Every finding on record at Sedgwick County Memorial Nursing Home

Based on record review and interviews, the facility failed to ensure one (#7) of four residents reviewed for accidents out of 18 sample residents remained free of accidents.Resident #7, who was identified as a high fall risk, sustained a fall on 2/27/25 resulting in bruising to her forehead. The facility failed to review the resident's care plan after the fall to determine if the resident's fall interventions were effective or if new interventions were needed to prevent further falls. Additionally, documentation failed to indicate the resident was assessed by a registered nurse (RN) following the fall.On 5/31/25, Resident #7 sustained another fall which resulted in a hospitalization for a hip fracture. Again, documentation failed to indicate the resident was assessed by a RN following the fall. Upon Resident #7's return to the facility on 6/18/25, the facility again failed to review the resident's care plan after the fall to determine if the resident's fall interventions were effective or if new interventions were needed to prevent further falls.Specifically, the facility failed to:-Review Resident #7's fall interventions for effectiveness and implement new fall interventions if needed following the resident's falls in order to prevent a fall with major injury; and,-Ensure Resident #7 was assessed by a RN following her falls on 2/27/25 and 5/31/25.Findings include:I. Facility policy and procedureThe Fall policy and procedure, undated, was provided by the director of nursing (DON) on 9/10/25 at 8:55 a.m. It read in pertinent part, The purpose of this policy is to ensure the facility has a process to make appropriate care decisions for persons that have fallen and may have obtained an injury. The policy will be followed to ensure processes are set up upon admission to prevent harm from falls.Each resident will be evaluated on their fall risk level upon admission and have appropriate interventions implemented and reassessed quarterly and with changes in status. Assessment for elimination or alternate interventions to prevent falls and injuries from falls will be conducted quarterly and with changes. The risk assessment will be completed by a nurse or designee on admission and at the time of any new fall and quarterly thereafter. Update the care plan, communicate interventions and initiate neurological assessments.II. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, age related osteoporosis (increased risk of fracture), chronic respiratory failure with hypoxia (low oxygen), chronic fatigue and urinary incontinence. The 6/18/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She used a walker and a wheelchair. She was dependent on staff assistance for bathing, upper/lower body dressing, putting on/off footwear and personal hygiene. She required maximal assistance with toileting hygiene, oral hygiene, sit to stand, chair to chair transfers, toilet transfers and shower transfers. She was always incontinent of urine. The assessment indicated the resident had a fall prior to admission and a fracture related fall at the facility. B. Record reviewResident #7's fall care plan, initiated 4/10/23 and revised 7/1/25, revealed the resident was at a high risk for falls related to gait imbalance, poor safety awareness and history of fracture. The interventions included determining and addressing causative factors of falls (initiated 9/24/24), keeping walkways free of clutter (initiated 2/7/25), providing activities that promoted exercise and strength building where possible (initiated 10/13/23), encouraging participation in group exercise (initiated 10/13/23) and encouraging ambulation (initiated 10/23/23).-There was no documentation to indicate the facility reviewed Resident #7's fall care plan after the resident's falls on 2/27/25 and 5/31/25 (which resulted in a fracture) in order to determine if the fall interventions were effective or if new fall interventions were needed in order to prevent further falls for the resident.A nursing progress note, dated 2/27/25 at 9:36 a.m., revealed Resident #7 had a fall which was reported from the prior shift and bruising was noted on the resident's forehead. The resident complained of dizziness when standing, which had resolved. The unwitnessed fall incident report, dated 2/27/25 and documented by a licensed practical nurse (LPN), revealed a staff member entered Resident #7's room and she was sitting in her recliner. The resident told the certified nurse aide (CNA) that the chair moved on her and that she hit her head on the bed frame. Resident #7 was observed by the CNA to have swelling and a mark to the right side of her forehead. The CNA immediately informed the nurse. The resident's walker was noted to be directly in front of her dresser. She denied having to get up from the floor and she was unsure what happened. The bed frame was at approximately waist height on the resident. No injuries were noted to the resident other than the right side of her forehead, which had an approximate 2.5 centimeter (cm) area of redness and swelling.-The incident report failed to include documentation to indicate that the resident was assessed by a RN after the fall. -Additionally, the incident report failed to document if new fall interventions were implemented to prevent further falls for the resident.A nursing progress note, dated 6/4/25 at 11:18 p.m., revealed the note was a late entry documentation for a fall that occurred on 5/31/25 at 5:00 a.m. The note documented Resident #7 had an unwitnessed fall with injury to her right hip area and a small skin tear with a lime-sized bruise/hematoma above her pinky finger. The nurse was walking past the resident's room and heard a thud on the other side of the door. The resident was found sitting on the floor facing away from the door with her right leg bent at the knee and her right ankle under her left leg. She was unable to perform range of motion and expressed extreme pain in her right hip. Emergency medical services (EMS) were notified and the resident was transported to the hospital. A 6/5/25 hospital note revealed Resident #7 required surgical repair of a closed right hip fracture.The unwitnessed fall incident report, dated 5/31/25 at 4:05 a.m. and documented by a LPN, revealed Resident #7 was unable to give a description of the fall. The nurse documented the resident had an unwitnessed fall with injury to her right hip area and a small skin tear with a lime-sized bruise/hematoma above her pinky finger. The nurse was walking past the resident's room and heard a thud on the other side of the door. The resident was found sitting on the floor facing away from the door with her right leg bent at the knee and her right ankle under her left leg. She was unable to perform range of motion and expressed extreme pain in her right hip. EMS were notified and the resident was transported to the hospital. The predisposing physiological factors included confusion, incontinence and gait imbalance. The resident was ambulating without assistance with a walker. -The incident report failed to include documentation to indicate that the resident was assessed by a RN after the fall.-Additionally, the incident report failed to document if new fall interventions were implemented to prevent further falls for the resident.III. Staff interviewsCNA #1 was interviewed on 9/8/25 at 4:38 p.m. CNA #1 said when a resident had a fall she would notify the nurse. She said the nurse would complete the assessment and if there was no injury, the staff would get the resident up and check on them frequently. She said residents who were a high fall risk had a green leaf on the door frame to identify they were a fall risk. She said she did not know what interventions were put into place to prevent Resident #7 from falling. She said she would just remind the resident to use her call light. LPN #2 was interviewed on 9/8/25 at 4:41 p.m. LPN #2 said if a resident had a fall the nurse would assess the resident for injuries, range of motion and take their vital signs. She said if the nurse suspected any kind of injury, an ambulance was called to transport the resident to the hospital. She said if the resident did not have an injury, the staff would get the resident up off the floor and contact the DON, the physician and the resident's representative. She said there were not many RNs that worked in the facility so the LPNs would assess the resident after a fall. She said she was not aware that a RN was required to assess residents after a fall. She said Resident #7 did not have any new fall interventions initiated after her last two falls (on 2/27/25 and 5/31/25). The DON was interviewed on 9/8/25 at 4:51 p.m. The DON said if she was in the facility at the time of a resident fall, she would accompany the LPN to assess the resident for injuries. She said on the night shift, the LPNs assessed the resident after a fall and if there were no injuries, the LPN would text her to let her know about the fall. She said if the resident sustained an injury, the LPN would call the physician and the physician would make the decision of what treatment needed to be ordered. She said she was not aware that a RN was required to assess a resident after a fall.Cross reference F727 for failure to have a RN in the facility for at least eight consecutive hours, seven days a week. The DON said following a fall, she and the social services director (SSD) would meet and try to put interventions in place after each fall and track the interventions. However, Resident #7's previous interventions were not tracked for their effectiveness. The DON said Resident #7 was not a frequent faller, but when she did fall, she sustained injuries. She said she was not sure why the facility did not put interventions in place after the resident's falls on 2/27/25 and 5/31/25.

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week.Specifically, the facility failed to use the services of a RN for at least eight consecutive hours a day for seven days a week.Findings include: I. Facility policy and procedure The Staffing policy, undated, was received from the director of nursing (DON) on 9/10/25. It documented in pertinent part, It is the policy of this facility to employ appropriately qualified staff that shall consist of registered nurses (RN) and licensed practical nurses (LPN), who maintain current licensure or certification in the state of Colorado, and also certified nurse aides. Adequate coverage shall be determined by routine staffing schedules with additional staffing needs to be determined at the discretion of the charge nurse, the DON or the nursing home administrator (NHA).II. Record review A review of the facility's April 2025, May 2025 and June 2025 nursing schedules revealed there was not a RN scheduled in the facility on for 4/12/25, 4/13/25, 4/27/25, 5/11/25, 5/25/25, 5/26/25, 6/17/25, 6/21/25, 6/22/25, 6/28/25 and 6/29/25.On 9/9/25 a review of emails sent back and forth from the facility's chief executive officer (CEO) to The Center for Medicare and Medicaid (CMS) revealed the facility had made attempts to reach out for a federal staffing waiver and failed to get a response from CMS on how to obtain a waiver. III. Staff interviews The DON was interviewed on 9/9/25 at 2:45 p.m. The DON said there was no RN in the building on the dates of 4/12/25, 4/13/25, 4/27/25, 5/11/25, 5/25/25, 5/26/25, 6/17/25, 6/21/25, 6/22/25, 6/28/25 and 6/29/25. The DON said she was on-call for those dates and there was also an on-call physician a block away from the facility, at the hospital. She said if a resident required an assessment to be completed by a RN, she was available over the phone to assist the LPN who was present in the building. The chief executive officer (CEO) and the DON were interviewed together on 9/10/25 at 10:30 a.m. The CEO said for as long as he was aware of, there had been no RN coverage seven days a week for eight consecutive hours each day at the facility. The CEO said the facility was actively trying to recruit and hire RNs to work at the facility. He said they had the job posted on several online job sites, had an advertisement on social media and in the local newspaper. He said the facility offered sign-on bonuses, they covered 80% of health insurance premiums and offered shift differentials for pay to try to get RNs hired. The CEO said agency RNs required up to 100 dollars/hour to cover shifts at the facility and if the facility were to rely on agency RNs, the facility would be at risk of closing. The CEO said the facility was not aware the state staffing waiver they were approved for did not cover the federal regulations until last year. He said since then, the facility had actively been seeking out a way to obtain a federal staffing waiver but that the federal agency (CMS) had not been able to offer a solution to them.

Based on observations, record review and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of one units. Specifically the facility failed to:-Ensure an effective process to identify residents who required enhanced barrier precautions (EBP); -Ensure staff were aware of which residents required EBP; -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who required EBP; and,-Ensure staff sanitized the rubber stop on an insulin pen before administering to Resident #17. Findings include: I. EBP failures A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 9/12/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs (multidrug resistant organisms). The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions policy, revised March 2024, was received from the director of nursing (DON) on 9/10/25 at 9:36 a.m. The policy read in pertinent part, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms in the facility. Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition and residents with wounds or indwelling medical devices. All staff received training on enhanced barrier precautions upon hire, annually, PRN (as needed) and are expected to comply with all designated precautions. All staff received training on high-risk activities and common organisms that require enhanced barrier precautions. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required PPE, and the high-contact resident care activities that require the use of gown and gloves. An order for enhanced barrier precautions will be obtained for residents with any of the following wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers); and, indwelling medical devices (central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, medical device care and use and wound care of any skin opening requiring a dressing. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. C. Observations On 9/8/25 at 10:26 a.m. Resident #5 was sitting in a recliner in her room. Licensed practical nurse (LPN) #1 washed her hands and put gloves on. LPN #1 disconnected Resident #5's tubing from the feeding tube. LPN #1 removed her gloves, used alcohol based hand rub (ABHR) and exited the resident's room. She returned to the resident's room with a drainage sponge and tape. She put on gloves and placed the drain sponge around the feeding tube insertion site. She taped the sponge in place. She retrieved water from the sink, filled the syringe with water, inserted the syringe into the feeding tube and flushed Resident #5's feeding tube with 30 ml (milliliters) of water. She removed her gloves and washed her hands. -The facility failed to identify Resident #5 required EBP and LPN #1 failed to put on PPE prior to providing care to Resident #5, who required EBP. On 9/9/25 at 8:21 a.m. LPN #2 was observed during medication administration. She entered Resident #5's room which had a EBP sign posted on the door and a PPE cart next to the entry of the door. LPN #2 washed her hands and put gloves on. She used a feeding syringe to push air into the feeding tube to check for placement. She flushed the feeding tube with 30 ml of water. She hung the feeding bag up and poured a carton of the resident's nutrition formula into the bag. She hooked the feeding bag tubing to the resident's feeding tube and opened the clamp to allow the formula to flow into the feeding tube. She washed her hands and put on clean gloves. She performed oral care for the resident. The feeding bag ran empty and LPN #2 poured water into the bag to flush the tubing and feeding tube. -LPN #2 failed to put on a gown. D. Staff interviews LPN #1 was interviewed on 9/8/25 at 10:40 a.m. LPN #1 said she did not know what EBP was or when a resident was required to be on EBP. She said she was not aware that PPE needed to be worn when giving care to a resident with a feeding tube. She said she never wore PPE when proving cares to Resident #5. LPN #2 was interviewed on 9/9/25 at 8:40 a.m. LPN #2 said Resident #5 was on EBP since she had a feeding tube. She said a gown and gloves were only required when performing incontinence care. She said she was not aware she needed to put on a PPE for device (feeding tube) care. She said she did not know during what care areas the PPE was required. LPN #2 was interviewed a second time on 9/9/25 at 4:41 p.m. LPN #2 said she was not aware that Resident #5 needed to be on EBP prior to her shift on the day of the interview. She said she had never heard of EBP. She said the DON provided education to her at the start of her shift. The DON was interviewed on 9/9/25 at 4:51 p.m. The DON said EBP had completely slipped her mind. She said residents who had any medical devices or openings to the body required EBP to protect the resident and staff from transmission of infectious organisms. She said once LPN #1 questioned her about EBP during the survey, she reached out to the medical director and initiated EBP for the resident. The DON and the chief executive officer (CEO) were interviewed together on 9/10/25 at 12:30 p.m. The DON said any resident with an indwelling medical device or chronic wound would require EBP. The DON said the personal protective equipment worn for residents on EBP was a gown, gloves and a face shield if there was risk for splashing. The DON said when staff performed any high risk care area they should be wearing PPE for residents on EBP. She said residents on EBP should have a physician's order for it and have it in their care plan. The DON said there were three residents currently on EBP in the building and they had implemented EBP in the building on 9/9/25. The DON said this was because it was recently identified that the facility needed to implement EBP. The DON said when it was identified that the building needed to implement EBP, she sent out a video to all staff and a quiz to complete, as well as a binder with a powerpoint of information located at the nurses desk. II. Failure to sanitize the rubber seal on an insulin pen A. Manufacturer's recommendations According to the Humalog (insulin lispro, which is a prefilled quick acting insulin pen) medication package insert (2022), retrieved on 9/16/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/020563s214,205747s038lbl.pdf, Humalog KwikPen is a disposable single-patient-use prefilled pen containing 300 units of Humalog. You can give yourself more than one dose from the pen. Each turn (click) of the dose knob dials one unit of insulin. Pull the pen cap straight off. Wipe the rubber seal with an alcohol swab. Check the liquid in the pen. Humalog should look clear and colorless. Do not use it if it is cloudy, colored, or has particles or clumps in it. Push the capped needle straight onto the pen and twist the needle on until it is tight. Pull off the outer needle shield. Do not throw it away. Pull off the inner needle shield and throw it away. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming, no more than four times. B. Observation and interview On 9/8/25 at 11:40 a.m. LPN #1 was preparing Resident #17's medications for administration. LPN #1 removed Resident #17's Humalog insulin pen from the medication cart. She attached a needle to the end of the rubber seal. She dialed the pen to 10 units of insulin. She went to Resident #17 in the dining room, wiped his left upper arm with an alcohol swab and administered the insulin to Resident #17. -LPN #1 failed to sanitize the rubber seal on the end of the insulin pen prior to attaching the needle to it. LPN #1 said she was told by another nurse when she received orientation that the only time insulin pens were primed at the facility was when they were opened for the first time. She said she had been a nurse at other facilities and they always primed the insulin pens prior to each administration of insulin. LPN #1 said she had not clarified the information she received from the other nurse regarding priming insulin pens with the DON. C. Additional staff interviews The DON was interviewed on 9/8/25 at 1:32 p.m. The DON said while preparing to administer an insulin pen, the nurse should wipe the rubber seal with an alcohol wipe, prime the pen, and then prepare to administer it to the resident. The DON said the importance of sanitizing the rubber seal is to ensure the nurse was not putting a clean needle onto a dirty surface, causing risk for infection.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in one of one medication carts and one of one medication storage rooms. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and,-Ensure expired medications were removed and discarded from medication carts.Findings include: I. Professional referencePharMerica (1/12/25) Abridged List of Medications with Shortened Expirations Dates, was retrieved on 9/15/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-[NAME]-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. it revealed in pertinent part, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's package insert under the 'How Supplied/Storage & Handling' section. A drug product's beyond use date (BUD) is the manufacturer supplied expiration date or the shortened date after opening whichever comes first.These in-use medications should be labeled such that the date opened is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration.The Pharmcare USA's (4/9/23) Medication Disposal Practices in Assisted Living and Long Term Care, was retrieved on 9/15/25 from https://pharmcareusa.com/education/medication-disposal-practices-in-assisted-living-ltc/#:~:text=As%20an%20experienced%20healthcare%20professional,a%20legal%20and%20ethical%20obligation. It revealed in pertinent part, When medications are not disposed of correctly, they can pose serious threats to both human health and the environment. Improper disposal can lead to accidental ingestions, overdose and even death.II. Failed to ensure medications were labeled with the date they were openedA. Observations and staff interviews On 9/9/25 at 9:15 a.m., the Main medication cart was observed with licensed practical nurse (LPN) #2. The following items were found: -An open inhaler of Trelegy 200 micrograms (mcg)/62.5 mcg/25 mcg (long term maintenance inhaler for asthma and chronic obstructive pulmonary disease) was labeled with a resident's name and dosage information, but no open date. -An open inhaler of Advair Diskus (long term maintenance inhaler for asthma and chronic obstructive pulmonary disease) 250 mcg/50 mcg was labeled with a resident's name, but no open date. LPN #2 said she thought the resident the Trelegy inhaler was prescribed for was admitted from assisted living and the medication came with her unlabeled. LPN #2 said she would dispose of the Trelegy inhaler and the Advair Diskus and ensure the residents who used them had a new one. III. Failed to ensure expired medications were removed and discarded from medication cartsA. Observations and staff interviews On 9/9/25 at 9:15 a.m., the Main medication cart was observed with LPN #2. The following items were found: -An open bottle of house stock Ibuprofen tablets 200 milligrams (mg) had an expiration date, verified with LPN #2, of August 2025. -An open bottle of house stock Senokot tablets 8.6 mg had an expiration date, verified with LPN #2, of August 2025.-A bag containing Bisacodyl rectal suppositories 10 mg, labeled with a specific resident's name, had an expiration date, verified with LPN #2, of 3/19/25. -An open bottle of Loteprednol-Tobramycin eye drops 0.5-0.3%, labeled with a specific resident's name, had an open date of 6/24/25 and expired 30 days after opening, verified with LPN #2. LPN #2 said she would dispose of the expired medications. She said night shift nurses were responsible for disposing of expired medications when they did medication change over with the pharmacy every two weeks. IV. Additional staff interview The director of nursing (DON) was interviewed on 9/9/25 at 10:30 a.m. The DON said the pharmacist conducted a monthly audit of the medication cart and the medication storage room. She said the night shift nurses were expected to audit the medication cart every two weeks when they changed over the medications with the pharmacy. The DON said labeling medications with the date the medication was opened was important so the nurses knew when medications should be disposed of. The DON said the importance of discarding expired medications was to ensure the residents were not receiving expired medications that could be too potent or not potent enough.

Based on observations, record review and interviews, the facility failed to provide nursing services according to accepted professional standards of clinical practice for two (#17 and #18) out of 18 residents reviewed out of 18 sample residents. Specifically, the facility: -Failed to transcribe physician's orders into the electronic medical record (EMR) correctly for Resident #17 and Resident #18; and,-Failed to notify a provider when Resident #17 had a change in condition and obtain a physician's order to hold a routinely scheduled medication Findings include: I. Failure to transcribe physician's orders into the EMR correctly A. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Hypoglycemia (Nursing) (12/26/22), retrieved on 9/16/25 from https://www.ncbi.nlm.nih.gov/books/NBK568695/#:~:text=It%20is%20the%20nurse's%20responsibility,possible%20side%20effects%20of%20hypoglycemia, Hypoglycemia is often defined by a plasma glucose concentration below 70 milligram (mg)/ deciliter (dl); however, signs and symptoms may not occur until plasma glucose concentrations drop below 55 mg/dl. It is the nurse's responsibility to assess for signs and symptoms of hypoglycemia and to report any abnormal findings. It is also the nurse's responsibility to assess that medications are taken as prescribed and report any possible side effects of hypoglycemia.B. Resident #171. Resident status Resident #17, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (autoimmune disease that affects the central nervous systems), type 1 diabetes and neuromuscular dysfunction of the bladder. The 6/30/25 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) score of three out of 15. 2. Observations and interviews On 9/8/25 at 11:40 a.m. licensed practical nurse (LPN) #1 was preparing Resident #17's medications for administration. LPN #1 checked Resident #17's blood sugar while he was in the dining room eating lunch. LPN #1 said the resident's blood sugar was 316 milligrams per deciliter (mg/dl).LPN #1 checked the physician's orders for sliding scale insulin and realized the physician's order did not reflect a blood sugar of 316 mg/dl. LPN #1 said Resident #17 came back from the hospital yesterday (9/7/25) with a new physician's order for Humalog and she had not transcribed it into the EMR correctly. She notified the director of nursing (DON) of the error and called the provider on call to clarify the order. 3. Record review A review of Resident #17's September 2025 CPO revealed the following physician's order: Humalog Kwikpen Solution pen-injector 100 units/milliliter (ml), inject as per sliding scale: if 136-180 mg/dl = 2 units, 181-225 mg/dl = 4 units, 226-270 mg/dl = 6 units, 271-315 mg/dl = 8 units, 321-360 mg/dl = 10 units. Blood sugar 50-70 mg/dl: give four ounces of juice or one cup of milk. Notify the on-call physician if the blood sugar is above 400 mg/dl, subcutaneously with meals for type 1 diabetes mellitus with other diabetic neurological complications, ordered 9/7/25 and discontinued 9/8/25.-The physician's order failed to include a blood sugar ranging from 316-320 mg/dl. C. Resident 18A. Resident status Resident #18, age less than 65, was admitted on [DATE] and discharged on 6/7/25. According to the June 2025 CPO, diagnoses included malignant neoplasm of the uterus (uterine cancer), acute kidney failure and hypertension (high blood pressure).The 5/27/25 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. B. Record review A review of Resident #18's September 2025 CPO revealed the following physician's orders: Morphine sulfate oral solution 100 mg/5 milliliters (ml), give 0.25 ml by mouth every four hours as needed for pain/restlessness, ordered 6/4/25 and discontinued 6/6/25. Morphine sulfate oral solution 100mg/5ml, give 2.5 ml by mouth every two hours as needed for pain/restlessness, ordered 6/6/25 and discontinued 6/9/25. -LPN #1 entered the order for Morphine as 2.5 ml instead of 0.25 ml (see interviews below).C. Staff interviews The DON and the chief executive officer (CEO) were interviewed together on 9/10/25 at 10:30 a.m. The DON said LPN #1 came to her when entering the morphine order into the computer. The DON said that LPN #1 did not check off the final check mark to complete an order to be able to push it through and make it an active order. The DON said she checked off the final checkmark in the order to make it an active order without double checking the order. She said the order should have been morphine sulfate, 0.25 ml every two hours, but instead was transcribed to 2.5 ml every two hours. The DON said every nurse checking off a physician's order should double check that the order matched exactly what was prescribed. The DON said there was an automated note that came after she signed off on the incorrect order that she did not see saying that the order was outside the recommended dose. The DON said that the next nurse on night shift brought it to the DON's attention, saying the order was incorrect. The DON said that the nurse confirmed she was going to correct the order. The DON said the order never was corrected and she did not know where the breakdown came from. The DON said she reviewed the controlled substance count sheet and confirmed that the dose of 0.25 ml was given each time. The DON said she confirmed the final count of the medication left was the correct amount. III. Failure to notify a physician when Resident #17 had a change in condition and obtain a physician's order to hold a routinely scheduled medicationA. Resident #171. Record review The 6/21/25 nursing progress note documented Resident #17's fasting blood sugar was low today. It was 53 mg/dl at breakfast and the nurse did not give Lantus. The blood sugar was within normal limits at lunch of 91mg/dl. This was on the provider note (see interview below). A review of Resident #17's September 2025 CPO revealed the following physician's order: Lantus subcutaneous solution, 100 units/ml (long acting insulin), inject 18 units subcutaneously in the morning related to type one diabetes mellitus with other neurological complications, ordered 1/24/25 and discontinued 6/24/25. 2. Staff interviews The DON and the CEO were interviewed together on 9/10/25 at 10:30 a.m. The DON said if a resident's blood sugar was outside of the normal limits, she would expect the provider on call to be notified right away. She said the provider note that the nurse was referring to in the progress note was a once daily note that was sent to the provider from the DON. The DON said this was a list of non-urgent items such as needing a stool softener. The DON said blood sugars outside of the normal limits should not be put on this list and should instead be called into the provider right away. LPN #2 was interviewed on 9/10/25 at 3:00 p.m. She said she would always notify the provider, the DON and the medical power of attorney (POA) right away if a resident experienced a change in condition. She said if she had a scheduled medication due and was unable to administer it to the resident, she would notify the DON and the provider.

Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#17) of one resident reviewed for significant medication errors out of 18 sample residents. Specifically, the facility failed to ensure that Resident #17 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Facility policy and procedureThe Medication Administration policy and procedure, revised 3/1/19, was received from the director of nursing (DON) on 9/10/25 at 8:55 a.m. It documented in pertinent part, The purpose of this policy is to administer medication as ordered by the resident's physician in a timely manner and with the highest degree of efficiency and safety to the resident.II. Manufacturer's recommendationsAccording to the Humalog (insulin lispro, which is a prefilled quick acting insulin pen) medication package insert (2022), retrieved on 9/15/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/020563s214,205747s038lbl.pdf, Humalog KwikPen is a disposable single-patient-use prefilled pen containing 300 units of Humalog. You can give yourself more than one dose from the pen. Each turn (click) of the dose knob dials one unit of insulin. Pull the pen cap straight off. Wipe the rubber seal with an alcohol swab. Check the liquid in the pen. Humalog should look clear and colorless. Do not use it if it is cloudy, colored, or has particles or clumps in it. Push the capped needle straight onto the pen and twist the needle on until it is tight. Pull off the outer needle shield. Do not throw it away. Pull off the inner needle shield and throw it away. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming, no more than four times.III. Resident #17A. Resident status Resident #17, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (autoimmune disease that affects the central nervous systems), type 1 diabetes and neuromuscular dysfunction of the bladder. The 6/30/25 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) score of three out of 15. The MDS assessment indicated the resident was on daily injection medication for diabetes. B. Observation and interview On 9/8/25 at 11:40 a.m. licensed practical nurse (LPN) #1 was preparing Resident #17's medications for administration. LPN #1 checked Resident #17's blood sugar while he was in the dining room eating lunch. LPN #1 said the resident's blood sugar was 316 milligrams per deciliter (mg/dl). LPN #1 removed Resident #17's Humalog insulin pen from the medication cart. She attached a needle to the end of the rubber stopper. She dialed the pen to 10 units of insulin. She went to Resident #17 in the dining room, wiped his left upper arm with an alcohol swab and administered the insulin to Resident #17. -LPN #1 failed to prime the Lantus insulin pen prior to drawing up the 10 units of insulin.LPN #1 said she was told by another nurse when she received orientation that the only time insulin pens were primed at the facility was when they were opened for the first time. She said she had been a nurse at other facilities and they always primed the insulin pens prior to each administration of insulin. LPN #1 said she had not clarified the information she received from the other nurse regarding priming insulin pens with the DON. C. Record review A review of Resident #17's September 2025 CPO revealed the following physician's order: Humalog Kwikpen Solution pen-injector 100 units/milliliter (ml), inject as per sliding scale: if 136180 mg/dl = 2 units, 181-225 mg/dl= 4 units, 226-270 mg/dl = 6 units, 271-315 mg/dl = 8 units, 316-360 mg/dl = 10 units. Blood sugar 50-70 mg/dl: give four ounces of juice or one cup of milk. Notify the on-call physician if the blood sugar is above 400 mg/dl, subcutaneously with meals for type 1 diabetes mellitus with other diabetic neurological complications, ordered 9/8/25.IV. Additional staff interviewThe DON was interviewed on 9/8/25 at 1:32 p.m. The DON said she had not worked on the floor in a while but she knew that insulin pens had to be primed to one or two units prior to dialing up the insulin dose on the pen and administering the dose of insulin. She said it was important to prime insulin pens to ensure the resident was administered the full correct dose of insulin. She said she was not aware of any nurses at the facility who were not priming the insulin pens prior to administration.-However, LPN #1 failed to prime Resident #17's insulin prior to administering the resident's insulin (see observation above).

Based on observations and interviews, the facility failed to maintain the emergency response cart and equipment in safe operating condition for one of one emergency response (crash) cart. Specifically, the facility failed to: -Ensure staff completed the daily equipment checks; -Ensure expired items were removed from the crash cart; and, -Ensure emergency oxygen canister on the emergency response cart was maintained and ready for use. Findings include: I. Professional references A. According to [NAME], [NAME], (2022). Crash cart preparedness and failure to rescue a case study review. Retrieved on 12/18/23, from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review and read in pertinent part, A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency. A crash cart is typically located in the setting of an unexpected medical emergency. This could include severe allergic reaction, cardiac or respiratory arrest, and conditions with an unexpected sudden deterioration of vital signs. This would require equipment located on the card cart which would be used by a credentialed life support provider. While crash carts vary depending on location, the fundamentals for the crash cart will contain similar equipment. Although the organization of requirements for a crash cart is not generic, there is a fundamental standard which provides effortless access to emergency medical equipment. Note that all these organizational points are checked, dated, and signed by the staff member who performed the daily routine inventory and inspection. Top shelf/drawer -The top section typically has the most frequently used equipment employed in a resuscitation event such as power cords and personal protective equipment. Side or rear -The oxygen cylinder should be secure on the side of the cart, with a full oxygen pressure level; -A suction apparatus/charging battery for the portable use; -A sharps container should be secure on cart; and, -A rigid plastic/fiberglass backboard for chest compressions. Recommended equipment and medications -Organization and location specific. Recommended maintenance -Check expiration dates on equipment and medications per organization policy and replace as required. Schedule inventory check The purpose of a crash cart inventory is to organize a schedule of when to check for expiration dates of equipment and supplies. Check that equipment is operating as required in the event of an emergency. In addition to recording who performed the inventory checks, with dates, times, and signatures. An alarming situation for the healthcare personnel requiring a crash cart is to find unusable equipment or expired medications in an emergency. Ensuring that an up-to-date, accurate, and truthful inventory record can avoid potential patient safety situations such as absence of equipment, equipment failure, expired or missing medication, and empty oxygen cylinders. The patient safety risk incident failure to rescue is perpetrated by healthcare professionals when they do not check cart accurately. Failure to follow standard or policy for checking equipment compromises patient safety and creates potential to harm patients. II. Facility policy The Nursing Home Crash Cart policy, issued 12/23, was received from the director of nursing (DON) on 12/13/23 at 12:18 p.m. and read in pertinent part, The DON will ensure the equipment is stocked in the E-Cart (emergency cart). The DON contacts the materials management clerk for the equipment supplies. The E-Cart will be inventoried and restocked after each use and checked at least monthly and documented by nursing staff. All emergency equipment in the E-Cart will be checked monthly by the DON. Once a month the E-Cart should be opened and checked for outdated supplies. Internal and external equipment should be checked by ensuring proper function of equipment. E-Cart checks should be documented on the lists maintained on the E-Cart. E-Carts will be maintained and supplied in accordance with the crash cart minimum requirements list which include respiratory equipment. III. Observations Crash cart #1 was observed on 12/12/23 at 9:02 a.m. The following items were found: -There was not a daily checklist on the cart; -One 100 milliliter (ml) bottle of sterile water, expired on 12/21; -Ambu (manual self-inflating resuscitator) bag, expired in 2013; -Midline catheter, expired on 12/31/2020; -Catheterization tray, expired on 2/13/2020; -Suction tubing, expired on 3/1/21; -Yankauer device (oral suctioning tool), expired on 7/19/17; -Yankauer device, expired on 7/31/23; -Three sets of sterile gloves, all expired in April 2020; -Sterile gloves, expired in August 2020; -Basic oxygen mask, expired on 6/31/23; -Carbon dioxide detector, expired on 7/9/19; -Carbon dioxide detector, expired on 7/11/2020; -Two suction tray kits, both expired on 2/13/2020; -Two boxes of standard gloves, expired in June 2015 and May 2015; and, -The oxygen canister on the cart did not have any oxygen in it. IV. Interviews The DON was interviewed on 12/12/23 at 11:39 a.m. The DON said she was responsible for completing the daily checklists for the crash cart. She said she would contact the supply department and have them go over everything on the crash cart and order new supplies. She said she would make sure the oxygen canister was replaced with a full canister immediately. The DON said it was important for the crash cart to be stocked with current ready to use supplies and equipment to be able to effectively resuscitate someone in the event of an emergency. Licensed practical nurse (LPN) #1 was interviewed on 12/13/23 at 10:04 a.m. She said she did not know who was responsible for checking the crash cart or the items on it. She said she was not instructed to do so. She said the crash cart should have all of the supplies required to be able to use if someone had an emergency and needed to be revived.

Based on observations and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) on one of one unit. Specifically, the facility failed to: -Ensure staff wore and removed personal protective equipment (PPE) correctly; and, -Ensure infection control practices were followed during medication pass. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019, retrieved 12/18/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Source control options for HCP (healthcare personnel) include a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filter or higher. Source control is recommended for individuals in healthcare settings who: Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances: By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over ( no new cases of SARS-CoV-2 infection have been identified for 14 days); Eye protection (goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters. I. Facility policy The Infection Control policy, issued 5/1/21, was received from the director of nursing (DON) on 12/13/23 at 12:18 p.m. The policy documented in pertinent part, This facility has established and maintains 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. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. II. Failure to ensure staff doffed (removed) and donned (put on) PPE properly for COVID-19 isolation rooms A. Observations The two Covid-19 isolation rooms were observed on 12/11/23 at 9:56 a.m. Two isolation carts were noted in front of resident rooms and both of the rooms had clear plastic zippered material covering the doorways. At 9:57 a.m. certified nurse aide (CNA) #1 and CNA #2 prepared to enter the room. CNA #1 put on a yellow cloth gown and gloves and entered the room. She was wearing the same surgical mask she had been wearing previously. CNA #2 removed her surgical mask and set it on the table outside of the room. She put on a yellow cloth gown, gloves and a new surgical mask and entered the room with CNA #1. Both CNA #1 and CNA #2 assisted the isolated resident with toileting. At 10:08 a.m., CNA #1 and CNA #2 exited the room. They both had removed their yellow cloth gowns in the room. Upon exiting the room, the CNAs rolled up the gowns and put them back in the storage bin outside of the room. They removed and disposed of their gloves in the room. CNA #1 asked CNA #2 if they were reusing the yellow gowns and CNA #2 responded that they were and that is why they put them back in the storage bin. CNA #1 left the area. CNA #2 disposed of the surgical mask that she was wearing inside the room and put on the original surgical mask that she had left on the table outside of the room. On 12/12/23 at 2:39 p.m., licensed practical nurse (LPN) #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. On 12/12/23 at 2:41 p.m., LPN #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. On 12/13/23 at 9:37 a.m., LPN #1 was observed sitting at the nursing station. She had a surgical mask under her chin. It was not covering her nose or mouth. B. Interviews CNA #2 was interviewed on 12/11/23 at 10:10 a.m. She said there were two rooms on isolation precautions for positive Covid-19 tests. She said the room she just exited would be coming off of isolation in the next couple of days. She said all staff should be wearing N95 masks but since the isolation was almost over she did not think it was important. She said the CNA's had to reuse the isolation gowns and that was why she put her gown back in the container after she exited the room. The DON was interviewed on 12/11/23 at 10:50 a.m. She said Covid-19 positive residents were placed on a ten day isolation. She said the correct process for entering an isolation room was to perform hand hygiene, don a gown, gloves and N95 mask. Upon exiting the room, she said all of the PPE should be removed in the room and put into a red biohazard bag before exiting. Once staff was outside of the room the red bag should be placed in a specific trash can and the staff should perform hand hygiene again. She said it was not appropriate to wear a surgical mask when providing care inside an isolation room or to reuse the gowns. She said she would re-educate staff on the proper technique for PPE. The DON was interviewed again on 12/13/23 at 9:56 a.m. She said all of the staff had been told they were required to wear a surgical mask covering their nose and mouth unless they were in the break room to eat. She said it was important for staff to follow proper mask procedures to avoid contamination and spread of the Covid-19 virus. Licensed practical nurse LPN #1 was interviewed on 12/13/23 at 10:04 a.m. She said she was aware of the mask mandate for the facility that was currently being required due to the Covid-19 outbreak. She said all staff and visitors were to wear masks covering their nose and mouths at all times. She said masks should be worn properly even if the nurse was sitting at the nurses station. III. Failure to follow infection control practices during medication pass A. Observations Licensed practical nurse (LPN) #1 was observed on 12/12/23 at 11:54 a.m. during medication administration. She had just returned from a meeting with the DON when she approached the cart and began preparing medications for a resident. -She did not sanitize her hands prior to getting a medication cup and dropping the medications in it. LPN #1 carried the medication cup to the resident in the dining room and the resident put the cup to her lips to take the medications. LPN #1 took the medication cup back from the resident and threw it away in the trash can. She returned to the medication cart and got another medication cup to begin preparing the medication for the next resident. -She did not sanitize her hands prior to preparing the next resident's medications She carried the medication cup to the resident in the dining room and the resident put the medication cup to her lips to take the medication. LPN #1 took the medication cup back from the resident and threw it in the trash. At 11:58 a.m., LPN #1 took the medication cup back from a resident in the dining room and threw it in the trash. She proceeded to touch a handheld radio, scratch her head, use the computer mouse and unlock the medicine cart with her keys. She then got a medication cup and began putting the medications in the cup for the next resident. -She did not sanitize her hands prior to preparing the next resident' s medications At 12:00 p.m., LPN #1 administered medications mixed with applesauce to a resident in the dining room. She used a spoon to administer the medications to the resident After the resident ingested the medications she threw the medication cup and spoon into the trash can. She returned to the medication cart and unlocked the cart using her keys. She got a medication cup and began dropping the medications into the medication cup for the next resident. -She did not sanitize her hands prior to preparing medications for the next resident. She took the medication cup to the resident who put the medication cup to their lips to take the medications. LPN #1 took the cup back from the resident and threw it in the trash. -Without sanitizing her hands, LPN #1 then got another resident a cup of coffee from the kitchen and gave it to the resident. At 12:07 p.m., LPN #1 prepared and administered medications in a medication cup to another resident in the dining room. She threw the medication cup in the trash and returned to the medication cart. She got a new medication cup from the cart and began preparing medications for the next resident. She put the medications in the medication cup with some applesauce, took it to the resident and administered it. She then threw the medication cup and spoon in the trash and returned to the medication cart. -She did not sanitize her hands prior to preparing the medications for the next resident. At 12:16 p.m., LPN #1 began preparing medications for the next resident. An alarm began sounding at the nurses station so she walked to the nurses station and pushed a button to cancel the alarm. She returned to the medication cart and placed a medication cup on top. The alarm began sounding again so she returned to the nurses station and pushed the button again to cancel the alarm. She returned to the medication cart and continued to prepare the medications for the next resident in the dining room. -She did not sanitize her hands after touching the button on the alarm at the nurses station She carried the medication cup to the resident in the dining room and the resident placed the cup to their lips to take the medications. LPN #1 took the medication cup back and threw it in the trash. -She did not sanitize her hands prior to preparing the next resident's medications. At 12:20 p.m., LPN #1 delivered a medication cup to a resident in the dining room. The resident placed the medication cup to his lips to take the medication. LPN #1 took the medication cup back and threw it in the trash. She walked back to the medication cart, got a medication cup and placed it on top of the cart. She unlocked the medication cart with her keys and began preparing the medication for the next resident. -She did not sanitize her hands prior to preparing the next resident's medications She carried the medication cup to the resident and he refused to take the medication. LPN #1 returned to the medication cart and put the medication in the medication waste container and threw the medication cup away. B. Interviews The DON was interviewed on 12/13/23 at 9:56 a.m. She said all staff were expected to wash their hands or use hand sanitizer between each medication pass. She said staff should use hand sanitizer before getting the medications, after taking the medication to the resident and again before starting the next resident. She said it was important to perform hand hygiene to prevent the spread of pathogens from one resident to the next. LPN #1 was interviewed on 12/13/23 at 10:04 a.m. She said nursing staff should use hand sanitizer between each resident during medication administration. She said failure to perform hand hygiene between each resident could result in germs spreading from resident to resident.

Based on observations, record review, and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#12) of four residents reviewed for nutrition out of 15 sample residents. The facility failed to identify and implement appropriate interventions to prevent a significant weight loss for Resident #12. On 2/20/22, the resident weighed 165.4 pounds (lbs). On 8/14/22, the resident weighed 144.1 lbs, which was a loss of 21.3 pounds in six months. During the six month time frame, the facility failed to reassess Resident #12's nutritional supplement for effectiveness, despite nutrition assessments which indicated the resident was malnourished. The facility's failure to reassess Resident #12's nutritional status resulted in the resident sustaining a significant weight loss of 12.88% in six months. In addition, Resident #12 sustained two pressure injuries during that same six month timeframe.Cross-reference F686 Treatment/Services to Prevent/Heal Pressure Ulcers Findings include: I. Facility policy and procedures The Weight Monitoring policy, dated January 2022, was provided by the nursing home administrator (NHA) on 8/31/22 at 8:45 a.m. It read in pertinent part, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should be updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new cause of nutrition-related problems are identified. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. The physician should be informed of a significant change in weight and may order nutritional interventions. The registered dietitian (RD) or dietary manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. II. Resident status Resident #12, age 76, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/10/22 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 10 out of 15. She was totally dependent on the assistance of two staff members for bed mobility, transfers, dressing, and toilet use. She was totally dependent on the assistance of one staff member for personal hygiene. The resident had had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a prescribed weight loss regimen. The 7/10/22 MDS assessment further revealed the resident had two stage 2 pressure ulcers. III. Record review Review of Resident #12's nutrition care plan, initiated 11/11/19 and last revised 7/14/22, revealed that the resident had a potential nutritional problem related to diabetes, vitamin D deficiency, gout, [CONDITION(S)], heart failure, and impaired vision. Pertinent interventions included offering snacks between meals, providing alternate menu choices, providing supplements as ordered: 4 oz of 2.0 supplement two times per day, providing diet as ordered, RD evaluating and making diet change recommendations as needed, and weighing the resident per policy or as ordered and notifying the RD or MD of any significant changes. -The care plan was not updated in July 2022 to include the intervention of increasing the resident's nutritional supplement to 4 oz three times per day (see below). Review of the Resident #12's documented weights from 2/20/22 through 8/28/22 were as follows: -2/20/22: 165.4 lbs; -There were no weights recorded from 2/20/22 until 3/9/22; -3/9/22: 168.7 lbs; -3/13/22: 170.4 lbs; -3/20/22: 163.7 lbs; -There were no weights recorded from 3/20/22 until 4/3/22; -4/3/22: 163.4 lbs; -4/10/22: 164.6 lbs; -4/17/22: 159.7 lbs; -4/24/22: 152.9 lbs; -5/1/22: 156.1 lbs; -5/8/22: 155.3 lbs; -There were no weights recorded from 5/8/22 until 5/19/22; -5/19/22: 153.9 lbs; -5/22/22: 163.9 lbs; -5/29/22: 163.7 lbs; -6/6/22: 148.5 lbs; -6/12/22: 149.3 lbs; -6/19/22: 150 lbs; -6/26/22: 142.7 lbs; -7/3/22: 143.5 lbs; -7/10/22: 147.6 lbs; -7/17/22: 142.5 lbs; -7/24/22: 147.5 lbs; -8/1/22: 143.1 lbs; -8/3/22: 143.1 lbs; -8/7/22: 143.2 lbs; -8/14/22: 144.1 lbs; -8/21/22: 141.5 lbs; and, -8/28/22: 145.1 lbs. -The weights revealed Resident #12 had a significant weight loss of 12.88% in six months between the dates of 2/20/22 and 8/14/22. -Despite documentation indicating the resident continued to lose weight, the facility did not increase her nutritional supplement to three times per day until 7/27/22, after she sustained a 17.9 lbs weight loss. Review of Resident #12's August 2022 CPO revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2.0 supplement 4 oz three times a day. The order had a start date of 7/27/22. This order was discontinued on 8/29/22 when the supplement was increased (see below). 2.0 supplement 6 oz three times a day. The order had a start date of 8/30/22 (during the survey). Pro-Stat Liquid 30 milliliters (ml) by mouth two times a day for open wounds. The order had a start date of 8/18/22. Review of Resident #12's meal intakes from February 2022 through August 2022 revealed her intakes were inconsistent and varied greatly. Documentation showed the resident would eat less than 25% at times, and at other times she would eat 25-100% of her meals. Review of Resident #12's nutritional supplement intakes from February 2022 through August 2022 revealed she consistently consumed 100% of the supplement. -Despite documentation that the resident consumed 100% of her nutritional supplement consistently, the supplement was not increased to three times per day until 7/27/22. Review of Resident #12's electronic medical record (EMR) revealed the following quarterly Mini Nutritional assessments: 2/1/22: The assessment documented the resident was at risk for malnutrition with a score of eight out of 14 (a score of seven or below indicated the resident was malnourished). The assessment further documented the resident had had a moderate decrease in food intake in the prior three months. -Despite the assessment indicating the resident was at risk for malnutrition, the facility did not increase her supplement or make other dietary changes in an attempt to prevent the resident from losing weight. 5/5/22: The assessment documented the resident was malnourished with a score of five out of 14. The assessment further documented the resident had had a moderate decrease in food intake and a weight loss of 6.6 lbs or more in the prior three months. -Despite the assessment indicating the resident was malnourished, the facility did not increase her supplement or make other dietary changes in an attempt to prevent the resident from losing weight. 7/14/22: The assessment documented the resident was malnourished with a score of seven out of 14. The assessment further documented the resident had had a moderate decrease in food intake and a weight loss between 2.2 lbs and 6.6 lbs in the prior three months. -Despite the assessment indicating the resident was malnourished, the facility did not increase her supplement in an attempt to prevent the resident from losing weight until 7/27/22. Review of Resident #12's EMR revealed the following RD progress notes, documented in pertinent part: 3/29/22: Nutrition note: Current body weight is 163.7 pounds, weight stable times 30 days. Continues with Stage 2 area to left heel. Regular diet, oral intakes 25-100% with poor to good fluid intakes. May need more assistance with meals; eats very slowly but was trying to eat food that wasn't in the particular spot of her plate. Needs some cueing of where food is. Offered 4 oz supplement two times per day (480 kilocalories, 20 grams of protein) - takes 100% daily. Supplement will aid in meeting nutrition needs. Will continue the plan of care and monitor. 6/6/22: Nutrition note: did strike out most recent weight as it was 149 lbs and previous weight was 163.7 lbs; note that there is a four week period from 4/24/22 to 5/19/22 where weights are questionable and causing significant weight triggers; otherwise those weights are right and the 160 weights are wrong. Oral intake has declined eating less than 50% at most meals, sometimes more. Has a doctor's appointment due to decline. She is refusing to open her mouth for medications. Offered 4 oz supplement two times per day (480 kilocalories, 20 grams of protein). The last couple of days she is not taking it as well. Continues with Stage 2 area to left heel and new area Stage 1 to sacrum. Will continue to monitor at this time and await results of provider appointment today. Will follow up to see how she is doing. -There was not a follow up progress note from the RD after the resident's doctor's appointment and the nutritional supplement was not increased until 7/27/22 despite the concern of the resident's weight loss. 7/22/22: Nutrition note: Height: 62 inches, current body weight (7/17/22): 142.5 pounds. Body Mass Index is 26.1, indicating overweight status. Significant weight loss noted. Regular diet, mechanical soft texture, honey consistency. Oral intakes approximately 25% at most meals,with occasional refusals. Supplement: two times per day, accepting well, one refusal noted. No chewing/swallowing problems noted. Skin: pressure ulcer to left buttock. No [CONDITION(S)] noted per nursing. No new labs to note. Recommend increasing supplement to three times per day to provide additional 360 kilocalories and 15 grams of protein. Also provide fortified meals. Will continue to monitor weight trends, oral intakes, and supplement acceptance. Notify RD of significant changes or concerns. 8/1/22: Nutrition Note: current body weight: 143.1 pounds. BMI 26.2, indicating overweight. Significant weight loss triggered, however, weight seems to be stable for 30 days. Regular diet, mechanical soft texture, honey consistency. Oral intakes are varied but approximately 25% at most meals, with occasional refusals. Fluids with meals 0-850 ml, several refusals noted. Supplement: 4 oz three times per day, accepting well, one refusal noted. No chewing/swallowing problems noted. Skin: pressure ulcer to left buttock has slough present, starting to show signs of tunneling. No [CONDITION(S)] noted per nursing. Will fax provider to recommend 30 cc ProStat two times per day to see if this aids with wound healing. Continue plan of care. Will continue to monitor weight trends, oral intakes, and supplement acceptance. Notify RD of significant changes or concerns. 8/15/22: Nutrition Note: current body weight: 144.1 pounds; up 1.1% over 30 days. BMI 26.4, indicating overweight. Significant weight loss triggered over 180 days,however, weight seems to be stable over 30 days. Regular diet, mechanical soft texture, honey consistency. Oral intakes are varied but have improved since last review, ranging 0-100%. Fluids with meals 0-720 ml. Supplement: 4 oz three times per day, accepting well. No chewing/swallowing problems noted. Skin: pressure ulcer to left buttock has worsened per nursing. No [CONDITION(S)] noted per nursing. Will continue to monitor weight trends, oral intakes, and supplement acceptance. Notify RD of significant changes or concerns. IV. Interviews The registered dietitian (RD) was interviewed on 8/29/22 at 1:55 p.m. The RD said she had only worked at the facility since July 2022, so she could not accurately speak to what had occurred to contribute to Resident #12's significant weight loss. She said she knew the facility had been struggling to find a consistent RD. She said the resident's meal intake varied and so it was hard to predict how she would eat. She said in addition to her poor nutritional status, the resident also had developed two pressure wounds. The RD said according to the resident's EMR, she had been receiving 4 oz of a nutritional supplement two times per day since at least January 2022. She said the facility had added fortified meals, adding an extra protein and calorie powder, to her nutrition plan in June 2022. The RD said she had increased the resident's nutritional supplement to 4 oz three times per day, and added Prostat for wound healing in August 2022. She said the resident usually drank most of her supplements. The RD said Resident #12's intakes and weight loss should have been tracked by a RD or the physician at least every two weeks to prevent the significant weight loss. She said, according to the resident's EMR, she was only seen by a RD every two to three months between January and May of 2022. The RD said the facility/physician should have monitored the resident's weight loss and increased the nutritional supplement and added fortified meals sooner than they did in order to try to prevent the resident's significant weight loss. The RD said the resident's weight had been stable and was beginning to increase since the nutritional supplement had been increased to three times per day. Dietary aide (DA) #2 was interviewed on 8/30/22 at 8:36 a.m. DA #2 said Resident #12 did not always eat very well. She said how much the resident ate was dependent on her mood. She said the resident would sometimes allow staff to assist her with eating, however she would get upset with staff if they bothered her too much. Certified nurse aide (CNA) #2 was interviewed on 8/30/22 9:00 a.m. CNA #2 said Resident #12 had a wound on her left heel and a wound on her buttocks. He said the resident did not always eat well. He said staff would try to assist and encourage her when she did not eat. CNA #3 was interviewed on 8/30/22 at 9:10 a.m. CNA #3 said Resident #12 would generally eat if staff assisted her or encouraged her. He said she had a supplement that she usually drank all of. He said she had a wound on her left heel and one on her buttocks. RN #1 was interviewed on 8/30/22 at 10:45 a.m. RN #1 said Resident #12 had two pressure ulcers. She said the resident did not always eat very well, and staff would try to encourage her or assist her with eating. She said the resident would sometimes accept assistance with eating, however, she said it depended on the mood the resident was in. RN #1 said the resident received a nutritional supplement which had recently been increased to three times per day, in addition to being increased from a four ounce (oz) serving to a six oz serving. She said the resident usually drank most of her nutritional supplement. RN #1 said the resident had also recently been started on Prostat (a liquid protein medical food) to assist with wound healing. The NHA was interviewed on 8/30/22 at 2:03 p.m. The NHA said the facility had been experiencing some difficulties with obtaining a consistent RD over the previous several months which coincided with the time that Resident #12 sustained her significant weight loss. She said the facility had recently hired a RD, and the resident's weight was beginning to improve. The NHA said resident weights were obtained on Sundays. She said the charge nurse should monitor the weights in order to identify resident weight loss. She said if a charge nurse identified a weight loss concern for a resident, the nurse should notify the NHA and she would then notify the dietician, consultant, and the physician. The NHA said physicians should always be notified when a weight loss occurred. She confirmed that there was no documentation in Resident #12's EMR to indicate the physician had ever been notified regarding the resident's weight loss. The NHA said the facility should have been more proactive in notifying Resident #12's physician about her weight loss and monitoring the nutritional interventions put in place for the resident in order to prevent a significant weight loss. She said the resident's nutritional supplement should have been increased sooner than it was in an attempt to prevent the weight loss.

Based on resident observation, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for one (#12) of one resident with a pressure ulcer out of 15 sample residents. Resident #12, who was totally dependent on the assistance of two staff members for bed mobility, transfers, dressing, and toilet use, was known to be at risk for skin impairment due to her immobility, poor nutrition, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility initially classified the pressure injury as a stage 2 pressure injury, despite documentation indicating the wound was covered by eschar (dead/necrotic tissue) which would classify the wound as an unstageable pressure injury as indicated by staff interviews. The facility had provided the resident with a standard pressure reducing mattress (the facility was unable to provide the stage of pressure injury prevention the mattress was rated for) which was provided for all residents upon admission to the facility. Additionally, the facility implemented a left heel protector bootie for the resident. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident developed [CONDITION(S)] to the surrounding skin of the left heel wound and was treated with antibiotics from 7/29/22 through 8/12/22. On 6/3/22, Resident #12 developed a stage 1 pressure injury to her sacrum. On 6/17/22, the physician's assistant (PA), who provided wound care for the facility, documented the sacral wound had worsened to a stage 2 pressure injury. The sacral wound continued to be classified as a stage 2 wound, with stable measurements. On 6/30/22, the PA documented the wound was improving. On 7/7/22 through 7/9/22, Resident #12 was hospitalized for [CONDITION(S)] following a fall at the facility. Upon the resident's return from the hospital, the depth of the sacral wound had increased, and the PA documented the wound had worsened. Despite evidence that the sacral wound had worsened during the resident's hospital stay, the PA documented the wound continued to be a stage 2 pressure injury. The facility implemented a low air loss mattress following the resident's return from the hospital. Despite the facility placing a low air mattress as an intervention, Resident #12's wound continued to worsen. The wound was classified as a stage 3 pressure injury on 7/29/22, and eventually classified as a stage 4 pressure injury on 8/19/22 (despite documentation that the depth measurement of the wound was the same as when the resident had returned from the hospital on 7/9/22). In addition to the inconsistent and inaccurate wound documentation, there were no weekly wound assessments in Resident #12's electronic medical record (EMR) for the left heel wound from 4/22/22 until 6/3/22, 6/10/22, from 6/30/22 until 7/15/22, and 8/26/22. There was no weekly wound assessment documentation for the sacral wound for 6/10/22, from 6/30/22 until 7/15/22, and 8/26/22. Additionally, Resident #12 had poor nutrition that the facility failed to address appropriately. The poor nutrition potentially contributed to the poor healing of the resident's wounds. Cross-reference F692 Nutrition/Hydration Status Maintenance. Due to the facility's failures, including inconsistent and inaccurate weekly wound assessments, Resident 12's wounds increased in size and/or failed to progress towards healing as anticipated. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 9/7/22, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover ' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (9/7/22), Interventions for Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nutrition for Pressure Ulcer Prevention and Treatment Multivariable analyses of epidemiological data indicate that a poor nutritional status, indicated by low body weight or poor dietary intake among other signs, is a factor that impacts upon pressure ulcer risk. All individuals at risk of pressure ulcers should have their nutritional status screened. A comprehensive assessment should be conducted where risk of malnutrition is identified, and in individuals with existing pressure ulcers. Repositioning and Early Mobilization Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Repositioning to Prevent and Treat Heel Pressure Ulcers Heel pressure ulcers are a challenge to prevent and manage. The small surface area of the heel is covered by a small volume of subcutaneous tissue that can be exposed to high mechanical load in individuals on bedrest. It is important to conduct regular inspection and correct positioning in order to relieve heel pressure while avoiding potential complications such as Achilles tendon damage, foot drop and deep vein [CONDITION(S)] (DVT). Support Surfaces Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. II. Facility policy and procedure The Pressure Ulcer policy, dated 1/20/21, was provided by the nursing home administrator (NHA) on 8/31/22 at 8:45 a.m. It read, in pertinent part, The purpose of this policy is to maintain the integrity of residents ' skin, a significant factor in health, minimize the risks and prevent the occurrence of skin breakdown, provide for early detection and intervention of all breakdown evident upon admission to the nursing home, and to promote prompt evaluation and intervention of any changes in skin integrity. It is the policy of this facility that nursing, in collaboration with the health care team, will assess and manage skin integrity of all residents. The care and intervention for any identified skin breakdown or wound will be aimed at prevention of any further advancement of the wound, or additional breakdown, implementation of appropriate evidence-based care indicated for the problem identified, collaboration with the interdependent and interdisciplinary health care teams regarding the presence of breakdown and the intervention plan, and close monitoring of the response to treatment. A care plan will be initiated to include cognitive changes or impairment of the patient, current state of skin integrity, interventions to prevent further breakdown, and notification of the dietary manager/dietitian. III. Resident status Resident #12, age 76, was admitted on [DATE], and readmitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/10/22 minimum data set (MDS) assessment, which was conducted upon the resident's return from the hospital, revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 10 out of 15. She was totally dependent on the assistance of two staff members for bed mobility, transfers, dressing, and toilet use. She was totally dependent on the assistance of one staff member for personal hygiene. The 7/10/22 MDS assessment further revealed the resident had two stage 2 pressure ulcers. IV. Resident observations On 8/28/22 at 4:56 p.m., Resident #12 was seated in her wheelchair watching television in her room. She had a heel protector bootie on her left foot. There was a cushion in her wheelchair and a low air loss mattress on her bed. On 8/29/22 at 9:07 a.m., Resident #12 was lying in bed on her right side. She had a low air loss mattress on the bed, however she was lying on top of all of the bed covers, which placed an extra amount of material between the resident and the beneficial attributes of the low air loss mattress. The resident had a heel protector boot on her left foot. On 8/30/22 at 9:03 a.m., Resident #12 was in bed, lying on her right side. She was again lying on top of all of the bed covers. She had a heel protector bootie on her left foot and a pillow between her legs. V. Wound care observations and interview On 8/30/22 at 10:25 a.m., the wound care for Resident #12's left heel wound and sacral wound was observed with registered nurse (RN) #1 and the nurse practitioner (NP) who was covering for the PA that normally conducted the weekly wound care for the facility. The NP observed the wounds, but did not assist with the wound care. Resident #12 was in bed, lying on her left side, again on top of all the bed covers. RN #1 began by explaining what she was going to do to the resident. Resident #12 was agreeable to having her wound treatments conducted. RN #1 proceeded to wash her hands with soap and water before putting on a pair of gloves. She removed Resident #12's left heel protector bootie and sock. There was no dressing on the resident's left heel wound. RN #1 said the PA had recently recommended that the left heel wound be left open to air with no dressing. The wound to Resident #12's left heel wound was the size of a 50-cent piece. The entirety of the wound was covered with loose, black eschar, and slough was visible on the surrounding edges of the wound. The stage of the wound was unable to be determined due to the eschar covering the wound. The surrounding skin was intact. There was no redness present to the surrounding skin. After cleaning the wound with wound cleanser, RN #1 removed her gloves, sanitized her hands with soap and water, and put on a new pair of gloves. RN #1 then proceeded to measure the left heel wound. RN #1 said the wound measured 2.5 centimeters (cm) by 3.0 cm. She said she could not determine the depth of the wound because of the eschar covering the wound. RN #1 said the wound had had the eschar covering it since Resident #12 first developed the wound on 3/23/22. She said she was not sure what the PA had initially staged the wound as, however, she said it should have been classified as an unstageable wound due to the presence of the eschar covering the wound. After measuring the wound, RN #1 put Resident #12's sock and heel protector bootie back on, leaving the wound without a dressing. She proceeded to remove her gloves, wash her hands with soap and water, and then put on a new pair of gloves. RN #1 proceeded to remove the old dressing, dated 8/26/22, from Resident #12's sacral wound. The dressing had a moderate amount of serosanguineous (thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) drainage on the old dressing. The wound had a slight odor once the dressing was removed. The wound was located at the top and just slightly to the right of the gluteal cleft. The wound was the approximate size of an egg. There was a large area of [CONDITION(S)] (redness) surrounding an open area approximately the size of a 50-cent piece. There was a band of healing scar tissue between the open area and the surrounding redness. There was a small area of slough (yellowish dead tissue) at the top of the wound. The open part of the wound had discernible depth. RN #1 said the sacral wound had initially started as a stage 1 wound. She said it was red, but the skin had been intact. She said the physician was notified and recommended monitoring and keeping the resident off of the wound area. RN #1 said the wound opened up within a few days and had gradually gotten worse. She said she would classify the current wound as a stage 4 wound. RN #1 said the wound was slowly beginning to heal. RN #1 removed her gloves, washed her hands with soap and water, and put on a new pair of gloves. She proceeded to clean the sacral wound with wound cleanser. After cleaning the wound, RN #1 removed her gloves, washed her hands with soap and water, and put on a new pair of gloves. She then proceeded to measure the size of the sacral wound. RN #1 said the wound, including the area of [CONDITION(S)], measured 6.0 cm by 5.4 cm. She said the open area of the wound measured 2.5 cm by 1.5 cm, with a depth of 2.2 cm. After measuring the wound, RN #1 removed her gloves, washed her hands with soap and water, and put on a new pair of gloves. She proceeded to apply collagen powder to the open area of the wound and covered the entire wound with a foam dressing dated 8/30/22. After covering the wound with the dressing, RN #1 removed her gloves, washed her hands with soap and water, and exited Resident #12's room. VI. Record review Review of Resident #12's Braden Scale assessment (a tool used to predict a resident's risk of developing pressure injuries) dated 7/11/22 revealed that the resident was at moderate risk for developing a pressure injury. Review of Resident #12's pressure ulcer care plan, initiated 4/26/22 and revised 7/11/22, revealed the resident had a pressure ulcer to her left heel, a stage 2 pressure ulcer on her sacrum (6/3/22), and a potential for pressure ulcer development related to immobility. Pertinent interventions included administering treatments as ordered and monitoring for effectiveness, offloading the resident's heels at all times, encouraging the resident to wear a heel protector boot on her left foot, educating the resident/family/caregivers as to causes of skin breakdown including transferring/positioning requirements, good nutrition and frequent repositioning, following facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -The care plan was not revised to include the specific low air loss specialty mattress when the intervention was implemented in July 2022. -The care plan documented the resident's sacral pressure ulcer, which developed on 6/3/22, was a stage 2 pressure ulcer, despite the PA staging the wound as a stage 1 pressure ulcer when it first developed. Review of Resident #12's August 2022 CPO revealed the following physician's orders: 2.0 supplement 4 oz three times a day. The order had a start date of 7/27/22. This order was discontinued on 8/29/22 when the supplement was increased (see below). 2.0 supplement 6 oz three times a day. The order had a start date of 8/30/22 (during the survey). [MEDICATION(S)] (an antibiotic) tablet 600 mg by mouth two times a day related to other skin changes for 14 days. The order had a start date of 7/29/22 and was discontinued following completion of the antibiotics on 8/12/22. -However, according to the nurses progress notes (see below) the antibiotic was ordered for the resident's left heel wound [CONDITION(S)]. Pro-Stat Liquid 30 milliliters (ml) by mouth two times a day for open wounds. The order had a start date of 8/18/22. Dressing change to sacral wound: cleanse area, measure, apply Collagen to bed of wound and cover with [MEDICATION(S)] sacral dressing on bath days, every Tuesday and Friday. The order had a start date of 8/5/22. Review of Resident #12's electronic medical record (EMR) revealed the resident was admitted to the hospital for [CONDITION(S)] following a fall on 7/7/22 through 7/9/22. -The hospital records documented the hospital was aware of the resident's left heel wound, however, the hospital did not document any awareness of the resident's existing sacral wound throughout the resident's three day stay in the hospital. The Nursing Admission Screening assessment conducted upon Resident 12's readmission to the facility on [DATE] documented the resident continued to have the previously existing wounds to her left heel and sacrum. -The assessment did not document the measurements or stage of the wounds upon the resident's readmission. Review of Resident #12's EMR revealed the following weekly wound assessments for the resident's left heel wound: 3/25/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: First observation, no impression, no percentage of necrotic tissue present in the wound. Length: 5.0 cm Width: 5.0 cm Depth: 1.0 cm Treatment: No dressing needed at this time. Keep foot in a padded boot at all times and be sure to float heels when in bed. Evaluation: First observation Other comments: Stable eschar (dead/necrotic tissue) with normal appearing tissue surrounding the border. Keeping pressure off this heel is critical for its healing. Will check on it again next week. Be sure and use pillows under legs with feet and heels floating. -The PA initially classified the left heel wound as a stage 2 pressure injury, despite documenting the wound was covered with eschar, which would classify the wound as an unstageable pressure injury (see professional references above). -The PA documented there was no percentage of necrotic tissue present in the wound, however she also documented the wound had stable eschar. -The PA documented the wound had a depth of 1.0 cm despite documenting eschar was present in the wound, therefore the full depth of the wound would not be discernible. 3/31/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Worsening, necrotic tissue present in 75% of the wound. Length: 4.0 cm Width: 4.0 cm Depth: 2.0 cm Treatment: Reviewed with the nurse and administrator the importance of floating the heel at all times. They will continue to instruct the certified nurse aides (CNAs) in properly floating the heel. Evaluation: A little worse today from last week. Other comments: No additional comments documented. -The PA documented the wound had a depth of 2.0 cm despite documenting necrotic tissue was covering 75% of the wound. 4/8/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 90% of the wound. Length: 4.0 cm Width: 4.0 cm Depth: 2.0 cm Treatment: Continue to keep open to air but keep heel floated at all times. Evaluation: Slight improvement Other comments: No additional comments documented. -The PA documented the wound had a depth of 2.0 cm despite documenting necrotic tissue was covering 90% of the wound. -There was no left heel weekly wound assessment for 4/15/22. 4/22/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 100% of the wound. Length: 4.0 cm Width: 4.0 cm Depth: 1.0 cm Treatment: Continue with present care. No dressing required. Be sure to keep the heel floated at all times. Evaluation: Improving slowly Other comments: No additional comments documented. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 100% of the wound. -There were no left heel weekly wound assessments from 4/22/22 until 6/3/22. 6/3/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 100% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: No depth Treatment: Continue keeping heel floated. Evaluation: Improving Other comments: Stable eschar with healthy surrounding tissue. -There was no left heel weekly wound assessment for 6/10/22. 6/17/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 75% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 1.0 cm Treatment: May keep open to air again. Continue floating heel at all times. Will start antibiotics for surrounding [CONDITION(S)]. Evaluation: Gradually improving overall, recent development of periwound [CONDITION(S)] Other comments: Stable eschar still intact. [CONDITION(S)] (redness) to surrounding skin now, new since the last observation, extending about 3 - 4 cm. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 75% of the wound. 6/24/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 100% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 1.0 cm Treatment: Continue floating heel. Continue and finish out the antibiotics. Evaluation: Improving Other comments: No additional comments documented. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 100% of the wound. -The PA documented the wound was improving, despite documentation indicating the wound had not changed in size for seven days and had gone from being 75% covered by eschar to being 100% covered by eschar. 6/30/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 100% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 1.0 cm Treatment: Continue floating heel and proper positioning. No dressing required. Evaluation: Gradually resolving Other comments: No other comments documented. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 100% of the wound. -The PA continued to document the wound was improving, despite documentation indicating the wound had not changed in size for 14 days and continued to be 100% covered by eschar. -There were no left heel weekly wound assessments from 6/30/22 until 7/15/22. 7/15/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 100% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 1.0 cm Treatment: Scab is quite persistent. May use topical ointment on it and cover with [MEDICATION(S)] to see if we can expedite the resolution of the scab. Evaluation: Stable Other comments: Air or other specialized pressure relieving mattress requested today. Stable eschar. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 100% of the wound. -The PA continued to document the wound was improving, despite documentation indicating the wound had not changed in size for 21 days and continued to be 100% covered by eschar. 7/22/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 100% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 1.0 cm Treatment: Will try to speed up loosening of the eschar with use of vaseline gauze over the scab. After bath, the nurse will apply vaseline gauze over the wound, then treat surrounding skin with skin prep and apply [MEDICATION(S)] over the vaseline gauze. Evaluation: Stable Other comments: Air mattress being used now. Stable eschar with little change. Mild [CONDITION(S)] to periwound. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 100% of the wound. -The PA continued to document the wound was improving, despite documentation indicating the wound had not changed in size for 28 days and continued to be 100% covered by eschar. 7/29/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Unchanged, necrotic tissue present in 80% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 1.0 cm Treatment: Continue the vaseline to try to remove the scab that has been present for so long. Start antibiotics for the suspected infection. Evaluation: Hopefully will start to see some progress after removal of the scab. Other comments: [CONDITION(S)] has developed again since starting the vaseline to soften the scab. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 80% of the wound. 8/5/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 100% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 1.0 cm Treatment: Continue with vaseline gauze with [MEDICATION(S)] to secure and for occlusion. Evaluation: Slowly improving Other comments: Air mattress being used. -The PA documented the wound had a depth of 1.0 cm despite documenting necrotic tissue was covering 100% of the wound. -The PA documented the wound was improving, despite documentation indicating the wound had not changed in size for 42 days and had gone from being 80% covered by eschar to being 100% covered by eschar. 8/12/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 2 Current stage of wound: Stage 3 Overall impression: Unchanged, necrotic tissue present in 100% of the wound. Length: 2.0 cm Width: 3.5 cm Depth: 2.0 cm Treatment: Continue with the vaseline gauze occluded with [MEDICATION(S)] to try to loosen the eschar. Evaluation: Stable Other comments: No undermining. Difficult to determine staging under the eschar. -The PA documented the wound had a depth of 2.0 cm despite documenting necrotic tissue was covering 100% of the wound. -The PA documented the current stage of the wound was stage 3, despite documenting it was difficult to determine the staging under the eschar. 8/19/22: Location: Left heel Date acquired: 3/23/22 Original stage of wound: Stage 3 Current stage of wound: Stage 2 Overall impression: Improving, necrotic tissue present in 75% of the wound. Length: 3.0 cm Width: 3.0 cm Depth: 2.0 cm Treatment: Keep open to air and continue to float heel at all times. Evaluation: Slowly improving Other comments: No additional comments documented. -The PA documented the original stage of the wound as stage 3, despite all prior documentation classifying the original stage of the wound as stage 2. -The PA documented the wound had a depth of 2.0 cm despite documenting necrotic tissue was covering 75% of the wound. -The PA documented the wound should be kept open to air, however, there was no physician's order in the resident's EMR to reflect the order change (see physician's orders above). -There was no left heel w

Based on record review and interviews, the facility failed to employ a director of food and nutrition services with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 23 census residents. Specifically, the facility utilized the nursing home administrator (NHA) to also serve as the dietary manager (DM) and she was unable to work full time hours as the DM. Cross-reference F692 for the facility's failure to monitor and prevent significant weight loss. Findings include: I. Record review Review of the August 2022 dietary department schedule revealed there was not a DM scheduled for the month of August 2022. The dietary department had a day and evening shift cook scheduled and one to two dietary aides scheduled for each shift, however there was not a designated full time qualified DM scheduled weekly as required. II. Staff interviews The NHA was interviewed on 8/29/22 at 12:30 p.m. She said she did not have a dedicated dietary manager for the department. She said she had a contracted certified dietary manager (CDM) that provided offsite support weekly as well as onsite visits two days a week. The NHA said she also had a registered dietitian (RD) that provided clinical oversight for diet changes one day every other week. The NHA said she had a dietary manager that did not complete her certification and had not worked there for over a year. She said the department had been without a dedicated DM for over a year and she had been filling in when needed as the DM. She said the dietary cook (DC) #2 and dietary aide (DA) #1 had been with the dietary department for over [AGE] years and they were able to run the kitchen well without a DM, however she understood she needed to fill the position. She said it was difficult to fill her management positions because of their rural location. The RD was interviewed on 8/29/22 at 1:30 p.m. She said she was new to the facility and recently started in July 2022. She said she came into the facility on e day every two weeks and worked remotely the rest of the time. She said there was a contracted CDM that came in two days a week to provide oversight to the dietary department. The RD said she mainly focused on reviewing new admission diets, change of conditions in diets and weight loss. She said the dietary department currently did not have a full time DM, however DC #2 helped with the weekly ordering of the food and the organization of the kitchen. DC #2 was interviewed on 8/30/22 at 12:15 p.m. He said he had worked in the kitchen as a cook for [AGE] years. He said the kitchen has been without a DM for around one year. He said they had a contracted CDM that came in twice a week to help with the management of the dietary department. He said DA #1 had also been working in the kitchen for over [AGE] years and helped keep the kitchen clean and organized. He said he was the main cook for the daytime and there was an evening cook as well. He said he did not assist with any management of the dietary department, however he did take over the weekly ordering of the food and helped organize the kitchen and food storage areas.

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis. Specifically, the facility utilized the nursing home administrator (NHA) to also serve as the DON and she was unable to work full time hours as the DON. Cross-reference F686 for the facility's failure to monitor and prevent pressure ulcers. Findings include: I. Record review Review of the August 2022 nursing schedule revealed there was not a DON scheduled for the month of August 2022. The NHA was on the schedule as an RN and NHA for the month of August 2022. She was not assigned to work the floor as a nurse, however she was scheduled to provide the nursing oversight. II. Staff interviews The NHA was interviewed on 8/29/22 at 12:30 p.m. She said she did not have a registered nurse designated as the DON on a full time basis. She said her previous DON left and she did not have the position filled for a few months. She said she did have RNs she delegated tasks with the DON position not filled. She said she offered the DON position to RN #1, however she declined the position. She said she had two open management positions she was covering to include the DON position as well as the dietary manager (DM) position. She said it was difficult to fill her management positions because of their rural location. III. Additional information Review of the state facility licensing database showed the 3/3/22 facility license update documented the NHA has served as the DON since 12/8/21.

Based on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary [CONDITION(S)] drugs as possible for three (#6, #8 and #14) of six residents out of 15 sample residents. Specifically, the facility failed to: -Provide documentation that a risk versus benefit statement to justify the resident's continual use of the medications was provided to the resident and/or the resident's representative for Resident #6, Resident #8, and Resident #14; -Attempt a gradual dose reduction (GDR) of an antipsychotic medication for a resident with dementia for Resident #6 and Resident #8; and, -Appropriately assess Resident #14's need for the use of an antipsychotic medication for a diagnosis of nausea. Findings include: I. Facility policy and procedure The Psychopharmacological Medication Use policy, revised June2022, was provided by the nursing home administrator (NHA) on [DATE] at 8:45 a.m. It read in pertinent part, Psychopharmacological (psych) medications are used to relieve symptoms of psychotic behaviors, depression, anxiety and agitation. It is the policy of this facility to use screening and assessment to determine the proper use of psychopharmacological medications in accordance with state and federal regulations. The facility supports the appropriate use of psych medications that are therapeutic and enabling for residents suffering from mental conditions. A consent form will be discussed with the resident and family at admission or upon initiation of [CONDITION(S)] medication stating the risks versus the benefits and the non-pharmacological interventions that will be in place and attempted. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental and/or behavioral management as well as psych medications, can be utilized to meet the needs of the individual resident. [CONDITION(S)] medication will be reviewed for the need to conduct a gradual dose reduction (GDR). State regulations require a GDR every six months for the first year and yearly thereafter. Appropriate monitoring and documentation will be maintained in residents' charts. II. Resident #6 A. Resident status Resident #6, age 90, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance, restlessness and agitation, and major depressive disorder, recurrent with severe psychotic symptoms. The [DATE] minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of eight out of 15. He required one-person limited assistance with bed mobility, transfers, dressing, and toilet use. He required supervision for personal hygiene. The [DATE] MDS assessment further revealed the resident did not exhibit any potential indicators of [CONDITION(S)] such as delusions or hallucinations. He did not exhibit any physical or verbal behaviors, rejection of cares, or wandering behaviors during the seven day MDS assessment look-back period. He received an antipsychotic medication daily. B. Observations On [DATE] at 5:10 p.m., Resident #6 was seated in his recliner in his room watching television. He was pleasant, and smiling. He said his wife had gone shopping and had not yet returned. He said he was concerned about how much money she might have spent. On [DATE] at 9:37 a.m., Resident #6 was seated in his recliner with the footrest up. He was asleep. On [DATE] at 4:25 p.m., Resident #6 was wheeling his wheelchair in the hallway. He was smiling and greeting people as he passed by them in the hallway. On [DATE] at 8:27 a.m., Resident #6 was wheeling his wheelchair in the hallway. He is smiling and pleasant. As a staff member walked past him, the resident smiled and said good morning. C. Record review Review of Resident #6's [DATE] CPO revealed the following physician's orders: [MEDICATION(S)] ([MEDICATION(S)]) capsule 20 milligrams (mg) by mouth two times a day related to dementia with behavioral disturbance. The order had a start date [DATE]. Monitor behaviors related to antipsychotic medication: increased agitation, calling out for family, physical aggression, or verbal aggression. The order had a start date of [DATE]. Non-pharmacological interventions to be used for agitation: reassurance, reposition, redirection, encourage to attend nursing home activities, television, visit one on one with staff, and ask resident if having pain. The order had a start date of [DATE]. Review of Resident #6's [CONDITION(S)] medication care plan, initiated [DATE] and revised on [DATE], revealed the resident used [MEDICATION(S)] (an antipsychotic medication) related to dementia with behaviors. Pertinent interventions included discussion with the physician/family regarding ongoing need for use of the medication, educating the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of [CONDITION(S)] medication drugs being given, and monitoring/recording occurrence for target behavior symptoms and non-pharmacological interventions attempted and their effectiveness - see treatment administration record (TAR). -The care plan did not list the specific target behaviors or non-pharmacological interventions for the resident. -Review of Resident #6's electronic medical record (EMR) failed to show documentation that a risk versus benefit statement to justify the resident's use of the medications was provided to the resident and/or the resident's representative. Review of Resident #6's behavior tracking sheets (monitoring of physical/verbal behaviors, wandering, and frequent crying), which were documented by the certified nurse aides (CNA), were reviewed for [DATE] through [DATE]. The behavior tracking sheets revealed the following: -February 2022 (prior to starting the antipsychotic medication): the resident exhibited behaviors on 19 days out of 28 days; -[DATE] (after starting the antipsychotic medication: the resident exhibited behaviors on six days out of 31 days; -[DATE]: the resident exhibited behavior on six days out of 30 days; -[DATE]: the resident exhibited behavior on four days out of 31 days; -[DATE]: the resident exhibited behaviors on three days out of 30 days; -[DATE]: the resident exhibited behaviors on 12 days out of 31 days; and, -[DATE]: the resident exhibited behaviors on five days out of 29 days. Review of Resident #6's treatment administration record (TAR) from ,d+[DATE] through [DATE] revealed the following: -February 2022 (prior to starting the antipsychotic medication): the resident exhibited behaviors on 19 days out of 28 days; -[DATE] (after starting the antipsychotic medication: the resident exhibited behaviors on four days out of 31 days; -[DATE]: the resident exhibited behavior on one day out of 30 days; -[DATE]: the resident exhibited behavior on one day out of 31 days; -[DATE]: the resident exhibited behaviors on zero days out of 30 days; -[DATE]: the resident exhibited behaviors on three days out of 31 days; and, -[DATE]: the resident exhibited behaviors on four days out of 29 days. -Despite the nurse and CNA documentation which indicated Resident #6's clinical condition had improved overall and/or stabilized, as evidenced by his decrease in behaviors, the facility failed to attempt a GDR of the antipsychotic medication, as is required two times within the first year of the medication being started unless clinically contraindicated. -There was no documentation from the physician in the resident's EMR which indicated a GDR of the medication was clinically contraindicated. Review of Resident #6's EMR revealed the following progress notes documented in pertinent part: [DATE] at 4:43 a.m: Resident continues with verbal and physical aggression, yelling out throughout the night, getting out of bed unassisted, noncompliant and uncooperative with care. [DATE] at 4:37 a.m: Resident with physical and verbal aggression during cares, continues to yell and call out throughout the night, noncompliant with cares, continues to get out of bed, one on one with staff, redirectirection, and re-approach without success, also refuses to take medication. [DATE] at 2:04 p.m: Resident has been very anxious since waking up this morning. Resident believes that this is a hotel and we are not allowing him to leave. He has threatened to 'call the cops' multiple times. When the resident's wife came to visit he was yelling at her and thinks she is seeing other men and that is why he can't go home. Wife crying with today's visit. Attempted to redirect, reposition, one on one with staff. [DATE] at 2:06 a.m: Resident has not been to sleep tonight. He has scooted around his room, self transferred to his wheelchair and propelled himself down the hallway. He has called out frequently looking for his wife. He yelled for anyone who walked down the hallway. He was also caught standing against the door jamb going to the hallway twice. He was looking for a way out. He also was asking for breakfast. He wanted oatmeal and coffee. When he was told that it would be at least 6 hours before breakfast was ready, he said he would die of hunger before breakfast time. We gave him some hot chocolate and instant oatmeal. [DATE] at 3:20 a.m: Resident has been very active after being assisted to bed. Climbing out of bed, removing all clothing on the lower half of his body. Redirection and one on one with staff helped. In his conversations with the CNAs he was sexually inappropriate. [DATE] at 9:33 p.m: Resident was exit seeking this evening. He was trying to go find his wife and his dog. We convinced him that his wife was at home getting some rest and he needed rest also. 1:1 was required to keep him semi-calm. [DATE] at 4:18 a.m: Resident has been calling out for his wife all night. He has slept for short periods of time, 15 - 20 minutes at a time. He is then climbing out of bed and crawling around on his mattresses and floor, pulling off his clothing, including the brief or pull-up. He has required lots of 1:1 attention to keep from waking/disturbing other residents. [DATE] at 6:12 a.m: Resident did not sleep all night, would not keep his clothes or briefs on. Would not stay on lowered bed or mattresses on the floor. Agitated when trying to get him on the mat or put on briefs. Urinated on floor and mats. Would get up on own and ambulated clear down the hall to the front lobby and got in the closet. One on one and reassurance not effective. Very difficult to redirect. [DATE] at 2:45 p.m: Resident was having increased agitation today and was looking everywhere for his wife. Resident was redirected several times by different staff members with little success. As needed medication given as ordered. The resident is currently visiting with his wife in his room and signs/symptoms of agitation have decreased. [DATE] at 5:45 a.m: Resident slept very little. Refused to stay in bed. Crawls onto the mat and into hallways. When assisted back to bed crawls right back in the hallway. Resident put in wheelchair and wheeled up and down halls most of the night yelling for wife. Resident was in the front lobby, got in the closet and tore out coats and when trying to get out of the closet swung at staff. Very difficult to redirect. One on one and reassurance. [DATE] at 5:38 a.m: Resident continued crawling out of bed throughout the night, does not use call light, yelling and calling out all night, verbally and physically aggressive towards staff, uncooperative with cares, one on one with staff, redirect, and re-approach all unsuccessful. [DATE] at 5:22 a.m: Resident continues with aggressive behavior with cares, both verbally and physically, hitting and kicking, continues crawling out of bed at night, yelling and calling out throughout the night, one on one with staff, redirect, and re-approach all without success. [DATE] at 5:35 a.m: Resident was very restless throughout the night. Unable to keep resident in bed. Wheeling wheelchair up and down halls, calling out for wife. Difficulty to keep out of other residents' rooms. Very difficult to redirect. One on one given, snacks given and non-effective. [DATE] at 11:00 a.m: Communication with physician and power of attorney (POA): Notified physician of escalation of resident's behaviors, staff is unable to calm him down or redirect. New orders received and noted. Notified residents POA of new orders. [DATE] at 8:24 p.m: Resident was out to supper meal. Took 100% of supper meal and was pleasant and cooperative with taking meds. After supper, was upset and wanted his car and wanted to talk to his wife and go home. Called wife and resident visited with wife and daughter and yelled at them on the phone. Very difficult to redirect. Staff one on one and reassurance with resident and he calmed down. Resting well at this time in bed. [DATE] at 1:19 p.m: Resident woke up from a nap and was crying insisting that he was dead and no one could see him. He stated that he died three years ago and woke up as a ghost on earth. One on one with staff provided with emotional support and reassurance provided. Then while walking to lunch he started yelling down the hall 'There is that (derogatory word). Get her the hell out of here' and was pointing at a staff member. Redirected resident to the dining room. In the dining room, resident continued to call that staff member a (derogatory word). Tried to redirect resident but resident insisted that he knew this staff member when he was younger and she betrayed him and would do it to everyone. After lunch, the resident rested in his chair with call light within reach. Wife here to visit. No other behaviors noted. [DATE] at 5:07 p.m: Resident became very emotional while wife was visiting. The resident stated that he hates his disease and wishes that the 'good lord would just take me'. One on one provided by staff with reassurance and emotional support. [DATE] at 8:33 p.m: Resident disruptive with another resident, entering other resident's room through shared bathroom, yelling and arguing with the other resident, refusing to leave room. One on one with staff and redirect with little success, increased resident's agitation. [DATE] at 4:17 p.m: Today resident showed several different instances of verbal aggression and agitation. During the parade he was cussing at staff members and calling CNAs 'bunch of dumb (derogatory word)'. He also continuously tried to roll down the sidewalk onto the street. Would not pick feet up for staff members to wheel his wheelchair back to a safe area. Once staff members were able to assist him inside he stood up from his wheelchair and walked aggressively toward a staff member, yelling that he wanted the police. He was also very upset due to not having his car and called all staff members liars when told that his wife has the car. Also stated 'well she's going to pay for that if that's the truth' referring to his wife. Also yelling at police officers in the parade for help. Interventions taken for behaviors today included one on one with different staff members throughout the day, reassurance that his wife has the car and is at home, and also this nurse showed the resident his chart to show him when he was admitted here. Interventions ineffective. Continues to be verbally aggressive towards staff members. Wife was here to visit with him this afternoon, after talking with his wife about the car, the resident shows no further aggression while she is visiting. [DATE] at 5:45 a.m: Resident noncompliant with cares in the morning, yelling and aggressive with staff. [DATE] at 4:12 p.m: Resident noted to have increase in agitation today. Agitation displayed verbally. Yelling at staff to 'shut up'. Also was calling wife names and made her cry. Wife did not tell staff what he said, but was visibly upset. Interventions used for agitation today included one on one with different staff members throughout the day, attempted to reassure, but was ineffective. All interventions ineffective, resident continued to be verbally aggressive to staff and wife. [DATE] at 3:38 p.m: Resident is noted to be verbally aggressive toward staff members when staff try to explain to him why his wife is not here to visit today. Interventions taken today to help with agitation included reassurance that his wife did not abandon him, but had personal circumstances today where she could not visit, snacks and beverages given for distraction, and also different staff members provided one on one with resident throughout the day. Interventions are effective for some staff members, but for others, the resident continues to be verbally angry and upset. Review of a [CONDITION(S)] Medication Review form dated [DATE] revealed the physician did not recommend any changes to Resident #6's antipsychotic medication. The form was signed by the facility's interdisciplinary team (IDT), the medical director, and the pharmacist. -The form did not document a clinical rationale for failing to decrease the resident's medication. -The form also documented that the date of the last risk versus benefit statement was not applicable. D. Interviews Dietary aide (DA) #2 was interviewed on [DATE] at 8:36 a.m. DA #2 said she had not seen Resident #6 exhibit any behaviors. She said he could be ornery, however, she said she had never seen him be aggressive or mean. CNA #2 was interviewed on [DATE] at 9:00 a.m. CNA #2 said Resident #6 would sometimes get confused. He said the resident could be verbally aggressive to his wife and to staff. He said he had never seen the resident be physically aggressive. CNA #2 said when the resident was agitated, staff usually tried to spend one on one time with him. He said that would sometimes work to calm the resident down. He said if one-on-one time did not decrease the behavior, staff would try to distract the resident by offering food or coffee. CNA #2 said if the resident could not be calmed, staff would keep him in their line of sight to make sure he was safe until he calmed down. CNA #3 was interviewed on [DATE] at 9:10 a.m. CNA #3 said Resident #6 exhibited behaviors at times. He said the resident would often try to leave and say he did not belong at the facility or look for his wife. He said staff would try to redirect him with snacks or sit in the front lobby with the resident. CNA #3 said if the resident could not be redirected, staff would make sure he was safe and the resident would usually calm down. He said he had only seen the resident be physically aggressive one or two times. He said the resident would swat at a staff member if he was upset, however, he said it was not very aggressive. CNA #3 said the resident would sometimes get upset and be verbally aggressive, but would usually calm down with redirection or leaving him alone for a while. Registered nurse (RN) #1 was interviewed on [DATE] at 10:45 a.m. RN #1 said Resident #6 was very verbally and physically aggressive when he was first admitted to the facility in [DATE]. She said he had a very difficult time settling in. RN #1 said the resident did not exhibit any physical behaviors anymore. She said he could sometimes exhibit some verbal behaviors, however the behaviors were nothing like they were when he first admitted . She said the resident liked to talk and reminisce about the past. RN #1 said he was fairly redirectable now. She said his behaviors never interfered with other residents. She said his behaviors were all directed at staff or his wife. The NHA, the medical record coordinator (MRC), and the social services coordinator (SSC) were interviewed together on [DATE] at 2:50 p.m. The NHA said Resident #6 had multiple physical and verbal behaviors when he was admitted to the facility in [DATE]. She said he was lashing out at staff, yelling, and exit seeking. She said he had been very difficult to redirect. She said since the antipsychotic medication was added to his medication regimen, the resident was able to hold conversations with staff members, and no longer exhibited many behaviors. She said when he did have behaviors, he was usually redirectable. The NHA said the IDT and the physician had not attempted to reduce the resident's medication because he was doing so much better on the medication. She said the physician had not documented a statement which indicated that reducing the dose of the resident's medication would be clinically contraindicated. The NHA said the risk versus benefit form for [CONDITION(S)] medications was supposed to be filled out by the physician. She said once the form was completed, a facility staff member would have the risk versus benefit discussion with the POA. She said the discussion would be documented in the resident's progress notes. The NHA confirmed that there was no documentation in Resident #6's EMR that indicated the risk versus benefit discussion had taken place with the resident's POA. III. Resident #8 A. Resident status Resident #8, age greater than 90, was admitted on [DATE]. According to the August CPO, diagnoses included Alzheimer's disease, major depressive disorder, and other depressive episodes. The [DATE] MDS assessment revealed that the BIMS was not conducted. The staff assessment for mental status was also not conducted. According to the [DATE] MDS assessment, the resident's cognitive skills for daily decision making were severely impaired. The [DATE] MDS assessment revealed that the resident required one person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The [DATE] MDS assessment further revealed the resident exhibited potential indicators of [CONDITION(S)] such as delusions or hallucinations. She did not exhibit any physical or verbal behaviors, rejection of cares, or wandering behaviors during the seven day MDS assessment look-back period. She received an antipsychotic medication daily. B. Observations On [DATE] at 4:50 p.m., Resident #8 was lying in bed with her bed in a low position. The resident was sleeping. On [DATE] at 9:40 a.m., Resident #8 was seated in her recliner with the footrest up. She was awake. The resident was calm and was not exhibiting any behaviors. On [DATE] at 8:42 a.m., Resident #8 was again seated in her recliner calmly in her room. C. Record review Review of Resident #8's [DATE] CPO revealed the following physician's orders: [MEDICATION(S)] tablet 2.5 mg by mouth in the evening for dementia with behaviors. The order had a start date of [DATE]. Behavioral monitoring for antipsychotic use: Exit seeking, distressful yelling for family/need for transportation. The order had a start date of [DATE]. Non-pharmacological interventions for antipsychotic medication use: provide distraction through preferred activity per list posted on closet door, enter her reality and engage her in reminiscing. The order had a start date of [DATE]. Review of Resident #8's [CONDITION(S)] medication care plan, initiated [DATE] and revised on [DATE], revealed the resident used antipsychotic medications related to Alzheimer's dementia with behaviors/agitation. Pertinent interventions included administering antipsychotic medications as ordered by physician, attempting and documenting non-pharmacological interventions and effectiveness every shift, discussing continued need for [CONDITION(S)] medications in the [CONDITION(S)] Medication Review Meeting and approaching physician for a gradual dosage reduction when clinically appropriate, and monitoring/recording occurrence of target behavior symptoms (see TAR). -The care plan did not list the specific target behaviors or non-pharmacological interventions for the resident. -Review of Resident #8's electronic medical record EMR failed to show documentation that a risk versus benefit statement to justify the resident's use of the medications was provided to the resident and/or the resident's representative. Review of Resident #8's behavior tracking sheets (monitoring of physical/verbal behaviors, wandering, and frequent crying), which were documented by the certified nurse aides (CNA), were reviewed for [DATE] through [DATE]. The behavior tracking sheets revealed the following: -February 2022: the resident exhibited behaviors on 11 days out of 28 days; -[DATE]: the resident exhibited behaviors on seven days out of 31 days; -[DATE]: the resident exhibited behavior on five days out of 30 days; -[DATE]: the resident exhibited behavior on three days out of 31 days; -[DATE]: the resident exhibited behaviors on five days out of 30 days; -[DATE]: the resident exhibited behaviors on four days out of 31 days; and, -[DATE]: the resident exhibited behaviors on three days out of 29 days. Review of Resident #8's TAR from ,d+[DATE] through [DATE] revealed the following: -February 2022: the resident exhibited behaviors on zero days out of 28 days; -[DATE]: the resident exhibited behaviors on zero days out of 31 days; -[DATE]: the resident exhibited behavior on zero days out of 30 days; -[DATE]: the resident exhibited behavior on two days out of 31 days; -[DATE]: the resident exhibited behaviors on zero days out of 30 days; -[DATE]: the resident exhibited behaviors on three days out of 31 days; and, -[DATE]: the resident exhibited behaviors on zero days out of 29 days. -Despite the nurse and CNA documentation which indicated Resident #8 was not exhibiting behaviors which warranted the use of an antipsychotic medication, the facility failed to attempt a GDR of the antipsychotic medication, as is required two times within the first year of the medication being started and annually thereafter unless clinically contraindicated. -There was no documentation from the physician in the resident's EMR which indicated a GDR of the medication was clinically contraindicated. Review of Resident #8's EMR revealed the following progress notes documented in pertinent part: [DATE] at 1:49 p.m: Resident was crying today. Was able to redirect resident and provide one on one with staff. [DATE] at 4:42 p.m: Resident crying. One on one with staff provided. [DATE] at 1:09 p.m: Resident has had poor appetite today with multiple episodes of crying. One on one with staff provided with reassurance. [DATE] at 9:52 a.m.: Resident was crying. Stated she didn't know what she was going to do. One on one with staff provided with emotional support and redirection was effective. [DATE] at 12:39 p.m: Resident tearful and crying in the dining room. One on one with staff provided with reassurance and distraction. The resident offered a nap as well. -There were no other behavior notes documented in the progress notes. Review of a [CONDITION(S)] Medication Review form dated [DATE] revealed the physician did not recommend any changes to Resident #8's antipsychotic medication. The form was signed by the facility's interdisciplinary team (IDT), the medical director, and the pharmacist. The form documented the resident had exhibited no behaviors. -The form did not document a clinical rationale for failing to decrease the resident's medication. -The form did not include a date of the last risk versus benefit statement. D. Interviews DA #2 was interviewed on [DATE] at 8:36 a.m. DA #2 said Resident #8 would sometimes tell staff to get out of her room. She said she had never seen the resident be physically or verbally aggressive with anyone. CNA #2 was interviewed on [DATE] at 9:00 a.m. CNA #2 said Resident #8 could be difficult at times, but for the most part she was pleasant. He said sometimes the resident could get upset when staff tried to change her brief. He said she would push staff away, but then she would allow them to complete care. CNA #2 said he had never seen the resident be really verbally or physically aggressive. CNA #3 was interviewed on [DATE] at 9:10 a.m. CNA #3 said he had never seen Resident #8 have any behaviors. He said sometimes the resident would yell out to get up, but he had never seen her with verbal or aggressive behaviors. RN #1 was interviewed on [DATE] at 10:45 a.m. RN #1 said Resident #8 would sometimes cry, however, she said that was the extent of her behaviors. She said the resident could occasionally get upset with staff during care, but she was not physically or verbally aggressive. RN #1 said staff would play music for her to calm her down. She said if the resident got agitated, it was usually because she wanted to lay down but had difficulty expressing her needs. RN #1 said if staff put the resident to bed and put her music on, the resident would calm down quickly. The NHA, the MRC, and the SSC were interviewed together on [DATE] at 2:50 p.m. The NHA said Resident #8 had been on the [MEDICATION(S)] since 2019. She said the resident should have had several GDRs attempted since starting the medication. The NHA said the only behaviors the resident exhibited were crying episodes, asking where her family was, and other typical dementia questions. She said the resident did not have any verbal or physical aggression. She said there should be behaviors documented in the resident's EMR to justify keeping her on an antipsychotic medication. The NHA confirmed there were very few behaviors documented in the resident's EMR. The NHA confirmed that there was no documentation in Resident #8's EMR that indicated the risk versus benefit discussion had taken place with the resident's POA. IV. Resident #14 A. Professional reference According to Saunders Nursing Drug Handbook, 2020, read in part: [MEDICATION(S)] ([MEDICATION(S)]), an antipsychotic. Black Box Alert: Elderly patients with dementia related [CONDITION(S)] are at increased risk for mortality due to [CONDITION(S)] events. Uses: [CONDITION(S)] and acute [CONDITION(S)] in [CONDITION(S)] disorder. Off-label use: prevention of [CONDITION(S)] induced nausea/vomiting. B. Resident status Resident #14, age 82, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included heart failure, pancreatic insufficiency and [CONDITION(S)]. The [DATE] MDS assessment revealed moderately impaired cognition with a brief interview for mental status (BIMS) score nine out of 15. He required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, and supervision with walking and eating. Medications included an antipsychotic administered daily. C. Resident observations and interview Resident #14 was interviewed on [DATE] at 5:00 p.m. He said he was independent in his room and throughout the facility using his walker. He said he was not aware of any [CONDITION(S)] medications that he was taking. Resident #14 was observed in the dining room on two occasions, on [DATE] at 5:30 p.m., eating dinner, and on [DATE] at 12:15 p.m. during lunch meal. He ate most food for both meals, approximately 80% without any observed difficulties or signs of nausea. The resident was interviewed on [DATE] at 2:50 p.m. He said he did not have any issues with appetite or nausea. He said he was eating most of his meals 100% and did not experience any problems. D. Record review The comprehensive care plan revealed the following: -The resident uses antipsychotropic (an antipsychotic) medication r/t (related to) disease process, prostate CA (cancer)/ nausea. Dated [DATE]. Interventions included: administer [CONDITION(S)] medications as ordered by physician. Monitor for side effects and effectiveness q-shift (every shift). Consult with pharmacy, MD (physician) to consider dosage reduction when clinically appropriate at least quarterly. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antipsychotropic med (medication) being given. The physician ord[TRUNCATED]

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 for two of two rooms. Specifically, the facility failed to: -Ensure housekeeping staff followed proper hand hygiene protocols when cleaning resident rooms; -Ensure proper room cleaning procedures were followed; -Ensure spray bottles were properly labeled with the disinfectant they contained; and, -Ensure housekeeping staff adhered to the appropriate wet/contact/dwell time (the time a chemical must remain in contact on a surface in order to eradicate organisms) for disinfection. Findings include: I. Professional references A. The Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (updated January 2020), retrieved on 9/1/22 from https://www.cdc.gov/handhygiene/providers/guideline.html, read in pertinent part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: after touching a patient or the patient's immediate environment and after contact with blood, body fluids, or contaminated surfaces. B. The CDC: Healthcare-Associated Infections (HAIs) 4.1 General Environmental Cleaning Techniques (updated on 4/21/2020), retrieved on 9/1/22 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, read in pertinent part, Proceed from cleaner to dirty areas to avoid spreading dirt and microorganisms. Clean low touch surfaces before high touch areas surfaces. Some common high touch surfaces were sink handles, bedside tables, call bells, door knobs, light switches, bed rails, wheel chairs, and counters where medications or supplies were prepared. Proceed from high areas to lower areas (top to bottom) to prevent dirt and microorganisms from dripping/falling onto surfaces below thus contaminating already cleaned surfaces. Change cleaning cloths between each resident zone (use a new cleaning cloth for each resident area). Never shake mop heads and cleaning cloths-it disperses dust or droplets that could contain microorganisms. C. Dwell Times Explained (dated 4/7/21), retrieved on 9/1/22 from https://vitaloxide.com/blogs/blog/dwell-times-explained, read in pertinent part, Giving a surface a quick spray, followed immediately by a wipe or two, may not allow enough time for the product to work effectively. To make sure a disinfectant is doing its job, it's crucial to follow the recommended 'dwell time', also known as 'contact time' or 'kill time.' The Environmental Protection Agency (EPA) defined dwell time as the amount of time that a sanitizer or disinfectant must be in contact with a surface and remain wet to achieve the product's advertised elimination (kill) rate. Disinfectant solutions could target a wide range of pathogens, and the surfaces these pathogens inhabit could vary greatly. To ensure a surface has been thoroughly disinfected, it is essential to always pay attention to the dwell time recommendations on the product's label. II. Facility policy and procedures A. The Handwashing Policy, last revised 1/29/22, was provided by the nursing home administrator (NHA) on 8/31/22 at 8:45 a.m. It read, in pertinent part, The purpose of this policy is to state that handwashing is the single, most important way to prevent the spread of infection. Hands are exposed to pathogens in the work area continuously. Proper hand washing will help prevent spreading pathogens from one resident to the next and to staff. All personnel will wash their hands according to CDC guidelines to prevent the spread of infections. Using Alcohol-Based Hand Rubs (ABHR): Alcohol containing hand sanitizers may be used. Alcohol content must be 60% or greater. Apply enough product to thoroughly wet hands. Rub hands together until dry. Key opportunities to perform hand hygiene: When coming on duty prior to entering work area, after removing gloves, when the hands are obviously soiled, between handling of individual residents, on completion of duty. B. The Room Cleaning Policy, last revised 2/2020, was provided by the chief financial officer (CFO) on 8/29/22 at 3:00 p.m. It read, in pertinent part, To prevent the spread of infection within the facility by maintaining a thoroughly clean and safe environment. An approved disinfectant will be used. Cleaning should always progress from the least soiled areas, and from high to low areas so that the dirtiest areas and debris that falls on the floor will be cleaned last. -The policy had not been revised since before the COVID-19 pandemic. III. Room cleaning observations A. room [ROOM NUMBER] On 8/29/22 at 9:45 a.m. housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER]. The room was a double occupancy room, however, there was only one resident residing in the room. The room was not an isolation room. HSK #1 began by sanitizing her hands with alcohol based hand rub (ABHR) and putting on a pair of gloves. She proceeded to enter the room and dumped the trash cans in the room and the bathroom. She returned to her cart to dispose of the trash. She unlocked a compartment on her cart and removed a container which contained various cleaners and disinfectants. She relocked the compartment and returned to the room with the container. HSK #1 placed the container of chemicals on top of the trash can by the sink. HSK #1 proceeded to spray the sink area with a spray bottle containing a yellow colored disinfectant. The spray bottle was not labeled with the name of the chemical contained in the bottle. After spraying the sink area with the disinfectant, HSK #1 applied Creme Cleanser to the inside of the sink and faucet. She then wiped off the faucet and the inside of the sink with a rag and turned on the water to rinse the sink. She tossed the rag on the floor just inside the entrance to the room. HSK #1 then proceeded to wipe the disinfectant off the sink area with a clean dry rag. The disinfectant had been on the surface of the sink area for four minutes. She again tossed the rag on the floor, just inside the entrance of the room. Without changing her gloves or sanitizing her hands, HSK #1 then proceeded to spray the yellow colored disinfectant on the dresser and other flat surfaces on side B of the room. She immediately wiped off the disinfectant with a dry rag without allowing the disinfectant to sit on the surfaces for any amount of time. HSK #1 again tossed the rag on the floor, just inside the entrance of the room. Without changing her gloves or sanitizing her hands, HSK #1 proceeded to spray the yellow colored disinfectant on the dresser and other flat surfaces on the unoccupied side of the room, side A. She again immediately wiped the disinfectant off with a rag without allowing the disinfectant to sit on the surface for any amount of time. After wiping off the surfaces on side A, HSK #1 picked up all of the rags that had been thrown on the floor of the room. She returned to her cart and disposed of the rags in the dirty rag bin on her cart. Without changing her gloves or sanitizing her hands, HSK #1 returned to the room to clean the toilet area. She sprayed the toilet bowl with a spray bottle containing a purple colored disinfectant. The spray bottle containing the disinfectant was not labeled. She then proceeded to clean the toilet bowl with a scrub brush. After using the scrub brush on the toilet bowl, she rinsed the brush with a spray hose, which was attached to the bathroom wall. HSK #1 then proceeded to tap the toilet brush on the side of the toilet several times which caused liquid from the toilet brush to spray on multiple surfaces in the bathroom. Without changing her gloves or sanitizing her hands, HSK #1 sprayed the outside of the toilet with the purple colored disinfectant and then immediately wiped the disinfectant off all of the surfaces without allowing the disinfectant to sit on the surface for any amount of time. After cleaning the toilet, without changing her gloves or sanitizing her hands, HSK #1 grabbed the yellow colored disinfectant spray bottle and sprayed all of the door handles in the room. After spraying the door handles, HSK #1 returned to her cart carrying the container of cleaners and disinfectants. She was still wearing the same gloves she had been wearing the entire time she cleaned and disinfected the room. HSK #1 took a set of keys from her pocket, opened the locked compartment on her cart, and put the container of cleaners/disinfectants away. She did not change her gloves or sanitize her hands. HSK #1 proceeded to grab another rag from her cart, then went back to the room to wipe off the door handles still wearing the dirty gloves. As HSK #1 was returning to the room to wipe off the door handles, she used her dirty gloves to pull up her pants. After wiping off the door handles, she returned to her cart and put the rag in the dirty rag bin on her cart. HSK #1 was then observed touching her face mask with her dirty gloves. Without changing her gloves or sanitizing her hands, HSK #1 returned to the room to sweep the floor. After sweeping the floor, she mopped the room, starting on side B and then working her way to side A. She mopped the bathroom last. While she mopped the room, HSK #1 continued to pull up her pants with her dirty gloves. At 10:15 a.m., HSK #1 returned the mop to the mop bucket outside the room. She removed her gloves and sanitized her hands with ABHR. She said she was finished cleaning the room. At 10:25 a.m. HSK #1 opened the door to the housekeeping closet where the cleaning chemicals/disinfectants were stored. She said the spray bottles were filled from the bigger bottles of chemicals stored in the closet. HSK #1 said the yellow colored chemical was Pine Quat. The instructions on the bottle of Pine Quat said to let the chemical sit on surfaces for a full 10 minutes for effective disinfection. HSK #1 said the purple colored disinfectant was X-Effect. The instructions on the bottle of X-Effect said treated surfaces must remain wet for 10 minutes. B. room [ROOM NUMBER] On 8/29/22 at 11:30 a.m., HSK #1 was observed cleaning room [ROOM NUMBER]. The room was a double occupancy room with two residents residing in it. The room was not an isolation room. HSK #1 began by sanitizing her hands with ABHR and putting on a pair of gloves. She proceeded to enter the room and dumped the trash cans in the room and the bathroom. She sprayed both trash cans with Pine Quat disinfectant and then immediately wiped them down with a dry rag and replaced the bags in the cans. She did not allow the disinfectant to sit on the trash can surfaces for the required 10 minutes. HSK #1 took the dirty rag and trash to her cart. She removed her gloves, sanitized her hands with ABHR, and put on a new pair of gloves. HSK #1 returned to the room and sprayed the door handles and flat surfaces on both sides of the room with Pine Quat disinfectant. After spraying the sink area with the disinfectant, HSK #1 applied Creme Cleanser to the inside of the sink and faucet. She then wiped off the faucet and the inside of the sink with a rag and turned on the water to rinse the sink. She tossed the rag on the floor just inside the entrance to the room. HSK #1 then proceeded to wipe the disinfectant off the sink area with a clean dry rag. The disinfectant had been on the surface of the sink area for three minutes. She again tossed the rag on the floor, just inside the entrance of the room. HSK #1 then used the same gloves and rag that had been used on the sink area to wipe down the flat surfaces on side B of the room. The disinfectant had been on the flat surfaces for five minutes. HSK #1 picked up the dirty rags from the floor, returned to her cart, placed the rags in the dirty rag bin, removed her gloves and sanitized her hands with ABHR. She put on a new pair of gloves, grabbed a clean dry rag from her cart, returned to the room and proceeded to wipe down side A. HSK #1 then used the same rag to wipe the door handles. The disinfectant had been on the surface on side A for eight minutes. The surfaces were no longer wet when she wiped them down. HSK #1 returned to her cart and disposed of the dirty rag in the bin on her cart. Without changing her gloves or sanitizing her hands, she returned to the room and swept the floor. After sweeping the floor, HSK #1 proceeded to clean the toilet. She sprayed the toilet bowl with the X-Effect disinfectant. She then proceeded to clean the toilet bowl with a scrub brush. After using the scrub brush on the toilet bowl, she rinsed the brush with a spray hose, which was attached to the bathroom wall. HSK #1 proceeded to tap the toilet brush on the side of the toilet several times which caused liquid from the toilet brush to spray on multiple surfaces in the bathroom. She next sprayed the outside of the toilet with the X-Effect disinfectant. She allowed the X-Effect disinfectant to sit for one minute before wiping it off with a rag. After disinfecting the toilet, HSK #1 returned to her cart, disposed of the rag, changed her gloves and sanitized her hands. She put on a new pair of gloves and returned to the room to mop. At 11:52 a.m., HSK #1 returned the mop to the mop bucket, removed her gloves and sanitized her hands with ABHR. She said she was finished cleaning the room. IV. Staff interviews HSK #1 was interviewed on 8/29/22 at 10:15 a.m. HSK #1 said she sanitized her hands at the beginning of cleaning a room and then put on gloves. She said she would remove her gloves and sanitize her hands again when she was finished cleaning the room. She said she would put on a new pair of gloves prior to starting to clean a new room. She said hands should probably be sanitized after cleaning the toilet and new gloves put on. She said the toilet should be the last thing cleaned. She said she could not remember the names of the cleaners she was using. She thought they had to sit on the surface for a dwell time of five minutes. The chief financial officer (CFO), who oversaw the housekeeping staff, was interviewed on 8/29/22 at 12:06 p.m. The CFO said the housekeepers received annual training on infection control and how to properly clean a room. She said the training was a video on a website that they watched. She said the video included the types of chemicals the housekeepers should use, and the proper way to clean a room. She said the new housekeepers then spent about a week with an experienced housekeeper. She said the facility conducted random audits to make sure rooms were being cleaned properly, however, she said she did not have documentation of the audits. The CFO said the housekeepers should use one disinfectant for all surfaces. She said the facility had just switched to a different chemical, however she could not remember the name of the chemical. She said she thought the dwell time for the disinfectant was five minutes. She said she would find the information. She said the disinfectant should be left on surfaces, and remain wet, for the recommended amount of time to properly disinfect. She said spray bottles should be clearly labeled with the name of the chemical they contained. The CFO said toilet brushes should not be tapped on the edge of the toilet bowl because that had the potential to spread germs to other surfaces. She said HSK #1 should have changed her gloves and sanitized her hands any time she touched something dirty and after she cleaned the toilet. She said gloves should also be changed and hands sanitized between each side of a resident room. She said the toilet should always be the last item cleaned in the room. The NHA, who was an RN and the facility's certified infection preventionist, was interviewed on 8/30/22 at 1:00 p.m. The NHA said she was in the process of training a nurse to help with infection prevention. She said when cleaning a room, gloves should be changed and hands should be sanitized anytime they touch something dirty. She said the toilet should be the last thing cleaned in a room. The NHA said HSK #1 should have cleaned one side of the room and then the other. She said she should have changed gloves, sanitized hands, and used separate rags on each side of the room. The NHA said spray bottles should be properly labeled with the name of the chemical in the bottle. She said manufacturer's instructions should always be followed for chemical dwell times to ensure surfaces were thoroughly disinfected V. Facility followup On 8/29/22 at 3:00 p.m., the CFO provided information on the X-Effect disinfectant. She said the disinfectant was an Environmental Protection Agency (EPA) approved disinfectant. She said the chemical had a recommended dwell time of 10 minutes. The CFO also provided documentation infection control/room cleaning training for HSK #1. The training included how to set up the cleaning cart, hand hygiene, how to clean an occupied resident room, how to clean a discharged resident room, how to clean a resident isolation room, how to clean a resident bathroom, and how to clean and disinfect high touch surfaces. The training documentation provided indicated HSK #1 had received training on 8/5/2020, 6/11/21, and 5/10/22. VI. Facility COVID-19 status The NHA was interviewed on 8/30/22 at 1:00 p.m. The NHA said the resident census was 23. She said the facility had no current COVID-19 positive residents or staff members. She said there were no COVID-19 tests pending for residents or staff. The NHA said the facility was currently in an outbreak status. She said all staff and residents had been tested on [DATE] and all tests had come back negative. She said all staff and residents would be tested again on 9/1/22, per the guidance of the state health department. The NHA said if all tests from 9/1/22 came back negative, the facility would no longer be in the outbreak status.

Based on record review and interviews, the facility failed to ensure all staff had current abuse and dementia care training. Specifically, the facility failed to ensure five out of five licensed nurses and CNAs reviewed within the previous year received dementia management training and abuse prevention training. Findings include: I. Record review Staff competencies/annual training for the selected nursing staff (CNAs and licensed nurses) were requested from the NHA on 8/29/22 at 12:30 p.m. The NHA provided the staff new hire competency checklists the following day on 8/30/22 at 5:13 p.m. -However, there was no record of annual training to include abuse, neglect and exploitation training and dementia care training. II. Staff interview The NHA was interviewed on 8/29/22 at 12:30 p.m. She said she did not have the training records and competency checklists available to her and would need to contact her HR representative to send her the requested documentation. She said her director of nursing (DON) was no longer employed and she could not find the employee training logs and competency checklists. The NHA said she was not sure where those were kept and was concerned her DON did not keep record of the facility training. She said she did not believe the annual training had been completed for 2021 or 2022. She said she was not sure when the last all staff training was completed to include dementia care training and abuse training. She said she would work with her HR representative to schedule the required annual training. She said she would usually depend on the DON to assist her with the training, however she currently did not have a DON on staff.

Based on record review and interviews the facility failed to ensure two (#8 and #19) out of three of 21 sample residents reviewed were free from abuse. Specifically, the facility failed to prevent incidents of physical abuse toward Resident #8 and #19 by Resident #16. I. Facility policy The Abuse Prevention policy, issued date of 5/2019, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m. read in pertinent part; Purpose: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom form corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and phyican or chemical restraint not required to treat the residents symptoms. Policy: It is the policy of the facility to ensure that all of the residents are free from abuse, neglect, misappropriation of resident property and exploitation. II. Resident #16 A. Resident status Resident #16, age 90, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/18/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of seven out of 15. She required extensive assistance with two people for bed mobility, transfers, toilet use, dressing and limited assistance for personal hygiene. She had delusions. III. Incidents of resident-to-resident abuse A. 4/5/21 with Resident #8 1. Resident status Resident #8, age 75, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 3/15/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of seven out of 15. She required extensive assistance with one person for dressing total care of two people for transfers and toileting. She had limited assistance with one for hygiene. She had physical and verbal behaviors directed toward staff and rejection of cares. 2. Facility investigative report The facility investigative report dated 4/5/21, was provided by the nursing home administrator (NHA) on 5/19/21 at 10:30 a.m., it read in pertinent part; Resident #8 passed by Resident #16, when Resident #16 reached out and grabbed her. Resident #8 yelled and the staff were there immediately. Both residents were assessed and no injuries were noted. Both residents were taken to their rooms. Resident #16 was assessed for pain as that increased her agitation at times. She did receive pain medication. Resident #8 was interviewed and assessed for pain. She said she was in pain but did not recall the incident. Staff was educated on close monitoring of Resident #16, and to give her alternative activities such as video call to her daughter and family, coloring, soft music, pain medication to her knees, interaction with staff with a calm voice. Resident monitoring by staff when she was in the hallway independently. All notifications to the police department, ombudsman and family were completed.`Behavior nurse note for Resident #16 dated 4/5/21 at 8:23 p.m. read in pertinent part; Resident #8 passed in front of Resident #16 and Resident #16 grabbed Resident #8 right arm in an aggressive manner. Resident #8 screamed and staff separated the residents. No significant injuries noted. Resident #16 was assisted to her room and assisted with night cares in bed and no further outburst occurred. NHA was notified. B. 4/6/21 with Resident #19 1. Resident status Resident #19, age 95, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/26/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit. She required extensive assistance with one person for dressing and limited assistance with one person for toileting, transfers and hygiene. She had delusions and rejection of cares. 2. Facility investigative report The facility investigative report dated 4/6/21, was provided by the nursing home administrator (NHA) on 5/19/21 at 10:30 a.m., it read in pertinent part; Resident #16 was being assisted with the sit to stand lift in the hallway when Resident #16 aggressively grabbed Resident #19 by the arm and attempted to hurt her. Licensed practical nurse (LPN) immediately intervened. Resident #16 was transferred to the bathroom as they were in the process of assisting with that during the incident. Once the task was completed, Resident #16 was assessed for pain, and medication was given. Resident was given the opportunity to call her daughter as that often relieved her agitation. She was placed away from other residents and monitored by staff. Resident #19 was assessed for injury and none were noted. Resident #19 was interviewed and said she did not recall the incident and she was not fearful of any resident in the building. The police, physician and family were called and the facility. Staff were educated to monitor the resident and to monitor the close proximity of Resident #16 to other residents when in the activity room and the hallway. All notifications to the police department, ombudsman and family were completed. Behavior nurse note for Resident #16 dated 4/6/21 at 5:34 p.m. read in pertinent part; Resident #16 grabbed another resident aggressively on the upper arm. Resident #16 was removed from the situation, placed in her room, given pain medication, massage and allowed to watch her daughter on video call. Director of nurses (DON) was notified. IV. Record review for Resident #16 There was a computerized physicians order dated 4/29/21 for Resident #16 that read in pertinent part ' Document non-medication interventions for anxiety manifested as verbal and physical aggressive behaviors: Encourage diversional activities, coloring, music, and televisio. Assess for pain and or toileting needs. Calm reassuring approach. Assist her in watching a video-taped bible study presentation or other video from her daughter. Document intervention attempted and chart effectiveness in progress note. -This order was put in 23 days after the abuse incidents occurred between residents. The activities of daily living (ADL) care plan for Resident #16 was revised 4/22/2021, it read in pertinent part; Resident #16 had a self care deficit related to dementia, impaired balance and limited mobility. The goal said the resident would maintain the current level of function. The anti-anxiety care plan for Resident #16 was revised on 4/21/21, it read in pertinent part; Resident #16 used anti-anxiety medication. The goal was Resident #16 would be free from discomfort or adverse reactions related to anti-anxiety therapy. The intervention was to administer anti-anxiety medication as ordered, monitor and document any signs and symptoms of adverse side effects of the medication daily. When anxious or agitated, offer and assist with thumb drive video to call family. Intervene before agitation escalates, engage away from source of agitation, engage calm in conversation. -This care plan was not updated after the incidents with both Resident #8 and #19 that occured on 4/5/21 and 4/6/21 to ensure additional steps were taken to keep other residents safe from Resident #16. -Record review of the care plan for Resident #16 revealed no care plan for delusions. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/19/21 at 9:30 a.m. She said when a resident had an altercation with another resident she made sure the residents were safe then she reported the incident to the nursing home administrator (NHA). She said a progress note was written and the family and physician were notified. Resident #16 had a lot of behaviors at times due to pain but since they increased her pain medication she had less agitation. The NHA was interviewed on 5/19/21 at 2:00 p.m. She said she had several incidents with Resident #16 lashing out at staff and other residents. She said there were multiple interventions used when Resident #16 became agitated. She said she did the investigation and substantiated for abuse because Resident #16 did grab Resident #8 and #19 arm. She said anytime an allegation of verbal, physical abuse, falls, neglect and injury of unknown origin it was reported to the State Agency. The nurses were responsible for completing a process note for any incident and the interdisciplinary team (NHA, DON, nurse, physician) updated the resident's care plan.

Based on record review and interviews, the facility failed to complete a through and timely abuse investigation for two(#18 and #23) out of four of 21 sample residents. Specifically, the facility failed to investigate thoroughly: -Resident #18's allegation of being grabbed by a male staff member; and, -Allegation of abuse reported by Resident #23's representative Findings include: I. Facility policy The Reporting and Abuse Investigations policy, last reviewed on May 2019, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m. it read in pertinent part; All reports of abuse, neglect, exploitation, misappropriation of residents property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than; - two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or -24 hours if the alleged violation does not involve abuse. II. Resident #18 A. Resident status Resident #18, age 89, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/31/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance with one person for dressing and limited assistance with one person for bed mobility, transfers, toilet use, and hygiene. She had no behaviors. B. Record review Record review on 5/18/21 at 9:30 a.m. revealed the following, in part, They concluded the resident had a possibility of hitting her arm against the wall or foot board during the night terror incident on 4/26/21 which the resident told the staff she was trying to get away. During her night terror the resident said a male grabbed her arm, however there were no male staff working the night of 4/26/21. In conclusion of the investigation it was determined the resident may have sustained injury to her right arm on 4/26/21 during the night terror. Cross-reference F689 A schedule was provided by the NHA to indicate no male staff member was working, however, no documentation was provided to indicate staff members were questioned or other residents to complete a thorough investigation of an unwitnessed injury. The facility failed to thoroughly investigate the allegation made by Resident #18. C. Staff interviews Nursing home administrator (NHA) was interviewed on 5/19/21 at 2:00 p.m. She said the initial incident report for injuries of unknown origin or abuse allegations was completed by the nurse and she was notified to do the investigations. She said she put the information about Resident #18 head injury into the portal within a few hours and filled out the investigation form. She said injuries of unknown origin are reportable incidents. D. Follow up No further documentation was provided during or after the survey. II. Allegation of abuse reported by Resident #23's representative The Fall Scene Investigation Report dated 1/24/21 at 8:10 a.m., revealed the resident had an unwitnessed fall at this time. The resident was in her room alone and unattended. The resident was found seated on her buttocks with her legs straight out in front of her. She was located on the floor in the middle of the room facing the bathroom. Incident note dated 1/24/21 at 12:45 p.m., revealed a follow-up on the resident's fall by the nursing home administrator (NHA). The NHA called the hospital this morning and was told the resident would be admitted . The nurse told the NHA that the family had been to the hospital to see the resident. Communication with the family note dated 1/25/21 at 12:48 p.m., by the NHA revealed a return call to the resident's power of attorney (POA) to discuss the fall on 1/24/21. The POA asked questions regarding the staff rounding (visualization of the resident) that was completed on the resident. The NHA explained the last round on the resident was at approximately 6:45 a.m., and she refused care at this time. The NHA told the POA that the resident was independent in room, requiring cueing at times, but often refused any help from staff. The NHA explained that staff went into the resident's room to get her for breakfast and the resident was found on the floor. The POA was appreciative of the call and the provided information. The POA had no concerns at this time. Nursing Admission Screening history dated 1/27/21 at 2:43 p.m., revealed the resident returned from the hospital. Care Conference note dated 2/23/21 at 9:51 a.m., by the DON revealed during the care conference the POA had concerns regarding the resident's fall and how it happened. Investigation Report by the NHA dated 2/26/21 (not timed) regarding the resident's fall on 1/24/21 revealed during the care conference on 2/23/21 the family stated that the resident told them that she was pulled out of bed by a red haired nurse which caused her to trip and fall. This was new information for the facility. The NHA wrote that according to the incident reports, a CNA went to get the resident for breakfast and found the resident seated on the floor with her legs out in front of her. The resident was sent to the hospital for further evaluation. During the initial investigation, because the resident was independent in her room, the conclusion was the resident slipped in her room related to wearing socks that were non-skid socks. This event did not meet the criteria of reporting through the State Agency. This incident was re-evaluated and did not agree with the family's statement of staff involvement with the fall On 2/26/21 staff attempted to interview the resident. She said that a red haired nurse (first name provided) pulled her out of bed and broke her leg. After this statement, the resident refused to talk further with staff. The facility had three to four CNAs that had red hair but no nurses with red hair. The resident named a CNA with red hair but her hair was actually black. Of the CNAs that were working on the day of the fall, one had red hair. -The CNA with red hair, however, was not interviewed during the investigation. It was determined that the resident was potentially walking in her room and fell as there was no other person in the room that we were unable to determine. At the time of the fall, staff were helping other residents with morning routines. The Initial Report to the State Agency revealed the date of the allegation of physical abuse was reported to the facility by the family on 2/23/21 at 10:00 a.m. The initial report was submitted by the facility to the State Agency on 2/26/21 at 1:46 p.m. This was three days after the facility was made aware by family in a care conference that the resident stated a red haired nurse pulled her/pushed her out of the bed causing her to trip and fall (cross-reference F609 for failure to report timely). C. Staff interviews The DON was interviewed on 5/19/21 at 12:28 p.m. She reviewed the nurse notes for the resident's fall on 1/24/21. She said the notes revealed the resident was alone in her room at the time of the fall. She said to her knowledge there were no staff in her room at the time of the fall. She was sent to the hospital almost immediately after the fall. The DON said the first she knew about the concern about the resident's fall being caused by a red haired nurse (named) at the care conference on 2/23/21. She said the facility did not have any staff member with the name provided by the resident. She said the facility did not have any red haired nurses. She said after the family's allegation, the NHA reported the allegation in the State Agency. She said did not interview any staff because the NHA was the abuse coordinator. The NHA was interviewed on 5/19/21 at 1:40 p.m. She said the first time she heard of this allegation was during a care conference on 2/23/21. She said she submitted it to the State Agency system on 2/26/21 at 1:46 p.m. She said she should have reported it within two hours but was at a loss and researched what to do. She said the facility policy revealed to submit the report within two hours for physical abuse. The NHA said the investigation was completed and the conclusion was unsubstantiated due to the fact the facility did not have a red haired nurse or a nurse with the name provided by the resident. She said there was staff in the room next to the resident's room and there were no staff in her room at the time of the fall. The NHA said she interviewed four staff members but did not have any documents from the staff or the staff names to collaborate the interviews. The NHA said she only interviewed the resident and did not interview any other residents. She said she did not feel the need to interview other residents because the resident was in the room by herself. She said none of the red haired staff members were working on the day of the fall. She said no staff were sent home during the investigation period which began 2/23/21 after notification during the care conference. The NHA said the facility had an Ambassador program with a staff member assigned to individual residents. She said they do weekly discussion with the residents and on the week of the fall 1/24/21, none of the residents in the facility at that time expressed that they were scared of any staff members or had concerns about any staff members. D. Conclusion The NHA reported the allegation of staff physical abuse to the State Agency three days after the allegation was made by the resident's family during a care conference (cross-reference F609). The NHA did not interview residents during the investigation period. The NHA interviewed two staff members; however, there was no specific statement documentation from the two staff.

Based on record review and interviews, the facility failed to ensure that all alleged violations were reported timely for two (#23 and #18) of four out of 21 sample residents. Specifically, the facility failed to report: -An allegation of physical abuse in a timely manner for Resident #23; and, -Resident #18's injury of unknown origin. I. Facility policies and procedures The Reporting and Abuse Investigations policy, last reviewed on May 2019, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m. it read in pertinent part; All reports of abuse, neglect, exploitation, misappropriation of residents property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than; -two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or -24 hours if the alleged violation does not involve abuse. II. Resident #23 A. Representative allegation of abuse A Care Conference note dated 2/23/21 at 9:51 a.m., written by the DON, revealed during the care conference the POA had concerns regarding the resident's fall and how it happened. Cross-reference F610 failure to investigate allegations thoroughly. Investigation Report by the NHA dated 2/26/21 (not timed) regarding the resident's fall on 1/24/21 revealed during the care conference on 2/23/21 the family stated that the resident told them that she was pulled out of bed by a red haired nurse which caused her to trip and fall. This was new information for the facility. The Initial Report to the State Agency revealed the date of the allegation of physical abuse was reported to the facility by the family on 2/23/21 at 10:00 a.m. The initial report was submitted by the facility to the State Agency on 2/26/21 at 1:46 p.m. -This was three days after the facility was made aware by family in a care conference that the resident stated a red haired nurse pulled her/pushed her out of the bed causing her to trip and fall. B. Staff interview The nursing home administrator (NHA) was interviewed on 5/19/21 at 1:40 p.m. She said the first time she heard of this allegation was during a care conference on 2/23/21. She said she submitted the information to the State Agency system on 2/26/21 at 1:46 p.m. She said she should have reported it within two hours but was at a loss and researched what to do. She said the facility policy revealed to submit the report within two hours for physical abuse. III. Resident #18 A. Resident status Resident #18, age 89, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/31/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance with one person for dressing and limited assistance with one person for bed mobility, transfers, toilet use, and hygiene. She had no behaviors. B. Record review Record review on 5/18/21 at 9:30 a.m. revealed the following, in part, They concluded the resident had a possibility of hitting her head on the foot board during the night terror incident on 4/26/21 which the resident told the staff she was trying to get away. In conclusion of the investigation it was determined the resident may have sustained injury to her head on 4/26/21 during the night terror. Cross-reference F689 The nursing home administrator (NHA) provided no documentation to indicate staff members were questioned or other residents to complete a thorough investigation of an unwitnessed injury. C. Staff interviews Nursing home administrator (NHA) was interviewed on 5/19/21 at 2:00 p.m. She said the initial incident report for injuries of unknown origin or abuse allegations was completed by the nurse and she was notified to do the investigations. She said she did not put the information about Resident #18 head injury into the portal because there was no section to enter injuries of unknown origin in the portal. She said she knew injuries of unknown origin are reportable incidents so she investigated on her own with the paperwork she created. D. Follow up No further documentation was provided during or after the survey.

Based on observations, record review and interviews, the facility failed to ensure a comprehensive care plan was developed for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for two (#6 and #13) of four out of 21 sample residents. Specifically, the facility failed to ensure a comprehensive care plan was developed for: -Resident #6's use of oxygen and respiratory cares, and, -Resident #13's use of an antidepressant for [CONDITION(S)] related to lower extremity pain. I. Facility policies and procedures The Care Plan policy, revised November 1988, was provided by the director of nursing (DON) on 5/19/21 at 12:47 p.m. The policy revealed, the plan should be evaluated according to the goals set out in the plan, following each assessment and whenever the resident's condition changes. -A comprehensive cafe plan must be developed for each resident that included measurable objectives and timetables to meet a resident's needs. The plan must developed within seven days after the completion of the comprehensive resident assessment, prepared by an interdisciplinary team that included the attending physician, a registered nurse responsible for the resident, and other appropriate staff as determined by the resident's needs and with the participation of the resident, family/legal representative to the extent practicable. -The care plan should be periodically reviewed and revised at least quarterly and per significant change in the resident's physical/mental/psychosocial condition. -The care plan would be reviewed to ensure that the plan and updates were timely and that the plans contained identifiable integrated staff input, resident/legal representative and physician participation. II. Resident #6 A. Resident status Resident #6, age 93, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/9/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit. She required extensive assistance with two people for dressing, toileting, transfers and limited assistance with one person for hygiene. She had hallucinations and used oxygen. B. Observations Resident #6 was observed on 5/17/21 at 1:15 p.m. sitting in her reclining chair in her room. She wore oxygen, she had a nebulizer machine on her bedside table and she moaned because she was short of breath. -At 1:32 p.m. she pulled her call light bell out of the pocket of the recliner chair and an alarm went off, certified nurse aide (CNA) #1 went into the room to check on her, reassured her she was there to help and left to go get the nurse. -At 1:53 p.m. medical records (MR), who was a nurse, assisted Resident #6 to use a nebulizer medication treatment to help with her shortness of breath. Resident #6 was observed on 5/19/21 at 10:35 a.m. to sit in her recliner chair. She had her oxygen on via nasal cannula and she was calm. She said hi to people who walked by her. -At 12:15 p.m. she was observed in the dining room, she wore her oxygen via nasal cannula. C. Record review The May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -May apply oxygen at two liters (L) per nasal cannula every day and at night, order date was 5/4/21; -[MEDICATION(S)]-[MEDICATION(S)] Solution medication, inhale orally every 12 hours for [CONDITION(S)], order start day 4/29/21 and discontinued on 5/4/21; -[MEDICATION(S)]-[MEDICATION(S)] Solution medication, inhale orally every six hours as needed for shortness of breath or wheezing via nebulizer, start date was 5/13/21. -[MEDICATION(S)] Aerosol Solution medication, one puff inhaled orally four times a day for [CONDITION(S)] order start date was 5/4/21. -[MEDICATION(S)] Suspension one puff in each nostril at bedtime for [CONDITION(S)] start date was 4/29/21. -Record review of Resident #6 care plans on 5/18/21 at 9:30 a.m. revealed no care plan for oxygen and no care plan for respiratory medications. D. Interviews CNA #1 was interviewed on 5/18/21 at 12:30 p.m. She said Resident #6 did wear oxygen and she had shortness of breath at times. She said the resident had to use the inhaled medication a lot to help her with her anxiety. Registered nurse (RN) #1 was interviewed on 5/18/21 at 1:10 p.m. She said she was in charge of doing a minimal data set (MDS) monthly review and when there was a discrepancy she would fix it. The MDS guide assisted with care planning for each resident. She said the facility had a quarterly meeting with the interdisciplinary team to discuss any updates or changes needed to the care plan. The director of nurses (DON) was interviewed on 5/18/21 at 1:30 p.m. She said when a resident entered the facility to admit or readmit, a care plan was created to show the care needed for each resident. She said when a change of condition occurred the care plan was updated by the nurse or the interdisciplinary team. The staff then followed the care plan for each resident. The nursing home administrator (NHA) was interviewed on 5/19/21 at 2:00 p.m. She said the medical records (MR) nurse started the care plan with the director of nurses (DON). She said the care plans were updated when a change occurred to the resident. She said a progress note followed any changes. III. Resident #13 (cross-reference F758 for unnecessary medication) A. Resident status Resident #13, age 87, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/5/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of nine out of 15. The resident was totally dependent on staff for bed mobility, transfers and dressing. B. Record review A nurse practitioner note dated 4/29/21 at 3:20 p.m., revealed the resident had pain in her lower extremity etiology uncertain [CONDITION(S)]. Will administer [MEDICATION(S)] (antidepressant medication) not for depression but rather for treating the [CONDITION(S)] and hopefully pain control also. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 5/5/21 at 10:50 a.m. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident's clinical record did not reveal a care plan for the use of an antidepressant medication with measurable goals and objectives. -The record also did not include non-pharmacological interventions to be attempted prior to the administration of the medication. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Staff interviews The DON was interviewed on 5/19/21 at 9:45 a.m. She said the resident did not have a care plan for the use of an antidepressant medication. A care plan should have been developed to include goals, interventions for the medication and non-pharmaceutical interventions to be implemented prior to the administration of the medication. She said the facility was not tracking the resident's behaviors for the use of this medication. -At 12:14 p.m., the DON said the antidepressant was ordered for [CONDITION(S)] related to lower extremity pain. She said the facility did not have a care plan for the resident's [CONDITION(S)] and one should have been developed. She said the facility was not tracking the resident's hours of sleep. The nursing home administrator (NHA) was interviewed on 5/19/21 at 1:51 p.m. She said a care plan for the use of an antidepressant should have been developed with measurable goals and interventions. She said the plan should have included non-pharmacological interventions to be implemented prior to the administration of the antidepressant. She said the facility should have been tracking the resident's behaviors for the use of this medication. The NHA said a care plan for [CONDITION(S)] should have been developed and the facility should have been tracking the resident's hours of sleep.

Based on observations, record review and interviews, the facility failed to keep the resident free from accident hazards as was possible for one (#18) of four out of 21 sample residents. Specifically the facility failed to: -Ensure thorough and complete neurological assessment for an unwitnessed head injury for Resident #18. I. Facility policy The Occurrence Reporting Policy, reviewed date on 10/2020, was provided by the nursing home administrator (NHA) on 5/1/21 at 1:20 p.m., it read in pertinent part; It was the facilities policy to provide a safe environment as free from hazards as possible and to report the occurances, that meet the elements to be reportable, to the Colorado Department of Public Health and Environment within two hours after the occurence or the facility become aware of the occurrence. Procedure: When an incident occurs an Incident Report and or occurrence report was completed by the charge nurse at the time of the incident. The report was given to the director of nurses (DON) and NHA for review. The report was reviewed within two hours to determine if the elements were met for a reportable.The DON or NHA will submit the occurrence through the health facilities portal and submit the final report within five days after the investigation was completed. The Accident Incident Care and Documentation Guideline, not dated, was provided by the director of nurses (DON) on 5/19/21 at 10:30 a.m., it read in pertinent part; Charge nurse to assess the resident with vital signs and range of motion. Notify the physician and family. Complete the incident report and fall screen investigation report. Update care plan with an intervention. Record on the 24 hour report sheet and document neurological assessments in the computer. Vital signs and neurological status were done every 15 minutes for four times then every 30 minutes for four times then every four hours daily for three days. All other injuries check vitals and neurological status every eight hour shift for 24 hours The Neurological Assessment Flow sheet, provided by the DON on 5/19/21 at 10:30 a.m., read in pertinent part; Instructions were to document the date and time of each assessment. Document the level of consciousness, pupil response time, motor functions with hand grasps and extremities. Pain response, vital signs and any observations such as seizures, headache, vomiting and paralysis. II. Resident #18 status Resident #18, age 89, was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), pertinent diagnoses included traumatic brain injury, dementia depression and [CONDITION(S)]. The 1/31/21 minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance with one person for dressing and limited assistance with one person for bed mobility, transfers, toilet use, and hygiene. She had no behaviors. III. Resident observations and interview Resident #18 was observed and interviewed on 5/17/21 at 1:15 p.m. She was seated in her recliner chair in her room and was asleep, but woke when spoken to. She said she had no pain and she did have night terrors and often moved around in the bed. She reclined in her chair and fell asleep often during the interview. -On 5/19/21 at 3:00 p.m. the resident was interviewed and she said she had a history of night terrors and she did not recall having a fall. Her bed was observed to have enabled bars (half rails) on her bed. She said she used those to help her get out of the bed. The enablers had pads attached to them. The bed measured one inch between the enable bars which were 20 inches long on both sides of the bed were padded. Resident #18 was observed on 5/18/21 at 8:55 a.m. in another residents room. She sat in her wheelchair and rummaged through the drawers of the room. She appeared calm and looked around when staff walked by the room. IV. Record review A. Incident investigation note The incident accident report for Resident #18 dated 4/26/21 at 5:50 a.m. read in pertinent part; A resident yelled down the hallway Resident #18 needed help. Staff entered the room and found Resident #18 to lay backwards on the bed with her head by the foot of the bed. There was a small amount of blood to the back of the head. The investigation typed note regarding the head injury for Resident #18 was provided by the nursing home administrator (NHA) on 5/18/21 at 10:45 a.m., it read in pertinent part: On 4/26/21 Resident #18 was found with her feet at the head of the bed and head at the foot of the bed. Her head was lying on the foot board and blood was there. Resident had been having a restless night and the resident stated she was having bad dreams. Staff were in her room with one on one monitoring most of the night, however at 5:50 a.m. 4/26/21 the resident was heard yelling for help. The staff immediately entered her room to find her in the above noted position. Resident had no complaints concerning her head and a small amount of blood was there with no bump on her head. Vital signs were normal. NHA and DON attempted to reenact the incident from the reports of the staff. They concluded the resident had a possibility of hitting her head on the foot board during the night terror incident on 4/26/21. Cross-reference F609 failure to report. B. Nurse notes The nurse note for Resident #18, dated 4/26/21 at 6:23 a.m. read in pertinent part; Resident #18 had been restless most of the night and the resident stated I am having bad dreams. At 5:50 a.m. resident was found to be crossways at the foot of bed with the back of her head at the foot board. Resident denied pain from the head area, and the nurse saw a small amount of blood on the back of the resident's head. No bump found. Vitals signs completed. Ice applied to the back of her head area. Oncoming nurse was going to inform the doctor, family and the DON. The nurse note for Resident #18, dated 4/26/2021 at 9:40 a.m. read in pertinent part; Notified medical director and residents power of attorney of resident hitting her head on the enabler rail. Resident does have a one centimeter raised, bruised area on the back left side of her head. Resident #18 denied headache, dizziness and nausea. Neurological checks were completed and within normal limits prior to residents going to the assisted living center to visit her husband. The nurse note for Resident #18, dated 4/26/2021 at 7:57 p.m. read in pertinent part; Neurological checks were within normal limits, resident denies any nausea, vomiting, headache or [CONDITION(S)] but does complain of left arm kinda sore. Nurse offered pain medication but the resident refused and stated no its (pain) not that bad ''. Denied any pain to the back of the head areas and the resident refused ice to her head that evening. Night time cares given and in bed at this time. Bed low position, mat by bed. Call light at bedside. Over head light left on per residents complaint of night [NAME] and door left wide open for her. One on one and reassurance given. C. Neurological checks Neurological assessment flow sheet for Resident #18, revealed two assessments were completed on 4/26/21 at 5:50 a.m. The rest of the flowsheet was blank. The neurological checklist note for Resident #18 dated 4/26/21 at 5:50 a.m. revealed the vitals were completed, orientated to person, place and situation. Her level of consciousness was alert and confused. Her pupils and responses were equal and appropriate. Resident denied headache, nausea, vomiting, or [CONDITION(S)] and she had an ice pack to the head area. The neurological checklist note for Resident #18 dated 4/26/21 at 9:43 a.m. revealed the vitals were completed, orientated to person, place and situation. The resident was in the assisted living center visiting her husband. Her level of consciousness was alert and confused with no new onset of confusion. Her pupils and responses were equal and appropriate. Comment note read the medical director and the power of attorney were notified of the resident hitting her head that am. The resident had a one centimeter raised bruised area on the back left side of her head. The resident denied pain, dizziness or nausea. D. Care plan The fall care plan for Resident #18 revised on 5/6/21 read in pertinent part; Resident #18 had a high risk for falls related to confusion, unsteady gait, weakness dizziness and recent (4/29/21) fracture to the right humerus. The goal was to be free from falls with injury and then interventions were to anticipate and meet the residents needs. Ensure the resident was wearing appropriate footwear, non skid shoes. Follow fall protocols and have a physical therapy occupational therapy consultation and treatment as ordered. The activities of daily living (ADL) care plan for Resident #18 revised on 4/28/21, read in pertinent part; The resident had an ADL self-care performance deficit related to impaired balance, limited mobility and range of motion. The goal was the resident will maintain the current level of function in ADL. The intervention was to emulate with one to two people assist, bathing required by one person assistance. Bed mobility required one to two person assistance to reposition and to use the enable rail to assist with repositioning. V. Interviews Licensed practical nurse (LPN) #1 was interviewed on 5/19/21 at 3:00 p.m. She said Resident #18 had a history of night terrors and took medication to help with those. She said the resident had an unknown head injury which she said the staff found the resident to lay backwards in her bed and some blood on her sheets was found. She was not there on that day but received information in daily report. She said the resident had an enabler bar on her bed to help her get up out of bed and the pads on there had been there since she was admitted . She said when a resident hit their head or a fall occurred the fall packet was filled out. She said neurological checks were every 15 minutes for the first four hours then every 30 minutes for four hours and the assessments were documented on the neurological form and also documented in the computer. She said neurological assessments were completed to assess for any changes from the fall or head injury. A potential brain bleed could occur so neurological checks had to happen. Director of nurses (DON) was interviewed on 5/18/21 at 1:00 p.m. She said she had no reports of a fall only that Resident #18 had an incident on 4/26/21 where the resident was found in her bed with blood on her head. She said Resident #18 had night terrors and thrashed around in her bed often. She said when a resident had an injury of unknown origin, a fall or head injury, a neurological assessment was completed every 15 minutes for the first hour then every 30 minutes and the nurse documented the results in a progress note. She said the neurological checks were important with a head injury because a brain bleed may have occurred and the assessments showed any changes. Facility failed to complete neurological assessments in a thorough, timely manner, and in its entirety after a head injury.

Based on record review and interviews, the facility failed to provide a safe environment and protect residents from resident-to-resident abuse, involving three of 17 residents reviewed (#7, #3, #9) and two unidentified residents. (Cross-reference F609, F610, F726, F744, F947). Record review revealed willful abusive behavior (hitting, grabbing, smacking) by Resident #9 on 5/22/2020 and 5/27/20. On 5/22/2020, Resident #9 grabbed the forearm of a resident from room [ROOM NUMBER] and squeezed it real hard, then swung at another resident almost knocking her down, and backhanded the nurse. When told her actions were inappropriate, Resident #9 did not care. Five days later, Resident #9 stood and smacked another unidentified resident on the top of the head. When asked sit down, Resident #9 turned around and smacked the resident again. Record review further revealed Resident #3, severely cognitively impaired and ambulatory, was documented as wandering repeatedly into resident rooms, a behavior contributing to Resident #7's mental distress. Resident #7 expressed Resident #3 gets in her room and it scares her. Interviews revealed facility administration failed to recognize resident-to-resident altercations as abusive and as potentially abusive situations, and take steps to protect residents from physical and mental abuse. The facility's failures above created a situation for serious harm if not immediately corrected. I. Immediate jeopardy A. Findings of immediate jeopardy Record review revealed willful abusive behavior (hitting, grabbing, smacking) by Resident #9 on 5/22/2020 and 5/27/20. On 5/22/2020, Resident #9 grabbed the forearm of another resident from room [ROOM NUMBER] and squeezed it real hard, swung at another resident, almost knocking her down, and backhanded the nurse. When told her actions were inappropriate, she did not care. Five days later, Resident #9 stood and smacked another unidentified resident on the top of the head. When asked to sit down, Resident #9 turned around and smacked the resident again. Record review further revealed Resident #3, severely cognitively impaired and ambulatory, was documented as wandering repeatedly into resident rooms, a behavior contributing to Resident #7 mental distress. Resident #7 expressed Resident #3 gets in her room and it scares her. Interviews revealed facility administration failed to recognize resident-to-resident altercations as abusive and potentially abusive situations, and take steps to protect residents from physical and mental abuse. The facility's failures above created a situation for serious harm if not immediately corrected. On 9/30/2020 at 7:05 p.m., the nursing home administrator (NHA) was notified the facility's failure to recognize and protect residents from resident-to-resident altercations created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 10/1/2020 at 2:26 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Corrective Action: CEO (chief executive officer), NHA (nursing home administrator), DON (director of nursing), and Social Services Coordinator will attend a Zoom presentation on Friday October 2, 2020 with (name of consulting firm) time TBD (to be determined). Immediate Action: All staff working at this time will be educated on what resident to resident abuse is by the NHA, who will read F600 in the State Operations Manual highlighting key terms that will need to be educated to the staff for understanding the definition of abuse. They will acknowledge understanding with verbal read back and by signature. Others will be trained via a phone call by the end of the day on October 1, 2020. Staff will be educated by NHA to monitor for any behaviors that may provoke a reaction by a resident or others which include but are not limited to: - Verbally aggressive behavior - Physically aggressive behavior - Sexually aggressive behavior - Taking, touching or rummaging through other's property - Wandering in others rooms/space. (Name of facility's online training) training has been initiated by (facility name) CEO on 10/1/2020 and is assigned to NHA and DON to complete 10/1/2020 via (name of facility's online training). Verification by certificate. This education has also been assigned to all nursing home staff including dietary and will be verified through (name of facility's online training). Systemic Changes: All staff will be required to do (name of electronic charting program) charting in the hallways in order to more effectively monitor and supervise residents indefinitely. Contract staffing will be educated on abuse prevention and reporting prior to the start of their shift by DON/NHA or designee. Due to turn over and contract staffing; abuse prevention, reporting, investigation education will occur monthly. Monitoring: All education will be monitored to ensure that all staff are getting monthly training. All training will be documented and will be audited monthly to ensure all staff stay up to date and this will be reported in the monthly QA/PI (quality assurance/performance improvement) meeting. During weekly Care Conference social services coordinator will conduct an abuse screening. Consisting of asking resident or family member via phone call if the resident feels unsafe in anyway, and document results in (electronic medical record). An audit will be conducted by the DON or designated personnel weekly for 6 months and monthly therefore until compliance has been assured. This will be reported in the monthly QA/PI meeting. C. Removal of immediate jeopardy On 10/1/2020 at 2:26 p.m. the NHA was notified that based on review of the facility plan, the immediate jeopardy situation had been abated. However, deficient practice remained at an F level, the potential for more than minimal harm that is widespread. II. Failure to provide a safe environment and protect residents from resident-to-resident abuse A. Residents involved in resident-to-resident abuse and potential abuse 1. Physical abuse Resident #9 Resident #9, age 89, admitted on [DATE]. According to the September computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 8/10/2020 minimum data set (MDS) revealed the resident had severe cognitive impairment with a mental status score of 6 out of 15. She required extensive assistance of one staff person for bed mobility and dressing. She required limited assistance of one staff person for transfers, ambulation, toilet use, and personal hygiene. Resident #9's care plan initiated 5/24/19 and last revised 6/10/2020, identified the resident as having a potential to be physically and verbally aggressive with other residents and staff related to dementia. -Interventions initiated on 3/24/2020 included attempt non-medications interventions including activity participation; assessing for pain or toileting needs; reminiscing; providing music activities as the resident previously played the piano and had enjoyed music all of her life; -Interventions initiated on 8/25/2020 included taking the resident outside daily for a short visit as weather permits. 2. Mental Abuse a. Resident #3 Resident #3, age 85, admitted on [DATE] and readmitted on [DATE]. According to the September CPO, [DIAGNOSES REDACTED]. The 8/9/2020 MDS revealed the resident had severely impaired cognitive skills for daily decision making based on the staff assessment for mental status. He was independent with bed mobility and ambulation. He was totally dependent on two staff people for transfers. He was totally dependent on one staff person for dressing and personal hygiene. He required extensive assistance from two staff people for toilet use. b. Resident #7 Resident #7, age 95, admitted on [DATE]. According to the September CPO, [DIAGNOSES REDACTED]. The 7/13/2020 minimum data set (MDS) revealed the resident had moderate cognitive impairment with a mental status score of 12 out of 15. She required limited assistance of one staff person for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. Review of Resident #7's comprehensive care plan revealed Resident #7 had depression related to dementia which was manifested by tearfulness or crying. Pertinent interventions included to monitor/document/report as needed any signs or symptoms of depression including hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. B. Instances of resident-to-resident physical and mental abuse 1. Resident-to-resident physical abuse a. Review of Resident #9's progress notes revealed the following documented behavior notes: -On 5/27/2020 at 5:01 p.m. Resident #9 started to stand up and staff heard the alarm and went in there and Resident #9 was standing and smacking another resident from room [ROOM NUMBER] on the top of the head. Staff asked resident (Resident #9) to sit down and Resident #9 turned around and smacked the resident again. Staff finally got the resident to sit down and she started to hit staff. Staff walked away so the resident could cool down. -On 5/22/2020 at 7:25 p.m. Shortly before supper, the resident became agitated. She grabbed the forearm of the resident from room [ROOM NUMBER] and squeezed it real hard. Two staff members had to pry her hand from his arm. She then started swinging at the resident from room [ROOM NUMBER] when she walked by, almost knocking her down. When the nurse approached her to find out what the problem was, she backhanded the nurse. She was informed that her action was inappropriate. She did not care. When asked if she was in pain, she replied Yes. When asked where her pain was, it was located in her stomach. It was rated at a 10. Her supper time [MEDICATION NAME] and tylenol were given a bit early to ease her discomfort. b. Failure to protect residents from Resident #9. While Resident #9 had a care plan addressing her aggressive behaviors (see above), the plan failed to identify situational triggers that agitated the resident and led her to strike out, such that staff could prevent Resident #9's physically abusive behavior. Moreover, it was unclear what if any interventions were added after the May incidents above. Further, record review revealed no report to the state or investigation of Resident #9's behaviors as abuse. (Cross-reference F609 and F610). 2. Resident-to-resident mental abuse a. Interview with Resident #7 and the activities director (AD) Resident #7 was interviewed on 9/24/20 at 4:10 p.m. She had a STOP sign barrier attached to her door and both sides were attached to one side, leaving the door open. She said, as she pointed to the STOP sign barrier, it doesn't work, he still gets in. She said she was scared when he came into her room. Resident #7 was interviewed again on 9/30/2020 at 1:00 p.m. She said she remembered Resident #3 coming into her room and going through her drawers. She said he made her uncomfortable and she did not want him in her room. She said she did not want to fight with him either because she had seen the way he treated other staff and residents so she would just stay away from him. The activity director (AD) was interviewed on 9/30/2020 at 3:08 p.m. She said Resident #3 frequently entered into Resident #7's room, even though she had a stop sign that was fastened with Velcro across the doorway. The AD said Resident #7 would yell at him (Resident #3) frequently to get out of her room. The AD said when this would happen, she would attempt to diffuse the situation, and then report it to the charge nurse. b. Review of Resident #3's behavior notes documented repeated instances of Resident #3's wandering into resident rooms. -7/3/2020 at 2:34 p.m. Resident continues to wander into other residents' rooms and urinates or attempts to urinate in inappropriate places. He is difficult to redirect. -6/22/2020 at 1:46 p.m. This resident has urinated on the floor in rm(room) 22 and in the tub room today. Is not easily redirected, resident wanders and gets into other residents rooms. -6/20/2020 at 3:01 p.m. Resident has been wandering a lot today. Has been in other residents rooms (#23 and #15). Has been extremely hard to redirect without him being somewhat combative. Has set the alarms off multiple times today. -5/26/2020 at 6:03 p.m. Resident has been wandering the halls, setting off alarms and wandering into other residents' rooms. He is difficult to redirect. -5/9/2020 at 2:23 p.m. This resident was just now in room [ROOM NUMBER]. Had to go remove from room, and room [ROOM NUMBER] was very angry. room [ROOM NUMBER] is standing in her door yelling very loudly I do not want that man anywhere near my room. I do not want him in here ever. -5/5/2020 at 4:00 p.m. Resident was zipping and unzipping his pants in front of a female resident. This was upsetting the female resident. c. Failure to protect Resident #7 and other residents from Resident #3. Record review of Resident #3's 2/26/2020 care plan revealed Resident #3 did not have a care plan or any interventions in place to address his wandering into other residents' rooms, a behavior that contributed to Resident #7's mental distress, as well as others, and also placed Resident #3 at risk for abuse. Resident #7, despite a care plan that addressed her depression, anxiety, sadness and tearfulness, included no references to instances of abuse involving Resident #3. Record review further revealed no report to the state or investigation of abusive and/or potentially abusive resident-to-resident abuse involving Resident #3 (Cross-reference F609 and F610). C. Systemic failure to recognize and respond to abuse The facility abuse prevention policy, issued May 2019, provided by the NHA on 9/30/2020 at 5:48 p.m. documented, in pertinent part: -Policy of (facility name) to ensure all residents are free from abuse; -Protect our resident from abuse by anyone including, but not limited to: other residents; -Require staff training; -Identify all possible incidents of abuse; -Protect residents during abuse investigations; and -Investigate and report any allegations of abuse within timeframes as required. Review of the facility policy and procedures and interviews with direct and administrative staff revealed the facility failed to develop and implement comprehensive written policies and procedures designed to prohibit and prevent abuse, thoroughly investigate allegations of abuse, train staff on recognizing and responding to abuse, and monitor and review staff's understanding and implementation of its abuse policies and procedures. 1. Certified nurse aides (CNAs) CNA #4 and CNA #5 were interviewed on 9/30/2020 at approximately 4:00 p.m. Both CNAs said they were not aware that resident-to-resident altercations were considered abuse. CNA #5 said she does not recall having abuse training since she started at the facility about a year ago, but did have some while working at another facility. Cross-reference F947-the facility failed to ensure certified nurse aides had the required 12 hours of training, including abuse training. 2. Administration The chief executive officer (CEO) was interviewed on 9/29/2020 at 5:30 p.m. He said he had been the CEO since January 2020, but had not been in the facility since March due to Coronavirus. He said he was aware of Resident #3 abusing staff, but he was unaware of the resident abusing other residents. The CEO said he had not provided any training to the NHA specific to abuse. The NHA and DON were interviewed on 9/30/2020 at 12:15 p.m. The NHA said she was probably the abuse coordinator for the facility, but had not provided any training or communication to her staff regarding the abuse coordinator role. She said staff were trained annually, with their last training completed in July 2019 (Cross-reference F726). She did not indicate she or the DON monitored staff's understanding of the facility's abuse policies and procedures. -The NHA and DON said when there was a resident-to-resident altercation in the facility, they were treating it as a behavior and not as abuse. The NHA said she felt like she could identify abusive situations, although said she was unaware that willful (non-accidental) resident-to-resident altercations were considered abuse. -The DON said she had just read the SOM (state operation manual) today, and it was at that time she realized resident-to-resident altercations were not considered behaviors, but were considered abuse. -The NHA said the facility had dropped the ball on understanding all types of abuse. -The DON said that all staff in the facility were in need of education, to ensure they understood all types of abuse.

Based on record review and staff interview the facility failed to ensure Residents (#2, #7, #1 and #3) received adequate supervision to prevent accidents. (Cross-reference F725) Specifically: The facility failed to determine the level of supervision Residents #2, #7, and #1, who ate in the north dining room (NDR), required when eating and, therefore, failed to ensure they received adequate supervision at mealtime to prevent accidents. Resident #2 was ordered an altered diet on admission (textured ground meat). The order was changed to regular texture on [DATE]; however, there was no evidence a chewing, swallowing or nutritional assessment was conducted to explain the change. Further, there was no evidence of a diet order and communication documentation in the medical record indicating a diet change. On [DATE], the resident ate in the NDR unsupervised, choked and/or aspirated per staff reports and subsequently expired. The [DATE] physician's note read, in pertinent part, It does appear that patient died while eating, and aspiration could not be totally excluded. Per the diet card provided by the dietary manager, on the day of the resident's death, she remained on an altered diet, a dysphagia level four diet and received ground meat. Interviews confirmed no staff was supervising the residents in NDR on [DATE] or other days, due to staffing shortages (cross-reference F725); this put Residents #7 and #1, who also had limitations affecting their ability to eat safely, at risk for serious harm unless the situation was immediately corrected. The facility also failed to promptly intervene when Resident #3 fell on [DATE]. The resident fell a second time the same day, sustaining a [MEDICAL CONDITION]. The resident, previously ambulatory, was now in a wheelchair. I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to determine the level of supervision Residents #2, #7, and #1, who ate in the north dining room (NDR), required when eating and, therefore, failed to ensure they received adequate supervision at mealtime to prevent accidents. Resident #2 was ordered an altered diet on admission (textured ground meat). The order was changed to regular texture on [DATE]; however, there was no evidence a chewing, swallowing or nutritional assessment was conducted to explain the change. Further, there was no evidence of a diet order and communication documentation in the medical record indicating a diet change. On [DATE], the resident ate in the NDR unsupervised, choked and/or aspirated per staff reports and subsequently expired. The [DATE] physician's note read, in pertinent part, It does appear that patient died while eating, and aspiration could not be totally excluded. Per the diet card provided by the dietary manager, on the day of the resident's death, she remained on an altered diet, a dysphagia level four diet, and received ground meat. Interviews confirmed no staff was supervising the residents in NDR on [DATE] or other days, due to staffing shortages (cross-reference F725); this put Residents #7 and #1, who also had limitations affecting their ability to eat safely, at risk for serious harm unless the situation was immediately corrected. On [DATE] at 7:02 p.m., the nursing home administrator (NHA) was notified the facility's failure to provide residents with necessary supervision to avoid preventable accidents created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On [DATE] at 2:20 p.m. the NHA submitted the following plan to remove the immediate jeopardy. Corrective Action: 1. Policy will be developed that will address the supervision of residents on altered diets as well as evaluation and assessment of resident's dietary needs. 2. Immediate corrective action on [DATE] all residents are supervised while they are eating a meal or snack. Residents that are eating in their rooms and those that have an altered diet are 1:1 (constant supervision) until assessed by speech therapist or OT (occupational therapist) if OT is qualified to perform assessment. 3.Education with staff that was present (CNA/LPN) (certified nurse aide/licensed practical nurse) on the evening shift/night shift completed [DATE] RN(registered nurse)/NHA. Education completed by LPN with oncoming day shift [DATE] and signatures obtained for education a. Education completed included: i.No residents will eat unsupervised; and specifically mentioned those that have an altered diet. ii.Those that are eating an (sic) HS (bedtime) snack on [DATE] would be supervised iii.Those coming on at 6:00am would be educated by the night LPN iv.Signatures would be obtained by those educated. 4. All staff will be educated on the dietary terminology for diets to ensure all staff are aware of diets that are ordered by [DATE]. Registered dietician notified [DATE] to come review diet cards for accuracy and education for dietary manager regarding diet cards based on the assessment. Kitchen staff will also be educated to ensure that proper diets are being served. 5.Chewing and swallowing assessments will be included in the admission H & P (history and physical) with the physician with referral to the Occupational Therapist if indicated by the physician. 6.Charge nurse on shift, with the assistance of Dietary will monitor residents for chewing and swallowing difficulties and for aspiration risk. At the time of the meal service any diet changes must be approved by the charge nurse. If there are concerns the risk will be addressed by the physician and occupational therapy if indicated or speech therapist if indicated. 7. Facility has increased staffing by hiring three CNAs this month who are completing their orientation. A local staffing agency also provides staffing for the facility. A contract has also been signed with a staffing company for more staffing options. Facility will also utilize office staff for additional supervision. Agency staff will be educated prior to the start of their shift by the charge nurse on the supervision guidelines. C.Who is affected or impacted by this: 1.Those that are indicated for an altered diet will be seated in the dining room so that CNAs/LPN will provide supervision at meals. Residents that have altered diets will eat snacks in a group setting with and monitored by CNA or LPN. 2.All residents prior to admission will be assessed for appropriate diet by physician or Occupational therapy or speech therapy as indicated. D.Systemic Changes: 1.Immediately all residents that are on an altered diet were moved to the dining room for closer supervision by staff. 2.Residents that eat in their room and those that have an altered diet and refuse to leave room will have 1:1 (constant supervision). 3.All current residents will be assessed for appropriateness of altered diet by Occupational therapist or speech therapist as indicated to ensure diets are appropriate. This will be completed by [DATE]. Any concerns brought up after initial assessment will be further discussed with physician and Occupational therapy or speech therapist as indicated. 4. HS snacks will be offered covering all diet orders for residents and residents will be supervised while eating. E. Monitoring: 1.DON or designee will conduct an audit 2 time(s) per week for 90 days in order to ensure residents with alter(ed) diets who are at risk for choking or aspiration are monitored while eating. DON/ designee will report to QAPI (quality assessment performance improvement) any identified issues. DON /Designee will be responsible for any follow up recommendation made by QAPI. C. Removal of immediate jeopardy The immediate jeopardy was removed on [DATE] at 2:20 p.m. based on the facility's plan above. However, deficient practice remained at G level; actual harm that is isolated. II. Residents #2, #7, and #1-Failure to provide adequate supervision The facility failed to determine the level of supervision Residents #2, #7, and #1, who ate in the north dining room (NDR), required when eating and, therefore, failed to ensure they received adequate supervision at mealtime to prevent accidents. A. Resident #2 1. Resident status Resident #2, age 96, was admitted on [DATE] and expired at the facility on [DATE]. According to the September computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent for bed mobility, transfers, ambulation, dressing, eating, toilet use, and personal hygiene. The MDS did not indicate that she had a swallowing disorder. However, record review revealed the resident was to receive an altered diet until [DATE]. -The [DATE] admission orders [REDACTED]. -The nutritional review assessment completed on [DATE], revealed the resident had a regular diet order with a dysphagia level 4 texture order, indicating the resident required foods to be chopped into small pieces. This diet order also was identified on her care plan, initiated [DATE]. - The [DATE] physician's orders [REDACTED]. 2. Failure to determine the level of supervision Resident #2 required while eating a. Record review revealed that although both the nutritional review and the care plan identified Resident #2's diet order as ground meat, neither the nutritional review nor the care plan included a focus to monitor for safety with eating related to Resident #2's altered texture diet order. b. Record review further revealed that although Resident #2's diet was upgraded on [DATE], there were no chewing or swallowing assessments to explain the change or to determine what level of supervision, if any, she now required to eat safely. 3. Failure to provide Resident #2 supervision during mealtime on [DATE], contributing to resident harm. According to the diet card provided by the dietary manager on [DATE] at 5:30 p.m., on [DATE], despite the September CPO that upgraded the resident's diet to regular, the resident's diet card on [DATE] read she was to receive an altered diet, dysphagia level four. The dietary manager said on [DATE] the resident received chopped meat (hamburger). Record review revealed Resident #2 appeared to choke and/or aspirate at the noon meal on [DATE]. She became cyanotic, stopped breathing and her heartrate subsequently ceased. Record review indicated, and interviews confirmed, no staff was supervising residents in the NDR at the lunch meal on [DATE] when Resident #2 experienced this significant change in condition. A progress note, documented by licensed practical nurse (LPN) #1, dated [DATE] at 12:30 p.m. read, About 12:30 p.m. I was called to the NDR for a choking resident. When I arrived a certified nurse aide (CNA) was performing the (H)eimlich maneuver to dislodge the offending object. The resident had a grayish coloring. Her skin looked blue in color. I took over and performed the (H)eimlich. I got up a clear mucus like substance with no solid food particles. The director of nursing (DON) came into the room and assisted with moving the resident to her room. The CO-DONs took over the care of this resident. Another note, documented by the DON, dated [DATE] at 12:41 p.m. read, Called to the NDR to assist with a choking emergency. Upon arrival, the resident was cyanotic with agonal breathing present. Staff report possible choking as the resident was eating her meal at the time when she suddenly stopped breathing. [MEDICATION NAME] maneuver had been attempted multiple times without relief, only clear mucus returned. Resident lifted into a wheelchair and transferred to her bed. No respirations. Heart beat initially present. Resident unresponsive and color ashen. Oral suctioning attempted without improvement. Resident is a DNR (do not resuscitate). Death confirmed at 1:00 p.m. with no breathing, no heartbeat present. Significant other notified and here to see resident. Daughter notified and mortuary preference provided. Physician notified. Coroner here to investigate. A [DATE] physician's note documented, in pertinent part, Cause of death was thought to be a foreign body aspiration; however, it is not clear why patient did not apparently struggle or indicate that she had a problem regarding getting her breath, or choking on something. Also, while foreign body was not removed, it was reported that patient gave a gasp. Patient did have a recent history of [MEDICAL CONDITION], which seemed to be successfully treated. It does appear that patient died while eating, and aspiration could not be totally excluded. Resident #7, moderately cognitively impaired, was interviewed on [DATE] at 4:10 p.m. She said she was in the NDR room about five feet away from Resident #2 who choked. She said she started calling for help. She said there were no staff in the NDR when the incident occurred until residents started yelling for help. The occupational therapist (OT) was interviewed on [DATE] at 5:09 p.m. She said she was at the nurses' station working with another patient when she heard someone faintly screaming for help. She looked toward the NDR and saw a resident waiving her arms and ran down to get help. She said she was able to get the resident help in approximately 20 seconds. Housekeeper (HSK #1) was interviewed [DATE] at 10:09 a.m. She said that she was by the nurses' station with the OT when she and the OT saw Resident #7 screaming help help! The OT told HSK #1 to go get help. She said she went to the MDR and told staff she needed help, she said at that time, the OT ran to the NDR. She said certified nurse aide (CNA) #1 went into the dining room and she thought started the [MEDICATION NAME]. She said she ran and got the resident's wheelchair and took it into the NDR. CNA #1 was interviewed on [DATE] at 10:24 a.m. She said on [DATE], she saw the OT turn the corner from the NDR and heard her yelling for help. She said she went into the NDR and saw the resident sitting at the table, her head was cocked to the side, her eyes were open and her face was blue. She said she started the [MEDICATION NAME] until LPN #1 entered the NDR then she took over the [MEDICATION NAME]. She said then HSK #1 and the DON came into the NDR and said they had the resident's wheelchair in the hall and needed to get the resident out of the NDR. She said she and another staff took the resident into the hall and then put her into her wheelchair. She said as she moved Resident #2, her body was limp and her face was blue, her eyes were open and she was not responding. They took her to her room and put her in bed. She said they gave the resident some oxygen and then the DON said she was a DNR (do not resuscitate so that was all they could do. She said she along with other CNAs cleaned up the resident and covered her up with a blanket. LPN #1, in an interview on [DATE] at 5:25 p.m., said she was near the MDR passing medications when the housekeeper came to her and told her she needed a nurse because someone was choking. She said when she arrived in the NDR she saw a nurse performing the [MEDICATION NAME] on the resident, she took over and sent the nurse to get the NHA and DON. She said the resident brought up clear thick fluid. The DON arrived in the NDR and took over. The DON said she transported the resident to her room in her wheelchair and they placed her in bed. The DON said the resident was in respiratory distress and saw nothing in her airway. She said the NHA attempted to suction her. She said since the resident was a DNR they did nothing else. She said the coroner said that the resident probably did not choke but aspirated. B. Interviews revealed the facility lacked a policy and procedures to identify the level of supervision residents in the NDR required and, therefore, failed to ensure it provided these residents adequate supervision. 1. Residents #7 and #1 who also ate in the NDR a. Resident #7, age 95, per the [DATE] care plan, required assistance with meal set up and cut up due to arthritic hands. Interventions included providing assistance with meal set up and cut up for every meal. b. Resident #1, age 90, per her [DATE] care plan and [DATE] nutritional assessment had difficulty chewing foods. 2. Staff interviews a. CNA #4 was interviewed on [DATE] at 4:05 p.m. She said that she was not working the day Resident #2 died . However, when she started her next shift she was told that no one will be eating alone in the NDR because of the choking death. She said usually there were five to six residents who ate in the NDR independently. She said staff never went into the NDR because they had to stay in the main dining room (MDR) to assist residents who required assistance with meals. b. CNA #2 and CNA #3 were interviewed on [DATE] at 4:30 p.m. CNA #2 said that after the choking incident, every resident was moved to the MDR and no one was allowed to eat in the NDR alone. She said when residents were eating in the NDR, staff would use wipes to wipe residents' hands, ensure they had what they wanted to drink and leave the room. She said there was never any staff in the room while residents ate. c. LPN #1 and the DON were interviewed on [DATE] at 5:25 p.m. about the residents that dine in the NDR and the level of supervision they received during the meal. The DON said that residents in the NDR were independent with meals and were safe to be in the NDR because they were not considered high fall risks and did not have a mechanically altered diet. The DON said that she was not aware Resident #2 had a mechanical texture. She stated, however, they would not do anything different in the NDR, knowing this, indicating that residents on an altered diet were not assessed to determine the level supervision they required to eat safely. The DON said when a resident would eat a meal either in their room or in the NDR, rounding was basically what we offer for supervision and rounds were completed every hour. She agreed residents would normally take less than one hour to finish eating and that a resident could choke in under one hour. LPN #1 said the facility did not have a rounds protocol but would usually round every two hours. She said during meals, all staff were in the MDR assisting residents. The LPN reviewed the current census that was provided by the NHA on [DATE], and said currently there are 13 residents who need assistance and that's not including anyone who requires set up. b. The NHA was interviewed on [DATE] at approximately 2:00 p.m. She confirmed the lack of staff supervision in the NDR. The NHA said that residents who had any type of difficulty with eating or weight loss should be supervised but confirmed the facility had no specific policy about the assessment of or the level of supervision a resident required if they had an altered diet. She confirmed they did not have enough staff to also provide supervision for residents who had been eating in the NDR because all of the available staff were in the MDR during all meals to assist residents who required more assistance with meals. (Cross-reference F725) III. Resident #3-Failure to intervene to prevent a repeat fall with injury A. Resident #3's status Resident #3, age 85, admitted on [DATE] and readmitted on [DATE]. According to the September CPO, [DIAGNOSES REDACTED]. The [DATE] MDS revealed the resident had severely impaired cognitive skills for daily decision making based on the staff assessment for mental status. He was independent with bed mobility. B. Known to wander and assessed at high risk to fall 1. Record review revealed he was ambulatory and wandered the facility and into resident rooms (cross-reference F600) until the fall on [DATE]. After his fall and return to the facility he wandered the facility into resident rooms while in his wheelchair. 2. The [DATE] Morse Fall Scale documented an individual who had a high risk of falling would be over a 45. Resident #3's score was a 75 indicating he had a high fall risk. 3. Record review further revealed his [DATE] care plan documented the resident was at high risk for falls related to confusion, impulsive behavior and unawareness of safety needs. The goal was for the resident to be free from falls, minor injury and serious injury. Interventions included using a cushion for wheelchair positioning, anticipate resident needs, ensure call light is within reach, encourage activity participation, and ensure appropriate footwear. C. Repeat falls [DATE] 1. A [DATE] fall scene investigation report documented the resident fell at 12:45 a.m. The resident slid to floor on buttock while in his room and staff found him on the floor. Vital signs were not obtained. Staff documented Roommate (sic) state(d) resident amb(ulated) around room prior to noticing resident sitting on buttock on floor, back leaned up against wall with legs straight out in front of resident. There was no documentation a fall huddle occurred. The root cause of the fall area on the form indicated the cause was medication. There was no further explanation and no plan to increase supervision of the resident. 2. A second [DATE] fall scene investigation report documented also documented the resident fell at 12:45 a.m. The resident was ambulating down the east hall going towards NDR. He was going kind of fast and by the time he got to the end of that hall he fell . Landed on R (right) side but (complained of) L (left) hip/ankle/foot pain. Was sent to the ER (emergency room ). The resident was ambulating in the hallway prior to the fall. Staff documented Got chair at NDR to put him in. He yelled/screamed horribly when getting him up off the floor. Noticed outward position of Left food. Landed on Right side, but complained of Left side hip, foot, ankle pain. Neither fall scene investigations had any fall interventions listed or staff signature indicating that the interdisciplinary team (IDT) had reviewed the fall. The [DATE] physician consult from the hospital upon admission documented the resident was being transferred to the hospital due to a left hip intertrochanteric [MEDICAL CONDITION] after a mechanical fall at the facility. C. Staff interviews The DON was interviewed on [DATE] at approximately 9:30 a.m. She said the fall scene investigation was the only thing staff had completed for each fall. She said there were no additional interventions put into place between the first and second fall and no other type of assessment. She said it really was awful; commenting on how the resident had changed and now was in a wheelchair.

Based on record review, and interviews, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicated otherwise for one (#3) of four out of 17 sample residents. The facility failed to adequately assess and monitor the nutritional needs for Residents #3 timely. Resident #3 had nutritional risks based on his [DIAGNOSES REDACTED]. Furthermore, the occupational therapist recommended a puree (blenderized) diet, the resident be fully erect at meals and staff providing assistance on 8/17/2020, which was not consistently implemented by facility staff. Moreover, the registered dietitian recommended a supplement, which was not addressed timely, after the resident had a 20 pound weight loss and was not provided due to the lack of a physician's orders [REDACTED].#3 sustaining significant weight loss and Resident #3 was put at significant risk due to the facility staff not consistently providing the diet prescribed to him (cross-reference F689 for accident hazards). Findings include: I. Facility policy The weight loss policy and procedure was requested on 10/1/2020 at 9:30 a.m. No policy was provided by the facility. II. Resident #3 A. Resident status Resident #3, age 85, admitted on [DATE] and readmitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 8/9/2020 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive skills for daily decision making based on the staff assessment for mental status. He was independent with bed mobility. He was totally dependent on two staff people for transfers. He was totally dependent on one staff person for dressing and personal hygiene. He required extensive assistance from two staff people for toilet use. He required limited assistance from one staff person for eating. He had experienced a weight loss of five percent or more in the last month or 10 percent or more in the last six months, and was not on a physician prescribed weight loss regimen. B. Record review Review of the resident's electronic medical record revealed he sustained a left [MEDICAL CONDITION] following a fall on 7/25/2020. The resident was discharged to the hospital for treatment of [REDACTED]. Review of the resident's weights for July, August, and September 2020 revealed the following: -7/5/2020-153 pounds (lbs) -7/12/2020-153 lbs -8/9/2020-136.7 lbs, the resident had a loss of 16.3 lbs between 7/12/2020 and 8/9/2020 following the left [MEDICAL CONDITION], a significant weight loss of 10.7 percent in one month. -8/16/2020 - 137.1 lbs -8/23/2020 - 126.7 lbs, the resident had a loss of 10 lbs between 8/9/2020 and 8/23/2020, a significant weight loss of 7.3 percent in two weeks. -8/30/2020 - 132.9 lbs -9/06/2020 - 133.1 lbs -9/13/2020 - 135.9 lbs -9/20/2020 - 137.5 lbs -9/27/2020 - 136.7 lbs The 8/6/2020 diet order read advanced level three texture (ground meat) and nectar like thickened liquids. The 8/10/2020 diet order read to trial finger foods for three days. The 8/11/2020 diet order read mechanical altered texture and nectar-like thickened liquids per OT (occupational therapy) recommendations. Review of the comprehensive care plan initiated on 8/11/2020 and revised on 9/9/2020 revealed Resident #3 had a potential nutritional problem related to dementia and loss of weight following [MEDICAL CONDITION]. Interventions included to serve regular diet as ordered, for the registered dietitian (RD) to evaluate and make diet change recommendations as needed (PRN), and for the resident to eat his meals in the dining room so staff could cue him and assist him with meal set up and cut up. The nutritional review assessment completed on 8/11/2020 revealed the resident had a regular diet order with a mechanical soft, dysphagia level 3 texture order with nectar thick liquids, indicating the resident required moist foods in bite sized pieces. He required liquids the consistency of fruit nectars. The 8/17/2020 occupational therapy initial examination documented the resident had a history of [REDACTED]. The 8/17/2020 physician's orders [REDACTED].>-Ensure patient fully erect when eating; -Puree diet; -Thin liquids only; and, -Continue to aid with meals. The 8/17/2020 daily note/occupational therapist evaluation documented the resident demonstrated no difficulty with thin liquids when seated upright from a cup. Additionally the evaluation documented that the resident demonstrated his greatest success with achieving proper nutritional intake via puree food that does not require extensive chewing prior to swallowing. The documented plan recommended thin liquids, puree food, upright at 90 degrees for all meals with assistance and supervision. The 8/17/2020 diet order read thin liquids with no clarification of diet texture. In addition, the recommendations from the OT on 8/17/2020 were not placed on the resident's comprehensive care plan, a directive for staff care. A progress note written by the RD on 8/23/2020 at 3:32 p.m. documented the following: Resident's weight measured on 8/23/2020 was 126.7 lbs and weight measured on 8/9/2020 was 136.7 lbs as this is a 7.3 percent weight loss in two weeks or significant change in weight. Weight measured on 7/12/2020 was 153 lbs as this is a 17.1 percent weight loss or change in weight in one month or significant. Weight measured on 5/24/2020 was 145.9 lbs as this is a 13.2 percent weight loss in three months or significant. Current body mass index (BMI) is 18.2 or down from 19.6 two weeks ago or underweight for age/elderly or less than 23. Ideal body weight is 166 lbs as resident is 76 percent of ideal body weight. Resident recently returned from the hospital after left hip surgery on 7/31/2020. It is noted that resident is three person assist for transfers and is full cares as incontinent of bladder and bowel. Resident is being fed (assisted) by nursing in bed as it's been noted that he has been consuming 25 percent to 50 percent of meals. Resident's meal plan has been switched and continues to be nectar-thickened liquids and mechanical soft foods. Resident is consuming 890 milliliters (ml)/3.8 cups/30 ounces (oz) of fluids. Recommend to continue to offer Mighty Shake/120ml/1.7kcals (kilocalories)/6 grams of protein three times a day (TID) between meals and TID with meals for healing and strengthening as this will provide 52 percent to 59 percent of recommended energy needs (based on current body weight and based on 35kcals/kg (kilogram) to 40kcals/kg) and provide 40 percent to 48 percent of recommended protein consumption (based on ideal body weight and based on 1.0 gm (grams)/kg to 1.2 gm/kg). Recommend to encourage fluid consumption. Recommend to continue to help feed resident in the resident's room. Recommend to follow-up with a primary care provider for continued care. Will continue to monitor. -There were no orders for supplemental nutrition found in the September CPO that was recommended for the residents weight loss on 8/23/2020. The resident had lost 26.3 lbs from 7/5/2020 to 8/23/2020 that was not addressed timely by the RD and nutritional interventions initiated. The 8/31/2020 daily note/occupational therapist evaluation documented the resident had no episodes of coughing or dysphagia with this diet level (puree), diet was not changed on this evaluation. Review of the September CPO revealed the resident had an order with a start date of 9/11/2020 for a regular diet with regular texture food that was contrary to the diet order recommended in the nutritional assessment on 8/11/2020 and by the OT on 8/17/2020. Review of the progress notes revealed the following note written by the director of nursing (DON) on 9/1/2020 at 7:24 p.m. Resident #3 was able to feed himself a regular texture diet without difficulty swallowing and no coughing or choking. Diet will be permanently advanced to regular texture. Dietary notified. The progress note did not indicate that an order for [REDACTED]. The 9/1/2020 diet order read regular texture foods with thin liquids. The upgraded diet order on 9/1/2020 was signed by the DON. There were no chewing or swallowing assessments to determine eating safety and the need for supervision found in the resident's electronic medical record. III. Staff interviews The director of nursing (DON) was interviewed on 10/1/2020 at 9:45 a.m. She said the resident had his diet upgraded after he was eating safely upon observation by staff, including CNAs and the DON. She said they were concerned about his weight and thought by upgrading him this could potentially help him gain weight if his texture was changed. The DON confirmed this change had been determined by her and the decision was not discussed with the occupational therapist. The registered dietitian (RD) was contacted on 10/1/2020 at 2:51 p.m. during the time of the survey, the RD did not return the call and was unable to be interviewed. The nursing home administrator (NHA), chief executive officer (CEO), and DON were interviewed on 10/1/ at 4:13 p.m. The DON said after looking at the resident's diet orders, there needed to be a new system for diet orders because there was too much confusion as to the actual diet order. The DON said she would need to review Resident #3 chart to see all of the weight loss interventions that were in place in an attempt to prevent his weight loss. The DON said there was some confusion in the documentation, which did not include the time the resident was in the hospital. The DON said she would review the chart and follow-up. The CEO said only a resident's physician, a registered dietitian or a speech language pathologist (SLP) could upgrade a resident's diet. The CEO said the facility did not currently have a (SLP), so only a resident's physician could upgrade a resident's diet, meaning they could write an order for [REDACTED]. The NHA said there were several problems with the facilities current procedure for inputting resident diet orders. The NHA said the current system was confusing, and could lead to the kitchen not knowing if a resident's diet had been upgraded or downgraded. The NHA said it was a system that needed to be addressed and updated.

Based on observations, interviews and record reviews, the facility failed to ensure one (#24) of three out of 17 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to adequately supervise Resident #24. Resident #24 was assessed at high risk for falls due to her [DIAGNOSES REDACTED]. Contrary to her toileting care plan, she was left unattended in the bathroom, stood up and fell , hitting her head on the floor. Her fall was followed by [MEDICAL CONDITION] activity. Findings include: A. Facility Policy and Procedure The facility Fall Management policy, developed 11/06 with the last review on 10/14, read in pertinent part: - A resident that scores a ten or higher on the fall risk assessment will have interventions initiated on the potential for fall care plan; - A review of interventions implemented on the specific resident to determine benefits associated with each intervention will be done by interdisciplinary team (IDT) and restorative nurse; and - A resident that triggers for fall risk will have care plans implemented addressing underlying illness and problems, medications, functional status, sensory status, psychiatric status, environmental barriers and interventions implemented. B. Resident #24 1. Resident #24 Status Resident #24, age 92, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders, [DIAGNOSES REDACTED]. a. Minimum Data Set (MDS) assessment According to the 12/19/17 minimum data set (MDS) assessment, the resident had both short term and long term memory problems as evidenced by not knowing the current season, the location of her room, staff names or faces, or that she was in a nursing facility. The resident was moderately impaired regarding daily decision making and required cues and supervision. The resident required one person assistance with bed mobility, dressing, eating, toilet use, personal hygiene, walking in her room and in the corridor, and locomotion on and off the unit. She was not steady moving off the toilet and was only able to move off the toilet with human assistance. Since admission in 2013, she had a fallen but had not had major injury from the falls. The following alarms were in use daily: bed alarm, chair alarm and an elopement alarm. b. Fall risk assessments and investigations Review of the resident's fall risk evaluations revealed the resident was evaluated 15 times for her fall risk. Her scores from 3/15/16 to 12/22/17 revealed she was assessed at high risk for falls each time with scores ranging from 11 to 22; a score over 10 represented high risk. Review of fall investigations revealed the resident had fallen five times in (YEAR), with her last fall 12/9/17. Review of the investigations and interview with the restorative nurse/licensed practical nurse (LPN) #1 on 4/5/18 at 12:35 p.m. revealed while in her wheelchair, the resident frequently tried to pick things up from the ground and would fall out of the wheelchair. c. Care plans Review of the resident's care plans revealed the facility had developed many interventions to address the resident's safety from falls and while toileting. Review of the resident's fall care plan related to dementia revealed it had been frequently updated with interventions, including call light within reach, pressure alarm to surfaces, and to wheelchair the following: tab alarm, lap tray, anti-roll back, and bolster cushion with dycem. (The lap tray was discontinued 9/17/17 and the bolster cushion discontinued 6/8/17.) Review of the resident's toileting care plan related to dementia also had been updated several times. Interventions included one to two person assist every two to three hours and as needed with toileting and observe and monitor when toileting 2. Fall 3/2/18 Review of nurses' notes, fall investigation, and hospital discharge summary revealed the resident was not observed and monitored while toileting on 3/2/18 as care planned (see above) despite knowledge of her high risk for falls. The resident stood, fell , hit her head and experienced [MEDICAL CONDITION] activity after the fall. a. Nurses' notes and hospital discharge summary A 3/2/18 7:25 p.m. nurses' notes documented, Resident in bathroom with CNA (certified nurse aide). CNA stepped out to let another CNA take over care. Resident fell (very, very loud bang). CNA enter bathroom with this nurse. Resident on floor with pants down. Resident hit head, [MEDICAL CONDITION] noted - pupils big, hand, leg, body straight and rigid (confusions noted). Breathing irregular, mouth had small amount of blood, this lasted about 1 minute. A 3/2/18 nurse's note beginning at 7:30 p.m. documented, Ambulance and hospital notified. Family (name) notified. 7:40 p.m. ambulance arrived, transported to hospital emergency room for evaluation. 9:30 p.m. - family call to see if they know anything. Hospital call stated alert, headache CT done. No finding noted. 10:00 p.m. transported back to nursing home, via wheelchair and CNA. Neuros (neurological assessments) and vitals signs started per policy. The 3/2/18 hospital discharge summary documented in pertinent part, patient was brought by emergency medical services (EMS) from the nursing home after falling in the bathroom. Nursing home staff were just outside the door and heard the patient fall. Licensed practical nurse (LPN) said the patient was staring and not answering, with fingers extended for about a minute when they opened the door, interpreted as a possible [MEDICAL CONDITION] . b. Fall investigation The 3/2/18 fall investigation documented the resident was in the bathroom with a CNA, the CNA stepped out to let another CNA in the bathroom. The resident fell hard, hit head, [MEDICAL CONDITION] noted. The CNA said the resident was trying to get self off toilet. Interventions included don't leave her alone for one second, use stand up lift. This intervention, Do not leave alone in bathroom, was added to her fall care plan 3/5/18. 3. Staff interviews Staff interviews confirmed the resident should not have been but was left alone while toileting. CNA #3, who was working with Resident #24 when the fall occurred, was interviewed on 4/5/18 at 2:15 p.m. The CNA said she had taken the resident to the bathroom in the hallway bathroom because it was easier to move the resident around in that bathroom. The CNA said the resident was sitting on the toilet prior to the fall. -She said the other CNAs working that evening were coming back from their break and she opened the bathroom door a crack to talk with the other CNAs but said she looked over her shoulder to check on the resident to make sure she was still seated on the toilet. -She said as she was leaving the bathroom to let in another CNA, the resident stood up and then fell . The CNA said when the resident fell , she hit her head on the ground. LPN #1 was interviewed on 4/5/18 at 3:40 p.m. The LPN said she was not in the building when the fall happened, but she talked with the staff that were working as part of the fall investigation. -The LPN said she had received conflicting stories about what occurred when the resident fell ; one CNA working the evening of the fall told her the door was closed and the resident was alone in the bathroom and another CNA, CNA #3, said the door was open a crack when the resident fell . -The LPN said the resident was a known fall risk and should not have been left alone in the bathroom. The interim nursing home administrator (INHA) was interviewed on 4/5/18 at 3:59 p.m. The INHA said she was not in the building at the time of the fall. The INHA said it was her understanding the CNA took Resident #24 to the bathroom, left her unattended and then heard a loud bang. Upon entering the bathroom, staff saw the resident exhibit [MEDICAL CONDITION] activity. The INHA said the resident had a history of [REDACTED]. The director of nursing (DON) was interviewed on 4/5/18 at 4:05 p.m. She, too, said she was not in the building at the time of the fall and was not sure what had occurred when the resident fell . The DON said Resident #24 was a known fall risk and any resident who was a known fall risk should not be left unattended in a bathroom.

Based on observations, record review, and interviews, the facility failed to provide an environment free from accident hazards for 3 of 3 sample residents out of 9 residents at risk for accident hazards. Specifically: -The facility failed to prevent resident #14 from repeated falls, including one fall that resulted in a hip fracture. The facility failed to review the resident's existing fall interventions for efficacy, continued to promote known ineffective interventions (instructing the resident to call for assistance, placing her call light in reach), and failed to implement new interventions to promote safety, including increasing supervision of the resident. -The facility failed to ensure that side rails and mattresses were secure and safe for residents #16 and #30. The findings include: A. Fall policies The facility's current fall prevention policy was provided on 9/17/14 as part of a policy request. The policy stated that the intent was to "...identify each resident that is at risk for accidents and/or falls and ... adequately plan care and implement procedures to prevent falls." The facility's fall policy stated, "... Fall Risk Assessments will be repeated ... with every fall and with every significant change ..." and required "...a review of interventions after completion of the fall RAP (resident assessment protocol) module to determine benefits associated with each intervention." B. Resident Failures 1. Resident #14 Resident #14, age 101, was readmitted to the facility on [DATE] following a hospital stay. The resident's face sheet indicated that she suffered from dementia, hypertonicity of bladder, and osteoarthrosis. a. Resident Status The resident's most recent minimum data set (MDS), dated [DATE], indicated that the resident was totally dependent for toileting and transferring. The resident was frequently inattentive, displayed disorganized thinking and suffered from memory loss; she was not able to remember staff, the current season, or that she was in a nursing home. The resident's cognition and decision making capacity were impaired. The resident's three most recent fall risk assessments, dated 3/14/14, 6/11/14, and 7/30/14, all indicated that the resident was at high risk for falls. The resident's medical chart contained an informed consent for the use of safety devices, which indicated that on 1/8/13, the resident had begun to use a bed and wheelchair alarm, due to a lack of safety awareness. -A note on the consent form, dated 1/30/14, indicated that the resident continued to require the alarm due to lack of safety awareness and the resident not utilizing her call light. -A note on the consent form, dated 3/21/14, indicated that the resident continued to require the alarm due to lack of safety awareness. b. Record Review A review of the resident's medical chart and incident reports indicated that the resident had fallen four times in the previous six months. Record review revealed the facility failed to review existing fall interventions for efficacy, continued to promote known ineffective interventions (instructing the resident to call for assistance, placing her call light in reach), and failed to implement new interventions to promote safety, including increasing supervision of the resident. (1) Fall #1 An incident report from 3/25/14 indicated that the resident had been found on the floor of her room by a certified nurse aide (CNA), who heard a "yelp" from the hallway and turned to see the resident falling onto the floor. The resident landed in front of her bathroom with the wheelchair behind her. The incident report indicated that a motion alarm was in place. The report did not identify any new interventions to be put in place following the fall. A nurse's note, dated 3/25/14 at 2:15 p.m. indicated that the resident was observed falling in her room by a CNA. The CNA stated that the resident fell and hit her head in front of the bathroom. The nurse's note indicated that the resident received a neurological check and vital signs in accordance with the facility's fall policy. However, the nurse's note did not indicate that a fall assessment was conducted for the resident. A nurse's note dated 3/26/14 at 3:00 p.m. indicated that the resident had a neurological exam and vital signs taken as follow up to the fall. The nurse's note also indicated that the resident was encouraged to call for assistance, and that the resident's call light was placed within reach. The nursing note did not mention a follow up fall risk assessment or increased supervision to ensure resident safety. A nurse's note dated 3/27/14 at 10:05 p.m. indicated that the resident received a neurological check and follow up vital signs regarding the fall on 3/25/14. The nurse's note indicated that the resident was instructed to call for assistance and that the call light was placed within reach. Failures in facility response: -There was no fall assessment in the medical chart that was conducted in association with the resident's fall on 3/25/14, contrary to facility expectations (see above). -The resident's fall prevention care plan did not contain any new interventions put into place following the fall on 3/25/14, and nursing notes continued to refer to placement of the resident's call light (see above), even though the resident was known to not use her call light. There was no reference to increasing the resident's supervision. -A note on the consent for the use of safety devices form, dated 6/10/14, indicated that the resident continued to require the alarm due to a lack of safety awareness. No note was made of the resident's fall on 3/25/14, and no assessment of the efficacy of the device was included. (2) Fall #2 An incident report from 7/16/14 indicated that the resident's alarm had sounded, and the resident was found sitting on the floor in the bathroom. The resident was confused and had been trying to transfer to the toilet. The incident report indicated that fall prevention care had been in place. The incident report did not indicate any new interventions to be put in place following the fall. A nurse's note dated 7/16/14 at 5:10 p.m. indicated that the resident was found on the floor in the bathroom with her alarm sounding. A nurse's note dated 7/16/14 at 7:45 p.m. indicated that a CNA requesting help transferring the resident to the toilet when she began complaining of leg pain in both her right and her left legs. The nurse's note described the resident as yelling out in pain and then becoming unresponsive with a pale color and pinpoint pupils. When the resident became responsive, she described her pain as being a 10/10 with movement. The resident was transported to the hospital via ambulance. An intake record dated 7/16/14 from the County Health Center indicated the resident was admitted to the hospital on [DATE] at 8:35 p.m. with hip pain following an unwitnessed fall. The intake record indicated that the resident had been trying to go to the bathroom when she fell . -An examination record dated 7/16/14 indicated that the resident had an x-ray due to pain following an unwitnessed fall. The record indicated that the resident had a fracture on her left hip. -A physical therapy note dated 7/28/14 indicated that the resident was seen for physical therapy following the fall on 7/16/14. -A quarterly fall risk assessment was conducted for the resident on 7/30/14. The fall assessment indicated the resident was a high risk for falls, the resident's balance during transfers or standing was not present without physical assistance, and the resident displayed cognitive or behavioral patterns that placed her at risk for falls. The fall assessment also indicated that the resident toileted independently and was incontinent. Failures in facility response: -The resident's Fall Risk care plan did not demonstrate any new interventions following this fall, and was most recently reviewed in the quarterly care conference 6/10/14, which was prior to the fall. Although the resident had fallen twice near or in the bathroom, there was no plan to assess the resident's toileting schedule or her need for supervision when transferring to the bathroom. (See above fall assessment, documenting the resident toileted "independently.") -The resident's most recent ADL functional/restorative assessment was on 6/10/14, and scored the resident as independent to set up assist only in transfers and ambulation. There was no updated ADL assessment subsequent to the fall on 7/16/14 whether the resident could continue to safely transfer and ambulate after two falls. -The resident's consent for use of safety devices form did not include any information regarding the fall on 7/16/14. No additional devices were added, and no assessment of the efficacy of the current device (the chair alarm) was included. -The resident's care plan for fall prevention did not contain any new interventions put into place as a result of the 7/16/14 fall. There was no plan to increase supervision of the resident. (3) Fall #3 An incident report from 8/8/14 indicated the resident had been found beside her bed next to her wheelchair. The incident report indicated that the resident had a skin tear on her left arm. The incident report indicated that the same preventative measures included in the 7/16/14 incident report were in place; namely, a fall prevention care plan was in place, and the resident had a fall alert identifier and a call light in reach. The incident report also indicated that there were no additional interventions put in place. A nurse's note dated 8/8/14 at 2:00 p.m. indicated the resident was found lying on the floor in front of her wheelchair beside her bed. The note indicated that the alarm on the wheelchair had not gone off. The resident had a two inch by two inch L shaped injury on her upper right arm. A steri strip was applied and the wound was wrapped. A nurse's note dated 8/9/14 at 11:00 a.m. indicated follow up care was performed for the resident after the fall on 8/8/14. The note indicated that the resident had a neurological check. The note did not contain information about any interventions relating to the resident's fall risk. A nurse's note dated 8/10/14 at 9:15 p.m. indicated that the resident received a vital sign check and a neurological examination as follow up to the fall on 8/8/14. The note indicated that the resident was encouraged to call for assistance. A nurse's note dated 8/11/14 at 2:00 p.m. indicated that the last set of neurological examinations and vital signs was conducted as follow up to the 8/8/14 fall. The note stated that the resident was reminded to call for assistance. Failures in facility's response: -The resident's medical chart did not indicate a fall assessment was conducted after this fall. -The resident's care plan was not updated to reflect any changes in the resident's fall prevention interventions as a result of the fall. There was no indication that current interventions were re-evaluated for effectiveness and no plan to increase the resident's supervision. -The resident's consent for use of safety devices form did not include any information regarding the fall on 8/8/14. No additional interventions were added, and no assessment of the efficacy of the current device (the chair alarm) was included. There was no information on why the alarm had not sounded because the resident had self transferred from her bed to her wheelchair when she fell or if the resident was in the process of self transferring from her wheelchair to bed and if so, why the alarm had not sounded. (4) Fall #4 An incident report from 8/18/14 indicated the resident was found on her back in front of her closet with her chair alarm sounding. The incident report indicated that the resident had a call light in reach as well as a motion alarm and gait training. The incident report did not indicate any new interventions were to be initiated. A nurse's note, dated 8/18/14 at 2:00 p.m. indicated that the resident's wheelchair alarm had sounded, and the resident was found lying on the floor in front of her closet. The note indicated that the resident had hit her head on the wall, but that there was no swelling or bleeding. The note indicated that the resident's power of attorney was notified and he requested that a lap tray be placed on her chair so she could not get up and would quit falling. A nurse's noted dated 8/18/14 indicated that the resident received vital signs and a neurological check as follow up to the fall. The resident was encouraged to call for assistance. An update, dated 8/18/14, on the resident's informed consent for use of safety devices indicated that the resident's power of attorney requested that a lap tray be added to the resident's wheelchair to prevent her from independently transferring while in her wheelchair. A physician order [REDACTED]. risk care plan was updated to reflect the addition of a lap tray to the resident's wheelchair. However, nurses' notes 8/18, 8/19, and 8/20/14 indicated the resident refused the placement of the lap tray on her wheelchair. Failures in facility response: -There was no fall risk assessment in the resident's medical chart in response to the fall on 8/18/14. -There was no plan to increase the resident's supervision, no plan to investigate why the resident was self transferring, no plan to re-evaluate her toileting schedule, no evidence the facility investigated the resident's resistance to the lap tray. -There was no plan, when the resident refused the placement of a lap tray, of other interventions to keep the resident safe from additional falls even though nursing documented multiple attempts by the resident to stand on her own. Rather, notes 8/20 and 8/21/14 continued to encourage the resident to call for assistance, which she was known not to do. c. Observations Multiple observations of the resident revealed the ordered lap tray was not in use. Although she was observed with the wheelchair tab alarm in place, no staff were observed in the resident's hallway or room to ensure the resident was adequately supervised. In one instance, the resident was observed attempting to use the bathroom by herself; staff was not aware of this incident until notified by surveyors who witnessed the event. Specifically: (1) On 9/15/14 at 1:00 p.m. the resident was observed napping in her wheelchair in her room with a tab alarm, but no lap tray, in place. There were no staff present in the resident's room or in the hallway. (2) On 9/15/14 at 3:17 p.m., the resident was observed sitting in her wheelchair in her bedroom with a tab alarm, but no lap tray, in place. The hallway outside of the resident's room did not have any staff present, and the resident was alone in her room. (3) On 9/16/14 at 12:05 p.m. the resident was observed self-propelling through the halls of the facility in her wheelchair. The resident did not have a lap tray in place. (4) On 9/17/14 at approximately 3:00 p.m., the resident was observed in the bathroom by herself, with her chair alarm sounding. There were no nursing staff in the immediate vicinity or at the nurses' station, and no staff was responding to the alarm. The surveyor notified the first available staff, which was the facility's MDS coordinator, that the resident's alarm was sounding and that she was trying to use the toilet unaccompanied. The MDS coordinator and a second surveyor proceeded to the resident's room, where the MDS coordinator confirmed by observation that the resident was on the toilet by herself and stated, "Oh (Resident's name).Well, you made it." At that time, CNA #2 entered the room and told the MDS coordinator that she would assist the resident. d. Staff Interviews Interviews with the facility's nursing and social services staff confirmed that the resident suffered from cognitive impairment to the point that she was unable to assess her own physical limitations. The staff interviews also confirmed that the resident frequently experienced falls while attempting to independently use the bathroom, that the resident had broken her hip during the fall on 7/16/14, and that the lap tray was not in use. (1) On 9/17/14 at 9:20 a.m., CNA #1 was interviewed. The CNA stated that the resident required assistance with toileting and wore a brief due to incontinence. The CNA stated the resident tried to get out of her bed or her chair and had fallen multiple times, so the facility had a tab that was attached to the resident's clothes. If the resident tried to get up, the tab would pull out and an alarm would sound, alerting the staff that the resident was trying to get up. (2) On 9/17/14 at 7:02 p.m., CNA #2 was interviewed. The CNA stated that she had been at the facility for three years, and she had worked with resident #14 since she had been there. The CNA stated that the resident had a pattern of multiple falls, and the facility had placed a tab alarm on the resident's chair and bed so that there would be an alarm if the resident tried to get up on her own. The CNA stated that the resident was incontinent of bladder about half the time. The CNA stated that the resident frequently attempted to transfer herself onto the toilet, and that she had fallen multiple times as a result. The CNA also confirmed that a fall on 7/16/14 had resulted in a hip fracture, and that the resident had fallen two times since then. The CNA stated that she was unaware of any interventions currently in place aside from reminding the resident to wait for assistance and the tab alarms. The CNA stated the tab alarm had been in place for as long as she could remember, and that the nursing staff was aware that they needed to run for the resident's bathroom if they heard the resident's chair alarm. However, the CNA was not sure whether the alarm could be heard throughout the building. The CNA also stated that reminding the resident to call for assistance would not be a practical intervention because the resident's memory was impaired to the point that she did not remember to use her call light. The CNA stated that the facility had ordered a lap tray for the resident, but that the resident did not like it, so it was not in use. (3) On 9/18/14 at 9:35 a.m., the Social Service Director (SSD) was interviewed. The SSD confirmed that the resident was experiencing memory loss, and that her condition had deteriorated in the last six months. The SSD stated that the resident was not oriented to time, so sometimes she would think it was time for bed at 10:00 in the morning. The SSD also stated that the resident was not always very aware of her limitations, and would try to do things like getting into bed or going to the bathroom by herself, leading to falls. The SSD stated that the resident would not be able to remember that she needed to wait for assistance, and stated that she could not be left alone if she wanted to go to bed or the bathroom. (4) On 9/18/14 at 10:29 a.m., Licensed Practical Nurse (LPN) #1, who was the charge nurse for the resident, was interviewed. The LPN stated the resident was oriented to self, but not to time or place, and that her memory was impaired to the point that she may not remember something that happened a few seconds ago. The LPN stated that the resident frequently fell either while trying to get to the bathroom, or while trying to put herself to bed. The LPN stated that they had put an alarm on her, but acknowledged that the facility had not increased staff monitoring of the resident. The LPN also acknowledged that the primary intervention in place regarding the resident's falls was to remind the resident to ask for help, and confirmed that because of her memory problems, this would not be an appropriate intervention. The LPN also confirmed that the facility was no longer using a lap tray for the resident although this intervention remained on the resident's care plan. 2. Resident #16 Resident #16, age 90, was admitted to the facility on [DATE]. According to the Minimum Data Set ((MDS) dated [DATE], the resident was not coded with a Brief Interview for Mental Status (BIMS) score, but was coded with disorganized thinking continuously present and dementia. The resident was coded as independent with no staff oversight or help at anytime for bed mobility and transfers. The resident used corrective eyeglasses. a. Observations 9/15/14: At 2:07 p.m., the resident's mattress on her bed moved easily from one side to the other on the bed rails. The distance between the mattress and side rail measured a fist-width distance. 9/17/14: At 1:34 p.m., the distance measured between the resident's mattress and the inside edge of the side rail on her bed was 3 1/4 inches. Both side rails were loose and easily moved back, forth and sideways. The mattress was positioned with the foot end of the mattress flush against the footboard. The head of the mattress did not lay flat at the head of the bed since the mattress laid over the mattress anchors, as the mattress was too long. b. Record Review The Evaluation for Use of Side Rails dated 5/21/14 (updated 8/20/14) revealed the resident utilized the side rails for safety to pull herself from a lying to seated position. The resident's physical need for side rails revealed "bow leg." The resident used side rails as enablers at times for balance with transfer or mobility in bed. The Fall Risk Evaluation dated 8/21/14 revealed a total score of 17. A resident who scored 10+ was considered at a higher risk. The facility's policy and procedure on the Use of Side Rails indicated side rails were to be used to provide a safe environment for the resident. Safety checks on all side rails were performed on a regular basis. c. Interviews On 9/17/14 at 9:20 a.m., the certified nurse aide (CNA) #5 who was familiar with the resident was interviewed and stated the resident transferred independently. On 9/18/14 at 11:08 a.m. the director of nursing (DON) and assistant director of nursing observed the mattress was easily movable back and forth on the bed rails, the side rails were very loose, and the mattress was lying on top of the mattress anchors due to the mattress being too long. -The DON acknowledged the gap could be an accident risk and stated the side rails would be removed. The DON said she did not think the resident currently used the rails. The DON said there was a new bed on order as a replacement and the restorative licensed practical nurse did quarterly assessments for side rails. 3. Resident #30 Resident #30, 89-years-old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 7/19/14 quarterly MDS coded the resident with severely impaired cognitive skills for daily decision making and identified the resident was totally dependent upon staff for bed mobility and transfers. The resident's height and weight at the time of assessment was 5'1" and 108 pounds. The 1/14/14 care plan, last reviewed on 7/28/14, regarding the resident's potential for falls identified quarter rails were used on the bed as enablers. a. Observations Observation on 9/16/14 at 3:30 p.m. revealed the resident sat in the recliner in her room. Both of her legs were off the left side of the chair between the seat and the foot rest. The resident made rocking motions as if to get out of the recliner and, during six minutes of continuous observation, remained in motion, constantly fidgeting and trying to move herself from her position in the recliner. At 3:36 p.m., Registered Nurse (RN) #1 entered the room and shortly thereafter, the resident was taken to the hallway bathroom by CNA #3 and CNA # 4. Observation on 9/17/14 from 1:45 p.m. to 2:55 p.m. revealed the resident was in bed lying on her back. The bed contained quarter rails on each side of the bed which were in the "up" position. The rail facing the room and the mattress on the bed frame were very loose, creating a 3-inch gap between the outer edge of the mattress and the inner edge of the rail. The gap created was sufficient for possible entrapment of the resident's limbs and/or neck given her petite frame. Review of an undated form entitled, "Consent For Use of Side Rails," revealed the facility intended to use the rails only at night as enablers for positioning. The form described the potential negative outcomes/risks of utilizing rails, such as "getting caught in the rails, getting caught between the rail and mattress, strangulation ..." b. Record Review Review of an "Evaluation For Use of Side Rails" form, dated 1/13/14, revealed the resident's family informed facility staff that the resident tended to move around in bed and hang her legs off the side of the bed. LPN #1 documented side rails were recommended as the resident "may grab side rails as enablers" when cares were rendered in bed. The evaluation lacked an assessment regarding the safety of the rails, taking into consideration the resident's tendency to move around and hang her legs over the mattress while in bed, the resident's petite frame, and the gap created by the loose rail and the loose mattress. c. Staff Interview The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed on 9/18/14 at 11:10 a.m. They were shown and confirmed that the resident's room-facing rail and mattress were both very loose, creating a 3-inch gap. The DON stated the resident did not use the rail, saying, "It should probably just be taken off by maintenance." The DON identified LPN #1 conducted the side rail evaluations and that safety of the rails should be included in the evaluations. The DON confirmed that the rails were a hazard for entrapment for the resident "especially since the resident will swing her legs over the side of the bed."

Based on observation, interviews and record review, the facility failed to ensure that one (#13) of 18 sample residents, who entered the facility without limited range of motion (ROM), did not experience reduction in ROM. Specifically, the facility failed to take steps to prevent resident #13 from developing a contracture. The findings include: Resident #13, [AGE] years old, was admitted to the facility on [DATE]. According to the facility face sheet, her [DIAGNOSES REDACTED]. According to the minimum (MDS) data set [DATE]: -The resident was coded as a 4 (total dependence-full staff performance every time during entire 7 day period) a 3 (two + person physical assist) in bed mobility, transfer, dressing, a 4 (total dependence-full staff performance every time during entire 7 day period) a 2 (on person physical assist) in eating, toilet use and personal hygiene. -The resident was coded as a 2 (moderately impaired, decision poor, cues/supervision required) for cognitive skills for daily decision-making skills, a 1 (behavior continuously present, does not fluctuate) in [MEDICAL CONDITION] for inattention, disorganized thinking and psychomotor [MEDICAL CONDITION]. No contractures were noted. The resident was not able to be interviewed due to her cognitive impairment. According to the ADL (activities of daily living) functional/restorative assessment and progress forms dated 6/30/10, 9/28/10, 12/28/10 and 4/25/11, the resident did not have any contractures noted. According to the ADL functional/restorative assessment and progress form dated 7/20/11, the resident was prone to contracture of her left hand. Observations and Interviews: On 8/17/11 at 3:40 p.m., the resident's left hand was observed with the nurse on the floor. -The nurse attempted to straighten the middle finger. The resident cried out and pulled her hand away. The nurse stopped immediately and put the resident's hand down. The nurse indicated that the finger would not move, that it was contracted. She indicated that the facility had tried a cone (in the resident's hand) but the resident always took it out. -When asked if she thought that the resident would benefit from a restorative program, the nurse stated that she thought the resident would benefit. She stated that sometimes the resident could be resistive to cares, but at other times she was not. She said that if staff tried range of motion on a regular basis, they could figure out what worked and the best times for her. The nurse indicated that the resident's left hand middle finger contracture was new, about 2-6 months old. On 8/17/11 at 3:29 p.m. a certified nurse aide (CNA), who regularly worked with the resident, was interviewed. She indicated that she had been working at the facility for about 2 years and the resident's finger had been that way for about 6 months. She said that the resident could not move the middle finger on the left hand. She, too, stated they had tried the cone that goes in her hand under her fingers but the resident took it out. When asked if she was aware of any other things that had been tried for the resident or if the CNAs were regularly doing range of motion (ROM) for the resident, she stated "no." On 8/17/11 at 3:47 p.m. the restorative nurse was interviewed. -She indicated that the resident was on comfort care so they had not done anything for her finger. She indicated that the resident's demeanor changed from hour to hour so they could not do anything for her finger. -She indicated that she and the director of nursing (DON) had talked this week about maybe getting a brace the resident could wear so her fingernails would not cut into her hand. She indicated that she did not have the authority to order things because there was a budget so she was waiting for the approval from the DON. --At the end of the interview the restorative nurse was told to provide any information related to the resident's contracture that was found; however, no information was provided. On 8/17/11 at 4:15 p.m. the DON was interviewed. -She indicated that she would expect the staff to provide interventions for the resident's contracted finger. She indicated that she was not aware of the interventions that had been tried or put into place. -She said the restorative nurse had ordered some kind of brace for the resident's hand. -The DON, when informed that the restorative nurse had indicated that the facility had not provided interventions for the resident's contracted finger because she was on comfort care, indicated that her expectation would be that the staff provide the same care to all residents; just because the resident was on comfort care did not mean that the staff does not provide cares and interventions for them. -She stated that it would be her expectation that the resident had a care plan for the contracted finger. Informed her that there was no care plan in the resident's medical record related to the contracted finger, and asked her to provide any additional information if she had it. As of 8/26/11 no information had been provided. Record Review: -Upon review of the resident's care plan dated 7/20/11, the restorative section of the medical record, and the nurses (NN) notes dated from 2/20/11 to current, indicated there was no documentation to support the resident's contracture to her left hand or that any interventions had been attempted or implemented to address the contracture. Upon review of the medical record, the resident did not have a care plan for the contracture to her left hand.