Every finding on record at Skylake Post Acute

Based on record review, observations and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#4 and #16) of seven sample residents reviewed for change of condition assessments out of 14 sample residents. Resident #4 was admitted on [DATE] with diagnoses of dementia, severe, with other behavioral disturbance, pancytopenia (lower than normal count of all three types of blood cells), and protein-calorie malnutrition.On 12/10/25 the facility documented that Resident #4 had decreased oral and fluid intake. On 12/11/25 Resident #4 sustained an unwitnessed fall, where his mattress was found partially off the bed frame. The staff documented a decline in the resident's function and he continued to have decreased oral and fluid intake, had increased weakness and confusion, had unsteady balance and was pale. Despite the nursing staff noticing a change in condition, the facility failed to notify the physician of the change in condition to provide further treatment to the resident. On 12/11/25 at 6:50 p.m. the resident sustained an additional unwitnessed fall. Upon assessment, the resident was noted to have pain. The resident was sent to the hospital for further assessment. While at the hospital the resident was diagnosed with a fractured hip and four subdural hematomas (bleeding between the brain and skull). Following treatment at the hospital he returned to the facility under hospice care on 12/19/25 and passed away on 12/20/25.Specifically, the facility failed to:-Monitor Resident #4 after he experienced a change of condition with multiple falls; and, -Appropriately assess and monitor Resident #16 after sustaining an unwitnessed fall. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 12/10/25, Resident #4 began to have decreased oral and fluid intake. On 12/11/25 at 5:00 a.m. Resident #4 had an unwitnessed fall in his room. The physician and his responsible party were notified. The resident was educated to call for assistance before transferring. At 1:06 p.m. the nurse documented he had refused breakfast and had slept most of the morning. The facility failed to adequately monitor the resident after this fall. The neurological checks (measuring level of consciousness, orientation, pupil response, strength, and vital signs) were documented as refused from 7:00 a.m. through 10:00 a.m. At 3:06 p.m. the nurse documented a drop in his blood pressure and an increase in his heart rate as well as a decrease in appetite and fluid intake and generalized weakness resulting in the need for extra assistance with activities of daily living (ADLs). He had been independent prior to fall. The provider was notified and informed the nurse that the nurse practitioner would see the resident the next day. At 6:30 p.m. the nurse documented Resident #4 did not want to eat, was sleeping more, and was unsteady when he tried to stand. At 6:50 p.m. he sustained a second unwitnessed fall from bed. He was unable to state what he was doing, was confused, and had external rotation of his right leg. He was transferred to the hospital. Following surgery and multiple blood transfusions at the hospital he returned to the facility on hospice care. He was only responsive to pain and passed away on 12/20/25. B. Facility notice of immediate jeopardy On 5/7/26 at 3:45 p.m. the nursing home administrator (NHA) and regional director of clinical services were notified that the facility's failure to identify and respond to Resident #4's change of condition created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 5/7/26 at 6:45 p.m. the facility submitted a final plan for removal of the immediate jeopardy. The plan read: On 5/7/26, Resident #16 was immediately reassessed by the director of nursing (DON) regarding the completion of a neurological assessment after a fall. A complete neurological assessment, including pupillary response to light, level of consciousness, grip strength, extremity movement, and vital signs, was completed and documented. The physician was notified immediately. The physician orders were obtained for a skin tear neurological monitoring was initiated and the care plan was updated. On 5/7/26, the involved licensed nurse received immediate one-on-one education regarding post-fall neurological assessments and documentation requirements. Beginning 5/7/26, the DON/designee completed a review of all residents with falls and concerns about changes in condition to identify any additional residents at risk for post-fall assessment, physician notification, neurological monitoring, or changes in condition that have occurred in the last seven days. The Change of Condition policy and Neurological policy were reviewed on 5/7/26 by the NHA, the DON, and medical director. Beginning on 5/7/26, the staff development coordinator/designee educated all licensed nurses currently in the facility on post-fall assessment and neurological monitoring protocols, including required vital signs, neurological assessment parameters, physician notification requirements, documentation if a resident refuses neurologic monitoring, identifying a change in condition, and documentation expectations. The plan documented any nurse who had not yet received this education would not work the floor until training was completed. Beginning on 5/7/26, the staff development coordinator/designee would educate agency-licensed nurses on the facility's policy regarding the following: The education was uploaded to the agency portal on 5/7/226. The agency platform required agency nurses to complete training before confirming the shift. Beginning on 5/8/26, and continuing daily for 30 days, then weekly for 60 days, then monthly thereafter, the DON would audit all changes of condition occurring in the facility to ensure: A complete neurological assessment was performed immediately following the fall and properly documented, including the use of a penlight for pupil assessment, grip strength, and extremity movement. Complete vital signs were obtained immediately following the fall and at required intervals per protocol. The physician was notified per protocol with documentation of time, information provided, and orders received. When residents refused any portion of the assessment, documentation included specifically what was assessed, what was refused, alternative methods attempted, the resident's level of consciousness, and the plan for reassessment. All changes in condition resulted in appropriate interventions and escalation per protocol. Care plans were updated as needed in response to falls and identified risk factors. Audit results will be compiled in a written report that notes the compliance rate, any identified deficiencies, and the corrective actions implemented. Any incidents of non-compliance will result in immediate individual staff education and re-auditing. Beginning on 5/8/26and continuing five times per week for 30 days, then weekly for 60 days, then monthly thereafter the DON/designee will audit 100% of all changes of condition. D. Removal of the immediate jeopardy: Based on the facility's plan above, the immediate jeopardy was removed on 5/7/26 at 7:00 p.m. However, deficient practice remained at a G level, actual harm, isolated. II. Facility policy and procedure The Change in a Resident's Condition or Status policy, revised February 2021, was provided by regional director of clinical services #1 on 5/11/26 at 5:04 p.m. It read in pertinent part, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an): accident or incident involving the resident; significant change in the resident's physical, emotional, mental condition; need to transfer the resident to a hospital; and specific instruction to notify the physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff; impacts more than one area of the resident's health status; and ultimately is based on the judgment of the clinical staff. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status; or it is necessary to transfer the resident to a hospital. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical and mental condition or status. The Falls-Clinical Protocol policy, revised September 2012, was provided by regional director of clinical services #1 on 5/11/26 at 5:04 p.m. It read in pertinent part, The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE], readmitted on [DATE], and passed away on 12/20/25. According to the December 2025 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage without loss of consciousness, fracture of right femur (thigh bone), dementia, severe, with other behavioral disturbance, pancytopenia (lower than normal count of all three types of blood cells), and protein-calorie malnutrition. According to the 10/15/25 minimum data set (MDS) assessment Resident #4 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. He was independent with ADL's and required occasional reminders to complete oral hygiene. He had no previous falls. B. Record review The fall care plan, initiated 12/11/25, indicated Resident #4 was at risk for falls related to cognitive losses and wandering. Interventions included monitoring for changes in condition that increase risk of falls. The potential for fluid deficit care plan, initiated 10/10/25, indicated Resident #4 had the potential for fluid deficit related to dementia. Interventions included monitoring, documenting, and reporting any signs or symptoms of dehydration, such as new onset confusion, dizziness on sitting or standing, increased pulse, headache, fatigue, weakness, or dizziness. The nutritional risk care plan, initiated 10/15/25, indicated Resident #4 had the potential for altered nutrition and or hydration status related to the mini nutritional assessment completed on 10/15/25 with a score of six which indicated malnourished status in the setting of dementia. Interventions included observing for signs or symptoms of malnutrition as evidenced by refusing meals, exhibiting signs or symptoms of dehydration, and reporting to the physician as needed. Review of Resident #4's electronic medical record (EMR) revealed prior to the falls on 12/11/25 Resident #4 was able to make his needs known, he was pleasant and cooperative, had a good appetite, and ambulated independently around the facility. The nursing progress note, dated12/10/25 at 8:40 p.m., revealed Resident #4 refused dinner that evening. The staff offered some snacks and a Magic cup (frozen nutritional supplement), but he refused. The nursing progress note, dated 12/11/25 at 7:01 a.m., revealed the resident was noted on the floor next to his bed. The top of his mattress was half on the floor and half on his bed, the resident unable to tell what happened. He was assessed, cleaned, and was helped back into bed by staff. The note documented the resident's vital signs were stable, neurological checks were started by facility protocols. The resident was instructed to call before any transfer. The note documented the physician and the family were notified. The resident's blood pressure was 102/56 millimeters of mercury (mmHg), pulse 81 beats per minute (BPM). The note documented no changes were observed in his mental status. -However, according to the neurological sheet documentation the fall occurred at 5:00 a.m. The nursing progress note, dated 12/11/25 at 1:07 p.m., revealed Resident #4 was on charting for an unwitnessed fall. The resident's vital signs were stable. He refused to eat this morning and slept most of the morning shift. -However, review of Resident #4's EMR and the neurological sheet documentation revealed no vital sign readings had been documented since 6:30 a.m. (See licensed practical nurse [LPN] #2's interview below). The nursing note, dated 12/11/25 at 3:06 p.m., documented the resident had a change in food and or fluid intake. The resident's BP was 81/57 mmHg (decreased from the documented BP at 7:01 a.m.) and his pulse was 91 BPM (increase from the documented heart rate at 7:02 a.m.). Resident #4 needed more assistance with ADLs, and had general weaknesses. The nurse received a report that the resident had a decrease in appetite and fluid intake over the last three days, which culminated in weakness and a fall this a.m. The resident appeared pale in color. The physician was made aware of the resident's condition and indicated he would have his nurse practitioner see the resident tomorrow. -Review of Resident #4's EMR did not reveal documentation indicating the facility had notified the resident's physician of the resident's decrease in appetite, despite the facility documenting it for three days. The nursing progress note, dated 12/11/25 at 6:30 p.m., revealed Resident #4 continued on monitoring for a decline in condition. The resident's vital signs were: BP 102/63 mmHG, temperature 97.4 degrees Fahrenheit, pulse 90 BPM, respirations 14 breaths per minute, oxygen saturation 95% on room air. The nursing staff attempted to encourage the resident to eat and drink several times, getting him to take sips and eat a Magic cup. Staff attempted to have him eat dinner at bedside sitting up. The resident was confused attempting to stand and was unable to state why and also was unsteady with balance and was redirected back to bed. The resident was checked frequently afterwards and was sleeping. -However, the facility failed to notify the physician of the resident's further decline in his condition. The nursing note, dated 12/11/25 at 6:50 p.m., documented the staff heard a thud coming from the resident's room. Upon entering, the resident was lying on his back on the floor away from the bed. There was external rotation of the right lower extremity. The nurse called for a registered nurse (RN) to assess the resident. The RN assessment, dated 12/11/25, documented the resident was lying on the floor on his back next to the bed. He complained of right hip pain. His right foot was externally rotated. The resident was confused and was unable to state what he was doing. Emergency medical services (EMS) were called and he was transferred to the hospital. -Review of Resident #4's EMR did not reveal documentation indicating the facility assessed the resident's vital signs after this fall. The fall risk observation assessment completed on 12/11/26 at 9:11 p.m. after the second fall, indicated Resident #4's ambulation baseline was independent prior to his decline in conditions in which the resident became weaker and was in need of assistance with transfers and ambulation. The 12/11/26 hospital emergency room documentation revealed the resident's vital signs were BP 79/45 mmHg and his pulse was 94 BPM. The note documented he had experienced generalized weakness for about one week, with poor dietary intake and output. He had right hip pain and external rotation of the right foot. The resident was pale throughout. The right lower extremity was slightly shortened. There was tenderness over the right greater trochanter (bony protrusion). The resident was also reported to be hypotensive (low BP) en route to the emergency room. One liter of intravenous (IV) fluid was ordered. The resident presented with one or more acute injuries that posed a threat to life and/or bodily function. The resident had a hemoglobin (iron-rich protein in red blood cells) of 4.5 grams per deciliter (g/dL) (normal range 13.5 to 17.5 g/dL). There were concerns that the resident's shock may be multifactorial in the setting of hemorrhage. He had a mildly displaced right sided intertrochanteric hip fracture. There was an acute appearing subdural hematoma along the cerebral convexities (bleeding on the top and sides of the brain) bilaterally measuring 1.1 centimeter (cm) on the right and 1 cm on the left. There was a right parafalcine (between the inner layers of the brain) subdural hematoma measuring 7 millimeters (mm) in thickness. There was also a subdural hematoma in the right tentorium (area separating the cerebrum from the cerebellum) measuring 3 to 4 cm in thickness. He was admitted to the trauma intensive care unit with diagnoses of right intertrochanteric femur fracture, acute blood loss anemia (traumatic), and hemorrhagic shock, BP 79/55 mmHg. The nursing progress note, dated12/19/25 at 3:49 p.m., revealed Resident #4 returned to the facility on hospice care. The nursing progress note, dated 12/20/25 at 6:40 a.m., revealed the resident passed away. C. Staff interviews RN #2 was interviewed on 5/7/26 at 11:00 a.m. RN #2 said when a fall occurred the resident was to be assessed by an RN prior to moving them. RN #2 said vital signs and neurological checks were started if the fall was unwitnessed or they were observed to strike their head. She said if there was a decline in a resident's condition the provider was to be notified and if the nurse felt the resident needed labs drawn, x-rays, or needed to be sent to the hospital and the physician was reluctant to order those things, the nurse could make a nursing judgement call and notify the medical director to obtain orders. LPN #3 was interviewed on 5/7/26 at 11:15 a.m. LPN #3 said if a resident had a significant change in condition she would assess them and call the provider for orders and let the unit manager and the DON know. She said a change of condition assessment was to be completed. Certified nurse aid (CNA) #1 was interviewed on 5/7/26 at 11:30 a.m. CNA #1 said if a resident refused to eat or drink she would offer different choices and if they refused three times, she said she could not force them to eat or drink. She said if it became a repeated refusal she would then notify the nurse. CNA #2 was interviewed on 5/7/26 at 1:00 p.m. CNA #2 said if she noticed any change in a resident's condition that was out of their normal behavior she would notify the nurse and if the nurse did not act on her concerns she would go to management and the DON. The DON was interviewed on 5/7/26 at 11:45 a.m. The DON said when a fall occurred or there was a change in a resident's condition, nursing staff were to complete a change of condition assessment, notify the provider, and the responsible party. She said neurological checks were to be started after a fall and completed in their entirety if the resident was observed to hit their head or if the fall was unwitnessed. She said if a resident refused all or part of the assessments, the nurse was supposed to obtain and document as much of the required information on the form as possible. She said she was not notified of Resident #4's decline in condition and vital signs. She said if she had been notified she would have had the resident sent to the hospital prior to the second fall. She said if nurses had doubts about what they were to do they should reach out to her and the issue could be escalated to the provider or the medical director for orders if necessary. LPN #2 was interviewed on 5/11/26 at 10:20 a.m. She said when she documented the progress note on 12/11/25 at 1:07 p.m. related to Resident #4 sleeping all morning and refusing to eat, that behavior was unusual for him. She said if a nurse noticed that something was off from the resident's normal behavior the provider should be notified for orders if indicated. She said she did not notify Resident #4's provider of the changes she noticed in his condition. She said frequent checks on Resident #4 were not timed but she would lay eyes on him if she passed his room. She said she passed on to the nurse that relieved her that day that Resident #4 was not doing well and to keep an eye on him. She said she documented that Resident #4 refused the neurological checks at 7:00 a.m., 7:30 a.m., 8:00 a.m., 9:00 a.m., and 10:00 a.m. on 12/11/25 because he pushed her away each time she tried to obtain his blood pressure. She said he stayed in bed that entire morning. She said she did not attempt any other areas of the neurological check assessment. She said if a resident refused the assessment she would normally document a progress note of the refusals and the resident's condition, but she did not do that. IV. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the May 2026 CPO, diagnoses included dementia with behavioral disturbance, generalized muscle weakness, unsteadiness on feet, difficulty in walking and repeated falls. The 3/13/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. The resident required substantial assistance from staff for most ADLs. B. Observations and record review During a continuous observation on 5/7/26, from 11:54 a.m. to 12:38 p.m., the following was observed: At 11:54 a.m. Resident #16 was sitting up on the floor in the common area with her legs tucked to the side and supporting her weight on her arm. Multiple nursing staff members were attending to the resident, including regional director of clinical services #2 and the DON. Resident #16 had an open area on her forehead approximately two centimeters (CM) by two CM which was bleeding, blood on her hand and a small puddle of blood on the floor. At 11:56 a.m. regional director of clinical services #2 began performing a neurologic assessment on Resident #16 using a cellphone flashlight. Regional director of clinical services #2 held the cellphone flashlight toward Resident #16's face as she turned her head away from the light. Regional director of clinical services #2 and the DON helped Resident #16 straighten her legs out in front of her and performed a brief range of motion assessment on the resident's legs. At 12:01 p.m. regional director of clinical services #2 and the DON assisted Resident #16 to a standing position using a gait belt around the resident's waist and walked with her to her room, where she was assisted into a chair near her bed. Regional director of clinical services #2 and the DON obtained Resident #16's vital signs using a vitals machine and performed another neurological assessment using a cellphone flashlight. Resident #16 turned her head away repeatedly and was squinting her eyes shut while the light from the flashlight was used to attempt to assess her pupil reaction for the neurological assessment. LPN #1 removed the vital signs machine from the room and brought in wound cleanser and gauze, and the DON and regional director of clinical services #2 began cleaning the wound to Resident #16's forehead. At 12:08 p.m. regional director of clinical services #2 and the DON closed Resident #16's door to perform a skin check and assist the resident with getting dressed in clean clothes. At 12:17 p.m. the DON and regional director of clinical services #2 assisted Resident #16 back into the dining room where the resident sat in a dining room chair. At 12:24 p.m. RN #3 reviewed with LPN #1 how to use the facility's neurological assessment sheet and told LPN #1 when Resident #16 would be due to assess her next set of vitals measurements. At 12:30 p.m. LPN #1 approached Resident #16 in the dining room and began collecting vital signs measurements using the vitals machine. LPN #1 used the vitals equipment to assess Resident #16's blood pressure, heart rate and blood oxygen saturation. LPN #1 then recorded this information on the neurological assessment sheet. -However, LPN #1 did not have any flashlight or pen light available to assess Resident #16's pupillary response. At 12:38 p.m. the neurological assessment sheet for Resident #16 was observed on LPN #1's medication cart. The sheet contained vital signs measurements for Resident #16 which were documented to have been taken at 12:15 p.m. and 12:30 p.m. on 5/7/26. Resident #16's pupils were documented as having been equal, round and reactive to light at the time of both the 12:15 p.m. and 12:30 p.m. assessments. -However, LPN #1 was not able to assess Resident #16's pupillary response to light during the 12:30 p.m. assessment period (see above). -Additionally, the vital signs machine had been removed from Resident #16's room prior to her door being closed at 12:08 p.m. C. Staff interviews LPN #1 was interviewed on 5/7/26 at 12:38 p.m. LPN #1 said she was not sure how Resident #16 had fallen as she was assisting another resident at the time. She said she only knew the resident had fallen when she heard a thump sound behind her. LPN #1 said the unit managers and the DON had immediately begun assessing Resident #16, and said she would continue performing neurological assessments for the resident per facility policy. LPN #1 said when performing neurological assessments, she only needed to look at the resident's pupils and see if they were reactive. LPN #1 said she did not have to use a light source when assessing the resident's pupils, and said the unit manager and the DON had assessed Resident #16's pupils before they assisted her up from the floor. LPN #1 said the unit managers and DON had used a cellphone flashlight to assess Resident #16 because her pen light batteries were dead. The DON and regional director of clinical services #2 were interviewed together on 5/7/26 at 1:33 p.m. The DON said neurological assessments were performed after a resident sustained a fall to monitor the resident for any change in neurological status, vital signs measurements, mentation or mental status. The DON said when performing neurological assessments, the nursing staff were looking to see if the resident was alert and oriented, had equal hand grasps on both sides, their pupils were reactive to light and equal between the left and right eye, if they had any pain, and their vital signs. The DON said pupil reactivity was assessed using a flashlight or a pen light. The DON said LPN #1 should have used a light source to assess Resident #16's pupillary reaction.

Based on observations, record review and interviews, the facility failed to ensure four (#17, #6, #7 and #5) of seven residents reviewed for abuse out of 14 sample residents were kept free from abuse.Specifically, the facility failed to:-Prevent an incident of physical abuse between Resident #6 and Resident #17;-Prevent an incident of physical abuse between Resident #6 and Resident #7; and,-Protect Resident #5 from physical abuse by Resident #6. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised April 2021, was provided by regional director of clinical services #1 on 5/11/26 at 5:04 p.m. It read in pertinent part, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support objectives including providing staff orientation and training which included topics such as handling verbally or physically aggressive resident behavior.II. Incident of physical abuse by Resident #17 towards Resident #6 on 3/30/26A. Facility investigationThe facility investigation, dated 3/30/26, was provided by the nursing home administrator (NHA)on 5/11/26 at 9:00 a.m. The investigation revealed the following:On 3/30/26 at 1:30 p.m. Resident #17 was sitting in the hallway in her wheelchair yelling about having her bed made. Resident #6 walked by Resident #17, and Resident #17 began screaming at him and telling him to just hit her already. Resident #6 stepped up to Resident #17 and she swung her arm at his stomach to hit him. Resident #6 grabbed Resident #17 by the neck/shoulder area to attempt to stop her from hitting him. The residents were separated by staff, de-escalated, assessed and placed on 15-minute checks.The investigation documented Resident #6 seemed to escalate with loud noises. Resident #6's representative said she would purchase headphones for him. Resident #6's physician was notified and medication adjustments related to the resident's anxiety and agitation.An interview with registered nurse (RN) #3, dated 3/30/26 at 2:00 p.m., revealed the nursing staff member had witnessed the altercation. The interview revealed Resident #17 was yelling at Resident #6, then told Resident #6 to just hit her and to do it already. Resident #6 stepped up to her and Resident #17 hit him in the stomach. Resident #6 then grabbed Resident #17 by the back of the neck and told her I don't do that hitting (expletive). RN #3 said they then approached the residents and began to try to de-escalate both of them. Resident #6 let go of Resident #17 and walked away with a member of the social services staff. RN #3 said Resident #6 remained agitated and responsive to any loud noise or situation and was constantly redirected to attempt to de-escalate him. Resident #6's physician was aware and the nursing staff were charting the resident's behaviors.The investigation documented both Resident #17 and Resident #6 were interviewed but had no recollection of the event. Both residents did not display any signs or symptoms of behavioral changes following the event.The investigation documented Resident #6 had a history of becoming verbally aggressive toward other residents and staff members, including calling others names, using derogatory language or making verbally inappropriate or hostile statements. Resident #6 would often sundown and think he was at work and become irritated when staff did not follow his directions.The investigation documented Resident #17 had a history of behavior problems including being angry at her placement and using foul language. Resident #17 was hard of hearing which caused her to speak in a loud tone.The investigation unsubstantiated the allegation of abuse as there were no signs or symptoms noted from either resident that Resident #17 had made contact with Resident #6 or vice-versa. The residents' care plans were updated following the event.-However, physical abuse occurred due to Resident #17 hitting Resident #6 and Resident #6 grabbing Resident #17's neck, per the staff interview included in the facility investigation.B. Resident #61. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included dementia with agitation. The 2/5/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of one out of 15. The resident required partial to substantial assistance from staff for most activities of daily living (ADL).The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.2. Resident's representative interviewResident #6's representative was interviewed on 5/11/26 at 10:15 a.m. The resident's representative said Resident #6 had dementia with aggression. The representative said the facility had handled Resident #6's aggression well and did so by calling the police and ambulances and trying to comfort the resident. The resident's representative said Resident #6 had been through hell and back, and said he had a lot of traumatic history and was reliving those traumatic moments due to his dementia. The representative said Resident #6's aggression was not predictable, and his triggers depended on his mood and surroundings. The resident's representative said Resident #6 could be comforted by using things like chocolate, coffee, or staff walking with him.3. Record reviewThe physical altercation care plan, revised 4/17/26, revealed Resident #6 was the victim of a physical altercation with another resident and documented that on 4/17/26 Resident #6 wandered into a female resident's room and was the victim of a physical altercation. Interventions included placing Resident #6 on 15-minute checks for the safety of himself and others, and keeping Resident #6 in high visibility areas when Resident #17 was nearby.The behavior care plan, revised 4/23/26, revealed Resident #6 had a behavior problem and was physically and verbally aggressive towards staff and other residents. Resident #6 was placed on one-to-one supervision for the safety of himself and others. Pertinent interventions included anticipating and meeting Resident #6's needs, administering medications as ordered, providing opportunities for positive interactions, keeping Resident #6 and Resident #5 separated, and monitoring behavior episodes and attempting to determine an underlying cause.The psychosocial-behavior care plan, revised 3/11/26, revealed Resident #6 exhibited or was at risk for behavioral symptoms due to his dementia. Resident #6 was attempting to forcefully open another resident's door and was not easily redirected. Resident #6 had a history of banging or punching his fist on objects including doors and walls. Resident #6 had a history of becoming physically aggressive toward staff members, and incidents included striking out, hitting, scratching and attempting to choke staff during redirection or care interactions. Resident #6 appeared to become more agitated at times when redirected by male staff members. Pertinent interventions included offering Resident #6 his favorite drinks including lemon-lime sodas or hot chocolate, reducing stimulation to the extent possible, observing and documenting changes in behavior, and using female staff to take lead during redirection or cares when possible.The psychosocial-trauma care plan, revised 2/10/26, revealed Resident #6 was at risk of emotional distress or decreased psychosocial well-being due to his history of combat or exposure to a warzone, history of fire, history of unwanted or uncomfortable sexual experiences and history of sudden, unexpected death of someone close to him. Resident #6's family had shared during his time in the army the resident was physically and sexually abused. Potential triggers included talking about Resident #6's mother and fire alarms. Pertinent interventions included attempting non-pharmacological approaches to reduce fears, observing for signs and symptoms of distress, and helping Resident #6 to identify triggers that prompted symptoms.The psychosocial-behavioral care plan, revised 5/6/26 (during the survey process), revealed Resident #6 exhibited or was at risk for behavioral symptoms due to his dementia. Resident #6 had a history of becoming verbally and physically aggressive towards other residents and staff. Resident #6's behaviors included calling others inappropriate names, using derogatory language and making hostile statements. Resident #6 had also struck items such as doors or the medication cart when expressing frustration, and held his closed fist up to staff and residents and shaken it, indicating his intent to strike someone with a closed fist. Pertinent interventions included documenting and recording behavioral episodes, managing environmental factors to optimize comfort and reducing stimulation to the extent possible.The psychosocial-behavior care plan, revised 5/7/26 (during the survey process), revealed Resident #6 exhibited or was at risk for behavioral symptoms due to his dementia. Resident #6 had a history of experiencing sundowning in the early evening, during which episodes he believed he was at work and became verbally agitated as he said he had a lot of work to do and no one was helping him. Resident #6 also verbalized he thought people hated him, which contributed to his distress and increased his agitation. Pertinent interventions included voice or video-calling Resident #6's representative, providing one-to-one supervision and reducing stimulation to the extent possible.The psychosocial-grief care plan, initiated 5/6/26 (during the survey process), revealed Resident #6 had experienced the loss of both of his parents and was often emotional about his parents when sundowning. Pertinent interventions included supporting Resident #6's grief reactions and exploring coping mechanisms with the resident.The behavior/mood section of Resident #6's Kardex (a staff directive tool) was reviewed on 5/11/26 and revealed pertinent interventions including anticipating needs, voice or video-calling Resident #6's representative, using a night-light, observing for signs or symptoms of distress, offering a lemon-lime soda, and using hot chocolate to deescalate any behaviors the resident may be having.The behavior section of Resident #6's Kardex (a staff directive tool) was reviewed on 5/11/26 and revealed pertinent interventions including administering medications as ordered, attempting non-pharmacological techniques, using female staff to take lead when redirecting care tasks as Resident #6 appeared less reactive with female caregivers, offering the resident his favorite drinks including lemon-lime sodas or hot chocolate, using non-threatening body language, reducing stimulation to the extent possible, and contacting Resident #6's representative for comfort and support.Hospital discharge notes, dated 1/30/26 at 11:52 a.m., revealed Resident #6 was admitted to the hospital for increased agitation and the inability for his family to continue to care for the resident at home. Hospital follow-up recommendations documented ongoing adjustments to Resident #6's agitation medications may be needed.A progress note, dated 2/4/26 at 7:57 p.m., revealed Resident #6 was agitated when the nurse was giving medication to his roommate. Resident #6 said why the (expletive) are you in my room taking my (expletive). Resident #6 came out of his room and was cursing and hitting his hand into his other hand, following staff members around and trying to swing at staff. Multiple staff members attempted to redirect Resident #6 and reassure him no one was stealing anything from his room.A progress note, dated 2/5/26 at 6:57 p.m., revealed Resident #6 confronted a nurse at his computer at 6:00 p.m. that evening and started to become agitated. Resident #6 told the nurse he needed to tell him how to press the two buttons, which made no sense in context. Resident #6 then became very angry and slammed his fist on the desk. The nurse explained he did not understand Resident #6's request and asked him to remain calm, but as the nurse stood up to assist Resident #6 to his room, he became very angry and physically aggressive. Resident #6 started shouting and getting into the nurse's face. The nurse was able to calm the resident down and assist him to his room.A progress note, dated 2/7/26 at 9:13 p.m., revealed Resident #6 became agitated around 8:30 p.m. that evening and began yelling and using derogatory language towards the CNA on shift, demanding to know why he was in his room, asking to go outside and saying he needed a strong medication to calm down. As the CNA left Resident #6's room to inform the nurse, the resident got out of his bed and began punching and hitting his door loudly and displaying verbal and physical aggression.A progress note, dated 2/24/26 at 1:09 a.m., revealed Resident #6 had been pacing and accusing staff of stealing from him and lying to him about getting his stuff back. Resident #6 entered another resident's room and was promptly escorted back out of the room by nursing staff. Resident #6 had not displayed any violent behavior yet but continued to pace up and down the unit. Resident #6 continued to state the staff had stolen from him and lied to him, and yelled expletives at the nursing staff.A progress note, dated 2/27/26 at 7:46 p.m., revealed Resident #6 was pacing and wandering. Resident #6 would approach staff or other residents in an angry voice and appear agitated for an unknown reason. Resident #6 did not make sense when he attempted to explain to staff. Staff attempts at redirection worked at times but not every time. Drinks and snacks were offered but no interventions worked.A progress note, dated 3/10/26 at 9:24 p.m., revealed at approximately 4:00 p.m. that evening Resident #6 started screaming and cursing at everyone without provocation. Resident #6 was redirected and snacks were given, one-to-one supervision initiated, offered to go for a walk with staff, and offered to lay down in his room but Resident #6's behavior continued. The unit manager and social services staff were present attempting to help with Resident #6, and Resident #6 was calmed and sat by the nurses' station.A change in condition note, dated 3/11/26 at 7:28 a.m., revealed Resident #6 had a change in condition and became increasingly agitated, started becoming aggressive toward other residents and staff and eventually began striking out at staff. Emergency services were called, and the police arrived and attempted to subdue Resident #6 but the resident was resistant to them and continued trying to strike out. Paramedics arrived eventually and took Resident #6 to the hospital for an M1 hold (an involuntary, 72-hour emergency mental health detention for individuals appearing to be an imminent danger to themselves or others).A progress note, dated 3/11/26 at 10:41 a.m., revealed no residents on the secured unit were negatively impacted by Resident #6's behaviors and all residents were kept safe during the resident's verbal outbursts and subsequent interactions with police and paramedics. Resident #6 was transported via ambulance to the hospital where he could be evaluated.A progress note, dated 3/12/26 at 9:12 p.m., revealed Resident #6 was in a good mood at the beginning of the evening shift, went to activities and ate his entire dinner. Later that night, Resident #6 became resistive and was yelling. Resident #6 was redirected, given space to calm down and an as-needed (PRN) dose of quetiapine (an antipsychotic medication) was administered with positive results. Resident #6 became calmer and cooperative with care.A progress note, dated 3/13/26 at 7:42 p.m., revealed Resident #6 had been agitated, yelling and using vulgarities at other residents and staff members. A PRN dose of quetiapine was administered to Resident #6. All staff members and residents remained safe, and Resident #6 tolerated the medication well.A progress note, dated 3/13/26 at 8:33 p.m., revealed Resident #6 was being monitored following his visit to the hospital on 3/11/26. Resident #6 had been well-mannered during the nurse's shift and calm for the majority of the shift. Resident #6 did have a few episodes in which he yelled vulgarities at other residents and staff, and was talking about conspiracy theories regarding people molesting their children and babies. A PRN dose of quetiapine was administered with positive results, and the resident was redirected with food and one-to-one supervision. All surrounding residents were unaffected by Resident #6's episodes and all staff and residents remained safe.A progress note, dated 3/14/26 at 6:30 a.m., revealed a PRN dose of quetiapine was administered as Resident #6 was agitated, verbally abusive towards staff and redirection attempts were unsuccessful.A progress note, dated 3/14/26 at 11:14 a.m., revealed Resident #6 had increased behaviors and agitation since approximately 6:30 a.m. that morning. Resident #6 was being verbally abusive to staff, calling them expletives, and had been escalating in his behaviors. Resident #6 became a physical danger to staff, attempting to hit and punch the nurse. Other residents were removed from the area to maintain safety and kept at a distance. Staff members attempted multiple de-escalation techniques including redirection, offering snacks and attempting to have Resident #6 watch television to calm down. Redirection attempts were unsuccessful and Resident #6 continued to damage facility property by striking items and breaking them. Emergency services were called, and the police arrived at 9:00 a.m. that morning, at which point Resident #6 was able to be redirected, cleaned and changed. Resident #6's physician was notified and new orders were received for a one-time dose of lorazepam (an antianxiety medication). Resident #6 continued to be monitored closely and redirected as needed. Resident #6's room assignment was changed.A progress note, dated 3/15/26 at 3:38 a.m., revealed Resident #6 was agitated and yelling, accusing people of making his pants wet. The one-time dose of lorazepam was administered.A progress note, dated 3/16/26 at 5:55 a.m., revealed Resident #6 was very agitated and was using foul language towards staff and other residents. After 3:00 a.m. that morning, Resident #6 became really upset, said he wanted to leave and began hitting the doors and one of the computers at the nurse's station. The police and Resident #6's physician were notified, and new orders for a one-time dose of quetiapine were received. A psychiatric follow-up note, dated 3/16/26 11:45 a.m., revealed Resident #6 was seen by the psychiatric nurse practitioner to address his episodes of agitation throughout the week prior. Resident #6 had experienced significant behavioral escalation over the past week, with multiple episodes of agitation and physical aggression requiring police intervention and emergency department evaluation. Notable incidents include aggressive behavior on 3/11/26 requiring emergency services transport, increased agitation on 3/14/26 with verbal and physical aggression toward staff, and continued episodes on 3/15/26 and 3/16/26 involving property damage and striking nursing station equipment. Current psychiatric symptoms included severe agitation, verbal aggression with profanity, physical aggression toward staff, paranoid ideation regarding conspiracies about child molestation, and confusion about his clothing being wet. Episodes typically occurred in early morning hours around 3:00 a.m. and appeared unprovoked. Resident #6 demonstrated partial response to current antipsychotic therapy but continued to experience breakthrough agitation requiring medication adjustments and environmental interventions such as room changes and one-on-one staff redirection. Resident #6's quetiapine dose was increased and PRN doses of lorazepam were ordered.A progress note, dated 3/16/26 at 1:43 p.m., revealed Resident #6 had been very aggressive the night prior and had punched and knocked over a computer at the nurses' station. Resident #6 was not able to be redirected at that time and became threatening to the nurse on duty. Resident #6 was eventually able to be calmed down by giving him hot chocolate. The psychiatric nurse practitioner visited Resident #6 and made changes to his medication regimen, which were approved by Resident #6's representative. The resident's representative was informed hot chocolate was able to calm Resident #6 down, and the representative told the staff Resident #6 loved chocolate. A progress note, dated 3/22/26 at 10:37 a.m., revealed Resident #6 had been administered a PRN lorazepam dose. Resident #6 had been verbally agitated that morning and was not able to be successfully redirected.A progress note, dated 3/25/26 at 9:21 p.m., revealed Resident #6 became agitated due to another resident's repeated yelling out. Resident #6 swung at the nurse and yelled at them shut the [expletive] up already and go to bed, no one is stopping you. Multiple staff members then redirected Resident #6 and offered several snacks to de-escalate Resident #6's behavior. Resident #6 was cursing and upset with staff. Other residents present in the area were not disturbed by Resident #6's behavior and were safe.A behavior note, dated 3/27/26 at 4:30 p.m., revealed Resident #6 was presenting with escalating behaviors. Resident #6 was observed talking loudly and expressing frustration about rich people knowing they had money and being okay with poor people not having what they needed, including families and children to care for. A social services staff member accompanied Resident #6 as he walked up and down the hallway, and Resident #6 became further escalated when the social services staff member offered him a soda, which the resident said the offer felt like hush money for the poor. The social services staff member continued walking with Resident #6 for approximately 25 minutes, throughout which the resident appeared to become calmer. Resident #6 eventually accepted a cookie and soda.A progress note, dated 3/27/26 at 8:37 p.m., revealed Resident #6 had been very agitated that afternoon, and was offered beverages and snacks with no success. An administrator came to calm down Resident #6 and offered him a snack, and a PRN dose of lorazepam was administered. Resident #6 calmed down after three hours and went to bed.A progress note, dated 3/28/26 at 2:23 p.m., revealed Resident #6 was still agitated early that morning. Staff attempted to redirect Resident #6 using beverages and snacks but were unsuccessful, so a PRN dose of lorazepam was administered. Resident #6 was still agitated but was slowly calming down.A progress note, dated 3/29/26 at 8:22 p.m. revealed a PRN dose of lorazepam was administered to Resident #6 because he started having behaviors and was raising his hand to staff.A progress note, dated 3/30/26 at 1:04 p.m., revealed Resident #6 continued to have escalated behaviors and was verbally abusive to other residents and staff members. Resident #6 was clenching his fist and waving aggressively to staff and peers. Resident #6 was placed on 15-minute checks.A change in condition note, dated 3/30/26 at 4:59 p.m., revealed Resident #6 was walking past Resident #17 when she started to talk in a loud tone towards Resident #6. An interaction was initiated between the two residents and Resident #6 stepped closer to Resident #17 when Resident #17 swung her outstretched arm to strike him. Resident #6 held onto Resident #17's shoulder/neck area to attempt to stop her from hitting him. Resident #6's physician was contacted and medication adjustments were made, including continuing the as-needed lorazepam order for another 14 days and adjusting his quetiapine dose.C. Resident #171. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the May 2026 CPO, diagnoses included senile degeneration of the brain, dementia with agitation, depression and mild neurocognitive disorder with behavioral disturbance.The 3/3/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident required partial to moderate assistance from staff for most ADLs.The MDS assessment documented the resident did not have physical behaviors directed at others or other behavioral symptoms not directed toward others. The assessment documented the resident had verbal behavioral symptoms directed towards others which occurred on one to three days in the seven-day assessment period.2. Record reviewA change in condition note, dated 3/30/26 at 4:34 p.m., revealed Resident #17 was involved in a resident-to-resident altercation. Resident #17 was sitting in her wheelchair by her door and was yelling about getting her bed made. Resident #6 was walking past Resident #17 and she started to scream at him to just hit her already. Resident #6 then stepped up to Resident #17 and she swung at his stomach to hit him. Resident #6 held onto Resident #17's shoulder/neck area to attempt to stop her from hitting him. A skin check was complete and no redness to her skin was noted. The facility administration, residents' physicians and representatives were notified.III. Incident of physical abuse by Resident #7 towards Resident #6 on 4/16/26A. Facility investigationThe facility investigation, dated 4/16/26, was provided by the NHA on 5/11/26 at 9:00 a.m. The investigation revealed the following:On 4/16/26 at 10:45 a.m. a nursing staff member heard a feminine voice yelling, followed by a male voice talking loudly and more yelling. The nursing staff member began walking down the hallway to search for where the yelling was coming from and observed Resident #6 standing in the doorway of Resident #7's room. The residents were separated and assessed, and Resident #7 was not found to have any injuries. Resident #6 seemed unphased, had a scratch on his left cheek and some redness to the left side of his neck. The residents were separated, placed on 15-minute checks and monitored for 72 hours for any psychosocial changes.An interview with RN #1, dated 4/16/26, revealed he heard Resident #7 yelling get out. Upon entering Resident #7's room, Resident #6 was observed walking towards the doorway, and Resident #7 appeared frantic. Resident #7 said Resident #6 had entered her room and pushed her, so she pushed him back. Resident #6 was unable to recall the incident. An interview with RN #2, dated 4/16/26, revealed the staff member heard yelling from a feminine voice. While trying to identify the source of the yelling, the nursing staff member found Resident #6 in Resident #7's room, and Resident #7 appeared scared. Resident #7 said she was scared, and Resident #6 scared her and pushed her. The residents were separated and redirected to calm them down.The investigation documented Resident #6 had a history of verbal outbursts and anxiety related to delusions he had from his time in military service.The investigation documented Resident #7 had poor impulse control and was territorial of her possessions and her room, and could become verbally aggressive when other residents touched her things or entered her room.The investigation determined the allegation of abuse was substantiated, as redness and discoloration was noted on Resident #6 immediately following the incident. The residents' care plans were updated following the event, and a stop sign was ordered for Resident #7's door to deter residents from wandering into her room.A. Resident #71. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the May 2026 CPO, diagnoses included dementia with agitation and mood disturbance, depressive episodes, anxiety disorder, cognitive communication deficits and bipolar disorder.The 4/15/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of six out of 15. The resident was independent for most ADLs.The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.2. Record reviewThe psychosocial care plan, revised 12/14/25, revealed Resident #7 was at risk for decreased psychosocial well-being due to a history of physical and sexual assault. Potential triggers included having people in close proximity or people approaching her quickly without warning. Pertinent interventions included administering medications as ordered and assisting Resident #7 with normalizing her feelings.A change in condition note, dated 4/16/26 at 3:37 p.m., revealed the nurse on duty heard a feminine voice yelling, followed by a male voice talking loudly and more yelling. The nurse searched for the source of the yelling and observed Resident #6 standing in the doorway of Resident #7's room with the door wide open. Both residents were separated and assessed, and Resident #7 did not have any injuries. Resident #6 calmly exited the room and was escorted away by another nurse. Resident #7 was placed on 15-minute checks.IV. Incident of physical abuse by Resident #6 towards Resident #5 on 4/21/26A. Facility investigationThe facility investigation, dated 4/21/26, was provided by the NHA on 5/11/26 at 9:00 a.m. The investigation revealed the following: On 4/21/26 at 9:30 a.m. Resident #5 was sitting in her wheelchair in the hallway by the nurses' station. As Resident #6 walked behind Resident #6, Resident #6 extended his arm in a closed fist and struck the left side of Resident #5's face. Resident #5 was noted to be tearful and non-redirectable for about 15 minutes afterwards. The residents were separated, placed on 15-minute checks and monitored for 72 hours for any psychosocial changes. Resident #6 was given hot chocolate to calm him down.Resident #5 was interviewed on 4/21/26 at 9:50 a.m. Resident #5 said someone hit her in the head. Resident #5 said she was not doing anything wrong and was just sitting there.Resident #6 was interviewed on 4/21/26 at 9:55 a.m. Resident #6 said she (Resident #5) hit him and slammed him in the mouth. Resident #6 said he was trying to push Resident #5 off, and said she hit him in the left side of his mouth. Licensed practical nurse (LPN) #4 was interviewed on 4/21/26 and said she had been standing at the nursing cart talking with Resident #5 when Resident #6 walked behind Resident #5 and quickly hit her on the left side of the face before he walked away.Certified nurse aide (CNA) #5 was interviewed on 4/21/26 and said she was standing at the nurse's station and observed Resident #6 punch Resident #5 on the left side of her head as Resident #5 was praying.The activities assistant was interviewed on 4/21/26, and said she had seen Resident #5 in her wheelchair crying and upset at the nurses' station following the incident.The investigation documented Resident #6 had a history of becoming verbally aggressive and had delusions which could upset him, causing him to become anxious and paranoid.The investigation documented Resident #5 had a history of making noises at times which could be disruptive to other residents, and cognitive impairments which made her unable to notice when her singing or noises were bothering others.The investigation determined the allegation of physical abuse was substantiated as immediately following the incident, Resident #5 had noted redness. The residents' care plans were updated following the event, and one-to-one supervision was implemented for Resident #6 to help prevent reoccurrence.A. Resident #5 (victim)1. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the May 2026 CPO, diagnoses included Alzheimer's disease, dementia without behavioral disturbance, cognitive communication deficits and unspecified intellectual disabilities.The 3/16/26 MDS assessment revealed the resident had moderate cognitive impairments with aBIMS score of nine out of 15. The resident was dependent on staff assistance for most ADLs.The MDS assessment documented the resident did not have physical or verbal behaviors directedat others or other behavioral symptoms not directed toward others.2. Record reviewA change in condition note, dated 4/21/26 at 3:14 p.m., revealed Resident #5 had been in a resident-to-resident altercation. Resident #5 was sitting in the hallway and as the assailant (Resident #6) went behind Resident #5, he made contact with her left facial area. Resident #5 was noted to be tearful and n

Based on record review and interviews, the facility failed to provide choices for preference of bathing schedule for one (#1) of three residents reviewed for self-determination out of eight sample residents.Specifically, the facility failed to ensure Resident #1 received showers consistent with her preferences.Findings include:I. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock (severe infection that causes organ failure), pneumonia, major depressive disorder, and weakness. The 1/22/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing. -The MDS assessment revealed that bathing was documented as not applicable for assistance. B. Resident's representative interviewResident #1's representative was interviewed on 3/3/26 at 1:26 p.m. The representative said Resident #1 told her staff were busy and were not providing her with showers. The representative said Resident #1 requested a shower the week after she was admitted to the facility (week of 1/18/26) and staff did not provide a shower to her. The representative said Resident #1 called her and said staff did not give her a shower and that was how she became aware of the concern. The representative said she had observed Resident #1 wearing the same clothing on multiple occasions, which led her to believe Resident #1 was not receiving showers. The representative said when she visited Resident #1, the resident had a personal female odor. The representative said Resident #1 appeared upset and expressed a desire to be clean. The representative said she asked the director of nursing (DON) for documentation showing completion of the showers for Resident #1, but the facility could not provide her with documentation. C. Record reviewResident #1's activities of daily living (ADL) care plan, initiated 1/16/26, documented the resident needed partial to substantial assistance for bathing or showering.-However, the care plan failed to include the resident's preferences or specific days for showers. A review of the certified nurse aide (CNA) bathing task documentation for Resident #1, from 1/16/26 through 1/28/26, revealed no documentation to indicate showers were provided to the resident during her stay at the facility.A review of Resident #1's electronic medical record (EMR) revealed the resident's shower preference assessment was not completed upon the resident's admission to the facility.II. Staff interviewsCNA #2 was interviewed on 3/4/26 at 11:14 a.m. CNA #2 said the residents' shower schedules were listed at the nurses' station and indicated how often residents were to receive showers. CNA #2 said residents were scheduled to receive showers three times each week and residents could choose a preference for morning or evening showers.CNA #2 said Resident #1 was scheduled to receive showers on Monday, Wednesday and Friday. CNA #2 said the shower schedule was communicated to staff during shift change and staff reviewed the shower schedule sheet. CNA #2 said if a resident refused a shower, staff would ask the resident three times if they wanted a shower and then documented the refusal in the resident's EMR and notified the nurse. CNA #2 said Resident #1 often prepared for therapy during the day shift and after therapy appeared exhausted and sometimes refused showers. CNA #2 said Resident #1 received therapy five times per week and sometimes refused showers due to fatigue. CNA #2 said refusals were documented and communicated to the night shift if the resident refused a shower during the morning shift. CNA #2 said if a shower was missed and staff had time the next day, they would attempt to provide the refused shower to the resident. CNA #2 said if staff were busy, the resident would not receive a shower until their next scheduled shower.Licensed practical nurse (LPN) #1 was interviewed on 3/4/26 at 11:30 a.m. LPN #1 said if a resident refused a shower, she would ask the CNA to offer the shower again and if the resident refused a third time, the nurse would document the refusal in a progress note. LPN #1 said the staff would contact the resident's family to see if the family could encourage the resident to accept the shower. LPN #1 said during shift change, staff communicated with the oncoming shift regarding showers that were not completed. LPN #1 said if a shower was missed, staff would attempt to provide the shower the next day and Saturdays were used as a make-up day for showers that were previously refused.The director of nursing (DON) was interviewed on 3/4/26 at 2:32 p.m. The DON said residents were supposed to be offered showers two times per week unless the resident wanted more frequent showers. The DON said a preference evaluation was completed as part of the admission packet and new admissions were to be offered a shower the day after admission. The DON said staff said they offered showers to Resident #1, but they forgot to document the offers or resident refusals.The DON said the facility completed shower audits five times per week to ensure residents were offered showers and to verify refusals were documented. The DON said if a shower log showed no documented showers during a resident's stay, the facility would investigate which staff members worked during that time and determine whether showers were offered and whether the staff completed documentation about the showers.The DON said she was not aware of any concerns or complaints from the resident or family regarding bathing while Resident #1 was at the facility. The DON said she became aware of the concern after Resident #1 had discharged from the facility.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of eight sample residents received adequate supervision to prevent risk for accident hazards.Specifically, the facility failed to ensure safe assistance was provided by staff during incontinence care for Resident #1, which resulted in the resident sustaining a fall with minor injuries when she rolled out of bed during the care.Findings include: I. Facility policy and procedureThe Falls - Clinical Protocol policy, revised March 2018, was provided by the director of nursing (DON) on 3/4/26 at 3:04 p.m. It read in pertinent part, The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and the caregiver or family about a history of falling. The staff and physician will document in the medical record a history of one or more recent falls. The nurse shall assess and document or report vital signs, recent injury, especially fracture or head injury, musculoskeletal function observing for change in normal range of motion and weight bearing, change in cognition or level of consciousness, neurological status and pain. The nurse will also assess the frequency and number of falls since the last physician visit, precipitating factors and details on how the fall occurred, all current medications especially those associated with dizziness or lethargy and all active diagnoses. II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock (severe infection that causes organ failure), pneumonia, major depressive disorder, and weakness. The 1/22/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing. The MDS assessment did not indicate the resident had a history of falls. B. Resident's representative interviewResident #1's representative was interviewed on 3/3/26 at 1:26 p.m. The representative said Resident #1 told her that during incontinence care, an unknown certified nurse aide (CNA) kept pushing her to roll over and she fell off the bed. The representative said a nurse entered the room and observed the CNA pulling Resident #1 off the floor by her right arm, even though she said she had pain in her right arm and told the CNA to stop. The representative said that Resident #1 was upset. Resident #1's representative said Resident #1 called her approximately 30 minutes after the fall on 1/23/26 and said she sustained injuries to her right shoulder. The representative said the resident's right shoulder had been hurting prior to the fall, but the fall made the pain worse because the CNA tried to pull her up by her right arm. The representative said every toe on the resident's right foot had abrasions or bruising and staff placed bandages on them.Resident #1's representative said later that night, on 1/23/26, the facility called and said Resident #1 had a fall and was fine and they wanted to notify her. The representative said the facility did not inform her that Resident #1 sustained injuries.C. Record reviewThe activities of daily living (ADL) care plan, initiated 1/16/26, revealed Resident #1 had a self-care performance deficit related to severe septic shock from pneumonia and needed staff assistance with care. -However, the bed mobility intervention did not identify the level of assistance required or the number of staff needed.Review of Resident #1's fall care plan, initiated 1/16/26 and revised 1/28/26, revealed the resident was at risk for falls related to respiratory failure, chronic obstructive pulmonary disease (COPD) and chronic pain. Pertinent interventions included one-on-one staff education, ensuring all items were in reach while the resident was in bed or her chair, anticipating and meeting the resident's needs, keeping the resident's bed at transfer height, physical therapy evaluate and treat as ordered and two staff members to provide incontinence care. A fall risk assessment, dated 1/16/26, revealed the resident was a high fall risk.A fall investigation report, dated 1/23/26 at 8:30 p.m., revealed a CNA was providing incontinence care to Resident #1 when the resident rolled out of bed, landing on her bilateral lower extremities. No injuries were observed at the time of the fall. The resident said her pain was 4 out of 10 in her right shoulder. The nurse observed five skin tears to Resident #1's toes and a right knee abrasion. An IDT (interdisciplinary team) progress note, dated 1/27/26 at 3:37 p.m., revealed Resident #1 lifted her right leg and her weight shifted while she was being provided incontinence care. Resident #1 then rolled left and slid out of bed onto the floor, landing on her knees. Resident #1 had no new skin impairments as a result of the fall. The interventions included one-on-one staff education and two staff members were to perform incontinence care for the resident. -Review of Resident #1's electronic medical record (EMR) revealed there were no nursing progress notes related to Resident #1's fall on 1/23/26. III. Staff interviewsCNA #2 was interviewed on 3/4/26 at 12:55 p.m. CNA #2 said staff determined how to safely turn and reposition a resident in bed based on the resident's ability to assist with movement. CNA #2 said staff reviewed the Kardex (a comprehensive directive tool for care), care plan and hospital report information, and would ask the nurse, another CNA familiar with the resident or the resident about their ability if staff were unfamiliar with the resident or if the resident was a new admission to the facility. CNA #2 said the number of staff assisting with repositioning, bed mobility and incontinence care varied, depending on the resident's needs. CNA #2 said staff determined whether one or two staff members were required based on the resident's level of assistance. CNA #2 said during Resident #1's initial admission to the facility (7/14/25), the resident required two-person assistance but later progressed to needing only one-person assistance. CNA #2 said during the resident's second admission to the facility (1/16/26), Resident #1 required two-person assistance for bed mobility. CNA #2 said she did not know whether Resident #1 had one or two person assistance on the night of the incident (1/23/26). CNA #2 said staff were aware Resident #1 was considered a fall risk and used a wheelchair. CNA #2 said staff did not have concerns that the resident could slide off the bed while being turned during care. Registered nurse (RN) #1 was interviewed on 3/4/26 at 1:08 p.m. RN #1 said staff reviewed the care plan and Kardex to determine whether a resident required one or two-person assistance for bed mobility or repositioning. RN #1 said if the resident was newly admitted or readmitted to the facility, staff reviewed hospital records and physical therapy notes from the hospital. RN #1 said prior to the fall on 1/23/26, Resident #1 required partial to moderate assistance with turning during incontinence care and this meant the resident was able to assist with care. RN #1 said fall interventions in place prior to the fall included nonskid footwear, the call light within reach and encouragement for the resident to use the call light as needed. RN #1 said she did not find any interventions in the care plan specifically related to bed mobility and repositioning. RN #1 said staff were informed about the resident's fall risk and required assistance through the falling staff program, which placed a star outside the resident's door to indicate fall risk. RN #1 said staff additionally reviewed the Kardex and EMR documentation. RN #1 said after the fall occurred on 1/23/26, Resident #1's care instructions were updated to include the resident required two-person assistance for incontinence care. RN #1 said prior to the fall, Resident #1 was considered a high fall risk. The DON was interviewed on 3/4/26 at 2:32 p.m. The DON said based on Resident #1's medical condition, level of weakness and diagnoses, the resident required one-person assistance for turning in bed prior to the resident's fall on 1/23/26. The DON said the level of assistance required for a resident was identified in the residents' care plans.The DON said Resident #1 had weakness, which increased her risk for falling. The DON aid staff assessed the resident's needs for assistance primarily based on information reported by staff working on the floor and through ongoing assessment of the resident's condition. The DON said staff received education to use the mechanical lifts when appropriate rather than lifting residents manually. The DON said after the fall on 1/23/26, Resident #1 sustained abrasions to the right knee and toes. The DON said following the fall, the resident's care plan was updated to require two-person assistance for during the resident's incontinence care and repositioning. The DON said written education was provided to staff indicating Resident #1 required two-person assistance.

Based on record review and interviews, the facility failed to ensure food served accommodated residents' allergies and intolerances for one (#1) of three residents reviewed out of eight sample residents.Specifically, the facility failed to ensure Resident #1 was not served food the resident was allergic to, despite the resident having a documented food allergy.Findings include:I. Facility policy and procedureThe Food Allergies and Intolerances policy, revised August 2017, was provided by the director of nursing (DON) on 3/4/26 at 3:04 p.m. It revealed in pertinent part, Residents with food allergies and or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen. Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment. All reported food allergies and intolerances are documented into the resident care plan. Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness. The 1/22/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing.B. Resident's representative interviewResident #1's representative was interviewed on 3/3/26 at 1:26 p.m. The representative said the facility had documented that Resident #1 was allergic to pineapple and the allergy was included on the resident's meal ticket. The representative said the facility still served pineapple to Resident #1, despite documentation indicating the resident was allergic to pineapple. The representative said Resident #1 ate a few pieces of pineapple before realizing it was pineapple. The representative said staff gave Resident #1 medication to prevent any allergic reactions after the resident ate the pineapple, and no reaction was noted. The representative said Resident #1 was upset and did not understand how the pineapple was served despite the allergy being documented in the resident's medical record and on her meal ticket the certified nurse aides (CNA) had access to when delivering the resident's meal tray. C. Record reviewReview of Resident #1's comprehensive care plan, initiated 1/16/26, revealed Resident #1 had allergies to pineapple and wool.The care plan report, initiated 1/16/26 and revised 1/26/26, identified Resident #1 as having an allergy to pineapple and included a nutrition intervention for staff to honor the resident's food preferences.-The care plan did not reveal the resident's food likes and dislikes.The nursing progress note, dated 1/21/26 at 9:10 p.m., revealed the resident had pineapple on her dinner tray. The progress note documented the resident had a pineapple allergy and ate two pieces of the pineapple. The progress note documented staff notified the on-call physician orders were obtained to give the resident Benadryl (antihistamine medication). The progress note documented staff noted no adverse reactions after the incident and the resident's vital signs were stable.The progress note, dated 1/22/26, documented a physician's order for Benadryl (diphenhydramine HCl) 25 milligrams (mg) capsule with directions to give 25 mg by mouth every six hours as needed for allergy. Review of the facility's Quality Assurance and Performance Improvement (QAPI) root cause analysis, dated 1/22/26, revealed Resident #1 was served pineapple on her dinner meal tray on 1/21/26, despite having a documented pineapple allergy. The review revealed the resident ingested two pieces of pineapple before staff identified the error and removed the food from the tray. Nursing management and the physician were notified and diphenhydramine (Benadryl) was ordered as needed. The resident was monitored and no allergic reaction or negative outcome was reported. Review of the QAPI root cause analysis revealed the dietary aide (DA) serving the residents' food on 1/21/26 did not note the resident's pineapple allergy on the meal card and pineapple was placed on the resident's tray as a dessert. The review further revealed the CNA identified the pineapple on the tray and removed it after the resident had already ingested two pieces of the pineapple.Review of the facility's corrective action plan revealed dietary staff were educated to verify that foods served matched the meal cards with attention to residents' documented allergies. The document additionally revealed nursing staff were educated to verify that the food served matched the resident's meal card. The plan documented residents' allergies would be clearly listed on meal cards to assist staff when passing meal trays.Review of the facility's staff education regarding meal verification and allergies revealed staff were educated to verify each resident's meal card accurately and ensured it reflected the resident's current diet order, texture and restrictions. The education documented staff should check meal cards daily and whenever there was a diet change for a resident. The staff education document revealed the education reviewed the process for clearly identifying residents' food allergies on the residents' meal cards and staff should immediately report any missing or incorrect allergy information to nursing and dietary services. The education further documented staff should confirm the meal being served matched the resident's meal card and should not provide food items that conflicted with physician ordered diets or documented allergies. Review of the in-service sign in sheet, dated 1/27/26, revealed dietary staff attended the education regarding meal card verification and accuracy.-However, the facility failed to ensure the corrective action was sustained (see resident council notes below). Review of the resident council meeting notes, dated 1/29/26, revealed residents reported meal service concerns. One resident communicated that CNAs blamed the kitchen for meal mistakes and did not correct the issue when errors occurred. Residents also communicated that some CNAs did not ask residents for their meal choices.Review of the resident council meeting notes, dated 2/26/26, revealed a resident communicated that meal tickets were not being followed correctly by CNAs on the Evergreen unit.III. Staff interviewsThe dietary manager (DM) was interviewed on 3/4/26 at 10:21 a.m. The DM said resident allergies were identified through the meal tickets printed by either the DS or the dietitian. The DM said the meal tickets included the residents' food allergies and the allergies were highlighted. The DM said the dDAs verified the meal tickets before the meal cart left the kitchen and the CNAs on the floor also checked the tickets.The DM said in the incident involving Resident #1's pineapple allergy, the DA did not review the resident's meal ticket correctly and did not pay attention to the resident's documented food allergy because staff were trying to serve trays quickly.DA #1 was interviewed on 3/4/26 at 10:31 a.m. DA #1 said residents' food allergies were identified by reviewing the meal tickets. DA #1 said the meal tickets listed diet textures such as soft and bite-sized diets and identified residents with allergies. DA #1 said residents' food allergies were highlighted in yellow so staff knew what to look for when preparing trays.DA #1 said if a food item on a tray was something a resident was allergic to, staff would remove the item and provide an alternative food, such as applesauce instead of pineapple. DA #1 said if a resident's meal tray had already been prepared with the incorrect food item, staff would discard the tray and prepare a new meal tray for the resident with the correct substitute food item.Cook (CK) #1 was interviewed on 3/4/26 at 10:36 a.m. CK #1 said residents' food allergies were identified by reviewing the meal tickets before giving the tickets to the DA. CK #1 said kitchen staff reviewed the meal tickets thoroughly to ensure residents did not receive foods they were not allowed to have.CK #1 said if a food item on a tray was something a resident was allergic to, staff ensured the item was not served to the resident and removed the tray. CK #1 said once meal tickets were printed and the DA highlighted residents' allergies, staff ensured residents did not receive foods that they were not allowed to have. CK #1 said the DAs checked meal trays before they left the kitchen.The registered dietitian (RD) was interviewed on 3/4/26 at 10:44 a.m. The RD said the residents' food allergies were documented at the time of the resident's initial admission and remained documented during subsequent admissions. The RD said the facility used a software program to track residents' food allergies, preferences and diet orders. The RD said the software program integrated with the residents' electronic medical records (EMR), and diet orders and allergies were communicated to the kitchen through that system and updated as needed.The RD said residents' food allergy information was communicated to kitchen staff and nursing staff through the residents' meal cards. The RD said the CKs prepared the entree, passed it to the DAs and the DAs placed the dessert on the meal tray and the meal tray on the meal delivery cart. The RD said floor staff were expected to review and verify the residents' meal cards before serving the meal trays to the residents.The RD said the incident regarding Resident #1 being served a food she was allergic to was discussed in a clinical meeting the next day following the incident (1/22/26) and education was provided to staff on 1/27/26. -However, education was not provided to staff until five days after the IDT discussed the incident and six days after the incident with Resident #1 occurred.CNA #1 was interviewed on 3/4/26 at 11:01 a.m. CNA #1 said staff identified foods a resident should not receive due to allergies or diet restrictions by reviewing the resident's meal ticket. CNA #1 said staff checked the meal tickets to verify the correct foods were served to residents. CNA #1 said everyone in the kitchen and on the floor passing trays checked the meal tickets. CNA #1 said if a food item on the tray was something the resident may be allergic to, staff would take the tray back to the kitchen to obtain an alternative food item and reported the concern to the unit manager.Registered nurse (RN) #1 was interviewed on 3/4/26 at 11:08 a.m. RN #1 said a resident's allergies would be documented in the admission paperwork and would then be entered into their EMR. RN #1 said the allergy information would be written on the resident's meal tray ticket so dietary staff and nursing staff would be aware of the resident's allergies. RN #1 said each staff member was expected to review the meal ticket on each resident's tray to ensure residents did not receive foods they were allergic to. RN #1 said if staff identified an allergen on a resident's tray, staff removed the meal tray and obtained a new tray from the kitchen with an alternative food item.RN #1 said if a resident ingested a food item they were allergic to, staff removed the food, obtained the resident's vital signs and notified the physician for further orders. RN #1 said the incident would be documented in the resident's progress notes.The DON was interviewed on 3/4/26 at 2:32 p.m. The DON said the meal ticket system populated residents' diet orders and allergies and staff highlighted the allergy information. The DON said kitchen staff and nursing staff were expected to review the meal tickets to ensure residents did not receive foods they were allergic to. The DON said the facility was attempting to determine where the break in the system occurred related to Resident #1's pineapple allergy incident.The DON said after the incident with Resident #1 on 1/21/26, the facility implemented audits and worked with the kitchen manager to ensure an additional staff member reviewed meal trays before they left the kitchen.The DON said nursing staff verified that the meals being delivered matched the resident's diet orders and allergy information by comparing the meal cards with the meal trays before serving the meal to the residents.The DON said staff compliance was monitored through ongoing audits and follow-up education with staff to ensure the process was followed.-However, review of resident council meeting notes revealed residents still had concerns with CNAs not following meal tickets on 2/26/26 (see record review above).

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure:-Beard nets were worn while preparing food in the main kitchen;-Hand hygiene was conducted during meal service and dishwashing; and,-Food was labeled and dated in the walk-in refrigerator, walk-in freezer and reach-in refrigerators. Findings include:I. Failure to ensure beard nets were worn in the kitchenA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/29/25. It revealed in pertinent part, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens and unwrapped single-service and single-use articles. (Chapter 2)B. Facility policy and procedureThe Preventing Foodborne Illness Employee Hygiene and Sanitary Practices policy, revised November 2022, was received from the director of nursing (DON) on 9/25/25 at 8:35 a.m. It read in pertinent part, Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.C. ObservationsOn 9/22/25 at 9:59 a.m. an unidentified male dietary aide (DA) with a goatee was standing by the three-compartment sink in the kitchen. He was not wearing a beard net. On 9/22/25 at 12:26 p.m. the unidentified male DA with a goatee was in the kitchen without a beard net on. On 9/24/25 at 10:06 a.m. the unidentified male DA with the goatee was in the kitchen without a beard net on washing dishes in the three-compartment sink. On 9/24/25 at 12:14 p.m. an unidentified male DA with a full beard came into the kitchen and did not put on a beard net. He went into the back area of the kitchen and began helping with food preparation after washing his hands. D. Staff interviewsThe dietary supervisor (DS) was interviewed on 9/25/25 at approximately 3:00 p.m. He said beard nets should have been worn. II. Failure to perform hand hygiene appropriately during meal service and dishwashingA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/29/25. It revealed in pertinent part, The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)B. Facility policy and procedureThe Preventing Foodborne Illness Employee Hygiene and Sanitary Practices policy, revised November 2022, was received from the DON on 9/25/25 at 8:35 a.m. It read in pertinent part, Employees must wash their hands: after personal body functions ( toileting, blowing/wiping nose, coughing, sneezing); after using tobacco, eating or drinking; whenever entering or re-entering the kitchen; before coming in contact with any food surfaces; after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; and/or after engaging in other activities that contaminate the hands.C. ObservationsDuring a continuous observation on 9/24/25, beginning at 11:00 a.m. and ending at 12:41 p.m., the following was observed during the meal service in the main kitchen:At 11:00 a.m. meal service began. [NAME] (CK) #1 was serving the main meal and DA #2 was making and plating the special orders. DA #2 washed her hands and donned a pair of gloves. At 11:07 a.m. DA #2 doffed (took off) her gloves and donned a new pair of gloves. She did not perform hand hygiene after taking her gloves off and before putting on new gloves. At 11:13 a.m. DA #2 took off her gloves after making a grilled cheese sandwich and donned a new pair of gloves without performing hand hygiene. At 11:15 a.m. CK #1 scratched her head underneath her hat, did not perform hand hygiene afterwards and continued to serve the meal. At 11:16 a.m. DA #2 cut the crust off of a peanut butter and jelly sandwich, took her gloves, placed the gloves on the cutting board with the crust from the sandwich. She then picked the used gloves and crust with her bare hands and threw all of it into the trash bin. Without performing hand hygiene, she then donned a new pair of gloves. At 11:20 a.m. without performing hand hygiene after she scratched her head, CK #1 left the serving line and returned with a new bag of paper plates. She opened the bag of plates and took out a large stack of paper plates, closed the opened bag of plates and began to serve the meal without performing hand hygiene. At 11:37 a.m. CK #2 switched spots with CK #1. At 12:20 p.m. DA #1 was washing dishes in the three-compartment sink with gloves on. He grabbed some dirty containers for the room trays so he could wash them for the meal service line. After placing some of the dirty lids and bottoms into the wash compartment, he went to the clean side and removed the clean dishes and put them away. He did not change his gloves or perform hand hygiene or remove his gloves after touching the dirty dishes and prior to touching the clean dishes. At 12:21 p.m. CK #2 touched the backside of her pants and began serving meals without performing hand hygiene. D. Staff interviewsThe DS was interviewed on 9/25/25 at approximately 3:00 p.m. He said hand hygiene should be performed after taking off gloves and when hands were soiled. III. Failure to ensure food was labeled and dated in the walk-in freezer, walk-in refrigerator and reach-in refrigerators. A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 9/29/25. It read in pertinent part,A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. (Chapter 3-29)B. ObservationsOn 9/22/25 at 7:10 a.m., during the kitchen tour, the following items were found in the main kitchen walk-in freezer:-An unidentified meat wrapped in tinfoil, that was not labeled or dated;-An unidentified meat that inside of a plastic bag, that was not labeled or dated;-An open bag of breakfast sausages that was not labeled or dated; and,-A large black bin filled with an assortment of different plastic bags filled with different meat patties, frozen mixed vegetables and unidentified foods that were not labeled or dated. On 9/22/25 at 7:16 a.m. the following items were found in the main kitchen walk-in refrigerator:-An opened bag of liquid eggs, without an open date; and,-An unidentified meat that was wrapped in plastic wrap that was not labeled or dated.On 9/24/25 at 10:06 a.m. in the walk-in refrigerator, there was a large container of food that resembled peeled and diced potatoes in water, which was not labeled or dated. On 9/24/25 at 11:32 a.m., during lunch service, DA #2 made a tuna salad sandwich; the tuna salad container was not labeled or dated. On 9/24/25 at 11:55 a.m., during lunch service, DA #2 reheated spaghetti with marinara sauce; the marinara sauce container was not labeled or dated. On 9/25/25 at 8:49 a.m. the following items were found in the reach-in refrigerators that was located next to the steam tables and where the facility stored sandwich supplies:-A large container of tuna salad that was not labeled or dated;-A large container of marinara sauce that was not labeled or dated; and,-An unidentified soup that was not labeled or datedC. Staff interviewThe DS was interviewed on 9/25/25 at approximately 3:00 p.m. He said everything should be labeled and dated.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure there were monitoring measures maintained for all control measures identified that may contribute to the spread of legionella (a type of bacteria that can cause legionella disease, a severe form of pneumonia): -Ensure the facility water management plan was reviewed annually; and,-Ensure the facility water management plan was personalized and specific to the facility. Findings include:I. Facility policy and procedureThe Legionella Water Management Program policy and procedure, revised June 2021, was provided by the nursing home administrator (NHA) on 9/25/25 at 12:27 p.m. It read in pertinent part, The purposes of a water management program are to identify areas in the water system where Legionella bacteria can grow and spread.Specific measures used to control the introduction and/or spread of legionella (temperatures and disinfectants)include; a system to monitor control limits and effectiveness of control measures.The water management program is reviewed at least once a year. II. Water Management Plan A. Record reviewThe Water Management Plan, dated 12/20/23, was provided by the NHA on 9/24/25 at approximately 10:00 a.m. and it revealed in pertinent part,Control measures and corrective actions include: Ice coolers are put on a daily cleaning schedule, HVAC (heating, ventilation and air conditioning) filters are serviced twice a year, The juice machine juice gun is soaked daily by dietary staff in a disinfectant, taken apart weekly and cleaned, Hot tubs should be drained, cleaned and refilled every three to four months and plumbing should be cleaned every 12 months; and, Decorative fountains should be run daily to avoid prolonged idle periods. On 9/25/25 at 10:18 a.m. audit logs for the daily cleaning of the ice coolers, the weekly cleaning of the juice machines, quarterly draining/cleaning of the facility hot tubs, and the twice yearly service of the facility HVAC were requested from the NHA via email on 9/25/25 at 10:18 a.m. -These documents were not provided during the surveyB. Staff interviews The maintenance director (MTD) was interviewed on 9/24/25 at 2:51 p.m. He said the facility followed the audit and cleaning schedule of the facility water management program to prevent the spread of legionella bacteria. The MTD said the program was discussed monthly in the facility quality assurance meeting. He said if the facility has moving water in the building and the water was not stagnant, then the water management plan was working. The regional clinical resource was interviewed on 9/24/25 at 3:34 p.m. She said the water management program should be reviewed and updated annually. The regional clinical resource said the facility did not have any decorative fountains and that should have been removed from the program control measures. She said it was important to keep the water plan up to day to prevent the risk of water borne illness and infections to the residents. She said the water management plan was outdated and not specific to the facility's areas of monitoring.

Based on observations and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect for two of four units. Specifically, the facility failed to:-Provide Resident #155 privacy while he used the restroom, and,-Staff announced themselves prior to entering residents' rooms. Findings include:I. Resident #155A. Resident statusResident #155, age [AGE], was admitted [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the skull) without loss of consciousness, dementia with agitation, cancer of the thyroid gland, and rheumatoid arthritis. The 6/25/25 minimum data set (MDS) assessment revealed Resident #155 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS further revealed Resident #155 was independent for all of his activities of daily living (ADL). B. ObservationsOn 9/23/25 at 9:14 a.m. certified nurse aide (CNA) #3 knocked on Resident #155's door then immediately walked into his room. Resident #155 was heard yelling, Hey, I'm on the toilet! CNA #3 then said, Sorry, can I grab your tray? CNA #3 then came out of his room without his tray and was heard saying to an unidentified CNA trainee, He's a very private person.II. Failure to knock before entering resident roomsA. ObservationsOn 9/23/25 at 9:14 a.m. after CNA #3 entered Resident #155's room, she proceeded to go from room to room on the 800 hall, knocking and immediately entering the residents' rooms to gather room trays. She did not announce herself upon entering the rooms. On 9/24/25 at approximately 2:22 p.m. an unidentified male CNA was going from room to room down the 700 hall taking residents' dinner orders. He was knocking then immediately entering the rooms (without announcing himself), without waiting for the residents to respond. B. Resident group interviewA group interview was conducted on 9/23/25 at 1:00 p.m. with 10 (#25, #31, #50, #2, #124, #140, #151, #152, #10 and #17) alert and oriented residents per facility and assessment. The residents said the staff knocked on their doors, but did not wait for a response. The residents said the staff knocked, then walked right in. The group called it the knock then walk. III. Staff interviewsCNA #2 was interviewed on 9/25/25 at 3:52 p.m. She said she knocked on the resident's doors before entering their rooms. She said she waited 30 seconds to one minute before entering the resident's room if she did not hear a response from the resident. She said if a resident was using the bathroom when she entered the room, the bathroom door was s usually closed or the resident would tell her before she entered the room. The director of nursing (DON) was interviewed on 9/25/25 at 3:56 p.m. She said the staff should knock before they enter a resident's room. She said staff should be asking if they could enter before they enter the room. She said staff should wait up to fifteen seconds before entering the room if they did not get a resident's response. She said there were certain circumstances, such as falls or other medical emergencies, where she did not want staff waiting too long before entering the resident's room.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in three of four medications rooms, one of five medication carts and one of one vaccine storage refrigerators.Specifically, the facility failed to:-Ensure expired vaccines were removed from refrigerators;-Ensure Tubersol (used to test for tuberculosis) vials were dated upon opening;-Ensure vaccinations were not stored in dormitory style refrigerator;-Ensure expired insulin pens were removed from the medication cart;-Ensure expired medications were removed from over the counter medications supply; and,-Ensure discarded medications were destroyed timely. Findings include:I. Professional referenceAccording to the Vaccine Storage and Handling Tool-kit, dated 3/29/24, retrieved on 9/29/25, from https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf, Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines even when used for temporary storage.According to the Tuberculin Purified Protein Derivative Tubersol package insert, retrieved on 9/29/25 from https://www.fda.gov/media/74866/download, A vial of Tubersol which has been entered and in use for 30 days should be discarded.According to the Lantus glargine insulin package insert, retrieved on 9/29/25 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, When not in use store in refrigerated temperatures of 36 to 46 degrees Fahrenheit (F). When in use, it can be kept at room temperature for up to 28 days.II. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was received from the nursing home administrator (NHA) on 9/25/25 at 9:30 a.m. it revealed in pertinent part, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and are discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.The Discarding and Destroying Medication policy, revised June 2025, was received from the NHA on 9/25/25 at 9:30 a.m. It read in pertinent part, Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. Except for the following situations, medications are not returned to the pharmacy for credit or disposal, Refusal upon delivery due to order change, Refusal upon delivery due to resident's death or expiration; and/or Pharmacy medication error in dispensing.III. Vaccine failuresA. ObservationsOn 9/24/25 at 1:18 p.m. the vaccine refrigerator on the Garden unit was reviewed with licensed practical nurse (LPN) #1 and the infection preventionist (IP). The vaccine refrigerator contained the following:One vial of Tubersol with an open date of 6/10/25;One vial of Tubersol with open date of 6/30/25;Eight vials of the COVID-19 vaccine mRNa Spikevax 2024-2025 formula that expired 6/2/25; and, Nine vials of influenza Fluad 2024-2025 formula expired on 5/14/25.B. Staff interviewsThe IP was interviewed on 9/24/25 at 1:20 p.m. She said Tubersol was only good for 30 days once opened and it could not be effective if used past the 30 days. The IP said it was the responsibility of the night nurses to review the medication refrigerators including the vaccine refrigerators. The IP said she would dispose of the expired vaccines. IV. Medication room failuresA. Observations On 9/24/25 at 10:47 a.m. the Evergreen medication refrigerator was observed with registered nurse (RN) #2. The refrigerator contained one open vial of Tubersol with no open date.-The facility failed to label the vial with an open date.The medication refrigerator also contained three vials of Gentamicin Sulfate (antibiotic) 40 milligrams per milliliter (mg/ml). Two vials expired July 2025 and the third vial expired May 2025-The facility failed to remove expired medications from the medication refrigerators. On 9/24/25 at 11:02 a.m the Garden medication room and refrigerator was observed with licensed practical nurse (LPN) #1. The medication refrigerator had one bottle of expired magnesium citrate (laxative) that expired 9/22/25 and one open Lantus insulin pen with no open date. -The facility failed to remove expired medication from the medication refrigerator. The facility failed to have an open date on an insulin pen. The Garden medication room had a large box overflowing on the floor and a cabinet full of discontinued medications belonging to residents who no longer resided in the facility. -The facility failed to have medications sent back or discarded timely. On 9/24/25 at 11:25 a.m. the Aspen medication room was observed with LPN #2. There were two open vials of Tubersol both had no open date. -The facility failed to label vials with open dates.The Aspen medication refrigerator was a dormitory style refrigerator. The freezer compartment was observed to have excess ice built up around the freezer compartment.-The facility failed to maintain the refrigerator clean and failed to store Tubersol in the appropriate refrigerator (see professional references above).The Aspen medication room had a cabinet labeled diabetic management. The cabinet contained over the counter medications. The following over the counter medications were found in the cabinet:One bottle of Vitamin C 500 mg that expired August 2025; One bottle of Zinc 50 mg that expired March 2025; Two bottles of Fiber laxative that expired July 2025; One box with bisacodyl suppositories 10 mg that expired April 2025; One bottle of Aspirin 325 mg that expired August 2025; One bottle of Oystershell plus Vitamin D 250 mg that expired July 2025; One bottle of Vitamin D 25 micrograms (mcg) that expired July 2025; and,One bottle of Docusate sodium (stool softener) 100 mg that expired June 2025. B. Staff interviews RN #1 was interviewed on 9/24/25 at approximately 10:50 a.m. during the observation of the medication refrigerator on the Evergreen unit. She said it was important to label vials with open dates to know when they expire as they were not as effective if used past the recommended open date. RN #2 said the gentamicin vials were expired and should have been removed from the refrigerator the month they expired. RN #2 said she would take the three vials of expired gentamicin and one vial of Tuberosol to the unit manager or the director of nursing (DON).LPN #1 was interviewed on 9/24/25 at approximately 11:05 a.m. during the observation of the garden medication room. He said open dates were important to ensure medication was used before they expired or they may not be as effective if used past the recommended date. LPN #1 said he did not know how long insulin was good once opened. LPN #1 said he was going to discard the expired medications. LPN #1 said the medication room had a cabinet for discontinued medications but it was full and the staff started to add them to the box on the floor. LPN #1 said the unit manager or DON were to dispose of the discontinued medications but he did not know when this was to occur. LPN #1 said the box had been there a while. LPN #1 said the nurses working the floor, unit manager and the DON had keys to the medication rooms. LPN #2 was interviewed on 9/24/25 at approximately 11:25 a.m. during the medication room observations. LPN #2 said she was not aware how long Tubersol vials were good for once accessed. LPN #2 said she did not feel the ice built up would cause any issues with medications stored in the refrigerator.RN #1 was interviewed on 9/24/25 at 11:34 a.m. when LPN #2 asked him about how many days the Tubersol was good once opened. RN #1 said it was good for 28 days. RN #1 said he did not know who was responsible for cleaning the ice out of the refrigerator. RN #1 said the ice that builds up could cause the refrigerator to not regulate temperatures effectively. RN #1 said it was the responsibility of the nurses to review the medication rooms and carts for expired medications. UM #2 was interviewed on 9/24/25 at 1:25 p.m. He said when the DON call\eds for the discontinued medications the nurses would take them to her for her to return them to the pharmacy or be destroyed appropriately. UM #2 said he believed she called for the medication to be destroyed monthly. V. Medication cart failuresA. ObservationsOn 9/24/25 at 11:20 a.m. the 600 hall on Aspen medication cart was observed with LPN #2. The following was observed:One open insulin glargine pen with an open date of 8/16/25; and, One open Lantus insulin pen with an open date of 8/1/25.-The facility failed to identify and dispose of insulin pens after the recommended 28 days from first access (see professional reference above). B. Staff interviewsLPN #2 was interviewed on 9/24/25 at approximately 11:25 a.m during observations of a medication cart and medication room on the Aspen unit. LPN #2 said the insulin vials were good for one month after the first use. LPN #2 said if the insulin was used after one month it may not be as effective for the resident. LPN #2 said she would discard the insulin pens, check the medication refrigerator for stock if not found she would contact the pharmacy to get them ordered. VI. Additional staff interviewsThe DON was interviewed on 9/24/25 at 1:58 p.m. She said it was the responsibility of all nurses and the unit managers to complete medication room and cart checks for expired medications. The DON said she was informed by her staff of the above observations and findings of expired medications found in the medication carts and rooms.The DON said the over the counter medications should not have been stored in the medication room because the facility kept over the counter medication stored in the central supply room in the basement. The DON said discontinued medications could be sent back to the pharmacy once a month. The DON said discontinued medications stored in the medication rooms could lead to the medication leaving the room or being placed back into the medication cart, which could lead to potential medication errors. The DON said she was not aware of the amount of discontinued medications in the cabinet and the box in the Garden medication room that needed to be sent back to the pharmacy. The DON said open dates were important to ensure the medication were used or discarded by the use of dates recommended by the manufacturer. The DON said insulin was good for 28 days from first access and Tubersol was good for 30 days from initial access. The DON said it was the IPs responsibility to monitor vaccines in the facility. The DON said the facility has always stored medications and vaccines in dormitory style refrigerators with no concerns. The DON said the medication refrigerators were cleaned as needed. The DOnNsaid if ice builds up it could cause storage concerns and would need to be defrosted. The DON said the medications in the refrigerator needing to be defrosted would be temporarily moved to another medication refrigerator while they defrosted the freezer. The DON said once the medication refrigerator was defrosted and temperature maintained within range the medication could safely be returned to the original refrigerator.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#175 and #45) out of five residents reviewed for personal funds accounts out of 71 sample residents.Specifically, the facility failed to notify Resident #175 and Resident #45, who were Medicaid funded, or their legal representative when the resident's personal funds account reached $200.00 less than the eligibility resource limit. Findings include:I. Resident accountsA. Resident #175Resident #175 had an account balance of $1,915.07.-There was no documentation the facility had notified Resident #175 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit.B. Resident #45Resident #45 had an account balance of $1,892.06.-There was no documentation the facility had notified Resident #45 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit.II. Staff interviewsThe nursing home administrator (NHA) was interviewed on 9/23/25 at 1:15 p.m. The NHA said the business office manager (BOM) was out of the office. The NHA said there was some confusion as to what the allotted limit for Medicaid funded residents was. The NHA said the facility was going to reach out to the residents' representatives to spend down the funds.

Based on record review, observations, and interviews, the facility failed to provide supervision, assistance, services, and implement effective person centered interventions to prevent falls with injuries for one (#156) of three residents reviewed for accidents/hazards out of 71 sample residents.Specifically, the facility failed to ensure the staff were aware and implemented Resident #156's fall interventions consistently. Findings include:I. Facility policy and procedureThe Fall Risk policy, revised March 2018, was provided by the nursing home administrator (NHA) on 9/25/25 at 9:21 a.m. It read in pertinent part,The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff will identify and implement relevant interventions (hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. II. Resident #156A. Resident statusResident #156, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO) diagnoses included dementia, diabetes and osteoporosis (a disease that weakens the bones, making them less dense and thinner).The 9/12/25 minimum data set (MDS) assessment revealed the resident had significant cognitive impairments with a brief interview of mental status (BIMS) score of one out of 15. The resident required extensive assistance with showers and transfers and used a wheelchair for mobility. The assessment revealed the resident had two falls with injury since the last review period. B. Observations On 9/22/25 at 8:45 a.m. Resident #156 was sleeping in her bed. The door was closed and the call light was on the floor. On 9/23/25 at 12:56 p.m. Resident #156 was asleep in her. The door closed. C. Record reviewThe fall care plan, revised on 6/3/25, revealed the resident was at risk for falls due to a history of falls with fractures and dementia. Interventions included to ensure the resident's call light was within reach (initiated 6/3/25), ensure the resident was wearing appropriate footwear when ambulating or mobilizing in her wheelchair (initiated 6/3/25), leaving the door open while the resident was in her room (initiated 6/30/25), assisting the resident with transfers after meals to the bed to lie down (initiated 8/8/25), ensuring the resident was in high visible areas during waking hours as tolerated (initiated 8/19/25), having the physician review the resident's blood sugars, metformin (diabetic medication) and A1C (diabetic blood test) (initiated 8/21/25). Review of the certified nurse assistant (CNA) abbreviated care plan (tasks) did not reveal resident specific fall interventions. A nursing progress note, dated 6/2/25, revealed the resident had been admitted after an intracapsular fracture (a bone break that occurs within the joint capsule) of left femur. A physician note, dated 6/3/25, revealed the resident had significant cognitive deficits and was a high risk for falls with physical injury. 1. Fall on 6/29/25 - unwitnessed A change of condition note, dated 6/29/25, revealed the resident was found on the floor facing the wall towards the headboard in between her wheelchair and her bed. A puncture wound was noted to the right elbow, bruising to the right knee and bruising with a raised area to the back of her head near the crown. The resident was assessed by the nurse. The physician and the family were notified. An exam revealed a small laceration to her right elbow. The physician r ordered Xrays and wound care treatment. A follow up note, dated 6/30/25, revealed the Xrays showed no abnormalities. A fall interdisciplinary team (IDT) note, dated 6/30/25, revealed risk factors identified included: difficulty locking breaks when self transferring, impulsivity, primarily Russian speaking, poor safety awareness and walking without assistance. Prior interventions were to keep her bed in the low position and ensure call light was within reach. The new interventions implemented were to add brake extenders to the wheelchair and to ensure the resident's room door remained open while the resident was in the room. -However, observations revealed the resident's door was not open while the resident was in her room (see observations above).2. Fall on 8/4/25- unwitnessedA change of condition note, dated 8/7/25, revealed the resident had an unwitnessed fall in her room while trying to move the tray from the side table into the vanity. The resident stated she felt dizzy and fell to the ground. The nurse assessed the resident and was able to get the resident into a standing position.A physician assistant progress note, dated 8/7/25, revealed the resident was complaining of pain to the left side of her face but her physical exam was unremarkable.A health status note, dated 8/7/25, revealed at the time of the unwitnessed fall, the resident was observed laying on her back on the floor in her room. The resident was assessed by the nurse and a reddened area to her left cheek was observed. The area was tender to the touch and also had a 2 centimeter (cm) scratch. Through the translator line, the resident said she had gotten up out of her bed to do the dishes and her legs had given out, causing her to fall. A fall IDT note, dated 8/8/25, revealed risk factors identified included: difficulty locking breaks when self transferring, impulsivity, primarily Russian speaking, poor safety awareness and walking without assistance. Prior interventions were to keep her call light within reach, transfer height bed, brake extenders and to ensure the door to her room remained open while the resident was in there. The new interventions implemented were to provide supervision from staff after meals for the resident to transfer and lie down. 3. Fall on 8/18/25 - unwitnessedA nursing note, dated 8/18/25, revealed the nurse was called to assess the resident after she was found on her bathroom floor after an unwitnessed fall. The resident had no complaints of pain and was wearing non-skid socks. A fall IDT note, dated 8/18/25, revealed risk factors identified included: primarily Russian speaking, dementia and ambulating without assistance. Prior interventions were to keep her call light within reach, transfer height bed, brake extenders, ensure the door to her room remained open while the resident was in there and to provide supervision from staff after meals for the resident to transfer and lie down. The new interventions implemented were for the resident to remain in high visibility areas during waking hours as tolerated unless assisted to lie down.4. Fall on 8/21/25 - unwitnessedA change of condition note, dated 8/21/25, revealed the resident was heard screaming in her room and was found sitting on the floor by her bed with her shoes on. A fall IDT note, dated 8/21/25, revealed risk factors identified included: history of falls and high risk medications. Prior interventions were to ensure non-skid socks, labs, de-cluttered the resident's bed, provide the resident education to call for assistance with care and adding the resident to the restorative program. The new interventions implemented were to call the medical director to review the resident's blood sugars and A1C.-Prior interventions of labs, de-cluttered the resident's bed, providing the resident education to call for assistance with care, and adding the resident to the restorative program were not included on the resident's care plan. A physician assistant note, dated 8/22/25, revealed the resident had multiple falls since the month of August 2025 without any significant injuries, recent labs had been within acceptable ranges. The note documented the falls were most likely exacerbated by generalized weakness/debility, poor safety awareness, and dementia.III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 9/24/25 at 1:53 p.m. She said she looked at the resident's CPO for fall interventions. LPN #2 said she was unable to locate specific fall interventions for Resident #156 in the electronic medical record (EMR). She said she would use general fall interventions such as checking on her every two hours, keeping her bed in the low position, decluttering the floor in the room, ensuring the call light was in reach and answering the call light promptly.CNA #4 was interviewed on 9/24/25 at 1:59 p.m. She said she had worked at the facility for three years. She said she was not aware of where to find resident specific fall interventions. She said she would use general interventions such as watching them when they ambulated down the hallway and making sure there was nothing in their path. CNA #4 said Resident #156 was a fall risk before she was admitted to the facility. She said she was no longer a fall risk, she just had poor safety awareness. Unit manager (UM) #1 was interviewed on 9/24/25 at 2:06 p.m. He said he gave a verbal report to the staff on the unit where Resident #156 resided, twice a day. He said he would go over the falls that were discussed by the IDT and provide the staff with updates on fall interventions. UM #1 said some of the interventions he expected were to ensure the resident's door remained open and the staff were rounding every hour. He said the resident specific fall interventions were located in the residents care plan and the CNA tasks. He said when reviewing Resident #156's EMR, he said he was unable to locate her specific interventions in the tasks. Registered nurse (RN) #1 was interviewed on 9/24/25 at 2:21 p.m. He said he was new to the unit that Resident #156 was residing on. RN #1 said he checked a resident's tasks for fall interventions because he did not have access to the care plan. The director of nursing (DON) was interviewed on 9/24/25 at 3:30 p.m. She said after a resident had a fall, the IDT reviewed the fall, discussed the prior interventions and why those interventions did not work and added the specifics of the fall to the resident's care plan. The DON said the CNAs and the nurses were notified of new fall interventions when the fall prevention nurse went around and verbally told them. She said she expected the staff to also look in the resident's care plan and tasks because they were updated after every fall. She said she was not aware the staff were unclear on where to find resident fall interventions.

Based on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#144) of three residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure individualized care approaches were provided for Resident #144 to prevent re-traumatization. Findings include:I. Facility policy and procedureThe Trauma Informed Care and Culturally Competent Care policy, revised August 2022, was provided by the director of nursing (DON) on 9/25/25 at 9:29 a.m. It read in pertinent part, Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident.II. Resident #144A. Resident statusResident #144, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), post-traumatic stress disorder (PTSD), psychotic disorder not due to a substance or known psychological condition and anxiety.The 9/18/25 minimum data set (MDS) assessment revealed Resident #144 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #144 had no documented behaviors. B. Resident interviewResident #144 was interviewed on 9/24/25 at 9:21 a.m. She said she was scared of the nursing home administrator (NHA) because he entered her room and made himself look taller while raising his voice at Resident #144. She said she filed a grievance and the NHA responded each time, telling her she should find a new place to live since she was not happy at the facility and filed so many grievances. Resident #144 said she did not want to move facilities.C. ObservationsOn 9/24/25 at 9:50 a.m. Resident #144 needed assistance to go to an activity. The NHA said he would assist the resident to the activity. The regional clinic resource told the NHA she would assist the resident to the activity due to the resident having an issue with men. D. Record reviewResident #144's psychosocial care plan, revised 11/15/24, revealed the resident was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills and poor impulse control related to a history of being sexually assaulted by a male physician. Interventions included administering medications as ordered and monitoring for side effects, allowing the resident extra time to respond to questions, assisting the resident to normalize feelings so the resident knew she was not alone in her thoughts, experiences, feelings and behaviors, providing behavioral and psychological services as indicated, contacting the resident's representative for comfort and support, encouraging the resident to express emotions, helping the resident identify triggers that prompt symptoms; monitoring for complaints of pain, observing for signs of distress, safeguarding the resident from alleged or suspected abuse perpetrator and transferring to acute care for further evaluation if indicated.Resident #144's trauma-informed care plan, revised 3/24/25, revealed the resident was at risk for decreased psychosocial well-being due to adjustment issues, emotional distress, ineffective coping skills, and poor impulse control because she had a tornado hit her house as a child, she had a work related injury where a microwave fell on her head, a vehicle accident as a child, getting a life threatening illness and the sudden and unexpected death of her mother and uncle. Interventions included allowing the resident time to make choices regarding her care and encouraging active decision making. approaching the resident in a calm, reassuring manner, encouraging family visits and interactions, encouraging relaxation techniques, encouraging the resident to verbalize her feelings, encouraging activities of the resident's choice, monitoring for signs and symptoms of decreased psychosocial well-being; offering pastoral visits as indicated, providing a psychiatry evaluation and treatment as indicated, providing psychological evaluation and treatment as indicated; reorienting and redirecting the resident as necessary; and social services visits as indicated.-The care plan did not provide interventions to address the resident's fear of the NHA III. Staff interviewsThe NHA was interviewed on 9/24/25 at 12:50 p.m. The NHA said he was not aware that the resident was afraid of him, but knew at times she did not like the NHA. He said any time he responded to grievances he brought a female staff with him into Resident #144's bedroom as a witness. The NHA said he did not tell the resident she should move facilities, but asked if she wanted to move facilities because she did not seem happy with where she was. -The facility failed to identify the resident had been sexually abused by a male in power and provide appropriate interventions to address the resident's grievances. Registered nurse (RN) #3 was interviewed on 9/24/25 at 1:07 p.m. RN #3 said Resident #144 had behaviors where she was involved in a family member's care who also resided at the facility. RN #3 said Resident #144's trigger was being educated on anything she did not want to hear. She said she was unaware of triggers involving men or being afraid of men. She said she only knew men were not allowed to provide her care due to her past trauma. Certified nurse aide (CNA) #5 was interviewed on 9/25/25 at 9:54 a.m. CNA #5 said Resident #144 became really anxious if things did not go her way or if she was told no. She said Resident #144 did not have issues with men but preferred females providing her care and CNA #5 said she was unsure why. CNA #5 said it was possibly documented in her care plan but said she was not sure.-The facility failed to ensure the staff caring for Resident #144 were aware of her past trauma. The DON and the regional clinical resource were interviewed together on 9/25/25 at 11:21 a.m. The DON said Resident #144 had behaviors of being accusatory of staff and one time she had expressed she wanted to kill herself, but nothing current. The DON said the resident's triggers were hard to identify but she felt male figures were a trigger. She said the resident's biggest fear was that the NHA would pack up her room and kick her to the curb. The DON said the resident was explained the process for discharging a resident.The regional clinical resource said Resident #144 always had a problem with something and there never seemed to be a resolution that made her feel satisfied. The DON said more education was going to be provided to staff so the staff knew where to find pertinent information like trauma and triggers.

Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#130) of three residents reviewed out of 71 sample residents.Specifically, the facility failed to:-Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #130; and,-Document attempted non-pharmacological interventions prior to the administration of a as needed (PRN) anti anxiety medication. Findings include:I. Resident #130A. Resident statusResident #130, age greater than 65, was admitted to the facility 8/21/25. According to the September 2025 computerized physician orders (CPO), the diagnosis included cognitive communication deficit and dementia with behavioral disturbances and agitation.The 8/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required substantial to maximal assistance with toilet hygiene, lower body dressing and partial to moderate assistance with upper body dressing.The MDS assessment indicated the resident did not have any behaviors during the assessment look back period.B. Record reviewThe anti-anxiety care plan, dated 8/22/25, documented Resident #130 used anti anxiety medication related to adjustment issues and agitation. Pertinent interventions included administering anti anxiety medication as ordered, monitoring for side effects and effectiveness, monitor the resident for safety for increased risk of confusion, amnesia, loss of balance and cognitive impairment, monitor and record occurrence of for target behavior symptoms.The psychosocial-behavior care plan, revised on 9/16/25, documented behavioral symptoms included delusions, anxiety and yelling out. The care plan documented Resident #130 had been physically aggressive with staff. Pertinent interventions included administering medication as ordered, anticipating the residents needs and meeting promptly, encouraging the resident to verbalize feelings and maintaining a calm, slow, understandable approach.A second psychosocial-mood care plan, dated 9/16/25, documented the resident was at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental physical social or spiritual well being related to: other displays of delusions and would threaten staff that he had a gun. Pertinent interventions included administering medications as ordered and monitoring for side effects as indicated, assessing coping strategies and respecting resident's wishes to the extent possible, assisting with conflict resolution as needed, encouraging to voice feelings and frustrations as indicated, observing for tearfulness, increased agitation and decreased participation in care. -Review of the resident's care plan did not reveal person-centered interventions to trial prior to the administration of the PRN lorazepam.The 9/2/25 behavioral health nurse practitioner (NP) progress note, dated 9/2/25, from the documented a new diagnoses of Alzheimer's dementia with psychotic disturbance, Alzheimer's disease with late onset and dementia in other diseases classified elsewhere with psychotic disturbance.A review of the September 2025 CPO revealed the following physician's orders:Lorazepam (Ativan- anti anxiety medication) oral tablet 0.5 milligrams (mg). Give one tablet by mouth every 12 hours as needed for dementia with behavioral disturbance for 14 days, ordered 9/2/25.Lorazepam oral tablet 0.5 mg. Give one tablet by mouth every eight hours as needed for dementia with agitation for 14 day, ordered 9/16/25.-Review of Resident #130's electronic medical record (EMR) did not reveal non-pharmacological interventions that were to be trialed prior to the administration of the PRN lorazepam medication.A progress note, dated 9/4/25 at 4:03 a.m., documented Resident #130 received PRN Ativan for agitation. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. A progress note, dated 9/4/25 at 10:20 p.m., documented Resident #130 received PRN Ativan for being anxious, he tried to walk without assistance and looking for an exit. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. A progress note, dated 9/7/25 at 11:01 p.m., documented Resident #130 received PRN Ativan for yelling at the staff. Staff attempted to redirect but the resident continued to yell out.-There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan.A progress note, dated 9/12/25 at 7:12 a.m., documented Resident #130 received PRN Ativan for agitation and stated he owned the place and called the staff names. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. A progress note, dated 9/15/25 at 4:15 p.m., documented Resident #130 received PRN Ativan for agitation. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. C. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 9/24/25 at 9:35 a.m. LPN #3 said when a resident exhibited behaviors the staff were to document the specific behaviors in the resident's electronic medical record (EMR). She said when a resident was prescribed a PRN psychotropic medication, non-pharmacological interventions should be attempted prior to the administration of the medication, if the non-pharmacological interventions were not successful then the PRN medication would be administered. She said the non-pharmacological interventions that were attempted were documented in the MAR.LPN #3 said she reviewed Resident #130's EMR and was not able to find the non-pharmacological interventions.The director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on 9/25/25 at 8:18 a.m. The DON said a PRN psychotropic was given a 14 day stop date and then then resident would be reassessed to determine if a PRN medication was effective. The DON said the interdisciplinary team (IDT) and medical providers used the behavior monitoring charting and progress notes from the EMR to assess the frequency the medication was administered, what non-pharmacological interventions were used prior to the administration of the medication and the effectiveness of the non-pharmacological interventions and PRN medication. The DON said non-pharmacological interventions should be attempted and documented prior to administering a PRN medication. The DON said the non-pharmacological approaches were found in the EMR and were specific to the resident.The DON and the RCR said they were unable to find the non-pharmacological interventions specific to Resident #130 prior to administering the PRN Ativan.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on two of four hallways.Specifically, the facility failed to ensure safe and appropriate storage of food items in resident's personal refrigerators. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 9/29/25 read in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained at 135 degrees Fahrenheit (F) or above, or at 41 degrees F or less (3-501.16). Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (3-501.17). II. Facility policy and procedure The Foods Brought by Family/Visitors policy, dated 5/28/25, was provided by the nursing home administrator (NHA) on 9/22/25 at 11:30 a.m. It read in pertinent part, Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The dietician, nurse supervisor, or other designee will explain safe food handling practices to family/visitors in a language and format they understand. The dietitian, nurse supervisor, or other designee will provide necessary education to the nursing staff on safe food handling practices and identify where this information is readily available for reference. Nursing staff is responsible for assisting residents to access food brought to the facility and for assisting with the consumption of the food item if the resident is not able to do so independently. The food service or nursing staff may assist with reheating or other preparation activities using safe food handling practices including safe reheating, hot/cold holding, handling of leftovers, and contamination avoidance. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration for longer than two hours are discarded. III. Resident interview Resident #4 was interviewed on 9/22/25 at 11:54 a.m. Resident #4 said there were only two staff members that checked his refrigerator, and that one night shift nurse checked his refrigerator consistently. IV. Observations On 9/22/25 at 12:00 p.m. the following observations were made in Resident #4's personal refrigerator: -A clear four ounce container of cottage cheese with a date of 9/12/25; and, -A four ounce container of yogurt with a use by date of 9/18/25. On 9/24/25 at 2:25 p.m. the outdated food items observed on 9/22/25 (see observation above) had not been removed from the refrigerator. V. Staff interviews The NHA was interviewed on 9/25/25 at 4:00 p.m. The NHA said the residents 'personal refrigerators should be monitored by overnight staff, specifically the nurses but the nurses could delegate the task to a certified nurse aide (CNA) to complete the temperatures. VI. Additional resident interviews Resident #14 was interviewed on 9/22/25 at 10:42 a.m. She said the facility staff helped her keep her refrigerator clean. She said that the staff also checked the temperature in her refrigerator. Resident #153 was interviewed on 9/23/25 at 2:56 p.m. He said the staff checked his refrigerator regularly. He asked two unidentified certified nurse aides (CNAs), that were in the hallway, where they logged the refrigerator temperatures, they told him that there is a binder that is kept at the nurse's station. VII. Observations On 9/22/25 at approximately 10:45 a.m. the following was observed in Resident #14's personal refrigerator: -Three thawed Uncrustables, that were not dated. -There was not a thermometer in the refrigerator or freezer. VIII. Record review The Garden unit's personal refrigerator logs for the month of September 2025 were provided by the NHA on 9/25/25 at 1:23 p.m. The temperature logs revealed that the refrigerator temperatures were not being taken constantly. From September first through September 25th there were approximately 12-14 missing temperatures missing on each of the refrigerator logs for the Garden unit. Resident #14's temperature log documented that her refrigerator was new on 9/4/25 and did not have a thermometer. The log indicated from 9/9/25 to 9/13/25it was documented that she still did not have a thermometer. It was documented on the log that the nurse was notified the thermometer was missing on 9/13/25. On 9/17/25 to 9/19/25 and on 9/25/25 the log documented there was not a thermometer in Resident #14's refrigerator. IX. Staff interview Licensed practical nurse (LPN) #5 was interviewed on 9/24/25 at 2:46 p.m. He said the temperatures of the residents' personal refrigerators should be taken by the overnight shift. He said there was a binder at the nurse's station where they were supposed to log the temperatures and if the refrigerator had been cleaned. He said there were some logs that were posted on the resident's refrigerator. He said he was not sure why some logs were kept in different places. He said that the overnight shift was usually the one that helped clean the refrigerators. He said any staff could help clean the refrigerators. He said that Resident #14's family member had brought in her personal refrigerator and had not told any staff members that she was going to bring one in. He said that was why she did not have a temperature log. -However, Resident #14 did have a temperature log. Her refrigerator did not contain a thermometer (see record review above).

Based on record review and interviews, the facility failed to establish a communication process that included how the communication would be documented between the facility and the provider for two (#11 and #9) of four residents reviewed for hospice care out of 71 sample residents.Specifically, the facility failed to establish a communication process according to the hospice agreement that included documentation of care and services provided by hospice filed and maintained for Resident #11 and Resident #99. Findings include: I. Facility policy and procedure The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 9/25/25 at 9:30 a.m. It read in pertinent part, Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. Hospice providers who contract with this facility must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; and are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following: Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care; notifying the hospice about the following such as a significant change in the resident's physical, mental, social, or emotional status, clinical complications that suggest a need to alter the plan of care or a need to transfer the resident from the facility for any condition; and communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. II. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included acute respiratory failure, acute kidney failure, heart disease with heart failure and depression. The 8/11/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She needed substantial assistance with hygiene and toileting and set up for eating and dressing. The assessment documented the resident received hospice care. B. Hospice agreement The hospice agreement for Resident #11's hospice services was provided by the director of nursing (DON) on 9/24/25 at 3:15 p.m. It read in pertinent part, Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each resident hospice patient receiving nursing facility services and hospice services under this agreement in accordance with prudent record keeping procedures and as required by applicable federal and state law and regulations and applicable federal program guidelines. Each clinical record shall completely, prompt and accurately document all services provided to, and events concerning, each residential hospice patient (including evaluations, treatments, progress notes, authorizations to admission to hospice and/or nursing facility and physician orders entered pursuant to this agreement. Nursing facility and hospice shall cause each entry made for services hereunder to be signed by the person providing the services. C. Record review Resident #11's hospice care plan, initiated 8/11/25, documented she had a terminal prognosis related to a diagnosis of acute respiratory failure and received hospice care provided by a local hospice provider. Pertinent interventions, initiated 8/11/25, included working cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, adjust the provision of activities of daily living (ADL) to compensate for the resident's changing abilities and encouraging participation to the extent the resident wished to participate. Resident #11's skin impairment care plan, initiated 8/13/25, documented she had actual impairment to skin integrity related to wounds to her right and left lower extremities, sacrum and the need for treatment. Pertinent interventions, initiated 8/13/25, included following the facility's protocols for the treatment of injury and to monitor and document the location, size and treatment of skin injury and reporting abnormalities, failure to heal, signs and symptoms of infection, and maceration to the physician. -However, Resident #11's comprehensive care plan did not document what care was to be completed by the hospice provider and when. A review of Resident #54's February 2024 CPO revealed the following physician orders: admitted to hospice care prior to admission, ordered 8/20/2025. Resident #11's hospice binder was retrieved from the nurses' station and provided by licensed practical nurse (LPN) #1 on 9/24/25 at approximately 6:20 p.m. The hospice binder contained weekly visit verification forms. The binder had three hospice visits documented as routine visits on 8/8/25, 8/25/25 and 8/29/25. A review of Resident #11's electronic medical record (EMR) revealed an 8/18/25 hospice note by an RN with routine care. -However, the 8/8/25 hospice note did not include documentation of the staff who completed the routine visit. The 8/18/25, 8/25/29 and 8/29/26 hospice notes were signed by a registered nurse (RN) but did not include any care or assessments provided. No other hospice visit notes were in the resident's EMR. Resident #11's hospice notes were provided by the DON on 9/25/25 at approximately 9:30 a.m. and uploaded into Resident #11's EMR (during the survey). A review of the hospice notes revealed the following visits documented by hospice staff: A chaplain visit on 8/28/25 declined by Resident #11 due to scheduling conflicts. A certified nurse aide (CNA) completed visits on 8/28/25, 9/2/25, 9/4/25, 9/9/25, 9/16/25, 9/18/25 and 9/23/25 that included the following completed care planned interventions: Apply moisturizing lotion to skin Tuesdays and Thursdays; assist with oral care Tuesday and Thursday, and bed bath and shampoo Tuesday and Thursday. An LPN visit completed 8/15/25, 8/22/25, 9/15/25. The 9/15/25 LPN visit documentation included the following assessments and care provided: vital signs, respiratory breath sounds and wound care was completed according to the resident's care plan. Social worker visits completed on 8/15/25, 8/28/25, 9/11/25. A registered nurse (RN) completed visits on 8/18/25, 8/25/25, 8/29/25, 9/4/25, 9/8/25, 9/10/25, and 9/19/25. The 9/4/25 RN visit note documented wound care was completed according to the care plan for the resident's right and left leg wounds. D. Staff interviews The DON was interviewed on 9/25/25 at 11:00 a.m. The DON said the hospice company checked out with her after visits. The DON said the hospice company would also usually check out with the unit manager if they came in. The DON said the notes were usually provided on a week or two week basis. The DON said the notes were sent to the facility and she/the DON would upload them in the chart. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included subacute osteomyelitis (bone infection), quadriplegia, type two diabetes and pressure-induced deep tissue damage. The 9/2/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The assessment revealed that he was dependent on staff for most of his ADLs. B. Record review Resident #9's hospice care plan, initiated 2/21/25, documented he had chronic osteomyelitis and received care from a local hospice provider. Pertinent interventions, initiated 2/21/25, included working cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, o things like ice cream, sherbet, milk shakes, more often and focus on potential pleasure foods, allowing the resident one beer a day for his pleasure, adjusting provision of ADLS to compensate for the residents changing abilities and encourage participation to the extent the resident wishes to participate. Review of Resident #9's EMR revealed hospice notes from March 2025 through the middle of July 2025 and the hospice care plan (from the hospice provider) were missing from his EMR. C. Staff interviews LPN #6 was interviewed on 9/25/25 at 9:35 a.m. She said there was a hospice communication book/binder for each resident that was on hospice services. She said the hospice book/binders were used mostly for the hospice employees to communicate with each other. She said she would use the book/binder every once in a while to see which hospice certified nurse aide (CNA) had given Resident #9 a bath. She said the hospice team communicated with the facility nursing staff verbally. She said that the facility staff could call the hospice phone number if they had any questions. She said that she did not look at the hospice notes that are uploaded into the EMR. The DON was interviewed on 9/25/25 at 1:47 p.m. She said that Resident #9's hospice care plan (from the hospice provider) should have been uploaded into the EMR. She said the hospice team would email hospice notes either weekly or biweekly to a facility email. She said sometimes the hospice team might email the notes directly to medical records. The DON was interviewed again on 9/25/25 at 1:55 p.m. She said she had received Resident #9's notes from the hospice provider.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) when providing direct care to a resident who was on enhanced barrier precautions (EBP); and, -Follow appropriate infection control measures during wound care. Findings include: I. PPE failures A. Facility policy and procedure The Enhanced Barrier Precautions policy, undated, was provided by the director of nursing (DON) on 5/7/25 at 9:20 a.m. It read in pertinent part, 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 of infected with a multi-drug resistant organism (MDRO) as well as those at increased risk of MDRO acquisition. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting; device care or use and wound care. B. Observations On 5/6/25 at 10:26 a.m. an unidentified certified nurse aide (CNA) changed and repositioned Resident #1. The unidentified CNA was wearing gloves, but did not have a gown on. Resident #1's door had a sign on it that indicated Resident #1 was on r EBP. The unidentified CNA failed to wear a gown when providing direct care to Resident #1. On 5/7/25 at 9:10 a.m. licensed practical nurse (LPN) #1 and LPN #2 provided wound care and repositioned Resident #1 with gloves on. -LPN #1 and LPN #2 failed to put on a gown when providing direct care to Resident #1. C. Staff interviews The DON was interviewed on 5/7/25 at 10:40 a.m. The DON said when a staff member was providing direct care to a resident who was on EBP, the staff member needed to wear gloves and a gown. II. Wound care failures A. Observations LPN #1 and LPN #2 were observed performing wound care for Resident #1 on 5/7/25 at 9:10 a.m. The following was observed: LPN #2 took a pair of scissors out of her pocket and cut a piece of calcium alginate (wound dressing) and returned the scissors to her pocket. -LPN #2 did not sanitize the scissors prior to cutting the piece of calcium alginate. LPN #1 pulled a retractable tape measure out of his fanny pack and measured an open area on Resident #1's buttock that had blood on it. He touched Resident #1's skin with the tape measure. He then pushed a button which caused the tape measure to retract and returned it to his fanny pack. -LPN #1 did not sanitize the retractable tape measure before or after using it. LPN #2 retrieved wound care supplies and placed them directly on Resident #1's nightstand. Resident #1's nightstand had Resident #1's personal items on it. -LPN #2 did not have a clean working surface before completing wound care. C. Staff interviews The wound care nurse (WCN) was interviewed on 5/7/25 at 10:12 a.m. The WCN said each resident had their own wound care bag, which included scissors, dressings and wound cleansers to prevent the spread of infections. The WCN said a clean work area was important for infection control and preventing wound contamination. The DON was interviewed on 5/7/25 at 10:40 a.m. The DON said each resident had a bag of wound care supplies that were specific to the resident and the scissors needed to be in the bag for the resident to prevent cross-contamination. The DON was interviewed on 5/7/25 at 10:40 a.m. The DON said the nurse needed to place the wound care supplies on a clean area. The DON said LPN #2 should have placed the materials on a disposable chuck (absorbent pads).

Based on interviews and record review, the facility failed to protect and keep residents safe from abuse and neglect for two (#2 and #11) of three residents reviewed for abuse out of 16 sample residents. A review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care-secure unit that protected residents from resident-to-resident abuse. RESIDENTS #6 AND #2 On 4/8/24, Resident #6 was admitted to the facility's memory care-secured unit. It was known to the facility, before the resident's admission, that he was displaying an increase in unsafe wandering and physical and verbal aggression toward other residents at the facility where he had previously resided. Resident #6 was discharged from his previous facility to the hospital due to his aggressive behaviors and remained at the hospital waiting until another long-term care facility placement could be obtained. A pre-admission long-term care (LTC) level of care eligibility assessment completed on 3/27/24 at the hospital documented Resident #6 exhibited inappropriate behaviors that put himself and others at risk and he frequently required more than verbal redirection to interrupt inappropriate behaviors. During the admission process, the facility failed to fully assess Resident #6's care needs and develop and implement a behavioral management care plan with interventions to monitor his behavior through his transition and adjustment to the facility's secured memory care unit and to prevent Resident #6 from being aggressive towards other residents residing in the facility. Additionally, the facility failed to inform the facility staff about the resident's history and increasing aggressions that led to his discharge from the previous facility where he had resided. In the first 48 hours of Resident #6's stay in the memory care unit, staff did not identify the resident's behaviors were becoming more aggressive. There was no reassessment of Resident #6's care needs despite staff observing changes in his demeanor from being extremely polite and asking for permission to do things, to wandering the unit and engaging in aggressive behaviors, which included rude mocking and bullying towards the unit's other residents. On 4/10/24 at approximately 5:00 p.m., Resident #2 was in her bed for the night. Licensed practical nurse (LPN) #1 heard moaning noises and a second person making mocking noises following each of Resident #2's moans. LPN #1 went to check on the resident and discovered Resident #6 on top of Resident #2 punching her in the face several times with a closed fist. LPN #1 called for additional staff assistance to separate the residents. Resident #2 suffered severe injuries to her face and body as a result of the physical assault. Because the staff did not have a full history of Resident #6 behavior or assess the resident's care needs and develop a behavior-focused care plan with interventions to monitor and treat potential aggressive behaviors, they failed to monitor Resident #6's activities closely enough to prevent him from physically assaulting Resident #2 who was incapable of protecting herself. As a result of the facility's failures, Resident #2 suffered significant facial trauma, including a subdural hematoma (pooling of blood between the brain and its outermost covering), left frontal scalp hematoma (pooling of blood outside of a blood vessel and under the skin), frontal process of the maxilla (upper jaw) fractures, nasal septum (cartilage between the right and left nostril) fractures, hemorrhaging of the right parietal gland (gland located on each side of the face just below the ears), left periorbital (area around the eye) soft tissue hematoma and bilateral sacral (the bone located at the base of the spine) fractures. Resident #2's injuries required hospitalization and ongoing monitoring of her injuries. Although Resident #6 was discharged from the facility on 4/10/24 due to the incident involving Resident #2, record review and interview revealed the facility failed to identify and correct gaps in its screening and admission process. Specifically, the facility failed to consider and implement practices to obtain and communicate information that would ensure an admission was safe and appropriate for the newly admitted residents and residents who were already settled in the facility. Further, the facility failed to consider and implement practices to screen prospective residents with behavioral needs to ensure the facility could provide care as identified during the screening assessment. The facility's failures in its screening and admission process and the communication to staff of the information obtained during this process created a situation of immediate jeopardy with the potential for serious harm to other residents residing in the facility's memory care-secured unit. RESIDENTS #5 AND #11 Record review revealed the facility failed to take sufficient steps to prevent Resident #5 from physically abusing Resident #11 who Resident #5 hit when Resident #11 wandered into Resident #5's room. Resident #11 sustained a bloody nose and cuts to his face. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy A review of resident records and interviews with staff revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care-secure unit that protected residents from resident-to-resident abuse. On 4/8/24 Resident #6 was admitted to the facility's memory care-secured unit. It was known to the facility, before the resident's admission, that he was displaying an increase in unsafe wandering and physical and verbal aggression toward other residents at the facility where he had previously resided. Resident #6 was discharged from his previous facility to the hospital due to his aggressive behaviors and remained at the hospital until placement in another facility could be obtained. A pre-admission long-term care (LTC) level of care eligibility assessment completed on 3/27/24 at the hospital documented Resident #6 exhibited inappropriate behaviors that put himself and others at risk and he frequently required more than verbal redirection to interrupt inappropriate behaviors. During the admission process, the facility failed to fully assess Resident #6's care needs and develop and implement a behavioral management care plan with interventions to monitor his behavior through his transition and adjustment to the facility's secured memory care unit, and to prevent Resident #6 from being aggressive towards other residents residing in the facility. Additionally, the facility failed to inform the facility staff about the resident's history and increasing aggression that led to his discharge from the previous facility. In the first 48 hours of Resident #6's stay in the memory care unit, staff did not identify that the resident's behaviors were becoming more aggressive. There was no reassessment of Resident #6's care needs despite staff observing changes in his demeanor from being extremely polite and asking for permission to do things, to wandering the unit and engaging in aggressive behaviors, including rude mocking and bullying towards the unit's other residents. On 4/10/24 at approximately 5:00 p.m., Resident #2 was in her bed for the night. Licensed practical nurse (LPN) #1 heard moaning noises and a second person making mocking noises following each of Resident #2s moans. LPN #1 went to check on the residents and discovered Resident #6 on top of Resident #2 punching her in the face with a closed fist. LPN #1 separated the residents. Resident #2 suffered severe injuries to her face and body as a result of the physical assault she endured. Because the staff did not have a full history of Resident #6 or a care plan with interventions to monitor and treat potential aggressive behaviors, they did not monitor Resident #6's activities closely enough to prevent him from physically assaulting Resident #2 who was incapable of protecting herself. As a result of the facility's failures, Resident #2 suffered significant facial trauma, including a subdural hematoma (pooling of blood between the brain and its outermost covering), left frontal scalp hematoma (pooling of blood outside of a blood vessel and under the skin), frontal process of the maxilla (upper jaw) fractures, nasal septum (cartilage between the right and left nostril) fractures, hemorrhaging of the right parietal gland (gland located on each side of the face just below the ears), left periorbital (area around the eye) soft tissue hematoma and bilateral sacral (the bone located at the base of the spine) fractures. Resident #2's injuries required hospitalization and ongoing monitoring of her injuries. Although Resident #6 was discharged from the facility on 4/10/24 due to the incident with Resident #2, record review and interviews revealed the facility failed to identify and correct gaps in its screening and admission process. Specifically, the facility failed to consider and implement practices to obtain and communicate information that would ensure an admission was safe and appropriate for the newly admitted residents and residents who were already settled in the facility. Further, the facility failed to consider and implement practices to screen prospective residents with behavioral needs to ensure the facility could provide care as identified during the screening assessment. The facility's failures in its screening and admission process and the communication to staff of the information obtained during this process created a situation of immediate jeopardy with the potential for serious harm to other residents residing in the facility's memory care-secured unit. B. Facility notice of immediate jeopardy On 6/13/24 at 4:15 p.m., the director of nursing (DON) and corporate nurse consultant (CNC) #1 were notified the facility's failure to ensure its new resident admission screening process was effective and created an environment in the memory care-secure unit that protected residents from resident-to-resident abuse, created a situation of immediate jeopardy with the potential for serious harm if not immediately corrected. C. Plan to remove immediate jeopardy On 6/14/24 at 2:36 p.m., CNC #1 and the DON presented the following plan to address the immediate jeopardy situation. It read in pertinent part: Plan to remove Immediate Jeopardy Immediate Action Done Resident# 6 was discharged from the facility. On 6/13/24, Resident #5 was placed on one-to-one monitoring. Will continue one-to-one support and will review with the interdisciplinary team (IDT) team on 6/18/24. The facility will hold admissions until it can review the pre-admission screening tool for residents with known behaviors. Once the review is completed, an ad hoc (done for a particular purpose) quality assurance performance improvement (QAPI) meeting will be held. The abuse policy was reviewed on 6/13/24. On 6/14/24, the nurse practice educator (NPE)/designee educated all staff on the facility abuse policy. Staff not educated on this date will be educated prior to their next shift. On 6/14/24, facility management staff reviewed the facility assessment on staffing and skills to care for residents with behaviors. Plan: Beginning 6/14/24, the facility revised its pre-admission screening intake form to include a history of behaviors and supervision needs by the admissions director. This will be an ongoing process. The admission team will review electronic records and utilize the pre-admission screening tool. Pre-admission screening forms will be reviewed with nursing, social services, and administration to determine if the facility can meet the needs of residents based on the screening process or if additional information is needed to decide. On 6/14/24, the director of nursing educated the admissions team on the pre-admission screening tool and process. Beginning 6/14/24, residents in the memory support unit will be reviewed by social services and/or nursing/designee for behaviors, wandering, current interventions, and their care plan related to behaviors. This review will be completed by 6/21/24. Upon completion of the review, staff who are assigned to the memory support unit will be trained in specific resident care needs. The training will be completed prior to their next assigned shift. Any admission to the memory support unit will be reviewed by social services and nursing to enter behavior tracking and a baseline care plan to meet the resident's needs. The facility assessment was reviewed and revised to include staffing levels for all departments in the memory support unit. New hires will receive education on abuse prevention and de-escalating behaviors during onboarding by the NPE (nurse practice educator). The nursing home administrator (NHA) will implement a review with the quality assurance performance improvement (QAPI) committee to review and interpret all abuse findings. All audit findings will be reviewed at the monthly meeting for at least three months or until the compliance pattern is maintained. D. Removal of immediate jeopardy On 6/14/24 at 3:30 p.m., the DON and CNC #1 were notified that the facility's plan to remove the immediate jeopardy was accepted based on the facility's plan to implement the measures above. However, the deficient practice remained at a G level, isolated, actual harm. II. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Prevention Program policy, revised April 2021, was received from the DON on 6/14/24 at 10:30 a.m. The policy read in pertinent part, Residents have the right to be free from abuse. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to, facility staff and other residents. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and responding to abuse, stress management, and handling verbally or physically aggressive resident behavior. Implement measures to address factors that may lead to abusive situations, for example: -Adequately prepare staff for caregivers' responsibilities; -Provide staff with the opportunity to express challenges related to their job and work environment without reprimand or retaliation; -Instruct staff regarding appropriate ways to address interpersonal conflicts; and, -Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. III. Resident-to-resident physical abuse between Resident #6 and Resident #2 A. Resident #2 (victim) 1. Resident status Resident #2, age 89, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, depression, and disorder of bone density. The 4/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to complete the brief interview for mental status (BIMS). The resident had short and long-term memory problems and was unable to recall staff names or faces, the location of her room, and was unaware she was in a nursing home facility. The resident had unclear speech and only sometimes understood conversations and responded only to direct communication. The resident was dependent on staff for bed mobility, toilet use, and transfers and was unable to walk. 2. Record review A hospital service report, dated 4/11/24, documented Resident #2 presented to the emergency room (ER) on 4/10/24 via EMS (emergency medical services) for evaluation after she sustained an assault. The resident was residing at a memory care facility when a staff member found the patient in her bed with another patient on top of her and hitting her in the face with a closed fist. Per EMS, staff denied any loss of consciousness and stated she was nonverbal at baseline. Imaging was obtained by the ER provider with findings of a subdural hematoma, bilateral sacral fractures, frontal processes of maxilla and nasal septum fracture, injury to the right parotid gland, facial and left periorbital soft tissue hematomas. The ER provider consulted neurosurgery who recommended the resident be admitted to the floor. Facial trauma was also consulted by the ER provider. The ER provider consulted trauma surgery services for admission and medical management. Resident #2 discharged from the hospital on 4/12/24 with a referral to see a neurosurgeon within two weeks of discharge. She was to follow up with facial trauma specialist as needed and follow up with her primary care physician in one week for further medical management and refill of medications. A nurse practitioner exam note dated 4/29/24 documented Resident #2 had increased weakness since she was assaulted, per reports from nursing staff. The resident used to feed herself and was now requiring assistance with meals. The resident was previously a two-person assist for transfers and was now requiring the use of a sit-to-stand lift for transfers. A neurosurgical consult follow-up dated 5/7/24 documented the subdural hematoma collections had resolved with no increase in intracranial hemorrhaging and further treatment was not warranted. B. Resident #6 (assailant) 1. Resident status Resident #6, age 70, was admitted on [DATE] and discharged to the hospital on 4/10/24. According to the April 2024 CPO, diagnoses included cerebral palsy, dementia, and major depression. The 4/10/24 discharge MDS assessment revealed the resident needed partial to moderate assistance with toileting hygiene; putting on and taking off footwear; and with dressing and grooming. He was independent with chair-to-chair transfers, rolling left to right, sitting, and lying down. The resident was able to walk short distances but was using a manual wheelchair to get around. The assessment documented the resident was prescribed antipsychotic and antidepressant medications. 2. Record review A hospital admission summary dated 3/16/24 documented Resident #6 had a pertinent history of dementia with behavioral disturbance and presented to the hospital for chief complaints of agitation. The patient was at an assisted living memory care facility (facility name) where, according to EMS, he had attacked people in the past. Per EMS, they were called because he was in the common area and was screaming and inconsolable. A referral for placement dated 3/21/24 documented Resident #6 presented to the emergencyER on [DATE] for agitation. The facility where he lived was unable to handle him anymore. The facility would not take the resident back due to his behavior and he has been in the ER awaiting placement. The resident would be very difficult to place given his history of aggression/agitation. While in the hospital, Resident #6 was prescribed the following psychotropic medications: Escitalopram oxalate (Lexapro) (an antidepressant medication) tablet 20 milligrams (mg) daily for depression and anxiety, ordered 3/17/24. Risperidone (an atypical antipsychotic medication) tablet 0.5 mg two times a day for agitation, ordered 3/16/24. Trazodone (Desyrel) (a medication used for major depressive disorder) tablet 150 mg at bedtime for sleep, ordered 3/16/24. Quetiapine (Seroquel) (an antipsychotic medication) tablet 25 mg two times a day as needed for delirium or agitation, ordered 3/21/24. The medication was given during the resident's stay in the hospital. A LTC (long-term care) level of care eligibility assessment for Resident #6, dated 3/27/24, revealed the resident exhibited inappropriate behaviors that put himself, others, or property at risk and he frequently required more than verbal redirection to interrupt inappropriate behaviors. Resident #6 was assessed to be delusional with mood instability. He needed supervision due to aggressive behavior, agitation, disruption to others, impaired judgment, need for medication management, memory impairment, verbal abusiveness, and wandering behaviors. Per Resident #6's court-appointed guardian, the resident was asked to leave the memory center where he was living due to yelling, screaming outbursts, and hitting other residents and staff with his walker. The guardian reported the behaviors tended to happen in the late afternoon or early evening, and there were no known prompts for behaviors. Resident #6 could not verbalize when he was upset or identify why he was upset. Resident #6's baseline care plan, dated 4/10/24, revealed the resident was alert and oriented to self and needed cueing and prompts to complete activities of daily living. Resident #6's comprehensive care plan, initiated on 4/10/24, documented the resident was able to make his needs and preferences known. He was pleasant and cooperative. He used a wheelchair and could self-propel. His vision and hearing were adequate. He enjoyed watching television, listening to music, playing the harmonica, having conversations with staff, and napping. He passively participated in most scheduled activities. -Neither care plan included a behavior management focus or interventions to manage Resident #6's aggressive behaviors. A social services note dated 4/10/24 at 4:30 p.m. revealed Resident #6 was starting to show aggressive behaviors similar to behaviors he was displaying at his previous facility when he was discharged . The note documented that when Resident #6 was eating, he would wheel himself away from the table and run his wheelchair into other residents who were standing or passing nearby and he had to be redirected to the dining room table. C. Facility investigation of the incident between Resident #2 and Resident #6 A facility physical abuse investigation dated 4/10/24 revealed that on 4/9/24 at approximately 5:38 p.m., licensed practical nurse (LPN) #1 discovered Resident #6 on top of Resident #2 punching her in the face with a closed fist. Resident #6 was using his bodyweight to pin Resident #2's arms down while using his right hand to hit her in the face. LPN #1 called for help and staff separated the residents. Immediately following the incident, Resident #2 presented with labored breathing and hyperventilation, repeated troubled calling out, loud moaning, groaning and crying, facial grimacing, rigidity, clenched fists, knees pulling up, pulling and pushing staff away, and striking out. The resident was inconsolable. Resident #2 showed signs of being in pain and had observable abrasions, lacerations, skin tears, and discoloration on her body. Resident #6 had no observable injuries. Emergency medical services (EMS) were called and Resident #2 was sent to the emergency room to be assessed for trauma and injuries. Resident #6 was sent out to the hospital for assessment and monitoring due to his aggressive behaviors. Staff witness statements Certified nurse aide (CNA) #1 was interviewed on 4/10/24 following the resident-to-resident physical assault. CNA #1 said she heard LPN #1 yelling for help. CNA #1 said she ran to the area of the call for help and encountered LPN #1 in the hall. LPN #1 instructed CNA #1 to respond to Resident #2's room to help. Upon entering Resident #2's room, CNA#1 observed Resident #6 punching Resident #2 in the face. Resident #6 would not stop. CNA #1 said CNA #2 arrived at the room and they pulled Resident #6 off Resident #2 by the back of his shirt and dragged him to the floor and out into the hall because he was hitting them as well. CNA #1 said Resident #6 was physically and verbally aggressive toward the staff intervening to stop the assault. CNA #2 was interviewed on 4/10/24 following the resident-to-resident physical assault. CNA #2 said between 4:30 p.m. and 5:00 p.m., she was in the other hallway assisting a resident to eat dinner when she heard LPN #1 yelling for help. CNA #2 said she responded immediately and witnessed Resident #6 punching Resident #2 nonstop in the face. She and another CNA (CNA #1) who responded to the call for help had to pull Resident #6 off of Resident #2 to get him to stop punching her. LPN #4 was interviewed on 4/10/24 following the resident-to-resident physical assault. LPN #4 said he was called to Resident #2's room to assist with Resident #6. LPN #4 said he arrived at Resident #2's room and saw Resident #6 on the floor in the hall sitting on the floor scooting back towards Resident #2's room. Resident #6 was redirected away from Resident #2's room. LPN #4 said Resident #6 had blood on his hands and Resident #2, still in bed, had blood on her face and her bed linens and her face had visible signs of swelling. LPN #4 said Resident #6 was starting to get physically aggressive with other residents in the common area. LPN #4 said he had to shield the other residents from Resident #6's physical aggression. Resident #6 then directed his aggression toward staff and began kicking LPN #4 in the legs. After approximately 10 minutes, EMS arrived, restrained Resident #6, and transported him to the hospital for assessment. -The facility failed to show they implemented any new process for their admission screening of new residents or assessed other residents for appropriate interventions for behaviors and behavior monitoring following the incident. D. Staff interviews The DON was interviewed on 6/13/24 at 11:05 a.m. The DON said the facility had a marketing intake person who conducted initial screens on potential new admits and provided her with potential candidates for admission. The DON said she reviewed the available documentation that the recruiter or marketer gave to her to decide whether or not the facility could meet the individual's needs as a resident of the facility. The DON said if the documentation indicated the individual had behaviors she would have to look deeper. The DON said Resident #6's intake referral papers documented that he had behaviors that were resolved at the hospital, so the interdisciplinary team (IDT) allowed his admission to the facility. The DON said the IDT based admission decisions on the current information presented. She said that in the case of Resident #6, the facility was given limited information. She said the facility had no documentation from the resident's previous placement to review. -However, the facility knew the name of the previous facility the resident was discharged from and did not ask the resident's guardian for assistance in requesting treatment records from that facility for review before the resident's admission. Further, the facility was aware of the resident's extended hospitalization due to difficulty finding placement. The DON said the intake documentation did not raise red flags and it looked like Resident #6 presented with typical concerns. She said there was no indication that his behaviors would escalate to him becoming abusive towards the other residents. The DON said the referral just provided her with a snippet of information and if she had more information when reviewing the resident's intake, she would not have accepted him. The DON said she did not receive any information that Resident #6 had a history of aggressive behaviors toward other residents. She said she did not recall seeing the long-term care eligibility assessment (see record review above) and was not familiar with the assessment that the resident was verbally and physically aggressive towards others and required more than verbal redirection to interrupt inappropriate behaviors. -However, the long-term care eligibility assessment was uploaded to Resident #6's EMR on 4/8/24. The DON said Resident #6 was fine upon arrival. She said he was acclimating to the environment and was playing his harmonica. The DON said she was not aware that Resident #6 had displayed any behaviors before his assaulting Resident #2. The DON said the number one goal of the facility was to keep the residents safe and be a partner for the non-clinical needs. LPN #1 was interviewed on 6/13/24 at 1:20 p.m. LPN #1 said the day of admission (4/8/24), Resident #6 was pleasant and cooperative. Resident #6 was talking to staff and asking permission for everything. He said on the second day, in the evening, Resident #6's behavior started to change. He said Resident #6 was wandering around the unit and was mocking other residents' actions. LPN #1 said staff had to redirect him several times throughout the day. LPN #1 said when Resident #6 was admitted to the unit, he was told some past reports documented Resident #6 had been aggressive in the past but his record was sealed so they did not know exactly what happened at his previous facility. LPN #1 said when he arrived on shift on 4/10/24, he was informed by the previous shift staff that he needed to keep an eye on Resident #6 as he was mocking others in an inappropriate tone. LPN #1 said one example of his aggressive behavior was that one of the female residents was drinking coffee and expressing her pleasure of it uttering an mm-hmm sound. Resident #6 started mocking and mimicking her sound, getting louder and more aggressive in his actions. Resident #6 progressed and moved closer to her face and continued his mocking. LPN #1 said he had to approach Resident #6 to get him to stop. LPN #1 said later in the day, Resident #6 had to be redirected to the dinner table. He said after the resident was done he wandered from the dining room area. LPN #1 said Resident #6 was quick and quiet when wandering around and he did not notice him leaving the dining room. LPN #1 said it was very noisy in the dining room because the television was turned up loud and another resident was listening to his music, which also was loud. LPN #1 said, for some odd reason, the sound stopped and it got quiet in the room. He then heard moaning noises and heard another resident mocking the first resident's moaning sounds. LPN #1 said, thinking something was not right, he went down the hall to see what was going on. He said as soon as he arrived at the source coming from Resident #2's room, he saw Resident #6 on top of Resident #2. LPN #1 said at first, from the doorway, he thought Resident #6 was kissing Resident #2 but then he observed Resident #6 rocking backward and making a fist. He said Resident #6 made a moaning sound and punched Resident #2 in the face. LPN #1 said Resident #2 moaned when he punched her. LPN #1 said he immediately called for help and staff responded to assist in separating the residents. LPN #1 said Resident #2 was not able to move or defend herself. LPN #1 said Resident #2 was very distressed following the incident and was inconsolable. He said she was bleeding and crying and appeared to be in pain. He said EMS was called immediately so her injuries could be assessed and treated at the hospital. LPN #1 said Resident #2 returned to the facility two days later. He said the EMS provider reported that the resident was showing fear of male caregivers at the hospital and with the EMS providers. LPN #1 said resident-to-resident aggression occurred frequently in the unit but it had never been this severe. He said he worked four shifts a week and would estimate that, on average, there were two to three instances of resident-to-resident aggression each shift. He said most of the time the staff were able to intervene and redirect the residents before it rose to a physical altercation or abusive nature. Resident #6's legal guardian was interviewed on 6/13/24 at 9:00 a.m. The guardian said she talked with the facility during Resident #6's admission intake to request that they keep a close eye on him due to his unsafe wandering and past aggression because he was aggre[TRUNCATED]

Based on record review and staff interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital. Findings include: I. Record review A request was made to the director of nursing (DON) and corporate nurse consultant (CNC) #1 on 6/13/24 at 4:27 p.m., for the facility's hospital transfer agreement. -The facility was unable to provide a written agreement for the one area hospital. II. Interview The interim nursing home administrator (INHA) and CNC #1 and CNC #2 were interviewed together on 6/14/24 at 3:55 p.m. The INHA said the facility did not have a hospital transfer agreement. The INHA said no area hospitals would provide the facility with a transfer agreement because the hospitals took residents based on the hospital's availability to accept patients. She said since patients were diverted to the closest available hospital a transfer agreement was not necessary.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of 16 sample residents had the right to be informed of and participate in care plan meetings and to develop his or her treatment plan including the right to be informed, in advance, of the care to be furnished and the type of caregiver or professional that would furnish care. Specifically, the facility failed to: -Inform Resident #1's legal representative in advance of the facility's scheduled care plan meetings so the representative could participate in care planning; -Inform Resident #1's legal representative of when upcoming podiatry and dental services were to be provided so the representative could be informed and assist with treatment decisions; and, -Notify and inform Resident #1's legal representative of changes in the resident's condition, including falls. The findings include: I. Facility Policy and Procedure On 6/13/24 the Resident Representative policy, revised February 2021, was provided by the director of nursing (DON) on 6/13/24 at 3:30 p.m. The policy read in pertinent part, The facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated to by the resident or to the extent required by the court, in accordance with applicable law. A resident who has been found to be incompetent by the state court has the right to appoint a resident representative who may exercise the resident's rights to the extent provided by state and federal law. The Resident Participation - Assessment/Care Plans policy, dated 2021, was provided by the DON on 6/13/24 at 3:30 p.m. The policy read in pertinent part, The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Spouses and other members of the family may participate in the resident assessment and development of the person centered care plan with the resident's permission. The resident/representative's right to participate in the development and implementation of his or her plan of care includes (but is not limited to): -Participating in the planning process; -Requesting revision to the care plan; -Participating in the type, amount, frequency and duration of care; -Being informed, in advance of changes to the plan of care; and, -Refusing/requesting changes to and/or discontinuing care or treatment offered or proposed. The care planning process: -Facilitates the inclusion of the resident and/or representative; -Holds care planning meetings at times of the day when the resident, representative and family members can attend and are functioning at their best; and, -Provides sufficient notice in advance of the meetings. II. Resident #1 A. Resident Status Resident #1, age 76, was admitted on [DATE] and discharged to another facility on 5/5/24. According to the May 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with behavioral disturbance and chronic kidney disease. According to the 3/9/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment and was not able to complete the brief interview for mental status (BIMS) assessment. The staff assessment for mental status revealed the resident usually understood others and had difficulty communicating some words or finishing thoughts but was able to communicate when prompted or given time, however, the resident missed some parts or intent of conversations. The resident had short and long-term memory problems and had moderately impaired cognitive skills for daily decision making for which the resident required cues and staff supervision. B. Resident representative interview Resident #1's legal representative was interviewed on 6/13/24 at 6:13 p.m. The representative said the facility had a care conference meeting on 3/8/24 without informing her in advance of the meeting and then called her after the meeting and left a two and a half minute voice message where the staff member read the meeting minutes over the phone. The resident's representative said that the phone call when the facility left the voicemail to summarize the care conference meeting was the first time she had been told about the frequency of the resident's falls. She said she had only been notified of one fall when the resident was injured and had to go to the hospital. The resident's representative said the voicemail was the first time she was informed that Resident #1 had been seen by a dentist, dental hygienist and podiatrist. The resident's representative said when she questioned the facility's social services assistant (SSA) about not being informed in advance of the planned care conference meeting, the SSA told her she did not have enough time to send out a letter inviting her to the care conference. The SSA did not offer the representative an alternative opportunity for the representative to meet with the interdisciplinary team (IDT) to discuss and give input into the revisions of the resident's care plan. The resident's representative said, in addition to not notifying her of the care conference meeting, the facility only notified her of one of the resident's falls that had occurred earlier in the year, and they failed to notify her that the resident was seen by a dentist, a dental hygienist and a podiatrist. The resident's representative said what was most concerning in regards to not being notified was that she was in the facility every day around lunchtime to visit with Resident #1 and still she had not been notified of all of the changes in the resident's care, condition and treatment services so that she could take an active role in the resident's care. C. Record Review A care conference invitation letter addressed to the resident's legal representative and the resident's durable power of attorney for health care and financial decision-making (DMPOA/DFPOA), dated 2/29/24, was provided by the DON on 6/14/24. It read in part There will be a resident care plan conference for Resident #1 on Friday 3/15/24 at 1:00 p.m. The conference is scheduled to last about 15 minutes. -However, Resident #1's care conference meeting was held on 3/8/24 instead of 3/15/24 (see representative's interview above and progress note below). The social services review assessment, dated 3/8/24 and completed by the SSA, documented the resident's spouse was very involved in the resident's care. The resident was easily distracted and provided nonsensical answers to questions asked. The resident's legal representative was appointed as the resident's DMPOA/DFPOA. A care plan conference summary note dated 3/8/24 revealed the care planning meeting was held without the resident's legal representative present. The IDT discussed the resident's fall history, medications, hospice care, ambulation status and appointments with the dentist and hygienist. The IDT also discussed the resident's advanced directives and do not resuscitate status. -A review of the resident's comprehensive care plan, revised on 4/19/24, revealed no interventions to keep the resident's representative involved in care or informed of changes. -There was no care plan documenting the need for ancillary services including dental or podiatry services. A podiatry note dated 3/1/24 revealed the resident was seen as a new patient by the podiatrist and was assessed and treated for long dysphoric (deformed, thickened and discolored) nails. Several issues were diagnosed , including nail dystrophy (abnormal changes of the nail often caused by fungus), corns and callosities (thickened skin) and a missing toenail. Keratin debris toenail treatment (removal of fungus from the nail) was provided using nail nippers during the visit. -A review of the resident's electronic medical record (EMR) revealed there was no documentation to indicate the resident's legal representative was informed of the resident's appointments so she could attend the appointment and participate in treatment planning. There was no documentation to indicate the representative was informed of the outcome of the appointment. -Additionally, the EMR revealed no documentation of the resident's dental services. C. Staff Interviews Licensed practical nurse (LPN) #3, who was the memory care unit manager,was interviewed on 6/12/24 at 1:36 p.m. LPN #3 said the facility did not notify the residents' representative when the resident attended in-house or routine appointments for the dentist, podiatrist or eye doctor. She said the residents' representative would be notified if there was something out of the ordinary scheduled for the resident, such as a tooth extraction or a need for new glasses. The SSA was interviewed on 6/12/24 at 1:38 p.m. The SSA said she was responsible for setting up ancillary (dental, eye doctor and podiatry) medical appointments, most of the time at a resident's or family member's request, but she did not notify the resident's representative of upcoming routine doctor and ancillary visits. The SSA said sometimes she did not know that the resident was scheduled to be seen until the day of the appointment. The SSA said the IDT set up and scheduled upcoming care conference meetings and then she sent out a letter to invite the resident and the resident's representative/family, as applicable. The SSA said the facility only called the resident's representative/family members when there wasn't enough time to send a letter out in the mail. The SSA said the facility held care conference meetings based on the IDT's availability and if the family members could not attend the meeting, she would meet with the family after the IDT met and read the IDT minute notes to the resident's representative. The SSA said she did send a letter to Resident #1's representative for the March 2024 care conference meeting. -However, the care conference invitation letter provided (see record review section above) documented that the care conference was to be held on 3/15/24 and the meeting per the care conference summary notes was held on 3/8/24 (see record review above). The DON was interviewed on 6/13/24 at 11:05 a.m. The DON said the facility was having problems setting up care conference meetings so that the residents' representatives could attend and participate in the care planning process. She said everyone was scheduling meetings differently so they streamlined the process for consistency and accuracy of the dates of the care conference meetings. The DON said the procedure for scheduling care conference meetings was for the social services department to set up care conferences using the facility's scheduling system and invite staff to attend. The DON said an email was sent to the residents' family to invite them to the care conference and the facility maintained a copy of all emails sent to the families. She said if the family did not use email, the social worker would set up another method of notification that met the needs of the resident's family/representative. The DON said the family was only notified of a care conference meeting by phone if the resident was newly admitted . The DON said the social services department should notify the resident and resident representative of all scheduled ancillary visits so they could decide if they wanted treatment and so the representative could decide if they wanted to be present during the visit. The DON said there was no reason Resident #1's representative had not been informed of the resident's treatments and changes in condition because the representative was in the facility every day to visit Resident #1.

Based on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately for one (#1) of three residents reviewed out of 16 sample residents. Specifically, the facility failed to report an allegation of an injury of unknown origin (bite wound) to the State oversight agency within 24 hours of the injury being discovered. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was received from the director of nursing (DON) on 6/14/24 at 10:30 a.m. The policy documented in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of property are reported to the local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, misappropriation of resident property or injury of the unknown source is suspected, the suspicion must be reported immediately to the administrator and the other officials according to the state law. Immediately is defined as: -Within two hours of an allegation involving abuse or resulting in serious bodily injury; or -Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. II. Allegation of abuse -injury of unknown source (bite wound) On 4/9/24 the hospice provider and the resident's legal representative reported that Resident #1 had a bite wound on the top of his left hand. The cause of the bite wound was unknown and suspected to have been caused by someone other than Resident #1. III. Record review The State oversight agency facility reported incident portal was reviewed on 6/12/24. The review revealed that the facility had not reported the allegation of abuse identified by an injury (bite wound) of an unknown source. IV. Resident representative interview Resident #1's representative was interviewed on 6/13/24 at 6:13 p.m. The representative said she was at the facility every day to visit with Resident #1. She said on the morning of 4/9/24 she received a call from Resident #1's hospice nurse asking if she knew about a bite mark on the top of Resident #1's wrist. The representative said that was the first time she was made aware that there was a bite mark on Resident #1's hand. The representative said she was at the facility the day prior (4/8/24) at lunchtime and the resident did not have the bite mark on his arm at that time so the injury had to have happened sometime after she left the faciity on [DATE] and the morning of 4/9/24. The representative said she went to the facility on the morning of 4/9/24, to find out what happened and observed the bite wound on Resident #1's arm. The representative said she talked to the staff on duty and no one knew that the resident had a bite wound and nobody could reasonably explain how the bite happened. The representative said she took a picture of the resident's wound to show the facility administration. The representative said she spoke to licensed practical nurse (LPN) #3, who was the memory care unit manager and asked her to find out how Resident #1 got the bite wound. The representative said she never heard anything further from facility staff about how Resident #1 got the bite mark on his hand or who bit him. The representative said she was concerned for Resident #1's safety. V. Staff interviews LPN #3 was interviewed on 6/12/24 at 1:36 p.m. LPN #3 said she had no knowledge of the resident having a bite mark on his arm. LPN #3 said she did not examine the resident's injury but was aware that the resident had some scratches on his person which were attributable to his wandering. The memory care unit social services assistant (SSA) was interviewed on 6/12/24 at 1:38 p.m. The SSA said Resident #1's representative mentioned that Resident #1 had a bite mark on his hand. The SSA said she did not see the bite mark and the resident's representative had made no further inquiry about the nature of the bite mark. The hospice registered nurse (HRN) was interviewed on 6/12/24 at 2:16 p.m. The HRN said the resident's hospice CNA called her on the morning of 4/9/24 to report that the resident had a wound on the top of his left forearm that looked like a bite mark. The HRN said the hospice CNA reported to her that the facility staff were unaware of how the resident got the wound. The HRN said she called the facility before calling the resident's representative but had to leave a voice message when the memory care unit manager (LPN #3) did not answer the phone. The HRN said when she called the resident's representative to see if she was at the facility or had knowledge of what happened to Resident #1, the resident's representative did not even know the resident had a bite mark wound on his person. The HRN said she assessed the resident's wound on 4/11/24 and cleaned the wound and bandaged it. The HRN said the wound on Resident #1's upper forearm at the wrist was definitely teeth impression marks. She said the bite was in a pattern of a full set of upper teeth and partial bottom teeth and it was in a placement pattern that was unlikely that the resident could have done it himself. The HRN said she had concerns because Resident #1 was known to wander into other residents' rooms and was often injured as a result of some other residents being upset over his wandering behaviors. The HRN said there were a lot of residents on the unit who were physically aggressive toward other residents The DON was interviewed on 6/13/24 at 11:05 a.m. The DON said the facility did not have an investigation for the resident's bite wound and it was not reported to the State oversight office as an injury of unknown origin. The DON said she had heard about the allegation that Resident #1 had a bite mark on his arm so she asked one of the facility nurses to look at his arm. The DON said she did not examine the resident herself and could not remember which nurse she asked to look at the resident' s arm but she said she remembered the nurse reported the resident did not have a bite wound. The DON said she did not know why there was no documentation of the assessment of Resident #1 done by the nurse but said she would try to find out which nurse assessed the resident and look to see if the facility had any documentation of the allegation and the assessment of the resident. -The DON did not provide any additional evidence to indicate the allegation that Resident #1 sustained a bite wound of unknown origin was investigated or that the nursing staff assessed and monitored the resident's injury. Cross-reference F610 for failure to investigate an allegation of abuse related to an injury of unknown origin.

Based on interviews, record review, and facility policy review, the facility failed to supervise residents that required supervision while smoking, ensure residents assessed to wear a smoking apron were provided one, and failed to ensure independent and supervised residents had a safe place to discard cigarette butts after smoking for 3 of 3 residents reviewed for smoking (R #110, R #74, and R #21). Failed to ensure Resident #74 smoked in designated area, and used the trash can It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The IJ began on 09/12/2022 when Resident #21 was observed unsupervised while smoking, without wearing a smoking apron, and threw a lit cigarette into a trash can. The Administrator and DON were notified of the IJ on 09/12/2022 at 7:02 PM and provided the IJ Template at 7:03 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 09/14/2022 at 5:22 PM. The IJ was removed on 09/16/2022 at 9:50 AM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F689. Findings include: The facility policy, OPS131/Smoking Policy, revised on 11/20/2018, revealed, For centers that allow smoking, smoking will be permitted in designated areas only. Patients will be assessed upon admission, quarterly, a change in condition, for the ability to smoke safely and if necessary, with supervision. The policy indicated 2.2.1 An area as a smoking area will be environmentally separate from all patient care areas (e.g., outdoors or a smoking lounge), will be well ventilated, and, if outdoors, will protect patients from weather conditions. 2.1.4 Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances. 2.3 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. 2.3.1 Patients will be re-evaluated quarterly and with a change in condition. 2.5 A patient's smoking status-independent, supervised, or not permitted to smoke-will be documented in the care plan. 2.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. 2.6.1 Patients will not be allowed to maintain their own lighter, lighter fluid, or matches. 2.7 Center leadership will consider special circumstances on an individual basis (e.g., the need for a smoking apron and/or flame retardant clothing. 1. A review of Resident #21's Admission Record revealed the resident had diagnoses of [CONDITION(S)], [CONDITION(S)] with behavioral disturbance, muscle weakness, polyneuropathy, dysphagia, and lack of coordination. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #21 had a Brief Interview for Mental Statis (BIMS) score of 9, indicating moderately impaired cognition. The MDS revealed Resident #21 required limited assistance of one person with bed mobility, transfer, toileting, and personal hygiene; and was independent with eating. According to the MDS, Resident #21 had no behaviors, and did not reject care that was necessary to achieve the resdient's goals for health and well-being. Indicated utilized oxygen while a resident of the facility and within the last 14 days. A review of Resident #21's care plan revised 05/11/2022 revealed the resident was resistive to care related to being noncompliant with supervised smoking times. The care plan indicated Resident #21 would get cigarettes from other residents. The goal was for Resident #21 to ask for staff assistance when going out to smoke. The facility developed interventions that included evaluating the nature and circumstances of the resistive behavior; encouraging participation in identified special treatment programs; providing a consistent, trusted caregiver and structured daily routines, when possible; explaining all care; and providing for opportunities for choice during care/activities to provide a sense of control. Continued review of Resident #21's care plan revised on 05/11/2022 revealed the resident may smoke with supervision per the resident's smoking assessment. Interventions included educating the resident on the facility's smoking policy, informing of and reinforcing smoking restrictions, reassessing the residents ability to smoke with supervision with any change in condition, providing a smoking apron if indicated, supervising the resident with smoking in accordance with the resident's assessed needs, ensuring there was no oxygen in use in the smoking area, ensuring appropriate cigarette disposal receptacles were available in smoking areas, monitoring residents compliance with the smoking policy, and maintain residents' smoking materials at the nurses' station. A review of Resident #21's Smoking Evaluation dated 08/02/0222 revealed had dementia, had a history of unsafe smoking habits, had a history of sharing/selling cigarettes or smoking material. According to the evaluation, Resident #21 could safely hold a cigarette, had the ability to light a cigarette, properly disposed of ashes or butts, and could smoke safely without use of a smoking apron. According to the evaluation, supervised smoking was required for Resident #21. Observation was conducted on 09/12/2022 at 3:45 PM of Resident #21 placing a lit cigarette into the trash can in the smoking area. Resident #21 was not wearing a smoking apron, and there were no staff in the line of sight of the smoking area or the resident. Observation revealed there were several burn holes in the resident's yellow sweatpants. An observation and interview on 09/12/2022 at 4:21 PM with Resident #21 revealed the resident was sitting in a wheelchair in the hallway wearing yellow sweatpants and a dark colored sweatshirt. Observation revealed there were also visible burn holes on the front of the resident's shirt. Resident #21 stated he/she smoked in the morning and afternoon. The resident stated staff did not ask the resident to wear an apron while smoking, and staff did not remain outside while the resident smoked. Resident #21 stated he/she lit his/her own cigarettes. The resident pulled out a blue lighter from his/her pocket and grabbed an object in the other pocket and stated that was his/her pack of cigarettes. Further interview with Resident #21 revealed the resident stated the holes in his/her sweatshirt was burn holes from cigarette ashes falling on the resident's clothing while smoking. An interview on 09/13/2022 at 1:40 PM with Licensed Practical Nurse (LPN) #1 revealed a resident smoking schedule was located on the Garden Unit that listed smoking times and the staff member assigned to supervise the smoke break. LPN #1 stated the schedule listed a hall number and the Certified Nursing Aide (CNA) assigned to that hallway was required to monitor the residents while they smoked. According to LPN #1, Resident #21 let staff know when he/she wanted to go outside to smoke, and there should never be a resident smoking without a staff member aware or present to monitor. LPN #1 stated both independent and supervised smokers followed the same smoking schedule, and all the cigarettes and lighters were kept secured in a cart and labeled with the resident's name at the nurse's station. LPN #1 stated there were no residents that she was aware of that kept their cigarettes or lighter with them. LPN #1 stated she when she was alerted that Resident #21 threw a lit cigarette into the trash can outside, she, Registered Nurse (RN) #4 and another staff member ran outside and retrieved the cigarette from inside the trash can to extinguish it. LPN #1 stated she saw several staff members standing outside in the smoking area wearing black scrubs, but she was unsure who the staff were, and she did not try to speak to any of them about the situation. According to LPN #1, there were no other residents outside. Further interview with LPN #1 revealed she was unsure where the list was located that indicated which residents required supervision with smoking. Subsequently, she did not know which residents required supervision and which did not. An observation and interview on 09/13/2022 at 2:41 PM with the Assistant Dietary Manager (ADM) revealed the ADM was smoking in the designated smoking area where residents also smoked. The ADM confirmed that staff smoked in the same designated smoking areas as the residents. The ADM stated he was usually outside on a smoke break four to five times during his shift, but he was not familiar with smoking protocol. The ADM stated he believed there were some residents that required supervision while smoking, but he did not observe staff supervising residents during smoke times and he had not seen that occur for about two years. However, the ADM stated when he was outside smoking, he had no way of knowing which resident required supervision when smoking or which were independent unless he personally knew the resident. Continued interview with the ADM revealed most residents kept their lighters and cigarettes with them and lit their own cigarettes without staff supervision. According to the ADM, there used to be specific smoking times for residents, usually after a meal because he remembered staff assisting residents to smoke. However, the ADM stated that currently, residents smoked at all times during the day, and there usually was not any a staff member monitoring the resident. He stated staff may be smoking while in the designated smoking areas but were not monitoring residents for safety while they were smoking. The ADM stated he was not sure why the process to supervise smoking residents stopped being enforced, and he stated he had not seen a silver smoking apron on a resident in about two years. The ADM stated he had voiced concerns about the safety of residents who smoked to staff in the past but not recently. An interview on 09/13/2022 at 3:13 PM with RN #4 revealed she was a unit manager on the Garden Unit. RN #4 stated a smoking list was kept at the nurses' station at the front of the staff schedule book. The smoking list had smoking times for the residents on the Garden Unit and listed a hall number that indicated which CNA was responsible for supervising each smoke break. RN #4 stated all residents who smoked were supposed to smoke during the designated times unless a resident who had behaviors had an intervention to offer a cigarette. RN #4 stated she was aware that residents were allowed to smoke on their own in the past and were allowed to keep their own cigarettes and lighters. The RN stated there were still some residents who kept their own cigarettes and lighter, but other residents needed staff to provide them. According to RN #4, when staff observed a resident go outside to smoke, staff had to go with them to monitor the resident. RN #4 also stated staff knew which residents required supervision because they had to request to smoke since staff had to provide their cigarettes and a lighter. RN #4 stated she was not familiar with Resident #21 and did not know if the resident required supervision. RN #4 stated a surveyor alerted her when Resident #21 dropped a lit cigarette in the trash can. She said she went out to the trashcan to retrieve the lit cigarette. RN #4 stated she did not remember if there were any staff present in the smoking area because she never thought to see what staff allowed Resident #21 to leave the smoking area before extinguishing the cigarette. RN #4 also stated smoking aprons were kept in the medication room on the Garden Unit, but those were only for the residents who lived on that unit. She stated residents from other units would need to bring smoking aprons with them from their unit. Further interview with RN #4 stated revealed Non-Certified Nursing Aide (NCNA) #1 assisted residents outside for the smoke break on 09/12/2022 at 3:30 PM. The RN stated she expected staff to remain outside during the entire smoke break. According to RN #4, she did not know which residents were smoking safely since she was not familiar with the residents from other units. She stated staff would intervene if they observed something obviously unsafe, but otherwise staff would not know which residents required supervision from other units in the facility. An observation and interview on 09/13/2022 at 4:52 PM with Registered Nurse (RN) #4 revealed the medication room located on the Garden Unit had two smoking aprons, and another smoking apron was located at the nurse's station. RN #4 stated there were no more smoking aprons that she was aware of. During an interview on 09/14/2022 at 1:16 PM, NCNA #1 revealed there was a smoking schedule with a list of smoking times, and the staff scheduled to monitor each time was on a board located at the nurse's station on the Garden Unit. NCNA #1 stated the facility was provided a handwritten list of residents who smoked who required staff supervision, but she did not have the list anymore. NCNA #1 stated she got rid of the list after she became familiar with the residents on the garden unit. NCNA #1 stated there were residents who smoked who lived on other units, but the provided list of residents did not identify what type of supervision residents from other units required. She states she assumed the list of times located on the board was only for the residents on the Garden Unit, but she had never asked for clarification. NCNA #1 stated that on Monday, 09/12/2022, she was responsible for monitoring the smoke break at 1:30 PM and 3:30 PM. NCNA #1 stated she had observed residents from other units smoking during the Garden Unit smoke times, but she was not sure what level of supervision those residents required, and she had never seen aides from other units supervising residents while smoking. NCNA #1 stated staff got the residents together about five or ten minutes before the scheduled time by asking the residents on the Garden Unit if they wanted to go outside to smoke. NCNA #1 stated there were four residents that smoked who lived on the Garden Unit. NCNA #1 stated she provided the cigarettes and lighter to each resident, lit all the residents' cigarettes for them, and then took the finished cigarette and extinguished it for the resident. Further interview revealed NCNA #1 did not typically provide the residents anything else during their smoke break. NCNA #1 stated she tried to get residents to wear a smoking apron, but not all the residents complied and allowed those residents to smoke without the apron. NCNA #1 stated she was not familiar with Resident #21 and was not in the smoking area when Resident #21 placed a cigarette in a [CONDITION(S)] can. Further interview with NCNA #1 revealed all residents who smoked independently were allowed to keep their cigarettes and lighters and she had never been instructed otherwise. NCNA #1 stated she had observed some of the independent residents going to the smoking area that day. NCNA #1 stated independent smokers did not adhere to the smoking times, and she had never been instructed to ensure all residents smoked during the scheduled times. NCNA #1 also stated she had never received any training about the smoking protocol, and all her knowledge came from asking questions during her orientation. An interview on 09/14/2022 at 4:10 PM with the Director of Nursing (DON) revealed staff were The DON stated staff received training related to the smoking protocol about six to twelve months ago. all residents were assessed upon admission for smoking status. Each unit had a list of residents at the nurses' station who smoked. The list also indicated which residents required supervision and which were independent. The DON stated that each unit was responsible for supervising their residents during smoke breaks, and those units had their own designated smoke times. The DON stated there were carts with cigarettes, lighters, and smoking aprons stored on a cart on the Garden Unit and assumed they could also be found on the Evergreen Unit also had a cart, and she assumed there were also smoking aprons stored there. The DON stated there were no residents who smoked who lived on the Arbor Unit. Only one resident who smoked, Resident #21 lived on the Aspen Unit, and the DON stated she was not sure where Resident #21's smoking supplies were stored. According to the DON, Resident #21 was considered an independent smoker and the resident did not require a smoking apron. The DON stated CNAs were required to escort residents who needed supervision to the smoking area, provide their cigarettes, and light the cigarette for the resident. The CNA was required to remain with the residents for the entire break. The DON stated CNA staff were also required to either assist the residents with extinguishing the cigarette or observe the resident extinguishing the cigarette in the correct receptacle. Further interview revealed residents who were assessed to smoke independently were allowed to smoke at different times. The resident was supposed to ask staff to provide them with their cigarettes and lighter. The DON stated residents should not have been allowed to keep their lighters and cigarettes on them. The DON did state that residents that required supervision were required to wear a smoking apron when smoking, but if a resident refused they still allowed the resident to smoke with staff supervision. Staff would notify the responsible party about the refusal. The DON also stated there was a chance that staff may not know which residents required supervision or were independent. She was aware of the incident when Resident #21 threw a lit cigarette into the trash can. When provided with documentation that Resident #21 was a supervised smoker, the DON stated she would have expected staff to be outside supervising Resident #21 during smoke breaks. The DON was also provided documentation by corporate nurse there was only one smoker list for all smokers located on the Garden Unit and only staff from that unit supervised smoke breaks. An interview on 09/15/2022 at 4:43 PM with the Administrator revealed there were supervised and independent residents and a list of smoking times. Administrator stated any residents that required supervised smoke breaks should have been offered smoking aprons and assisted by staff, but the independent residents were allowed to be unsupervised when smoking and light their own cigarettes. Administrator stated he was not sure if the independent residents were able to keep their cigarettes and lighter or if staff had them stored somewhere. Administrator stated residents were only supposed to smoke in designated areas. If staff became aware of a resident smoking in a nonsmoking area, they were supposed to intervene. Administrator stated staff should have remained with Resident #21 until after staff properly disposed of the cigarette butt for the resident. Administrator stated there were designated smoke times for all independent and supervised smokers, and staff were only required to supervise if there was a resident smoking who required supervision. Administrator also stated residents should not have been allowed to keep their lighters and he was aware that some residents had them in their possession. However, if staff asked the resident to give them their lighter and the resident refused, staff would only educate the resident but allow them to keep it. Administrator stated he expected all smokers to properly dispose of cigarette butts in proper receptacles. Administrator further stated he was unaware that Resident #21 was assessed to be a supervised smoker and he thought Resident #21 was independent. He did not know that Resident #21 kept their own cigarettes and lighter and the resident should not have been allowed to do so. Administrator stated the facility policy stated residents should not have been allowed to keep their lighter in their possession. F-689-Free of Accident Hazards/Supervision/devices Corrective Action: 1. Nurse Manager and/or designee completed a smoking assessment on RI #110, RI #74, and RI #21 on September 12, 2022 and revised the plan of care to include supervised smoking and q15 min checks for 24 hours. 2. RI #110, RI #74, and RI #21 were placed on supervised smoking on September 12, 2022. Supervised smoking consist of direct staff observation during smoking times. 3. Social Service Director and/or designee re-educated RI #110, RI #74, and RI #21 on the Smoking Policy and Procedure on September 12 202. Education included adherence to the smoking times, smoking allowed only with staff supervision, smoking in designated smoke areas, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to Nursing. A Behavior Contract was initiated with RI #110, RI #74, and RI #21 to acknowledge and obtain written agreement to smoke only in designated smoke areas, dispose of cigarette butts in fire receptacles, adhering to smoke times, and wearing smoking aprons if needed. 4. Licensed Nurse (s) implemented enhanced monitoring consisting of every 15 minute checks of RI #110, RI #74, and RI #21 on September 12, 2022 until September 13, 2022. One on one supervision will be implemented as needed to maintain resident safety. 5. Administrator and/or designee conducted a room search of RI #110, RI#74, and RI #21 to search for and confiscate cigarette paraphernalia. Cigarette lighters were retrieved and placed in a secure (locked) storage cart on Evergreen unit. Only Nursing and/or Ancillary staff will have access to the storage cart. 6. Effective September 13, 2022, designated smoking times will be implemented for all residents who smoke. 7. Maintenance Director and/or designee placed signage on the trash can in the smoking area on September 13, 2022 for trash only. 8. Administrator hosted an Ad Hoc Quality Assurance Performance Improvement meeting with Medical Director engagement on September 12, 2022 to discuss Smoking Policy and specific emphasis on supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance. Version 4 F 689 Identification: 1. Nurse Managers and/or designee completed a new smoking assessment on all residents identified as smokers on September 13, 2022 and revised the plan of care as needed. 2. Interdisciplinary Team thoroughly checked resident rooms to ensure all smoking materials have been confiscated and securely place in the supervised smoking compartment on September 13, 2022. Any resident who would not relinquish cigarette paraphernalia on September 13, 2022 was placed on one to one supervision until materials were confiscated and secured. 3. Interdisciplinary Team thoroughly checked clothing for all resident identified as smokers to ensure no holes or [CONDITION(S)] were observed on September 13, 2022. No additional concerns were identified 4. Maintenance Director completed an audit of the smoking area on September 12, 2022 to validate availability of smoking blanket, fire receptacles, and fire extinguishers. Effective September 13 2022, smoking aprons will be located in the designated smoking storage cart. 5. Maintenance Director and/or designee validated no smoking signage is posted in non-smoking areas on September 12, 2022. Systematic Measures: 1. The Nurse Practice Educator or designee re-educated Nursing, Social Services, Housekeeping, Dietary, Therapy, and Maintenance employees on the Smoking Policy and Procedure beginning September 12, 2022 with emphasis on designated smoke times, supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance. Any employee on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. 2. On September 13, 2022, Social Service Director and/or designee re-educated residents identified as smokers on adherence to the Smoking Policy to include: smoking only in designated smoke areas, designated smoke times, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to Nursing. 3. Effective September 13, 2022, designated smoking times will be implemented for all residents who smoke. Cigarette paraphernalia and smoking aprons will be stored in a secure designated smoking storage cart. Additionally, documentation outlining individualized safety measures will be based on the smoking assessment and located on or inside the storage cart. 4. Effective September 13, 2022, Director of Nursing and/or designee will review new admissions during the Clinical Meeting to identify smokers and validate a smoking assessment has been completed and a plan of care is in place to maintain resident safety. 5. If a resident is observed as being non-compliant with supervised smoking, a care plan meeting will be scheduled with resident and/or legal representative. Smoking privileges may be revoked. Any further non-compliance may result in the issuance of an immediate discharge notice and/or a 30-day notice for discharge if the residents clinical or behavioral status or condition endangers the safety of individuals within the facility. Quality Assurance and Monitoring: 1. Nurse Managers and/or designee will randomly observe smokers during smoking times on each shift 3x a week for four weeks, 2x a week for four weeks, and weekly for four weeks to ensure supervision of smokers, validate smoking is occurring in the designated smoke areas, application of smoking aprons, and disposal of cigarette butts in the appropriate receptacle. 2. Maintenance Director or designee will inspect the smoking area 2x a day to ensure and all safety items remain in place. Version 4 F 689 3. Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting on September 12, 2022 with Department Managers and reviewed with the Medical Director on the center's Smoking Policy and the performance improvement measures outlined in this document. Verification of AOC: Review of smoking eval dated 9-12-22 #110, #74, & #21 were completed. All evals indicated supervision while smoking was req. Review of care plan #110, #21 & #74 revealed it was revised to include education on smoking policy, supervised smoking & q shift x24 hours. No revisions. Review #110, #74, & #21 care plans and smoking assessments revealed residents were supervised smokers. Review of Resident Inservice 9-13-22 Cigarette & Smoking policies revealed R#110, #74 & 21 were present during the in-service. Review of signed Behavior Contracts related to smoking policy were signed by #110, #74 & #21. Review of Q-15 check log revealed R#110, #74 & R#21 were completed every 15 minutes for 24 hours starting on 9-12-22. Review of doc room search was completed on 9-12-22 for #110, #74 & #21 revealed were searched and cigarette paraphernalia was confiscated if found. Review of smoke times for all unit's revealed set smoking times. Observation of trash can revealed green sign with black lettering that stated, trash only. Review of AdHoc QUAPI Smoking meeting occurred on 9-12-22 related to smoking policy. Review of 26 resident smoking assessments completed on 9-13-22. Review of Smoking-room search dated 9-13-22 revealed all rooms checked for smoking paraphernalia. Review of clothing search dated 9-13-22 revealed all rooms checked for clothing with holes or burn marks. Review of smoking area audit dated 9-12-22 (6p-6a), 9-13-22 (6a-6p), 9-13-22 (6p-6a), 9-14-22 (6a-6p), 9-14-22 (6p-6a), 9-15-22 (6a-6p). All fire safety items were available. Observation of in and around smoking area revealed smoking signs were located throughout. Interviews and observations of staff Smoking Policy and Procedure training log started on 09/12/22 revealed 121 nursing staff, 2 administrative staff, 5 physicians, 6 business office staff, 4 activities staff, 17 housekeeping staff, 3 social services staff, 15 dietary staff, 16 rehab staff and maintenance staff completed the training. Review of Resident Inservice 9-13-22 Cigarette & Smoking policies revealed 18 res were in attendance. Review of smoke times for all unit's revealed set smoking times posted. Review of admission review revealed no new admissions to reassess. Review of Resident Inservice 9-13-22 Cigarette & Smoking policy revealed smoking residents made aware of the policy and how facility will address noncompliance. Review of smoking audits revealed smoking observations were completed at least once each shift. Review of smoking area audit dated 9-12-22 (6p-6a), 9-13-22 (6a-6p), 9-13-22 (6p-6a), 9-14-22 (6a-6p), 9-14-22 (6p-6a), 9-15-22 (6a-6p). Review of AdHoc QUAPI Smoking meeting occurred on 9-12-22 related to smoking policy. 2. A review of an Admission Record revealed Resident #74 had diagnoses which included chronic obstructive pulmonary disease, anxiety disorder, and dependence on supplemental oxygen. A review of Resident #74's care plan revealed an intervention dated 01/25/2019 that directed staff to reassess the patient's ability to smoke with supervision with any change of condition. The care plan also directed staff to ensure that appropriate cigarette disposal receptacles were available in the smoking area. A review of Resident #74's Smoking Evaluation (SNF) [skilled nursing facility] form, dated 07/06/2022, revealed the resident could demonstrate the location of the designated smoking area, had no history of unsafe smoking habits, had no history of fire setting or arson, properly disposed of ashes or cigarette butts, smoked safely without the use of a smoking apron, and was allowed to smoke independently. A review of Resident #74's quarterly Minimum Data Set (MDS) assessment, dated 07/09/2022, revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. During an observation and interview on 09/12/2022 at 2:25 PM, Resident #74 sat in a motorized wheelchair at the front of the building smoking a cigarette. The resident sat by a bench. Resident #74 stated he/she usually smoked in front of the building and noted that, when done with a cigarette, he/she threw the cigarette butt in a nearby trash can since there was nowhere else to put them out. An observation on 09/12/2022 at 2:35 PM revealed the trash can where Resident #74 was observed smoking ten minutes prior contained cigarette ashes on top of the trash can. The trash can was lined with a plastic bag and had combustible materials, namely paper bags, inside of the receptacle. During an observation and interview on 09/12/2022 at 3:10 PM, Resident #74 was lying in bed and stated he/she could smoke when desired and had been instructed by the facility to smoke out back in a facility-designated smoking area or off the property. The resident stated he/she sometimes went off the property to smoke. Resident #74 reported he/she always maintained possession of his/her cigarettes and lighter. The resident confirmed the facility instructed him/her not to smoke at the front of the building. During an interview on 09/12/2022 at 3:15 PM, Certified Nursing Aide (CNA) #3 confirmed Resident #74 smoked and had been told to smoke outside in the designated smoking area, which she noted had a smoking sign designating it as such. She identified she had observed the resident smoking outside at the front of the facility, which she noted was not a designated smoking area. CNA #3 reported she was unaware the front of the building lacked a smoking receptacle since it was not a designated smoking area. During an interview on 09/12/2022 at 3:21 PM, Licensed Practical Nurse (LPN) #4 confirmed Resident #74 smoke [TRUNCATED]

Based on interviews and record review, the facility failed to take the necessary steps to ensure two (#4 and #5) of two residents were free from resident to resident abuse out of nine sample residents. Resident #4 was admitted to the facility for long term care on 2/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required limited assistance with locomotion on the unit and utilized a walker and wheelchair for mobility. Since admission to the facility on [DATE], the resident wandered around the unit, including into other resident rooms that put him at risk of a resident to resident altercation. The facility failed to address the wandering and provide appropriate person-centered interventions (cross-reference F744 for dementia care). Resident #5 voiced concerns to staff of Resident #4 wandered into his room but there was no follow-up by the facility. Due to the facility not addressing Resident #5 concerns and knowledge that Resident #4 wandered into Resident #5's room and other resident rooms, it led to a resident to resident altercation on 4/3/22. Due to the facility failures, Resident #4 wandered into Resident #5's room and an altercation ensued with Resident #4 having a fall which resulted in Resident #4 sustaining a left wrist fracture, left hip fracture and bruise to scalp (see hospital documentation below). Findings include: I. Facility policy The Abuse Prohibition policy and procedure, revised 4/9/21, was provided by the social services director (SSD) on 4/27/22 at 1:37 p.m. It read, in pertinent part, The Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. II. Altercation on 4/3/22 The DON provided the documents included in the facility incident investigation on 4/26/22 at 11:30 a.m. The investigation included interviews with residents, staff, abuse in-service records, and hospital records. Certified nurse aide (CNA #3 provided a statement on 4/4/22. CNA #3 indicated he heard Resident #5 call out for help on the night of 4/3/22 at 9:20 p.m. When he got to the room he saw Resident #4 was on the floor. Resident #5 said Resident #4 was in his room and he tried to redirect him to his room when he lost his balance and fell . CNA #3 notified the nurse and paramedics came to take Resident #4 to the hospital. Resident #5 was interviewed by law enforcement on 4/5/22. Resident #5 said he was in bed when Resident #4 wandered into his room. Resident #5 got up from bed and told him to leave. Resident #4 grabbed his cane and lost his balance and fell . Resident #5 said he alerted staff to come assist. Resident #5 also reported Resident #4 had come into his room multiple times before and staff had not done anything to stop this. Registered nurse (RN) #2 provided a statement on 4/12/22. RN #2 indicated on 4/3/22 around 9:50 p.m. she arrived on the floor following a break. CNA #3 informed her that Resident #4 was on the floor. RN #2 indicated Resident #4 was on the floor by the bathroom. RN #1 was interviewed by facility staff on 4/13/22. RN #1 indicated she did not see Resident #4 wandering the night of 4/3/22. She said she heard commotion and walked to the Resident #5's room and found Resident #4 on the floor outside of the bathroom. She said he had an injury above his eye and it seemed he had a wrist injury. She said he complained of pain. Hospital records indicated Resident #4 was admitted on [DATE]. Injuries included a hematoma (bruise) to his scalp, left wrist fracture, and left hip fracture. Resident #4 returned to the facility on [DATE]. -There was no interview from Resident #4 included in the facility investigation. III. Resident #4 A. Resident status Resident #4, age 81, was admitted on [DATE], readmitted [DATE] and passed away 4/10/22. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/26/22 minimum data set (MDS) assessment indicated the resident was severely cognitively impaired with a brief interview of mental status score of five out of 15. It indicated the resident required limited assistance with activities of daily living which included locomotion on the unit. It indicated the resident had both a wheelchair and walker for mobility. It indicated the resident wandered and was not at significant risk of getting into a potentially dangerous place and the wandering did not significantly intrude on the privacy or activities of others. B. Record review The behavior care plan, initiated 2/28/22, indicated Resident #4 had a tendency to exhibit sexually inappropriate behavior and was noted to wander into hallways and resident rooms undressed. Interventions included monitoring conditions that may have contributed to inappropriate sexual behaviors, monitoring medications for potential contribution to sexually inappropriate behaviors, and evaluating the nature and circumstances of sexually inappropriate behaviors. -There was no specific care plan for dementia or wandering behaviors or personalized interventions for the resident wandering into other resident's room (cross-reference F744). The DON provided two dementia functional assessment tools that were utilized for secure placement decisions which revealed the following: The assessment from 2/22/22 indicated Resident #4 had memory deficits, difficulty with complex tasks, decreased concentration, and withdrawal from challenging situations. The assessment indicated the resident had wandering behaviors but was not exit seeking. It indicated the wandering was purposeless. The assessment noted the resident was at level four on the global deterioration scale which indicated moderate cognitive decline. The assessment indicated the facility would attempt the general unit before considering a secured memory care unit. The assessment from 3/9/22 indicated Resident #4 was disoriented to time and place, had sleep disturbances, wandered with purpose (looked for a way out), catastrophic reactions, and resistance to care. The assessment noted the resident was at level five on the global deterioration scale which indicated moderate severe cognitive decline. The assessment indicated a chart review would occur and options would be discussed with family as needed. An additional document was attached to the assessment and dated 3/9/22. It indicated the assessment was completed due to repeated instances of the resident wandering into another resident's room. The note indicated the resident's representative was contacted in order to set up a care conference to discuss a secure unit placement and the resident representative declined the care conference. -Although, the facility documented moving the resident to a secured unit on 3/9/22, there was no additional follow-up to include safety measures were put in place to deter the resident from wandering into other resident rooms. Progress notes from 2/18/22-4/10/22 were reviewed and revealed the following: On 2/18/22 a progress note was completed upon Resident #4's admission. It indicated Resident #4 was severely impaired in decision making for daily routine. It indicated when Resident #4 was walking with an assistive device, Resident #4 was not steady but able to stabilize without staff assistance. On 2/25/22 a progress note was completed that indicated Resident #4 undressed and wandered into the hallway and other residents' rooms. On 3/3/22 a progress note was completed that indicated Resident #4 was up during the night and wandered into other residents' rooms. It noted two residents complained because he was in their room and staring at them when they woke up. The note indicated the resident was educated on safety and staying in his room at night. It indicated the resident seems to understand. On 3/24/22 a progress note was completed that indicated Resident #4 was walking in the hallway without his walker. It noted the writer walked with the resident towards his room. The resident attempted to walk into the wrong room. The writer explained it was not his room and was redirected to his room. It indicated Resident #4 was educated on using his walker or wheelchair when ambulating. IV. Resident #5 A. Resident status Resident #5, age 66, was admitted on [DATE]. According to the April 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 3/15/22 MDS assessment indicated the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. It indicated the resident did not have physical or verbal behaviors directed towards others. It indicated the resident was independent with activities of daily living and utilized a cane for mobility. B. Resident interview Resident #5 was interviewed 4/27/22 at 8:41 a.m. He said for weeks Resident #4 had wandered into his room and other residents' rooms prior to the altercation with Resident #4. He said Resident #4 would typically come into his room at night. He said he kept his door closed but he could see when Resident #4 entered his room. He said Resident #4 would go to the bathroom and urinate on the floor. Resident #5 said he would clean up the mess himself. He said he notified staff that this bothered him and staff did not have suggestions to reduce this. He said on the evening of 4/3/22, Resident #4 entered his room while he was sleeping and it woke him up. He said he got out of bed and told Resident #4 he was in the wrong room. He said Resident #4 insisted it was his room. Resident #5 walked over to Resident #4 to block his room. He said Resident #4 grabbed his cane and this was the first time Resident #4 had been aggressive towards him. He said there was a struggle between the two for the cane. Resident #5 said he had poor balance and he did not want to fall. He said Resident #4 lost his balance and fell on the floor. He said he yelled for help and nurses came shortly after to tend to Resident #4. He said he did not get injured from the event. He said he believed Resident #4 should have been in the secure unit. He said he had mentioned this to staff. He said the next morning he sent an email to the facility's corporate office and ombudsman in order to clarify the situation. C. Record review The DON provided notes from social services on 4/27/22 at 11:17 a.m. The social services specialist (SSS) completed a document on 3/8/22 based on an interview with Resident #5. Resident #5 stated Resident #4 wandered into his room a week ago. He also noted he observed urine on the floor of his bathroom three days prior. He then stated Resident #4 wandered into his room two days ago and he was able to ask him to leave. The document indicated SSS would write up the report and submit it to the necessary parties. -The action taken after this involved reassessment for the secure memory care unit and an attempt to set up a care conference with Resident #4's representative (see Resident #4 assessment above). On 4/12/22 a progress note was completed in regards to an interdisciplinary team meeting that discussed the resident-to-resident altercation. It indicated Resident #5 stated Resident #4 wandered into his room to use his bathroom. Resident #5 asked Resident #4 to leave and Resident #4 said it was his room. Resident #4 attempted to grab Resident #5's cane. Resident #4 lost his balance and sustained a fall. Resident #5 contacted staff for assistance. Resident #5 was assessed and no injuries were noted. Provider was notified and no new orders were placed. Resident #5's behavior plan was to be reviewed and revised, he was moved to a private room, and one-to-one supervision was implemented. -However, the one-to-one supervision was implemented nine days after the initial altercation on 4/3/22. Resident #5 provided the email sent to the facility's corporate office and ombudsman on 4/27/22 at 8:53 a.m. It read in pertinent part, The elderly man with dementia who lives directly across the hall from me once again walked into my room to use my toilet; he mistakenly believes that (Resident #5's room) is his and this intrusive behavior has occurred at least a dozen times in the past month or two. Staff is very much aware of his aimless wandering, but has failed to address the problem. As far as I'm concerned, this other resident requires a greater level of supervision in order to ensure everyone's safety. D. Observation During survey from 4/25/22 to 4/27/22 a one-to-one CNA was observed outside of Resident #5's room. The one-to-one CNA accompanied the resident when he left his room. V. Staff interviews The DON was interviewed on 4/26/22 at 11:30 a.m. She said initially the staff thought Resident #4 fell in Resident #5's room. She said the staff were unaware there was an altercation until Resident #5 emailed the corporate office and the ombudsman. She said Resident #5 had never been aggressive but they placed him with a one-to-one CNA in order to ensure safety. -The one-to-one supervision was implemented nine days after the altercation occurred. She said Resident #4 had a wrist and hip injury from the accident and returned from the hospital and was no longer mobile. Licensed practical nurse (LPN) #1 was interviewed on 4/26/22 at 2:55 p.m. She said Resident #4 wandered on the unit. She said the protocol was to redirect the resident to his room. She said residents that wandered and were not redirectable were considered for the secured memory care unit. Certified nurse aide (CNA) #2 was interviewed on 4/26/22 at 3:00 p.m. She said Resident #4 wandered the unit fairly often. She said she would redirect him to an appropriate place and never had any issues redirecting him. She said Resident #4 had a wheelchair and a walker but was forgetful and would not use either. She said she never received training from the facility specific to residents who wandered. LPN #3 was interviewed on 4/26/22 at 3:12 p.m. She said Resident #4 was a big time wanderer. She said other residents had complained about the wandering. She said staff would redirect him with no issues. She said other residents would also redirect him. The social services director (SSD) was interviewed on 4/27/22 at 8:58 a.m. She said Resident #4 was evaluated for the secure memory care unit but the resident representative was not in agreement and wanted the resident to live in one of the general units. She said upon admission Resident #4 wandered around the unit but was easily redirected. She said staff would tell the resident to go to his room and he did not get upset with the redirecting. She said he was not exit seeking. She said the resident should have a wandering care plan to address concerns but could not confirm if Resident #4 had a care plan. She said Resident #5 complained about the wandering and the unit social worker would have more information. She said she did not know what the follow-up was done when Resident #5 brought up his concerns. The social services specialist (SSS) was interviewed on 4/27/22 at 9:09 a.m. He said Resident #5 complained about Resident #4 wandering into his room. The SSS said he wrote up the interview and gave it to the SSD and the nursing home administrator. He said he was unsure what the follow-up was. He said it was not filed as a grievance. He said the unit manager made an attempt to have Resident #4 moved to the secure memory care unit. The unit manager (UM) was interviewed on 4/27/22 at 9:54 a.m. She said Resident #4 would wander up and down the hallways. She said she recalled one instance when Resident #4 attempted to go into the wrong room. She said she was able to redirect the resident to the correct room. She said Resident #4 never got angry or violent when redirected. She said she had mentioned moving the resident to the secure memory care unit during a staff meeting but there was no follow-up. She said no other interventions besides redirection were trialed. She said there was no wandering specific care plan but there was a care plan for behaviors related to his inappropriate sexual behaviors. She said she was not aware of any incident that involved inappropriate sexual behaviors. She said if a resident wandered, there should be a specific care plan on wandering with personalized interventions. The DON was interviewed on 4/27/22 at 10:46 a.m. She said a resident could wander at the facility as long as they were not exit seeking or causing a disruption. She said the social services department completed the assessment regarding the secured memory care unit. She said she did not hear of any residents complaining about Resident #4 wandering into their rooms. She said she could not speak to Resident #4's care plan specifically but that if a resident wandered there should be a specific care plan on wandering with personalized interventions. The SSD was interviewed again on 4/27/22 at 11:46 a.m. She said moving Resident #4 to the secure memory care unit was discussed during morning meeting with nursing staff and the UM called the family to set up a care conference. She said the family declined the care conference. She said if a family declined a care conference then the staff did not have it. She said nothing further was done regarding moving the resident to the secure memory care unit since he was easily redirected. -In addition, the facility failed to implement safety measures when the family declined to move the resident to a secured unit to prevent the resident from wandering into other resident rooms. The SSD was interviewed again on 4/27/22 at 12:42 p.m. She said she completed behavior tracking based on progress notes completed by the nursing staff. She said there was no formal behavior tracking system in order to determine the root cause of the wandering. She said Resident #4 wandered mostly in the evenings and it appeared to be related to toileting. She said one incident involved Resident #4 getting undressed and wandering into the hallway in a brief and this may have been related to toileting.

Based on interviews and record review, the facility failed to ensure one (#4) of one resident reviewed for dementia care of nine sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident #4 was admitted to the facility for long term care on 2/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required limited assistance with locomotion on the unit and utilized a walker and wheelchair for mobility. Since admission on 2/18/22, the resident wandered around the unit. The facility failed to address the wandering and provide appropriate personalized-centered interventions. Resident #5 voiced concerns to staff of Resident #4 wandering into his room but no follow-up was provided by the facility. Due to the facility failures, Resident #4 wandered into Resident #5's room on 4/3/22 and an altercation ensued with Resident #4 having a fall which resulted in a left wrist fracture, left hip fracture, and bruise to scalp (see hospital documentation). Cross-reference F600 the facility failed to prevent a resident to resident altercation by implementing appropriate safety measures to prevent Resident #4 from wandering into other resident rooms. Findings include: I. Facility policy and procedures A. The Scope of Service and Core Dementia Care Standards policy and procedure, revised 3/12/18, was provided by the social services director (SSD) on 4/27/22 at 1:37 p.m. It read in pertinent part, The abilities and needs of individuals who have Alzheimer's disease or a related dementia vary and, as such, the care for these individuals requires a specialized approach and specific programming. All individuals deserve to be free from mental, physical, sexual, and verbal abuse or neglet. All behavior has meaning and informs caregivers of underlying experiences or needs that may not be easily expressed in words; careful clinical evaluation is a critically important aspect of quality dementia care. B. The Person-Centered Care Plan policy and procedure, revised 1/15/21, was provided by the SSD on 4/27/22 at 1:37 p.m. It read in pertinent part, Social services staff, as members of the Interdisciplinary Care Team, will participate in developing a comprehensive individualized care plan for each patient. Develop individualized plan of care based upon Social Services Assessment and Documentation, subsequent assessments, Care Area Assessment triggers, and other observations. Review, evaluate and update care plans as required. II. Resident census and conditions The 4/25/22 Resident Census and Conditions documented there were a total of 181 residents at the facility with 53 residents that had dementia (29.3%) and 12 residents with behavioral health (6.6%). III. Resident status Resident #4, age 81, was admitted on [DATE], readmitted [DATE] and passed away on 4/10/22. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/26/22 minimum data set (MDS) assessment indicated the resident was severely cognitively impaired with a brief interview of mental status score of five out of 15. It indicated the resident required limited assistance with activities of daily living which included locomotion on the unit. It indicated the resident had both a wheelchair and walker for mobility. It indicated the resident wandered and was not at significant risk of getting into a potentially dangerous place and the wandering did not significantly intrude on the privacy or activities of others. IV. Record review The behavior care plan, initiated 2/28/22, indicated Resident #4 had a tendency to exhibit sexually inappropriate behavior and was noted to wander into hallways and resident rooms undressed. Interventions included monitoring conditions that may have contributed to inappropriate sexual behaviors, monitoring medications for potential contribution to sexually inappropriate behaviors, and evaluating the nature and circumstances of sexually inappropriate behaviors. -There was no care plan for dementia or his wandering behaviors with personalized interventions to deter him from wandering into other resident rooms. The activities care plan, revised 3/18/22, indicated Resident #4 enjoyed watching television and engaging in favorite activities. -The care plan did not indicate what the preferred activities were nor did it have personalized interventions for his dementia care programming. The DON provided two dementia functional assessment tools that were utilized for secure placement decisions which revealed the following: The assessment from 2/22/22 indicated Resident #4 had memory deficits, difficulty with complex tasks, decreased concentration, and withdrawal from challenging situations. The assessment indicated the resident had wandering behaviors but was not exit seeking. It indicated the wandering was purposeless. The assessment noted the resident was at level four on the global deterioration scale which indicated moderate cognitive decline. The assessment indicated the facility would attempt the general unit before considering a secured memory care unit. The assessment from 3/9/22 indicated Resident #4 was disoriented to time and place, had sleep disturbances, wandered with purpose (looked for a way out), catastrophic reactions, and resistance to care. The assessment noted the resident was at level five on the global deterioration scale which indicated moderate severe cognitive decline. The assessment indicated a chart review would occur and options would be discussed with family as needed. An additional document was attached to the assessment and dated 3/9/22. It indicated the assessment was completed due to repeated instances of the resident wandering into another resident's room. The note indicated the resident's representative was contacted in order to set up a care conference to discuss a secure unit placement and the resident representative declined the care conference. -Although, the facility documented moving the resident to a secured unit on 3/9/22, there was no additional follow-up to include safety measures put in place to deter the resident from wandering into other resident rooms to prevent abuse (cross-reference F600). Progress notes from 2/18/22-4/10/22 were reviewed and revealed the following: On 2/18/22 a progress note was completed upon Resident #4's admission. It indicated Resident #4 was severely impaired in decision making for daily routine. It indicated when Resident #4 was walking with an assistive device, Resident #4 was not steady but able to stabilize without staff assistance. On 2/25/22 a progress note was completed that indicated Resident #4 undressed and wandered into the hallway and other residents' rooms. On 3/3/22 a progress note was completed that indicated Resident #4 was up during the night and wandered into other residents' rooms. It noted two residents complained because he was in their room and staring at them when they woke up. The note indicated the resident was educated on safety and staying in his room at night. It indicated the resident seems to understand. On 3/24/22 a progress note was completed that indicated Resident #4 was walking in the hallway without his walker. It noted the writer walked with the resident towards his room. The resident attempted to walk into the wrong room. The writer explained it was not his room and was redirected to his room. It indicated Resident #4 was educated on using his walker or wheelchair when ambulating. V. Altercation on 4/3/22 Resident #4 wandered into Resident #5 room on 4/3/22 where an altercation occurred and Resident #4 was subsequently sent to the hospital. Resident #5 had previously voiced concern to the facility staff that Resident #4 would wander to his room to use his bathroom (cross-reference F600). Hospital records indicated Resident #4 was admitted on [DATE]. Injuries included a hematoma (bruise) to his scalp, left wrist fracture, and left hip fracture. Resident #4 returned to the facility on [DATE]. VI. Staff interviews The DON was interviewed on 4/26/22 at 11:30 a.m. She said initially the staff thought Resident #4 fell in Resident #5's room. She said the staff were unaware there was an altercation until Resident #5 emailed the corporate office and the ombudsman. She said Resident #4 had a wrist and hip injury from the accident and returned from the hospital and was no longer mobile. Licensed practical nurse (LPN) #1 was interviewed on 4/26/22 at 2:55 p.m. She said Resident #4 wandered on the unit. She said the protocol was to redirect the resident to his room. She said residents that wandered and were not redirectable were considered for the secured memory care unit. She said she had received dementia training. Certified nurse aide (CNA) #2 was interviewed on 4/26/22 at 3:00 p.m. She said Resident #4 wandered the unit fairly often. She said she would redirect him to an appropriate place and never had any issues redirecting him. She said Resident #4 had a wheelchair and a walker but was forgetful and would not use either. She said she never received training from the facility specific to residents who wandered. LPN #3 was interviewed on 4/26/22 at 3:12 p.m. She said Resident #4 was a big time wanderer. She said other residents had complained about the wandering. She said staff would redirect him with no issues. She said other residents would also redirect him. She said she had received general training on dementia care. The social services director (SSD) was interviewed on 4/27/22 at 8:58 a.m. She said Resident #4 was evaluated for the secure memory care unit but the resident representative was not in agreement and wanted the resident to live in one of the general units. She said upon admission Resident #4 wandered around the unit but was easily redirected. She said staff would tell the resident to go to his room and he did not get upset with the redirecting. She said he was not exit seeking. She said the resident should have a wandering care plan to address concerns but could not confirm if Resident #4 had a care plan. She said Resident #5 complained about the wandering and the unit social worker would have more information. She said she did not know what the follow-up was done when Resident #5 brought up his concerns. The social services specialist (SSS) was interviewed on 4/27/22 at 9:09 a.m. He said Resident #5 complained about Resident #4 wandering into his room. The SSS said he wrote up the interview and gave it to the SSD and the nursing home administrator. He said he was unsure what the follow up was. He said it was not filed as a grievance. He said the unit manager made an attempt to have Resident #4 moved to the secure memory care unit. The unit manager (UM) was interviewed on 4/27/22 at 9:54 a.m. She said Resident #4 would wander up and down the hallways. She said she recalled one instance when Resident #4 attempted to go into the wrong room. She said she was able to redirect the resident to the correct room. She said Resident #4 never got angry or violent when redirected. She said she had mentioned moving the resident to the secure memory care unit during a staff meeting but there was no follow up. She said no other interventions besides redirection were trialed. She said there was no wandering specific care plan but there was a care plan for behaviors related to his inappropriate sexual behaviors. She said she was not aware of any incident that involved inappropriate sexual behaviors. She said if a resident wandered, there should be a specific care plan on wandering with personalized interventions. The DON was interviewed on 4/27/22 at 10:46 a.m. She said a resident could wander at the facility as long as they were not exit seeking or causing a disruption. She said the social services completed the assessment regarding the secured memory care unit. She said she did not hear of any residents complaining about Resident #4 wandering into their rooms. She said she could not speak to Resident #4's care plan specifically but that if a resident wandered there should be a specific care plan on wandering with personalized interventions. The SSD was interviewed again on 4/27/22 at 11:46 a.m. She said moving Resident #4 to the secure memory care unit was discussed during the morning meeting with nursing staff and the UM called the family to set up a care conference. She said the family declined the care conference. She said if a family declined a care conference then the staff did not have it. She said nothing further was done regarding moving the resident to the secure memory care unit since he was easily redirected. -In addition, the facility failed to implement safety measures when the family declined to move the resident to a secured unit to prevent the resident from wandering into other resident rooms. The activities assistant (AA) was interviewed on 4/27/22 at 12:15 p.m. She said Resident #4 did not participate in group activities. She said she provided leisure packets but he did not complete them. She said she was unsure if he was social or joined activities in the evening. The SSD was interviewed again on 4/27/22 at 12:42 p.m. She said she completed behavior tracking based on progress notes completed by the nursing staff. She said there was no formal behavior tracking system in order to determine the root cause of the wandering. She said Resident #4 wandered mostly in the evenings and it appeared to be related to toileting. She said one incident involved Resident #4 getting undressed and wandering into the hallway in a brief and this may have been related to toileting.

Based on interviews and record review the facility failed to make prompt efforts to resolve grievances and to keep the residents appropriately apprised of progress toward resolution for two out of five neighborhoods. Specifically, the facility failed to address grievances in a timely manner about receiving bathing according to preferences and improper food temperatures which resulted in residents experiencing feelings of not being heard, not mattering, and frustration that their voices were not heard and concerns were not resolved. Cross-reference citations: F677 the facility failed to provide showers according to resident preferences for Residents #20, #11, #1, #10, #6; and, F804 palatable food temperatures. Findings include: I. Facility Policy The Grievance/Concern policy last revised on 7/1/19, was provided via email on 10/13/21 from the regional quality assurance consultant (RQAC). It read in pertinent part,All residents and/or their representatives may voice grievances/concerns and recommendations for changes. Center leadership will investigate, document and follow up on all formal concerns and grievances registered by any resident. II. Resident interviews A. Resident meeting during survey A resident meeting was held on 10/12/21 beginning at 1:41 p.m. with four alert and oriented residents (#16, #17, #18, and #15) selected by the facility. The residents had the following complaints: -All four residents stated the food was served cold, which they felt they discussed in several meetings but was not heard because nothing changed; -All four residents said they were missing clothing and the facility failed to notify them of their determinations during the grievance process; -All four residents said showers were not provided as scheduled. They said that at times they went up to three weeks without a shower. Resident #16 said they would bathe themselves in the bathroom sink. The residents said grievance forms were not filled out, as they did not receive follow up regarding their concerns. They stated the facility was aware of their concerns because these issues were common knowledge and had also been discussed in resident council meetings. The residents reported they consider the facility their home and family. They stated the facility had meetings but nothing ever got done. It made them feel bad and have stopped going to meetings because they felt nothing they said would make a difference. They felt like their voice did not matter because no changes happened after reporting concerns so they felt frustrated. They said they felt like they did not matter and the facility staff could do whatever they wanted to them and they would have no recourse. B. Resident and culinary council minutes The 6/9/21 resident council meeting was held with 29 residents. The minutes documented that the residents had complaints about the meals not being served timely. The facility responded that they were working with staff regarding time management. The facility was in the process of hiring a dietary service manager (DSM). The minutes documented that heated carts had been ordered to keep trays warm, along with acknowledgement of staffing challenges. The 7/14/21 resident council meeting was held with 17 residents. The minutes documented, the residents had complaints of not receiving showers as scheduled and cold food was served in the dining room and on room trays. The 8/11/21 resident council meeting documented the 7/14/21 concerns that were reviewed. The previous concern regarding residents not receiving showers timely revealed 14 residents continued to report there had been no resolution, and continued to not receive showers. Fourteen residents reported the kitchen ran out of food and kitchen staff not being available to address concerns. Fourteen residents continued to have the concern that food continued to be served cold. The culinary council minutes conducted by the dietary service manager (DSM) were reviewed for 8/5/21, 8/12/21, 8/25/21, 9/1/21, 9/8/21, 9/15/21, 9/22/21 and 10/13/21. Menu choices were the primary focus of these meetings. Food temperatures were not specially addressed. However, on 8/12/21 meeting notes revealed salad not being stored properly and delays in meal carts. C. Staff interviews The DSM was interviewed on 10/11/21 at 1:11 p.m. The DSM acknowledged the residents had complaints that the food was often served cold. She explained she was transferred to the facility in July 2021. Beginning in August 2021 she scheduled weekly culinary council meetings with the residents to address concerns regarding the kitchen. She stated the kitchen staff was interested in feedback from residents, families and facility staff to improve satisfaction. The social services assistant (SSA) was interviewed on 10/12/21 at 12:00 p.m. The SSA explained that he assisted with reported grievances and forwarded grievance concerns to the director of nursing (DON) and nursing home administrator (NHA) depending on the severity of the grievance. The social service director (SSD) was interviewed on 10/14/21 at 12:31 p.m. She said that she was being trained by the NHA on how to track the grievances. She was involved in the followup and documentation on the grievance forms. She said that it was her responsibility to talk to the residents, especially after losing their clothing. She said it was the policy of the facility to reimburse for lost items not found. She said the process was to document the results on the grievance form then notify the resident of the results. She said she had recently taken this task over and would be more diligent at documenting the results on the form including the conversation with the residents. She said she was not involved in the food temperature grievances since the DSM was responding to the concerns. She said it would be put into the log but she was not sure as to the reason for the missing grievances from the log. She said she was notified about the grievances concerning missing clothing, hearing, dental and nail concerns.

Based on record review, and staff interviews, the facility failed to ensure two (#2 and #5) of four out of five sample residents receive the care and services necessary to prevent the development of pressure ulcers and to promote healing of pressure ulcers. Specifically, for Resident #2, the facility failed to prevent the development of pressure injuries. Resident #2 was admitted [DATE] to the facility with intact skin. Upon admission to the facility, the staff identified that she was at risk for pressure injuries and documented it on her care plan (staff directive for care). The facility failed to complete accurate skin assessments and delayed treatment contributed to the development of pressure injuries. On 3/3/21, Resident #2 developed a pressure injury to her left heel. Recommended treatments for her left heel were not added to the treatment administration record (TAR) and it was unclear if the resident received any care for the pressure injury on her heel. On 3/10/21 Resident #2 developed a pressure injury to the coccyx. Interventions to the TAR were added two days later on 3/12/21. The resident was followed by the wound care team eight days later on the day of her discharge, 3/18/21. Due to the facility failures, Resident #2 was discharged on [DATE] with three avoidable, facility acquired pressure ulcers, two unstageable pressure ulcers on her left and right heel and stage 2 pressure ulcer on her coccyx. In addition, for Resident #5, the facility failed to prevent the development of pressure injuries. The resident was admitted to the facility on [DATE] with an existing pressure injury on her left foot. Delay in prompt interventions and lack of communication with a [CONDITION(S)] agency contributed to the development of an avoidable, facility acquired, unstageable pressure injury to the resident's right heel. Findings include: I. Professional reference National Pressure Ulcer Advisory Panel (2016) Pressure Injury Stages. Retrived on 4/26/21 from: https://npiap.com/page/PressureInjuryStages. Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. According to the National Pressure Injury Advisory Panel, https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/Unavoidable_in_COVID_Pandemi.pdf , 2021: Before any decision is made about the avoidability or unavoidability of a pressure injury that developed during the COVID-19 crisis, all factors should be considered on a case-by-case basis, including both the [MEDICATION(S)] issues in the critically ill patient and the extrinsic issues in the health care facility at the time of the injury. Every reasonable effort should be taken to prevent pressure injuries. The mere diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Facility policy and procedure The Skin Integrity Management policy and procedure, revised 1/31/2020, was provided by the director of nursing (DON) on 4/19/21. It read in pertinent part: To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatments, and promote healing of all wounds. Perform skin inspection on admission/readmission and weekly. Document on Treatment Administration Record (TAR) or in Point Click Care (PCC, the electronic resident medical record system). Perform daily monitoring of wounds or dressings for presence of complications or declines and document. III. Failure to prevent pressure injuries for Resident #2 A. Resident #2's status Resident #2, age 89, was admitted on [DATE]. According to the March 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/11/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance with all activities of daily living. She was identified at risk for developing pressure ulcers. On 3/18/21 resident was discharged back to an assisted living facility with hospice care services. B. Record review The care plan initiated on admission on 2/4/21, revealed the resident was at risk for skin breakdown related to frail and fragile skin, incontinence, limited mobility, and an actual skin breakdown moisture associated skin damage (MASD) to left breast, groin, and buttocks. Interventions included to provide treatments to skin tear per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin assessment on admission 2/4/21, documented the resident had the following skin conditions: -Bruises under right breast, and on arms and legs; -Discoloration to arms and legs; -Rash in groin area; and, -Redness to back and buttocks. The Braden Scale for Predicting Pressure Ulcer Risk assessment was conducted at the same time. However, the score of the assessment was not listed on the assessment. The physician note on 2/4/21 documented the resident was at high risk for new wounds. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Pressure redistribution cushion to chair and pressure redistributing mattress to bed. Both orders were written on the admitted [DATE]. -Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable, additional documentation in nurses notes if needed every shift. Monitor redness to peri area and buttocks. Resident has very thin skin and may tear easily. The TAR for February 2021 documented the same note as in physician orders: Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain.Monitor for status of dressing(s), if applicable additional documentation in nurses notes if needed every shift. Monitor redness to peri area and buttocks. Resident has very thin skin and may tear easily. -There was no order in the TAR for daily monitoring of bruising on arms and legs, and functioning of the pressure redistributing mattress that was used. The skin assessment one week later on 2/11/21 documented that no skin injuries identified, no mention of the previous injuries. Same was documented for the week of 2/19/21 and 2/26/21. The Situation, Background, Assessment, and Recommendation (SBAR) form, dated 3/3/21, revealed the resident developed a skin wound or ulcer. The note Read the resident had a discoloration to the left heel measuring 2.5 centimeters (cm) by 2 cm. Area was mildly boggy, with no drainage or signs of infection. The physician was contacted and ordered to apply [MEDICATION(S)] (topical anaesthetic) to both heels and pressure reducing booties every shift. -There were no new orders on the TAR for skin wounds or ulcers identified on 3/3/21. Pressure booties and [MEDICATION(S)] to both heels were not recorded on the TAR and there was no evidence that treatment was provided to the resident. The skin assessment completed on 3/5/21 documented no skin injuries identified. The nurses note, dated 3/6/21, documented the wound care was completed for the left heel. The resident complained of pain in her heel and received pain medication. The SBAR on 3/10/21 documented residents had a skin wound or ulcer. -There were no notes describing the type, location or etiology of the wound. The fields indicated for physician notification and response were left blank. The nurses note on 3/11/21 documented that the resident had a wound to her left heel and deep tissue injury (DTI) to her coccyx. -There were no new orders on the TAR for skin wounds identified on 3/10/21 and 3/11/21. The TAR was updated on 3/12/21 with an order to apply [MEDICATION(S)] to the coccyx every shift for DTI. On three occasions treatments were not administered 3/12/21 evening shift, and 3/13/21 on day and night shifts. On the same day, 3/12/21, the skin assessment documented the resident had MASD on her coccyx. The resident's care plan was updated to apply barrier cream, and observe skin condition daily. The skin assessment on 3/12/21 documented the resident had no new skin issues. She had old skin issues which was the MASD to the coccyx. -The skin assessment did not mention a wound on the left heel. The skin assessment did not identify the DTI as indicated in the nurses note 3/11/21. -Review of TAR for March 2021 showed no evidence the resident received treatments for her left heel since the pressure injury was identified on 3/3/21. There was no evidence that the resident was provided with pressure reducing booties to prevent further damage to her heels or if a pressure reducing mattress was utilized. The resident was not assessed by the wound care team/physician when the first initial pressure injury to the left heel was identified on 3/3/21. On 3/18/21 (the day of discharge to the assisted living facility), the resident was assessed by the wound care physician with the following findings: -Wound #1 sacral (coccyx), stage 2 pressure injury, measuring 4 cm by 7 cm. -Wound #2, left heel, unstageable, measuring 1 cm by 1.5 cm. -Wound #3, right heel, unstageable, measuring 2.5 cm by 2 cm. The recommendations included applying [MEDICATION(S)] to heels and continue to use offloading booties. For sacral (coccyx) wound, he recommended keeping it clean and dry, and repositioning the resident every two to three hours. -The resident had a stage 2 pressure injury to the coccyx which was previously identified as DTI on 3/11/21, with no assessment by the wound team subsequently until 3/18/21. The resident's left heel developed into unstageable from the first assessment on 3/3/21 that identified the wound as mildly boggy. The resident developed a right heel wound that was not identified in the assessments previous to being identified on 3/18/21. The admission assessment to hospice, dated 3/18/21, revealed Resident #2 returned to assisted living facility, following hospitalization for Covid-19 infection and severe metabolic [CONDITION(S)]. She had underlying dementia with severe anxiety disorder. She is alert but disoriented and confused. Lung sounds clear, no respiratory distress. Peri care is done very gently due to severe [CONDITION(S)] (skin disorder characterized by [NAME]-eye-shaped lesions) of bilat (bilateral, both) buttocks, perineum and bilateral groin areas. Open areas of skin breakdown at bilateral posterior iliac crests (area where arching bones sit on either side of your pelvis). Distal lower legs discolored to a purplish hue with skin intact. Review of skin assessments from 2/4/21 to 3/18/21 revealed no documented skin conditions except the ones that were mentioned by the wound care physician. C. Staff interviews Licensed practical nurse (LPN) # 1 was interviewed on 4/15/21 around 2:00 p.m. She said she was a unit manager and part of her responsibilities included to follow the wound care team and oversee the care for residents on her unit. She said she recalled the resident and was briefly involved in her care. She said skin assessments were done on admission and weekly after that. She said when the resident was admitted with a stage 2 or higher pressure injury to the facility, they automatically would be referred to the wound care team. She said Resident #2 was admitted with intact skin and did not need the wound care on admission. She said the resident had some other skin conditions such as bruises and a rash that should be monitored on the TAR. She reviewed skin assessment for the resident and stated she could not comment on the accuracy of them because she was not present at the time of the assessment. She said the resident's skin should be assessed each week and not document what was on the previous skin assessment, unless it continued to be present. She said she usually reviewed previous skin assessments to see what other issues residents had. She said she did not know if other nurses reviewed previous skin assessments. She said when a skin issue is resolved, it should be documented. The director of nurses (DON) was interviewed 4/19/21 around 12:00 p.m. She said the facility did not have a wound nurse for the entire building. She said unit managers on every unit had the responsibility of managing wounds and following wound physicians during the wound rounds. She said she did not review the record for Resident #2 and did not know the details. She said she recalled that Resident #2 was admitted from hospital as she was recovering from COVID-19, was very weak and had several other medical conditions that made her a high risk for pressure injuries. She said resident overall was declining, had poor intake and transitioned to hospice care at the time of her discharge from the facility. She said she believed the resident received appropriate professional care during her stay in the facility. D. Information submitted by DON after the exit of the survey. On 4/20/21 the DON submitted an email regarding Resident #2. She said Resident #2 was admitted to the facility with compromised skin. It was compromised due to MASD. The resident was COVID positive and had not returned to baseline as indicated in the physician note. The physician also stated this resident was at risk for skin breakdown. The resident had poor intake and this is noted all throughout her records. The primary reason for the poor intake was a result of COVID-19. The documentation for The National Pressure Injury Advisory Panel (NPIAP) speaks for itself in the fact that Center for Medicare and Medicaid (CMS) acknowledges the fact that COVID-19 contributes to the development of pressure ulcers and they are unavoidable. -However, the physician documentation of the resident's initial high risk for pressure ulcers and wound treatment initiated on 2/4/21 did not document the resident wounds were unavoidable or the wound physician documentation of the three pressure injuries on 3/18/21. IV. Failure to prevent pressure injuries for Resident #5 A. Resident #5's status Resident #5, age 82, was admitted on [DATE]. According to the March 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/13/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance with activities of daily living. The resident was coded at risk for developing pressure ulcers. She was using a pressure reducing device for the chair, and bed, and she was not on a turning and repositioning program. B. Resident interview and observation The resident was interviewed on 4/15/21 around 3:00 p.m. Resident was sitting in a wheelchair next to her bed. A regular mattress was observed on the bed. The resident was wearing pressure relieving booties on both of her feet. She said her left leg was hurting really badly (six out of 10 on the pain scale). She said she just received medication for pain and was waiting for it to kick in. She said the pain was coming from her heel where she had a wound. She said she was not sure how she got the wound, she said probably when she was wearing her regular shoes to [CONDITION(S)]. She said now she was wearing these booties all day long and to her [CONDITION(S)] treatments as well. Regarding the mattress, she said that was the only mattress she ever had since she came to this place. Resident #5 did not consent to wound observation. C. Record review According to the nurse's admission note, on 1/8/21, the resident was admitted for diabetes management. Skin assessment revealed following findings: -Bruise to right forearm, round greenish; -Left lower abdomen with three steri strips; -Coccyx- red and sheared; -Black raised area to right lower back; -Discolorations, reddish purple spot under incision to left lower abdomen, bilateral lower abdomen-greenish yellow; -Abrasion to top left small toe; -Raised area to top of right foot; -Left foot outer area next to small toe -hard dry pressure area, unstageable, 4 cm by 4.75 cm. Bilateral heel protectors in place. Nurses daily skilled note on 1/10/21 documented the resident was confused, oriented to person only and that was her baseline (per family). Skin was not assessed at that time. Resident (requires) two person assist with ADLs (activities of daily living). Resident has complained of pain to shoulders, mid back and buttocks. Resident is independent with eating. Resident is incontinent of bowel. Pain medication given, effective for back and shoulder pain. The care plan for skin care initiated on 1/11/21 revealed the resident was at risk for skin breakdown related to advanced age, frail fragile skin, shear/friction risks, diabetes type two and end stage [CONDITION(S)]. Interventions included to offload weight frequently while up in a chair, use offloading boots as the resident would allow, provide services by wound care clinic and follow recommended treatments. -However, the care plan did not identify the resident had an wound to her left outer foot (see above). In nurses' daily notes on 1/12/21, 1/13/21 and 1/14/21, the skin section was not completed. The Braden Scale for Predicting Pressure Ulcer Risk assessment completed on 1/15/21 identified the resident was at mild risk (score 15) for developing pressure ulcers (despite existing unstageable pressure injury on her left foot on admission). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound clinic report, dated 1/11/21, showed that the resident had an unstageable pressure injury to her left foot at the 5th toe. Measuring 3 cm by 2 cm with 76-100 percent of eschar. The recommendations included to apply [MEDICATION(S)] to the left heel and continue to use offloading booties. -Review of the TAR for the month of January 2021 (upon admission) revealed no treatments or monitoring were in place for skin concerns identified on admission. The wound clinic order for [MEDICATION(S)] to the left heel and offloading booties was not entered on to the TAR. The SBAR on 1/26/21 documented the resident had a new skin wound or ulcer. -There were no notes describing the type, location or etiology of the wound. On the same day, 1/26/21 the TAR was updated with two new orders: -Treatment to right heel: Apply [MEDICATION(S)] to right heel once a shift every shift. Start Date- 01/26/2021 -Pressure relieving boots to bilateral feel while in the chair and the bed every shift. Start Date- 01/26/2021. -The pressure relieving booties order was initiated after the resident developed a new unstageable pressure injury to her right heel and was ordered 15 days after it was initially recommended by a wound care physician on 1/11/21. The wound clinic physician assessed Resident #5's right heel on 2/1/21. The resident had a deep tissue injury measuring 4 cm by 4 cm. The wound on the right heel was noted after returning from [CONDITION(S)] on Monday. It is an intact deep tissue pressure injury and is very tender. Recommend taking offloading booties to [CONDITION(S)] and floating heels with offloading boots while in bed. Recommendations included to apply [MEDICATION(S)] and use offloading booties. The primary care physician documented on 2/28/21, Pressure-induced deep tissue damage of right heel: Foot wounds continue to resolve well with [MEDICATION(S)] coating, pressure offloading boots. Efforts are underway to provide offloading boots at hemodialysis where the wounds developed due to the positioning of the resident during long [CONDITION(S)] sessions. Wound care team following. -Review of the [CONDITION(S)] notes from January 2021 to March 2021 revealed no communication between the [CONDITION(S)] center and nursing facility regarding the resident's footwear. -Review of the nurses' progress notes for the same period revealed no notes mentioning the resident's wish to wear tennis shoes to [CONDITION(S)]. No education was provided to the resident regarding footwear for [CONDITION(S)]. Resident #5's left lateral foot (5th toe) wound resolved on 2/22/21. Resident #5 continued to receive wound care clinic services for right heel wound on 4/19/21 at the time of the survey. -Prior to 4/5/21 it was the same size 4cm by 4 cm. -On 4/5/21 wound was measured as 3cm by 4cm with 76-100 percent of eschar; -On 4/19/21 it was 3 cm by 3.5 cm with 76-100 percent of eschar. -It was not documented by the wound care practitioner that the wound was unavoidable. D. Staff interviews LPN #3 was interviewed on 4/15/21 around 2:30 p.m. She said the resident had only one pressure injury to one of her heels (she did not identify the right heel). The nurses were providing [MEDICATION(S)] treatment to the heel and offloading booties. Certified nurse aide (CNA) #1 was interviewed on 4/19/21 around 12:00 p.m. She said Resident #5 required total assistance with care and was not able to move or reposition herself independently. She said the staff provided her with assistance and made sure she was wearing her booties at all times. She said they repositioned the resident every two hours and upon request. She said she documented that in their electronic medical record under the tab for resident care. LPN #4 was interviewed on 4/19/21 around 11:00 a.m. She said Resident #5 had one pressure injury on her heel, the nurses provided [MEDICATION(S)] treatment and made sure she was wearing her booties daily, including days she went to [CONDITION(S)]. She said she did not know if Resident #5 had a pressure redistribution mattress. She checked physicians' orders and said it appeared that it was ordered by a physician to provide the resident with a pressure relieving mattress, and she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #5 had a regular mattress that most residents in the building had. LPN #1 was interviewed in the presence of LPN #2 on 4/19/21 around 2:00 p.m. She said she was new to the position of the unit manager. She was aware the resident was on the list for wound care rounds, but she could not recall by memory all the skin conditions the resident had. She looked at the resident's records and stated the resident had a pressure injury to her heel that appeared to be related to [CONDITION(S)] services. LPN #2 clarified that the resident attended [CONDITION(S)] sessions earlier in the month, and she was wearing regular shoes. As it appeared later, she developed the wound due to wearing shoes for a long period of time during her [CONDITION(S)] session. She said nurses all made sure the resident wore offloading booties to the [CONDITION(S)] but she was not sure where that was documented. The DON was interviewed 4/19/21 around 12:00 p.m. She said Resident #5 was admitted with a pressure injury to the facility and she was not sure if the current wound was the same pressure injury or new. Later she corrected herself and stated she recalled the injury as it was related to the [CONDITION(S)]. She said the resident preferred to wear her regular shoes to [CONDITION(S)] and that was the cause of pressure injury on her heel. She said it was a matter of honoring the resident's choice and she was positive that the resident was educated on the risks of wearing shoes for a long period of time. She said she would submit that as additional information later by email. She said all mattresses in the building were appropriate for pressure injuries. She said she would submit the specifications of the mattress that was used by the resident in the email. E. Information submitted by DON after exit of the survey On 4/20/21, the DON submitted an email regarding Resident #5. The email included a specification for the mattress. The specifications indicated that the mattress was recommended for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -There were no additional notes regarding communication with the resident to show that she was educated on the risk of keeping her preferred shoes during the [CONDITION(S)] session.

Based on observations, record review and interviews, the facility failed to ensure effective fall interventions were in place to prevent resident falls for one (#1) of three residents reviewed for falls. Record review and interview revealed the facility failed to effectively and consistently develop and implement care plan interventions to ensure the resident was provided the assessed levels of supervision. Resident #1 had a history of [REDACTED].#1's initial admission on 2/12/2020, that she had a history of [REDACTED]. She needed extensive assistance with activities of daily living, had severe cognitive impairment and was taking two antidepressant medications, all factors that contribute to continued falls. However, the facility failed to identify and implement effective measures to anticipate and meet her needs to prevent further falls with injury. Documentation revealed the resident was confused and unsteady of her gait/balance and her care plan documented that she was at significant risk for future falls due to weakness, impulsivity, and unawareness of safety needs. The facility failed to reassess, develop and implement appropriate interventions to effectively prevent a fall where the resident sustained [REDACTED]. Resident #1 fell seven times while in care of the facility. The falls occurred when the resident tried to get up unassisted. The latest fall on 3/18/2020, assessed by the facility as unwitnessed (fall # eight), per resident's statement, resulted in a major injury requiring surgical intervention to repair damaged bone of the left femur. The hospital postsurgical report dated 3/19/2020, documented medical [DIAGNOSES REDACTED]. Findings include: I. Facility policies and procedures The Falls Management policy revised 2/18/2020, was provided by the director of nursing (DON) on 4/2/2020 at 3:00 p.m. The policy revealed all residents (patients) will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall will receive appropriate care and investigation of the cause. The facility policy failed to address extensive measures for residents admitted with high risk for falls and include implementation of every 15 minutes checks or one on one close supervision for a specific time period after admission. II. Resident #1 A. Resident status Resident #1 age 56, was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 3/2/2020 minimum data set (MDS) assessment revealed moderately impaired cognition with a brief interview for mental status (BIMS) score of eight out of 15. She had no hallucinations, delusions or rejection of care behavior. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She was independent with eating. She had two or more falls with no injury since the admission. She received an antidepressant medication daily. The 3/30/20 MDS assessment revealed the resident was not able to complete a BIMS. The score was documented at 00. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, and supervision with eating. She had two or more falls with no injury since her prior assessment. She received an antidepressant medication daily. The assessment did not appropriately code the resident's falls as the resident sustained [REDACTED]. B. Family interview The resident's daughter was interviewed on 4/7/2020 at 10:45 a.m. She said when her mother was admitted to the facility, staff were aware she was at high risk for falls. She said her mother lived with her for approximately a year and half. She said her mother was getting up a couple times at night to use the bathroom and also had a tendency to get up at night to close the bathroom door. She said on a few occasions she slid down from a couch to the floor. She said her mother was very unsteady in standing position and required assistance from another person. She said at the beginning of February (2020) her mother fell and broke her wrist. C. Record review The comprehensive care plan initiated on 2/13/2020, revealed the resident was at risk for falls due to cognitive loss, lack of safety awareness, history of falls and [MEDICAL CONDITION] medication use. Interventions included: - When resident is in bed, place all necessary personal items within reach (2/13/2020) - maintain a clutter free environment in the resident's room and consistent furniture arrangements (2/13/2020) - remind resident to use call light when attempting to ambulate or transfer (2/13/2020) - place call light within reach while in bed or close proximity to the bed (2/13/2020) - provide verbal cues for safety and sequencing when needed (2/13/2020) - staff will place floor mat next to bed at hours of rest (2/15/2020) - staff provided non-skid socks (2/17/2020) - staff to increase safety checks (2/21/2020) - staff brought patient out to nurses station (2/23/2020) - therapy evaluation and treatment (2/26/2020) - staff sat outside patient door to provide high supervision. Later staff brought her out to TV room to color (3/8/2020) - staff got patient up, assisted her in toileting needs and brought her out to common area (3/12/2020) - x-ray left hip related to pain complaints. Patient sent out to acute for evaluation and treatment (3/18/2020) The interventions were gradually added after each fall, however failed to address resident's toileting schedule and one on one close supervision. The computerized physician orders [REDACTED]. Both medications side effects included [MEDICAL CONDITION], dizziness and drowsiness. The care plan interventions failed to address side effects for both antidepressants pertinent to resident's fall risk. The 2/12/2020 nursing admission assessment revealed the resident was admitted for long term care after hospitalization . She had a history of [REDACTED]. She had no pain. She received an antidepressant medication. Pt (patient) is oriented to person. Resident balance during transitions and walking after observation is not steady, but able to stabilize with staff assistance .Resident speech is limited does not make long sentences .Pt. unable to locate significant landmarks without assistance, e.g., bathroom, dining room, patient room. Pt exhibits attempts to maintain daily routines and leisure interests are not consistent with their new environment routines. Musculoskeletal system reviewed Description/location of device/cast/splint: (Right) arm. Pt has right-sided upper extremity functional limitations. Pt. has right arm extremity weakness. Pt. has left leg extremity weakness. Pt. has right leg extremity weakness. Rehab services/ability reviewed with the following results: Could not determine if he or she is capable of increasing independence in at least some ADLs. Device(s) in use: Split Yes. The 2/12/20 nursing follow-up note documented in parts: admitted (age) female resident to (facility) with the following Dx (diagnoses) - [DIAGNOSES REDACTED], depression (Right) distal ulnar fracture. Resident alert, verbally responsive with limited words can not make long statements, denied pain or discomfort up on admission. Resident has split on right arm, wt (weight) bearing status is not clear yet. Resident is one or two person assist with transfer can go to the bathroom with two person assistance. Resident is incontinent of urine. Resident is vegetarian, can not eat beef, pork, and chicken, but can eat fish. Resident is full core. D. Falls -fall #1 On 2/15/2020 at 12:33 p.m., a nurse documented in Change in Condition Evaluation: Resident was observed sitting on floor close to bed assessed by RN (registered nurse), no injury, neuros checks started in WNL (within normal limitations). The 2/17/2020 interdisciplinary team note revealed: IDT review note for unwitnessed fall on 2/15/20. Staff observed patient on floor in her room. Patient unable to state what she was doing at time of fall. Denied pain and no s/s (signs and symptoms) of pain noted. No injury noted with RN assessment. Staff note patient had on her non-skid socks at time of fall. Patient is a new admit to facility on 2/12/20 and is likely still getting accustomed to the facility. Staff placed fall mat next to bed at hours of rest. All other fall interventions to remain in place. -fall #2 On 2/17/2020 at 4:40 p.m., a nurse documented in Change in Condition Evaluation: un-witnessed fall no injury. The 2/18/2020 IDT note revealed: IDT review note for unwitnessed fall on 2/17/20. Staff noted patient on floor in her room next to her bed. Patient stated she was going to the bathroom and slid out of bed. Staff note patient was in bare feet. Staff provided her non-skid socks and assisted her into the bathroom for toileting assistance. Patient is a recent admit to facility. Staff assisted patient out to common area for closer observation. All other fall interventions to remain in place. -fall #3 On 2/21/2020 at 11:00 p.m., a nurse documented in Change in Condition Evaluation: Resident was getting out of bed to shut the door and she sat on the mat. The 2/24/2020 IDT note revealed: IDT review note for unwitnessed fall on 2/21/2020. Staff observed patient on floor in her room. Patient states she got up to shut her door to her room. Denied pain. No injury noted with RN assessment. Staff assisted patient up off of the floor. Staff will increase safety checks on patient as she continues to demonstrate poor safety awareness. Staff offered toileting assistance while in room post fall. All other fall interventions to remain in place. -fall #4 On 2/23/2020 at 9:18 p.m., a nurse documented in Change in Condition Evaluation: Unwitnessed fall with no injury. The 2/24/2020 IDT note revealed: IDT review note for unwitnessed fall on 2/23/2020. Staff observed patient on floor in her room. Patient unable to state what she was doing at time of incident. No s/s of pain noted by staff. RN assessment revealed no injury. Staff note patient had on her non-skid socks. Staff assisted patient up from fall and brought her out to nurses station for closer observation. Staff offered toileting assistance at that time as well. MD gave orders for therapy to eval and treat. Patient has early onset advanced dementia and demonstrates poor safety awareness. All other fall interventions to remain in place. -fall #5 On 2/26/2020 at 10:04 a.m., a nurse documented in Change in Condition Evaluation: Observed resident laying supine on floor in room next to floor mat. Unable to articulate what happened. RN (registered nurse) assessed resident. No injuries noted. Neuros without deficit. No s/s of discomfort. The 2/27/2020 IDT note revealed: IDT review note for unwitnessed fall on 2/26/2020. Staff observed patient on floor in her room next to mat on floor. Patient unable to state what happened. No s/s of pain noted by staff. No injury noted with RN assessment. Staff noted the patient had on non-skid socks at time of incident. Staff assisted patient up off of the floor. Staff offered toileting assistance. Staff brought patient out for breakfast. Therapy orders given by MD for eval and treat. All other fall interventions to remain in place. The therapy evaluation order was requested after Resident #1 suffered five falls in the facility. -fall #6 On 3/8/2020 at 11:00 p.m., a nurse documented in Change in Condition Evaluation: Resident was ambulating to the bathroom and sat on the floor. The 3/9/2020 IDT note revealed: IDT review note for unwitnessed fall on 3/8/2020. Staff noted patient on floor in her room. Patient states she was going to the bathroom. Denied pain. No injury noted with RN assessment. Staff noted patient was wearing her non-skid socks. Staff assisted patient up and offered toileting assistance. Staff assisted patient to TV room to color. When patient was ready to go to bed staff sat outside her door for closer observation. All other fall interventions to remain in place. -fall #7 On 3/12/2020 at 5:52 a.m., a nurse documented in Change in Condition Evaluation: Patient was found on the floor beside her bed. No injury noted. Assisted up and taken to the bathroom. The 3/13/2020 IDT note revealed: IDT review note for unwitnessed fall on 3/12/2020. Staff observed patient sitting on the floor in her room next to her bed. Fall mat was in place on floor next to her bed. Patient was sitting on the floor next to fall mat. Patient unable to state what she was doing to advanced dementia. No visible pain noted. No injury noted with RN assessment. Staff note patient was in her non-skid socks. Staff assisted patient to her bed. Staff offered toileting assistance. Staff got her up and brought her out to common area for closer observation. All other fall interventions to remain in place. The IDT failed to investigate the cause of each of the resident's falls (per the facility policy) and implement effective measures. There was no documentation whether or not Resident #1 was capable of using the call light or was her call light ever turned on? The IDT failed to address the medication regimen review to determine what meds and conditions placed her at greater risks, and plan accordingly to intervene. -left hip pain (fall #8 per IDT note) On 3/18/2020 at 4:03 a.m., a nurse documented in Change in Condition Evaluation: Resident complains of pain in left trochanter. A change in condition has been noted. The symptoms include: Pain uncontrolled. Res. complains of pain in left trochanter. Pain 7/10. Orders obtained include: X-ray of left trochanter. On 3/18/2020 a nurse documented: Called non emergent at 10:20 a.m. ambulance to transport resident to emergency department at (hospital). The 3/19/2020 IDT note revealed: IDT review note for unwitnessed fall on 3/18/2020. Staff observed patient on floor mat next to bed. Patient unable to state what she was doing at time of incident due to her advanced dementia. Patient complained of left hip pain by grabbing onto left hip. Provider ordered left hip x-ray which did show fracture. Provider gave order to send patient out to acute for eval and treat. Patient continues to demonstrate poor safety awareness. Staff provide frequent safety checks and offer toileting assistance frequently. All other fall interventions to remain in place. Further record review, including the facility investigation, revealed the resident was not found on the floor as the previous seven falls. The 3/2/2020 occupational therapy (OT) note revealed: Since admission to (facility) approximately three weeks ago, patient has experienced several falls. Throughout OT treatment, have practiced completing functional transfers. Amount of assistance required can be variable as patient has very significant [DIAGNOSES REDACTED] and her ability to functionally assist with transfers and follow instructions varies. Patient completed transfers with minimum assistance and moderate verbal/tactile cues for hand placement. Requires holding onto therapist ' s arms for support during transfer. CNA (certified nurse aide) staff reports that they feel most comfortable with completion of functional transfers without use of front wheeled walker. The hospital admission and treatment record dated 3/19/2020, revealed the resident was admitted with displaced left intertrochanteric fracture of left femur. She underwent a surgical intervention that included an open reduction internal fixation (ORIF) of left intertrochanteric proximal femur with hardware placement. The resident returned to the facility and was readmitted on [DATE]. D. Interviews Licensed practical nurse (LPN)#1 was interviewed on 4/2/2020 at 12:15 p.m. She said the resident had several falls in the facility prior to [MEDICAL CONDITION]. She said the resident was unable to ambulate independently and always required staff assistance with transfers. CNA#1 was interviewed on 4/2/2020 at 12:22 p.m. She said the resident was at high risk for falls and recently returned from a hospital. She said she was aware the resident was at risk for falls. She said the resident was always seated in her wheelchair and was able to take a few steps during transfers with staff assistance. She said the resident should not be left unattended and between meals was placed in her wheelchair in front of the TV in the common area so she could be observed by staff. She said she did not see any particular CNA was assigned for one on one supervision to Resident #1. RN#1 was interviewed on 4/2/2020 at 3:48 p.m. She said after admission to the facility, Resident #1 was frequently taken back to her room after meals and transferred to bed. She said after the falls the resident was placed in front of the TV in the living room so the staff could keep an eye on her. She said there was no one on one staff supervision with the resident. The director of nursing (DON) was interviewed on 4/2/2020 at 3:34 p.m. She said Resident #1's care plans were updated by the unit manager after each fall with additional intervention and CNA and nurses were responsible to make sure care planned interventions were carried out. The DON said despite the fact Resident #1 was not found on the floor, the IDT reviewed the hip pain as an unwitnessed fall due to the resident's statement of having a bad dream that made her feel like she was in a drunken state. The director of rehabilitation (DOR) was interviewed on 4/2/2020 at 3:57 p.m. She said the resident was not referred to physical or occupational therapy for evaluation despite the fact she was admitted with a wrist fracture after a fall at home and required extensive assistance with all activities of daily living because of an unknown medical insurance status. She said the resident was evaluated by an occupational therapist after sustaining five falls in the facility.

Based on observation, record review and interview the facility failed to ensure the resident environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent multiple falls. Specifically, the facility did not timely plan and implement adequate fall prevention measures to prevent seven falls with two fractured bones for one (#2) out of three sample residents. The findings included: Sample resident #2, age 87, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set (MDS), quarterly assessment, dated 8/12/15 revealed the resident had clear speech, was understood and was able to understand others. The brief interview for mental status (BIMS) score was four out of 15 and indicated severe cognitive deficit. The presence of hallucinations was documented. The resident required extensive assistance with bed mobility, transfers and toilet use, limited assist with walking, dressing, personal hygiene, and was independent with eating. The resident was frequently incontinent of urine. The assessment documented two or more falls since the last MDS assessment. The resident received an antidepressant medication daily. Review of the resident's comprehensive plan of care (CP) revealed (read in part): - Resident requires limited to extensive assist with one or two staff for ADL (activities of daily living) care in bathing, grooming, dressing, bed mobility, transfer, locomotion, toileting d/t (due to) dementia. The CP was revised on 6/4/15 and updated on 8/19/15 with a note Recent fall with fractured wrist. Interventions included (in pertinent part): 1. Staff to ambulate with resident in room and to meals with 4WW (four wheel walker) and gait belt. 2. Provide verbal cues for safety and sequencing when needed. 3. Resident has been noted to self ambulate without walker and without staff present. - Resident is at risk for falls: decreased safety awareness, frequent falls and dementia. The CP was revised on 8/13/15 and updated on 8/19/15 with a note Recent fall with fractured wrist. Interventions included (in pertinent part): 1. Provide verbal cues for safety and sequencing when needed. 2. Remind resident to use call light when attempting to ambulate or transfer. 3. Monitor for and assist toileting needs. - Resident has a potential for pain d/t OP (due to osteoporosis). CP initiated 5/29/15. - Resident has dx (diagnosis) of irritable bladder and need for staff assist with toileting. The CP revision was dated 6/4/15 and interventions included (in part): 1. Assist with perineal care as needed. 2. Provide privacy and comfort. 3. Use absorbent products as needed. 4. Utilize appropriate continent product. Review of the Nursing Progress Notes revealed: On 6/26/15: Resident noted walking outside unattended. Staff member assisted her back into facility without difficulty . On 6/29/15 a nurse documented the resident was not responding to nursing staff, sent to ER (emergency room ) for an evaluation at 7:30 p.m. Review of Falls Fall #1 On 7/15/15 (at 6:30 p.m.) a nurse documented the resident was in the dining room standing up from her chair to the walker, lost her balance and fell . The resident complained of pain in the left side of her body. Fall #2 On 8/5/15 (at 5:38 p.m.) a nurse documented the resident was in her room, stood up from a chair and fell . Fall #3 On 8/10/15 a nurse documented the resident was found sitting on the floor in front of television in the common area at 6:30 p.m. On 8/11/15 a Physical Therapy (PT) progress note documented: pt (patient) lists toward the left running into hallway rails and objects on L(eft) . pt c/o (complained of)more pain on L(eft) side under rib cage, notified nursing. On 8/12/15 a PT progress note documented: Sit to supine on mat table (with) min(imum) assist secondary to pain on L(eft) below rib cage area, notified pts (patient's) nurse on 8/11(/15) and 8/12(/15) regarding this issue. Review of the nursing documentation for 8/11/15 and 8/12/15 revealed the resident had no c/o of pain or discomfort, which conflicted with the therapy note documenting the resident had pain and it was reported to the nurse (see above PT note). On 8/13/15 a nurse documented: PT staff has reported that when they are assisting resident with ADL training she has been c/o of discomfort. This writer has been asking if she is in pain and she has consistently been denying any. When this writer asked resident if she was in pain today she stated she had some on a scale of 5 (five). She currently is receiving scheduled pain meds BID (twice daily). Fall #4 On 8/16/15 a nurse documented: At approx(imately) 11:20 a.m. resident was found laying on the floor on her left side near her closet crying. Resident complained of pain in her left shoulder, wrist and hip. On 8/15/15,(corrected dated of 8/16/15) at 5:45 p.m., a nurse documented the resident returned from an emergency room with her daughter. The resident had a splint on her left wrist due to a fracture of distal left radius that would need a cast in one week due to swelling. Fall #5 On 8/17/15, at 7:14 a.m., a nurse documented the resident was observed sitting on the floor next to her bed. On 8/17/15 the physician orders [REDACTED].>- Bed alarm to alert staff of pt rising and staff to offer assistance every shift for fall precaution - chair alarm to alert staff of pt rising and offer assistance every shift for fall precautions - cms (circulation, motion, sensation) checks to left hand q(every) shift for fx (fracture) left wrist Fall #6 On 8/19/15, at 2:50 p.m., a nurse documented: Resident noted sitting on the floor by lounge chair leaning against back of roommates (sic) dresser. Further documentation review revealed Tab alarm on person sounding notifying staff of incident. The assessment did not document (left blank) resident's level of consciousness, orientation, skin, behavior, additional observations. Fall #7 On 8/23/15 a nurse documented: At 11:05 a.m. resident was sitting in her wheelchair with chair alarm. Both CNA (certified nurse aide) and this writer heard a thump and alarm sounding. Resident was noted to be on the floor lying on her left side. Resident had a bump on her left parietal region, c/o (complained) neck and back pain. The resident was sent to ER (emergency room ). On 8/23/15 the computerized tomography CT scan (exam) of resident's chest was performed in a hospital and revealed (in pertinent part): There is an acute displaced fracture of the lateral left eight rib .and .pneumothorax. On 8/28/15 the PT progress note documented: Wrote communication to nsg (nursing) re: use of sling when pt out of bed, but to be removed when pt is out of her room, or lying in bed and pt to elevate L UE (left upper extremity) .Spoke w/pt's (with patient's) nurse and unit nurse manager re: above. (Record review revealed there was no documentation of the resident's sling being applied or removed, and no documentation of elevating the resident's left upper extremity was found.) The physician documented a sling was not needed at that time. Record review revealed the facility failed to update the resident's comprehensive plan of care related to the frequent falls, fractures, and pain and assistance needed to prevent falls. Resident Observations On 9/1/15 at 11:30 a.m. the resident was observed sitting in her wheelchair in the common television (TV) area near her room. The resident was observed with a cast on her left wrist and forearm. The resident stated I can't get up and can't walk by myself. I always fall down. The resident was observed on 9/1/15 and 9/2/15 throughout the day, in her w/c or in her recliner. The resident's left arm was positioned on her left leg. The resident's left hand fingers were observed swollen with dark blue discoloration at the distal edge of the cast. On 9/2/15 at approximately 10:30 a.m. the unit's medication nurse was informed of the above findings. The nurse did not immediately react; however, at 11:30 a.m. the resident was observed with her hand elevated appropriately. Interviews On 9/1/15 at 11:35 a.m. the resident's roommate who was cognitively aware of the events, stated that the resident kept falling frequently as she was trying to take herself to the bathroom and the nursing staff was not offering the assistance with toileting. On 9/2/15 at 5:35 p.m. the Director of Nursing (DON) with the facility administrator (NHA) and assistant administrator (ANHA) present, stated that the facility implemented frequent checks on the resident. The tab alarm was removed as the facility plan was to eliminate restraints and the resident had the right to fall. The DON stated that the facility addressed residents' falls in a formal QA (quality assessment) process, however did not specify appropriate interventions related to each fall and to prevent further falls including falls resulting in two fractured bones. The facility provided documentation for post fall interventions, not dated, which included, continue to monitor resident and assist with ambulation, remind resident to use call light, frequent safety checks with wheelchair and bed alarms. There was no documented IDT review of the material provided by the facility which would indicate the facility had assessed the root cause of falls, nor the effectiveness or appropriateness of interventions.

Based on record review and observations, the facility failed to ensure two (#1 and #4) of three residents reviewed for weight loss of five sample residents received the care and services necessary to maintain acceptable parameters of nutritional status. The failure resulted in both resident #1 and #4 suffering a significant weight loss. Specifically the facility failed to: - Timely assess residents' nutritional status and needs to prevent decline - Appropriately assess residents' food preferences - Provide appropriate assistance for the residents during meals - Provide a variety of nutritional supplements to the residents to prevent weight loss - Appropriately document food/fluid and supplements intakes or refusals - Monitor and follow laboratory values for causes of weight loss and symptoms of undernutrition - Appropriately revise/update residents' comprehensive care plan for alteration in nutritional status - Timely address residents' significant weight loss with the IDT (interdisciplinary team) 1. Professional Reference a. According to Long Term Care Medicine, A Pocket Guide dedicated to the American Medical Directors Association (AMDA) staff, by Pamela A. Fenstemacher MD and Peter Winn MD (2011), chapter nine, Weight and Nutrition, by Todd H. Goldberg MD, CMD and Joel L. Levine MD, Chief of [MEDICATION NAME], West Virginia University, read in pertinent part: As with persons of all ages, proper nutrition and maintaining a healthy weight are very important in elderly long-term care residents . Optimal nutrition should ideally improve health, functioning, and quality of life and reduce the risk of morbidity, mortality, and complications such as weakness, impaired immunity . Weight loss is a negative quality indicator and risk factor for poor outcomes - survival is markedly improved with appropriate and adequate nutrition . Every resident has important and individual nutritional needs, but those with chronic illness and disability require extra attention to diet and nutritional assessment and need for assistance . Serum [MEDICATION NAME] is the single most commonly used indicator of protein undernutrition and the level is correlated with mortality in older person. (Serum [MEDICATION NAME] level less than 3.5 mg/dl indicating abnormal laboratory result) . The laboratory tests should be ordered not only when problems are reported but perhaps considered periodically in all elderly residents at risk for poor nutrition, and are often abnormal in the elderly requiring changes in medications or supplements . AMDA's Clinical Practice Guideline on Altered Nutritional Status; available from http://www.amda.com recommends that treatment should address underlying issues identified, tailoring meals/food to individual preferences and function, limiting unnecessary dietary restrictions, adding supplements, and as a last resort, tube feeding on an individual basis. Individuals at facilities must further be continually monitored for maintenance and improvement of nutrition . It should be noted that caloric supplements optimally might need to be given between meals to minimize appetite suppression. b. Handbook of Assessment in Clinical Gerontology by Peter A. Lichtenberg, second edition 2010, chapter 14, Nutrition in the Elderly by Kathryn E. Brogan, read in part: As human age, a series of physiological changes inevitably occur. These changes may lead to reduced appetite and food intake, body weight loss, malnutrition, and a compromised immune system .The most frequently reported anthropometric data is BMI (body mass index), which is based on body weight and height. BMI has been widely used to indicate the disease risk. Normal BMI is classified between 18.5 and 24.9 . All the anthropometric, biochemical, and clinical data only provide a clue for the potential diet-related problems. In order to accurately identify the sources of the health problems, a dietary history is required. 2. Resident Failure Sample resident #1, age 84, was admitted to the facility for rehabilitation, on 6/20/15 with [DIAGNOSES REDACTED]. The minimum data set (MDS) admission/five day Medicare part A (PPS) assessment dated [DATE] revealed the resident had clear speech, usually was understood and usually was able to understand others. The brief interview for mental status (BIMS) score was three out of 15 and indicated impaired cognition. No hallucinations or delusions were documented. The resident required extensive assistance with bed mobility, transfers, walking, dressing, toilet use and personal hygiene, and supervision with eating. Section K (nutrition) documented weight loss with the resident's height of 70 inches and weight of 104 pounds. Review of the resident's comprehensive care plan revealed that the resident was at nutritional risk and documented: unintended wt (weight) loss r/t (related to) dementia AEB (as evidenced by) CBW (current body weight) below UBW (usual body weight). PO (oral) intake not adequate to meet nutritional needs. Interventions included: Honor food preferences within meal plan, provide fortified milk at meals, offer snacks between meals, monitor intake at all meals, alert dietician and physician to any decline in intake. A nursing assessment dated [DATE] documented the resident's nutrition was very poor. A physician's history and physical (H&P), dated 6/22/15, documented the resident was hospitalized between 6/14/15 and 6/20/15, with [DIAGNOSES REDACTED]. The resident was admitted to the facility for rehabilitation and for anorexia and a weight loss and nutritional consultation was pending. The physician documented: (4) Failure to thrive with anorexia: as stated above, the patient has had a 30 lb weight loss noted by family over the last 6(six) months . Review of the resident's laboratory results, collection date 6/22/15, revealed: - [MEDICATION NAME] 2.3 g/dl (gram per deciliter), (normal range 3.5 - 5.7) - Protein, total 4.2 g/dl, (normal range 6.4 - 8.9) The facility failed to timely assess the resident's nutritional status and needs to prevent further decline. On 6/25/15 the Physician Note documented under Labs: [MEDICATION NAME] 2.3, Total Protein 4.2 and under assessment: Failure to Thrive with moderate to severe malnutrition: Dietary consult. Recommend offering protein supplement BID (twice daily) with shakes between meals. The Registered Dietician (RD) Assessment was completed and dated 6/26/15 (six days after admission) revealed the resident's height was 70 inches and their weight was 104 lbs. The BMI was 14.9, diet was documented as regular/liberalized. The RD documented Dines with set-up with po (oral) intake 25-100% of meals. PO intake may be decreased at times r/t (related to) distraction in DR (dining room). Has own teeth in poor condition and jaw pain s/p (status [REDACTED]. Reports 30# (lb) weight loss over about 6 mos (months) per H&P (history and physical). Working with SLP (speech language pathologist) re: (related to) cognition issues which may increase po intake. Nutrition interventions included, fortified milk at meals and snack between meals. The facility failed to follow the physician's recommendations of protein supplement with shakes BID (see physician's recommendation above). Review of the resident's records revealed his weights as documented: - 6/20/15 - 104 (pounds) - 6/29/15 - 103 - 7/1/15 - 98 (6% weight loss in 10 days) Review of the ADL (activities of daily living) record revealed incomplete documentation of resident's food, fluid and snack intakes between 6/20/15 and 6/30/15. There was no record of the resident receiving any snacks as recommended by the RD, there was no documentation of the resident's supplement intake, and the facility staff failed to document the resident's food and fluid intake for nine meals in ten days. On 7/1/15 the physician order [REDACTED]. The resident passed away on 7/3/15. 3. Resident #4, age 93, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, quarterly assessment, dated 8/11/15 revealed the resident had clear speech, was understood and was able to understand others. The BIMS score of five out of 15 indicated severely impaired cognition. No hallucinations or delusions were documented. The resident required extensive assistance with bed mobility, transfers, walking, dressing, toilet use and personal hygiene. Eating was documented as independent. The resident was frequently incontinent of urine. No swallowing disorder, no weight loss and no nutritional approaches were documented and the resident's weight was 78 lbs. On 6/4/15 the MDS assessment, documented the resident's weight was 82 lbs and no weight loss. The MDS assessment did not appropriately identify the resident's most recent weight and significant weight loss since the admission. Review of the resident's records revealed her weights as documented: - 5/5/15: 85.8 lbs - 5/28/15: 82.2 lbs - 6/1/15: 79.6 lbs (weight loss of 7% in one month) - 7/7/15: 80.8 lbs, and - 8/7/15: 78 lbs (a significant weight loss of 9% in three months). Review of the resident's comprehensive care plan revealed that the resident was at nutritional risk and documented: increased nutr(itional) needs due to underweight aeb(as evidenced by) low BMI and hx of altered skin integrity. The CP was dated and revised 5/8/15, 6/3/15, and 6/19/15. Interventions included (read in part): Honor food preferences within meal plan, offer fortified milk with meals, provide diet as ordered, supervise/cue/assist as needed with meals). The CP did not address resident's significant weight loss. The CP was not revised/updated after the significant weight loss documented on the most recent MDS assessment dated [DATE]. Pertinent lab values: Review of the resident's hospital discharge note dated 5/5/15 revealed the [DIAGNOSES REDACTED]. On 5/8/15 the laboratory results (collection date 5/7/15) documented 2.8 g/dl. On 5/8/15 the RD completed a Nutrition Assessment and documented the resident, has hx (history) of insufficient po (oral) intake and pna (pneumonia). Has some own teeth in poor condition and lower partial. Receives ST (speech therapy) d/t (due to) decreased swallow fx (function) with compensatory swallow strategies and education . BMI (16.8) puts resident in underweight category. Goal of weight gain to IBW (ideal body weight) 90 - 100 # (lbs). Will provide diet as ordered by SLP (Speech Language Pathologist) and fortified milk at all meals. Diet was documented as advance mechanical soft with ground meat. On 6/10/15 the RD note documented: Current weight is 79.6# (lbs) indicating a 7.2% weight loss in one month .Accepts sips of fortified milk at each meal. Action: Weigh per facility protocol. Resident agreed to receive ice cream at lunch and to continue to receive fortified milk with each meal even if only a few sips are consumed. The facility failed to appropriately assess the resident's (with 2+ [MEDICAL CONDITION] which should be taken under consideration as an additional weight) needs for an increase of nutritional supplements related to a significant weight loss. Review of the resident's medical records revealed no documentation of the resident's nutritional supplementation intake to prevent significant weight loss. Resident observation On 9/1/15 between 12:00 p.m. and 1:00 p.m. and on 9/2/15 at 8:45 a.m. the resident was observed in the dining room. Most of the resident's food was not consumed and she did not drink the fortified milk. The resident did not reeive an ice cream as recommended by the RD. Observation during both meals revealed the resident was not cued to eat or drink. 4. Facility responses On 9/1/15 at approximately 4:00 p.m. the RD was asked to scheduled a time for an interview for the following day. On 9/2/15 the RD was not at the facility and not available for an interview. There was no interdisciplinary team (IDT) documentation in the residents' records addressing appropriate approaches to prevent significant weight loss for resident #1 and #4.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for two (#1 and #5) out of four residents reviewed out of five sample residents. The failures resulted in resident #1 not receiving treatment for [REDACTED].#5 needing medical interventions to counteract low blood pressure caused by a medication error. The facility further failed to review resident medications to prevent a reoccurrence of an error, when resident #5 subsequently received another resident's medications for five days. Specifically the facility failed to ensure: - Resident #1 received the medications prescribed by the physician - Resident #5 did not receive a full course of medications prescribed for another resident. Resident #1 Sample resident #1, age 84, was admitted to the facility for rehabilitation, on 6/20/15 with [DIAGNOSES REDACTED]. The minimum data set (MDS) admission/five day Medicare part A (PPS) assessment dated [DATE] revealed the resident had clear speech, usually was understood and usually was able to understand others. The brief interview for mental status (BIMS) score was three out of 15 and indicated impaired cognition. No hallucinations or delusions were documented. The resident required extensive assistance with bed mobility, transfers, walking, dressing, toilet use and personal hygiene, and supervision with eating. A physician's history and physical (H&P), dated 6/22/15, documented the resident was hospitalized between 6/14/15 and 6/20/15, with a [DIAGNOSES REDACTED]. The resident was admitted to the facility for rehabilitation and strengthening with a physician order [REDACTED]. Review of the physician progress notes [REDACTED].>- On 6/25/15 at 10:56 a.m. the physician documented: Yesterday I was called as the on-call physician for increased hypoxemia on room air with sats (oxygen saturation) dropping <88% (below 88 per cent) with exertion. I advised nursing to keep sats >90% (above 90 per cent) with oxygen per nasal cannula and to start [MEDICATION NAME] (nebulizer) treatment TID (three times daily) scheduled for 7 (seven) days . for wheezing or cough. The patient has had an adequate response from the new treatment plan. However, this morning, after working with therapy, he began to show significant hypoxemia again with increased loose cough, although nonproductive. -On 6/25/15 at 3:00 p.m. the physician documented: 1.Pneumonia, recurrent: I did leave a message for his daughter (name), the MD POA (medical durable power of attorney) today explaining a change of condition .and add [MEDICATION NAME] (an antibiotic) 500 mg (milligram) po (orally) daily x 7 days (for seven days). Complete the [MEDICATION NAME] (an antibiotic prescribed on the resident's admission) prescription, which was previously ordered. 2. [DIAGNOSES REDACTED]: start Potassium Chloride 20 MEQ (milliequivalent) daily and recheck BMP (basic metabolic panel-blood test that provides information about body's metabolism) in 3 (three) days. The hand written Physician order [REDACTED].[MEDICATION NAME] 500 mg po daily x 7 days . BMP for 6/29/15. - On 6/30/15 the physician documented: Asked by nursing to evaluate for [DIAGNOSES REDACTED] along with medication transcription Error. 1. [DIAGNOSES REDACTED]; Earlier this morning I was notified of the patient's Potassium level reducing down to 2.8 from 3.1 last week despite ordering Potassium Chloride supplementation. Upon nursing review of active medication orders in (computerized resident record), it was found that the Potassium has not been given to the patient at any time since the order was written on 6/25/15. Upon further inspection, the patient has not been receiving the oral [MEDICATION NAME] for the Pneumonia either. The patient continues to complain of leg cramps, worse in the evening. He is eating 25-30 % of his meals most days . As stated above, the patient has not received the [MEDICATION NAME] as ordered 5 days ago . O2 saturation remains stable on 4 l (four liters) at 92% . I did explain the med(ication) error to his daughter in law and his son over the phone today, as nursing has addressed this with the patient and his family as well. Facility investigation - Risk Management System dated 7/1/15 revealed Nurse placed orders for this resident into another resident's chart. An individual Performance Improvement Plan dated 7/1/15, Description of Event noted: 24 hour chart checks were signed as done and orders written in one chart were placed in another resident's MAR (medication administration record) and medications were given to the wrong resident for 5 doses and (the nurse) signed chart checks in both charts and didn't check that there were no orders for medications on 2 (two) different residents. The 24 hour chart checks are in place to help prevent these types of errors. Review of the resident's MAR (June 2015) revealed that the resident did not receive the above documented medications as ordered by the physician. On 7/1/15 the physician order [REDACTED]. The resident passed away on 7/3/15. On 9/2/15 at approximately 3:00 p.m. the director of nursing (DON) stated that the nurse made the medication errors for two residents and received a written warning. The DON added that the medication errors were not reported to the Department of Regulatory Agency. Resident #5 Resident #5, age 89, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medication Error #1 review of the resident's medical record revealed [REDACTED].I was notified yesterday as the on-call provider, that the floor nurse inadvertently gave the patient a dose of [MEDICATION NAME] (an antiarrhythmic medication with indications for [DIAGNOSES REDACTED]. I advised them to check her blood pressure and pulse every 2 (two) hours over the next 24 hours to ensure that she was not becoming [MEDICAL CONDITION] (slow heartbeat) or hypotensive. A few hours later, I received a call from the floor nurse stating her BP (blood pressure) was dropped to 88/60 with mild lightheadedness. I ordered 1L (one liter) normal saline IV (intravenous) to be given. The patient feels much better today without lightheadedness, chest pain, pressure, or palpitations. Medication Error #2 Review of the resident's MAR (June 2015) revealed the resident was administered an antibiotic, [MEDICATION NAME] tablet, 500 mg by mouth one time a day for pneumonia every day between 6/26/15 and 6/30/15. Nursing staff initials were noted each day and the time of the medication given was 9:00 a.m. (The resident was not prescribed this medication.) Potassium Chloride 20 MEQ tablet, daily, orally each morning for low potassium was administered between 6/26/15 and 6/30/15. (The resident was not prescribed this medication.) The physician note dated 7/2/15 addressed the above documented medication error. Laboratory report dated 7/1/15 revealed: Potassium 4.4 (Normal = 3.5-5.1) Sodium 137 (Normal = 136-145) Calcium 8.8 (Normal = 8.6-10.2) On 9/2/15 at 4:00 pm the resident was observed in her room resting in her bed. The resident did not have any concerns except of her back pain and asked for her medication. The medication nurse was notified. On 9/2/15 at approximately 3:00 p.m. the director of nursing (DON) stated that the nurse made the medication errors for two residents and received a written warning. The DON added that the medication errors were not reported to the Department of Regulatory Agency. She did identify that resident #5 was administered an antibiotic and potassium supplement prescribed for resident #1 for five days. The nurse who had made the error was the same nurse that had mistakenly administered resident #5 [MEDICATION NAME] and [MEDICATION NAME] on 6/25/15 (the day before making the second error).

Based on observations, record review and staff interviews, the facility failed to ensure a resident's environment remained as free of accident hazards as was possible and that adequate supervision was provided to prevent accidents for 2 of 5 sampled residents (#3 and #1). Specifically: -Resident #3 was assessed to require a 2 person transfer with a mechanical lift. The facility failed to properly ensure that all staff was following this policy and had been properly educated, which lead to the resident's fall with a head laceration. -The facility did not implement "educate staff " training to ensure lifts were being used properly until weeks after the incident occurred. -Resident #1 was assessed to require a 2 person transfer with a mechanical lift, which was not followed. The findings include: Facility Policy on Safe Resident Handling Equipment (in part):-Staff may use Safe Resident Handling equipment, such as lifts or repositioning equipment, for patients when needed. Patients will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment. -The Total Lift will be used as the primary intervention to manual lifting, transferring, and repositioning and requires a minimum of two persons to perform the lift. -Use of the Sit to Stand Lift requires two staff members. Use of only one staff member requires discussion by the interdisciplinary team. 1.Resident #3, [AGE] years of age, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. A BIMS score (brief interview for mental status) on the minimum data set assessment (MDS) was noted on 2/25/2014 to be a 5, which indicated modified cognitive impairment, but oriented to person and place. Resident Record Review: A quarterly nursing assessment dated [DATE] indicated the resident's functional status required a 2 person mechanical lift device. A physician order [REDACTED]. A fall risk evaluation completed on 12/8/2013 indicated the resident was not a high fall risk, with a score of 7 (below the needed 12 to be high risk). A fall risk evaluation completed on 4/8/2014 after the fall again indicated the resident was not a high fall risk, with a lower score of 3 (below the needed 12 to be high risk). Resident Fall: An interdisciplinary progress note dated 4/8/2014 read, a call was placed to 911, to transport to emergency room . "CNA states that resident fell through golvo lift sling". Change of Condition Documentation on 4/8/2014 read "at 0800 this a.m. this nurse was called into room by CNA. Resident was lying on left side with head resting on golvo lift feet, blood on floor. Right foot up on bed frame. Resident noted to have 3cm x 3 cm hematoma to back of head with laceration, applied pressure to stop bleeding". Triage report from the emergency roiagnom on [DATE] revealed the resident "was being transferred via hoyer lift at SNF (skilled nursing facility) when CNA 'dropped' patient. Patient landed on tile floor". Laceration to scalp, 2.5cm. Closure of superficial layer (5 staples). Resident Fall Investigation Form for the fall on 4/8/2014 for resident #3 indicated, "CNA and student were transferring resident with golvo lift, resident fell through sling according to CNA and CNA student ". Preventative measures in place prior to incident: education of staff and 2 staff members in room to use golvo lift. Immediate action taken to prevent further incidents/injuries: "education of staff". This investigation indicated that 2 staff members were assisting the resident with a lift transfer, when in fact other documentation and interviews indicated there was one staff member and a student transferring the resident. Post fall action taken indicated that staff were educated, yet facility provided documentation and interviews indicated only the staff CNA was initially educated, and other staff were not informed until much later. Neurological Assessment Flow Chart for the fall on April 8, 2014 indicated that the facility monitored the resident's neurological status from 4/8/2014 when she returned from the hospital until 4/9/2014 at 6:30 p.m. This did not indicate a 72 hour neurological assessment was completed for this resident's head wound. A physician order [REDACTED]. Apply TAO to wound bed BID until healed. A physician order [REDACTED]. Notify MD of signs or symptoms of infection. A physician order [REDACTED]. Care plans: The comprehensive care plan dated 2/5/10 and revised on 7/12/11 read in pertinent part . . . needs total assist with ADL's related to decreased mobility, multiple sclerosis, weakness, tremors, depression, memory, and cognitive impairment. Interventions (in part): provide privacy as able; provide rom (range of motion) during daily cares; staff to provide oral care bid (twice daily) and prn. Has own teeth; resident doesn't ambulate; total assist with dressing, eating, toileting, grooming, and bathing needs; total assist of 2 for bed mobility and transfers. . . The comprehensive care plan dated 6/11/2009 and revised on 10/29/2012 read in pertinent part..... is at risk for injuries due to falls related to history of falls, decrease balance, lower extremity weakness. Goal: will have no injuries due to falls. Interventions (in part): continue with mechanical lift for all transfers (golvo only); continue with self releasing strap to bilateral legs when up for increase wheelchair positioning; each fall will be reviewed by idt (interdisciplinary team) for further preventions; will often talk staff into using the wrong lift, if they are new working with her. She is to use the golvo lift with 2 assists; right elbow splint during day and right hand splint on at night; 2 staff members in attendance when using golvo lift. Facility Fall Prevention Documentation: During the abbreviated survey the facility provided numerous Safe Resident Handling Program Skills Checklist forms, for staff members that were evaluated for their skills in providing safe lifts. However, these forms were completed on individual staff members beginning on 1/20/2014, and continuing through 4/29/2014. Some of the forms were not signed by a trainer, some did not show complete lift demonstrations according to the checklist, and some were not signed by the trainee. The majority of these forms were completed prior to the fall with resident #3. An in-service sign in sheet was provided for a 4/6/2014 in-service that read "2 people required for all lifts, transfers". This was signed by numerous staff, but did not appear to be signed by the CNA involved in the fall accident with resident #3. An in-service sign in sheet for "proper demonstration of lift equipment" was provided. This in-service sheet was signed by numerous staff members, but dated 5/1/2014; the day after the abbreviated survey began. Additional sign in sheets were also provided as having been completed on 5/4/2014 and 5/6/2014. None of these forms appear to have been signed by the CNA involved in the fall accident with resident #3. A repeated in-service form was provided, after the CNA, noted below, was terminated for failing to ensure residents were transferred with 2 staff members. This was dated 5/7/2014 and read, " Proper lift protocol requires staff to use two people with all lifts". This was signed by numerous staff members. An undated letter was provided regarding the training of the CNA involved in the accident with resident #3. " (employee name) CNA was placed with a team member CNA (second employee name) to provide extra training and evaluate her ability to use lift properly. (Employee names) worked together for approx. five shifts". The CNA noted in this letter that supervised and evaluated their coworker was the CNA terminated on 5/7/2014 for failure to use a lift properly. See observations for resident #1 and interviews below. 2. Resident #1, [AGE] years of age, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The last quarterly MDS (minimum data set) assessment dated [DATE], noted the resident with a BIMS (brief interview for mental status) score of 13 which indicated cognitively intact. Observation: The surveyor was interviewing resident #1 on 5/7/2014 at 10:43 a.m. when a CNA came into the room to get the resident out of bed, pushing a Sabina lift. This CNA was noted to have been the CNA that was assigned to supervise the retraining of the CNA responsible for the injury to resident #3. This CNA asked resident #1 if he still wanted to get out of bed, which he did. The surveyor left the room, and the resident's door was closed. Two CNAs were observed walking down the hallway, past the resident's room and past the surveyor. Instead of entering the room of resident #1, both CNAs continued down the hall to another resident room. The door to resident #1's room reopened, and the CNA was observed pushing the Sabina lift out into the hallway. She then pushed resident #1 in his wheelchair towards the doorway. The surveyor asked the staff member if she had just transferred the resident independently, and she stated 'yes'. The CNA promptly added that she knew the resident was a 2 person lift, but her partner (the other hall CNA) was unavailable. This CNA also confirmed she had been assigned to retrain and supervise the CNA responsible for the fall of resident #3 during a lift transfer. Resident Record Review: The resident was noted to have had an unwitnessed fall on 4/18/2014. The resident was noted to have stated, "I was bending over to get my oxygen tubing ". The documentation also noted "hoyer lift used x 2 staff with assessment, transferred to bed". An annual nursing assessment completed on 4/19/2014 indicated the resident required a 2 person assist with a mechanical device for transfers. A fall risk evaluation was completed on 4/19/2014 which indicated the resident was at a high risk for falls. A physician progress notes [REDACTED]. He is at risk for falls and fracture". Care Plans: The resident's comprehenisve care plan read in pertinent part. . . resident needs assist with adl's related to impaired balance, weakness, parkinsons, depression. Goals: will participate in adl's daily and have a neat, clean, well groomed appearance; will be odor free, appropriately dressed, groomed, and needs will be met daily. Interventions (in part): assist with cleaning clutter in room and keeping floor free of obstacles; extensive assist with locomotion on/off unit in wheelchair. Resident also propels own wheelchair; require extensive assist with bed mobility and transfers; adjust level of care according to individual needs and report persistent changes to physician and family; call light within reach and answer promptly. This was initiated on 4/19/2013 and revised on 1/2/2014. . . risk for falls related to [DIAGNOSES REDACTED]. Goal: no significant injury related to a fall. Interventions (in part): anticipate needs and offer help frequently; resident declined use of wheelchair alarm; assist resident with ambulation providing assistance using a standard walker; have commonly used articles within easy reach; ensure environment is free of clutter. This was initiated on 4/12/2013 and revised on 4/16/2014. Interviews: An interview was conducted with resident #3 on 5/2/2014 at 1:05 p.m. regarding a recent fall. The resident confirmed that when she fell , there had been a regular certified nursing assistant (CNA) and a student CNA helping to transfer her with her regular lift. She could not remember exactly how it had happened. An interview with a registered nurse (RN), #4, on 5/5/2014 at 11:30 a.m. revealed that resident #1 was very independently minded and hated to ask for help, and that his cognition was generally very good. A certified nursing assistant (CNA), #8, was interviewed on 5/6/2014 at 11:15 a.m. about resident #3's recent fall. The CNA stated that she had worked with this resident before, but it had been awhile. The CNA stated that she did not know the resident had fallen until "the other day", weeks after the incident had occurred. This CNA stated she had never had any problems with the golvo lift and really could not understand how a resident could slip through the sling. The CNA did confirm that sometimes "it can be hard to get a second staff person to help with a lift". The CNA said that all aides had now signed a form promising that they will ensure they have the proper staff number for a resident in a lift, but she said that some of the staff have a hard time waiting for help. This CNA stated that she waits for assistance, because the thought of a resident falling concerned her. The CNA added that she had heard that there was going to be an inservice on the use of the lifts, but that it had not happened yet as far as she knew. An interview was conducted with the RN, #4, on 5/6/2014 at 12:10 p.m. related to resident #3"s fall. The RN stated that the lift had been looked at and nothing was wrong with it. The RN stated that they had been watching about 30 staff members now to ensure they know how to use a lift properly. The RN said that it was thought that the CNA had possibly placed the resident in the sling just a little off-center and because of it, the resident was off balance and fell . The RN stated that the CNA employee had been supervised for awhile to ensure she knew what she was doing. An additional interview with the RN, #4, above on 5/6/2014 at 12:40 p.m. confirmed that the facility only used 2 types of lifts, the golvo and the Sabina, and that these were the lifts that they observed the staff using. An interview was conducted with a second CNA, #10, on 5/6/2014 at 1:30 p.m. This CNA was confirmed to be the staff employee working with resident #3 during the fall. The CNA stated that she had never worked with this resident before, and informed the nurse that she did not know much about the resident's needs. The CNA stated that the nurse was not concerned with this information. The CNA confirmed she had worked with the golvo lift numerous times and had never had a problem before. The CNA stated that during this time frame the facility had student CNAs in the building and one was assigned to work with her. The nurse informed this CNA that the student CNA was allowed to assist with lifts. During the transfer with the lift, the CNA stated that the resident was fine initially while over the bed, and that once she moved her away from the bed, she very quickly slid out. It happened very quickly, but the CNA thought the resident hit her head either on the lift legs or on the floor, and then had a laceration to the back of her head. Although the student CNA was present, it was indicated that the staff CNA was handling the lift process almost independently, and the student did not truly assist in the transfer. The CNA stated that after the fall, during the investigation, she was informed that student CNAs cannot assist with lifts. The CNA stated that after the investigation she was allowed back to work and was shadowed for a few days by another CNA for lift training. A third CNA, #11, was interviewed on 5/6/2014 at 2:15 p.m. about resident transfers. The CNA stated that although the students were allowed to start helping with some things, they were not allowed to assist with lifts. She stated that the students were never allowed to help with lifts. A fourth CNA, #12, was interviewed on 5/7/2014 at 9:30 a.m. about resident #3's fall. The CNA stated that the resident had moved to the Garden unit not too long ago, and then came right back. The CNA said that she had heard that resident #3 had a fall on the Garden unit, and that the family wanted her moved back to her former room. This CNA stated she had not heard about the fall until the resident came back to the Evergreen unit, and that she was not very informed about what had happened. The CNA indicated that the facility does have inservicing "sometimes" and that the staff will be asked to sign sheets acknowledging that they are "aware of something". The CNA said that when the student CNAs had started working, her unit manager had come to tell all the staff that the students were not allowed to use lifts, but everything else was permitted with their training and supervision. An interview with a fifth CNA, #13, was conducted on 5/7/2014 at 9:40 a..m. This CNA stated that she had heard about the fall resident #3 had recently had. She stated she did not know who was at fault, but that the aides were told that students could not assist with lifts. She did not know if there was miscommunication or not. After the fall, the CNA stated that the facility made sure to let everyone know that the students did not count ( as staff) during lifts and transfers, and that you still needed to have the appropriate amount of staff members. The CNA stated she had just signed some inservicing forms "just the other day" about lifts, but could not remember when. She stated that a nurse came by "the other day " and asked to watch her work to make sure she knew how to use a lift. An interview was conducted with a restorative staff member, #14, on 5/7/2014 at 10:05 a.m. regarding the recent fall of resident #3. The staff member stated that she assisted in training new employees on alarms, lifts, and positioning. The employee stated that they also will re-educate staff members if the unit manager or staff development coordinator comes and asks them to, but she did not recall working with anyone regarding the fall of resident #3. An interview with a second restorative staff member, #15, was conducted on 5/7/2014 at 10:21 a.m. The staff member stated that the CNA involved in the fall was required to be with someone for 5 days, at all times. "That's how they retrained her". The staff member stated that they trained new employees, and will retrain staff, if asked. This employee stated that she had informed all staff on the Garden unit that 2 aides were required to do lift transfers, not counting student CNAs. The employee stated she didn ' t know why the CNA didn ' t get another aide to help her. The staff member also stated that she had not been involved with any inservicing related to the fall that occurred. An interview with a third restorative staff member, #16, on 5/7/2014 at 10:30 a.m. revealed that she also had not provided any re-education for anyone regarding the fall resident #3 had recently had. An interview was conducted with a sixth CNA, #18, on 5/7/2014 at 10:43 a.m. regarding the fall resident #3 recently exprienced. This CNA was noted to have been the CNA that was asked to supervise the CNA involved in resident #3's fall. This CNA was observed to have transferred resident #1 without assistance, using a Sabina lift. This CNA confirmed that she should not have transferred resident #1 without a second staff member, but did not have assistance available. She confirmed that she had been assigned to the CNA involved in the accident to ensure she properly transferred residents in lifts. See the above observation under resident #1. On 5/7/2014 at 11:06 a.m. an LPN, #19, informed the surveyor that the CNA, whom had just transferred a resident without assistance, had been suspended, and that she was not going to let improper transfers happen on her unit. The LPN confirmed that the suspended CNA had been supervising the CNA involved in the fall of resident #3. The nursing home administrator (NHA), #6, informed the surveyor on 5/7/2014 at 11:45 a.m. that the CNA involved in the improper transfer on 5/7/2014 at 10:43 a.m. had been terminated and that she was tired of training staff on lifts and those staff members making the decision to not follow the rules. An interview was conducted on 5/7/2014 at 1:26 p.m. with the RN, #4, regarding the fall of resident #3. The RN stated that the documentation of inservicing provided, had occurred on 4/6/2014 prior to the resident's fall. This was indicated to have been done because the facility had changed corporate policies and had informed all staff that lifts were always a 2 person job for transfers. The RN confirmed that observations of staff compliance had not been started until last week, and that they were going to be ongoing. The RN stated that the CNA involved in the accident had been supervised by the CNA that was just terminated, to be watched and have extra training for a few shifts to make sure she was doing her lifts right. The RN confirmed that the nurse had improperly told the CNA that a student aide could assist with transfers and the lift. The RN stated that perhaps the facility should have looked into more information prior to the students ' training. The observations of the staff using lifts properly were started on 5/1/2014. " We could have probably started checking the other staff a little bit sooner ".

Based on observation, record review and resident/staff interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being of two (#12 and #11) of 14 sample residents. Specifically: -Resident #12's pain was not adequately managed, contributing to the resident experiencing unrelieved pain (on a level of 8 out of 10) after admission to the facility for approximately seven hours. -Resident #11's pain was not controlled (the resident was crying in pain), for approximately 6 hours after admission. Findings include: Resident #12 was admitted to the facility on [DATE]. According to the 7/25/13 physician history and physical [DIAGNOSES REDACTED]. According to the initial Minimum Data Set (MDS), dated [DATE], the resident had no cognitive impairments. The resident required extensive assistance with activities of daily living. The MDS indicated the resident had experienced pain within five days of the completion of the assessment. a. Pain Management Plan The CPO included an order for [REDACTED]. The 7/13 Pain Management Flow Sheet documented in pertinent part, ". . . Pain rating for cognitively intact residents 0 = no pain; 1-2 = mild pain; 3-4 = moderate pain; 5-6 = moderate/severe pain; 7-8= severe/horrible pain; 9-10= excruciating pain . . ." The resident's admitting physician orders [REDACTED]. --[MEDICATION NAME] 50 mg twice a day for chronic pain. --[MEDICATION NAME] 5% topical patch for pain. --[MEDICATION NAME] 5-325 mg to be administered as needed every four hours for pain 4-5 out of ten. --[MEDICATION NAME] HCI 5 mg every four hours as needed for pain 6-8 out of ten. --[MEDICATION NAME] 10 mg extended release tablet twice a day for pain. Review of the 7/19/13 care plan identified the resident as having a potential for pain related to spinal [MEDICATION NAME] abcess. The goal was for the resident to have decrease in pain within 1 hour. Pertinent approaches were monitor pain on scale of 0-10, position pillows as needed for comfort, give PRN medications for breakthrough pain per physician orders [REDACTED]. The 7/17/13 pain assessment documented the resident had a pain level of 8 out of 10. The resident identified the pain location was her lower back and legs and that the pain was frequent. She described the pain as numbness, and needles, persistent or lightning like down the leg. The resident identified medication and positioning helped the pain. The pain made it hard to sleep at night. A Request for Removal of Schedule II-V Medication from the emergency kit was requested on 7/17/13 at 11:15 a.m. The authorization from the pharmacy was received at 12:43 p.m. However, review of the PRN (as needed) Pain Management Flow Sheet and the MAR indicated [REDACTED] Further review of the medical record showed the resident had requested a PRN pain medication on 7/18/13 at 9:30 a.m. for a pain of 7 out of 10. The resident was administered [MEDICATION NAME] 5 mg. The flow sheet documented the resident was checked for the effectiveness of the pain medication at 10:30 a.m., however, the pain level was not recorded. On 7/27/13 at 1:30 a.m., the resident had a pain level of 7 out of 10 and was administered [MEDICATION NAME] 5 mg. However, when she was evaluated for effectiveness of the pain medication, the result remained 7 out of 10. The resident was not provided any other interventions. Interviews: --The resident was interviewed on 7/30/13 at 3:20 p.m. The resident stated that she had sharp pain in her back and also leg spasms. She stated that she received medications every four hours however, the medication did not always cover the pain. She stated that she was told she had to wait for pain medication if it was less than four hours after administration. She stated that pain was not controlled and at night her pain level of her legs would often not allow her to sleep. The resident stated her legs would spasm and when that happened it was uncomfortable. She stated that repositioning helped, however, that was not always done. The unit manager (UM) was interviewed on 7/31/13 at approximately 2:00 p.m. The UM reviewed the medical record and stated that she was unable to know if the resident was premedicated prior to the transfer to the facility. She stated that the facility did not have a check list to ask the hospital if the resident received pain medications. She stated that it was up to the admitting nurse to ask. However, the questions asked depended on the specific nurse. She stated the resident should not be told she needed to wait for pain medications, as she had other orders which would cover her pain level. The UM stated the nurse should always monitor the effectiveness of the medication and provide interventions if the pain level remained unchanged. The UM stated non-pharmaceutical interventions should be utilized. 2. Resident #11 was admitted to the facility on [DATE]. According to the 3/18/13 history and physical [DIAGNOSES REDACTED]. According to the 3/15/13 hospital history and physical, the resident had bilateral total knee replacement on 3/11/13. The resident was discharged to the hospital on [DATE] for a change of condition. An MDS assessment was not completed for this resident as she resided in the facility less than 14 days. The family member was interviewed on 7/30/13 at 2:08 p.m. The family member stated the resident was admitted to the facility on [DATE] at approximately 4:00 p.m. She stated that the resident had bilateral knee replacements on 3/11/13. The resident was to have rehabilitation at the facility prior to returning home. The family member stated at 10:00 p.m., the resident was crying in pain, as she had not received any pain medication at the facility. She stated that she requested the pain medication and the pharmacy had not delivered any medications. The family stated that when the resident was crying in pain, she went to the house and retrieved pain medication to give the resident. Record Review Review of the medical record showed a hand written report from the hospital on [DATE]. The note documented the resident had a bilateral knee surgery, and the last dose of pain medication ([MEDICATION NAME] and [MEDICATION NAME]) was administered at 3:00 p.m. The request for the removal of schedule II-V 5-325 mg from the emergency kit was reviewed. The request was sent at 10:36 p.m. The pharmacy received, processed and sent back the request to the facility with the authorization code at 2:20 a.m. However, according to the 3/16/13 nurses note the [MEDICATION NAME] 5-325 was not dispensed from the emergency kit as the resident's prescriptions arrived at the facility. According to the 7/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The nurses note dated 3/15/13 documented the resident was admitted to the facility at 5:00 p.m. The note documented the physician verified the medications and the orders were sent to the pharmacy. The pharmacy was called at 10:45 p.m., to find out the status of the medications. The pharmacy was then called at 11:30 p.m. The pharmacy reported the driver had left ? hour ago. The pharmacy was called again at 1:40 a.m., as the authorization was not received to remove the pain medication from the emergency kit and the resident's medications had not been delivered by the pharmacy. Interviews: The unit manager (UM) was interviewed on 7/30/13 at approximately 3:00 p.m. The UM stated after the physician verified medications, then the orders were sent to the pharmacy for delivery of medications for all newly admitted residents. In the event a medication needed to be administered prior to the medication arriving, then a request for a pain medication to be removed from the emergency kit could be used. The UM stated the process should be no longer than an hour. The UM was interviewed a second time on 8/1/13 at 10:21 a.m. The UM reviewed the medical record. The UM confirmed there was a delay in the delivery of the prescriptions and that the resident first received pain medications at 3:00 a.m. The UM stated that she would not be able to tell from the medical record if the resident received pain medication at an earlier time from the family member. After reviewing the pain assessment the UM confirmed the pain assessment did not determine the resident's pain level tolerance. The director of nurses (DON) was interviewed on 8/1/13 at 11:45 a.m. The DON stated the pharmacy authorization to remove a schedule II-V drug from the emergency kit should be received within two hours maximum. The DON stated if the physician did not call the pharmacy back for approval of the pain medication, then the medical director can be called.

Based on record review and staff interviews, the facility failed to prevent one of seven sample residents (#1) from developing pressure sores. Specifically, a foot brace was applied without proper monitoring and the resident developed three open wounds on the foot. The findings include: A concern was filed with the health department regarding the lack of oversight to prevent sores from developing for this resident. An onsite visit at the facility was conducted. A. Facility Expectations The facility's written skin care and pressure ulcer management program was reviewed. It read, in pertinent part, "..It takes a team - Pressure ulcers are a serious concern for nursing home residents - especially when compromised residents are involved. Preventing, treating and managing ulcers are complex, multifaceted challenges. .Together the team works towards prevention of pressure ulcers, quickly identified unavoidable occurrences, and uses evidence-based practices to provide appropriate treatment.." B. Resident #1 Resident #1's medical chart was reviewed during the investigation, from 12/11 through 4/12. The resident no longer resided in the facility (discharge date was 4/7/12). The resident was at risk for skin breakdown. 1. Closed record review revealed resident #1, [AGE] years old, was admitted to the facility facility on 2/16/10. According to the monthly physician order [REDACTED]. No current Minimum Data Set information was found in the state reporting system. The 12/27/11 Norton Plus Pressure Ulcer Scale showed a score of 12. A score of 10 or less = high risk for pressure sores. 2. A 1/5/12 care plan identified the resident was at risk for skin breakdown related to diabetes mellitus, recent change in condition, weakness and decreased mobility. The resident was experiencing an increase in fluid retention. Staff was directed to keep his skin clean and dry, apply pressure reducing/relieving devices as ordered and observe skin every shift for s/sx (signs/symptoms) of potential skin breakdown. Staff was directed to alert the charge nurse if skin problems were observed and the physician would be notified as needed for treatments. Nursing staff was directed to complete weekly skin assessment. A 1/5/12 self care deficit care plan noted the resident had recently experienced a change of condition and required extensive assistance of one for all ADLs (activities of daily living). 3. On 1/17/12, per the therapy documentation, an orthotist assessed the resident for a foot brace. According to the 1/14/12 assessment form completed by the orthotist, (provided to the surveyor on 5/23/12), the clinical rationale for the referral, "pt. is diabetic and needs room in shoe to accommodate AFO (ankle foot orthosis) and foot deformity. Shoes will have lifts to accommodate (illegible word)." One week later, on 1/25/12, the Physical Therapist (PT) documented, "Pt. D/C (discharge) from skilled PT services.. D/C to LTC (long-term care). (illegible word) for now secondary awaiting for AFO to arrive (in approximately 2 weeks)." At the time of discharge on 1/25/12, the foot brace had not been delivered. There were no other notes about the brace. After surveyor inquiry during the investigation, the Director of Nursing (DON) said the foot brace arrived on 1/26/12 (see interviews below). Review of the nurse's notes from 1/9/12 - 2/9/12 revealed no reference to the arrival of the brace on 1/26/12. The only reference found in the nurse's notes during this period occurred on 1/30/12 at 1:00 p.m. The nurse documented, "..resident has no complaints of pain or discomfort. Assisted resident with new prosthesis to left leg. No complaints of discomfort." There was no care plan developed to address the application of the brace or monitoring of the resident's skin for pressure areas secondary to use of the brace. Review of the medical record revealed no monitoring by either therapy or nursing staff after the brace was applied. 4. Review of the skin assessments indicated the resident's skin was intact prior to the application of the foot brace on 1/26/12. On 2/7/12, the resident's skin broke down due to pressure from the foot brace. Review of the 1/19/12 skin assessments, ordered weekly beginning 11/30/11, revealed the resident's skin was intact. There was no skin breakdown. There was no evidence of a weekly skin assessment on 1/26/12. On 2/2/12, the skin assessment indicated the resident's skin was intact. On 2/7/12, a change of condition document was initiated (to notify the physician), "Resident present with a 2.0 cm x 1.5 cm open area to left foot. Also a 1.8 cm x 2.0 cm open area to lateral heel. Resident has been wearing a brace to the left Le (lower extremity) for support. A schedule had been placed on the closet door in resident's room informing resident the daily duration time for resident to wear said brace. Call placed to (name) in PT - He stated he was unaware of this schedule and removed brace from room. New orders RCD (received)." Although this note stated a schedule had been developed for the brace, there was no care plan or physician order [REDACTED]. On 2/7/12, as documented on the Physical Therapy evaluation, three open areas were identified on the left foot (plantar surface) - unstagable, scant drainage and no pain. -1 - 1st metatarsal 2 x 1.5 x 0 cm -2 - 5th metatarsal 1 x .8 cm -3 - lateral heel 1.8 x 2 x 0 cm On 2/7/12, the Physical Therapist (PT) documented, "A case of 62 y/o male resident referred for skilled PT services secondary to new onset of pressure ulcer to left foot plantar surface secondary from AFO Left. Pt. apparently was wearing the AFO ...wrote telephone order for Non-weight bear to left foot to facilitate healing.." As a result of the pressure sores, the brace was discontinued and the resident was unable to bear any weight on the foot for walking. On 2/7/12, a care plan was developed, "open areas to left foot and left lateral heel - work with PT for proper fit on brace to left leg. Orthotic assessment, tx as ordered. Non weight bearing left LE - may wt. bear with transfers only." Even though the wound was identified on 2/7/12, there were no nursing notes on 2/8 about the wound. On 2/9/12 at 10:00 a.m., the interdisciplinary team documented a nursing note, "IDT pressure ulcer review: Res/ has 2 open areas to left foot. PT has been in to eval (evaluate) resident and receive tx (treatment) orders. PT will work with res. for transfer and pressure ulcer training PT to follow." Although nursing staff reported weekly monitoring of the foot wound was completed, the facility was only able to locate measurements and monitoring of the wounds on 2/7/12, 2/9/12, 2/16/12 and 2/22/12. The resident was briefly hosptalized on [DATE] - 2/25/12, for a low blood sugar event. (Cross-reference F309). Record review revealed that upon his return to the facility on [DATE], no measurements of the wounds were documented in the medical chart (the re-admission paperwork only indicated a pressure ulcer on the foot). A timeline of the resident's sores, developed by the facility and given to the surveyor on 5/8/12, indicated the resident's foot wounds had worsened upon his return to the facility. The facility requested a wound care consult with an outside practitioner. The consult occurred on 3/1/12, and documentation showed three open areas, #1 - 1.5x1.3x0.1 cm, #2 1.0x1.0 and #3 2.0x2.0 cm. Record review revealed no weekly wound measurements, conducted by the facility, were documented for March describing the progress of the wounds. Review of facility and hospital records and documents provided by the facility (orthotist notes) revealed the resident saw the wound care specialist again on 3/15/12. On 3/22/12, the resident's wounds worsened and the facility sent the resident to the wound care specialist. The resident was directly hospitalized from the appointment. On 3/22/12, the [DIAGNOSES REDACTED]. The surgeon conducted an irrigation/debridement and a partial fifth toe amputation. Seven days later, the surgeon conducted another surgery on the left foot. On 3/29/12, the [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE], with a wound vac in place to assist with healing the wounds from the amputation. 5. The resident's psychosocial mood declined with the onset of the sores On 2/13/12 at 10:00 p.m., one nurse documented, "Resident has been isolating from others this shift. After being told he cannot walk/needs to use a wheelchair due to ulceration on foot. This resident has been sharing s/s of depression/seems discouraged. Resident stayed in bed this shift, did not attend meals or other activities. Will cont. to monitor resident via education about this order and will reinforce importance and discuss positive outcomes." The facility did initiate a referral to have a counselor to speak with the resident. 6. After the surveyor inquiry, the facility provided a document from the orthotist (provided on 5/23/12) Review of the documents, presented from the orthotic company, revealed the brace was delivered to the facility on [DATE]. The orthotist documented the following information in pertinent part, "..Written and/or verbal instruction/information provided to patient and caregiver Usage/break-in period, fitting issues, safety issues, how/whom to report problems related to device/change in physical condition." Review of this document, only signed by the resident, showed instructions were given to the patient and caregiver, device function, benefits and precautions, donning/doffing of device, skin inspection, care and cleaning. The resident signed the paperwork indicating he received the brace on 1/26/12. There was no indication of what caregiver received instructions and the resident was dependent on staff for ADLs. 7. Staff Interviews On 5/23/12 at 12:20 p.m., the DON stated the orthotist (that developed the foot brace) delivered the brace to the resident without informing the Physical Therapy department. The DON said nursing thought PT was aware. A week later, when nursing staff removed the brace, three sores had developed on the foot due to pressure from the foot brace. Per the DON, nursing staff assisted donning the brace on and off the resident until 2/7/12 (the date of the sores developing). Attempts to interview the Physical Therapist were unsuccessful.

Based on record review and interviews, the facility failed to ensure the medication regimes for one of 45 sample residents (#266) and one supplemental sample resident (#A) were free from unnecessary drugs. Specifically: -The facility failed to evaluate, prior to administration, resident #A's order to restart (after one month) the antipsychotic medication [MEDICATION NAME], at an elevated dose (100 mg) and its effect in association with the resident's other medications. The facility also failed to hold the resident's blood pressure medication as ordered. The resident was found outside, slumped over in his chair, after receiving his morning medications on 8/18/11, which included his first dose of [MEDICATION NAME] after one month. -The facility failed to adequately monitor resident #266's behavior to determine the effectiveness of various antipsychotic medications and failed to clarify the reason for the use of another medication, [MEDICATION NAME]. The findings include: A concern was filed with the health department regarding medications and lack of monitoring. An onsite investigation was conducted at the facility 8/31/11 to 10/5/11. 1. Resident #A (closed record) Resident A, age 62, was admitted to the facility 7/28/11 from the hospital. According to the hospital discharge summary, the medical [DIAGNOSES REDACTED]. a. Resident Status on Admission - Medications Review of the resident's hospital records prior to the resident's admission into the facility revealed the resident was receiving [MEDICATION NAME] 100 mg twice a day and 200 mg in the evening for treatment of [REDACTED]. At the time of admission, the resident took [MEDICATION NAME] 5 mg (a medication to treat, among other conditions, [MEDICAL CONDITION] type symptoms) and [MEDICATION NAME] 20 mg (an antipsychotic), to assist with the management of his [MEDICAL CONDITION]. The physician prescribed an anti-hypertensive medication, [MEDICATION NAME] 40 mg, for blood pressure management. According to the 7/29/11 Physician's Assistant (PA) note, [MEDICATION NAME] was to be held for blood pressure (BP) less than < 100/60." This was consistent with facility standing orders that directed staff to hold blood pressure (BP) medications when the BP was less than 100/60. According to the Lippincott Williams and Wilkins 2012 Nursing Drug Handbook, -on pages 672-674, '[MEDICATION NAME] is classified as an antipsychotic medication. Adverse reactions (not all inclusive) included sedation and [MEDICAL CONDITION].' -on pages 1139-1141, '[MEDICATION NAME] is classified as an antihypertensive. ..Check blood pressure and apical pulse before giving drug. If [MEDICAL CONDITION] or extremes in pulse rate occur, withhold drug and notify prescriber. Adverse reactions included (not all inclusive) [MEDICAL CONDITION] (low blood pressure) and [MEDICAL CONDITION] (slower heart rate).. drug to drug interactions - [MEDICATION NAME] may cause [MEDICAL CONDITION]. Avoid using together ...' -According to http://www.drugs.com/pro/[MEDICATION NAME]. html website, side effects of [MEDICATION NAME] (not all inclusive) included dizziness, psychiatric manifestations such as [MEDICAL CONDITION] and hallucination and drowsiness. b. Reintroduction of [MEDICATION NAME] 8/18/11 (1) Review of physician orders [REDACTED]. Specifically: -On 8/17/11, the Nurse Practitioner (NP) documented (in pertinent part), "[MEDICAL CONDITION] - will re-initiate [MEDICATION NAME] at this time (antipsychotic used to treat [MEDICAL CONDITION]). Cont. [MEDICATION NAME]." -On 8/17/11, the NP ordered, "Please start [MEDICATION NAME] 100 mg po (by mouth) at OA (on awakening) and noon, 200 mg po qhs (every evening). Please obtain psychological evaluation and treat for follow up paranoid [MEDICAL CONDITION]." -On 8/17/11, a mental health consult was obtained with a licensed clinical social worker. The recommendation, "concur with re-start of [MEDICATION NAME] refer back to community reach for ongoing f/u (follow up) with his psychiatrist (name). Will need to monitor WBC (white blood cells) secondary to [MEDICATION NAME] use." On 8/31/11 at 12:00 p.m., the NP who ordered the [MEDICATION NAME] at 100 mg stated the resident's behaviors were increasing in the facility. The NP stated she reviewed the hospital records and based the restart of his medications on his previous therapeutic level and dosing. The NP stated the physician was aware of the restart but not the dose level. c. Resident's status following reintroduction of [MEDICATION NAME] on 8/18/11 See above; review of the resident's record, physician notes, physician orders [REDACTED]. On the same day of the resident's first dose of [MEDICATION NAME], the resident's blood pressure was low and the nurse administered the blood pressure medication when it should have been held. The resident was found un-responsive and hospitalized . -Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. -Review of nurses' notes revealed that on 8/18/11 at 10:30 a.m., the nurse documented, "Res. was found sitting outside in chair slumped over by social worker at 9:45 a.m. RN (registered nurse) was notified, RN was not able to rouse pt. Respirations 8/minute. Res. returned to bed with 3 (person) assist. BP 70/46, PO 82? O2 (oxygen) at 3 L/NC (nasal cannula) placed PO increased to 98%. Pt. non-responsive to sterna rub. EMT 911 called. Res. transferred to (hospital). At time of transfer BP 98/64, PO 98%/3L, BS (blood sugar) 122. Continued responsive only to painful stimuli. Residents mother notified of transfer." -Review of the 8/18/11 hospital records showed the following information, "antipsychotic poisoning, resolved [MEDICAL CONDITION], paranoid [MEDICAL CONDITION], tardive dyskinesia." The patient has normal tone and normal reflexes, but otherwise, the patient is unresponsive so I am unable to obtain strength, gait, sensation, judgment, and mood. 1. Likely antipsychotic poisoning as patient has just started back on his [MEDICATION NAME] flow instead of a slow increase. Did discuss this case with poison control, who has a concern that he may have been taking an overdose on other sedating medications as his symptoms are not 100% consistent with an antipsychotic poisoning ...If it just overdose in sedating medications, then over the next 12-24 hours, he should slowly resume his normal mental status ...will discuss with his psychiatrist who will restart his medications, the proper course at this point. The resident was discharged from the hospital on [DATE] to another facility. On 8/31/11 at 12:00 p.m., the NP stated it was possible with the combination of medications administered that morning contributed to the unresponsive episode. d. Facility Failures (1) Failure to evaluate orders for re-introduction of [MEDICATION NAME] According to the Lippincott Williams and Wilkins 2012 Nursing Drug Handbook, p. 345-348, '[MEDICATION NAME]'s classification (is) an antipsychotic medication. For adults, initial dose would include 12.5 mg once a day or twice a day and adjust the dose upward by 25 to 50 mg daily (if tolerated) to 300 - 450 mg daily by the end of two weeks. Individual dosage (is) based on clinical response, patient tolerance, and adverse reactions. Subsequent dosage shouldn't be increased more than once or twice weekly and shouldn't exceed 50 - 100 mg increments. Side effects include (not all inclusive) drowsiness, sedation, [MEDICAL CONDITION], confusion, fatigue, lethargy, weakness, [MEDICAL CONDITION], and orthostatic [MEDICAL CONDITION]. Drug to Drug interactions (use cautiously) include antihypertensive: may potentiate hypotensive effects and monitor blood pressure. With combination of other [MEDICAL CONDITION] drugs, may increase risk of sedation, and respiratory arrest. Use together cautiously.' On 9/26/11 at 1:50 p.m., the resident's physician stated, 'with any antipsychotic medication including [MEDICATION NAME], the medication should be started at the lower dose and built up from there.' Review of nurses' notes revealed no documentation in the resident's record that nursing staff had evaluated the NP order to reintroduce [MEDICATION NAME] at the resident's previous dose of 100 mg or considered the effect of the administration of [MEDICATION NAME] with administration of the resident's other medications. Likewise, there was no documentation that the facility pharmacy had evaluated the NP order to reintroduce [MEDICATION NAME] at the resident's previous dose of 100 mg or evaluated the effect of this medication in conjunction with the resident's receipt of [MEDICATION NAME] and [MEDICATION NAME]. On 8/31/11 at 11:15 a.m., the Registered Nurse (RN) who gave the medications on 8/18/11, stated the resident was acting normal that morning. The resident received his medications around 8:30 a.m. and then went to sit outside as usual. The resident's blood pressure was low that morning. The RN stated if she had a question about a dose, she would look it up in the drug book. The RN stated she knew the resident was on the medication before. She indicated she did not look up [MEDICATION NAME], question the dose ordered by the NP, or consider the effect of the administration of [MEDICATION NAME] with the administration of the resident's other medications, such as [MEDICATION NAME], and [MEDICATION NAME]. On 9/27/11 at 5:30 p.m., the Pharmacy Director stated the pharmacy only sent a three day supply of [MEDICATION NAME] for the resident when filling the 8/18/11 order. The Director stated it was difficult to determine if this was a new medication for the resident or if the resident was not already stabilized on that dose. However, the Director did not indicate, and the resident's record did not show, that the pharmacy sought clarification of the order or that the pharmacy reviewed the potential for interaction with the resident's other medications. The Director stated the pharmacy would be looking at their policies and procedures. On 10/3/11 at 1:50 p.m., the Director of Nursing made the following comments: "The hospital called (8/18/11) to discuss the concerns. The Physician was contacted and spoke with the family. The Physician spoke with the NP and re-educated her staff. The pharmacy should have caught the dose of the new medication (being started at a higher dose). The only thing that triggered from the pharmacy was a need for lab work. The nurse gave the medication without the knowledge of the medication and side effects. There was no formal education to the nursing staff (after the incident). Drug books were available at the nurse's station. Pharmacy would be available. The nursing staff should be familiar with the medications before they were administered and reactions." (2) Failure to hold [MEDICATION NAME] for low blood pressure On 8/31/11 at 12:00 p.m., the NP confirmed that there were standing orders/parameters for the nursing staff to follow with any blood pressure medication (directing staff on when to hold blood pressure medications). See above; on 8/18/11, the resident's morning blood pressure reading was 90/68, which is below the parameters for the administration of [MEDICATION NAME], per the NP note, as well as the facility standing orders. On 8/31/11 at 11:15 a.m., the RN, who gave the medications on 8/18/11, stated there were no parameters associated with resident #A's blood pressure medication. 2. Resident #266 Resident #266, age 80, was documented on their Admission Record to have been initially admitted on [DATE]. This resident's September 2011 monthly computerized physician orders [REDACTED]. The CPO listed the following [DIAGNOSES REDACTED]. a. Record Review (1) Medications Review of this resident's record revealed orders for the use of the following anti-psychotics: -[MEDICATION NAME], an antipsychotic medication, 1 mg tablet to be given by mouth twice daily for dementia. The order date was 6/15/11. -[MEDICATION NAME] 1 mg tablet by mouth to be given every four hours as needed for agitation. This order was dated 6/15/11. -[MEDICATION NAME], an antipsychotic medication, 50 mg twice a day for dementia with behavior disturbances i.e..: yelling out, trying to kick residents, crying, anxious. This order was dated 7/28/11. Both the medication [MEDICATION NAME] and [MEDICATION NAME], per Food and Drug Administration include "black box warnings" regarding the use of these drugs for controlling behaviors in the elderly. The "black box warnings" list the increased risks for use of these drugs in geriatric individuals. The boxed warning for medications including [MEDICATION NAME] and [MEDICATION NAME] states, "WARNING-Increased Mortality in Elderly Patients With Dementia-Related [MEDICAL CONDITION]." The information found on the internet in "About.com" under "Antipsychotic Medications-Black Box Warning" listed an example found on an antipsychotic medication from a national chain pharmacy, "WARNING: This medicine is an antipsychotic. It may increase the risk of death when used to treat mental problems caused by dementia in elder patients. Most of the deaths were linked to heart problems or infection. This medicine is not approved to treat mental problems caused by dementia." (2) Behavior Monitoring Review of Behavior Monitoring revealed: -September 2011: a. aggression as evidenced by: negative statements, grabbing. This monitoring was started on 9/22/11. b. Yelling/cursing. Behavior "a" (aggression) was documented to have occurred on six of 25 shifts. Two to four occurrences were listed per shift plus one "C" and 2 "F's". When asked what the "F" meant, staff stated it meant frequently during the shift. "C" meant constantly during the shift. Behavior "b" (yelling/cursing) two or four behaviors had occurred on a shift, plus 4 "F's." -August 2011: a. aggression/agitation. b. anxiety. c. crying. Behavior "a" was documented with a "C" on 16 shifts and "F" on two shifts out of 93 shifts. The resident also had from one to three behaviors documented on 12 shifts and one "occasional." Behavior "b" had 20 shifts listed with a "C" and 10 shifts with "F." Plus the behavior occurred from one to three times on a shift on eight shifts. Behavior "c" was documented to have occurred from one to three times on eight shifts. -July 2011: a. agitation/aggression b. anxiety c. crying Behavior "a" was listed with a "C" on 18 shifts and "F" on 18 shifts. From one to two behaviors occurred on 12 shifts. Behavior "b" occurred with a "C" on 16 shifts, "F" occurred on 21 shifts. Plus on nine shifts the behavior occurred once or twice. Behavior "c" occurred with a "C" on five shifts and "F" on 18 shifts. Additionally the behavior was documented from one to six times on 11 shifts. Failures in Behavior Monitoring: The tracking of behaviors related to the use of antipsychotic medications did not adequately describe the severity of the behavior or how to count continuous or frequent behaviors. This lack of specific identification of the problem behaviors made the effectiveness and continued need for the drugs unclear. Moreover, the lack of specificity of the behaviors being tracked left the determination of which behavior was being addressed by each medication up to each individual nurse. Minimum Data Set (MDS) The MDS initial admission review of 12/15/10, listed this resident to have [MEDICAL CONDITION]. The 6/25/11 PPS (prospective payee system) MDS listed the resident to have hallucinations and [MEDICAL CONDITION] and had verbal problems one to three times in the seven day review period. The 7/4/11 quarterly review listed the resident to have hallucinations, [MEDICAL CONDITION] and verbal behaviors from one to three times in the seven day review period. Although, the MDS reviews listed hallucinations and [MEDICAL CONDITION], these behaviors were not being monitored or care planned and were not found elsewhere described. (3) Care Plan The current care plan listed the following problem: Resident has [DIAGNOSES REDACTED]. The resident also has a [DIAGNOSES REDACTED]. The resident has verbal outbursts and is usually easily redirected. The resident has a history that indicates possible paranoid [MEDICAL CONDITION]. This problem was initiated on 1/4/11. -Goal: Resident will join in small group activity and feel more safe in environment. -Interventions: --reacts well to one on one quiet activity; --if she gets tearful-get to quiet area and calm her-use music, art for distraction; --current medications include antipsychotic for mood stabilizer and work with anxiety with the new stimuli and help clarify thinking as she may have more paranoid thoughts. She also utilizes an anti-depressant for depression as evidenced by tearfulness. --added later without an indication of the date: administered an antidepressant. Failures in Care Planning: The behaviors being monitored were not care planned. The behaviors listed on the order for the use of [REDACTED]. The only behavior specifically mentioned in the care plan was the resident being tearful. This care plan did not include interventions for consistent staff response to the behaviors being monitored for the use of the antipsychotic medications or identify how staff were to determine the effectiveness of and the need to continue the resident's medications. Although, the plan listed a possible [DIAGNOSES REDACTED]. b. Staff Interview An interview was held 10/4/11 at 1:20 p.m. with the Director of Nursing (DON), Director of Social Services (DSS), the Social Services (SS) staff member for the unit on which this resident resided and the Registered Nurse (RN) Manager for that unit. -When asked about behavior review by the psychoactive committee, the DSS stated that the social services staff was expected to count the number of behaviors and the committee made recommendations to the physician regarding the resident's continued medication use. -A request was made to review the psychoactive committee notes for the resident. As of survey exit (10/5/11), no committee notes had been provided for review. Later on 10/4/11, the SS staff and Nurse Manager for the resident's unit were able to share a more specific description of the resident's behaviors and staff responses; however, see above, these were not documented on the monitoring sheets or in the resident's care plan. The Nurse shared a notice of 9/19/11 by the pharmacist to the resident's physician regarding the concurrent use of two medications with "black box warnings" for an elderly individual. The physician had not yet had a chance to review the pharmacist's note. c. Drug documented for an off label use without documentation of the reason for its use: (1) Record Review This resident's record listed on the September 2011 monthly computerized physician orders [REDACTED]. The 2008 Mosby's Nursing Drug Reference book 21st Edition on pages 177 and 178 listed the following information: -Uses: [MEDICAL CONDITION] symptoms, EPS (extra pyramidal symptoms) associated with neuroleptic drugs, acute dystonic reactions and hypersalivation. -Potential central nervous system potential side effects included: anxiety, restlessness, depression, confusion and [MEDICAL CONDITION] (geriatric). -Precautions included use with geriatric individuals. No documentation was found in the resident's record of the resident being diagnosed with [REDACTED]. Although, the resident was receiving two medications, [MEDICATION NAME] and [MEDICATION NAME], that could cause EPS symptoms, according to the order, the medication was being given for "dementia." There was no documentation found or offered regarding the specific reason for use of this medication and no documentation how to determine its effectiveness or the need for continued use. (2) Staff Interview On 10/4/11 at the meeting at 1:20 p.m., which included the DON, staff was asked about the use of [MEDICATION NAME] for dementia, and if there was any information on the use of this medication. As of the survey exit on 10/5/11, no additional clarification for the use of this medication was provided.

Based on observation, record review, and staff interviews, the facility failed to ensure that one (#2) of seven sample residents received the care and services necessary to promote healing and prevent the development of pressure ulcers. Specifically: The facility failed to consistently implement physician-ordered measures to promote healing of a pressure ulcer on the resident's sacrum, and to prevent the development of ulcers on the resident's left (L) malleolus and (L) heel. The facility failures contributed to worsening of the resident's sacral ulcer and the development of new pressure ulcers on the resident's left (L) malleolus and heel. The findings include: A. Standards - risk factors and preventative interventions The U.S. Department of Health and Human Services, "Clinical Practice Guidelines" Number 3, "Pressure Ulcers in Adults: Prediction and Prevention," and Number 15 "treatment of [REDACTED]. -Factors that place a resident at a high risk for pressure sore development include: inability to reposition, incontinence . . . -All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. Clinical Practice Guidelines further provide: -Residents who have developed a pressure sore are at a higher risk to develop additional pressure sores. -Pressure sores can cause the resident to experience pain and discomfort from tissue damage, wound cleaning, or dressing changes. B. Resident Failure 1. Resident #2, [AGE] years old, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the resident's most recent Minimum Data Set (MDS), dated [DATE]: -Others usually understood the resident and she usually understood others. The resident had long memory and had short-term memory problems. The resident's daily decision-making skills were modified independent. The resident had no behavioral symptoms. -The resident needed extensive assistance of one staff for all activities of daily living (ADLs) and was non-ambulatory. -The resident was incontinent of bowel and bladder. -The resident had a feeding tube to meet her nutritional needs. -The resident had one pressure sore on admission. Pressure reducing devices, specifically chair and bed, were in place. The resident received wound care and nutrition interventions for her wounds. The resident experienced no weight loss. 2. Status on Admission Contrary to the MDS above, the admission nursing assessment dated [DATE] at 7:15 p.m., revealed the resident entered the facility without any pressure sores. The resident entered the facility with a surgical dressing to her left thigh on 11/16/10. The resident's pressure ulcer scale assessment, 11/16/10, revealed that the resident was at high risk for pressure sores. 3. Skin breakdown after admission - facility response a. Sacral pressure wound On 11/29/10, the resident was documented with a "new" sacral pressure wound. Nurses notes dated 11/29/10 at 8:25 p.m., "Noted that res (resident) has a 2 cm x 2 cm stage 2 to sacral area. Red around wound...New wound orders issued. Msg (Message) left for unit manager (UM)." Nurses notes dated 12/2/10 indicated that on that date, the resident's Medical Power of Attorney (MPOA) was notified of the resident's sacral wound. b. L heel and lateral malleolus wounds On 2/9/11, the resident was documented on the care plan with "L left) heel unstagable...(L) lateral Malleolus unstagable." Nurses' notes dated 2/9/10 revealed no notes regarding (L) lower extremity wounds. c. Facility response A skin breakdown care plan was initiated on 11/29/10, the date the stage II sacrum wound was initially documented. The care plan indicated that the resident was at risk for skin breakdown secondary to incontinence, dementia and medication use. The care plan also read in pertinent part, "2/11/11 Admit...(with) sacrum," however, see above; the resident was admitted without a pressure sore on 11/16/10, according to the nursing assessment completed on that date. -The goals for the care plan read in pertinent part, "Will have no skin breakdown daily...Target Date: 12/5/2010. -The approaches to the care plan read in pertinent part, "Prevalon boots to Bil (bilateral) feet when in bed (start date of 2/9/11)." "Pressure reducing devices as ordered...Position patient/resident off affected areas...Use positioning and pressure reliving devices (air mattress/reduction/relief mattress/pillows)." -There were no updates after 2/9/11 (identifying the left lower extremity wounds) even though the resident's wounds failed to improve (see below). Review of computerized physician (CPO) dated 2/7/11 and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"air mattress to aid in wound healing...Complex wound." CPO dated 2/10/11 indicated heel protectors while the resident was in bed. The MAR indicated Preventative heel protectors bilaterally when in bed only." CPO dated 2/10/11 and MARs dated 2/11, revealed orders that read in pertinent part, "Sacrum: cleanse with wound cleanser, apply Maxisorb alginate tuck into undermining at 12 o'clock after applying parasol, cover with foam adhesive qd (every day)." 4. Status of wounds upon and after discovery a. Sacrum wound Review of the Pressure Ulcer Documentation Form (PUDF) revealed the PUDF for the sacral wound was initially dated 11/29/10. It indicated the following: Sacrum wound stage 2, measured 2 X 2 cm, no depth, and no tunneling, any odor and wound bed tissue 100% [MEDICATION NAME] Review of the PUDF dated 12/2/10 indicated the following: Sacrum wound unstagable, measured 2.3 X 1.7 cm, 0.1cm depth, no tunneling, no odor with serous sanguineous exudate and wound bed tissue has 100% slough and the physician was notified of those changes. Review of the PUDF dated 12/7/10 indicated the following: Sacrum wound unstagable, measured 2.8 X 1.7 cm, 0.2 cm depth, no tunneling, no odor with serous sanguineous exudate and wound bed tissue has 100% slough. Review of the PUDF dated 12/15/10 indicated the following: Sacrum wound unstagable, measured 2.8 X 2.5 cm, 0 depth, no tunneling, no odor with serous sanguineous exudate and wound bed tissue has 100% granulation and the physician was notified of those changes. Review of the PUDF dated 12/20/10 indicated the following: Sacrum wound stage III, measured 2.3 X 2.2 cm, 0.9 cm depth, undermining at 12 o'clock 1.4 cm, at 10 o'clock 1.0 cm, no odor with serous sanguineous exudate and wound bed tissue has 100% granulation, surrounding skin warm and tender to touch, no physician notification was noted on that date. Review of the PUDF dated 12/27/10 indicated the following: Sacrum wound stage III, measured 2.1 X 2 cm, 0.6 cm depth, undermining at 3 o'clock 0.8 cm, 12 o'clock 1.1 cm, at 10 o'clock 1.2 cm, no odor with serous sanguineous exudate and wound bed tissue has 100% granulation, surrounding skin warm and tender to touch, no physician notification was noted on that date. Review of the PUDF dated 1/6/11, indicated the following: Sacrum wound stage III, measured 2.3 X 1.3 cm, 0.9 cm depth, undermining at 3 o'clock 0.8 cm, 12 o'clock 1.1 cm, at 10 o'clock 1.2 cm, no odor with serous sanguineous ecaudate and wound bed tissue has 100% granulation, surrounding skin warm, with [DIAGNOSES REDACTED] and tender to touch and the physician was notified of those changes. The sacral wound remained at a stage III throughout 1/11, with minimal changes in size, other than the increases in the tunneling. Review of the PUDF dated 2/23/11, indicated the following: Sacrum wound III, measured 1.2 cm X 1 cm, 0.3 cm depth, undermining at 3 o'clock 0.8 cm, 12 o'clock 3.4 cm, no odor with serous sanguineous ecaudate and wound bed tissue has 100% granulation, surrounding skin warm and tender to touch. Wound consult communication/physician(MD) order sheet dated 2/24/11 read in pertinent part, "Sacral - stage III pressure ulcer remains copious exudate...res is to continue with silver [MEDICATION NAME] dressing to help...healing." b. L Lateral Malleolus Review of the PUDF initially dated 2/9/11, indicated the following: (L) lateral malleolus unstagable, measured 0.6 cm X 0.9 cm, 0 depth, no odor wound bed tissue has 100% eschar, surrounding skin warm and tender to touch, the physician was notified of those initial changes. Review of the PUDF dated 2/17/11, indicated the following: (L) lateral malleolus unstagable, measured 0.5 cm X 0.9 cm, 0 depth, no odor wound bed tissue has 100% eschar, surrounding skin warm to touch. Review of the PUDF dated 2/23/11, indicated the following: (L) lateral malleolus unstagable, measured 1.6 cm X 1.8 cm, 0 depth, no odor wound bed tissue has 100% eschar, surrounding skin warm and tender to touch. While the physician was initially notified of the L lateral malleolus wound, there was no indication that the physician was notified of changes noted on 2/23/11. c. L Heel Review of the PUDF initially dated 2/9/11, indicated the following: (L) heel unstagable, measured 0.7 cm X 1.1 cm, 0 depth, no odor wound bed tissue has 100% eschar, surrounding skin warm to touch. The physician was notified. Review of the PUDF dated 2/17/11, indicated the following: (L) heel unstagable, measured 0.8 cm X 1 cm, 0 depth, no odor wound bed tissue has 100% eschar, surrounding skin warm to touch. The physician was notified. Review of the PUDF dated 2/25/11, indicated the following: (L) heel unstagable, measured 0.5 cm X 0.8 cm, 0 depth, no odor wound bed tissue has 100% eschar, surrounding skin warm to touch. 4. Observations On 3/3/11 at 2:40 p.m., wound care observations were conducted with the Director of Nursing (DON) and Unit Manager (UM). The resident was lying on top of the bed and tube feeding per (gastro-intestinal tube (GT) was infusing continuously without difficulty. The resident was observed fully dressed, lying on top of a specialized pressure reducing mattress. Two bed sheets, a blanket and a disposable chuck were observed to be placed on top of the bed and under the resident. Furthermore, the resident was observed to be wearing a thick pair of pants (velour) and when the pants were removed, the resident was observed wearing thick pair of incontinence briefs. A pillow was observed placed under the resident's legs and another pillow was observed placed at the bottom of the bed, away from the resident's feet. The resident's left foot was observed; her (L) malleolus and (L) heel were observed to be placed directly on the bed. No heel protectors were observed. The ordered Prevalon boots were not in place and were observed placed at a bedside table at another end of the resident's bed. The right foot was observed placed directly on the mattress which (see above) was covered with multiple layers of linen/protective covering. Wound round observations with the DON and UM were conducted on 3/3/11 at 2:40 p.m. and revealed: -The sacrum wound was at stage IV, and measured 1 cm X 0.7 cm, 0.5 cm depth, undermining at 1 o'clock 1.2 cm, 12 o'clock 2.2 cm, no odor with serous sanguineous exudate and wound bed tissue has 100% granulation, surrounding skin warm and tender to touch. - The (L) lateral malleolus wound was unstagable, measured 0.5 cm X 0.5 cm, 0 depth, no odor wound bed tissue had 100% eschar. -The (L) heel wound was unstagable, measured 0.5 cm X 0.6 cm, 0 depth; no odor wound bed tissue had 100% eschar, surrounding skin red and tender. 5. Staff interviews During the observations, on 3/3/11 at about 2:45 p. m., the DON stated, "When we have unstagable mushy heel, they are to be floated while in bed...The pressure sores (all pressure sores for resident #2) were acquired here (at facility)." The DON acknowledged that the resident's pressure areas on the left foot were placed directly on the mattress, with multiple layers of covers inappropriately placed under the resident. The DON stated, "The (L) malleolus is lying directly on the bed, it's not floated, the pressure is placed directly on the (L) malleolus." The DON described the (L) malleolus in pertinent part as, "unstagable, with eschar...black." The DON acknowledged that there were two bed sheets, a thick bed spread and a disposable chuck on top of the bed and the resident was lying on top of all these. Furthermore, the DON acknowledged that the resident was placed on all these items while she was fully dressed with adult incontinence attends in place. The DON stated that the multiple layers made the pressure reduction mattress ineffective. The DON stated that she was on the wound care team. She said, "As of last week the sacral wound was a stage III, today on assessment it (sacral pressure sore) is a stage IV with tunneling." On 3/3/11 at about 2:50 p.m., the certified nurse aide (CNA) who was responsible for taking care of the resident was interviewed. The CNA stated that the resident was already placed on top of bed with all the covers under the resident when she came on duty. The CNA stated that her shift started at 2:00 p.m. and she had not provided any care for the resident since coming on duty. On 3/3/11 at 2:55 p.m., the UM was interviewed. -The UM stated, "When in bed, she (resident #2) should not have attends on and chucks on together. . ." The UM further stated that the resident should have a pressure relieving boot in place while in bed, which were not in place at that time. The UM stated, "She should have...boots on when in bed (pressure reliving), they are over there." The UM pointed to the bedside table across the room where the pressure relieving boots could be seen on the table. -The UM stated that the resident may have chosen to keep attends and have multiple layers under her while in bed as she had behaviors of refusing care at times. However, review of the resident's behavioral record dated 3/11, revealed that the resident had no refusals of care on the day shift of 3/3/11. (Also - see above; the CNA stated resident #2 was lying on bed when she came on duty.) Moreover, the UM stated that after the surveyor requested, the multiple layers and attends were removed, and the pressure relieving boots were put in place for the resident without any refusals or problems. On 3/3/11 at 3:00 p.m., the surveyor and UM reviewed all the wound treatments that were initiated and ordered for the resident's sacral pressure wound from 11/29/10 through 3/3/11. During the review, the UM identified the use of each treatment that had been used for the resident's sacral pressure sore. The UM clarified that all these treatments were, "to help with drainage control, prevent infection of the wound, keep the wound moist and help with healing of that sacral wound." However, see above PUDF forms; the resident's sacral wound worsening and per DON and by observation, had progressed to a Stage IV on 3/3/11.

Based on observations, record review, and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for three of 30 sample residents (#15, #23 and #27) and nine supplemental sample residents (#35, #31, #36, #38, #39, #40, #41, #45 and #46). Specifically: -The facility failed to ensure residents, including residents #15, #23, #27, #35, #31, #38, #39, #40 and #41 had appropriate resident and bed assessments, and care plans for the safe utilization of bed side rails and/or bed canes. -The facility failed to ensure sink water was kept at safe temperatures in resident rooms -The facility failed to adequately supervise residents #35, #31 and #36. -The facility failed to ensure gerisleeves were applied as ordered for safety for resident #15. -The facility failed to ensure medications were secured. -The facility failed to ensure cigarette remains were removed from grassy areas to minimize fire hazards. I. IMPOSITION OF IMMEDIATE JEOPARDY Residents #15, #35, #41, #31, #38, #39 and #40, all with cognitive impairments, were observed with bed side rails and/or bed canes on their beds on 03/16/10. Gaps and mattresses, including one air mattress, that slid or could easily be compressed creating even greater gaps between the mattress and the rail and/or bed canes were also observed. Record review revealed the above residents had not been consistently evaluated for safety risks with the use of the bed side rail and/or bed canes, care planned for safety, and/or had orders for bed side rail and/or bed cane use. Additionally, some physician orders [REDACTED]. Following observations and record review completed on 03/16/10 at 7:28 p.m., the findings were reported to the Colorado Department of Public Health and Environment. It was determined at that time the residents' use of bed side rails and/or bed canes without safety assessments, consents, care plans and appropriate orders for use, as well as the observed gaps between mattresses and rails and/or canes created a situation of immediate jeopardy for serious harm. On 03/16/10 at approximately 7:30 p.m., the facility Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified that the failures above created a situation of immediate jeopardy for serious harm. A. FACILITY PLAN TO REMOVAL OF IMMEDIATE JEOPARDY 1. Initial plan to remove immediate jeopardy On 03/16/10 at 9:10 p.m., the NHA provided a copy of the facility's plan to remove the Immediate Jeopardy. The plan read as follows: Plan of Correction Annual Survey March 16, 2010 Bed Rails, Side Rails and Bed Canes herein referred to only as "side rails" 1. Immediately reassessments will be completed on six beds in question (#31, #40, #38, #39, #15, #41). All beds deemed appropriate will have bed rails removed. 2. Immediate education will be done regarding entrapment for evening staff, specifically on the Aspen unit, but will be done for entire house. NOC (night) shift will received education as well when shift starts, 11:00 PM 3. Physician orders [REDACTED]. Care plans, Care cards will be immediately updates (sic). Families will be notified. Full house audit will be re-conducted by 3/17/10 for any and all side rails used within the facility. 4. If deemed necessary step three will be followed. 5. Education will be provided to day shift beginning 3/17/10 2. Second plan to remove immediate jeopardy On 03/16/10 at 9:56 p.m., the NHA provided a copy of the facility's plan to remove the Immediate Jeopardy. The plan read as follows: Plan of Correction Annual Survey March 16, 2010 Bed Rails, Side Rails and Bed Canes herein referred to only as "side rails" 1. All bed rails in question will be removed immediately. Assessment will be done for these residents. (#31, #40, #38, #39, #15, #41) 2. Physician orders [REDACTED]. Families will be notified, care cards and care plans will be updated. 3. Education will be done immediately regarding entrapment to the evening staff, specifically on the Aspen unit, but will be done for entire house. NOC shift will receive education as well when shift starts, 11:00 PM 4. Full house audit will be re-conducted by 3/17/10 for any and all side rails used within the facility. This audit will include, but not be limited to, a full safety bed assessment for bed systems, support surfaces and side rails. 5. If deemed necessary, side rails will be removed, physicians (sic) orders will be obtained and care cards and care plans will be updated. If side rails are appropriate and consents are needed a verbal consent will be obtained and then we will have the families come in within 48 hours to sign. If they are unable to come in to sign the consent will be mailed to them certified mail with a return receipt requested. 6. If side rails are deemed appropriate for bed mobility the care plan, care card, and physicians order will reflect as bed mobility not fall prevention. 7. Education regarding entrapment will be provided to day shift beginning 3/17/10 The findings and plan to remove immediate jeopardy were reported to the Centers for Medicare and Medicaid Services on 03/17/10 at approximately 10:30 a.m. The facility's plan for removal of the immediate jeopardy was accepted with a request to the facility, presented at 11:47 a.m., that the facility change the title of the document detailing the plan from "Plan of Correction" to "Plan to Remove Immediate Jeopardy." On 03/17/10 at 3:14 p.m., the facility presented an amended copy of the plan to remove immediate jeopardy reflecting this change. B. REMOVAL OF IMMEDIATE JEOPARDY On 3/17/10 at 4:07 p.m., the facility was notified that the immediate jeopardy had been removed as of 3:14 p.m. on 03/17/10; however, deficient practice remained at an E level, the potential for more than minimal harm at a pattern level. II. BED SIDE RAILS AND/OR CANES A. Professional Reference The 2010 "Falls in Long Term Care" website, http://www.fallsinltc.ca/physicalrestraints/siderails.htm reads, in pertinent part: "...When planning resident care: ? the use of bed rails should never be automatically considered as they may pose as hazards to patient safety ? nurses should evaluate the risk of using bed rails compared to not using them ? decisions to use or to discontinue use of bed rail should be made according to the individualized patient/resident assessment along with interdisciplinary team and input from resident and family ? if bed rail(s) must be used: o include in the resident's chart a risk-benefit assessment that identifies why other care interventions are not appropriate or effective o include documentation that describes attempts to use less restrictive care interventions and their failure to meet patient's assessed needs o educate resident and family on bed rail risks and benefits o reassess resident's needs and re-evaluate equipment if an episode of entrapment occurs... As well, if bed rails are required, then staff should pay close attention to the design of the rails and its relationship with other parts of the bed: ? the bars between the bed rails should be closely spaced to prevent entrapment ? space between bed rails and mattress and space between headboard and mattress should be filled to prevent patients from falling in between ? latches securing bed rails should be stable ? maintenance and monitoring of bed, mattress, and accessories should be ongoing... The assessment should cover the following areas: ? Review of resident history, staff reasons for using side rails, health care records, and incident reports ? Physical examination ? Environmental characteristics of resident's bedroom and bathroom ? Identification of resident-specific problems... History: Resident/Staff ? determine resident's and family's views of side rails ? note whether side rails promote patient's independence in bed or create problems ? educate resident on the benefits and risks of side rails and after demonstration of an understanding, he or she should sign a consent form to confirm preference of side rails ? nursing homes should not be compelled to use side rails based on the interests of the family ? identify staff's reasons for side rails Resident/Staff Interview ? Assess patient's mental status ? Determine if there are sleep problems and if yes why they occur ? Describe patient's mobility at night, check for situations that increase injury risk such as trying to climb over bed rails ? Determine the number of times the resident goes to the bathroom at night and whether the frequency of urination has changed due to bed rails ? Determine reports of pain Record Review ? Look at the patient's medical [DIAGNOSES REDACTED]. ? Look at the patient's medications as some drugs are strongly correlated with fall risk and should therefore be reviewed ? Determine the circumstances of all falls Physical Examination ? Determine patient's Body Mass Index or stature: small stature increases likelihood of slipping through or between side rails and increased BMI may prevent fall-related injury because of the shock-absorbing capacity of muscle and fat ? Measure patient's lower leg length and whether they are equal ? Take patient's blood pressure and radial pulse ? Examine skin turgor, an indicator of dehydration, by lifting a skin fold and observing the speed with which it returns to place ? Check resident's vision and perception of light ? Check resident's range of motion of major joints ? Evaluate resident's feet, balance and gait, and muscle strength ? Describe site and intensity of pain Environmental Characteristics ? Bedroom assessment: assess firmness of the mattress, assess bed height compared to patient's lower leg length, evaluate furniture in patient's room (whether it acts as barrier), and determine distance from bed to bathroom ? Observe lighting conditions at night and make sure patient is able to turn on lights... The use of side rails, similar to physical restraints, can be safely reduced by a comprehensive assessment process. B. Administrative Staff Interviews On 3/16/10 at 7:10 p.m., the Nursing Home Administrator (NHA) and director of nursing (DON) stated the facility utilized two types of bed rails: bed canes, which were small "U" shaped grab bars and half side rails, which were longer rectangular bars at the side of the bed. She stated all residents in the facility who had either bed canes or half side rails used the devices for assistance with bed mobility or transfers; according to the DON, her expectation was that residents could use the half rails or bed canes for mobility if they could reposition themselves. The DON said there were no residents in the facility who used the devices as a restraint for fall prevention. The DON stated she expected a thorough assessment of the resident and the bed environment, a care plan, and a physician's orders [REDACTED]. She stated she was unsure whether consent from the resident or their responsible party was necessary to utilize the devices. The DON stated that if side rails were not able to be removed from the bed but were not in use or the resident was not safe with them, she would expect tie-downs be used. The DON stated the facility recently identified the use of bed canes or half side rails as a potential hazard in the facility. She stated the facility recently conducted an audit to ensure each resident who utilized bed rails had an assessment, physician's orders [REDACTED]. Indeed, review of resident council minutes, dated 01/15/10, revealed the DON had discussed the facility bed cane policy at the meeting attended by 21 residents (10% of census), explaining to residents that the facility was taking a good look at the bed cane usage and assessing all residents who use bed canes to assure safety. The DON further stated a facility-wide bed evaluation was done in early February to identify gaps between the rails and the mattress or other safety hazards associated with the use of bed canes or side rails, such as the use of a lipped mattress or air mattress. She stated if any hazards were observed, they were addressed by the maintenance department. On 3/17/10 at 2:40 p.m., the facility's medical director (MD) stated she was familiar with the Food and Drug Administration's (FDA) recommendations regarding bed rail safety, but was not familiar with the federal regulation regarding accident hazards. The MD stated she was aware large gaps between the mattress and bed rail could result in a resident's head getting caught, but had not considered smaller gaps and the potential for limbs to get caught. The MD also stated the use of lipped mattresses increased the potential for entrapment. C. Resident Failures 1. Resident #15 Resident #15, age 78, was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the face sheet, of dementia with behavioral disturbance, depression, hypotension, generalized pain, heartburn, and cough. She resided on the Alzheimer's/dementia special care unit. The 1/5/10 annual minimum data set (MDS) assessment documented: -The resident had short- and long-term memory problems and severely impaired decision-making skills. She was easily distracted and exhibited periods of restlessness (fidgeting, frequent position changes, or repetitive physical movements). The resident was rarely/never able to make herself understood and was sometimes able to understand others. She exhibited repetitive verbalizations, and repetitive physical movements. -The resident also exhibited wandering on a daily basis and used a wheelchair as her primary mode of locomotion. She had bed rails for assistance with bed mobility or transfers. The resident required extensive assistance by one staff member with bed mobility, transfers, locomotion, and all activities of daily living. She had limited functional range-of-motion and partial loss of voluntary movement in one hand, one leg, and one foot. -The resident was incontinent of bowel and bladder. -The resident was four feet, eight inches tall and weighed 80 pounds. -She had bed rails for assistance with bed mobility or transfers. a. Observations On 3/16/10 at 2:30 p.m., the resident was observed lying in bed in her room. The bed was low and had a lipped mattress. There was an alarm on the resident. There were bilateral half side rails on the bed, with a two-inch gap between the side rails and the mattress. The resident was awake, and was observed to move her arms and legs in "fidgety" motions and reach out as if to grab objects that were not there. On 3/16/10 at 6:15 p.m., the resident's bed was observed with the bilateral half side rails attached; there was a two-inch gap between the side rails and the mattress. When the mattress was compressed, it created up to a four-inch gap between the mattress and the rails. A certified nurse aide (CNA) working on the secured unit stated the resident did not use the half side rails for bed mobility as she was unable to comprehend their use or follow direction to use them. b. Record Review The 12/25/09 quarterly nursing assessment documented the resident had poor memory, severely impaired decision-making ability, and was oriented to herself only. She exhibited repetitive physical movements, was incontinent, required assistance by one staff member with transfers, experienced pain, and received medication for pain. A 12/28/09 fall evaluation documented the resident's fall risk factors included: the resident required assistance with bed mobility, transfers, or ambulation; she was incontinent; she was confused; her medication regime had changed; and she utilized a restraint. The comprehensive plan of care, printed 1/5/10, documented the resident wandered and was unaware of her needs and safety, was at risk for falls, required assistance with activities of daily living, was incontinent, had communication deficits due to cognitive loss, was at risk for skin breakdown due to impaired mobility, had poor safety skills, and was at risk for pain. The care plan did not document the resident's need for bilateral bed canes or half side rails. An undated restrictive device evaluation, provided to the surveyor on 3/16/10 upon request, documented the restrictive device (not specifically identified on the evaluation) was necessary to assist the resident with bed mobility and promote independence. -The evaluation further documented, however, that the resident had impaired memory, decreased awareness of her safety needs, lethargy, and a short attention span. She wandered and paced. The resident was non-verbal and was unable to make herself understood. She had an unsteady gait but propelled herself in her wheelchair. The resident's balance was impaired and she used narcotic or analgesic medication. -The evaluation failed to assess the resident's hearing, vision, bed mobility, and functional range-of-motion limitations. Moreover, the second page of the assessment, which included sections to document less restrictive interventions attempted, the type of device that was necessary, and when the device was to be used, was not completed. There was no signature on the assessment. A 2/1/10 restrictive device consent form documented the resident utilized bilateral bed canes to promote independence with bed mobility, even though (see above), bilateral side rails were observed on the resident's bed. There was no documentation in the resident's medical record indicating the potential risks and benefits associated with the use of bed canes or side rails were explained to the resident's responsible party. The 3/10 computerized physician orders [REDACTED]. An undated bed evaluation, which the DON stated was completed in early February during the facility-wide evaluation of beds for potential hazards, documented the type of rail used was "side" and the type of mattress used was "reg(ular)." Further review of the evaluation revealed: -There was no gap between the rail and the mattress. -The area to document the mattress compression was not filled out. -The resident's mattress was misidentified; the resident, by observation (see above) had a lipped mattress, not a regular mattress. c. Facility Follow-Up On 3/16/10 the resident's half side rails were removed after the above findings (incomplete assessment, inaccurate physician's orders [REDACTED]. The facility also conducted a restrictive device evaluation on 3/18/10 in response to the surveyor's concerns. A 3/16/10 physician's telephone order (TO) documented an order to discontinue the resident's bilateral bed canes. The 3/18/10 restrictive device evaluation documented: -The resident's memory and attention span were impaired, she had decreased safety awareness, she was combative or resistive to care at times, and was unable to understand others or make herself understood. The resident had impaired balance, required assistance with bed mobility and transfers, and utilized narcotic or analgesic medications. -The evaluation documented "Reassessed (due to) removal of bed canes - Res(ident) able to transfer (and) reposition (with) bed mobility (with) assist of staff...Device (discontinued) - Able to reposition in bed (and) do transfers (with) staff assist...Device (discontinued), no longer needed." 2. Resident #35 Resident #35, age 99, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of dementia with behavioral disturbance, congestive heart failure, hypertension, depression, constipation, and chronic pain. She resided on the Alzheimer's/dementia special care unit. A 1/18/10 significant change MDS assessment documented: -The resident had short- and long-term memory problems, was easily distracted, and had moderately impaired decision-making skills. She was sometimes able to make herself understood and understand others. The resident exhibited repetitive physical movements and wandering. -The resident required extensive assistance by one staff member for bed mobility, locomotion, and activities of daily living. She required extensive assistance by two staff members with transfers. The resident used a wheelchair as her primary mode of locomotion. She had bed rails for assistance with bed mobility or transfers. -The resident was frequently incontinent of bowel and bladder and had fallen in the past 30 days. -The resident was four feet, nine inches tall and weighed 111 pounds. a. Observations On 3/16/10 at 6:15 p.m., the resident was observed lying in bed in her room. The bed was low and there was an alternating airflow (air) mattress on the bed. The left side of the bed was against the wall. On the right side, there was a half side rail with a one-inch gap between it and the mattress. The mattress was able to be compressed approximately three more inches to create a four-inch gap. A CNA on the secure unit stated the resident did not usually use the side rail for mobility or transfers, as she relied on the staff for assistance. On 3/16/10 at 7:50 p.m., the resident was again observed in bed with an air mattress and right half side rail. b. Record Review A 1/19/10 quarterly nursing assessment documented the resident had unclear speech, memory problems, and severely impaired decision-making skills. She was oriented to herself only. The resident was resistive to care and received antipsychotic medications. The resident required assistance with transfers and limited functional range-of-motion. She did not use any assistive devices or restraints. A 1/18/10 fall evaluation documented the resident's fall risk factors included: the resident had a recent fall; required assistance with bed mobility, transfers, or ambulation; was incontinent; was confused; wandered; wore glasses; had a medication regime change; and utilized medications that could cause orthostatic blood pressure changes. The comprehensive plan of care, printed 1/27/10, documented the resident required extensive assistance with bed mobility and transfers, had a communication deficit due to cognitive loss, had no awareness of her safety or needs, was at risk for falls, received hospice care related to end-stage dementia, was incontinent, could be physically abusive while receiving care, and was at risk for pain and skin breakdown. -The care plan addressing the resident's fall risk included the approach to provide bilateral bed canes to promote bed mobility. -The care plan documented that this intervention was initiated on 12/21/09, although (see below) the physician's orders [REDACTED]. A 2/9/10 restrictive device evaluation documented the device, bilateral bed canes, was necessary to assist the resident and promote independence with bed mobility and transfers. -The evaluation further documented, however, that the resident had impaired memory and decreased awareness of her safety needs. She wandered but was cooperative. She used anti-psychotic and diuretic medications and had fallen in the last 60 days. Although the evaluation documented the resident was able to transfer and move in bed independently, she had been identified as requiring extensive assistance with bed mobility and transfers on the 1/18/10 MDS assessment (see above). -The evaluation failed to assess the resident's hearing, vision, functional range-of-motion limitations, communication, balance, and posture. Moreover, the second page of the assessment did not document any less restrictive interventions attempted. -The evaluation specified bilateral bed canes were deemed necessary and appropriate although (see above) a right half side rail was observed on the resident's bed. A 2/2/10 restrictive device consent form documented the resident utilized bilateral bed canes to promote independence with bed mobility and transfers, even though (see above) a right half side rail was observed on the resident's bed. There was no documentation in the resident's medical record indicating the potential risks and benefits associated with the use of bed canes (or side rail) were explained to the resident's responsible party. The 3/10 CPO documented an order, which originated 1/29/10, to apply bilateral bed canes, not side rails, to the resident's bed to promote independence with bed mobility and transfers. An undated bed evaluation, which the DON stated was completed in early February during a facility-wide evaluation of beds for potential hazards, documented the type of rail used was "side" and the type of mattress used was "air." There was a one-inch gap measured between the rail and the mattress. The area to document the mattress compression was not filled out. c. Facility Follow-Up On 3/16/10 the resident's half side rail was removed after the above findings (incomplete assessment, inaccurate physician's orders [REDACTED]. A 3/16/10 TO documented an order to discontinue the use of bilateral bed canes (although it was a side rail that had been in use). The facility conducted a restrictive device evaluation on 3/18/10. The evaluation documented the resident had impaired memory and attention span, decreased awareness of her safety needs, was unable to make herself understood at times, required assistance with transfers and bed mobility, had impaired balance, had impaired hearing, experienced a recent fall, and was utilizing antipsychotic and antidepressant medications. The evaluation documented, "Re-assessed after removal of bil(ateral) bed canes. Resident able to transfer and staff to assist (with) bed mobility when turning her for repositioning (and) changing...Device (discontinued), resident able to transfer (with) staff assist...Device (discontinued), no longer needed." 3. Resident #41 Resident #41, age 88, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of senile dementia, muscle weakness, abnormal gait, diabetes, depression, hypertension, esophageal reflux, and constipation. She resided on the Alzheimer's/dementia special care unit. The 2/23/10 quarterly MDS assessment documented: -The resident had short- and long-term memory problems, was easily distracted, and had moderately impaired decision-making skills. The resident was sometimes able to make herself understood and sometimes able to understand others. She exhibited repetitive verbalizations, wandering, and verbally abusive behaviors. -The resident required extensive assistance with bed mobility, transfers, locomotion, and all activities of daily living except eating. She used a wheelchair as her primary mode of locomotion and used bed rails for assistance with bed mobility or transfers. -The resident was frequently incontinent of bowel and bladder and had fallen in the past 31 to 180 days. -The resident was five feet tall and weighed 172 pounds. a. Observations On 3/16/10 at 6:15 p.m., the resident's bed was observed with a lipped mattress and a bed cane on the right side. The left side of the bed was against the wall. There was a two-inch gap between the mattress and the bed cane, but the mattress could be compressed to create up to a four-inch gap. On 3/16/10 at 7:50 p.m., the resident's bed was again observed with a lipped mattress, right bed cane, and two-inch gap between the device and the mattress. The resident was lying in bed with her head at the foot of the bed. b. Record Review An undated quarterly nursing assessment documented the resident had poor short-term memory and poor decision-making skills. She was oriented to herself only. The resident received psychoactive medications and exhibited tearfulness, agitation, anger, anxiety, and socially inappropriate, resistive, repetitive, and verbally abusive behaviors. The resident required assistance with transfers and limited functional range-of-motion. She did not utilize any assistive devices. The 2/15/10 fall evaluation documented the resident's fall risk factors included: a need for assistance with transfers, confusion, incontinence, wandering, and the use of medications that could cause orthostatic blood pressure changes. The comprehensive plan of care, printed 6/30/09, updated 12/09, documented the resident needed extensive assistance with bed mobility and transfers, was at risk for skin breakdown and was to use a pressure reduction mattress, had poor safety skills and cognitive deficits, was at risk for hypo/hyperglycemia due to diabetes, resided on the secure unit for cognitive deficits and behavioral symptoms associated with dementia, was at risk for falls, used a bolster (lipped) mattress. The care plan documented the resident had been assessed for a low bed but the interdisciplinary team felt it would increase her fall risk. The care plan did not address the resident's bed cane. The 3/10 CPO documented an order, which originated 6/1/08, to apply a bed cane to the resident's bed to improve her independence with bed mobility. A 9/30/09 restrictive device evaluation documented the resident had decreased awareness of her safety needs, impaired cognition, used several medications, wandered, required assistance with bed mobility and transfer, and had impaired balance. The evaluation documented the resident required a bed alarm, bolster mattress, automatic locking brakes, a chair alarm, and a self-releasing seat belt. The evaluation did not address the resident's use of a bed cane. review of the resident's medical record revealed [REDACTED]. A 7/15/08 restrictive device consent form addressed the resident's use of a self-releasing wheelchair seat belt. There was no consent form in the resident's medical record informing the responsible party of the risks and benefits of the use of bed canes. The undated bed evaluation, which the DON stated was completed in early February, documented the type of rail used was "cane" and the type of mattress used was "reg(ular)." -The evaluation noted that there was a greater than two-inch gap measured between the rail and the mattress; however, the area to document the mattress compression, which per observation above created a four-inch gap, was not filled out. -The evaluation misidentified the resident's mattress as "regular." See above; the resident's bed was observed with a lipped mattress. c. Facility Follow-Up On 3/16/10, the resident's right bed cane was removed after the above findings (incomplete assessment, inaccurate physician's orders [REDACTED]. The facility conducted restrictive device evaluation on 3/21/10. The evaluation documented the resident had impaired memory and a short attention span. She was unable to understand others or make herself understood. The resident had impaired balance and required assistance with transfers and bed mobility. The evaluation documented, "Resident re-assessed (due to) bed canes being removed-(continues) not to need them (at) this time...Removed." The evaluation determined the bed cane was not a necessary assistive device. A 3/21/10 TO documented an order to discontinue the use of the bed cane. 4. Resident #27 Review of resident #27's record revealed she was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. a. Decline in status - falls Review of a MDS assessment, dated 10/27/09, revealed the resident was independent with bed mobility, transfers, dressing, eating and hygiene. Her balance while standing was unsteady but able to re-balance without physical support. She had limited range of motion in one arm and one leg. She required the use of bed rails for b

Based on observations, record review and interviews, it was determined the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for two of 30 sample residents (#1, #27). Specifically: Resident #1, who had a history of [REDACTED]. This contributed to another episode of [DIAGNOSES REDACTED] that was associated with confusion and a fall from bed, as well as the need for repeated interventions to improve the resident's blood sugar levels. Resident #27 failed to consistently have her compression sleeves and splint applied as ordered by the physician. Findings include: 1. Resident #1 Williams L MSN, Hopper P MSN: Understanding Medical Surgical Nursing, p. 864. 3rd Edition. Copyright 2007, F.A. Davis Company, reads in pertinent part, "[DIAGNOSES REDACTED]...Symptoms of low glucose include hunger, sweating, pallor, tremor, palpitations and headache. These symptoms are caused by activation of the sympathetic nervous system. As [DIAGNOSES REDACTED] progresses, the brain is deprived of glucose and neurological symptoms such as irritability, confusion, [MEDICAL CONDITION] and coma may occur." Resident #1, [AGE] years old, was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS), dated [DATE], indicated the resident had no short-term or long-term memory problems. The resident was independent with cognitive skills for daily decision-making. The resident usually understood others and was understood by others. The resident had no indicators of depression, sad mood or anxiety. The MDS indicated the resident had no behavioral problems. Review of the 3/10 Medication Administration Record (MAR) revealed the resident had orders to receive the following medications for her DM prior to 3/7/10: -[MEDICATION NAME] 10 mg by mouth once a day (QD). The order was initiated on 2/20/10 and discontinued on 3/9/10. -Finger stick blood sugar (FSBS) three times a day, at 7:00 a.m., 11:00 a.m. and 4:00 p.m. This order was initiated on 3/1/10 and stopped on 3/9/10. -[MEDICATION NAME]-intramuscular (IM) 1 mg as needed (prn) for FSBS below 60 if resident is unable to swallow. This order was initiated on 3/7/10. -Glucose 40% orally. Give entire tube for FSBS below 60 if resident is able to swallow. This order was initiated on 3/7/10. -[MEDICATION NAME] (SQ) 20 units (u) daily at HS (bedtime). This order was initiated on 2/25/10 and discontinued on 3/7/10, after the resident had low blood sugar readings on that date at 4:10 p.m. (see below) a. Episode of [DIAGNOSES REDACTED] 3/7/10 - new insulin orders Review of nurses' notes, dated 3/7/10 at 4:10 p.m., prior to the initiation of insulin administration that night, revealed the resident had a low FSBS (finger stick blood sugar) of 32 for which she was treated. On that date, at that time, nurses' notes read in pertinent part, "proper nursing care to correct...This RN (Registered Nurse) called the (physician/doctor)...spoke with PA (Physician Assistant) received instructions/orders to cont (continue) to...(check) FSBS q (every) 10 min (minutes) until FSBS is...(above) 100...Holding all [MEDICATION NAME] (insulin) this [MEDICATION NAME] 1mg IM (intramuscular) for FSBS less than 60." After the [DIAGNOSES REDACTED] incident, new physician orders [REDACTED]. -Physician telephone orders (PTO) on that date (3/7/10) read in pertinent part, "DC (discontinue) orders for [MEDICATION NAME] (insulin), 30 u @ HS (but see above - MAR documented the resident had been receiving 20 u at HS units (u) @ HS/bedtime). -Start on 3/8/10 [MEDICATION NAME] SQ 15 u at 2000 (8:00 p.m.) -Hold all [MEDICATION NAME] for 3/7/10 (hold 8:00 p.m. insulin)...addendum 3/7/10. -[MEDICATION NAME] 1 mg for FSBS less than 60...3/7/10 - Give oral glucose for BS (less than) 60 if resident is able to swallow." On 3/8/10, following the resident's hypoglycemic episode on 3/7/10, the PA saw the resident and reviewed the resident's medications, per request of nursing staff. -Review of Physician orders [REDACTED]. Although untimed, interview with the Medical Director (MD) and Unit Manager RN (UMRN) on 3/17/10 revealed the new orders (superseding the orders obtained 3/7/10 for 3/8/10) were written between 3:00 p.m. and 4:00 p.m. on 3/8/10. -The new orders read, in pertinent part, "Discontinue previous [MEDICATION NAME] (long [MEDICATION NAME] insulin) orders - Start [MEDICATION NAME] 5 u subcutaneously (SQ) 6 p.m. (at 6 p.m.), hold for FBS...less than 110. Dx (diagnosis) diabetes." b. Failure to timely transcribe and implement new orders written 3/8/10 - series of low blood sugars, confusion and fall out of bed. Review on 3/16/10-3/22/10 of the resident's MAR and nurses' notes revealed: -Review of resident's MAR, dated 3/10, revealed no transcription of discontinuation of [MEDICATION NAME] 15 u and transcription of [MEDICATION NAME] 5 u as ordered on [DATE] between 3:00-4:00 p.m. that day. -Further review of the MAR indicated the resident's FSBS was 210 on 3/8/10 at 4:00 p.m. The MAR showed that on 3/8/10 at 8:00 p.m., the resident was administered [MEDICATION NAME] 15 u (insulin) instead of the ordered [MEDICATION NAME] 5 u - three times the intended dose. -The MAR further revealed that on 3/9/10 (no indication of time), the resident was administered Glucose 40% for blood sugar lower than 60. -Review of nurses' notes, dated 3/9/10 at 3:00 a.m. read, in pertinent part, "0140 (at 1:40 a.m.) Resident lying on floor beside bed on (R) side. Bed lines wrapped around resident...denies pain no injuries noted. Confusion noted. Placed back to bed...(with help) of 3 people. Blood sugar 35 and 33 on recheck. Gave tube of glucose. Rechecked at 0220 (2:20 a.m.) it (blood sugar) was 36. Gave salad sandwich...(with) much encouragement...BS (blood sugar) 52 @ 0240 (2:40 a.m.) and 75 @ 0300 (03:00 a.m.)...Left message for (physician's name) to re-evaluate all meds (medications)...Left message for unit manager." c. Staff interviews On 3/18/10 at approximately 11:45 a.m., the Director of Nursing (DON) was interviewed. She said the UMRN was the one who had all the information on the 3/8/10 incident and asked the incident be discussed with the UMRN. The DON said she agreed with the UMRN's conclusions. On 3/18/10 at 12:35 p.m., the UMRN who was on call the date of the resident's episode of [DIAGNOSES REDACTED] on 3/8/10-3/9/10, was interviewed. -The UMRN stated she was not the staff member who had documented the incident in the nurses' notes but she said she would review and clarify nurses' notes for that date. -The UMRN stated the PA saw the resident during the day on 3/8/10 after the incident of low FSBS on 3/7/10. The UMRN stated, "[MEDICATION NAME] orders were changed (again) on 3/8/10 to give 5 u [MEDICATION NAME]; however, that order was not taken off (not transcribed onto the MAR) until 3/9/10 at 9:32 a.m. That order was not transcribed on MAR on 3/8/10." According to the UMRN, new orders had to be entered in the computer system before they printed out on the MAR and that did not happen for this order until the next day (3/9/10 at 9:32 a.m.). -The UMRN further explained that because the PA's new order for [MEDICATION NAME] 5 u was not transcribed on 3/8/10, "the only order the nurse (who administered the 15 u of [MEDICATION NAME] on 3/8/10 at 8:00 p.m.) was aware of was the order to give [MEDICATION NAME] 15 u. . .and the resident was administered 15 u of [MEDICATION NAME] the night of 3/8/10." -The UMRN stated there was no need for further follow up or for education of staff following this incident because the MAR indicated the resident was to be administered 15 u ([MEDICATION NAME])." The UMRN stated she did not believe the administration of insulin on 3/8/10 at 8:00 p.m. was a medication error, as the orders for adjusting the resident's [MEDICATION NAME] were not transcribed on 3/8/10, and the evening nurse was not aware of the new orders. -The UMRN said, "I investigated (what happened) but I did not document...I spoke with the night nurse, the nurse who administered 15 u on 3/8/10...There is no documentation of the investigation." After the above interview, the UMRN documented her investigation of the incident on 3/7/10-3/9/10. The "Interview Record Investigation of Incident/Adverse Event" form, dated 3/18/10 (ten days after the incident), was provided on 3/18/10. -The report indicated resident #1's name and further indicated the UMRN interviewed the Licensed Practical Nurse (LPN) who had administered the 15 u [MEDICATION NAME] on 3/9/10. -The form read in pertinent part, "(UMRN) informed of potential med (medication) error by night nurse...stating that N.O. (new orders) were written by PA on 3/8/10 to...(decrease) [MEDICATION NAME] from 15 units to 5 units. Order in chart was not noted by the nurse until 9:30 (9:30 a.m.) the following morning of 3/9/10. Resident was given [MEDICATION NAME] 15 units @ 20:00 (8:00 p.m. on 3/8/10 instead of the intended 5 units) per current orders in MAR as the new orders had not yet been noted. -The report continued, "Spoke...(with) evening nurse for 3/8/10...to inquire if she was aware of order. Nurse stated she gave what was written in the MARs. PA was in on evening (3/8/10) that wrote the order. Drt (resident's daughter who was the medical power of attorney) was informed by myself (UMRN) when asked about med error, what our med policies were and what was being done. Informed daughter there was no error d/t (due to) when order was taken off by nurse. . ." On 3/18/10 at 4:30 p.m., the Medical Director (MD) was interviewed. -The MD stated the facility was using a new computer system (put in place prior to the 3/8/10 incident) for physician order [REDACTED]. -The MD stated, "The PA wrote the orders between 3:00 p.m. and 4:00 p.m. on 3/8/10, prior to the evening medication administration time. However, instead of the 5 u (of [MEDICATION NAME]) she (resident #1) got 15 u and her BS (blood sugar) dropped into the 30's." -The MD further stated, "I expect that new physician orders [REDACTED]." The MD said the nurses should have a system to take off orders before putting them through the computerized system. The MD further stated, "That day (3/8/10), they (nursing staff) should have given the 5 u ([MEDICATION NAME])...I discussed that with them (facility nursing staff)." -The MD stated that nursing staff would receive further education regarding insulin administration and prompt transcription of physician orders. The MD did not indicate when this education would be scheduled. The facility did not offer any further comments or documentation to show the transcription delay and resulting administration error had been discussed with nursing staff. 2. Resident #27 Resident #27 was admitted on [DATE], re-admitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent MDS assessment, dated 1/24/10, disclosed she had problems with short-term memory and decision making skills in new situations. She was assessed as having no limited range of motion. a. Record review Review of physician orders [REDACTED]. Review of a care plan titled at risk for falls, dated 10/28/09, revealed: -12/31/09 restorative nursing to apply left hand splint-on in AM and nursing to remove in PM as resident tolerates 3-6x weekly. Review of the treatment records for the month of 3/10 revealed nurses were signing initials next to the order "apply left [MEDICAL CONDITION] glove in AM, put glove over splint as tolerated" on two days of the survey from 3/16/10 to 3/17/10. Review of a nurse practitioner note, dated 3/2/10, revealed the resident had rotator cuff sprain and strain with recent increase in discomfort. Repeat x-ray revealed worsening injury. In addition, the resident had a recent stroke with right side facial droop, dysarthria, and left side [MEDICAL CONDITION]. A physician note, dated 2/4/10, disclosed the resident had [MEDICAL CONDITION] of the left hand, needing a shrinker sock and use an anti-contracture inserted in the hand. b. Observations Observation during the initial tour on 3/16/10 at 12:05 p.m., revealed a splint on the overbed table. Observation of the resident's hands and arms revealed she was not wearing a device or appliance on either arm. During a concurrent interview, the resident revealed her arm hurt 'terrible' if the splint was not placed on her. The resident was in bed on her back and two half rails were in the up position. Observations on 3/16/10 at 12:05 p.m., on 3/17/10 at 8 :00 a.m., 12:05 p.m., and 5:35 p.m., on 3/18/10 at 10:55 a.m. and on 3/22/10 at 9:27 a.m., revealed the resident in bed. In the resident's room were two beds but the resident did not have a roommate. On the other bed was a bluish gray splint. When the surveyor held up the splint during a concurrent interview, the resident said the staff had not put the splint on her yet. Observation of her hands and arms revealed she was not wearing a device or appliance on either arm. c. Interview and follow-up During an interview on 3/18/10 at 1:55 p.m., the Director of Nurses revealed nurses, including restorative, were to follow physician orders. The unit manager revealed on 3/22/10 at 7:32 a.m., that it was the nurses' responsibility to ensure the splints/sleeves are on. Review of group training documentation, dated 3/21/10 (during survey), revealed "resident (to) have left [MEDICAL CONDITION] glove and left hand splint on in AM and off at HS as tolerated. Restorative will put glove and splint on AM 3-6 times a week."

Based on observations, record review and staff interviews, the facility failed to ensure three of 30 sample residents (#21, #10, and #28) received the care and services necessary to prevent pressure ulcers and to promote healing of existing pressure ulcers. Specifically: -For resident #21, the facility failed to minimize the resident's risk factors for skin breakdown (incontinence, immobility) to promote healing of the resident's buttocks/coccyx ulcer. -For resident #28, the facility failed to obtain treatment orders/interventions for a stage II coccyx ulcer that developed two weeks after admission. Review of the records showed staff failed to monitor the ulcer. -For sample resident #10, the facility failed to float the resident's heels while in bed. The findings include: A. Expectations Review of an instruction sheet on pressure sores provided by the nursing home administrator (NHA) on 3/22/10 revealed: -"In bed, follow these guidelines, do not lie on the pressure sore as shown (diagram). Use foam pad or pillows to relieve pressure on the sore and change positions every 2 hours." -The sheet revealed "pressure sores form when there is constant pressure on certain parts of the body. Long periods of unrelieved pressure cause or worsen pressure sores and slow healing once a sore has formed. Taking pressure off the sore is the first step toward healing. -Pressure sores usually form on parts of the body over bony prominences (such as hip or heels) that bear weight when you sit or lie down for a long time. See pressure points where sore often form." (Pressure points included back of heels) B. Resident failures 1. Resident #21, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident status - pressure ulcer risk The 1/21/10 Minimum Data Set (MDS) documented that: -The resident had short-term and long-term memory problems. The resident's decision-making skills were moderately impaired. The resident usually understood others and usually others understood the resident. The resident had periods of restlessness. The resident's mood indicators included sadness. These mood indicators were easily altered. The resident had no behavioral symptoms. -The resident required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfer, dressing, toilet use hygiene and bathing. The resident was non-ambulatory. -The resident was incontinent of bowel and bladder. -The resident had no pressure ulcers or history of a pressure ulcer and no other skin problems. The resident had a pressure relieving bed and chair. An analysis of the resident's risk for pressure ulcer development, completed on 12/28/09, indicated the resident was at high risk for skin breakdown. b. Facility response to resident's risk for ulcer development. Review of the resident's care plan, initiated on 7/22/09, read that the resident had the potential for skin breakdown related to incontinence, wearing briefs, immobility and poor oral intake. -The goal indicated no skin breakdown for the next 90 days. The target date was 3/10. -The approaches to care included: --frequent position changes --skin inspections weekly and report changes to RN. --incontinence care with each episode of incontinence. The resident's incontinence care plan dated 7/22/09, revealed the resident was capable of using the toilet but forgot to ask at times. The care plan indicated the resident was frequently incontinent of bowel and bladder, related to her decreased mobility. -The goal indicated the resident was to receive services to help prevent urinary tract infections (UTIs) and was to be kept clean, dry and odor free until 3/10 (no specific date was given). -The care plan indicated the resident was to be checked and changed every 2 hours and as needed. c. Development of pressure ulcer Review of nurses' notes revealed a note dated 2/16/10 at 10:00 a.m. that read in pertinent part, "Nurse in to look at resident's buttocks (shears) 0 (no) new orders @ this time Nurses notes dated 2/16/10 at 4:30 p.m., read in pertinent part, "orders...to cleanse buttocks...(with) wound cleanser, apply [MEDICATION NAME] drg (dressing) to shear on buttocks...(change) q (every) three days and prn (as needed) niece notified." Review of the Resident's Computerized Physician Orders (CPO) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Cleanse buttocks with wound cleanser, apply [MEDICATION NAME] dressing to shearing on buttocks, change q (every) 3 days and prn (as needed). This order was initiated on 2/16/10. The 3/10 MAR indicated [REDACTED]. d. Failures (1) Monitoring of ulcer Review of the resident's medical record, Treatment Administration Records (TAR) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s buttocks shearing after its discovery on 2/16/10, even though the MARs and TARs, dated 2/10 and 3/10, indicated the resident received the ordered treatment for [REDACTED]. On 3/17/10 at 2:30 p.m., the Director of Nursing (DON) was asked to provide documentation on the resident's pressure ulcers progress, as no wound progress notes could be found in the resident's medical record. The DON stated that wound progress forms were placed in the nursing assessment section of the resident's chart. Review of this section of the resident's chart, however, also failed to reveal documentation on the status of the resident's pressure ulcers. On 3/17/10 at about 2:40 p.m., in another interview with the DON, she stated the resident's pressure sore progress should have been monitored on a pressure sore tracking form, but there was no form initiated from the time the pressure sore was noted on 2/16/10, until the omission was brought to the facility's attention on 3/17/10. (The DON initiated tracking forms on this date.) No further documentation on facility monitoring of the resident's pressure ulcers was provided by exit. No documentation was faxed after exit. (2) Failure to provide timely incontinence care Cross reference F315; incontinence care. On 3/17/10 at 9:45 a.m. and 10:54 a.m., the resident was observed while up in her wheelchair (WC) in her room. It was noted that the resident smelled of urine during the 9:45 a.m. observations, as well as at 10:54 a.m. -At 10:54 a.m., two certified nurse aides (CNAs) were observed with the resident in her room. The CNAs repositioned the resident but did not provide incontinence care. As the CNAs wheeled the resident out of the room, they were asked when the resident was last provided incontinence care. -At that time, CNA#1 stated she last provided the resident incontinence care at 8:00 a.m. She then stated, "I will change her at 12 (12:00 p.m.)" which would represent a period of four hours between such care. -CNA#1 wheeled the resident into the common area where she was observed periodically at the following times: 11:00 a.m., 11:15 a.m., and 11:20 a.m., until she was wheeled to lunch at about 12:00 p.m. -At 2:00 p.m., the resident was observed while up in her wheelchair with a nebulizer treatment in place. Again the resident smelled of urine. The unit Licensed Practical Nurse (LPN) was observed to remove the resident's nebulizer treatment which was done at around 2:05 p.m. In a brief interview with LPN at that time, she acknowledged the resident smelled of urine. The LPN stated, "The aides are supposed to change the resident...I will get one of the girls to change her...They need a lift to transfer her." -CNA#1 came in and assisted the LPN with transferring the resident from her WC to bed via lift. In a brief interview with CNA#1 at that time, she stated she had observed that the resident was taken to the dining room without incontinence care and that she had returned the resident from the dining room (at about 12:00 p.m. - a four hour period between care) and had provided incontinence care at that time. On 3/17/10 at about 2:40 p.m. in an interview with the DON, she stated the resident was to be checked and changed for incontinence. The DON stated, "She definitely needs to be checked and changed every two hours." (3) Failure to update care plan Although the resident had actual skin breakdown for which she was receiving treatment, her care plan was not updated to reflect this or to address staff interventions to promote healing until the omission was brought to the facility's attention on 3/17/10. e. Worsening of resident's ulcers On 3/17/10 at 2:15 p.m. during wound care/incontinence care observation, the resident's attends were removed and observed to have yellow stains. The resident smelled of urine and she was in process of having a bowel movement. -The Director of Nursing (DON) came to assist the LPN with the assessment of the resident's buttock wound. After the resident received incontinence care, the resident's wound dressing which was observed to be curled up from the bottom and upward, was removed by the LPN. -As the LPN removed the dressing from the resident's buttocks, she stated, "It's (buttocks wound) worse than it was on the 15th (3/15/10) when I put on the dressing...The tissue is macerated." -The LPN was interviewed during wound care, about the resident's wound progress and measurements. The LPN stated, "I have no access to the skin tracking form...that is done by the Unit Manager (UM)...I changed the dressing on 3/15/10...I just know it looks worse." -The DON measured the maceration and stated that the macerated tissue was "right above the rectum and measures 1 x 1cm." The DON measured the left buttock wound and stated "above the coccyx there is a .2 x .1 cm red open stage II wound, and a .4 x .2 cm stage II to the coccyx to the midline." -The LPN stated, "When I last changed the dressing she (resident #21) only had the one (wound) on top and it was smaller then." 2. Resident #10 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent MDS assessment, dated 2/7/10, disclosed she had problems with short-term memory and decision making skills in new situations. She required extensive assistance with bathing but was independent in all ADL areas. She was assessed as having a stage IV wound. a. Record review Review of a pressure ulcer documentation form for 3/16/10, revealed the resident had a wound on her left heel, that was unstagable, 1.5 x 1.0 x 0.3 cm with no undermining or tunneling present. Additional wound records revealed the left heel wound was unstagable and showed the following: -3/10/10 size 2.2 x 1.8 x 0.3 cm with scant serous exudate, -2/14/10 size 2 x 2.2 x 0.1 cm with small serous exudate, -1/4/10 size 1.5 x 2 x 0.1 cm with small serous exudate, -1/28/10 2 x 2 x 0.2 cm with small serous exudate, -1/20/10 4 x 2.1 x 0 cm with no exudate -12/28/09 6 x 6 x 0 cm with no exudate -12/23/09 6 x 6 x 0 cm with no exudate. Review of physician orders revealed the following: -12/23/09 keep heels elevated while in bed and -12/30/09 resident to wear bilateral Lenard boots at all times including in bed. Review of a care plan, titled potential for skin breakdown dated 11/12/09, revealed the following: -report any areas of potential skin breakdown -pressure reducing mattress on bed and cushion in w/c (wheelchair) -treatment as ordered and -Lenard boots to (capital B circled) feet/heels b. Observations and resident interview Observations on 3/16/10 at 4:37 p.m., on 3/17/10 at 7:33 a.m. and on 3/18/10 at 8:50 a.m., revealed resident #10 in bed. Her heels were not elevated and there were no supportive type devices to elevate her feet near her. She was not wearing Lenard boots in bed. On 3/18/10 at 8:50 a.m., the resident revealed "sometimes they do and sometimes they don't", when asked about staff elevating her heels or putting boots on her. She said it could happen anytime of the day. She stated she usually did not refuse to wear the boots or elevate her heels, because she had been instructed this would help the sore on the back of her foot. c. Staff interviews and facility follow-up During an interview on 3/18/10 at 1:55, the Director of Nurses revealed nurses were to follow doctor's orders. On 3/22/10 at 7:32 a.m., the unit manager revealed elevating heels was the responsibility of the CNA. She revealed nurses were supposed to check to make sure everything was in place, including heels elevated or boots on. Review of group training documentation dated 3/21/10, revealed the residents "boots are to be on at all times as tolerated even in bed. When resident is in bed and refuses to wear boots, her heels need to be floated on pillows." 3. Resident #28, [AGE] years old, (closed record) was admitted to the facility on [DATE]. The resident's medical [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. a. At risk for skin breakdown - actual skin breakdown According to the 12/18/09 MDS, the resident's cognition could not be assessed. The resident required extensive assistance from staff with all Activities of Daily Living and had one stage IV pressure sore. The 12/14/09 Norton Plus Pressure ulcer Scale showed a score of five. A score of 10 or less showed the resident was at high risk. Review of the 12/14/09 nursing admission assessment identified the resident had an unstagable ulcer to the right heel. There was no other identified ulcer. However, two weeks later, on 12/30/09, nursing staff reported a new pressure ulcer on the coccyx "stage two (II) - 1 x .5 cm." Review of physician progress notes [REDACTED]. resident's coccyx ulcer. This reference, by the physician assistant (PA) noted the coccyx "area is red but skin intact." b. Facility response to risk Review of the 12/18/09 impaired skin integrity care plan related to the pressure ulcer directed staff to follow the facility protocol/regime for treating breaks in the skin integrity/pressure ulcers. Staff was prompted to monitor the skin on a weekly basis. Review of the 12/18/09 nutritional care plan revealed it included a handwritten entry for a pressure-relieving cushion (there was no date to indicate when it was added to the original care plan). c. Failures in facility's response (1) Failure to monitor the resident's ulcer as expected Record review revealed staff measured the coccyx ulcer on 1/7/10 and 1/19/10 as a stage II pressure ulcer. After 1/19/10, however, there were no further measurements or monitoring of the coccyx ulcer. (The resident discharged home on[DATE].) Review of the nurse's notes from 12/30/09 through 2/15/10 only indicated a decubitus (not where or status) except on the following notations: -On 12/30/09 at 1:00 p.m., the nurse documented, "Res. (resident) noted to have sm (small) open area to left coccyx area 1 x .5 cm, cleansed area applied [MEDICATION NAME] cream." -On 1/19/10, the nurse referenced the bottom was chaffed. Although review of a note by the dietary manager on 1/26/10 read, "..note of worsening coccyx wound, "and review of notes by the bath aide for 2/10 revealed a "skin issue" 2/1 to 2/15/10 (discharge) neither nurse's notes or pressure ulcer records revealed any documentation by nursing after 1/19/10, on the status (stage and size) of the resident's coccyx ulcer. Review of the 2/15/10 discharge nursing assessment showed no indication of a coccyx wound, noting only the heel ulcer. (2) Failure to seek treatment orders to treat coccyx ulcer Record review revealed no physician orders to treat the coccyx wound: Review of the physician orders revealed no treatments for the coccyx pressure ulcer (from 12/30/09 through 2/15/10). Review of the treatment records revealed no documentation of daily or routine treatment of [REDACTED]. d. Staff interviews: On 3/18/10 at 11:16 a.m., when asked why the resident developed an ulcer, the resident's physician stated the resident was compromised medically. On 3/18/10 at 11:16 a.m., a Licensed Practical Nurse (LPN) who was familiar with the resident stated the resident probably developed the ulcer lying in bed. On 3/22/10 at 7:24 a.m., further information related to the facility's role in prevention of the resident's ulcer, lack of monitoring and lack of orders was requested of the Assistant Administrator. On 3/22/10 at 7:50 a.m., a LPN who was familiar with resident #28 stated the primary nurse (medication nurse) usually completed treatments but there was no set system for wound care, dressing changes or measuring of wounds. The LPN stated staff communicated with each other and usually the nurse who took the order would complete the treatments on their shift. The LPN stated if there was an order to treat a wound, it would be located on the treatment sheet. The LPN recalled staff applied barrier cream on the sacral region after incontinence care, but did not recall any dressings for the resident's coccyx. The LPN stated she would turn the resident. On 3/22/10 at 8:00 a.m., the Director of Nursing stated treatments were done weekly by the medication nurse and the unit managers generated a weekly report on wound measurements. However, neither reports generated after 1/19/10 nor information requested from the Assistant Administrator (see above) was provided prior to survey exit (3/22/10)