did Braden assessments, but stated that she did not know what was done with the results. The WN stated that preventative interventions that staff were doing prior to resident 38's pressure ulcer development were to encourage proper footwear, the CNA's did skin checks with every shower and filled out a shower sheet, and resident 38 had a standard pressure relieving mattress. (Note: Resident 38 did not get a shower from 9/12/19 to 9/21/19.) The WN verified that there was not an order for [REDACTED]. The WN stated that it would concern her if resident 38 was using his heels to self-propel, and that it could have contributed to his pressure ulcer. On 10/9/19 at 2:33 PM, another interview was conducted with resident 38. Resident 38 stated staff had not repositioned him all day. (Note: The facility Turn and Reposition Detail Report documented that the CNA's repositioned resident 38 every 2 hours on 10/9/19.) On 10/9/19 at 6:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 38 was on a standard pressure relieving mattress and had weekly skin checks by the floor nurse prior to the pressure sore appearing on his right heel. (Note: No skin checks had been done since 9/19/19.) The DON stated that resident 38 was cognitively intact so we don't worry too much about him. The DON stated that he was unfamiliar with Braden score results breakdown used in the facility electronic charting system; the DON stated that he did not use that score breakdown for care plan intervention developement. The DON stated that he would have to check with the corporate office to see which Braden score breakdown they used. The DON stated that he only put other skin breakdown prevention interventions in if the Braden score was less than 12. (Note: Resident 38's Braden score was 17 even after his stage III pressure ulcer was discovered.) On 10/10/19 at 10:57 AM, an interview was conducted with Physical Therapy Assistant (PTA) 1. PTA 1 stated that resident 38 had never been on therapy services at the facility, so they did not do anything to help with his wound healing or prevention. On 10/10/19 at 1:19 PM, a follow up interview was conducted with the DON. The DON provided the Braden score breakdown sheet that he referred to when implementing interventions, which he stated he printed off of the Braded website. The DON stated that he did not know why the WN or CRN 1 knew nothing about the Braden score breakdown used. The DON stated that even if a resident was only a mild risk for skin breakdown, every resident should have a skin breakdown prevention care plan upon admission. (Note: Resident 38's skin breakdown prevention care plan was not initiated until over a month after his admission.) On 10/15/19 further documentation was provided by the facility Administrator about interventions for skin breakdown prevention for resident 38. The documentation stated that the facility started resident 38 on vitamin C and a multivitamin upon admission. Upon further review of the discharge orders from the previous facility, resident 38 had been receiving those supplements prior to admission at the current facility. Potiential for Harm 2. Resident 59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/7/19 at 11:54 AM, an interview was conducted with resident 59. Resident 59 stated that she has a pressure sore on the bottom of her foot under the boot. Resident 59 stated that she developed the pressure sore because of the boot. Resident 59 stated that facility staff told her the best way to help the sore was to take the boot off. Resident 59 stated that the Wound Nurse was aware of the sore. Resident 59's boot was observed to start at the top of resident 59's calf and covered her toes. Resident 59's boot was curved below the heel and was not pressed against her heel. Resident 59's boot was observed to be flat along the ball of the foot. Resident 59 stated that she was going to the doctor the next day and hoped to get a brace. On 10/9/10 at 12:58 PM, an observation was made of resident 59's room. There was a wedge pillow with holes in it on her bed. Resident 59 was observed sitting in her wheelchair in the common area. Resident 59 stated that they found her sore on the bottom of her foot a couple weeks ago when she had a boot on. Resident 59 stated staff did not put a bandage on the wound and staff told her they wanted to keep the wound dry. Resident 59 stated staff placed pillows under her calves to keep her from getting sores on her foot. Resident 59 stated that staff were taking the boot off more often after they noticed the sore but have/had not put any bandages on it. Resident 59 stated that the wound was very painful when staff touched it. Resident 59 was observed to have a black laced brace around her ankle to the middle of her foot. Resident 59 stated that she got the brace the day before. On 10/9/19 at 2:05 PM, an observation was made of resident 59's wound. Resident 59 stated there was no dressing on her foot. Resident 59 stated that it was painful when Registered Nurse (RN) 4 nurse touched the wound. RN 4 was observed to remove resident 59's laced brace and there was a sock under the brace with no dressing on the wound. Resident 59's wound was on the lateral ball of foot. RN 4 was observed to measure the wound and stated the wound was 3.6 centimeter (cm) by 2.8 cm. An observation of the wound was non-blanchable dry/scabbed area with unclear edges. Resident 59 stated that the wound was very painful to touch, rated pain 9/10 when touched. Resident 59 was observed to be flinching, wincing, and shuddering. RN 4 was observed to cleaned the wound with normal saline and gauze, RN 4 applied lotion to the rest of the foot excluding the wound and periwound. RN 4 was observed to apply a bordered gauze dressing over the wound. Resident 59 stated that it felt better once the dressing was on. Resident 59 stated that the wound therapist said it was redder than when she saw it on Friday. Resident 59's medical record was reviewed on 10/10/19. A 60 day Minimum Data Set ((MDS) dated [DATE] revealed that resident 59 required extensive assistance with 1 person for bed mobility. The MDS further revealed that resident 59 did not have a pressure ulcer at that time but was at risk for developing a pressure ulcer. The MDS revealed that resident 59 had a cushion for her chair and ointments were used for treatments. A care plan for resident 59's skin integrity dated 8/8/19 revealed a goal that (resident 59) is at risk for skin impairment r/t (related to) fractures and decreased mobility. Another goal developed was (resident 59) will have no unaddressed skin issues TNR (through next review). There were two interventions developed Nurse to assess skin on admin (admission) and weekly TNR (and) Staff to assist with repositioning every two hours and prn (as needed). On 10/9/19 at 6:36 PM, an interview was conducted with Director of Nursing (DON). The DON stated that greater than 18 for a Braden score was low risk, 13-18 was moderate risk, and less than 12 was high risk for pressure sore development. Two skin/Braden assessments dated 7/22/19 and 8/17/19, both revealed resident 59 had very limited sensory perception, occasional moist skin, resident 59 was Chair Fast with 'Very limited mobility. Resident 59 had Probably inadequate nutrition with potential problems for Friction and Shear. Resident 59's Braden score was 13. A skin/Braden assessment dated [DATE] revealed that resident 59 had slightly limited sensory perception, skin was occasionally moist, walked occasionally, and mobility was slightly limited. Resident 59's nutrition was adequate with potential problems for friction and sheer. Resident 59's Braden score was 17. A skin/Braden assessment dated [DATE] revealed that there was no apparent friction or shearing problems, with a Braden score of 17. Resident 59's skin/Braden assessments dated 9/2/19, 9/3/19, 9/5/19, 9/6/19, revealed resident 59 had potential problems with friction and shearing, with a Braden score of 16. A skin/Braden assessment dated [DATE] revealed potential problems for friction and shear, with a Braden score of 15. An orthopedic physician's visit dated 9/10/19 revealed that resident 59 was 25 % weight bearing and to follow up in 2 weeks. There was no information that the cast had been removed. A skin/Braden assessment dated [DATE] revealed resident 59 had potential problems for friction and shearing, with a Braden score of 16. A physician's visit dated 9/23/19 revealed Subject: Pt (patient) doing well overall. Concerned about pressure sores on bottom of foot. The physician's assessment and plan was Pressures sores on bottom of feet, avoid pressure on bottom of feet, boot too tight. (MONTH) have boot off bid (twice daily) for at least 30 minutes to allow for break. (Note: There were no interventions developed on resident 59's care plan or treatment orders in resident 59's electronic medical record.) An orthopedic physician's visit dated 9/24/19 revealed, Physician observation: Lateral Plantar early blister no change in alignment. The physician's orders [REDACTED]. A skin/Braden assessment dated [DATE] revealed No apparent problem with friction or shearing, with a Braden score of 17. A physician's visit on 10/2/19 revealed, Pt doing ok today. Did want me to look at her pressure sore on the bottom of the foot. The Assessment/Plan revealed, Pressure sore 2/2 (secondary to) cast = healing nicely. Keep pressure off the foot when possible. She is still allowed activity per surgery for [REDACTED]. (Note: There were no treatments orders in resident 59's electronic medical record.) A note from the Wound Nurse (WN) dated 10/3/19 revealed, Patient has a DTI (deep tissue injury) to right lateral foot. Area is purple and does no (sic) blanch. The skin is intact. No blister noted. The wound is 3 x 2.2x0cm. Patient denies any pain or discomfort in the wound area. MD (Medical Doctor) was there to observe wound. MD ordered that the wound be covered with a foam dressing and changed 3 times a week. MD wants notified of any changes. Unknown cause of the wound. (Note: The measurements done on 10/9/16 showed that the wound had increased in size from the original measurements on 10/3/19.) A physician's orders [REDACTED].Foot, Right MWF (Monday, Wednesday, Friday) Deep tissue injury to right laderal foot. (MONTH) change PRN. Cover with bordered foam dressing. Notify MD of any changes. A note from the WN dated 10/4/19 revealed, (Resident 59's physician) ordered to have this patient on Juven one packet everyday r/t wound healing. The RD (Registered Dietician) recommended the order. A skin/Braden assessment dated [DATE] revealed No apparent problem with friction or shearing, with a Braden score of 20. (Note: This was after the pressure ulcer was discovered.) A skin/Braden assessment dated [DATE] revealed, No apparent problem with friction or shearing, with a Braden score of 17. A review of resident 59's Treatment Administration Record (TAR) revealed there were no treatments completed to resident 59's wound until 10/8/19. (Note: There was a note from the Orthopedic Physician on 9/24/19 that there was an early blister.) A review of resident 59's shower sheets revealed that resident did not any documented skin conditions on 8/27/19, 9/14/19, 9/19/19, 10/1/19 and 10/10/19. (Note: There was no documentation that there was a bandage on resident 59's foot on the above dates.) On 10/9/19 at 12:44 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that stated the she was unable to find documentation that dressing changes had been completed prior to 10/8/19. On 10/9/19 at approximately 2:00 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was the Wound Nurse (WN) for the facility. The ADON stated that if a Certified Nursing Assistant (CNA) discovered a wound during a shower, the CNA was to notify the nurse and then the nurse notified the physician. The ADON stated that the nurse then received an order from the physician and notified the family. The ADON stated that after she was notified of a wound she followed up the next time she was in the facility. The ADON stated that she conducted wound rounds on Monday with the Nurse Practitioner. The ADON stated that all new admission residents and new wounds were followed up on. The ADON stated that she compared wound measurements from the previous wound rounds. The ADON stated that she consulted with the resident's physician regarding any wounds and received orders from the physician. The ADON stated that there was a glitch in the electronic medical record which caused treatments to not be documented. The ADON stated that there was an area that needed to be clicked to trigger a treatment order to alert the nurses to complete the treatment. The ADON stated that nurses had no idea that a treatment needed to be completed because it did not flag them to complete it. The ADON stated that the physician's orders [REDACTED]. The ADON stated that the treatment to change the boardered foam was Monday, Wednesday and Friday. The ADON confirmed there were no treatments documented in resident 59's medical record until 10/8/19. The ADON stated that she was notified of the wound on 10/3/19. The ADON stated that it was a pressure ulcer, and she obtained an order for [REDACTED]. The ADON stated that she was unaware of any skin issues until 10/3/19. The ADON stated that not having documented treatments was a problem because of the computer system and how orders had to be inputted. The ADON stated that the wound most likely developed from the cast or the boot. The ADON stated she was not sure when resident 59's cast was removed. On 10/9/19 at 2:27 PM, an interview was conducted with CNA 14. CNA 14 stated resident 59 had a big gray boot on the day before, she now had a black brace. CNA 14 stated that she thought resident 59 had a boot for about a month, but wasn't sure. CNA 14 stated that when resident 59 had the boot that staff removed every 2 hours for 15 minutes. CNA 14 stated that the staff did not document when the boot was removed. CNA 14 stated that resident 59 was busy sometimes and the staff did not remove the boot. CNA 14 stated that resident 59 was alert and oriented and did not refuse care. CNA 14 stated that resident 59 was unable to remove the boot herself. CNA 14 stated that resident 59 had a foam thing while she was in bed, on the side of her leg to keep her leg in the straight direction. CNA 14 stated that he was not aware of other things to do for her foot. On 10/9/19 at 2:30 PM, an interview was conducted with RN 4. RN 4 stated that she was from a staffing agency. RN 4 stated that it was her first day working with resident 59. RN 4 stated that she was not familiar with the electronic medical record. RN 4 stated that treatment orders popped up on her computer screen to complete. RN 4 stated that she did not know how often resident 59's wound care was to be done. RN 4 stated I have no idea why she didn't have a dressing on it. RN 4 further stated that maybe the dressing fell off and the CNAs forgot to tell the nurse it came off when resident 59 was in the shower. On 10/9/19 at 2:47 PM, an interview was conducted with CNA 8. CNA 8 stated that he worked for a staffing agency. CNA 8 stated that he knew resident 59 needed to have her ankle straight. CNA 8 stated that resident 59's boot was removed yesterday and a little sleeve boot was applied. CNA 8 stated that he had not been instructed on checking resident 59's sore on her foot. CNA 8 stated that when resident 59 was showered, her brace would be removed for a full body skin check. CNA 8 stated that if he had seen any skin conditions, he would report them to the nurse. CNA 8 stated that the only instructions he was given was to keep resident 59's ankle and leg straight. CNA 8 stated that resident 59 was alert and oriented and able to verbalize needs. On 10/9/19 at 2:52 PM, an interview was conducted with CNA 6. CNA 6 stated that she had worked at the facility for 3 months. CNA 6 stated that resident 59 was alert and oriented and able to verbalize her needs. CNA 6 stated that resident 59 had a sore by her toes on the pad of her foot. CNA 6 stated that she had known about it for about 2 weeks. CNA 6 stated that she was told to leave resident 59's boot on at all times, so CNAs covered it with plastic when they showered resident 59 . CNA 6 stated that resident 59 told her that her doctor wanted to have her boot off twice a day for 2 hours. CNA 6 stated she was not sure why resident 59 needed her boot removed. CNA 6 stated that when she removed the boot there was a white sock under it and CNA 6 did not remove the sock. CNA 6 stated that she was unable to see if there was any skin issues under the sock. On 10/9/19 at 5:28 PM, an interview was conducted with resident 59's physician. Resident 59's physician stated that resident 59 had a cast on her ankle and the surgeon had removed it. Resident 59's physician stated there were noted pressure sores when the cast was taken off. Resident 59's physician stated that the WN informed him of any wounds. Resident 59's physician stated that the Physical Therapist had brought up the fact that she had skin breakdown under the boot. Resident 59's physician stated from what I recall she was non-weight bearing. Resident 59's physician stated that resident 59's wound was not a huge sore when he saw it. Resident 59's physician stated I take these very seriously and encouraged her to get pressure off of it as much as possible. Resident 59's physician stated he educated resident 59 on putting the pillow under calves to keep pressure off of it. Resident 59's (TRUNCATED)

Based on interview and record review, it was determined the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring. Specifically, 1 of 8 sample resident's [MEDICATION NAME] time (PT) and international normalized ratio (INR) laboratory values were not adequately monitored in accordance with [MEDICATION NAME] administration, which resulted in hospitalization . Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 2's medical record was completed on 10/19/16. Resident 2's Medication Administration Record [REDACTED]. Resident 2's physician orders [REDACTED]. The orders documented the following entries: a. 9/23/16; PT and INR, daily until 9/28/16; Status: Pending (Note: There was no documentation from the facility or the laboratory that PT and INR laboratory results had been obtained on 9/23/16, 9/24/16, or 9/25/16.) b. 9/26/16; PT and INR, once; Status: Ordered (Collected) Resident 2's PT/INR Tracking Sheet, dated 9/26/16, documented the following information: . PT- +96, INR- +8.0 . Current [MEDICATION NAME] Schedule M (Monday) 2.5, T/W/Th/Fr/Sat/Sun (Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday) 5.0 mg (milligrams) . New Orders for [MEDICATION NAME] Therapy 10 mg 1 ml (milliliter) Vit (vitamin) K given 10:15 (10:15 AM) . Follow-up PT/INR (Date) . 9/26/16 . INR ------------------- Reference Range: 0.7 - 1.3 Pro-Time ------------ Reference Range: 10.6 - 13.0 . Resident 2's nursing progress notes were reviewed from 9/22/16 through 10/19/16. The notes documented the following entries: a. 9/24/16; .16.8 INR, PT 13.2 . (Note: There was no PT/INR Tracking Sheet or laboratory results associated with this note. In addition, there was no evidence that the physician was notified of this critically high INR laboratory value.) b. 9/26/16; . resident sent to ER (emergency room ) for increased pt/inr > 96 and > 8. ambulance transported her to (name of local hospital) ER . Resident 2's admission paperwork from the ER, dated 9/26/16, documented that he was admitted with [DIAGNOSES REDACTED]. The admission paperwork further documented that laboratory results were obtained on 9/26/16 at 9:36 PM, which indicated a PT of 57.3 and INR of 6.1. The facility's [MEDICATION NAME] Time (PT/INR) Testing with INRatio System policy, dated 2/28/08, was reviewed. The policy documented the following information: . 1. Obtain and/or review physician's orders [REDACTED]. 2. Perform a fingerstick following the instructions for the lancet being used . 11. Notify physician of the results of the [MEDICATION NAME] Time. a. If a patient's/resident's INR results are less than 1 or greater than 4, a venipuncture should be performed on the patient/resident for PT/INR and the sample taken to a laboratory for results . On 10/19/16 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if she obtained critical PT or INR laboratory results, she would have notified the physician immediately by phone. RN 1 further stated she would have expected a response from the physician within a few minutes and documented his response within a nursing progress note. On 10/19/16 at 10:43 AM, an interview was conducted with RN 2. RN 2 stated if she obtained critical PT or INR laboratory results, she would have notified the physician immediately and documented his response within a nursing progress note. On 10/19/16 at 1:25 PM, a follow up interview was conducted with RN 1. RN 1 stated that a PT/INR Tracking Sheet should have been completed and scanned into the electronic medical record in accordance with the abnormal laboratory results documented for resident 2 within the nursing progress note dated 9/24/16. On 10/19/16 at 3:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that according to resident 2's physician orders, the blood draw was never performed to obtain resident 2's PT and INR laboratory values on 9/23/16. The DON further stated that since there was a nursing progress note that documented PT and INR laboratory values on 9/24/16, a blood draw must have been obtained within the facility by the nursing staff. In addition, the DON stated she was unable to locate laboratory documentation for 9/23/16 and a PT/INR Tracking Sheet should have been completed in accordance with the physician order. The DON further stated if the physician had been notified of the laboratory results documented within the nursing progress note dated 9/24/16, he would have taken action due to the abnormal nature of the PT and INR values.

Based on observation, interview and record review, it was determined the facility failed to operationalize written policies and procedures to ensure 4 of 30 sample residents were free from abuse. Although facility staff identified verbal abuse, the facility failed to identify physical abuse had occurred. The Certified Nurse Assistant (CNA) continued to provide direct care to the resident that was verbally and physically abused. Additionally, the facility did not put in place protective measures, thoroughly investigate all alleged occurrences, or report to required oversight agencies, as directed by written policies and procedures. The facility's failure to operationalize policies and procedures to prevent abuse was determined to constitute immediate jeopardy to residents' safety. Resident identifiers: 6, 41, 62 and 63. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 4/6/16 at 3:50 PM. At that time, the Administrator was asked to develop an immediate plan to ensure resident 62 (also referred to as resident 1 during the complaint investigation), and all residents were free from abuse. On 4/11/16, the Administrator provided the following written allegation of removal of immediate jeopardy: Based on the following corrective measures, Rocky Mountain Care - Mountain View believes immediate jeopardy was removed April 8, 2016 @ (at) 2030 (8:30 PM). Rocky Mountain Care Heber will do the following: In-service all staff before their next shift on the abuse policy Interview all residents regarding issues related to abuse Review of charts for any incidents of abuse that were not reported and then following of our policy on those issues identified. April 5, 2016 @ 11:30 (11:30 AM) Investigation continued by discussion with DON (Director of Nursing), RFA (Resident and Family Advocate) and reading and full review of statements provided by witnessing staff. (CNA 1) was terminated at this time Administrator, DON & (and) RFA educated on and reviewed policy #2001 with clinical educator (name redacted). Incident report started for resident 62 for missed lab. Lab completed. Nursing staff to be educated on lab procedures by DON by 4/8/16. April 2, 2016 @ 1600 (4:00 PM) Further investigation as to the depth of the problem continued in the facility. RFA, DON, Administrator and Admit Coordinator interviewed all residents the following questions: #1. Has staff, a resident or anyone else here abused you - this includes verbal, physical or sexual abuse? If 'yes', ask who the abuser was, what happened, when it occurred, where it occurred and how often. A. did you tell staff? Who did you tell? #2. How you seen any resident here being abused? If 'yes', ask who the abuser was, what happened, when it occurred, where it happened, and how often. Res (resident) (36) refused interview. All other residents were interviewed regardless of condition or status. 5 Residents answered yes to question #1. (Resident 64) answered yes started a full investigation. The administrator contacted family to discuss res statements. Brother stated that resident was not capable of understanding such complex questions due to cognitive limitations and that res (resident) has always been 'happy' being here. Residents asked in simple written statements with yes/no answers if he was 'happy' and 'safe here'. To which res answered yes. Reasked (sic) this resident on 4/7/16 @ 0900 (9:00 AM) the same written questions to which he answered yes again to both. Resident (1) stated yes was interviewed more fully by RFA. Resident (1) stated she was bossed around by a CNA. Further investigation resident denied feeling as though it was verbal abuse. Resident (41) who stated yes. Stated 'they make me take a shower when I don't want to' also stated 'I'm 6' (foot) 4 (inches) and I feel safe'. (Resident 41) it was multiple male/female staff over multiple periods. Staff to be inserviced on abuse and approaches with residents. Resident (34) answered yes to verbal abuse. Investigation was started by RFA. Resident stated, '(CNA 7) yells at me to sit down', When asked if he felt safe around him res said 'No'. When asked why resident stated 'afraid of falling' Investigation is still ongoing at this time and (CNA 7) in (sic) temporarily suspended until investigation completed. Resident (62) stated yes to abuse. 'Stated is a woman, once here, months ago'. This has been substantiated as evidenced from completed investigation. Mandatory inservice scheduled for all staff on abuse scheduled for 4/8/16 @ 1530 (3:30 PM) to be given by (name redacted), a licensed social worker. This inservice will encompass all staff and include but not limited to the abuse prevention, investigation and reporting policy #2001. All staff not in attendance of this meeting will be inserviced prior to their next shift. Completion of this training will be reviewed in QA (Quality Assurance) on 4/15/16. April 6, 2016 during the day Investigations and interview continued with newest complaints received as well as completing and follow up of prior reported complaints. Resident (1) unsubstantiated Resident (41) continued. Resident (34) unsubstantiated to a single person. All staff to obtain training on abuse. April 6, 2016 @ 1700 (5:00 PM) Employee files were reviewed for content of abuse training. None was found. HR (Human Resources) has been developing a general orientation program since the lack of one. General Orientation program as developed by HR through QA process will be implemented as of today 4/6/16 for all new hires. Resident rights and Abuse sections will be taught by Administrator to all new employees hired as of 4/6/16. This process will be reviewed in QA monthly for the next 3 months or until practice of training staff r/t (related to) abuse has been deemed satisfactory. Next QA will be held April 15, 2016. As part of QA an 'audit' of repeating abuse questions to all residents will be completed weekly by Administrator or designee as well as staff interviews for a minimum of 4 weeks or until QA determines that it is no longer necessary. Results of questions will be discussed monthly in QA beginning 4/15/16. As part of stand-up census meeting the question of concerns r/t (related to) abuse will be asked beginning 4/7/16. April 6, 2016 @ 2030 (8:30 PM) Training held for all available nursing staff on abuse policy and specifying reporting procedures. The inservice was given by Administrator and lasted 45 minutes: the following staff were in attendance; (Licensed Practical Nurse (LPN) 3, Registered Nurse (RN) 1, LPN 4, CNA 8, CNA 10 and CNA 2.) April 7, 2016 at 0930 (9:30 AM) Training held for staff in the facility working on the abuse policy, reporting procedures and incident form. Training done by Administrator and time spent 30 minutes. Staff in attendance: (Housekeeper (HSK) 1, Medical Records Clerk (MRC), CNA 3, CNA 6, DON, RN 2, Dietary Manager (DM), Dietary Staff Member (DSM) 1, Administrative Personnel 1, DSM 2, HSK 2. 1200 (12:00 PM) training: (Unknown Employee (UKE) 1, UKE 2, DSM 3.) See folder for complete list. April 8, 2016 at 1530 (3:30 PM) Abuse orientation and inservice for all staff, given by (name redacted), staff given copies of abuse policy and quiz after inservice. See copy of list, quizzes and acknowledgements. Hand delivery of deficiency also included an employee with a felony working in the facility. An audit of all current employee files was completed at this time. All employees that marked yes they have been convicted of a felony were removed from the floor at this time. At 2030 (8:30 PM), CNA 11 and CNA 10 were suspended from work pending investigation. On 4/11/16 after council with corporate HR it was determined that the two CNAs found to have marked 'yes' to having a felony would be terminated at this time. At 1230 (12:30 PM) terminations were completed. Findings include: 1. Resident 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview was conducted with Certified Nurse Assistant (CNA) 2 on 4/5/16 at 7:55 AM. CNA 2 stated that on 4/2/16 at 8:30 AM, she was walking out of a resident room to help CNA 1 to toilet resident 62. CNA 2 stated that resident 62 was rambunctious, and was hollering and asking for help to urinate during the morning meal. CNA 2 stated that she witnessed CNA 1 jerking resident 62's wheelchair forwards and backwards as he was being propelled down the hallway towards his room. CNA 2 stated that when CNA 1 pushed resident 62 into his room, she stated that she heard what sounded like a slap and went running into resident 62's room. Upon entering the room, CNA 2 stated that she saw arms flailing around and CNA 1 and resident 62 moving towards each other. CNA 2 stated that resident 62 had redness to the right side of his head. CNA 2 stated that resident 62 stated, She hit me. CNA 2 stated that she told CNA 1 to get out of the room and to stop providing any cares to resident 62. CNA 2 stated that CNA 1 told her, I had made a mistake. CNA 2 again told CNA 1 to get out of resident 62's room and to send another CNA into the room to assist her. CNA 2 stated that she immediately reported the incident to the Assistant Director of Nursing (ADON) via text message and verbally informed LPN 1, who was functioning as the charge nurse on 4/2/16, of what she had witnessed. CNA 2 stated that the RFA came into the facility approximately 2 hours after the incident had occurred to conduct an investigation. CNA 2 stated that CNA 1 continued to provide direct care to residents, for two hours, until approximately 10:30 AM when she was sent home. CNA 2 stated that CNA 1 was allowed to return to work the same day to work the night shift. On 4/5/16 at 9:30 AM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated on 4/2/16 at 9:30 AM, she provided services to resident 62 . The PTA stated that resident 62 told her, She slapped me in the back of my head. The PTA stated that resident 62 was unable to state who had slapped him in the back of his head. The PTA stated that at the time she did not see any redness or signs of injury. On 4/5/16 at approximately 9:35 AM, an interview was conducted with CNA 3. CNA 3 stated that she was aware of two other incidents related to CNA 1 that had occurred with regards to verbal and physical abuse towards two additional residents: a. Last summer, CNA 3 was providing cares to a male resident with CNA 1 assisting. CNA 3 stated that the male resident became combative and grabbed CNA 3's hands. CNA 3 stated that CNA 1 grabbed the resident's hand between his thumb and first finger then jerked her hand backwards that resulted in a significant skin tear to the resident's hand. CNA 3 stated that CNA 1 yelled at the resident stating, Stop it!. Stop screaming at us! CNA 3 stated that the male resident was sent to the local hospital for treatment of [REDACTED]. CNA 3 stated that the she reported the incident to the DON and was told that the incident would be investigated. CNA 3 stated that the incident was not investigated. A review of the investigations into the allegations of abuse revealed that the above incident had not been investigated. b. CNA 3 stated that while she and CNA 1 were providing cares to another male resident a couple of weeks ago, when the resident became combative and feisty. CNA 3 stated that CNA 1 yelled at the resident to, Shut up! Shut the (expletive removed) Up! CNA 3 stated that she did not report the incident to anyone. On 4/5/16 at 11:05 AM, an interview was conducted with CNA 1. CNA 1 stated that she had not received training on abuse at the time of hire or during the time of her employment at the facility. CNA 1 stated that on 4/2/16 she was helping other residents in the dining room and charting resident 62's behaviors when resident 62 became very agitated, screaming and yelling and making other residents uncomfortable. CNA 1 stated that resident 62 had become increasingly agitated because the staff were unable to immediately take him to his room. CNA 1 stated that facility staff had to wait and provide cares to other residents in the dining room and then get a CNA to assist resident 62 because he was a two person assist. CNA 1 stated that resident 62, kept swinging at her and that he was grabbing the handrails in the hallway and pulling himself toward the wall. CNA 1 stated she was pulling on the resident's hand to get him to let go of the rail. CNA 1 stated that she then pushed him a little bit more and then resident 62 grabbed a hold of the handrail again and again. CNA 1 stated that resident 62 reached back at her and hit her cheek causing a scratch. CNA 1 stated that she was, frustrated with resident 62 and that she should have taken a breath before helping him. CNA 1 stated, I lost my temper for telling him to shut up. On 4/5/16 at approximately 10:38 AM, an interview was conducted with the RFA. The RFA stated that on 4/2/16 at approximately 9:00 AM, she received a call to investigate an allegation that CNA 1 was jerking resident 62's wheelchair, was yelling at resident 62 and that his arms were moving around. The RFA stated that CNA 1 was very frustrated with resident 62 and that the incident was observed by another CNA . The RFA stated that CNA 1 continued to work the floor and provide care to residents until she was sent home at 10:30 AM. The RFA stated that she informed the Administrator (ADM) that she believed that verbal abuse had occurred and that she was unable to substantiate that physical abuse had occurred related to inconsistencies during her interview process. The RFA stated that no further disciplinary action had been taken. Review of the RESIDENT ABUSE INVESTIGATION FORM, dated 4/2/16 at 8:00 AM, revealed the following: .NATURE OF EVENT: Verbal Abuse, Physical Abuse, (and) Staff to Resident . Description: Reported that (CNA 1) yelled at possibly hit (resident 62) in hallway while headed to bathroom. NOTIFICATIONS (Notification must be made to APS (Adult Protective Services), Resident Assessment and the administrator for ALL allegations of abuse.) Administrator .4/2/16 (and) Physician 4/4/16 . (Note: The physician was not notified of the incident until 4/4/16, two days after the allegation was received. Additionally, the facility staff did not notify APS, the State Survey Agency, the family, or the local police department.) The RFA stated that she was aware of another incident that had occurred last summer when resident 41, was grabbing at CNA 1's arms and twisting her arm. The RFA stated CNA 1 had shoved the resident's arms away from her. The RFA stated that her consultant stated that CNA 1's action was defensive and not abusive. The RFA stated that the employees were allowed to defend themselves. Review of the RESIDENT ABUSE INVESTIGATION FORM, dated 7/6/15 revealed: .NATURE OF EVENT: Staff to Resident . Description: Reported that (resident 41) was refusing cares and grabbed at CNA (1) - CNA (1) shoved his arm away. NOTIFICATIONS (Notification must be made to APS, Resident Assessment and the administrator for ALL allegations of abuse.) .Administrator . (Note: Adult Protective Services, the State Survey Agency, the physician, the family, and the police were not notified of the allegation of abuse.) CNA 1 provided a typed statement that documented, .Incident Report: room [ROOM NUMBER] July 4, 2015; 1:15 AM On July 4TH at 1:15 A.M, Resident had got up on his own to use the restroom, tab alarm went off; so the nurse, the other CNA and I went running. Came into the room and resident had fallen on top of the protective mattress pad. Resident was combative and refused to assist in standing. Once resident was up and standing, we assisted him into the restroom, where he was still combative and refusing help. He tried to sit on the toilet head first so we tried to help him turn the correct way, as he was turning he grabbed my left arm, dug his nails in my arm and twisted and pulled down. After asking several times to let go, and behave himself I put my hand against his arm a little too forcefully which was a defense mechanism to being in pain, and I understand that was not the way to go about the situation. Afterwards I explained that it would be helpful if he would be cooperative. He apologized and I apologized, got up walked back to bed and we sat there and talked, and learned a lot about each other. The RFA documented her summary of the events that occurred on 7/4/15 which included: Interview with CNA 1, the interview time was not documented: (Resident 41) grabbed (CNA 1's) arm and was twisting. (CNA 1) put her hand on his arm to push it away. Interview with CNA 5 at 12:30 PM: (Resident 41) was having behaviors and grabbed (CNA 1's) arm, twisting it. (CNA 1) shoved his arm away. Interview with the facility contracted Licensed Clinical Social Worker (LCSW) at 1:30 PM: Staff are allowed to defend themselves. As long as it was defensive actions it is not abuse. The RFA documented her investigation summary was (CNA 1) acted in self defense and not abuse. The ADMINISTRATIVE DECISION documented was, ACTION WAS NOT CONSIDERED ABUSE BY DEFINITION. EMPLOYEE WAS REACTING TO BEING HURT BY RESIDENT DIGGING (AND) SQUEEZING HER ARM. WILL STILL DO EDUCATION ON WORKING WITH BEHAVIORAL PATIENTS FOR THIS CNA (and) ALL STAFF. On 4/5/16 at 11:05 AM, an interview was conducted with LPN 1. LPN 1 stated that she had not been inserviced on abuse. LPN 1 stated that on 4/2/16 at approximately 8:00 AM, CNA 2 stated that she heard CNA 1 tell (resident 62) to shut up and then heard what sounded like a slap. LPN 1 stated that she sent a text message to the ADON to notify her of the incident. LPN 1 stated that CNA 4 told her that she saw CNA 1 slap resident 62. LPN 1 stated that she was administering medications to the residents when the three CNAs talked to her about the incident. LPN 1 stated that she checked to make sure that resident 62 was O.K. but was not able to state that she had immediately assessed resident 62 for injuries. LPN 1 stated that the RFA told her that she did not need to do a report as she (LPN 1) did not see or hear what had happened. LPN 1 stated that she did not document the incident in resident 62's medical record. On 4/5/16, resident 62's medical record was reviewed. On 4/2/16 at 2:36 PM, LPN 1 documented, Resident has been aggitated (sic) throughout the day concerning his folley (sic) catheter and continued to pull his cather (sic) and complain of pain and that he needed to void. The catheter was patent and draining yellow urine. However it was my juidgement (sic) to d/c (discontinue) the folley (sic) catheter at this time d/t (due to) growing aggitation (sic) of resident. Brief in place for any incontenence (sic) and CNAs notified of change in voiding to be aware of when to change his brief. Will continue to monitor resident frequently. On 4/5/16 at approximately 10:50 AM, an interview was conducted with the DON. The DON stated that she had not been notified of the incident on 4/2/16 until returning to work on 4/4/16. The DON was told at that time that the incident had been investigated and that the staff member had been sent home. The DON stated that after reviewing the incident, she felt that CNA 1 had verbally abused resident 62. On 4/5/16 at 11:27 AM, an interview was conducted with the ADM. The ADM stated that on 4/2/16 she received a phone call from the RFA. She stated that the RFA told her that CNA 1 hit resident 62. The ADM stated that she called LPN 1 and was told that everyone was good and didn't know anymore of the incident other than what LPN 1 reported to her. The ADM stated that she believed CNA 1 verbally abused resident 62 but had decided to allow her to come back to work. The ADM stated that she made a mistake. A review of the facility policy and procedure for Abuse - Prevention, Investigating and Reporting revealed the following: PURPOSE: 1. To educate employees to issues of abuse, neglect and exploitation 2. To prevent abuse, neglect, and exploitation of the resident. 3. To ensure prompt reporting of actual or suspected abuse, neglect, or exploitation to the appropriate authorities POLICY: Rocky Mountain Care prohibits any abuse of residents from any source. This includes staff abuse, peer abuse, family or any person having contact with the resident. Rocky Mountain Care seeks to promote the well being of its residents by providing a safe and supportive environment. Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. DEFINITIONS: ABUSE: Means the willful infliction of injury, unreason able confinement, intimidation or punishment with resulting physical harm pain, or mental anguish. This includes the withholding of goods or services that is necessary to attain or maintain physical, mental and psychosocial well-being. VERBAL ABUSE: Means the use of oral, written, or gestured language that willfully includes degrading or derogator terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or their disability. Threats of harm Saying things to frighten a resident Making fun of a resident Saying something that would make the resident uncomfortable, or others uncomfortable. .PHYSICAL ABUSE: It also includes controlling behavior through corporal punishment. Striking Kicking Twisting limbs Pulling hair Pinching Subjecting to extreme heat or cold Use of unapproved restraints, or misuse of authorized restraints Withholding basic needs, warmth, food, clothing MENTAL ABUSE: Includes but is not limited to humiliation, harassment, and threats of punishment or deprivation. .PROCEDURE: 1. Screening: All potential employees will be screened as part of the application process. A Criminal Background Investigation will be completed on every new employee. Reference checks on new employees will include a minimum of two references, and should include contact with current, and past employers Licensure (where applicable) will be verified to ensure licensed employees are in good standing. If anything in the employee screening process indicates a history of abuse or misappropriation of property, the individual will be referred to the administrator. Where applicable by State law, yearly Criminal Background Investigations will be completed on all staff at the time the facility applies for a license renewal. Continued employment is contingent upon the Criminal Background investigation. 2. Training: All employees will be trained at hire and annually thereafter as to what would constitute abuse, neglect and misappropriation of resident property. 3. Prevention: New employees will be trained to identify potential signs and symptoms of abuse including behavior changes and injuries of unknown origin. Annual training to employees will be given to identify incidents or allegations, which need investigated (sic). .4. Identification: Any employee, consultant, or any other person affiliated with the operation of this facility that has reason to believe that a resident has been subject to abuse, neglect, or exploitation, will immediately notify the facility Administrator, Director of Nursing, or their designee, so that appropriate action may be taken. Obtain the name of any witnesses Complete an 'Incident Report' immediately which shall include a complete description of the circumstances and details of the incident relating to the abuse, neglect, or exploitation. The descriptions should include names of all persons involved, time, place, and all other pertinent information and evidence related to the occurrence in question. 'A person who is required to report suspected abuse, emotional or psychological abuse, neglect or exploitation of a resident and who wilfully fails to do so is guilty of a class B misdemeanor.' 5. Investigation: Investigating Injuries of Unknown Source: If the source of the injury was not observed by any person or the source of the injury cannot be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or over time, an investigation will be implemented: The attending nurse or resident advocate will ask the resident what happened. Residents with intact cognitive skills will be able to report what happened. If the resident is confused at times, they may be able to provide valuable information also. Document the resident's report. The attending nurse will do a skin assessment to determine if there are any related injuries or bruising. Upon assessment, suspicious bruises, skin tears, and injuries that appear to potentially be abusive or are inconsistent with the resident's verbal report or medical condition and activity level, will be investigated by the Resident Advocate, Director of Nursing, or designee and reported as per State and Federal regulations if abuse is suspected. An incident report will be completed at the time of the discovered injury by the attending nurse. Other Suspected Abuse Incidents: Any person who suspects that abuse, neglect or misappropriation of property may have occurred, will immediately report the alleged violation to the attending nurse who immediately notifies the Administrator, Director of Nursing, or Patient Advocate. The Administrator or his designee will initiate an investigative process as soon as possible, but not exceed 24 hours after discovery of the incident. This investigation may consist of: a. Review of completed incident report, and any supporting documents. b. Interview with person or persons reporting the incident. c. Interview with any witnesses to the incident. d. Review of the resident's medical record. e. Interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident. f. Interview with the resident's roommates, family members, and visitors who might have knowledge of the resident. g. Interviews with other residents who have been cared for by the staff member in suspicion. h. A review of all the circumstances around the incident. General Investigative Procedures: Witness reports shall be documented and signed by the witness .6. Protection: Following an allegation of abuse, the facility will immediately implement increased monitoring of any residents deemed to be at risk for further abuse. . If the complaint alleges abuse be (sic) a staff member, that staff member will be suspended or removed from direct patient care (whichever is appropriate to protect the resident) until an investigation has been completed. There will be no reprisal to staff for reporting abuse allegations. 7. Reporting: All alleged violations and all substantiated incidents, injuries of unknown source will be reported to the appropriate State Survey Agency immediately as possible with the results of its findings within five (5) working days. The Director of Nursing or designee will be responsible to notify the resident's attending physician. The Administrator, Director of Nursing, Resident Advocate, or designee will be responsible to notify the resident and his/her, legal representative. Any actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff will be reported by Rocky Mountain Care to the: a. State nurse aide registry b. Appropriate State Licensing Agency If appropriate: Notify the Ombudsman Adult Protective Services (APS) or law enforcement must be notified for: a. alleged violations b. injuries of unknown origin when abuse is suspected .If it is determined that abuse may have occurred, the Policy Committee will review the findings and determine if any changes in current policies and procedures are required to prevent further potential for abuse. 2. Resident 63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/5/16 at approximately 9:35 AM, an interview was conducted with CNA 3. CNA 3 stated that last summer she was providing cares to resident 63 with CNA 1 assisting. CNA 3 stated that the male resident became combative and grabbed CNA 3's hands. CNA 3 stated that CNA 1 grabbed the resident's hand between his thumb and first finger then jerked her hand backwards that resulted in a significant skin tear to the resident's hand. CNA 3 stated that CNA 1 yelled at the resident stating, Stop it!. Stop screaming at us! CNA 3 stated that resident 63 was sent to the local hospital for treatment of [REDACTED]. Resident 63's medical record was reviewed on 4/12/16. On 6/19/15 at 4:53 PM, a licensed nurse documented, CNA's (3) and (1) went in room to get resident ready for the day. He was hitting and yelling at them. He grabbed (CNA 1's) hand. When she went to pull away it tore his skin on his right hand. Skin tear is approximately 2 inches and was bleeding. Dressed right hand with [MEDICATION NAME] dressing and bordered gauze. Spoke to resident about his behavior towards CNA's. Review of the emergency room documentation revealed that resident 63 sustained an avulsion injury. The emergency room physician documented that a optiform dressing was placed and was to remain in place for seven days. On 4/14/16 at approximately 10:30 AM, the DON was interviewed. The DON stated that resident 63 had sutures placed at the emergency room . A review of the RESIDENT ABUSE INVESTIGATION forms for the above incident revealed the incident had not been investigated. 3. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/5/16 at approximately 9:35 AM, an interview was conducted with CNA 3. CNA 3 stated that a couple of weeks ago she and CNA 1 were assisting resident 6 with his activities of daily living. CNA 3 stated that resident 6 became combative and feisty. CNA 3 stated that CNA 1 yelled at resident 6 to, Shut up! Shut the (expletive removed) Up! CNA 3 stated that she did not report the incident to anyone. 4. On 4/5/16, three staff members were interviewed related to abuse training and education. a. CNA 3 was interviewed at 9:35 AM. CNA 3 stated that she had worked at the facility for the last 1 1/2 years and had not received any training on abuse. b. Nurse Assistant (NA) 1 was interviewed at 9:28 AM. NA 1 stated that she started working at the facility three weeks ago. NA 1 stated that she had not received any training on abuse. c. RN 2 was interviewed at 9:45 AM. RN 2 stated that she had had no abuse training since being employed at the facility. 5. A review of employee files were conducted and revealed the following: a. NA 1 was employed by t