Every finding on record at South Platte Rehabilitation and Nursing LLC

Based on record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for one (#2) of five sample residents reviewed for respiratory care out of 12 sample residents.Resident #2, who was admitted to the facility on [DATE], had a history of chronic obstructive pulmonary disease (COPD - air flow blockage) and required continuous oxygen. On [DATE] at approximately 8:30 a.m. the facility experienced a 45-minute electrical power outage and the backup generator failed to turn on. The social services director (SSD), who was also a certified nurse aide (CNA), transitioned two residents, including Resident #2, from their oxygen concentrators to their portable oxygen canisters when the power went out. On [DATE] at 10:15 p.m. Resident #2 was found unresponsive with an empty portable oxygen canister, requiring cardiopulmonary resuscitation (CPR). The resident was transported by emergency medical services (EMS) to the hospital and expired on [DATE].Licensed practical nurse (LPN) #1, who worked dayshift on [DATE] during the power outage, was aware Resident #2 had been placed on the portable oxygen canister. However, the nursing staff failed to: transition Resident #2 back to her oxygen concentrator from the portable oxygen canister once the electrical power outage was restored on [DATE] at 9:15 a.m., provide adequate monitoring of a resident on continuous oxygen and ensure Resident #2's portable oxygen canister was flowing and communicate to the nightshift team that Resident #2 was placed on a portable oxygen canister at 8:30 a.m.The facility staff were unaware Resident #2's portable oxygen canister was not delivering oxygen until registered nurse (RN) #1 found the resident unresponsive at 10:15 p.m., when the resident was still connected to the portable oxygen source. CNA #1 and RN #1 found the portable oxygen canister had been depleted of oxygen and was empty. The resident's oxygen saturation level was 82 percent (% - her normal oxygen saturation was 94% to 97%) and her heart rate was 48 beats per minute (bpm - a normal heart rate would be between 60 bpm and 100 bpm) when she was found. No additional vital signs were taken when the resident was found unresponsive.Specifically, the facility failed to:-Ensure Resident #2 received adequate monitoring of her continuous oxygen; and,-Ensure Resident #2 was provided with continuous oxygen per physician's order. Findings include:I. Immediate jeopardyA. Findings of immediate jeopardy The facility failed to have an effective system in place to ensure residents who required continuous oxygen therapy received oxygen during a power outage. Resident #2 had a diagnosis of COPD and received continuous oxygen via a nasal cannula. On [DATE] the facility experienced a power outage. The resident was placed on a portable oxygen tank during the power outage. The facility failed to return Resident #2 to a continuous oxygen concentrator once the power was restored. Additionally, the facility failed to check the amount of oxygen in the portable oxygen canister for a significant period of time resulting in the portable oxygen canister being empty for approximately eight hours. The resident became unresponsive and experienced a weak heart beat at a rate that was significantly lower than her typical heart rate. Lack of supplemental oxygen over an extended period of time for Resident #2, and any other resident, was likely to result in serious harm.B. Facility notice of immediate jeopardy On [DATE] at 6:44 p.m. the nursing home administrator (NHA) was notified that the facility's failure to ensure the staff ensured residents were receiving continuous oxygen per physician's orders and the facility's backup generator was functioning during a power outage created a situation of immediate jeopardy for serious harm. C. Plan to remove immediate jeopardyThe facility's investigation implemented in response to local law enforcement's investigation related to Resident #2's unexpected expiration on [DATE] was provided by the chief nursing officer on [DATE] at 4:45 p.m. The plan read as follows:1. Immediate actionRN #1 and CNA #1 immediately activated emergency procedures, notified the physician and called emergency medical services (EMS) when they discovered Resident #2 was unresponsive. The resident was transferred to the hospital for evaluation and treatment, where she expired.The NHA initiated and conducted, alongside the director of nursing (DON), an investigation on [DATE] at 9:15 p.m. All residents who received supplemental oxygen were assessed to ensure their oxygen equipment was functioning properly, they were properly connected to their prescribed oxygen delivery systems and to verify oxygen flow.The investigation was ongoing at the time of the survey. The facility determined that Resident #2's portable oxygen tank was found to be empty at the time of the incident, and documented that Resident #2 was alert and oriented throughout the day. Resident #2 was capable of making her needs known, including reporting if her oxygen was not functioning properly. Staff reported to the facility that Resident #2 was last observed around dinner time, at which point she was at her baseline and made no complaints. Nightshift staff checked on the resident approximately four hours later and found Resident #2 unresponsive. The resident's call light was within reach during this period, and there were no reported call light activations.2. Identification of others affectedThe facility determined the deficient practice had the potential to affect any resident in the facility who utilized supplemental oxygen.3. Systemic changesOn [DATE], the DON educated all nursing staff and CNA staff on how to verify the oxygen source and flow for residents using supplemental oxygen, safe use and monitoring of portable oxygen tanks, responsibilities for monitoring residents' oxygen status, reporting concerns promptly and routine rounding expectations. On [DATE], the DON initiated and educated staff on the Walking Shift Report, which would help ensure safe handoff of residents at shift change by requiring staff to document the percentage of meal intake, bath/shower status, if perineum care was performed, out of bed status, turn every two hours, vital signs, if oral care was performed and the behavior of each resident every shift.On [DATE], the facility implemented a plan to ensure there was a process to check portable oxygen supply on a regular basis until such time that the resident could be returned to a continuous oxygen concentrator. The process included: -The CNA would check residents on a portable oxygen supply every two hours until the resident could be returned to a concentrator, and the two hour checks would be documented on a portable oxygen check log;-Oxygen tanks would be refilled as necessary; and,-The nurse assigned to the unit would oversee the process to ensure checks were completed as required. Nurses would sign off on the process on the task administration record (TAR).4. MonitoringBeginning on [DATE], the DON would evaluate the effectiveness of the plan and audit all residents with supplemental oxygen orders to ensure the oxygen delivery equipment was properly functioning and providing the ordered liter flow. This audit would occur daily for two weeks, then three times per week for four weeks, then weekly for six weeks. Beginning on [DATE], the DON would also audit the portable oxygen check log for each resident with oxygen orders daily for two weeks, then three times a week for four weeks, then weekly for six weeks. Audits would be reported to the quality assurance and program improvement (QAPI) committee.5. Removal of immediate jeopardyOn [DATE] at 12:06 p.m. the NHA was notified that the immediate jeopardy was lifted based on the evidence of the facility's implementation of the plan. However, the deficient practice remained at a G level, actual harm that is not immediate. II. Facility policy and procedureThe Oxygen Administration policy, dated [DATE], was provided by the chief nursing officer on [DATE] at 11:44 a.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall document the ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.III. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included COPD, right heart failure (the heart can not effectively pump blood to the lungs) and type 2 diabetes mellitus with diabetic kidney complication.The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #2 was dependent on staff for activities of daily living (ADL), including dressing, showering, toileting and ambulating. She required set-up assistance for meals.B. Record reviewReview of Resident #2's [DATE] CPO revealed the following physician's orders:-Oxygen monitoring: obtain oxygen saturation every shift while on two liters per minute (LPM) via nasal cannula, continuous related to COPD, ordered [DATE].-COPD Monitoring: observe for shortness of breath (SOB) while performing activities and while lying flat. Observe for signs/symptoms of cyanosis (bluish discoloration of the skin and mucous membranes due to a lack of oxygen in the blood), accessory muscle use, chest wall movement and/or shape abnormalities, presence of cough and/or sputum, peripheral edema, or changes in level of consciousness (LOC). Obtain oxygen saturation results if abnormalities are observed. Every shift, ordered [DATE].-SOB (shortness of breath) monitoring: elevate the head of the bed to a minimum of 30 degrees if experiencing shortness of breath while lying flat every shift for SOB related to COPD, ordered [DATE].-A physician's order for two LPM of continuous oxygen via nasal cannula was not found in the [DATE] CPO at the time of the survey.Resident #2's oxygen therapy care plan, initiated [DATE], documented the resident was on oxygen therapy related to her COPD diagnosis. Pertinent interventions, initiated [DATE], included to change the resident's position often to facilitate lung secretion movement and drainage and to encourage or assist with ambulation as indicated.-Resident #2's care plan failed to address the resident's need or potential need for portable oxygen canisters and failed to specify the frequency staff should round on the resident to ensure the portable tank would not run out of oxygen.Review of Resident #2's electronic medical record (EMR) revealed the following documentation by LPN #1 on [DATE]:-Resident #2's oxygen saturation result was 97% at 3:38 p.m.-Resident #2's last documented blood sugar level check was 168 milligrams per deciliter (mg/dl) at 5:02 p.m.Resident #2's EMR revealed the following documentation by RN #1 on [DATE]:The nursing progress note, dated [DATE] and documented by RN #1, revealed RN #1 went into Resident #2's room to deliver her nighttime medications. The nurse tried to wake the resident up to administer medications, but the resident was unresponsive. The nurse started to sternum rub the resident to awaken her but the resident did not respond. The nurse called for help from nearby CNAs and asked if anyone could get vital sign supplies. The note documented CNA #1 ran into the room and also tried to awaken the resident, but the resident did not respond. The nurse yelled for nearby nursing staff to call EMS and check the code status of the resident. Resident #2 was breathing shallowly with a bounding pulse, her pupils were non-reactive to light. CNA #1 turned the oxygen up to four LPM. An unidentified CNA ran into the room with a crash cart where CPR was performed for approximately eight minutes. The note documented police officers arrived on the scene first, where they tried to awaken the resident by sternum rub without success. Resident #2's pulse returned but was thready (a weak but rapid pulse) and an oxygen mask was applied while the facility staff waited for EMS to arrive. The note documented EMS arrived and took over. The resident was shocked twice after the pulse weakened again. The note documented EMS was able to transfer the resident to a gurney after stabilization, and the resident was taken to a local hospital for evaluation. The resident's family was notified.Another nursing progress note was documented by RN #1 on [DATE] at 11:40 p.m. and clarified at 5:28 a.m. The note documented CPR was discontinued upon the return of Resident #2's pulse. A sternum rub was initiated by RN #1 and responding officers. A thready but palpable pulse was noted on the right wrist. The resident's oxygen saturation level was 82% after approximately 30 seconds on four LPM of oxygen via nasal cannula, with a heart rate of 48 bpm. EMS arrived on the scene and assumed care of the resident.IV. Staff interviewsRN #1 was interviewed on [DATE] at 8:20 a.m. RN #1 said her nightshift on [DATE] began with another resident causing a commotion and cursing at staff; simultaneously, she was called to the other unit within the facility to assess a resident who had sustained a fall. RN #1 said it was not unusual for her to administer Resident #2's nighttime medications around 9:30 p.m., but she did not enter Resident #2's room until 10:15 p.m. on [DATE]. She said Resident #2 was consistent about advocating for her needs with her call light, but the resident had not used her call light that evening. RN #1 said she had no reason to be concerned about Resident #2 at the start of her shift. She said the dayshift team reported to the nightshift team that the resident was acting like herself, speaking and without complaints of pain or shortness of breath. RN #1 said when she found the resident unresponsive at 10:15 p.m., she said she began sternal rubbing to which the resident remained unresponsive. She said she called nearby staff to call EMS and the staff collaborated to find out the resident's code status. RN #1 said the resident was breathing shallowly with an oxygen saturation level of 82% and a weak pulse rate of 48 bpm. She said no additional vital signs were obtained. RN #1 said the resident's pupils were nonreactive to light. She said she had transitioned the resident from the portable oxygen canister to an oxygen concentrator; however, the concentrator that had been in the resident's room was not functioning properly so another staff member retrieved a concentrator that worked. RN #1 said the resident was placed on four LPM of oxygen via nasal cannula and she initiated CPR per EMS' instructions. RN #1 said once EMS arrived at the scene, staff were asked to leave the room and the resident was transported to the hospital. RN #1 said she thought the last time anyone laid eyes on Resident #2 was between 6:00 p.m. and 6:30 p.m.The coroner was interviewed on [DATE] at 8:50 a.m. The coroner said he was investigating the death of Resident #2. CNA #1 was interviewed on [DATE] at 10:43 a.m. CNA #1 said the start of her nightshift on [DATE] was very busy, as there was a combative resident and multiple call lights were ringing at the same time. She said it calmed down around 10:00 p.m. just before RN #1 found Resident #2 unresponsive in her room. CNA #1 said RN #1 initiated CPR per EMS' instruction. She said there was a power outage that morning ([DATE]) at 8:00 a.m., so the resident had been connected to a portable oxygen canister. She said she noticed the portable oxygen canister was empty when the resident transitioned from the portable oxygen canister to an oxygen concentrator that functioned properly after RN #1 found the resident unresponsive. CNA #1 said EMS stabilized the resident, then transported her to the hospital. She said she thought the last time anyone laid eyes on Resident #2 was by someone on dayshift at dinner time around 5:30 p.m. and said staff did not normally perform bedside reports during shift change.RN #1 was interviewed again on [DATE] at 10:57 a.m. RN #1 said she did not know if the portable oxygen canister had been delivering oxygen when she found Resident #2 unresponsive. She said the nasal cannula was in the resident's nostrils, but she did not think the portable canister had been delivering oxygen because when the resident was placed on the oxygen concentrator at four LPM she did notice a slight increase in the resident's oxygen saturation. The coroner was interviewed again on [DATE] at 11:50 a.m. He said he was performing an autopsy that day and one of the things he was looking into was if Resident #2 was deprived of oxygen.The maintenance director (MTD) was interviewed on [DATE] at 12:50 p.m. The MTD said the power went out around 8:30 a.m. on [DATE] and was back on by 9:15 a.m. He said he came to the facility during the power outage and discovered a faulty wire on the emergency shutoff. The MTD said the generator was on automatic, however the generator did not kick on throughout the 45-minute outage as a result of the faulty wire. He said the faulty wire was repaired by an outside company on [DATE] and he had since performed a daily test on the generator to ensure it was functioning properly.The MTD said he tested the generators monthly with load and weekly without load. The MTD said prior to the [DATE] power outage, the last generator test was performed on [DATE] and the generator performed as expected and initiated after two and a half seconds. He said he was not aware of any issues the facility experienced as a result of the power outage on [DATE].The DON was interviewed on [DATE] at 1:20 p.m. The DON said she became aware of Resident #2's unexpected expiration on the morning of [DATE] via a phone call from the NHA. She said the resident's family had concerns related to her passing and were requesting an investigation, which prompted the facility's investigation to figure out what happened. The DON said staff had been in the room to offer the resident dinner around 5:30 p.m. on [DATE]. She said from what she could gather, no staff laid eyes on the resident between 5:30 p.m. and 10:15 p.m., although shift change occurred between 6:00 p.m. and 6:30 p.m. She said Resident #2 would ring the call light when she needed something, but she did not use her call light the evening of [DATE]. The DON said staff would only put residents on a portable oxygen canister if the resident were leaving their room or, in this case, a power outage occurred. The DON said when the power went out on [DATE], the SSD grabbed portable tanks for residents who were on oxygen concentrators and placed Resident #2 on a portable oxygen canister. The DON said Resident #2 was found unresponsive on the portable oxygen canister, and CNA #1 and RN #1 reported to her that the portable oxygen canister was empty. She said the nursing staff should have switched Resident #2 back to the oxygen concentrator right when they noticed the power was restored. The DON said if she were caring for residents with continuous oxygen on a portable oxygen canister, she would check on the residents at the beginning of, and frequently throughout, her shift. She said a resident who required continuous oxygen and did not receive it, would have a hard time breathing and would have decreased oxygen to the brain.The medical director (MD) was interviewed on [DATE] at 3:17 p.m. The MD said she had not yet been informed of Resident #2's expiration and she had not seen a death certificate. She said a resident with COPD who required continuous oxygen but did not receive it would have experienced oxygen saturation levels that would drop and continue to drop, creating a poor oxygen environment that the heart would not be able to function in.A representative from the vendor used by the facility for respiratory care was interviewed on [DATE] at 4:45 p.m. The representative said the manufacturer stated that a full portable tank would be empty after four to five hours. He said in his experience, the portable tanks last about three to three and a half hours at a rate of two LPM if the tank was properly filled. The representative said the staff need to fill the tank every time a resident was moved and the tank should be checked frequently. RN #1 was interviewed a third time on [DATE] at 5:28 p.m. RN #1 said it had not been communicated to her in report from the dayshift team that Resident #2 remained connected to a portable oxygen canister.The SSD was interviewed on [DATE] at 11:10 a.m. The SSD said when the power went out on [DATE], she placed residents who required a portable oxygen tank, including Resident #2, on the portable canister. The SSD said LPN #1 was aware Resident #2 had been placed on a portable oxygen canister. She said LPN #1 requested her to place Resident #2 on the portable oxygen canister. The SSD said she knew the oxygen canister was full when she placed Resident #2 on the portable canister because she filled it up herself and believed that oxygen tanks could last roughly eight hours at a rate of two LPM.LPN #1 was interviewed on [DATE] at 12:14 p.m. LPN #1 said she was Resident #2's dayshift nurse on [DATE]. She said she was aware Resident #2 had been placed on the portable oxygen canister and knew she had checked the resident's oxygen saturation level around noon that day. LPN #1 said she did not check if the portable canister had been delivering oxygen, nor did she check the amount of oxygen that was left in the portable canister at any time during her shift. She said the last time she spoke with Resident #2 was at 4:45 p.m. on [DATE], when she checked the resident's blood pressure and talked about dinner. She said during that time, Resident #2 was not cyanotic or gasping at that time. LPN #1 said she guessed it probably would have been her responsibility to switch Resident #2 from the portable canister to the oxygen concentrator. CNA #3 was interviewed on [DATE] at 12:22 p.m. CNA #3 said she was working dayshift on [DATE], but she only went into Resident #2's room for breakfast that morning. She said Resident #2 did not complain of any pain or shortness of breath at that time and the resident was really good at using her call light to let staff know if she needed something. CNA #3 said it was not routine to regularly round on residents who were on portable oxygen canisters. She said she did not know who should have been responsible for switching Resident #2 back to her oxygen concentrator when power was restored.The DON was interviewed again on [DATE] at 1:12 p.m. The DON said someone should have checked on the portable oxygen canister. She said the portable oxygen canister was full when the SSD put Resident #2 on the portable oxygen tank, but nurses or CNAs should have been monitoring to ensure the canister did not run out of oxygen.

Based on record review and interviews, the facility failed to ensure residents received services from qualified individuals who had the skills, experience, knowledge and proper licensure to meet the residents' needs for one (#1) of four residents out of 12 sample residents.Specifically, the facility failed to ensure a qualified and licensed nurse received shift report, evaluated the resident condition, obtained physician's orders for Resident #1.Findings include:I. Facility policy and procedureThe Provision of Quality Care policy, revised April 2025, was provided by the director of nursing (DON) on 10/14/25 at 2:07 p.m. It read in pertinent part, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans and the residents' choices. To ensure persons are qualified, department heads, in collaboration with facility leadership and the HR (human resource) department, will be responsible for verifying credentials of all employees prior to hire, oversight to ensure ongoing employee competency, and education regarding areas of employee weaknesses.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on 9/1/25. According to the September 2025 computerized physician orders (CPO), diagnoses included compression fracture of lumbar vertebrae (spine), diabetes, heart failure and urinary tract infection.The 7/28/25 minimum data set (MDS) assessment revealed Resident #1 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. He was independent with eating and required substantial assistance with showering, toileting, personal hygiene and dressing.B. Record reviewA nurse progress note, dated 9/1/25 at 1:56 p.m., documented Resident #1 was lethargic and not opening his eyes on 9/1/25 at 8:55 a.m. It documented the resident's blood sugar level was elevated and the on-call nurse practitioner (NP #2) was notified. New physician's orders were received for insulin and a blood sugar level recheck. The note documented NP #2 was notified again after recheck of the resident's blood sugar level. The note indicated additional physician's orders were obtained to administer Humalog insulin and follow-up blood sugar level checks.Review of Resident #1's September 2025 CPO and the resident's September 2025 medication administration record (MAR) revealed the following physician's orders and administration history:Humalog (insulin) 100 units per milliliter (ml), inject 4 units subcutaneously (SQ, the fatty tissue layer under the skin) one time only for elevated blood sugar, ordered 9/1/25 at 9:00 a.m -The September 2025 MAR documented the certified nurse aide with medication authority (CNA-Med) administered the injectable insulin medication at 9:00 a.m. Humalog 100 units per ml, inject 6 units SQ, one time only for elevated blood sugar, ordered 9/1/25 at 10:00 a.m.-The September 2025 MAR documented the CNA-Med administered the injectable insulin medication at 10:00 a.m.Humalog 100 units per ml, inject 10 units SQ, one time only for elevated blood sugar, ordered 9/1/25 at 10:30 a.m.-The September 2025 MAR documented the CNA-Med administered the injectable insulin medication at 10:30 a.m. Ciprofloxacin oral tablet, 250 milligrams (mg), one tablet by mouth two times a day for UTI (urinary tract infection) until 9/6/25, ordered 9/1/25 at 10:58 a.m.FSBS (fasting blood sugar), notify physician if above 450 milligrams (mg)deciliter (dl) or below 70 mg/dl, three times a day, ordered 9/1/25 at 12:00 p.m.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/13/25 at 1:30 p.m. LPN #1 said on 9/1/25 at 9:00 a.m. the CNA-Med informed her that Resident #1 was not as responsive as usual and that the CNA-Med had checked a blood sugar level on the resident and his blood sugar level reading was high. LPN #1 said the CNA-Med called NP #2 and NP #2 gave the CNA-Med a physician's order to check Resident #1's blood pressure using a manual cuff (not to use a machine) and a physician's order to give short-acting insulin to Resident #1. LPN #1 said she was the one who entered the physician's orders into the resident's electronic medical record (EMR). LPN #1 said she did not complete or document a physical evaluation of Resident #1's condition that day because she did not know she was responsible for Resident #1's care. LPN #1 said she was the only nurse in the building that day. LPN #1 said she did not receive a shift report of Resident #1s condition, however, she said the CNA-Med did receive the nursing shift report of Resident #1's condition. LPN #1 said she never received a nursing report regarding any of the residents the CNA-Med was assigned to on 9/1/25. LPN#1 said she later reviewed her responsibilities in this situation with the DON) and said she should have been overseeing Resident #1's care on 9/1/25.The CNA-Med was interviewed on 10/13/25 at 2:34 p.m. The CNA-Med said on 9/1/25, she received the nursing report for all of the residents whom she was assigned to pass medications to that day. She said at 9:00 a.m., she noticed Resident #1 was not as active or communicative and she thought something might be wrong. The CNA-Med said she checked Resident #1's vital signs (blood pressure, heart rate, respiratory rate and temperature) and his blood sugar level, and conveyed the results to LPN #1 who told the CNA-Med to contact NP #2. The CNA-Med said she called NP #2 and NP #2 gave her a physician's order to recheck Resident #1's blood pressure and she also received an insulin medication order from NP #2. The CNA-Med said NP #2 asked her to call back in 30 minutes after a recheck of Resident #1's blood sugar level. The CNA-Med said a head-to-toe evaluation of Resident #1's condition was not completed that day. The CNA-Med said she did not notify the DON of Resident #1's condition until Resident #1 was leaving the facility. The CNA-Med said she called NP #2 several times that day and received multiple physician's orders for insulin and blood sugar level monitoring from NP #2. She said she also received a physician's order to transfer Resident #1 to the hospital. The CNA-Med said she thought she could take physician's orders from a medical provider and after this incident, she learned she should not have evaluated and communicated Resident #1's condition or received physician's orders from NP #2. NP #2 was interviewed on 10/14/25 at 10:05 a.m. NP #2 said the CNA-Med contacted her at least five times on 9/1/25 and she provided several physician's orders to the CNA-Med. NP #2 said she was not aware at the time that the CNA-Med was not a licensed nurse and the CNA-Med only identified herself by name. NP #2 said LPN #1 did not communicate to her any information about Resident #1's condition. NP #2 said the CNA-Med could not do a nursing evaluation and this would have required an assessment by a licensed nurse. The DON was interviewed on 10/15/25 at 1:13 p.m. The DON said because Resident #1 was at the facility for skilled nursing care, he should have received a skilled nursing evaluation every shift, including the 9/1/25 day shift. The DON said LPN #1 did not receive a nursing shift report for all of the residents the CNA-Med was providing medications to, which included approximately 25 residents. The DON said LPN #1 should have received the nursing shift report for all of the residents in the facility, as she was the only licensed nurse in the facility during that shift. The DON said the CNA-Med should not have received the nursing shift report, independently evaluated the resident's condition or communicated with and received physician's orders from NP #2, as this was not within her scope of practice. The DON said LPN #1 should have been communicating with NP #2 and receiving the physician's orders.

Based on record review and interviews, the facility failed to provide catheter care in accordance with standards of professional practice for one (#3) of three residents out of 12 sample residents.Specifically, the facility failed to ensure the urinary catheter was changed timely for Resident #3. Findings include:I. Facility policy and procedureThe Catheter Care policy, dated 4/11/25, was provided by the chief nursing officer on 10/14/25 at 11:44 a.m. It read in pertinent part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.II. Resident #3A.Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), the diagnoses included dementia and bladder neck distention (the bladder is enlarged due to the opening where the bladder connects to the urethra being blocked).The 9/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. He required set-up assistance with eating and partial/moderate assistance with oral hygiene. He was dependent on staff for activities of daily living (ADLs) including dressing, showering, toileting and mobility. The 9/25/25 MDS assessment revealed the resident used an indwelling catheter.B. Record reviewResident #3's catheter care plan, initiated on 5/30/24 and revised on 9/5/25, revealed the resident had a suprapubic catheter. Pertinent interventions included documenting urinary output each shift, monitoring/recording/reporting to the physician any signs or symptoms of urinary tract infection (UTI), ensuring the catheter tubing was securely anchored to prevent accidental removal of the catheter and providing dressing changes to the suprapubic catheter site per the physician's orders.Review of Resident #3's October 2025 CPO revealed a physician's order for the following:Change the suprapubic catheter every month at the facility using an 18-French catheter, every night shift starting on the second and ending on the second of every month, ordered 9/2/25 at 1:36 p.m. and revised on 10/2/25 at 6:00 p.m.Review of Resident #3's electronic medical record (EMR) revealed the suprapubic catheter was last changed by overnight staff on 9/2/25 per physician's order.A nursing progress note, dated 10/3/25, revealed the resident's catheter did not get changed during shift. The staff reached out to an on-call provider and received authorization to place a one time order for a suprapubic catheter change on the overnight shift for 10/3/25 to 10/4/25.-However, review of Resident #3's EMR did not reveal documentation indicating the resident's catheter had been changed since 9/2/25.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/13/25 at 1:48 p.m. LPN #1 said an indwelling catheter should be changed every 30 days. She said she knew that Resident #3's suprapubic catheter had been placed by urology in August 2025. LPN #1 spent a few minutes searching the resident's EMR to find the date the suprapubic catheter was last changed. She said she did not know when the urinary catheter was last changed.The director of nursing (DON) was interviewed on 10/15/25 at 1:12 p.m. The DON said she was aware Resident #3 had physician's orders for suprapubic catheter care and for the catheter to be changed monthly. She said the urinary catheter was supposed to be changed on the second, but she saw a note that said the nightshift staff member received a one time order for dayshift to change it. The DON said based on what she saw documented on the task administration record (TAR), she did not think the catheter change had been completed yet. She said if the urinary catheter was left indwelling for too long, there could be a chance of infection or the catheter might not work properly. The DON said the urinary catheter should not be placed and then never replaced or removed.

Based on observations, record review and interviews, the facility failed to ensure two (#5 and #6) of two residents reviewed for abuse out of eight sample residents were kept free from physical abuse. Resident #4 was admitted to the facility on [DATE] with diagnoses which included alcohol abuse and encephalopathy (brain disease that affects brain function). The resident had a mood problem related to being quick tempered, had poor coping skills and could exhibit verbally aggressive outbursts towards others when he disagreed with them. On 10/21/24, certified nurse aide (CNA) #1 witnessed Resident #4, who was coming inside from the smoking area, purposefully run his wheelchair into Resident #5, who was in the hallway in her wheelchair waiting to go outside to the smoking area. Resident #5 sustained redness to the left lower leg above the ankle and an abrasion to her right forearm where the top layer of skin had come off, in addition to right shoulder and leg pain. Resident #5, who had a diagnosis of anxiety disorder, reported she had increased anxiety and felt more isolated since the incident with Resident #4 because she would stay in her room when Resident #4 was in the hallway due to the anxiety she felt when she was around him. Due to the facility's failures to protect Resident #5 from physical abuse from Resident #4 on 10/21/24, Resident #5 suffered psychosocial harm following the incident. Furthermore, the facility did not initiate additional interventions for Resident #4 following the 10/21/24 incident with Resident #5 to prevent the abuse from occurring again. On 11/21/24 Resident #4 stood up from his wheelchair and grabbed Resident #6 by the shirt collar and pushed Resident #6. Resident #6 pushed Resident #4 away and Resident #4 stumbled backwards and hit his head but did not sustain any injuries. Due to the facility's failures to implement effective behavior interventions and monitoring for Resident #4, the resident was involved in a second resident to resident altercation with Resident #6 one month after the incident with Resident #5. Findings include: I. Facility policy and procedure The Abuse policy, revised 6/11/24, was provided by the regional director of quality and compliance (RDQC) on 1/6/25 at 11:59 a.m. It read in pertinent part, Every resident has the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. This facility does not condone resident abuse and shall take every precaution to prevent resident abuse. Resident abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish or deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. Residents with aggressive or abusive behaviors shall have their care plans written and revised as needed to include approaches to reduce or eliminate the risk for abuse. The facility will ensure that all residents are protected from physical and psychosocial harm during and after abuse investigations, including but not limited to: examining the alleged victim for any sign of injury, including a physical examination and/or psychosocial assessment as indicated, increasing supervision of the alleged victim and other residents as indicated, providing emotional support and/or counseling to the resident during and after the investigation as needed. II. Incident of physical abuse of Resident #5 by Resident #4 on 10/21/24 A. Facility incident report and investigation The 10/21/24 incident report was provided by the RDQC on 1/7/25 9:14 a.m. The report documented the nurse was informed Resident #4 purposely collided into Resident #5 while both residents were seated in their wheelchairs. Resident #4 continued down the hall to his room and Resident #5 was assessed for injuries. Resident #5 reported her right arm was jarred and the nurse documented a 0.5 centimeter (cm) by 0.5 cm abrasion on her right forearm where the top layer of skin had come off. Resident #5 reported her left lower leg above the ankle hit the wheel of her wheelchair. The nurse documented redness to the skin above the resident's left ankle. According to the incident report, there were no predisposing factors which caused the incident to occur. The abuse investigation report, documented on 10/21/24 at approximately 2:37 p.m., documented CNA #1 witnessed Resident #4 run into Resident #5 who was in the hallway seated in her wheelchair. CNA #1 separated the residents and called the nurse for assistance. Resident #5 was assessed by licensed practical nurse (LPN) #1 and was noted to have physical injuries, including redness to the left lower leg above the ankle and an abrasion to her right forearm where the top layer of skin had come off. Resident #4 said he did not have any pain and refused a skin assessment. Immediate safety measures documented were placing the assailant (Resident #4) on frequent checks. Resident #5 (the victim) was interviewed and said she was wheeling down the hall towards the smoking area when the supervised smokers, including Resident #4 (the assailant), were coming inside. Resident #5 said she made a comment to Resident #4 that he was driving on the wrong side of the road. She said Resident #4 wheeled right into her with his legs hitting hers and spoke profanity to her. Resident #5 said the impact threw her back in her wheelchair causing right shoulder and leg pain. Resident #4 was interviewed and said he was coming inside from smoking. He said Resident #5 told him he should not be driving on the wrong side of the road. Resident #4 said he told her to stay where she was or he would run into her. Resident #4 said he ran into Resident #5 and left. The incident was substantiated by the facility. B. Resident #4 (assailant) 1. Resident status Resident #4, age 68, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included liver disease, epilepsy, diabetes, alcohol abuse and encephalopathy (brain disease that affects brain function). The 11/13/24 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. Resident #4 used a wheelchair, was independent with eating and transferring self and required set up assistance with showering. The MDS assessment revealed Resident #4 had no behavioral symptoms during the prior seven-day assessment look-back period. 2. Resident interview Resident #4 was interviewed on 1/6/25 at 2:50 p.m. Resident #4 said he got along well with other residents and had not had any altercations. Resident #4 laughed and said no one had made him angry at the facility but he said if anyone did make him angry, he would punch them. 3. Record review Resident #4's behavior care plan, initiated 8/16/23 and revised 11/14/24, documented that he had a mood problem related to being quick tempered, had poor coping skills, pressured others to move out of his way (sometimes verbally) and patted the backs of others wheelchairs in attempts to get them to move out of the way. Interventions included encouraging better coping skills and patience with others when they were moving slowly through the hall (initiated 8/16/24), administering medications as ordered, providing behavior health consultations as needed and observing and recording his mood to determine if problems were related to external causes, (all revised 8/20/24). -The facility failed to update the care plan with new interventions following the 10/21/24 incident with Resident #5. Resident #4's behavior success care plan, initiated 10/1/24 and revised 10/4/24, addressed the resident's verbally aggressive outbursts towards others when he disagreed with them. Interventions (all initiated 10/1/24) included encouraging self-calming behavior such as breathing exercises, ensuring the safety of the resident and others, establishing boundaries and limits with the resident, providing emotional support regarding new onset disruptive behavior and utilizing diversion techniques. -The care plan did not define any triggers for the aggressive outbursts or ways to ensure the safety of others. -The facility failed to update the care plan with new interventions following the 10/21/24 incident with Resident #5. Resident #4's physical aggression care plan, initiated 12/23/24, documented the resident had actual incidents of physical aggression and the potential to become physically aggressive related to the history of aggression and harm to others, poor impulse control and complications with self-mood regulations. The care plan identified Resident #4's triggers for physical aggression were primarily territorial. The resident disliked it when others hovered around his room or invaded his personal space. Interventions included administering medications as prescribed, assessing and addressing contributing sensory deficits (minimizing noise, dimming the lights, keeping the door closed and giving him space from others), providing physical and verbal cues to alleviate anxiety, assisting with verbalizing the source of agitation, encouraging the resident to seek out a staff member when agitated, conducting a thorough analysis of circumstances that may influence behaviors paying attention to triggers that contributed to the behavior, documenting observed behaviors and attempted interventions in the care plan, avoiding large crowds, recognizing his need for personal space, psychiatric consultation as needed and taking prompt action if the resident became agitated to prevent further escalation. -Resident #4's physical aggression care plan was not initiated until two months after the incident with Resident #5 and one month after the resident's second incident of physical abuse towards another resident (see below). -Resident #4's electronic medical record (EMR) failed to reveal documentation that frequent checks were conducted for Resident #4 after the incident, as was specified as an immediate intervention in the facility's investigation report (see investigation above). An interdisciplinary (IDT) team note, dated 10/23/24 at 1:09 p.m., documented the IDT met to review Resident #4 related to his smoking behavior and his recent resident-to-resident altercation with another resident. The note documented an additional plan of care was being implemented for behavior monitoring. The resident was scheduled to meet with the social services director (SSD) for a biweekly review. The facility would review and update as needed. -Review of Resident #4's care plan revealed his behavior care plan was not updated following the 10/21/24 incident (see care plan above). C. Resident #5 (victim) 1. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included acute infarction of spinal cord (spinal cord stroke causing pain or loss of sensation in the back down to legs), occipital neuralgia (pain or loss of sensation in the back of the head and neck), anxiety disorder, hypertension (high blood pressure) and type 2 diabetes mellitus. The 10/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with personal hygiene, dressing and transfers. She did not walk but was independent with mobility using a wheelchair. 2. Resident interview Resident #5 was interviewed on 1/6/25 at 9:06 a.m. She was sitting in her wheelchair in her room with both privacy curtains pulled around her. Resident #5 said she did not feel safe at the facility. She said Resident #4 waited in the hall near the door to the smoking area for long periods of time. Resident #5 said she stayed in her room if Resident #4 was in the hallway. Resident #5 said she did not go outside to smoke when Resident #4 went outside because it made her anxious to be around him. Resident #5 said she believed she had whiplash from the incident when Resident #4 rammed into her wheelchair. She said she had a tight knot in the back of her neck for a while afterwards and had to have physical therapy. Resident #5 said she just wanted to move to another facility. Resident #5 was interviewed again on 1/7/25 at 12:41 p.m. Resident #5 was lying in her bed with the privacy curtains closed on both sides with her television on. Resident #5 said she felt more isolated since the incident with Resident #4 because she stayed in her room more. Resident #5 said whenever she saw Resident #4 in the hall she felt anxious and went back into her room. She said she felt like Resident #4 was always in the hall. She said he came down early and sat by the exit to the smoking area. Resident #5 said she believed Resident #4 tried to intimidate her. Resident #5 said things were good for a couple of weeks after the incident with Resident #4 because the supervised smokers were going out back to smoke and she never saw Resident #4. However, Resident #5 said it only lasted for a couple of weeks because there was no fencing or shelter in the back smoking area so the supervised smokers were no longer smoking there. She said Resident #4 continued to go down her hallway past her room several times a day to get to the smoking area. 3. Record review Review of Resident #5's trauma-informed care plan, initiated 12/23/24 (two months after the 10/21/24 incident with Resident #4), documented Resident #5 was fearful related to an incident that occurred at the facility when another resident exhibited aggressive behavior towards her. Interventions included offering Resident #5 another room on the opposite hall (which she declined), offering to escort her to desired locations in the facility (declined due to personal choice), arranging for services with a mental health provider, encouraging her to share her feelings and concerns with staff, identifying items that lessened the effect of the trauma and monitoring her whereabouts and emotional state. -The facility failed to initiate a trauma care plan to address Resident #5's trauma related to the incident with Resident #4 until two months after the incident on 10/21/24. The 7/23/24 Resident Mood Interview assessment (prior to the incident), revealed Resident #5 scored a zero out of 30, indicating she did not have any symptoms of depression. Resident #5 indicated she never felt lonely or socially isolated. The 10/23/24 Resident Mood Interview assessment (after the incident), revealed Resident #5 scored a six out of 30, indicating she was experiencing depression. The resident indicated she felt down, depressed or hopeless, had trouble falling or staying asleep or was sleeping too much and felt tired or had little energy more than half of the days during a two week period. Resident #5 indicated she sometimes felt lonely or socially isolated. -Review of Resident #5's EMR revealed there was no documentation to indicate the resident's mood changes had been identified or addressed by the facility following the incident with Resident #4. Cross-reference F742 for failure to provide treatment/services for mental/psychosocial concerns. D. Staff interviews LPN #1 was interviewed on 1/6/25 at 9:56 a.m. LPN #1 said she did not witness the occurrence between Resident #4 and Resident #5 but she knew one of the residents was coming in from smoking and the other was going out. LPN #1 said Resident #5 told her Resident #4 rammed his wheelchair into her knees. LPN #1 said Resident #5 did not have any visible marks (however, the occurrence investigation revealed she had an abrasion on her arm and redness to her knee) but later Resident #5 said she got whiplash. LPN #1 said Resident #4 told her people should get out of his way. LPN #1 said they tried to watch for Resident #5 when she came out into the hall or went to smoke. LPN #1 said if Resident #4 was out in the hallway, Resident #5 went back to her room and did not go out to smoke. LPN #1 said frequent checks meant staff laid eyes on the resident every 15 minutes for 72 hours. LPN #1 said the staff documented these checks on paper. CNA #1 was interviewed on 1/6/25 at 11:33 a.m. CNA #1 said on the day of the incident (10/21/24) she saw Resident #4 close to Resident #5 and asked him what he was doing. She said Resident #4 backed away and wheeled down the hall but she did not see him run into Resident #5. CNA #1 said Resident #5 told her Resident #4 took hold of her wheelchair and rammed her into the wall. She said the residents were face to face in their wheelchairs. CNA #1 said the facility did not do 15-minute frequent checks on Resident #4 after the incident. CNA #1 she was not aware of any interventions in place for Resident #4's aggressive behaviors. She said staff were just told to intervene if the residents got too close to each other. The social service director (SSD) was interviewed on 1/7/25 at 10:30 a.m. The SSD said she did not know if there was a physical aggression behavior care plan for Resident #4 prior to the incident on 10/21/24 or when it may have been resolved. The SSD said the facility was using a different EMR program now and she was not able to access the old care plans. The nursing home administrator (NHA), director of nursing (DON) and the RDQC were interviewed together on 1/7/25 at 11:32 a.m. The DON said frequent checks for Resident #4 were implemented following the incident with Resident #5. The DON said frequent checks meant checking on the resident every 15 minutes for 72 hours. The DON said the staff documented on paper and the documentation was uploaded into the EMR. -However, there was no documentation provided to indicate frequent checks were completed for Resident #4 following the incident (see record review above). The NHA said Resident #4 had a brain injury and was triggered by other people not using common sense. The NHA said people knocking on his door agitated him if he was sitting right there and could see them. He was protective of his personal belongings. The RDQC said the facility would be implementing further interventions for Resident #4's behavior care plan. 48458 III. Incident of physical abuse of Resident #6 by Resident #4 on 11/21/24 A. Facility investigation The 11/21/24 facility abuse investigation documented the incident occurred on 11/21/24 at 10:01 a.m. The investigation documented Resident #4 stood up from his wheelchair and grabbed Resident #6 by the shirt collar. Resident #6 responded by pushing Resident #4 who then fell and hit his head on the wall. The residents were immediately separated and placed on frequent checks. The investigation documented two facility staff members witnessed the resident-to-resident altercation. It documented Resident #6 was an at-risk adult. The police, residents' families, the ombudsman and the physician were notified of the resident-to-resident altercation. The investigation revealed there was no evidence of injury to Resident #6. The investigation documented the NHA interviewed Resident #6 following the incident. The investigation documented Resident #6 said he was walking down the hall with a maintenance staff member when Resident #4 said stop acting tough in front of me. Resident #6 said Resident #4 then stood up and grabbed Resident #6's shirt and pushed Resident #6 and then Resident #6 pushed Resident #4 away. Resident #6 said Resident #4 stumbled backwards and hit his head. Resident #6 said he was not fearful of Resident #4 after the incident. The investigation documented Resident #4 was interviewed by the NHA on 11/21/24 at approximately 1:00 p.m. Resident #4 said Resident #6 was outside of Resident #4's room acting like a tough guy. Resident #4 said he told Resident #6 he would slap him around a little bit and then Resident #4 said he stood up and lost his balance and hit his head on a door frame. The investigation documented the following interviews with witnesses to the incident: -An interview with housekeeper (HK) #1 on 11/21/24 at 1:05 p.m. by the NHA. The interview documented HK #1 said Resident #4 stood up and pushed Resident #6 in the chest and then Resident #6 responded by pushing Resident #4 back. -An undated interview with CNA #4, who was also a member of the maintenance staff, was conducted by the NHA. The interview documented CNA #4 was walking down the hallway with Resident #6 when Resident #4 began yelling at Resident #6. Resident #6 approached Resident #4 to listen to Resident #4 and then Resident #4 stood up and grabbed Resident #6 by the shirt collar. Resident #6 pushed Resident #4 and Resident #4 stumbled back and hit his head. The investigation documented Resident #6 was placed on frequent checks, follow-up with mental health services and monitoring for psychosocial abnormalities for the following 72 hours. The care plan for Resident #6 was updated to redirect Resident #6 from wandering in front of rooms or doorways of those who had the potential to be upset by the increased presence. The investigation documented increased supervision and medication change were actions taken for Resident #4 to help prevent a recurrence. The investigation documented Resident #4 had been involved in previous altercations within the past 12 months. The investigation concluded the abuse was substantiated. B. Resident #4 (assailant) 1. Record review A nursing progress note, dated 11/21/24 at 12:55 p.m., documented the nurse heard Resident #4 raising his voice and telling someone don't be stupid in front of my door. When the nurse got up to walk out to hallway to see what was going on, Resident #4 stood up and grabbed Resident #6 by the front of his shirt and Resident #6 shoved him away and Resident #4 struck his head on the doorway and fell to his right side. The SSD immediately intervened and attempted to redirect Resident #6 away from Resident #4 as Resident #4 was attempting to get up and go back at Resident #6. -Review of Resident #4's behavior care plans revealed the care plans were not updated following the incident on 11/21/24 with Resident #6. -Review of Resident #4's comprehensive care plan revealed a care plan focus for physical aggression was not initiated until 12/23/24, one month after the incident with Resident #6 and two months after a previous incident on 10/21/24 with Resident #5 (see above). C. Resident #6 (victim) 1. Resident status Resident #6, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included drug induced dyskinesia (uncontrolled involuntary muscle movement), dysphagia (difficulty swallowing) and dementia. The 11/27/24 MDS assessment revealed the resident had a severe cognitive impairment with a BIMS score of five out of 15. The resident ate and walked independently and he required set-up assistance with showering. The MDS assessment did not reveal any behaviors displayed by the resident toward others. 2. Resident observation and interview Resident #6 was interviewed on 1/6/25 at 1:36 p.m. Resident #6 was standing in his room. He was calm and cooperative during the interview. Resident #6 said there was an incident a while back, but it was over and done and the resident could not remember the specific details of the incident between him and Resident #4. Resident #6 said he did not fear Resident #4. 3. Record review Resident #6's behavioral care plan, revised 5/7/24, revealed a behavior challenge related to Resident #6 being sexually inappropriate with staff and Resident #6 had taken items from staff in a playful manner. -Resident #6's care plan did not reveal any behavioral issues with other residents. A nursing progress note, dated 11/21/24 at 12:55 p.m., documented the nurse heard Resident #4 raising his voice and telling someone don't be stupid in front of my door. When the nurse got up to walk out to hallway to see what was going on, Resident #4 stood up and grabbed Resident #6 by the front of his shirt and Resident #6 shoved him away and Resident #4 struck his head on the doorway and fell to his right side. The SSD immediately intervened and attempted to redirect Resident #6 away from Resident #4 as Resident #4 was attempting to get up and go back at Resident #6. D. Staff interviews Registered nurse (RN) #1 was interviewed on 1/6/25 at 10:15 a.m. RN #1 said a CNA told her she was needed for assessment of the residents after the incident involving Resident #4 and Resident #6 on 11/21/24. RN #1 said she received a report that Resident #4 stood up and grabbed Resident #6 by the collar, Resident #6 defensively pushed Resident #4 away and Resident #4 hit the doorframe and slid to the floor. RN #1 said she did a physical assessment of Resident #6 and found no injuries. RN #1 said she completed a physical assessment of Resident #4 and found an abrasion on his head, which had stopped bleeding, and some scratches on his shoulder. RN #1 said Resident #4 was transferred to the hospital as a precaution for further assessment as he had a history of metal plates in his head. RN #1 said Resident #4 returned to the facility the same day without further concerns. HK #1 was interviewed on 1/6/25 at 10:35 a.m. HK #1 said she witnessed the incident between Resident #4 and Resident #6 on 11/21/24. HK #1 said the incident happened outside of Resident #4's room. She said Resident #4 said something to Resident #6 and then Resident #6 moved closer to Resident #4 to ask what he said. She said Resident #4 stood up from his wheelchair and pushed Resident #6's chest. HK #1 said Resident #6 stumbled back and pushed Resident #4 back. HK #1 said Resident #4's head bumped the door jam and the resident went down to his knees. HK #1 said Resident #6 was upset and shaking after the incident. The minimum data set coordinator (MDSC) was interviewed on 1/6/25 at 10:54 a.m. The MDSC said she witnessed the incident between Resident #4 and Resident #6 on 11/21/24. The MDSC said she was in her office and overheard Resident #4 talking loudly in the hallway. The MDSC said she entered the hallway and observed Resident #4 as he stood up and tried to hit Resident #6. She said Resident #6 then pushed Resident #4 back into the doorway. The MDSC said the SSD updated the care plans and she did not know if there was an IDT meeting after the incident. The SSD was interviewed on 1/6/25 at 11:26 a.m. The SSD said she had just spoken with Resident #6 prior to the incident with Resident #4 on 11/21/24. The SSD said she was in the hallway during the incident. he said she heard a loud male voice, turned around and saw Resident #4 shove Resident #6. She said Resident #6 shoved back and Resident #4 lost his balance and fell into the door. She said it appeared Resident #6 was being defensive when he pushed back at Resident #4. The SSD said since the incident, she had directed other residents to not pace in front of Resident #4's doorway. She said Resident #4 had some medication changes after the 11/21/24 incident. The SSD said she updated care plans related to residents' behaviors. The SSD said Resident #4 was the aggressor during the 11/21/24 incident and was also the aggressor during a previous incident on 10/21/24 (see above). The SSD said the IDT met after the incident on 10/21/24. The SSD said she did not see an addition to Resident #4's care plan for behavior monitoring after it was referenced in the IDT progress note on 10/23/24. The SSD said she could not find any notes about an IDT meeting after the 11/21/24 incident. The SSD said she did not see evidence that Resident #4's care plan was updated for behaviors to include his physically aggressive behavior until 12/23/24, four weeks after the 11/21/24 incident. The SSD said Resident #4 had prior physical aggression incidents more than a year ago. The SSD said she thought the care plan related to aggressive behaviors had been resolved since there had not been further incidents until recently. The SSD said Resident #4's triggers for his behaviors were added on 12/23/24. LPN #1 was interviewed on 1/6/25 at 2:00 p.m. LPN #1 said Resident #4 liked to have his way and was very particular about many things. LPN #1 said she was unaware Resident #4 and Resident #6 had an altercation on 11/21/24. CNA #4 was interviewed on 1/6/25 at 2:15 p.m. CNA #4 said he witnessed the altercation between Resident #4 and Resident #6 on 11/21/24. CNA #4 said he was talking with Resident #6 in the hallway outside of Resident #4's room. CNA #4 said Resident #4 became annoyed and stood up from his wheelchair. CNA #4 said Resident #4 grabbed Resident #6's shirt and then Resident #6 pushed him back. CNA #4 said Resident #4 had yelled at other residents before. CNA #2 was interviewed on 1/6/25 at 3:15 p.m. CNA #2 said she was not aware of any resident-to-resident altercations involving Resident #4 and she was not aware of any triggers that would make him upset. The SSD, the NHA and the RDQC were interviewed together on 1/6/25 at 3:21 p.m. The RDQC said she was trying to determine if Resident #4's care plan information had been lost due to technical issues. The SSD and the NHA said there should have been more information added to Resident #4's care plan related to his behaviors after the 10/21/24 altercation with Resident #5. The RDQC said a medication review for Resident #4 was requested on 11/21/24, as there was concern a medication change might have contributed to his behavior issues. The NHA said residents' behavior care plan should be updated within a week of a resident-to-resident incident. -However, the care plan for Resident #4's physically aggressive behavior was not initiated until 12/23/24 (see above). CNA #3 was interviewed on 1/7/25 at 10:34 a.m. CNA #3 said Resident #4 was triggered for behaviors if other residents made comments to him. CNA #3 said she was aware of recent altercations between Resident #4 and other residents. She said Resident #4 was told to watch what he said to other residents, but she said she was not aware of any other behavioral interventions initiated for Resident #4. She said one of the residents was told to be aware of the scheduled times for supervised smoker breaks (as Resident #4 was a smoker) to avoid Resident #4.

Based upon observations, record review and interviews, the facility failed to ensure that two (#4 and #5) of two residents out of eight sample residents, received the appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Resident #4 was admitted to the facility on [DATE] with diagnoses of alcohol abuse and encephalopathy (brain disease that affects brain function). The resident had a mood problem related to being quick tempered, had poor coping skills and could exhibit verbally aggressive outbursts towards others when he disagreed with them. The facility failed to implement effective interventions for Resident #4 and appropriately address Resident #4's abuse behaviors towards other residents. The facility failed to protect residents from continued verbal and mental abuse from Resident #4. Interviews and observations revealed Resident #4's behaviors resulted in Resident #5's increased anxiety and social isolation. The staff failed to thoroughly assess Resident #5 for changes in behavior after Resident #4 purposefully ran his wheelchair into Resident #5 on 10/21/24, which caused a skin tear on Resident #5's right forearm, shoulder pain, anxiety and self isolation. Due to the facility's failures to address Resident #4's behaviors, Resident #5 suffered physical abuse from Resident #4, which resulted in psychosocial harm for Resident #5. Findings include: I. Facility policy and procedure The Social Services policy, dated 12/19/16, was provided by the regional director of quality and compliance (RDQC) on 1/7/25 at 1:49 p.m. It read in pertinent part, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental or psychosocial well-being. The director of social services is a qualified social worker and is responsible for executing the social services for the residents of the facility, including but not limited to consultation with allied professional health personnel regarding provisions for the social and emotional needs of the resident and family. Factors that impact a resident's psychosocial functioning may include behavioral problems (anxiety, loneliness, depressed mood, anger, fear), poor interaction and social skills. The social services department is responsible for identifying individual social and emotional needs, assisting is providing corrective action for resident's needs by developing and maintaining individualized social service care plans, maintaining regular and follow-up progress notes indicating the resident's response to the plan, making referrals to social service agencies as appropriate and maintaining appropriate documentation of referrals. II. Incidents of physical abuse by Resident #4 on 10/21/24 and 11/21/24 The 10/21/24 incident report was provided by the RDQC on 1/7/25 at 9:14 a.m. The report documented the nurse was informed Resident #4 purposely collided into Resident #5 while both residents were seated in their wheelchairs. Resident #4 continued down the hall to his room and Resident #5 was assessed for injuries. Resident #5 reported her right arm was jarred and the nurse documented a 0.5 centimeter (cm) by 0.5 cm abrasion on her right forearm where the top layer of skin had come off. Resident #5 reported her left lower leg above the ankle hit the wheel of her wheelchair. The nurse documented redness to the skin above the resident's left ankle. According to the incident report, there were no predisposing factors which caused the incident to occur. Resident #5 (the victim) was interviewed and she said she was wheeling down the hall towards the smoking area when the supervised smokers, including Resident #4 ( the assailant), were coming inside. Resident #5 said she made a comment to Resident #4 that he was driving on the wrong side of the road. She said Resident #4 wheeled right into her with his legs hitting hers and spoke profanity to her. Resident #5 said the impact threw her back in her wheelchair causing right shoulder and leg pain. Resident #4 was interviewed and said he was coming inside from smoking. He said Resident #5 told him he should not be driving on the wrong side of the road. Resident #4 said he told her to stay where she was or he would run into her. Resident #4 said he ran into Resident #5 and left. The incident was substantiated by the facility. -However, the facility failed to implement person-centered interventions to address Resident #4's behaviors to prevent an additional altercation with Resident #6 on 11/21/24. -The facility failed to thoroughly assess Resident #5 for changes in mood and behavior, and provide interventions to help Resident #5's increased social isolation, anxiety and fear of Resident #4. The 11/21/24 facility investigation documented the incident occurred on 11/21/24 at 10:01 a.m. The investigation documented Resident #4 stood up from his wheelchair and grabbed Resident #6 by the shirt collar. Resident #6 responded by pushing Resident #4 who then fell and hit his head on the wall. The residents were immediately separated and placed on frequent checks. The investigation documented Resident #4 was interviewed by the nursing home administrator (NHA) on 11/21/24 at approximately 1:00 p.m. Resident #4 said Resident #6 was outside of Resident #4's room acting like a tough guy. Resident #4 said he told Resident #6 he would slap him around a little bit and then Resident #4 said he stood up, lost his balance and hit his head on a door frame. The investigation documented Resident #4 had been involved in previous altercations within the past 12 months. The investigation concluded the abuse was substantiated. III. Resident #4 A. Resident status Resident #4, age 68, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included liver disease, epilepsy (seizure disorder), diabetes, alcohol abuse and encephalopathy. The 11/13/24 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. Resident #4 used a wheelchair, was independent with eating and transferring self and required set up assistance with showering. B. Resident interview Resident #4 was interviewed on 1/6/24 at 2:50 p.m. Resident #4 said he got along well with other residents and had not had any altercations. Resident #4 laughed and said no one had made him angry at the facility, but he said if anyone did make him angry, he would punch them. C. Record review Resident #4's behavior care plan, initiated 8/16/23 and revised 11/14/24. The care plan documented that he had a mood problem related to being quick tempered, had poor coping skills, pressured others to move out of his way (sometimes verbally) and patted the backs of other's wheelchairs in attempts to get them to move out of the way. Interventions included encouraging better coping skills and patience with others when they were moving slowly through the hall (initiated 8/16/24), administering medications as ordered, providing behavior health consultations as needed and observing and recording his mood to determine if problems were related to external causes, (all revised 8/20/24). -The facility failed to update the care plan with new interventions related to the two physical abuse altercations with other residents on 10/21/24 and 11/21/24. Resident #4's behavior success care plan , initiated 10/1/24 and revised 10/4/24., addressed the resident's verbally aggressive outbursts towards others when he disagreed with them. Interventions (all initiated 10/1/24) included encouraging self-calming behavior such as breathing exercises, ensuring the safety of the resident and others, establishing boundaries and limits with the resident, providing emotional support regarding new onset disruptive behavior and utilizing diversion techniques. -The care plan did not define any triggers for the aggressive outbursts or ways to ensure the safety of other residents. -There were no new interventions for the behavior success plan after the 10/21/24 and 11/21/24 physical abuse altercations. Resident #4's physical aggression care plan, initiated 12/23/24, documented the resident had actual incidents of physical aggression and the potential to become physically aggressive related to the history of aggression and harm to others, poor impulse control and complications with self-mood regulations. Interventions (all initiated on 12/23/24) included administering medications as prescribed, assessing and addressing contributing sensory deficits (minimizing noise, dimming the lights, keeping the door closed and giving him space from others), providing physical and verbal cues to alleviate anxiety, assisting with verbalizing the source of agitation, encouraging the resident to seek out a staff member when agitated, conducting a thorough analysis of circumstances that may influence behaviors paying attention to triggers that contributed to the behavior, documenting observed behavior and attempted interventions in the care plan, avoiding large crowds, recognizing his need for personal space, psychiatric consultation as needed and taking prompt action if the resident became agitated to prevent further escalation. -Resident #4's physical aggression care plan was not initiated until two months after the incident with Resident #5 and one month after the resident's second incident of physical abuse towards another resident on 11/21/24. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/6/25 at 11:33 a.m. CNA #1 said she was not aware of any interventions in place for Resident #4's physically aggressive behavior. CNA #1 said staff were just told to intervene if Resident #4 got too close to Resident #5. CNA #3 was interviewed on 1/7/25 at 10:34 a.m. CNA #3 said Resident #4's behavior could be triggered by a situation, for example when a CNA asked if he wanted a shower. CNA #3 said other residents usually did not trigger him unless they made a comment first. CNA #3 said they reminded him of the scheduled times for supervised smoker breaks. She said she was not aware of any other behavior interventions that were initiated for Resident #4. The social services director (SSD) was interviewed on 1/7/25 at 10:30 a.m. The SSD said she did not know if there was a physical aggression behavior care plan for Resident #4 prior to the incident on 10/21/24 or when it may have been resolved. The SSD said the facility was using a different electronic medical record (EMR) now and she was not able to access the old care plans. The NHA and the RDQC were interviewed together on 1/7/25 at 11:32 a.m. The NHA said Resident #4 had a brain injury and was triggered by other people not using common sense. The NHA said people knocking on Resident #4's door agitated him if he was sitting right there and could see them. The NHA said Resident #4 was protective of his personal belongings. The NHA said the facility should have identified triggers and added more interventions to Resident #4's care plan after the first physical altercation. The RDQC said the facility would review and update Resident #4's care plan with interventions to prevent further altercations. IV. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included acute infarction of spinal cord (spinal cord stroke causing pain or loss of sensation in the back down to legs), occipital neuralgia (pain or loss of sensation in the back of the head and neck), anxiety disorder, hypertension (high blood pressure) and type 2 diabetes mellitus. The 10/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with personal hygiene, dressing and transfers. She did not walk but was independent with mobility using a wheelchair. B. Resident observation and interview Resident #5 was interviewed on 1/6/25 at 9:06 a.m. Resident #5 was sitting in her wheelchair in her room with both privacy curtains pulled around her. Resident #5 said she did not feel safe at the facility. Resident #5 said she stayed in her room if Resident #4 was in the hallway. Resident #5 said she did not go outside to smoke when Resident #4 went out because it made her anxious to be around him. Resident #5 said she just wanted to move to another facility. Resident #5 was interviewed again on 1/7/25 at 12:41 p.m. Resident #5 was lying in her bed with the privacy curtains closed on both sides with her television on. Resident #5 said she felt more isolated since the incident with Resident #4 because she stayed in her room more. Resident #5 said whenever she saw Resident #4 in the hall she felt anxious and went back into her room. She said she felt like Resident #4 was always in the hall. She said he came down early (before the supervised smoking times) and sat by the exit to the smoking area. She believed Resident #4 tried to intimidate her. Resident #5 said things were good for a couple of weeks after the incident because the supervised smokers were going out back to smoke and she never saw Resident #4. Resident #5 said it only lasted for a couple of weeks because there was no fencing or shelter in the back smoking area so the supervised smokers resumed using the prior smoking area at the end of her hallway. She said Resident #4 continued to go down her hallway past her room several times a day to get to the smoking area. C. Additional resident interview Resident #7 was interviewed on 1/7/25 at 11:30 a.m. Resident #7 said she was not afraid of Resident #4 because she just stayed to herself and ignored him. Resident #7 said some residents were afraid of Resident #4, especially Resident #5. D. Record review The 10/21/24 abuse investigation report documented Resident #5 was the victim of physical abuse by Resident #4. According to the report, after the incident, Resident #5 was hyper-focused on the situation and her injuries. Resident #5 was educated to choose alternate smoking times after the supervised smokers (including Resident #4) were finished and back inside the building. -The abuse investigation follow-up did not address Resident #5's psychosocial well-being, including her fear of Resident #4 or her anxiety related to the incident. Cross-reference F600 for failure to protect residents from abuse. The comprehensive care plan addressed psychosocial areas of mood related to her admission and current situation (initiated 10/1/24) and challenges adjusting to her admission (initiated 10/1/24). -The mood care plan was updated on 1/6/25 (during survey) to add Resident #5 was involved in a physical altercation with another resident related to physical aggression towards her. -The care plan revision documented the mood care plan was initiated on 10/21/24, however it was not part of the comprehensive care plan reviewed on 1/6/25 at 9:35 a.m. A risk for depression care plan, initiated 12/22/24, related to her recent decline in health, change in living situation, and financial situation. Interventions included observing for signs or symptoms of depression and contacting the provider if the depression screen was positive. -However, the care plan was initiated two months after the mood interview/depression assessment indicated Resident #5 had increased signs of depression and there was no documentation the provider was notified (see Resident Mood Interview assessments below). The trauma informed care plan, revised 12/23/24, revealed the resident had fearfulness from an event that occurred at the facility when another resident exhibited aggressive behavior towards her. Interventions (all initiated 12/23/24) included offering her another room on the opposite hall (which she declined), offering to escort her to desired locations in the facility (declined due to personal choice), arranging for services with a mental health provider, encouraging her to share her feelings and concerns with staff, identifying items that lessen the effect of the trauma and monitoring her whereabouts and emotional state. -The trauma informed care plan was initiated over two months after the traumatic incident with Resident #4 occurred. The 12/23/24 trauma interview revealed Resident #5 had experienced trauma related to being a victim of physical aggression. The interview documented Resident #5 experienced anxiety, feeling of detachment and fearfulness related to the incident. Resident #5 indicated counseling would help her to deal with the trauma. The 7/23/24 Resident Mood Interview assessment (prior to the incident), revealed Resident #5 scored a zero on the mood interview, indicating she did not have any symptoms of depression. Resident #5 answered the question regarding social isolation as she never felt lonely or socially isolated. The 10/23/24 Resident Mood Interview assessment (after the incident), revealed Resident #5 scored a six on the mood interview, indicating she felt down, depressed or hopeless more than half of the time, had trouble falling or staying asleep or was sleeping too much more than half of the time, and felt tired or had little energy more than half of the time over the past two weeks. Resident #5 answered the question regarding social isolation as she sometimes felt lonely or socially isolated. -There was no social service progress note regarding these mood changes for Resident #5. -There were no changes to the plan of care related to these changes. -There was no documentation that the physician or behavioral health services were notified of these changes. E. Staff interviews The activity director (AD) was interviewed on 1/6/25 at 4:35 p.m. The AD said Resident #5 liked to come to social activities, especially if there was food. The AD said Resident #5 was coming out of her room less often for the past month and had been sleeping in later in the mornings. The SSD was interviewed on 1/7/25 at 10:30 a.m. The SSD said she typically made a progress note if there was a change on a residents' MDS assessment. The SSD said she did not know why she did not make a progress note for Resident #5. The SSD said she should have made a quarterly progress note for Resident #5 in October 2024. The SSD verified there was not a social service progress note for Resident #5 in October 2024 after she completed the resident's mood interview assessment. The SSD said she sent an email to behavior health services requesting a visit for Resident #5 but did not document this in the medical record. The SSD said Resident #5 was experiencing stress about her finances and wanting to move to another facility. The SSD said a trauma care plan was added to Resident #5's plan of care on 12/23/24 because that was when the resident expressed she was still having fear from the incident with Resident #4. The SSD said they offered Resident #5 an alternate location for her puzzles and a room change but she declined. The SSD said she had sent several referrals to other facilities and Resident #5 had been accepted at a couple of them in another town, but Resident #5 was not interested in moving to those facilities. -Documentation of the behavioral health services referral and visit were requested at the time of survey but not received from the facility by the end of the survey on 1/7/25. The NHA was interviewed on 1/7/25 at 11:32 a.m. The NHA said the social services staff should have, at a minimum, a quarterly progress note for each resident, and more if there were resident changes. The NHA said if there was a change in a resident's mood or on the MDS assessment, there should be a social services note addressing the change.

Based on observations, record review and interviews, the facility failed to ensure resident assessments were provided by qualified persons for three (#8, #3 and #5) of eight residents out of eight sample residents. Specifically, the facility failed to: -Ensure Resident #8 and Resident #3, who experienced unwitnessed falls, were assessed by a registered nurse (RN) before they were assisted from the floor; and, -Ensure Resident #5, who was the victim of resident-to-resident physical abuse, was assessed by a RN following the resident-to-resident altercation. Findings include: I. Failed to have a RN assess Resident #8 and Resident #3 after unwitnessed falls, prior to assisting the residents from the floor A. Facility policy and procedure The Falls - Clinical Protocol policy, revised 10/2012, was provided by the regional director of quality and compliance (RDQC) on 1/6/25 at 11:59 a.m. The policy revealed as part of the initial assessment, nursing staff would identify individuals with a history of falls and risk factors for subsequent falling. Staff would ask the resident or resident's representative about a history of falling. While many falls were isolated individual incidents, a significant proportion occurred among a few residents. Those individuals might have a treatable medical disorder or functional disturbance as the underlying cause. The staff would document risk factors for falling in the resident's record and address the resident's fall risk factors with appropriate interventions in the resident's plan of care. The staff would evaluate and document falls that occurred on an incident report form, for example, when/where they happened, and any observations of the events. Staff should categorize falls as unwitnessed, witnessed, or assisted. For an individual who had fallen, the interdisciplinary team (IDT) would complete an evaluation to identify the root cause and recommend appropriate new interventions to address risk factors of falling. Causes referred to factors that were associated with or that directly resulted in a fall, for example, a balance problem caused by an old or recent stroke. Multiple factors in varying degrees might contribute to a falling problem. If the cause of a fall was unclear, if the fall might have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continued to fall despite attempted interventions, it might be appropriate to ask the attending physician to review the situation and help identify contributing causes. Nursing staff should initiate post-fall assessments after a fall occurred. Staff should complete an assessment to look for new injuries, changes in range of motion, complaints of pain or other adverse clinical changes related to the fall. For unwitnessed falls or falls wherein the resident hit their head, staff should complete neurological and vital sign checks according to the facility's neurological assessment flowsheet. Staff should initiate alert charting on each nursing shift for 72 hours or longer as indicated, wherein each nurse evaluates for adverse changes related to the fall and the efficacy of current fall interventions. -However, the policy did not specify that a RN should do an assessment of the resident before the resident was moved from off the floor for unwitnessed falls. B. Resident #8 1. Resident status Resident #8, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of the left femur, subsequent encounter for a closed fracture with routine healing, fracture of the right femur, fracture of the head/neck of the right femur, anxiety and chronic diastolic (congestive) heart failure. The 12/27/24 minimum data set (MDS) assessment revealed Resident #8 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident used a walker and/or a wheelchair. The resident had impairment on one side of the lower extremities (hip, knee, ankle or foot). The resident required substantial/maximal staff assistance for sit to stand (the ability to come to a standing position from a sitting position for a chair, wheelchair or on the side of the bed. 2. Record review The fall risk assessment dated [DATE] at 2:02 p.m., revealed a score of 16, which indicated the resident was a high fall risk Resident #8's care plan for being at risk for falls due to a history of falls, a fall with a fracture, cognition impaired safety awareness, and medication side effects was initiated on 4/3/24 and revised on 1/2/25. Interventions included to ensure the resident's call light was within reach, encourage the resident to use the call light for assistance as needed, ensure the resident's high/low bed was in the lowest position while in bed, ensure the resident was wearing appropriate footwear when ambulating and the resident had been provided a walkie talkie for use in the dining room to contact staff (this was the location the resident spent most of her day and a call light was not available in this area). Staff were to review information on past falls and attempt to determine the cause of the falls, document the possible root causes, alter/remove any potential causes, if possible and educate the resident/family/caregivers/ and the interdisciplinary team as to the causes. An incident report, dated 12/20/24 at 8:20 p.m., for an unwitnessed fall, was written by licensed practical nurse (LPN) #3 .The report revealed a call light went off in Resident #8's room. A certified nurse aide (CNA) went down to see what the resident needed and found the resident on the floor. The CNA went to go get a nurse. A nurse asked the resident how she ended up on the floor. The resident said everything slipped. The nurse asked a second time how the resident ended up on the floor and the resident asked if she had broken her back. A RN was called from the other side of the facility to do an assessment. LPN #3 and the CNA got Resident #8 from off the floor and into her chair and the resident had no complaints. After LPN #3 and the CNA had assisted Resident #8 back into her chair, the RN walked into the room. The resident started to say it hurts and she was not going to therapy the next day. Resident #8 had a skin tear to the left elbow and the RN was unable to determine the left hip trochanter (hip) condition. The resident was sent to the emergency department to be evaluated. The county hospital near the facility admitted Resident #8 on 12/20/24 at 8:24 p.m., with a chief complaint of falling out of a wheelchair to the ground and a complaint of left hip pain. The resident apparently had a low mechanism fall out of a wheelchair and had acute pain in the left hip and femur regions. The diagnosis was a left hip fracture and the resident would be transferred to another hospital with a higher level of care. The resident was discharged to the second hospital on 12/21/24 at 12:54 a.m. A situation, background, assessment, recommendation (SBAR) note, dated 12/20/24 at 8:56 p.m., revealed the resident had a change in condition related to a fall. The nursing observations, evaluation and recommendations revealed the resident fell with no injury and was sent to the emergency department because the resident started complaining of pain. A nurse note, dated 12/20/24 at 11:58 p.m., revealed the nurse spoke with the hospital and the resident broke her hip and was being transferred to another hospital for treatment. The second hospital admitted the resident on 12/21/24 at 2:13 a.m. The chief complaint was left hip pain from a fall. Resident #8 was transferred to the second hospital from the previous hospital secondary to a left intertrochanteric hip fracture. The resident said she was helping her roommate in the bathroom when she fell on her left side. The resident said she was unable to get up from off the floor due to sharp pain that was constant, which was at least an 8 or 9 out of 10 on a 1-10 pain scale. The musculoskeletal assessment revealed good muscle mass, tone, strength, normal range of motion, except for the left hip, which had pain on ranges of motion. An IDT event review, dated 12/23/24 at 10:28 a.m., revealed Resident #8 had a fall on 12/20/24 due to weakness and poor gait. The resident was sent to the emergency department for an evaluation and treatment. A skilled charting note, dated 12/24/24 at 2:24 p.m., revealed Resident #8 returned from hospital. The resident was confused at times, which appeared to be related to post surgical effects. The resident was able to make her needs known. A nurse note, dated 12/2024 at 8:52 p.m. and written by a LPN, revealed Resident #8 fell on to the floor on her left side, had a skin tear on her left elbow and was at the emergency department getting x-rays done to make sure nothing was broken. -Review of Resident #8's electronic medical record (EMR) did not reveal that a RN assessed the resident after the unwitnessed fall on 12/20/24 at 8:20 p.m., prior to the resident being assisted by staff from off the floor to a chair. The resident sustained a left hip fracture from the fall. 3. Staff interviews LPN #1 was interviewed on 1/7/25 at 10:10 a.m. LPN #1 said a RN should perform an assessment on a resident for an unwitnessed fall, before the resident was moved from off the floor. She said the assessment was out of the scope of practice of a LPN. LPN #2 was interviewed on 1/7/25 at 11:06 a.m. LPN #2 said a RN must assess a resident who had an unwitnessed fall before the resident was moved from off the floor. She said the complete resident assessment was not in the scope of practice of an LPN. RN #1 was interviewed on 1/7/25 at 11:27 a.m. RN #1 said a RN should do an assessment of a resident that had an unwitnessed fall before the resident was moved from off the floor. She said the complete resident assessment was not in the scope of practice of an LPN. The nursing home administrator (NHA), the director of nursing (DON), the assistant director of nursing (ADON) and the RDQC were interviewed on 1/7/24 at 1:04 p.m. The NHA, the DON, the ADON and the RDQC said Resident #8 had an unwitnessed fall on 12/20/24 at 8:20 p.m. and was sent to the emergency department for evaluation and treatment. The NHA, the DON, the ADON and the RDQC said the resident received a diagnosis of a left hip fracture. The NHA, the DON, the ADON and the RDQC said LPN #3 and a CNA moved Resident #8 off the floor, before a RN did an assessment of the resident. The NHA, the DON, the ADON and the RDQC said a RN should do an assessment of a resident with an unwitnessed fall, prior to the resident being moved from off the floor. The DON said it was not in the LPN's scope of practice to conduct an assessment of a resident after an unwitnessed fall. She said LPN #3, who moved the resident off the floor, received an in-service on falls on 12/23/24. C. Resident #3 1. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged home on 11/13 24. According to the November 2024, CPO, diagnoses included stable burst fracture of T9-T10 (thoracic) vertebra, subsequent encounter for fracture with routine healing, mechanical complication of internal fixation device of vertebrae, protein-calorie malnutrition and pneumonia. The 11/13/24 MDS assessment revealed Resident #3 was cognitively intact with a BIMS score of 15 out of 15. The resident used a manual wheelchair. The resident had no impairments in either the upper or the lower extremities. The resident required substantial/maximal staff assistance for sit to stand (the ability to come to a standing position from a sitting position for a chair, wheelchair or on the side of the bed. 2. Record review The baseline admission care plan, dated 11/10/24, revealed the resident was at risk for falls. The resident did not have any falls within the last two to six months prior to admission to the facility. The interventions included anticipating/meeting the resident's needs, keeping frequently used items within reach, educating/encouraging the resident to wear appropriate footwear, such as non-skid socks or shoes when ambulating, educating the resident/family/caregiver regarding safety reminders and what to do if a fall occurred, following the facility policy if a fall occurred, orienting the resident to the call light, keeping the resident's call light within reach, encouraging the resident to use the call light and referring the resident to therapy for evaluation/treatment as indicated to address the resident's fall risk. A care plan for the resident being at risk for fall related to an actual fall, impaired mobility and recent surgery was initiated on 11/12/24. Interventions included for staff to anticipate and meet the resident's needs, keep frequently used items within reach, keep the resident's call light within reach and encourage the resident to use it for assistance as needed, educate and encourage the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and follow facility fall protocol if a fall occurred and offer the resident a bedside commode. The incident report, dated 11/11/24 at 10:48 p.m. and written by LPN #3 for an unwitnessed fall, revealed LPN #3 went down to Resident #3's room because her call light went off and the CNA was working in another room. LPN #3 opened the door and the resident was on the floor. LPN #3 asked Resident #3 if anything hurt. The resident said no, but she hit her elbow. LPN #3 looked at the resident's elbow and there was no bleeding, however there was a small bruise. LPN #3 and a CNA helped the resident from the floor and back into bed. The nurse observed a skin tear on the resident's right knee. The skin tear was washed and a one centimeter (cm) by one cm bandage was placed on the skin tear. A RN came and assessed Resident #3 after the resident was assisted from the floor by LPN #3 and the CNA. The fall occurred when Resident #3 went to the bathroom and slipped on the floor. The resident wore socks with sticky pads on the bottom of the socks. The resident said that she went to the bathroom after pressing her call light and no staff came. The resident was oriented to person, place, situation and time. A weekly skin check assessment, dated 11/11/24 at 11:04 p.m., revealed Resident #3 had a skin tear to the right knee, a bruise to the right elbow and symptoms of a wound to the lower back area measuring approximately one foot long. A nurse note, dated 11/11/24 at 10:30 p.m., revealed this nurse (LPN #3) was notified of Resident #3's fall at 10:25 p.m. LPN #3 went into the resident's room to assess the resident. The resident was alert/orientated times four and appeared to be at baseline in mental status. The resident said she did not want to wait for assistance and got up to go to the restroom on her own. The resident said she had to grab onto the sink to keep from falling onto the floor. The resident said she landed on the right side of her body. Observations revealed old and new bruising to the right elbow. A bandaid was observed to the resident's right lower leg. The resident said she had a small cut from a fall and a nurse had placed a bandaid over the area. The resident complained of neck pain and lower back pain that was normal due to spinal fashion. The resident had no other apparent injuries observed. A nurse note, dated 11/11/24 at 11:01 p.m., revealed Resident #3 fell on to the floor. The resident had a skin tear to right leg and a bruise to right elbow. The DON, a RN and the physician were notified. The IDT event review note, dated 11/12/24 at 9:51 a.m., revealed Resident #3 had an unwitnessed fall on 11/11/24 related to poor safety awareness. The facility treated the skin tear and started neurological assessments. An intervention put in place was an in-room commode. There were no new physician orders. -Review of Resident #3's EMR did not reveal that a RN assessed the resident after the unwitnessed fall on 11/11/24 at 10:25 p.m., prior to the resident being assisted by staff from off the floor. 3. Staff interviews The NHA, the DON, the ADON and the RDQC were interviewed on 1/7/24 at 1:25 p.m. The NHA, the DON, the ADON and the RDQC said Resident #3 had an unwitnessed fall on 11/11/24 at 10:25 p.m. The NHA, the DON, the ADON and the RDQC said LPN #3 and a CNA moved the resident off the floor before a RN assessed the resident. The DON said a RN should have completed an assessment before Resident #3 was moved off the floor. The DON said the resident was not sent to the hospital after the fall. 50853 II. Failed to ensure a RN assessed Resident #5 following a resident-to-resident altercation A. Resident #5 1. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included acute infarction of the spinal cord (spinal cord stroke causing pain or loss of sensation in the back down to legs), occipital neuralgia (pain or loss of sensation in the back of the head and neck), anxiety disorder, hypertension (high blood pressure) and type 2 diabetes mellitus. The 10/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with personal hygiene, dressing and transfers. She did not walk but was independent with mobility using a wheelchair. 2. Resident interview Resident #5 was interviewed on 1/6/25 at 9:06 a.m. Resident #5 said another resident rammed into her wheelchair in the hallway in October 2024. Resident #5 said she believed she had whiplash from the incident when she was jolted back in her wheelchair. She said she had a tight knot in the back of her neck for a while afterwards and had to have physical therapy to relieve the tightness. 3. Record review The 10/21/24 incident report was provided by the RDQC on 1/7/25 9:14 a.m. The report documented LPN #1 was informed another resident purposely collided into Resident #5 while both residents were seated in their wheelchairs. Resident #5 reported her right arm was jarred and LPN #1 documented a 0.5 centimeter (cm) by 0.5 cm abrasion on her right forearm where the top layer of skin had come off. Resident #5 reported her left lower leg above the ankle hit the wheel of her wheelchair. LPN #1 documented redness to the skin above the resident's left ankle. The abuse investigation report, dated 10/21/24 at approximately 2:37 p.m., documented another resident ran into Resident #5 who was in the hallway seated in her wheelchair. CNA #1 separated the residents and called LPN #1 for assistance. Resident #5 was assessed by LPN #1 and did have physical injuries, including redness to the left lower leg above the ankle and an abrasion to her right forearm where the top layer of skin had come off. The abuse investigation included an interview with Resident #5. She said another resident wheeled right into her with his legs hitting hers. Resident #5 said the impact threw her back in her wheelchair causing right shoulder and leg pain. Cross-reference F600 for failure to protect residents from abuse. -There was no documentation in Resident #5's EMR to indicate a RN conducted an assessment of the resident following the resident-to-resident altercation. 4. Staff interviews LPN #1 was interviewed on 1/6/25 at 9:56 a.m. LPN #1 said she did not witness the resident-to-resident altercation but Resident #5 told her another resident rammed his wheelchair into her knees. LPN #1 said Resident #5 did not have any visible marks (however, the occurrence investigation revealed she had an abrasion on her arm and redness to her knee), but she said Resident #5 later said she got whiplash. LPN #1 said she was the only nurse who assessed Resident #5 after the incident. LPN #1 said there was not a RN supervisor in the building at the time of the incident and she did not call a RN to assess the resident because the resident did not fall. The DON and the RDCQ were interviewed together on 1/7/25 at 11:32 a.m. The DON said after a resident fell or there was an incident with potential injury, the LPN on duty should call a RN to assess the resident. The DON said this was the procedure not just for falls, but for any potential injury. The DON said a LPN could make observations of obvious injuries, provide first aid and do vital signs but then should contact a RN to advise over the phone or come in and do an in-person assessment of the resident. The DON said if there was not a RN in the building, the LPN should call the RN on-call. The DON said a RN should have been contacted to assess Resident #5's injuries after the resident-to-resident altercation. The RDQC said the facility would be doing additional education with all nurses on assessing injuries after physical altercations.

Based on observations and interviews, the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment on two of three hallways Specifically, the facility did not facilitate the necessary maintenance services to maintain resident rooms in a sanitary, safe and comfortable manner. Findings include: I. Facility policy and procedure The Quality of Life Homelike Environment policy, dated 12/19/16, was provided by the nursing home administrator (NHA) on 10/7/24 at 2:10 p.m. It read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment. The facility's designated environmental services director is responsible for developing and implementing a cleaning schedule for common areas and resident rooms to assure that each area of the facility is maintained in a safe, clean and comfortable manner. The environmental services director shall report any concerns related to maintaining the facility in a safe, clean, comfortable or homelike environment to the Quality Assessment and Assurance Committee for review as needed. II. Observations Observations of resident rooms were conducted on 10/3/24. The following observations were made: At 1:34 p.m., an observation of room [ROOM NUMBER] revealed broken floor tiles and a loose kick plate on the door. At 1:35 p.m., an observation of room [ROOM NUMBER] revealed a broken plastic kick plate on the door with a sharp piece of wood exposed which caused a potential safety hazard. At 1:40 p.m. an observation of room [ROOM NUMBER] revealed floor tiles broken in the bedroom and bathroom and floor tiles separated by gaps between each tile in the bathroom. The separated bathroom tiles had dirt and debris in the cracks. At 1:42 p.m. an observation of room [ROOM NUMBER] revealed a large piece (approximately six inches by nine inches) of floor tile missing near the sink and water damage on the wall behind the missing flooring. In addition, the kick plate on the door was broken with exposed sharp edges. The resident who resided in room [ROOM NUMBER] said he felt like he was living in a cockroach motel. III. Staff interviews The housekeeping supervisor (HS) was interviewed on 10/7/24 at 11:10 a.m. The HS said the floor tile in room [ROOM NUMBER] had been missing since he started working at the facility over one year ago. On 10/8/24 1:20 p.m. an environmental tour of the facility was conducted with the maintenance supervisor (MS). The MS said the facility used a computer program to remind them of maintenance repairs that needed to be completed in the facility. The MS said the facility had purchased paint for the hallways but were waiting for approval from the new ownership company to paint. The MS acknowledged and documented the above observations. The MS said the broken kick plates on the residents' doors were a safety concern and the facility had some extra kick plates in storage to replace the broken ones. The MS said she had some extra floor tiles to patch the broken tiles. The MS said the facility had discussed replacing the entire floor in room [ROOM NUMBER], but she said she would patch it for now. The NHA was interviewed on 10/8/24 at 2:09 p.m. The NHA said the facility had an ambassador program where staff visited assigned rooms daily. The NHA said staff were expected to report any repairs needed in the residents' rooms on Fridays. The NHA said maintenance requests should be completed and turned in to the MS. The NHA said the many maintenance concerns (including the damaged flooring and kick plates) had been previously reported but she said since the new company had taken over, the facility had to wait for approvals. The NHA said the facility did not have a current performance improvement plan for the physical environment. The NHA said they would repair the issues that were safety concerns immediately.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure expired medications were removed from the medication carts and medication storage rooms. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 10/9/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Facility policy and procedure The Medication Labeling and Storage policy, dated 2001, was provided by the nursing home administrator (NHA) on 10/8/24 at 3:50 p.m. It read 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. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 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 (needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. III. Observations On 10/7/24 at 3:01 p.m. the medication cart and treatment cart on the secure unit were observed with registered nurse (RN) #1. The following items were found: -One tube of anti-itch cream (topical analgesic and skin protectant) with an expiration date of July 2024. -One tube of anasep gel (antimicrobial wound gel) with an expiration date of 4/27/24. -One bottle of derma klenz wound cleanser with an expiration date of July 2024. On 10/7/24 at 3:53 p.m. the medication storage room on the west hall was observed with the director of nursing (DON). The following items were found: -Three bottles of aspirin 325 milligrams (mg) with an expiration date of August 2024. IV. Staff interviews The scheduler said she was responsible for ordering supplies and over the counter medication. The scheduler said she stocked the medication storage rooms weekly and checked for expired medications monthly. The scheduler said if she found expired medications she took them to the DON for disposal. The DON was interviewed on 10/7/24 at 4:11 p.m. The DON said the nurses should check medications for expiration dates before administering. The DON said if nurses found expired medications they should put them in the drug buster container (a medication disposal system). The DON said it was important to dispose of expired medications because they could cause an adverse effect or be less effective if they were expired.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of three hallways. Specifically, the facility failed to: -Ensure appropriate infection control practices were followed during wound care; and, -Ensure housekeeping staff followed appropriate hand hygiene practices when cleaning resident's rooms. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Clinical Safety: Clean Hands for Healthcare Workers (2/27/24), retrieved on 10/9/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety,: If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves. II. Facility policy and procedure The Hand Washing and Hand Hygiene policy, dated 12/19/16, was provided by the NHA on 10/7/24 at 2:10 p.m. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Hand hygiene is the final step after removing and disposing of personal protective equipment. The Wound Care policy, dated 12/19/16, was provided by the nursing home administrator (NHA) on 10/7/24 at 3:45 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers when part of the treatment order. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Disinfect reusable supplies per manufacturer's instructions (outsides of containers that were touched by unclean hands, scissor blades). III. Failure to follow appropriate infection control practices during wound care A. Observations On 10/7/24 at 12:55 p.m. licensed practical nurse (LPN) #1 was providing wound care to resident #201. LPN # 1 washed her hands with soap and water, put on a gown, donned (put on) gloves and a mask and obtained a pair of bandage scissors from a drawer in the resident's night stand. She placed the scissors on the clean field with the other wound care supplies. -LPN #1 did not disinfect the scissors prior to placing them on the clean field with the other clean wound care supplies. After cleaning the wound, LPN #1 donned clean gloves and applied silver cream (a cream used to prevent wound infections) directly to the wound bed with her gloved fingers. -LPN #1 did not use a sterile applicator when touching the wound bed. After applying cream to all wounds, removing her soiled gloves and donning clean gloves, LPN #1 cut the Hydrofera Blue (an antibacterial wound dressing) with the scissors and applied the dressings to the wounds. She did not disinfect the scissors before cutting the clean dressings. On 10/7/24 at 4:50 p.m. the infection preventionist (IP) was providing wound care for resident #10. The IP removed the soiled dressings from the wounds, donned cleaned gloves, sprayed wound cleanser on to the wounds and wiped all four wounds with the same piece of gauze. -The IP did not use a separate piece of gauze to clean each wound. The IP did not perform hand hygiene after removing her soiled gloves and before putting on new gloves. B. Staff interview LPN #1 was interviewed on 10/7/24 at 5:02 p.m. LPN #1 said she assumed the scissors in Resident #201's drawer were clean and so she did not clean them. LPN #1 said she should have cleaned them before cutting the new wound dressing. LPN #1 said she normally used a sterile applicator to apply cream directly to a wound. IV. Failure to follow appropriate hand hygiene practices when cleaning residents' rooms A. Observations During a continuous observation on 10/7/24, beginning at 10:40 a.m. and ending at 11:28 a.m., the following was observed: The housekeeping supervisor (HS) was observed cleaning room [ROOM NUMBER], a single occupancy room. The HS changed gloves frequently between cleaning tasks in the room. The HS sprayed disinfectant on the high touch surfaces in the room, moving the resident's personal items. The HS left the room, removed his soiled gloves, donned clean gloves and did not perform hand hygiene. After each task, such as cleaning the sink, sweeping, mopping and cleaning the toilet, The HS changed gloves. -However, the HS did not perform hand hygiene with any of the glove changes. At 11:12 a.m. the HS removed his gloves and exited room [ROOM NUMBER]. -The HS did not perform hand hygiene after removing his gloves. The HS moved his cart to room [ROOM NUMBER], a double occupancy room. Without performing hand hygiene, the HS donned clean gloves and began cleaning room [ROOM NUMBER]. The HS cleaned high touch surfaces, removed his soiled gloves and donned clean gloves without performing hand hygiene. The HS changed gloves several times between cleaning tasks and between side one and side two of the room. -However, the HS did not perform hand hygiene with glove changes. B. Staff interview The HS was interviewed on 10/7/24 at 11:28 a.m. The HS said he should have performed hand hygiene when changing gloves. The HS said he used to have a bottle of hand sanitizer on his housekeeping cart, but he said the bottle ran out and he had not replaced it. V. Additional staff interview The IP was interviewed on 10/8/24 at 12:08 p.m. The IP said scissors should be disinfected before being used to cut clean bandages. The IP said a separate gauze should be used when cleaning different wounds to avoid cross contamination. The IP said, when applying ointments directly to a wound, an applicator should be used. The IP said staff should perform hand hygiene after removing soiled gloves and before applying clean gloves.

Based on observations, record review and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#10 and #12) of three residents reviewed for pain out of 25 sample residents. Specifically, the facility failed to: -Ensure adequate pain management for Resident #10 and Resident #12; -Ensure a pain care plan was initiated for Resident #12; and, -Ensure pain medications were reconciled upon readmission for Resident #12. Findings include: I. Facility policy -The pain management policy was requested on 10/8/24 at 10:57 a.m. but was not provided by the facility. II. Resident #10 A. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physicians orders (CPO), diagnoses included bipolar disorder, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD - a common lung disease causing difficulty with breathing), acute respiratory failure, acute kidney failure, venous insufficiency (when legs have difficulty returning blood to the heart), unspecified osteoarthritis (degenerative joint disease) and chronic pain. The 7/1/24 minimum data set (MDS) assessment revealed Resident #10 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required total assistance from staff for transfers and toileting hygiene. She was unable to walk, but propelled herself in a wheelchair. The MDS assessment indicated the resident received scheduled and as needed pain medications. She had received non-medication interventions for pain during the seven-day assessment review period. The MDS assessment documented Resident #10 reported pain at a level of 8 out of 10 (on a scale of 1-10) that occasionally interfered with daily activities and made it difficult to sleep. B. Observations and resident interview On 10/7/24 at 4:50 p.m. Resident #10 was observed during wound care. When the infection preventionist (IP) cleansed the resident's wounds, Resident #10 cried out in pain. When the IP touched the wound lowest on her abdomen, Resident #10 screamed and banged her hand on the wall. The IP asked if she wanted her to stop and Resident #10 said to just hurry and get it over with. On 10/8/24 at 9:03 a.m. Resident #10 was sitting outside smoking. Resident #10 said the waist band of her pants rubbed on her abdominal wounds and it was painful. Resident #10 said the staff had not offered her other clothing, such as a dress without a waist band. C. Record review The pain management care plan, initiated on 1/25/17 and revised 6/22/23, revealed Resident #10 had pain related to generalized chronic pain and neuropathy and often refused non-pharmacological interventions and preferred pain medication. Pertinent interventions included, administering pain medication as ordered and documenting effectiveness, informing the physician of pain not resolved by pain medication and providing diversion activities that could distract from pain such as positioning, music or television. The pain care plan revealed Resident #10 had an acceptable pain level of 4 out of 10. -The pain care plan did not indicate Resident #10 had pain related to her abdominal wounds. -The pain care plan interventions had not been updated since Resident #10 acquired abdominal wounds on 5/15/24. The October 2024 CPO revealed Resident #10 had the following physician's orders for pain management: ramadol 50 milligrams (mg) one tablet every six hours as needed for moderate to severe pain from 4 to 10, ordered on 8/22/24. Acetaminophen 1000 mg three times a day, ordered on 5/16/24. There was no order to monitor pain levels during wound care. According to the October 2024 medication administration record (MAR), Resident #10 received tramadol 50 mg on 10/7/24 at 1:42 p.m., three hours prior to wound care. -However, Resident #10 cried out in pain during wound care on 10/7/24 and no further pain medication was offered (see observation above). -Review of Resident #10's electronic medical record (EMR) did not reveal any documentation to indicate the resident's physician was notified regarding the resident's increased pain levels during wound care. D. Staff interviews The IP, who was the facility's wound nurse, was interviewed on 10/7/24 at 5:00 p.m. The IP said she did not think staff had offered other clothing options to Resident #10 that would not cause pain by rubbing on her wounds. The wound physician (WP) was interviewed on 10/8/24 at 11:45 a.m. The WP said Resident #10 had had some pain when he was providing wound care. The WP said different clothing, such as a dress would be beneficial for Resident #10 to avoid the waistband rubbing on her wounds. The IP was interviewed again on 10/8/24 at 1:00 p.m. The IP said Resident #10's pain was not controlled. The IP said the facility would address this with the physician and ask for additional or alternative pain medication. III. Resident #12 A. Resident status Resident #12, age 73, was admitted on /8/5/24, discharged home on 9/3/24 and readmitted to the facility on [DATE]. According to the October 2024 CPO, diagnoses included a displaced fracture of the lateral malleolus of the left fibula (the bone on the outside of the ankle), chronic viral hepatitis C (lifelong liver infection), displaced trimalleolar (three bones in the ankle) fracture of the right lower leg , acute and chronic respiratory failure with hypoxia (low oxygen levels in tissues) and COPD. The 9/27/24 MDS assessment revealed Resident #12 was cognitively intact with a BIMS score of 15 out of 15. The assessment indicated Resident #12 required substantial assistance from staff for transfers and toileting hygiene. She required minimal staff assistance with upper body dressing and total assistance with lower body dressing. She was unable to walk, and used a wheelchair for mobility. The MDS assessment indicated the resident received scheduled and as needed pain medications. She had received non-medication interventions for pain during the seven-day assessment review period. The MDS assessment documented Resident #12 reported occasional pain at a level of 5 out of 10. B. Resident interview Resident #12 was interviewed on 10/2/24 at 1:42 p.m. Resident #12 said her pain medication was stopped a couple of weeks ago and the facility's physician did not talk to her about stopping it. Resident #12 said she had taken the pain medication for many years for her chronic pain. She said she currently only had Tylenol and ibuprofen prescribed for her pain and the medications did not adequately manage her pain. Resident #12 was interviewed again on 10/3/24 at 3:46 p.m. while she was lying in bed. Resident #12 said she was not having a good day and her pain level was a 9 out of 10. She said she had ibuprofen earlier in the day and would like something again for her pain. C. Record review Review of Resident #12's comprehensive care plan, initiated on 9/16/24, revealed there was not a care plan focus for pain management. The pain assessment dated [DATE] revealed Resident #12 had frequent severe pain that interfered with sleep and daily activities. Resident #12 indicated her acceptable level of pain was 1-4 on a scale of 1-10. The 9/3/24 primary care physician discharge note listed the plan for chronic pain to include the following medications: -Lyrica 150 mg two times per day; -Oxycodone 10 mg every six hours as needed for pain levels of 6 to 10; -Tylenol 325 mg two tablets every six hours for general discomfort; and, -Ibuprofen 200 mg two tablets as needed for pain. The September 2024 CPO revealed Resident #12 had the following physician's orders for pain management upon her readmission on 9/6/24: Lyrica (pregabalin) 150 mg one capsule two times a day for neuropathy (nerve pain), with a start date of 9/6/24. Acetaminophen (Tylenol) 325 mg two tablets every six hours as needed for general discomfort, with a start date of 9/6/24. Ibuprofen 200 mg two tablets every four hours as needed for pain, with a start date of 9/6/24. Percocet 5-325 mg (oxycodone 5 mg with acetaminophen 325 mg) one tablet every six hours as needed for pain for 14 Days, with a start date of 9/6/24 and discontinued 9/20/24. The nurse practitioner's readmission progress note, dated 9/14/24, documented Resident #12 was receiving the following physician orders for pain control: -Lyrica 150 mg two times per day; -Oxycodone 10 mg every six hours as needed for pain levels of 6 to 10; -Tylenol 325 mg two tablets every six hours for general discomfort; -Ibuprofen 200 mg two tablets every four hours as needed for pain; and, -Percocet 5-325 mg (oxycodone 5 mg with acetaminophen 325 mg) one tablet three times a day as needed for pain. -However, review of Resident #12's October 2024 CPO did not reveal a physician's order for oxycodone (see above). -Despite the nurse practitioner's readmission progress note indicating Resident #12 was to be receiving oxycodone, there was no documentation in the resident's EMR indicating why the oxycodone was not entered into the EMR when the resident was readmitted on [DATE]. D. Staff interviews The IP was interviewed on 10/8/24 at 1:00 p.m. The IP said the charge nurse reconciled the medications upon admission with a nurse manager. The IP said the facility had been managing Resident #12's pain with Tylenol and ibuprofen. The IP said she did not know why the oxycodone was not entered into the the physician's orders for Resident #12. The regional nurse consultant (RNC) was interviewed on 10/8/24 at 1:00 p.m. The RNC said the facility was revamping their admission process and had created a checklist for the nurses to use. The RNC said the new process should ensure medications were not missed in the admission process.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food with professional standards for food service safety. Specifically, the facility failed to: -Ensure proper refrigerator temperatures were maintained, and food was properly dated and discarded by the use by date in two out of two unit refrigerators; and, -Ensure sanitary conditions in the dish room. Findings include: I. Ensure proper refrigerator temperatures were maintained, food was properly dated and discarded by the use by date. A. Professional reference The Food and Drug Administration (FDA) Food Code 2022, last reviewed [DATE] and retrieved on [DATE] from https://www.fda.gov/food/retail-food-protection/fda-food-code, read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature ' danger zone ' of 41 degrees Fahrenheit to 135 degrees Fahrenheit too long. B. Facility policy The Refrigerators and Freezers policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:06 a.m. It read in pertinent part, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Acceptable temperature ranges are 35 to 40 degrees Fahrenheit. Monthly tracking sheets will include time, temperature, initials, and ' action taken. ' The last column will be completed only if the temperatures are not acceptable. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. All food shall be appropriately dated to ensure proper rotation by expiration dates. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Supervisors will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past perish dates. C. Observations The following expired food items were observed in the secured unit snack refrigerator and freezer on [DATE] at 2:43 p.m.: -An opened bag of frozen pizza rolls with an expiration date of [DATE]; -A bag of frozen chicken nuggets with an expiration date of [DATE]; -A container of applesauce in the refrigerator with an expiration date of [DATE]; -A container of yogurt in the refrigerator with an expiration date of [DATE]; and, -A undated plastic container in the refrigerator that contained yogurt, granola and fruit. Temperature logs for the secured unit snack refrigerator were reviewed on [DATE] at 2:43 p.m. Equipment temperatures for the secured unit snack refrigerator were not recorded for the following dates: Thirteen days in [DATE] days in [DATE], and [DATE], [DATE] and [DATE]. The secured unit snack refrigerator temperature log for [DATE] revealed recorded temperatures of 42 degrees Fahrenheit on ,d+[DATE], ,d+[DATE] and [DATE] and 44 degrees Fahrenheit on [DATE]. The temperature log listed 46 degrees Fahrenheit as the acceptable refrigerated upper temperature range limit. -However, the refrigerator temperatures should be at or below 41 degrees Fahrenheit. The following expired and undated items were observed in the west unit snack refrigerator and freezer: -A burrito in the freezer, labeled with a resident's s name and expiration date of [DATE]; -A package of spaghetti with meat sauce in the freezer with an expiration date of [DATE]; and, -A plastic cup that contained yogurt and fruit and covered by an exam glove with no expiration date. Temperatures for the west unit snack refrigerator were not recorded for the following dates in [DATE]: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. D. Staff interviews The life engagement coordinator (LEC) was interviewed on [DATE] at 9:05 a.m. She said she thought the kitchen staff maintained the snack refrigerators but she did check them sometimes for expired product. The kitchen account manager ([NAME]) was interviewed on [DATE] at 1:00 p.m. She said the overnight nurses monitored and recorded the unit snack refrigerator temperatures. She said she checked for cleanliness and expired products every Tuesday. She said she thought there was a performance improvement plan for the unit refrigerators but she had not seen the plan. The NHA was interviewed on [DATE] at 1:00 p.m. She said the dietary staff managed the expired product in the unit snack refrigerators and the nursing staff monitored the refrigerator temperatures. She said how the unit snack refrigerators were being managed was not working and she was going to change the process going forward so the kitchen staff would monitor the refrigerator temperatures. II. Ensure sanitary conditions in the dish room A. Professional reference The Food and Drug Administration (FDA) Food Code 2022, last reviewed [DATE] and retrieved on [DATE] from https://www.fda.gov/food/retail-food-protection/fda-food-code, read in pertinent part, Improper repair or maintenance of any portion of the plumbing system may result in potential health hazards such as cross connections, backflow, or leakage. These conditions may result in the contamination of food, equipment, utensils, linens, or singleservice or single-use articles. Improper repair or maintenance may result in the creation of obnoxious odors or nuisances, and may also adversely affect the operation of warewashing equipment or other equipment which depends on sufficient volume and pressure to perform its intended functions. Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted; nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, and warewashing areas, and areas subject to flushing or spray cleaning methods. If a ventilation system is inadequate, grease and condensate may build up on the floors, walls and ceilings of the food establishment, causing an insanitary condition and possible deterioration of the surfaces of walls and ceilings. The accumulation of grease and condensate may contaminate food and food-contact surfaces as well as present a possible fire hazard. B. Facility policy The Environment policy, revised September, 2017, was provided by the nursing home administrator (NHA) on [DATE] at 9:18 a.m. It read in pertinent part, The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. The Infection Prevention Program policy, undated, was provided by the NHA on [DATE] at 9:30 a.m. It read in pertinent part, The maintenance staff is responsible for maintaining the facility's ventilation systems, humidity and temperature control in addition to the utility systems of the facility. Leaks and areas of moisture should be fixed promptly and drywall, ceiling tiles and other materials should be replaced, using guidelines as above. C. Observations and interview The initial kitchen observation [DATE] was conducted with the kitchen account manager ([NAME]) at 9:30 a.m. A blower fan was on a shelf approximately six feet from the dish machine. Standing water was up to one inch in depth and covered half the dish room floor. A pink serving tray was on top of a rubber floor mat (on the floor). The exhaust vent over the dish machine was closed and did not have an exhaust grille cover. Water sprayed from multiple pin holes in a plumbing fixture underneath the dish table; the spraying water then hit the dish table and dripped on the floor, which created standing water. Small black and dried food spots were visible on the walls where the dish table was connected to the wall, on the side of the dish table and on a dish machine dish rack. The staff tracked water from their shoes into the main dining room upon exiting the dish room. The [NAME] said that the kitchen staff stood on the pink dish tray to do dishes so the water would not soak into their shoes. She said the dietary staff used the blower fan because the exhaust for the dish machine was not working. A kitchen observation was conducted on [DATE] at 3:00 p.m. Standing water was observed on the dish room floor and water sprayed from the plumbing fixture against the underside of the dish table. Small black and dried food spots were observed where the dish table connected to the wall. The blower fan was present in the dish room. The dish room ceiling was partially painted and a piece of drywall tape hung from the ceiling corner. A kitchen observation was conducted on [DATE] at 10:30 a.m. The dish machine exhaust switch did not turn the ceiling exhaust on and the exhaust vent was completely closed. Standing water covered approximately half the dish room floor, and water sprayed from the plumbing fixture against the underside of the dish table which caused the water to drip onto the floor and from the electric garbage disposal switch (under the dish table). Pooled water collected on the dish machine chemical buckets lids, a plastic container on the floor and dish rack shelf under the dish table. Water leaked from the dish room into the main dining room (under the shared wall) in an area six inches out from the wall, and four feet in length. Small black and dried food spots were observed where the dish table connected to the wall. The dish room tile floor grout under the standing water appeared crumbled and cracked. A pink serving tray was on top of the rubber floor mat (on the floor), and staff tracked water from the dish room into the main dining room as they exited the dish room. The shared dish room wall inside the kitchen was damaged at two cove (joined the wall to floor) base tiles with crumbled, damp grout. D. Record review The NHA provided two written work orders for the kitchen. Neither work order was for dish room repairs. E. Staff interviews The [NAME] was interviewed on [DATE] at 10:30 a.m. She said the dish machine exhaust used to have a grill cover, but the ceiling caved in and when the ceiling was repaired, the exhaust was completely covered instead of having a grille cover re-installed. She said she thought the ceiling was repaired in 2017 and the dish machine exhaust had not worked since, and the fan had been used since 2018 since the exhaust was broken. She said the plumbing leaked continuously for at least six months and the dish room would get condensation on the walls, and the kitchen staff scrubbed the small black spots off the walls with a brush, soap and water but the small black spots came back. She said she was not sure if there was any documented work order given to maintenance. The director of maintenance (DOM) was interviewed on [DATE] at 12:25 p.m. He said the contracted company that maintained the facility's dish machine had performed their routine visit recently. The company's representative said it looked like the plumbing could have been leaking for a year and what leaked was a booster heater for the dish machine. He said there were no electronic or written work orders submitted for the dish room. The NHA was interviewed on [DATE] at 12:40 p.m. She said there were no electronic or written work orders for the kitchen and sent the previous written work orders received. She said she did not have any kitchen audit or inspection reports. F. Facility follow-up The NHA provided two OSHA (Occupational Safety and Health Administration) Monthly Assessment Dining Reports dated [DATE] and [DATE] on [DATE] at 1:00 p.m. -The [DATE] report revealed, the 'dishwashing area' section listed 'floors clean, tiles unbroken' with a 'U' for unsatisfactory, followed by the comment 'broken floor tiles holding water in the ground.' -The [DATE] report revealed, the 'dishwashing area' section listed 'floors clean, tiles unbroken' with a 'U' for unsatisfactory.

Based on record review and interviews, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident's representative when there was a change of condition for one (#23) of two residents out of 23 sample residents. Specifically, the facility failed to notify the Resident #23's legal representative related to the resident's sudden excessive increase in weight and then subsequently sudden excessive weight loss. Findings include: I. Facility policy and procedures The Notification of Change policy, copyright 2020, was provided by the nursing home administrator (NHA) on 5/18/23 at 11:08 a.m. The policy revealed, the purpose of this policy was to ensure the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification. If there was a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. The circumstances that require a need to alter treatment might include a new treatment, discontinuation of a current treatment due to an acute condition. If a resident was incapable of making his/her own decisions; the resident's representative would make any decisions that have to be made and the resident should still be told what was happening to them. II. Resident #23 A. Resident status Resident #23, age 80, was initially admitted on [DATE] and readmitted on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), aphasia (a disorder that impacts speech), hemiplegia (paralysis) left nondominant side, non-traumatic subarachnoid hemorrhage (brain bleed), protein calorie malnutrition, cognitive deficit, dementia and dysphagia (swallowing difficulty). The 4/7/23 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident had inattention with difficulty focusing his attention, for example, being easily distracted or had difficulty keeping track of what was said? This behavior was present and fluctuated (came and went, changed in severity). The resident had disorganized or incoherent thinking (rambled or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? This behavior was present and fluctuated (came and went, changed in severity). The resident had an altered level of consciousness that was indicated by any of the following criteria: vigilant-startled easily to any sound or touch; lethargic-repeatedly dozed off when being asked questions, but responded to voice or touch; stuporous-very difficult to arouse and keep aroused for the interview; comatose-could not be aroused? This behavior was present and fluctuated (came and went, changed in severity). The resident required extensive staff assistance for bed mobility, dressing, and personal hygiene. The resident was totally dependent on staff for transfers, eating and toileting. The resident had a weight of 174 pounds and complained of difficulty or pain when swallowing. The resident utilized a feeding tube. The proportion of total calories the resident received through parenteral or tube feeding was 51% or more. The average fluid intake per day by intravenous or tube feeding was 501 cubic centimeters (cc) per day or more. B. Record review Care Plan for a nutritional problem or the potential of a nutritional problem related to a history of hypertension, hemiplegia, aphasia, atrial fibrillation, dysphagia, protein-calorie malnutrition, diabetes mellitus type II, respiratory failure, atherosclerotic heart disease, body mass index (BMI) of overweight, physician ordered nothing by mouth, altered skin integrity and tube feed for 100% of the resident's nutritional needs was initiated on 1/4/23. The pertinent interventions were to provide tube feed and flushes as physician ordered. The registered dietitian (RD) was to evaluate and change recommendations as needed. Care Plan for tube feeding related to dysphagia was initiated on 1/1/23. The pertinent interventions were tube feeding and water flushes to be administered by staff. Staff were to discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, and potential complications. Staff were to monitor/document/report as needed any signs or symptoms of: aspiration, fever, shortness of breath, tube dislodged, infection at the tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain/distension/tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and/or dehydration. Staff were to provide local care to the gastrostomy tube site as ordered and monitor for signs or symptoms of infection. The RD was to evaluate the resident quarterly and as needed, monitor caloric intake, estimate needs, and make recommendations for changes to tube feeding as needed. The resident was dependent on tube feeding and water flushes. The staff were to follow physician orders for current feeding orders. Health status note dated 4/26/23 by the assailant director of nursing (ADON) revealed the RD was notified the resident had a weight gain on 4/17/23 of 179.4 pounds and 194 pounds on 4/24/23. The resident had his tube feeding nutrition changed on 4/11/23 from Isosource 1.5 at 50 milliliters (ml) each hour continuous to Nutren 2.0 at 45 ml each hour for 20 hours. The goal was to have the resident not connected to the tube feeding machine for longer periods of time. It was requested that the RD review the resident's nutritional status for recommendations. Nutrition note dated 4/26/23 at 12:14 p.m., by the RD revealed the request was received and enteral nutrition related to weight gain was reviewed. The resident's current body weight (CBW) was 179.4 pounds on 4/17/23 and 194 pounds on 4/24/23. The resident's usual body weight (UBW) was 170 to 176 pounds from 1/1/23 through 4/10/23; with documented fluctuations and diuretic administration. There was not documented edema in the nurse notes this week. The current enteral nutrition of Nutren 2.0 at 45 ml per hour for 20 hours would provide 1800 kilocalories (kcal) or (~20 kcal/kg CBW). In addition, 15 ml water flushes with medications and 60 ml water flush daily for patency. The resident was currently nothing (food or water) by mouth. The recent rate of Nutren 2.0 at 42 ml per hour for 20 hours allowed for a slight decrease of 120 kcal each day to support weight maintenance/possible gradual weight loss to usual body weight. Interdisciplinary team (IDT) progress note dated 4/27/23 at 12:54 p.m., revealed the team met to review the resident's weight of 194 pounds on 4/24/23. Physician orders were received to decrease from 45 ml to 42 ml per hour tube feedings. IDT progress note dated 5/4/23 at 12:42 p.m., revealed the team met to review the resident for weight gain nutrition via tube feeding. The resident would be reevaluated for the volume of the tube feed related to recent weight decrease from 197.6 pounds on 4/27/23. Nutrition note dated 5/4/23 by the RD revealed the resident's weight was discussed at the IDT at risk meeting. On 5/1/23 the resident had a weight of 197.6 pounds which reflected a significant gain of 24 pounds or 13.8% in the past month. The resident had a weight gain of 3.6 pounds in the past week, despite a decrease in the tube feeding rate. The nursing staff did not report any edema and were confident in the accuracy of the recorded weights. The etiology of the weight gain was uncertain. There were no medication changes that affected the weights. The resident's usual body weight was 175 pounds. The recommended change for rate and duration were Nutren 2.0 at 62 ml each hour for 13 hours with nocturnal feedings from 6:00 p.m., to 7:00 a.m., (or times per nursing). This would provide 800 ml formula, 1600 kcal, and 64 grams of protein per 24 hours. Furthermore auto flush 75 ml of water during feedings to provide 975 ml water every 24 hours (total 1537 ml free water from formula/flushes); in addition to the water used with medication administration. Staff would continue to monitor tolerance and weights. The goal was to forestall further gain and potentially gradual correction toward his usual body weight range. IDT progress note dated 5/11/23 at 12:37 p.m., by the social services director (SSD) revealed the team met to review the resident for weight. The resident had a weight of 180.8 pounds. There were adjustments to his intake due to weight increase and the resident was now at his previous weight. The resident was tolerating the duration of the tube feeding. Nutrition note dated 5/12/23 at 8:37 a.m., (late entry) by the RD revealed the resident's weight was 180.8 pounds on 5/8/23, 197.6 pounds on 5/1/23 and 183.9 pounds on 4/17/23. From January 2023 through April 2023, most of the resident's weights were in the mid 170 pounds range. The resident was tolerating nocturnal feedings without reported difficulty. The etiology of weight loss of this magnitude in one week was uncertain. The resident was currently more within his baseline weight. Will continue to monitor next week's weight and consider adjustments to enteral feeds as indicated. Nurse note dated 5/15/23 at 10:01 p.m., by the ADON revealed the resident's physician was notified of the resident's weight changes and discussed how the weights were obtained. The plan was to observe the resident being weighted and observe the scale that was used. III. Staff interviews The NHA, quality nurse mentor (QNM), RD and the registered dietitian consultant (RDC) were interviewed on 5/18/23. The RD said she was unable to explain the weight differences. The RD said there was no edema, no abdomen ascites (accumulation of fluid in peritoneal cavity resulting in abdominal swelling), hospitalization s, visits out of the facility and no medication changes. The RD said there were no deviations from the tube feeding orders. The RD said the resident was on a stable antidiuretic medication that would not result in the fluctuations. The RD said during the weight gain the resident was provided with 1800 calories each day via his tube feeding and this was reduced to 1680 calories each day on 4/26/23. The RD said this was not a lot of calorie change each day. The RD said the resident's body mass index (BMI) was 27 (acceptable range) and his usual body weight (UBW) was 175 pounds. The RD said the resident was now back to his stable baseline weight and the 1800 calories per day had been resumed. The RD said the resident had variable weights that could not be explained and there were no reweights. The RD said there was no documentation that the resident's family was notified of the resident's weight gain nor his weight loss. The resident's first emergency contact was interviewed on 5/18/23 at 12:53 p.m. She said she was not notified of the resident's weight gain and then loss until yesterday (during the survey). She said she would have liked to have been notified of the weight changes when they occurred. The resident's power of attorney (POA) was interviewed on 5/18/23 at 1:03 p.m. He was not notified of the resident's weight gain and then loss until yesterday. He said he would have liked to have been notified of the weight changes when they occurred. The director of clinical risk management (DCRM) was interviewed on 5/18/23 at 1:13 p.m. The DCRM said families should be notified if a resident had significant weight increased or decreased.

Based on record review and interviews, the facility failed to ensure residents were free from abuse for one (#39) out of four residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to prevent incidents of physical abuse by Resident #31 toward Resident #39. Findings include: I. Facility policy and procedure The Elder Justice Act and Reporting Suspected Crime Against Residents policy, revised October 2017, was received from the nursing home administrator (NHA) on 5/16/23 at 12:52 p.m. It read in pertinent part: In response to allegations of abuse, neglect, exploitation or mistreatment the facility shall ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, or misappropriations of resident property are reported in the proper time frame (24 hours). Have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. Report the results of all investigations to the administrator and/or his or her designated representative and to other officials in accordance with state law, including the state survey agency, within 5 days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. II. Incident of resident to resident abuse 1/27/23 An incident report dated 1/27/23 was completed by licensed practical nurse (LPN) #1 at 9:00 am revealed LPN #1 heard Resident #31 yelling. According to the certified nurse aide with medication authority (CNA/MA #1) Resident #31 was seen grabbing the left wrist of Resident #39 and striking Resident #39 in the face with an open right hand. The life engagement coordinator (LEC) and CNA/MA #1 helped remove the grip of Resident #31 on Resident #39 and immediately separated the two. Resident #39 had redness to her left hand/wrist but no other injuries were identified. Resident #39 was oriented to self only which was the resident's baseline orientation. The incident identified overcrowding in the common area as a predisposing environmental factor. LPN #1 stated Resident #31 had an increase in irritation/agitation in the common area (television room) during shift. LPN#1 stated she did not witness the incident but understood CNA/MA #1 did. Per the incident report, two staff members (CNA/MA #1 and the LEC) removed Resident #31's grip on Resident #39 and immediately separated the two and called the nursing home administrator (NHA). The LPN assessed Resident #39 who had no other injuries and no treatment was offered. Resident #39 was oriented to staff only which was the resident's baseline. During the facility investigation, LPN #1 reported in the incident report the assailant escalated throughout the day and seemingly increased based on his surroundings from overstimulation. Two residents were also interviewed, Resident #9 stated he did not see or hear anything but reported Resident #31 often yells when in the dining room and that pisses people off. The police, the ombudsman, provider, daughter of Resident #39, and Adult Protective Services were notified of the incident. Cross-reference F744 for dementia care, the facility failed to provide personalized interventions/strategies to Resident #31, who was escalated by his surroundings from overstimulation. Interventions: Encourage Resident #31 to eat meals in his room as the resident was becoming increasingly irritated and over stimulated. Initiate every 15 minute checks to monitor behaviors beginning 1/27/23 at 10:00 p.m. through 1/30/23 at 5:45 a.m. Medication adjustments of Depakote capsule (less effective) to Depakote Elixir 250 mg/5 ml (more effective) per the interdisciplinary team meeting one day prior to incident. The internal investigation concluded the facility found the allegation of abuse unsubstantiated as the resident lacks the capacity of intent per the NHA. The director of operations provided documentation on 5/15/23 at 10:58 a.m. in reference to education provided to the NHA on Substantiating versus Unsubstantiating an Allegation of Abuse: The NHA has been educated that when substantiating and un-substantiating an allegation of abuse for residents with cognitive impairment/dementia their ability to form intent is not to be taken into consideration or account per their diagnosis of dementia. For example, if a resident with dementia hits another resident and it is witnessed, it should be substantiated due to it occurring even if intent cannot be formed. Staff Education on 2/7/23 was provided on Dementia Care and Challenging Behavior Acknowledgement and Dementia Capable Care Specialist Training/Certification (Secure Unit) to eight staff. III. Resident #39 A. Resident status Resident #39, age 71, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), pertinent diagnoses include dementia, atherosclerotic heart disease (narrowing of a heart artery(s) without chest pain), cerebral infarction (stroke) and hypertension (elevated blood pressure). The resident resided in the memory care unit. The 5/17/23 minimum data set (MDS) assessment revealed Resident #39 had severe cognitive impairment. The resident required extensive assistance with activities of daily living and required a wheelchair for locomotion. The resident exhibited behavioral disturbances, poor safety awareness, elopement risk, and was uncooperative with care at intervals. B. Resident representative interview The daughter of Resident #39 was interviewed on 5/15/23 at 3:40 p.m. She indicated the resident was in another resident's room and she was slapped in the face when she attempted to leave the room. She received a call from the facility who informed her of the event. They informed her the police were called. The facility asked her if she would like to file charges against the resident who slapped her mother and she declined. C. Record review The care plan, revised 2/9/23, identified the resident had activities of daily living (ADL) and self-care performance deficits, cognitive, communication, and memory deficits, as well as behavioral problems and a potential for physical aggression related to dementia. The care plan, revised 2/9/23 identified interventions to support ADLs, allow the resident to make choices, analyze triggers, and to provide verbal cues, assess and address contributing sensory deficits to alleviate anxiety and de-escalate behaviors. IV. Resident #31 A. Resident status Resident #31, age 77, was admitted on [DATE]. According to the May 2023 CPO, diagnoses included dementia without behavioral disturbance, unspecified mood (affective) disorder, and cognitive communication deficit. The resident resided in the memory care unit. The 4/24/23 MDS assessment revealed that the resident had severe cognitive impairment. The resident required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required supervision for eating and used a wheelchair for locomotion. B. Record review The care plan, revised 5/3/23, identified the resident required additional assistance with ADLs due to impaired cognition function and impaired thought processes related to dementia with behavioral disturbance. The resident was assigned an Adult Protection Services guardian related to significant cognitive impairment. The resident has displayed behaviors of becoming verbally and physically aggressive related to dementia and poor impulse control. The care plan, revised 3/6/23, identified interventions to assist with ADLs, observe, document, and report resident posing any danger to himself or others, redirect resident to low traffic areas, offer activities of choice, western movies, offer weighted blanket(s) for comfort and intervene before agitation escalates. V. Staff Interviews The LEC was interviewed on 5/15/23 at 4:16 p.m. She said the residents were eating breakfast in the small common area on the secure unit. As a result, the area was hot due to the crowding and the perpetrator became over-stimulated in the small hot confined area. Resident #31 did not do well with over stimulation; she had never seen Resident #31 socialize with other residents. She said she was not a witness to the incident but believed a CNA saw what occurred. LPN #1 was interviewed on 5/16/23 at 11:15 a.m. She said she did not witness the strike to the face and by the time she arrived the residents were already separated. When she entered the common area, she witnessed CNA/MA #1 and the LEC had removed the hand of Resident #31 from Resident #39's left arm as they separated the two residents. She stated she assessed Resident #39 for injuries and found none. She said she noted minor redness to the left wrist of Resident #39. She stated she completed an investigation, wrote an incident report and called the NHA, the provider, police, the daughter of Resident #39 and Adult Protective Services since Resident #31 had APS listed as a contact. She stated Resident #31 gets agitated easily but she could talk to him if he was willing to talk. She stated mechanisms to de-escalate resident #31 were to turn on the TV to programs with music, he liked looking at pictures in magazines, and snacks seemed to calm him. She said the staff recognized the resident could be tired, needed the bathroom, and/or required comforting words and snacks. The 15 minute checks were completed through 1/30/23 and no behaviors were observed. CNA #2 was interviewed on 5/17/23 at 7:26 a.m. She said she recognized when Resident #31 was agitated and she used a number of de-escalation tactics to calm him. She stated she would talk slowly, remain calm and explain why she entered his room to assist him. Often times, she asked Resident #31, if he needed to use the bathroom, asked and offered the resident a snack if he was hungry or if he was thirsty and he would generally calm down if the staff were calm. If staff appeared in his room suddenly, Resident #31 could escalate with anger, therefore, she knocked on his door, asked Resident #31 if she could enter and let him know why she entered his room. CNA #3 was interviewed on 5/17/23 at 7:32 a.m. She said she had not experienced aggressiveness from Resident #31. She stated staff understand the need to address Resident #31 calmly because if staff spoke too fast the resident asked staff to slow down or else Resident #31 could escalate. She often knocked first and let Resident #31 who she was before she entered his room. CNA/MA #1 was interviewed on 5/17/23 at 10:27 a.m. She said the incident occurred after meal time on 1/27/23 while she was passing medication. She stated about six to seven residents were eating in the common room when she heard Resident #31 hollering. She entered the common room and saw Resident #31 trying to move away from the table but his wheelchair's front wheel was stuck on Resident #39's back wheel on her wheelchair. He grabbed her left arm and hit her twice across the face. Resident #39 did not cry out but she did look surprised; Resident #39 did not try to defend herself nor did other residents try to intervene. She separated the residents' wheels and assisted Resident #31 back to his room. She said Resident #31 was frustrated/aggravated because he could not move his wheelchair but once she separated them, Resident #31 was calm. He was offered a snack when he was returned to his room. She said she de-escalated Resident #31 by getting down to his level, asking the resident if he needed the bathroom and assured him he was safe.

Based on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one ( #39) out of four residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to for Resident #39, effectively identify person-centered approaches for dementia care to prevent resident-to-resident altercations. Findings include: I. Resident census and conditions demographic The 5/15/23 Census and Condition form documented that 48 residents resided at the facility. The form further documented there were 36 residents with a dementia diagnosis and 22 residents with behavioral healthcare needs. The facility had a secure unit with 21 residents residing in it. II. Facility policy and procedure The Dementia Care policy, no revision date, was provided by the nursing home administrator (NHA) on 5/17/23 at 2:01 p.m. It read in pertinent part, The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or their representative, to the extent possible. The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting the goals. The care plan will be related to each resident's individual symptomatology and rate of dementia (or related disease) progression with the end result being noted improvement or maintenance of the expected stable rate of decline associated with dementia and dementia like illnesses. Care and services will be patient centered and will reflect each resident's individual goals. III. Resident #31 A. Resident status Resident #31, age 77, was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, unspecified mood (affective) disorder and cognitive communication deficit. The resident resided in the secured unit. The 4/24/23 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment. The resident required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required supervision for eating and used a wheelchair for locomotion. B. Record review The care plan, revised 5/3/23, identified the resident required additional assistance with activities of daily living (ADL) due to impaired cognition function and impaired thought processes related to dementia with behavioral disturbance. The resident was assigned an Adult Protection Services guardian related to significant cognitive impairment. The resident has displayed behaviors of becoming verbally and physically aggressive related to dementia and poor impulse control. The care plan, revised 3/6/23. identified interventions assist with activities of daily living, observe, document, and report resident posing any danger to himself or others, redirect resident to low traffic areas, offer activities of choice, Western movies, offer weighted blanket(s) for comfort and intervene before agitation escalates. IV. Incident of resident to resident abuse on 1/27/23 (cross-reference F600) Per an the incident report on 1/27/23 Resident #31 was yelling and grabbed the wrist of Resident #39 and striked Resident #39 in the face with an open right hand. Predisposing environmental factors indicated overcrowding in the common area. Resident #31 had an increase in irritation/agitation in the common area. Documented in the incident report, the assailant (Resident #31) escalated throughout the day and seemingly increased based on his surroundings from overstimulation. A resident stated reported Resident #31 often yells when in the dining room and that pisses people off. -The facility failed to provide personalized strategies/interventions to Resident #31 who was escalated during the day by his surroundings from overstimulation that caused the altercation with Resident #39. V. Staff interviews The LEC was interviewed on 5/15/23 at 4:16 p.m. She said the residents were eating breakfast in the small commons area on the secure unit. As a result, the area was hot due to the crowding and the perpetrator became over-stimulated in the small hot confined area. Resident #31 did not do well with over stimulation; she had never seen Resident #31 socialize with other residents. She said she was not a witness to the incident but believed a certified nurse aide (CNA) saw what occurred. LPN #1 was interviewed on 5/16/23 at 11:15 a.m. She said she did not witness the strike to the face and by the time she arrived the residents were already separated. When she entered the common area, she witnessed CNA/MA #1 and the LEC had removed the hand of Resident #31 from Resident #39's left arm as they separated the two residents. She stated she assessed Resident #39 for injuries and found none. She said she noted minor redness to the left wrist of Resident #39. She stated she completed an investigation, wrote an incident report and called the NHA, the provider, police, the daughter of Resident #39 and Adult Protective Services since Resident #31 had APS listed as a contact. She stated Resident #31 gets agitated easily but she could talk to him if he was willing to talk. She stated mechanisms to de-escalate resident #31 were to turn on the TV to programs with music, he liked looking at pictures in magazines, and snacks seemed to calm him. She said the staff recognized the resident could be tired, needed the bathroom, and/or required comforting words and snacks. The 15 minute checks were completed through 1/30/23 and no behaviors were observed. CNA #2 was interviewed on 5/17/23 at 7:26 a.m. She said she recognized when Resident #31 was agitated and she used a number of de-escalation tactics to calm him. She stated she would talk slowly, remain calm and explain why she entered his room to assist him. Often times, she asked Resident #31, if he needed to use the bathroom, asked and offered the resident a snack if he was hungry or if he was thirsty and he would generally calm down if the staff were calm. If staff appeared in his room suddenly, Resident #31 could escalate with anger, therefore, she knocked on his door, asked Resident #31 if she could enter and let him know why she entered his room. CNA #3 was interviewed on 5/17/23 at 7:32 a.m. She said she had not experienced aggressiveness from Resident #31. She stated staff understand the need to address Resident #31 calmly because if staff spoke too fast the resident asked staff to slow down or else Resident #31 could escalate. She often knocked first and let Resident #31 who she was before she entered his room. CNA/MA #1 was interviewed on 5/17/23 at 10:27 a.m. She said the incident occurred after meal time on 1/27/23 while she was passing medication. She stated about six to seven residents were eating in the commons room when she heard Resident #31 hollering. She entered the commons room and saw Resident #31 trying to move away from the table but his wheelchair's front wheel was stuck on Resident #39's back wheel on her wheelchair. He grabbed her left arm and hit her twice across the face. Resident #39 did not cry out but she did look surprised; Resident #39 did not try to defend herself nor did other residents try to intervene. She separated the residents' wheels and assisted Resident #31 back to his room. She said Resident #31 was frustrated/aggravated because he could not move his wheelchair but once she separated them, Resident #31 was calm. He was offered a snack when he was returned to his room. She said she de-escalated Resident #31 by getting down to his level, asking the resident if he needed the bathroom and assured him he was safe. CNA #1 was interviewed on 5/17/23 at 1:20 p.m. She said Resident #31 was increasingly unpredictable at times. CNA #4 was interviewed on 5/17/23 at 1:40 p.m. She said Resident #31 had been irritated lately.

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 for two residents (#25 and #23) out of 23 sample residents. Specifically, the facility failed to: -Ensure Resident #25's refrigerator temperatures were monitored for refrigerated food storage; and, -Ensure sanitary food storage for Resident #25 and Resident #23's personal refrigerators. Findings include: I. Facility policies The Food From Outside Sources policy, dated March, 2017, was provided by the nursing home administrator (NHA) on [DATE] at 9:15 a.m. It read in pertinent part, All foods shall be stored in a resident only area; designated refrigerator (personal or group) or cabinet. Facility reserved the right to discard any foods which are not correctly dated, or questionable content or source to assure safety for all residents. Perishable food is discarded within three days from any resident refrigerator source unless the food item is safe until a printed expiration date. The Safe Handling for Foods from Visitors policy, revised July, 2019, was provided by the NHA on [DATE] at 11:36 a.m. It read in pertinent part, Residents will be assisted in properly storing and safely consuming food brought to the facility for residents by visitors. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: Equipped with thermometers; have temperature monitored daily for refrigeration temperatures less than or equal to 41 degrees Fahrenheit and freezer less than or equal to 0 degrees Fahrenheit; daily monitoring for refrigerated storage duration and discard any food items that have been stored for seven day or more; cleaned weekly. II. Resident interview and observation Resident #25 was interviewed on [DATE] at 1:20 p.m. A personal refrigerator was observed in the resident's room. She said she was unsure if the temperature of the refrigerator was monitored. A package of six applesauce containers was observed in the resident's refrigerator with an expiration date of [DATE]. Resident #23 was interviewed on [DATE] at 3:29 p.m. A personal refrigerator was observed in the resident's room. He said he purchased the refrigerator and a certified nurse aide (CNA) checked the refrigerator temperature but not the dates of the food in the refrigerator. The following items were observed in Resident #23's personal refrigerator: unknown food items in a plastic container with an expiration date [DATE]; provolone cheese with an expiration date of [DATE]; a meat and cheese sandwich that was not labeled with a product name, made on or expiration date. III. Record review Temperatures were not recorded and temperature logs were not used for Resident #25's personal refrigerator. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on [DATE] at 9:30 a.m. She said the overnight staff recorded resident refrigerator temperatures in the residents' electronic record. The assistant director of nursing (ADON) was interviewed on [DATE] at 12:20 p.m. She said resident ambassadors (management) were responsible for checking expired food and monitoring and recording in the resident personal refrigerators and the ambassadors were assigned to specific residents. She said she was unsure if education regarding personal refrigerators was provided to the residents upon move in. The NHA was interviewed on [DATE] at 1:00 p.m. She said the facility managers served as resident ambassadors and the ambassadors were supposed to check resident refrigerators for expired food products. She said a resident that discharged from the facility in [DATE] gave Resident #25 her refrigerator; the information about the refrigerator was not transferred to Resident #25 and no refrigerator temperatures were recorded. She said education regarding food stored in resident personal refrigerators was not provided to residents or family members upon move in.

Based on record review, observation, and interviews, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by significant weight loss for one (#12) of three residents reviewed for nutritional status out of 10 sample residents. Specifically, the facility failed to ensure Resident #12 had interventions in place to prevent significant weight loss. Resident #12 experienced significant weight loss of 11.4% in three months, and 16.4% within a six months' time frame. The registered dietitian (RD) was not aware of the resident's weight loss until February 2022. The dietary manager was also not aware of the resident's weight loss. The facility's failure to have a system that ensured timely weights were obtained and reported to the interdisciplinary team (IDT), RD assessment was completed, and nutritional interventions were timely implemented, contributed to Resident #12's significant weight loss. Findings include: I. Facility policy and procedure The Nutritional Management policy, dated 10/1/21, was provided by the director of nursing (DON) on 2/23/22 at 12:39 p.m. It read in pertinent part: A systemic approach is used to optimize each resident's nutritional status: -Identifying and assessing each resident's nutritional status and risk factors -Evaluating/analyzing the assessment information -Developing and consistently implementing pertinent approaches -Monitoring the effectiveness of interventions and revising them as necessary. II. Resident status Resident #12, age 76, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/10/22 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. Physical and verbal behaviors directed towards others as well as rejection of care were present within the previous 1-3 days. He required supervision of two staff with bed mobility, transfers, walking in room; extensive assistance of two staff with dressing and toilet use; limited assistance of two staff with personal hygiene; and supervision with set-up for eating. The resident's height was 68 inches, weight was 221 pounds and no weight loss was documented. He received antipsychotic and antidepressant medications daily. III. Record review A. Care plan The resident's care plan, dated 7/29/21, identified: I have a regular diet, dysphagia advanced texture, with thin liquids. Resident prefers to drink a lot of milk throughout the day and night. Resident has had weight gain since entering this facility and he is fine with weight gain. Resident asks for sugar to put into drinks. Interventions included: I like to eat most foods. I like cookies, ice cream and chocolate milk, dated 6/7/21. The care plan dated 2/8/22 identified: I am at risk for a potential for nutritional problem related to varied intake, need for mech (mechanically) altered diet, ETOH (alcohol) dependence, refusal of meals and throwing foods in toilet Sig (significant) weight loss (undesirable). Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Monitor/record/report to MD (physician) PRN (as needed) s/sx (signs/symptoms) of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide and serve diet as ordered. HSG (acronym unknown) regular diet, HSG dysphagia advanced texture, regular consistency. Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD to evaluate and make diet change recommendations PRN (as needed). Weigh as ordered 12/22/21. Provide and serve supplements as ordered: Medpass 2.0, 4 oz BID (twice a day), dated 2/8/22. B. Resident's weights According to the vital signs report the following weights were documented in Point Click Care (PCC) , the electronic medical record, for Resident #12: 6/14/21 - 221.6 pounds 9/3/21 - 234.2 pounds 10/7/21 - 236.2 pounds 11/2/21 - 225.8 pounds 12/6/21 - 220.8 pounds 2/7/22 - 195.6 pounds -The resident had lost 30.2 pounds or 13.4% within three months, and 40.6 pounds or 17.2% within four months. C. Physician orders The February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Diet: HSG (acronym unknown) regular diet, HSG dysphagia advanced texture, regular consistency, distant supervision/meal time set-up; Per results of CSE (acronym unknown), d/g (downgrade) to dysphagia advanced diet textures d/t (due to) dentition status and patient preference for soft foods. Regular meats, chopped. Dated 6/8/21 -Weights monthly. Dated 11/8/21 -House (supplement) 2.0 two times a day for weight maintenance, at risk for malnutrition. Provide 4 (four) oz at AM (morning), PM (afternoon) snack time. Dated 2/9/22 D. Providers' notes On 1/8/22 a physician documented: Weight 220 pounds. On 1/30/22 a nurse practitioner (FNP) documented: He is taking in foods and fluids. There were no provider notes related to the resident's significant weight loss. E. Registered dietician (RD) assessments The 12/22/21 Nutrition Review documented: 76yr old male. Pmhx (past medical history): epileptic seizures, dementia, [CONDITION(S)], chronic a-fib ([CONDITION(S)]), B12 [CONDITION(S)], dysphagia, [CONDITION(S)], ETOH (alcohol) dependence. Meds: [MEDICATION(S)], MVI (multivitamin) w/minerals, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. Labs: will review as available. Skin: continues to receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 1mo: 225.8#; 3mo: 234.2#; 6mo: 221.6#. No sig (significant) changes in wt (weight) - favorable. Diet: HSG Regular diet, HSG Dysphagia Advanced texture, Regular consistency. NKFA (no known food allergy). Supplement: none. Nutrition Review: Rt (resident) feeds self with set-up and supervision from a distance. Appetite remains varied at meals. Rt (resident) accepting snacks. No reported problems chewing/swallowing and no GI (gastrointestinal) distress. Current nutrition interventions remain appropriate. Goal to maintain CBW (current body weight) with improved skin integrity. RD (registered dietician) to monitor. Continue POC (plan of care). The 2/8/22 significant weight change nutrition assessment documented: Supplements: none. Nutrition meds: [MEDICATION(S)], [MEDICATION(S)], MVI w/mins (multivitamin with minerals), bowel meds. Ht/Wt/BMI (height/weight/body mass index): 68 (inches), 195.6 lbs (2/7/22), BMI 29.7 indicates overweight. Wt (weight) History: sig (significant) weight loss of -14.1% x 6 months, -11.4% x 2 months, manner in which patient is losing weight is undesirable. Throwing food out and refusing meals frequently. So weight loss undesirable d/t (due to) no eating. Allergies: No known food allergies. PO (oral) intakes: PO intakes poor, consistent refusal of meals at times. When consuming meals, consumes around 25-50% of meals. Feeding ability: supervision and setup with meals. Location of meals: Room Chewing/swallowing: no chewing or swallowing issues noted with dysphagia advanced diet and thin liquids. Current Labs: no recent labs available for review. Skin: shearing of bilateral buttocks. [CONDITION(S)]: no [CONDITION(S)] noted. Notes: Resident is noted to be throwing food from his meals into the toilet and the sink. Staff encourage resident to eat meals which he refuses frequently. Patient difficult to redirect. Encouragement consistently with patient to consume foods. Interventions/Recommendations: recommend adding House 2.0 4 oz BID (twice daily) between meals (440 kcals, 20 g pro). At risk for malnutrition: yes related to Dx (diagnosis) of Dementia. Goals: maintain CBW +/-5% with no sig weight changes. No s/s of aspiration, malnutrition, or dehydration. Consume >50% of meals. -The assessments did not indicate communication with Resident #12's physician, the interdisciplinary team, and the dietary department. -The RD assessment did not include communication with Resident #12 or his family to identify his favorite foods to encourage meals intake. F. Interdisciplinary notes On 9/23/21 the social worker documented: POA (power of attorney name) contacted via phone. Nutrition; POA (power of attorney) notified resident has had a weight gain over this quarter. POA states she is ok with the change as long as he's happy, however; if pain or discomfort began, she would like to be notified. Nursing; No medication changes noted; drug regimen in place; compliant. Activities; Resident declines most activities, however; resident does enjoy watching movies, going on short walks. Advanced directives; POA requested a change in order; DNR (do not resuscitate): No ancillary concerns at this time will review and update as needed. On 11/27/21 a nurse documented: Resident came to nurses station and spit his chewed up food into his hand and threw it towards the fridge, when asked why he did that his response was, 'stupid' and walked away. On 12/16/21 the social worker documented: IDT (interdisciplinary team) met with POA (power of attorney) over the phone to complete a care conference. POA did not have any concerns. (Resident) has a recent medication change to [MEDICATION(S)] for his [CONDITION(S)] health. Monitoring is in place to ensure response to the medication is beneficial. Resident continues to enjoy his snacks and beverages throughout the day. No concerns at this time. His daughter explained that she was going to be in touch with us for a possible visit with her father. On 1/12/22 a nurse documented: This resident awoke around five a.m. This resident requested something to eat and drink. He was given 2 (two) sandwiches and chocolate milk. RCS (resident care staff - certified nurse aide) went in to change him. She was able to take his dirty pants and brief off. She placed new brief and pants on resident and this resident allowed her to pull them up over his knees and then he refused to let her pull them up any more. On second attempt RCS went into room and asked if she could fix his pants in which he stated NO. Resident was chewing and then spit sandwich into his hand. Resident seems to be having a more difficult time taking pills and eating. IV. Observation Resident #12 was observed on 2/23/22 at 8:30 a.m. He was in his room, resting in his bed. His breakfast was brought in by certified nurse aide (CNA) #3 and placed on a bedside table next to Resident #12's bed. The resident repositioned himself to the sitting position at the edge of the bed, looked at the food and did not eat it. -Further, a nurse documented the resident refused to eat his breakfast. V. Meals intake records Resident #12's meals intake records dated 1/1/22-1/24/22 revealed the resident refused 11 meals, consumed 0-25% during 29, and 26-50% during 21 out of 72 meals. Resident #12's meals intake records dated 1/25/22-2/23/22 revealed the resident refused 14 meals and consumed 0-25% during 50 out of 87 meals. VI. Interviews CNA #3 was interviewed on 2/23/22 at 8:25 a.m. in Resident #12's room. She said the resident was one on one with staff during the day and evening shifts due to his aggressive behaviors for the past several weeks. She said Resident #12 was independent with eating, however most of the time did not eat regular meals. He may take a bite and spit it out. She said he ate sweets, cookies, snack food and drinks lots of milk. She said she was not aware of his weight loss. The dietary manager (DM) was interviewed on 2/23/22 at 9:10 a.m. She said she was aware of one female resident who experienced a weight loss in the facility. She said the dietary interventions for residents who suffered a weight loss included fortified foods, protein supplements and protein cookies. She said she was not aware of Resident #12's significant weight loss. She said she was not aware of Resident #12's poor food intakes. The registered dietician (RD) was interviewed in the presence of the nursing home administrator (NHA) on 2/23/22 at 10:25 a.m. The RD said he was new to the facility as of mid-December 2021. He said the PCC electronic medical records system automatically triggered a weight loss as soon as a resident's weights were documented in the Weights/Vitals section. He said he was not aware Resident #12's weights were not documented in the PCC (see above). He said he was not aware of Resident #12's weight loss until the beginning of February 2022. He said as soon as the resident's weight of 195.6 pounds was put in the PCC record, the system sent a weight loss awareness trigger. He said he completed the nutritional assessment and the House 2.0 protein supplement was ordered. He said Resident #12 was on a regular mechanical soft diet. He said he was not aware of resident's throwing and spitting out his food. He said the nursing staff did not communicate the issue with him. The director of nursing (DON) was interviewed on 2/23/22 at 11:42 a.m. She said she was aware of Resident #12's weight loss. She said due to the medication changes, the resident was losing his appetite. She said she was not aware Resident #12's weights were not consistently documented in PCC. VII. Facility follow-up On 2/25/22 the DON submitted the January 2022 weights log. Hand written notes revealed Resident #12 ref (refused) weights that month. -The facility provided no further plans to address Resident #12's significant weight loss.

Based on record review and interviews, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated for two (#3 and #4) of three residents reviewed out of 10 sample residents. Specifically, the facility failed to: -Thoroughly investigate an allegation of abuse between Resident #3 and #4; and, -Take steps to prevent further potential abuse from occurring by determining if Resident #3 and Resident #4 had consent to engage in sexual activity. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, implemented 10/1/21, was provided by the nursing home administrator (NHA) on 2/21/22 at 3:10 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The facility will .establish policies and procedures to investigate any such allegations . Establishing a safe environment . identify when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded . The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. II. Incident between Resident #3 and Resident #4 on 1/24/22 The 1/25/22 abuse investigation report was provided by the NHA on 2/22/22 at 1:25 p.m. The report was completed by the prior social services director (SSD) and the NHA. The report revealed the following: Situation: Resident #4 was involved where Resident #3 put his hand down her pants and Resident #4 allowed it willingly. The report states that it occurred in the morning. Family member of Resident #4 notified 1/24/22 at 1:15 p.m. Report stated no mental or functional status changes were observed. Primary care clinician was notified on 1/24/22 at 1:14 p.m. Resident #4 investigation interview: How do you feel about your care at the facility? Good. Has anyone here voiced to you anything concerning/regarding themselves or others? They have my money. Has anyone abused or neglected you? I got bit by a dog, a dachshund. Who can you inform if you feel there was anything that would be concerning? No, I am scared of dogs. Anything we should know about the occurrence on 1/24/22? I asked him if he wanted (oral sex), I don't want to have another baby by him. That was a one time thing. Nurse description: I was doing my med (medication) pass and I went into room to check on a resident. I saw Resident #3 with another Resident #4. He (Resident #3) had his hand in her pants. I immediately said stop it separate which they did. This resident was not distress she was there in her own free will. Resident #4 stated, we are not doing anything wrong. Mental status of Resident #4: oriented to person, but not oriented to the situation, place or time. -However, this was documented as a situation, background, assessment, recommendation summary (SBAR) progress note in Resident #4's electronic medical record and the facility failed to interview the nurse (licensed practical nurse #1) about the incident (see NHA interview below). Immediate actions: Residents were separated, and female Resident #4 went back to her room. No injuries observed at time of incident. Resident #3-Situation: Resident #3 was found putting his hands down Resident #4's pants. Report stated this occurred in the morning. Report stated no mental or functional status changes were observed. Primary care clinician was notified on 1/24/22 at 10:39 a.m. Resident #3 investigation interview: I like the staff, they are nice to me. I do not have any issues with the residents either. Everyone was okay. Resident #3 states he and Resident #4 are friends and this was the first time they have been sexual. He thinks it was consensual since she came in asking for sex. Summary of facility findings: Investigation was concluded and found unsubstantiated due to participation of both residents in the act. Neither resident was fearful of the encounter and female (Resident #4) was in Resident #3 room, asking him for sex. Resident #4 stated he was her boyfriend and she was not doing anything wrong. When interviewing male (Resident #3), he seemed embarrassed of the encounter and stated Resident #4 frequently asks him to engage in sexual encounters. Nurse who witnessed the act stated neither resident looked uncomfortable and both residents appeared consenting. -The nurse report documented there were no witnesses, however, Resident #3 said his roommate was present at the time of the incident. The facility failed to interview Resident #3's roommate as part of the allegation of abuse (see Resident #3 interview and NHA interview below). -No additional staff abuse training or training related to residents engaging in sexual activity was conducted after the 1/24/22 incident with Resident #3 and #4. III. Resident #4 A. Resident status Resident #4, age 63, was admitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/5/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. She required moderate assistance with showers, toileting, dressing, bed mobility, transfers, and ambulation. The MDS revealed potential indicators of [CONDITION(S)] include delusions (misconceptions or beliefs that are firmly held, contrary to reality). There were Level II preadmission screening and resident review (PASRR) conditions due to serious mental illness. The resident mood interview (PHQ-9) revealed feeling down, depressed, or hopeless and feeling tired or having little energy with a score of two of 27 indicating minimal depression. No rejection of care was present. Wandering occurred one to three days and the wandering placed the resident at significant risk of getting to a potentially dangerous place, and intruded on the privacy or activities of others. B. Record review The care plan last updated on 7/22/21 identified the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was suspicion of a history of sexual abuse that may relate to this behavior. The behavior also appeared possibly related to delusions as she had stated that's my husband, that's my duty. Goal: Resident will respond to redirection toward other activities/interests, revision on 12/14/21. Interventions included administering medications as ordered. Avoid educating or reorientation by telling her he is not your husband, no one told you to do this as this creates increased distress for the resident. Instead, work to get her interested in something else, revision 10/1/21. Care provided by female caregivers, as much as possible. Showers are provided by female staff. Encourage her to participate in purposeful engagement in activities of interest (music-country pop, snacks-BBQ chips, diet Dr Pepper, easy puzzles). Observe the resident's behavior for wanting to kiss others, hanging outside of male residents' room doors, verbalizes that's my husband, it's my duty, the [NAME] are telling me to. Staff work to redirect her to purposeful activities that she enjoys. The care plan last updated on 7/22/21 identified the resident had a behavior problem at times, was observed to go into others' rooms and believes others are her sibling or spouse, whispering in others' ears causing annoyance. Goal: to remain safe and free of self harm throughout stay and have fewer episodes of behaviors mentioned, revised 12/14/21. Interventions included to anticipate and meet resident's needs, caregivers to provide opportunities for positive interaction. Stop and talk with her as passing by. Encourage the resident to participate in making choices within individual decision making abilities. Explain/reinforce why behavior was a problem for other residents in very basic clear terms in a calm manner. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention, remove from the situation and take to alternate location as needed. Observe behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Praise the resident when she listens and responds to redirection. Validate her feelings, attempt redirection with alternate subjects, offer snacks and hydration, take resident for a walk, last revision 10/1/21. The care plan last updated on 7/22/21 identified the resident was taking antidepressant medication for [CONDITION(S)] disorder hypersexuality. Resident will make reference to her husband relating to this behavior, possibly feeling that it was something she should be doing for males. She also has a history of unsubstantiated accusations that male care givers having sexual contact with her (delusional thoughts). Interventions included to observe for going into other resident rooms, following male residents, offering sexual favors such as oral sex, last revision 10/1/21. The care plan last revised on 11/29/21 identified the resident had a suspected history of trauma that affected her negatively (making statements that she had been raped and/or people tried to kill her. It was unclear whether these events actually occurred or if they were delusional in nature). Triggers that bring back a memory or a flashback of trauma include being around males and once triggered resident displays hypersexuality. Interventions include one-to-one supervision for resident's safety as well as the safety of others (date initiated 11/29/21, with no discontinuation date). All allegations of either sexual assault or physical assault/threats will be immediately and thoroughly investigated. Arrange to receive services from a psychologist or psychiatrist as needed. Ensure resident's safety, know what triggers reactions. -However, there care plan was not updated with interventions following the incident on 1/24/22 to protect Resident #4 from engaging in sexual activites with male residents. Progress note, dated 1/25/22 at 10:37 a.m.revealed the facility had reached out to obtain a bed open on a secured female unit. They were awaiting a return call. -However, the facility failed to follow-up after initiating placement at a female secured unit after 1/25/22 (see NHA interview below). The 1/9/22 at 11:28 a.m. interdisciplinary (IDT) nursing notes revealed the team met to review Resident #4. It revealed Resident #4 was currently on one-to-one staff supervision during the hours of 6:00 a.m. to 10:00 p.m., and 15 minute checks from the hours of 10:00 p.m. to 6:00 a.m. Stated that resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -The 15 minute checks were requested from NHA on 2/23/22 at 11:10 a.m., however the frequent checks were not provided before survey exit on 2/23/22. The 1/5/22 at 9:31 a.m. social services assessment note revealed the resident was stable psychiatrically. She did exhibit delusional thinking due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She continued to require one-to-one (staff) supervision due to inappropriate sexual behavior. -However there was no evidence of one-to-one staff supervision being provided (see staff interviews below). -Documentation of what supervision Resident #4 required including one-to-one supervision or 15 minute checks was requested from the NHA on 2/23/22 at 11:10 a.m. However, it was not provided during or after the survey on 2/23/22. IV. Resident #3 A. Resident status Resident #3, age 77, was admitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/11/22 minimum data set (MDS) assessment revealed the resident with moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required extensive assistance with two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. No moods, behaviors, or rejection of care were documented. B. Resident interview Resident #3 was interviewed on 2/23/22 at 9:44 a.m. Resident #3 recalled the sexual incident that occurred on 1/24/22. He said Resident #4 wandered into his room and the sexual encounter just happened the one time. He said his current roommate was not his roommate at the time of the incident but he had another roommate who was in bed at the time. Resident #3 said he did not know Resident #4 prior to the encounter. He said Resident #4 was not his girlfriend. He said he was befuddled (unable to think clearly, confused, and perplexed) and did not know why she was there. Resident #3 said she did a bit of oral sex on him. He said he did not know anything about Resident #4, her memory levels, or her history. He said licensed practical nurse (LPN) #1 came in and ran her off and Resident #4 had not bothered him since. He said Resident #4 had been given extra supervision in the past but she did not have it at the time of the sexual incident and not presently. C. Record review The care plan last updated 3/14/19 revealed Resident #3 had a potential to receive physical harm from others; however, at times he initiated confrontations. Goal: Safety will be maintained throughout his stay with fewer episodes. Interventions included to administer medications as ordered and observe/document for side effects and effectiveness. Allow choices within an individual's decision making abilities. Anticipate and meet the resident's needs. Ask if the resident was fearful, and if so respond accordingly and report. Caregivers provide opportunities for positive interaction and attention. Stop and talk with him as passing by. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed. Notify the medical doctor as needed. Observe behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Praise any indication of the resident's progress/improvement in behavior. Provide a program of activities that was of interest and accommodates residents status. -However, the care plan was not updated following the sexual incident on 1/24/22 to protect him from further encouters with Resident #4. V. Staff interviews The NHA, director of nursing (DON), and regional consultant were interviewed on 2/23/22 at 11:10 a.m. The NHA said that she was the abuse coordinator and completed the investigations. The NHA said she did not interview Resident #3's roommate, who witnessed the sexual incident, because she did not think of it. The NHA said she did not do an investigative interview with LPN #1 because LPN#1 documented the event in Resident #4's SBAR progress note. The regional consultant said the purpose of the facility doing a quarterly social worker assessment was to provide information on how a resident was doing with mood, behaviors, and cognition and any recommendations based on that. The NHA and regional consultant said that Resident #4 was not receiving one-on-one staff supervision at the time of the sexual incident on 1/24/22 as had been recommended by the social worker assessment (see above). -Documentation of what supervision Resident #4 required including one-to-one supervision or 15 minute checks was requested from the NHA on 2/23/22 at 11:10 a.m. However, it was not provided during or after the survey on 2/23/22. The NHA said that she determined that Resident #4 had the cognitive ability to consent, based on prior behaviors in seeking sexual activities. -Although, Resident #4 had a BIMS of 6/15 equating to severe cognitive impairment (see MDS assessment above). The NHA said regarding consent for a resident with a lower BIMS, We look at participation in the act and not saying no or pushing away. The NHA said she did not have documentation of an assessment that determined Resident #4 would be safe to participate in sexual activity with her diagnosis, history of sexual aggression and abuse, and current BIMS level. The NHA said she had not seen an assessment but would look into the social services files. -The 1/5/22 social services assessment (see above) did not document the resident was safe to participate in sexual activity as indicated by the NHA. The documentation of the facility's determination assessment of Resident #4's capacity to consent to sexual contact was requested from the NHA on 2/23/22 at 11:10 a.m. However, it was not provided during or after the survey on 2/23/22. The NHA said when the sexual incident happened on 1/24/22, LPN #1 had asked Resident #4 to leave Resident #3's room because we were not sure if it was consensual due to the differences in cognitive levels between the two residents. The NHA said Resident #4's cognitive status was not evaluated for capacity to consent before or after the sexual incident. -Due to the facility's failure to determine capacity for each resident to consent to sexual activity, they did not take steps to prevent future sexual incidents from occuring. The NHA and regional consultant said they would continue with redirection of Resident #4 and would continue to try to find placement at an all women's secured facility. -However, there was no additional follow-up after 1/25/22 regarding her placement. LPN #1 was interviewed on 2/23/22 at 11:47 a.m. She said she received abuse training in June 2021. LPN #1 said she was aware of Resident #4 sexually aggressive behaviors and how she lashed out or went into other male residents' rooms to participate in sex. LPN #1 said she was the caregiver that came upon the sexual incident on 1/24/22. LPN #1 said she was checking on Resident #3 in his room and saw Resident #4 in there and said what are you doing here? LPN #1 said she redirected Resident #4 back to her room. She said Resident #4 used to have one-to-one staff supervision in December 2021, but did not have supervision during the 1/24/22 incident, and there was no extra supervision presently (including one-to-one staff supervision or 15 minute checks). LPN #1 did not know why the one-to-one staff supervision stopped. Certified nurse aide (CNA) #1 was interviewed on 2/23/22 at 11:50 a.m. She said she received abuse training once a year. CNA #1 said she was aware of Resident #4's sexually aggressive behaviors and false accusations. CNA #1 said if she saw sexually inappropriate behaviors she would approach and remove the resident from the situation, and offer something else to do to distract. CNA #1 said Resident #4 was on one-to-one staff supervision in December 2021 but there was no supervision currently. CNA #1 did not know why the one-to-one staff supervision stopped. CNA #2 was interviewed on 2/23/22 at 11:53 a.m. She said she had worked at the facility since October 2021. She said she had received abuse training in December 2021. CNA #2 said she was aware of Resident #4's sexually aggressive behaviors such as naughty talk and going into male residents' rooms. CNA #2 said Resident #4 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #2 said Resident #4 had one-on-one staff supervision in December 2021 and Resident #4 had someone supervising at all times. CNA #2 said then it went to 15 minute checks and now there was no supervision, just standard. CNA #2 did not know why the one-to-one staff supervision stopped. The activities director (AD) was interviewed on 2/23/22 at 12:02 p.m. She said she had not received abuse training yet due to just starting AD work in November 2021. She said she had training in the past due to working on the floor as a CNA. The AD said she was aware of Resident #4's sexually aggressive behaviors and used redirection for that which was effective while she was having the behavior. The AD said she invited Resident #4 to all activities such as bingo, arts and crafts which she participated in them intermittently. The AD said Resident #4 used to have one-to-one staff supervision but that ended in about December of 2021, and was now just standard supervision like all residents received by the staff. The AD did not know why the one-to-one staff supervision stopped. VI. Facility follow-up On 2/25/22 at 12:07 p.m. the facility provided documentation of employee education as follows: Topic of abuse investigation on 10/7/21 with employee signatures; topic of abuse reporting on 6/22/21 with employee signatures; topic of abuse education on 6/21/21 on what was reportable and who to report to with employee signatures; topic of dementia training on 10/20/21 with employee signatures. -However, no additional staff training was conducted after the 1/24/22 incident with Resident #3 and #4.

Based on observations, record review and interviews, the facility failed to maintain a safe, functional, sanitary and comfortable environment for residents on the both the East and West wings of the facility. Specifically, the facility failed to ensure: -The kick plates on the doors were secure; -Resident room door functioned properly and stayed open without having to be propped open with the trash can; -Walls were free from peeling, scratched paint; and, -Baseboards in resident rooms were intact. Findings include: I. Observations The following observations were made on 4/28/21 during a tour of the East Wing of the facility: -The doors to Room 18 and 20 were being propped open with a trash can. When the trash can was removed, the door would shut on its own; -The kick plates on the doors to Room 6, 12, 18, and the shower room on the East Wing Hall were loose and coming apart from the doors; and, -The kick plate on Room 33 on the West wing was also loose and coming apart from the door. The following observations were made on 4/29/21: -The doors to Room 18 and 20 were propped open with a trash can. When the trash can was removed, the door would shut on its own. -Both of the top drawers of the night stands in the room were broken and would not shut properly. -Room #11 had multiple scratches in the paint and gouges in the wall behind the recliner just inside the door and the baseboard was missing, exposing a dirty, blackish-brown wall. -Multiple areas on the walls of the East Wing Hall had peeling or missing paint. II. Record review Review of the maintenance records from 1/23/21-4/29/21 revealed no work orders for repairs being requested or completed for the problems identified above. III. Interviews The maintenance supervisor (MS) and the nursing home administrator (NHA) were interviewed on 4/29/21 at 2:00 p.m. while doing an environmental tour of the facility to verify the above observations. The MS said the West side of the facility had been updated with new paint and other touch ups but they had not had an opportunity to do the East side of the facility yet. He said the facility did not have any official plan or calendar time frame for when repairs would occur. The NHA said the kick plates would be secured to the door immediately to prevent possible injury occurring to the residents and acknowledged that the areas identified during the survey needed to be addressed. The corporate consultant was interviewed on 4/29/21 at 3:10 p.m. She said she had a meeting with the MS earlier in the week and the facility was implementing a plan to address the updates and repairs the facility needed.

Based on record review and interviews, the facility failed to protect from and prevent abuse for two (#3 and #4) of three residents reviewed out of 10 sample residents. Specifically, the facility failed to protect Resident #3 from physical abuse from Resident #6 and failed to protect Resident #4 from physical abuse from Resident #5. Findings include: I. Facility policy The Abuse and neglect prohibition policy and procedure, revised 7/19, was provided by the nursing home administrator (NHA) on 12/17/19 at 4:01 p.m. It read in pertinent part: -Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resdient ' s medical symptoms. II. Physical altercation on 12/18/19 between Resident #3 and Resident #6 [NAME] Resident #3 1. Resident status Resident #3, age under 50, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 12/12/19 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. The resident required one person assistance with personal hygiene, and required setup help with all other activities of daily living (ADLs), except for dressing which the resident was independent with. The MDS did not identify any verbal or physical behaviors directed toward other residents. 2. Record review The care plan last revised on 12/19/19, identified the resident had the potential to be physically aggressive and was involved in a resident-to-resident altercation where the other resident kicked Resident #3 while she was walking by. The goal was for the resident to demonstrate effective coping skills through the next review date. Pertinent interventions included: -Immediate separation, frequent checks, encourage the resident to avoid entering the personal space of another resident to avoid others physically lashing out. -When the resident becomes agitated: intervene before agitation esculates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. B. Resident #6 1. Resident status Resident #6, age 77, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 11/12/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of 0 out of 15. Staff section was not completed. The resident required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident required one person physical assistance with locomotion on and off the unit and eating. The MDS identified, during the seven day look back period, the resident had physical and verbal behavioral symptoms directed at others one to three days. 2. Record review The care plan last revised on 12/18/19, identified the resident had displayed behavior problems such as: grabbing out at others with or without the point of injury, becoming territorial, agitation if her personal space is invaded causing her to strike out physically pinching, slapping, pulling, flanging (sic) limbs and hitting inanimate objects. The goal was for the resident to have fewer episodes of identified behaviors through the next review. Pertinent interventions included: -Resident ' s agitation for being physically or verbally aggressive with others is created by others in her personal space. Staff can aid in de-escalating the environment by inviting her to another calm environment or by prompting others to respect her personal space. -Intervene as necessary to protect the rights and safety of others. C. Summary of investigation The 12/18/19 suspected abuse investigation documented Resident #6 kicked Resident #3 in the legs when Resident #3 was walking past Resident #6. The plan of of action revealed the facility to the following actions: -Separated both parties and asked them to be respectful of personal boundaries. -Added a universal (television) remote. -Secondary television in another location for resident controlled use. The summary of the investigation revealed the facility substantiated the allegation of physical abuse because Resident #6 intentionally kicked Resident #3 and made contact. D. Staff interviews The nursing home administrator (NHA) was interviewed on 12/30/19 at 12:41 p.m. He said he was in the lobby at the time of the incident between Resident #3 and Resident #6. He said Resident #6 kicked at Resident #3 as she was passing by in the lobby. The NHA said Resident #3 did recall being kicked by Resident #6 several days after the incident occured. The NHA said the facility had implemented some new approaches with Resident #6 to attempt to decrease her striking out toward other residents. III. Physical altercation on 12/20/19 between Resident #4 and Resident #5 [NAME] Resident #4 1. Resident status Resident #4, age 61, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 12/3/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident required setup assistance with transfers, locomotion and eating. He was independent with all other activities of daily living (ADLs). The MDS identified, during the seven day look back period, the resident had physical and verbal behavioral symptoms directed at others one to three days. 2. Record review The care plan last revised on 12/23/19, identified the resident had the potential to be verbally aggressive related to dementia and ineffective coping skills. The goal was for the resident to verbalize understanding of the need to control verbally abusive behavior. Pertinent interventions included: -Analyzing key times, places, circumstances, triggers, and what de-escalated behavior. -Immediate separation from escalated situations. B. Resident #5 1. Resident #5 status Resident #5, age 71, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/7/3/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of 0 out of 15. The resident required extensive assistance of two with bed mobility, transfers, dressing, toilet use and personal hygiene. She required one person physical assistance with locomotion on and off the unit and setup assistance with walking. The MDS identified, during the seven day look back period, the resident had physical and verbal behavioral symptoms directed at others one to three days. 2. Record review The care plan last revised on 12/23/19, identified the resident had the potential to be verbally aggressive and un-redirectable physically, striking out and an actual resident to resident altercation, wandering in and out of other resident rooms, entering into others personal space related to dementia with behavioral disturbances. The goal was for the resident to not harm herself or others through the next review. Pertinent interventions included: -Analyzing key times, places, circumstances, triggers, and what de-escalated behavior. -Frequent checks, immediate separation from escalated situations. -When the resident becomes agitated, intervene before agitation esculates. C. Summary of investigation The 12/20/19 suspected abuse investigation documented Resident #4 attempted to grab a cup of coffee from Resident #4, and then Resident #5 slapped Resident #4 across the face. The plan of of action revealed the facility to the following actions: -Separated both parties, -Redirection, -Increased encouragement to participate in activities; and -Medication review by physician. The conclusion of the investigation revealed the facility substantiated the allegation of physical abuse. D. Staff interviews The life enrichment coordinator (LEC) was interviewed on 12/30/19 at 12:41 p.m. She said she was in the dining room with the residents when the physical altercation occurred. She said she had given Resident #4 a cup of coffee, and Resident #5 was pacing and agitated nearby. The LEC said she turned her back to assist another resident and heard Resident #5 scream, she turned around at that point, and witnessed Resident #5 slap Resident #4 across the face with an open hand. The LEC said she seperated the residents immediately. The NHA was interviewed on 12/20/19 at 12:41 p.m. He said he had completed the investigation and determined the abuse had occurred.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two of three halls where residents lived. Specifically, the facility failed to ensure hot water temperatures were monitored and maintained at safe and comfortable levels in the east hall (secure unit) and east central hall (directly outside of the secure unit). Findings include: I. Facility policy and procedure According to the Monitoring Water Temperature policy, revised (MONTH) 2007, provided by the nursing home administrator (NHA) on 9/25/19 at 6:15 p.m.: -Water temperatures were checked and recorded periodically to ensure the safety and welfare of the residents. -The maintenance supervisor (MS) collected water temperature logs monthly, investigated trends, and initiated corrective actions. -Hot water temperatures were checked and recorded at individual and common resident use areas. -Water temperature problem areas were sample checked and recorded daily. -Water temperature samples were scheduled to be checked and recorded, at a representative set of fixtures located throughout the facility, every three days. -The representative set of fixtures were on scheduled rotated checks to ensure all fixtures were monitored over a set period of time. -The acceptable hot water temperature range was 100 degrees Fahrenheit (F) to 110 F. -Random hot water temperature checks were done on each water heater. All water heaters should be sampled in any given two to three day period and temperatures recorded. -Hot water temperatures were checked and recorded during peak usage times; at the temperature gauges. -For recirculation pumps, hot water temperatures were checked and recorded at a point farthest along the hot water system and before the water re-entered the water heater or mixing valve. II. Initial observations Observations on the morning of 9/23/19 of resident room hot water temperatures, measured with a calibrated digital thermometer, revealed the following: -At 9:14 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 124.5 F. -At 9:23 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 128 F. -At 9:26 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 128.8 F. -At 9:27 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 123.2 F. -At 9:31 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 124.3 F. -At 9:35 a.m. the hot water temperature in the sink of room [ROOM NUMBER] could not be measured because the resident declined entry into the room. -At 9:37 a.m. the hot water temperature in the sink of room [ROOM NUMBER] could not be measured because resident care was in progress. -At 9:48 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 126.2 F. -At 10:26 a.m. the hot water temperature in the shower of the secure unit was 117 F. Staff verified there were no showers to be given until the afternoon. -At 10:19 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 122.6 F. -At 10:31 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 129.1 F. -At 11:06 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 128 F. -At 11:08 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 124 F. -At 11:10 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 124 F. III. Observations with the maintenance supervisor Observations made with the maintenance supervisor (MS) on 9/23/19, measured with the MS's calibrated digital thermometer, revealed: -At 11:57 a.m. the hot water temperature in the sink of room [ROOM NUMBER] was 126.5 F. -At 12:00 p.m. the hot water temperature in the sink of room [ROOM NUMBER] was 126.5 F. -At 12:01 p.m. the hot water temperature in the sink of room [ROOM NUMBER] was 127.9 F. -At 12:02 p.m. the hot water temperature in the sink of room [ROOM NUMBER] was 123.9 F. -At 12:05 p.m. the hot water temperature in the sink of room [ROOM NUMBER] was 125.6 F. -At 12:06 p.m. the hot water temperature in the sink of room [ROOM NUMBER] was 123.2 F. -At 12:09 p.m. the hot water temperature in the sink of room [ROOM NUMBER] was 128.1 F. -At 12:16 p.m. the hot water temperature in the sink of room [ROOM NUMBER] was 125.4 F. -At 12:17 p.m., the resident who lived in room [ROOM NUMBER] denied entry into the room. On 9/23/19 at 1:00 p.m., a request was made to the nursing home administrator (NHA) for the (MONTH) 2019 to (MONTH) 2019 documented hot water temperature logs. IV. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 9/23/19 at 9:52 a.m. She said two months ago the nursing home administrator (NHA) had the water heater fixed. Prior to it being fixed, the staff was told to be careful when residents were showered due to the hot water temperatures fluctuated. Licensed practical nurse (LPN) #6 was interviewed on 9/25/19 at 8:45 a.m. She said there was a time when the water was hot in residents' rooms and the shower room in the secure unit. Staff put signs up in resident rooms and in the shower room because the water was too hot. No residents were burned from the hot water. CNA #2 and CNA #8 were interviewed on 9/25/19 at 9:13 a.m. They said there was a time when the water was hot in residents' rooms and the shower room in the secure unit. Staff put signs up in resident rooms and in the shower room because the water was too hot. No residents were burned from the hot water. CNA #5 and CNA #10 were interviewed on 9/25/19 at 10:20 a.m. They said there was a time when the water was hot in residents' rooms and the shower room in the secure unit. Staff put signs up in resident rooms and in the shower room because the water was too hot. No residents were burned from the hot water. The MS was interviewed on 9/23/19 at 11:24 a.m. He said when he was hired, six months ago, he was not trained on how and when to monitor hot water temperatures. He did not monitor hot water temperatures in the secure unit this month. He confirmed the water temperature on the mixing valve gauge was 128 F, was in the red zone, and that he did not know what the water temperature should be. An unidentified night CNA informed him in (MONTH) 2019 the water was hot in the secure unit shower, and was fixed. He had not received complaints of [MEDICAL CONDITION] hot water in resident rooms or showers. He said the water pressure and temperature of residents' sinks and their shower rooms altered when toilets were flushed, which made the hot water temperatures become even higher than 120 F. The district director of clinical services (DDCS) was interviewed on 9/23/19 at 1:37 p.m. She said a plumbing company would come to help resolve the hot water temperature issues and the facility would train the MS on how to monitor hot water temperatures. The NHA was interviewed on 9/23/19 at 12:59 p.m. After being informed that the hot water temperatures in the secure unit and directly outside of the secure unit were over 120 F, he said he would have the plumbing company resolve it. He wanted the hot water temperatures in resident rooms to be at 115 F and in the resident rooms of the secure unit to be at 110 F due to their dementia; they could accidentally leave the hot water turned on and get burned. There were no complaints of hot [MEDICAL CONDITION] any residents in the secure unit nor outside of the secure unit. He said the mixing valve in the water line to the secure unit leaked a month ago and a new seal was placed in the mixing valve to stop the leak. A former maintenance assistant was supposed to have monitored hot water temperatures during the absence of the MS. The NHA said he wanted hot water temperatures to be checked daily to weekly and a quality performance improvement plan was going to be implemented to monitor hot water temperatures. He was unaware of the training the MS received regarding hot water temperature management. The MS had a corporate maintenance consultant as a resource, and he just hired a staff development coordinator who would ensure he would receive the trainings he required. V. Facility follow-up [NAME] Observation An observation on 9/23/19 at 3:40 p.m. revealed the maintenance director from a sister facility was in secured unit with the MS measuring hot water temperatures. B. Record review According to the 9/23/19 In-Service Report on Monitoring Hot Water Temperatures, provided by the NHA on 9/25/19 at 6:15 p.m., the MS was trained to monitor hot water temperatures every two to three days at random times. Hot water temperature logs from 9/23/19 through 9/25/19, provided by the NHA on 9/25/19 at 6:15 p.m., revealed hot water temperatures decreased to below 118 F in resident rooms and below 115 F in the shower room. C. Staff interviews The NHA was interviewed on 9/25/19 at 1:01 p.m. He said he did not have documented hot water temperature logs for (MONTH) 2019 through (MONTH) 2019. He did not have documented hot water temperature logs for the period of time after the mixing valve seal was replaced, to ensure the mixing valve was in operative condition. He was working to provide documentation of all the plumbing work done to the water heater and/or mixing valve in the last three months. The facility held an ad hoc quality performance improvement meeting, on 9/24/19, and discussed the plan to monitor hot water temperatures on a monthly basis. The sister facility maintenance director (MDW) and NHA were interviewed on 9/23/19 at 5:00 p.m. The MDW said he lowered the temperature at the mixing valve gauge and set it at 115 F, and hot water temperatures in resident rooms measured between 105 F and 106 F. The NHA said the facility installed new water heaters in (MONTH) or (MONTH) 2019 and later in the summer there was a period when the water temperatures were too hot. The maintenance director at a second sister facility (MDA) and the NHA were interviewed on 9/24/19 at 2:31 p.m. The MDA said the water temperature at the mixing valve gauge should be between 100 F and 120 F. the water that came from the mixing valve part of the line directly affected residents and if too hot would burn their skin. Adjustments were made at the mixing valve gauge that day, and the temperature measured 110 F. The NHA said the plumbing company would check the adjustments to the mixing valve, they kept the hot water to safe temperatures, and the locks were changed to the boiler room so only the MS and housekeeping supervisors had keys to it.

Based on observations, record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated this was not possible for three (#75, #37 and #15) of eight out of 27 sample residents. Specifically, the facility failed to: - Appropriately 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; - Timely communicate with residents' Medical Power of Attorney/family, and - Timely address residents' weight loss with the interdisciplinary team (IDT). The facility's failure to timely and appropriately assess, monitor and address resident's nutritional status contributed to resident #75 experiencing severe weight loss (20 pounds or 22% in three months). The findings included: I. Professional Reference 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 (the) older person . 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. The Clinical Nursing Skills and Techniques by Perry, Potter and Ostendorf, eighth edition, 2012, chapter four, Documentation and Informatics, reads in pertinent part: Nursing documentation is an essential and important component of health care delivery. Documentation is anything entered into a patient's health record .Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes .You are held accountable for the accuracy of documentation that is in the patient record .The trend among many health care organizations is to computerize care plans. These systems provide daily computer generated care plans, which incorporate several nursing [DIAGNOSES REDACTED]. After completing a nursing assessment, you identify the patient's nursing [DIAGNOSES REDACTED]. You individualize it for each patient .One advantage of standardized care plans is the establishment of evidence based standards of care .Standardized care plans do not replace your professional judgment and decision making. In addition, care plans need to be updated on a regular basis to ensure that content is current and appropriate. II. Facility policy According to the Weight/Hydration Management policy, revised 8/12, in pertinent part: Staff designated to weigh residents should be trained, competent and scheduled to obtain weight data. Consistent staff will be assigned to obtain weekly and monthly weights .As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweighed within 24 hours. Weight variance include: a. Weight change of 5 lbs b. Weight change of 3 lbs if weight less than 100 lbs Significant weight variance is defined as: 5% in one month (30 days) 7.5% in three months (90 days) 10% in six months (180 days) Those identified with significant weight change or insidious weight loss will be highlighted, underlined or circled on your weight change report .Meal intake records, supplement-nourishment/snack/fortified-food list with intake information, and diet order list will be brought to meeting by the Dietary Manager and/or Registered Dietician. Dietary Manager and/or Registered Dietician will visit with resident, family and care staff regarding weight status and acceptable interventions. Weekly At-Risk Review Meeting will be conducted on each resident with weight loss until the IDT (interdisciplinary team) determines weight has stabilized and can discontinue from weekly review. The DON (director of nursing) and/or Dietary Manager will ensure communication to staff members on the changes to the interventions related to the weight status will be completed. III. Resident failures A. Resident #75 1. Record review and staff interview Record review and staff interview revealed resident #75 experienced severe weight loss over three months. Although her risks for weight loss and actual weight loss were known and care planned, the facility failed to take steps to ensure implementation of the care plan, provide assistance during meals, provide a variety of nutritional supplements that would meet the resident's needs, and address resident's weight loss with the IDT as expected per policy. Resident #75, age 84, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to 2/15/17 minimum data set (MDS) assessment, the resident had unclear speech, sometimes made self-understood and sometimes was able to understand others. Section C, brief interview for mental status (BIMS) score was 00 indicating the resident did not answer any of the interview questions, and no staff interview was conducted for resident's mental status. No hallucinations or delusions were documented, and rejection of care behavior occurred in one to three days during the assessment period. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She was frequently incontinent of urine. No swallowing disorder was documented. Her weight was 77 pounds and no or unknown weight loss was documented. Weight gain of 5% or more in the last month was documented Yes, on physician-prescribed weight-gain regimen. Nutrition approaches included mechanically altered diet. She did not have any unhealed pressure ulcers. She received an antipsychotic, antianxiety, and antidepressant medications daily. The 11/15/16 MDS assessment revealed the resident had unclear speech, sometimes made self-understood, and sometimes was able to understand others. BIMS score was one out of 15 and indicated severe cognitive deficit. Section K documented the resident did not exhibit signs and symptoms of possible swallowing disorder. Her weight was 85 pounds. No weight loss or gain was documented. Mechanically altered diet was checked. No therapeutic diet (diabetic) was checked (not checked). Section N documented the resident received daily (7) antianxiety and (7) antidepressant medications. Comparison of the MDS above revealed the 2/15/17 MDS assessment incorrectly documented the resident's weight gain when the resident had lost eight pounds (9%) of her body weight in three months. Review of the physician orders [REDACTED]. -Regular diet, mechanical soft texture, regular consistency, dated 1/5/17. -Monthly weights, dated 8/18/16. -Check blood sugar finger stick two times per week every Sunday and Thursday related to diabetes mellitus with diabetic [MEDICAL CONDITION], dated 12/18/16. -[MEDICATION NAME] HCI tablet 500 mg, by mouth, two times a day related to diabetes mellitus, dated 8/16/16. [MEDICATION NAME] capsule 100 mg, by mouth, three times a day related to diabetes mellitus and diabetic [MEDICAL CONDITION], dated 8/16/16. -Increase four oz house supplement to TID (three times a day) between meals for weight loss, dated 11/4/16. -[MEDICATION NAME] (antidepressant) tablet 7.5 mg by mouth at bedtime for weight loss decreased appetite dated 1/11/17. The Allergy section in the resident's medical record documented: Banana. The allergy section did not document the resident was lactose intolerant. (See speech language pathologist's interview below, stating the resident is lactose intolerant.) Resident's weights documented in medical record: 9/28/16 91 pounds 12/11/16 89 pounds 2/15/17 78 pounds (11 lbs, or 12% severe weight loss in two months) 3/11/17 69 pounds (20 lbs, or 22% severe weight loss in three months) Review of the resident's Care Plan (CP) revealed: Nutrition: According to the 8/19/16 resident's comprehensive care plan (CP), the Nutrition section documented: (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITIONS], dementia, DM (diabetes mellitus), anxiety, depression,[MEDICAL CONDITION](hypertension). Less than 100 pounds. Advanced age. Fluctuating PO (oral) intake from 0-75%. Chewing difficulty: diet appropriate. The CP was revised and documented: -10/5/16 (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITION], dementia, DM, anxiety, depression,[MEDICAL CONDITION](hypertension). Less than 100 pounds. Advanced age Fluctuating PO intake from 0-75%. Chewing difficulty: diet appropriate. Wt loss: (10/5/16). Pressure ulcer: coccyx (10/4/16). -11/4/16 (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITION], dementia, DM, anxiety, depression, HTN. Less than 100 pounds. Advanced age. Fluctuating PO intake from 0-75%. chewing difficulty: diet appropriate. Wt loss: (10/5/16) (11/4/16) Pressure ulcer: coccyx (10/4/16). -1/3/17 (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITION], dementia, DM, anxiety, depression, HTN. Less then 100 pounds. Advanced age Fluctuating PO intake from 0-75%. Chewing difficulty: diet appropriate. Wt loss: (10/5/16) (11/4/16). Pressure ulcer: coccyx (10/4/16), reopened (12/21/16). -1/18/17 (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITION], dementia, DM, anxiety, depression, HTN. Less than 100 pounds. Advanced age. Fluctuating PO intake from 0-75%. Chewing difficulty: diet appropriate. Wt loss: (10/5/16) (11/4/16). -2/15/17 (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITION], dementia, DM, anxiety, depression, HTN. Less than 100 pounds. Advanced age. Fluctuating PO intake from 0-75%. Depends greatly on level of agitation. Chewing difficulty: diet appropriate. Wt loss: (10/5/16) (11/4/16) Reestablished wt goal: 75 +/- 1-3 pounds (2/15/17). -3/14/17 (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITION], dementia, DM, Anxiety, depression, HTN. Less than 100 pounds. Advanced age. Fluctuating PO intake from 0-75%. Depends greatly on level of agitation. Chewing difficulty: diet appropriate. Wt loss: (10/5/16) (11/4/16), (3/14/17). Reestablished wt goal: 75 +/- 1-3 pounds (2/15/17). -3/15/17 (resident name) is at potential increased nutritional risk due to dx: [MEDICAL CONDITION], dementia, DM, anxiety, depression, HTN. Less than 100 pounds. Advanced age. Fluctuating PO intake from 0-75%. Depends greatly on level of agitation. Chewing difficulty: diet appropriate. Wt loss: (10/5/16) (11/4/16), (3/14/17). Reestablished wt goal: 75 +/- 1-3 pounds (2/15/17). Reestablished wt goal: 69 +/- 1-3 pounds (3/14/17). The interventions included: - Provide diet as ordered which offers adequate calories and protein for estimated needs: regular diet, mechanical soft texture. - Offer preferred foods. Provide spouted cups at meal times, lip plate, and built-up silverware. - Assist with meals as needed: limited to total assist with meals. - Encourage fluids with and between meals. - Encourage resident to request large portions or second portions of food enjoyed. - Encourage juice and lactose free milk with meals for added calories. - Provide fortified foods when available to help maintain weight. - Provide sweet pastries and desserts when available if not eating provided meal, she really likes sweet foods. -The interventions did not include appropriate protein supplement for resident with [DIAGNOSES REDACTED]. On 3/16/17 at 11:25 a.m., the DON was interviewed. She said the resident should be on a diabetic diet. She said the resident should receive sugar free protein supplement. On 3/16/17 at 12:05 p.m., the resident's physician (MD) was interviewed. She said she expected a resident with diabetes mellitus to receive sugar free protein supplement. -The interventions did not include appropriate protein supplement for resident with lactose intolerance. -The interventions did not include resident's allergy to banana fruit. Diabetes: The 8/27/16 CP documented the resident had [DIAGNOSES REDACTED]. Observe/document for side effects and effectiveness; Observe/document/report PRN (as needed) any s/sx (signs or symptoms) of [DIAGNOSES REDACTED]: sweating, tremor, increased heart rate ([MEDICAL CONDITION], pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait; observe/document/report PRN compliance with diet and document any problems. -The interventions did not include appropriate diet for resident with [DIAGNOSES REDACTED]. Review of the resident's Blood Sugar Summary revealed in pertinent part: 3/12/17 132 mg/dl (normal range per the resident's physician on 3/16/17 at 1:40 p.m. was between 70 to 100 mg/dl.) 3/5/17 104 mg/dl 2/26/17 185 mg/dl 2/19/17 120 mg/dl The document did not have resident's blood sugar levels documented between 2/19/17 and 12/22/16. 12/22/16 109 mg/dl 12/18/16 240 mg/dl 12/8/16 121 mg/dl 12/6/16 158 mg/dl 12/2/16 356 mg/dl Dietary department notes revealed: On 1/3/17, the registered dietician (RD) documented: Nutritional continued follow up due to wt (weight) change and reopened pu (pressure ulcer) on sacrum. This RD notified of reopened area to buttocks along with wt decrease .Diet texture was changed to puree for ease in eating at this time. She remains total assist with her meals. Continue to send 4 oz house supplement TID, fortified foods for added Kcals (calories) and protein to aid with wt stabilization and wound healing along with assist with meals and continue medication adjustment . On 1/25/17 the dietary manager (DM) documented: IDT met to review resident for weight loss. Resident has gained 2 (two) pounds since last reviewed. Resident loves to eat sweets in the morning for breakfast she will eat everything that's sweet in front of her. Resident is being offered all meals but if resident refuses to eat meal, she is then offered sweets to make sure she does eat. Resident receives 4 oz house supplement four times a day. Will continue to monitor resident as needed. On 2/15/17 the RD documented: Nutrition continue follow up due to wt changes: current weight trends as follows: 75 (lbs) (2/11), 76 (2/5) 76.5 (1/22) indicating continued fluctuations of 1-3 pounds but trending downward. (resident name) is on regular diet with MSGM (mechanical soft) texture and po (oral) intake appears at baseline of approximately 25% most meals. She is continuing to receive fortified foods and house supplement TID. Her intake of her nutritional supplement varies greatly from refusing to 100% consumed. Her po intake depends greatly on level of agitation .Continues on [MEDICATION NAME]. Family, MD, and interdisciplinary team aware of wt changes. Continue weekly wt's and all current nutritional interventions understanding that if she continues on current trends further wt decrease may be unavoidable. On 3/14/17 (during survey) the RD documented: Nutrition continued follow up due to wt changes: This RD contacted via phone by facility nurse leadership on this date to review and address recent change. Current wt trends as follows: 69 (pounds) (3/11), 75.5 (3/5), indicating 6.5 pounds wt decrease x 7 days .She continues to actively refuse food and fluid at times by not opening her mouth and or turning her head. She continues to work with SLP (speech language pathologist) .(resident name) is and has been receiving numerous nutritional interventions .Will offer/provide sherbet at lunch and dinner or anytime she is awake and will take it for added calories and protein to aid wt stabilization .MD aware of wt change . The RD failed to address communication with resident's family to determine any particular foods the resident would like to eat. The RD failed to offer different varieties of protein supplements/flavors and restorative dining (see observations below) to prevent further weight loss. There were no IDT notes in the resident's records after 1/25/17, during the time resident severe weight loss occurred. 2. Observations On 3/13/17 between 11:45 a.m. and 12:45 p.m., the resident was observed in the main dining room, during lunch meal. The resident was not assisted by staff or encouraged to eat her meal at that time. The resident consumed her chocolate chip cookie and reached for the tablemate's cookie and ate it. The resident did not eat her lunch meal. On 3/14/17 between 11:45 a.m. on 12:45 p.m. the resident was observed in the main dining room, occasionally assisted for short periods and encouraged to eat her meal by the staff. The resident consumed approximately 25% of her meal. She was not offered any alternates, seconds or large portions. On 3/15/17 between 12:05 p.m. and 12:40 p.m. the resident was observed in the main dining room assisted by the restorative aide (RA) with the lunch meal. The resident consumed approximately 50% of her meal. She was not offered any alternates, seconds or large portions. 3. Staff interviews On 3/14/17 at approximately 2:00 p.m. the restorative CNA (RA) was interviewed. She said resident #75 was not assisted by the staff during meals. She said the resident required encouragement to eat. She said the resident was not on the restorative dining program. On 3/15/17 at 11:15 a.m., the RD was interviewed. She said she had not asked the resident's family about food preferences the resident would like to eat in the facility. She said she did not offer residents different protein supplements or different flavors. She said the milk base house supplement was the only supplement available in the facility. On 3/15/17 at 4:37 p.m. the speech language pathologist (SLP) was interviewed. She said the resident received speech therapy treatment for [REDACTED]. The SLP said she talked to the RD last week about sherbet (iced dessert containing fruit juice and milk fat). She said the resident is lactose intolerant and should not consume the milk base house supplement. On 3/16/17 at 10:55 a.m., Registered Nurse (RN) #3 was interviewed. She said the protein supplement drink, Med Pass 2.0 (house supplement) was not sugar free, and contained 22 grams of sugar per serving. She said the supplement also contained milk. On 3/16/17 at 11:05 a.m., the Dietary Manager (DM) and the Dietary District Manager (DDM) were interviewed. The DM said the resident was receiving regular diet. She said she did not know the resident was diabetic. She said the resident was always preferring foods with lots of sugar before she would eat her regular meal. On 3/16/17 at 12:10 p.m., the DDM said the RD ordered for residents in the facility one protein supplement, milk based, Med Pass 2.0, two flavors, butter pecan and vanilla. She said there were no lactose free or sugar free supplements in the facility. B. Resident #37 Record review revealed the resident experienced weight loss over six months (a 19-pound weight loss (13.4 percent) in 180 days.) Although his weight loss was being monitored, interviews revealed interventions to prevent further weight loss, such as meal and fortified food intake, were not being accurately monitored. Interviews noted the resident routinely sleep in and did not eat breakfast; however his intake records (NAES) documented he often consumed 76-100% of his breakfast meal. Resident interview and observation revealed his fortified food (parfait) was not being consumed. 1. Record review and observation Resident #37, age 59, was admitted on [DATE]. According to the admission, record his [DIAGNOSES REDACTED]. According to the MDS assessment, the resident had a brief interview for mental status (BIMS) score 13 out of 15 noting intact cognition. There were no behaviors present. The resident was independent in bed mobility, transfers, and dressing. He required staff supervision for eating, toileting, and personal hygiene. He had no swallowing, coughing or choking concerns during meals. The resident had a weight of 143 pounds. The care plan, initiated on 6/24/16, noted the resident had the potential for increased nutritional risk due to [MEDICAL CONDITIONS], increased lipids, liver disease, and gastro [MEDICAL CONDITION] reflux disease. He had weight loss on 12/14/16 and 1/25/17. The resident frequently refused breakfast. His breakfast intake had improved since 2/15/17. His re-established weight goal was 145 plus or minus five pounds started on 2/15/17. -The goal for the resident was to maintain his current weight plus or minus five percent monthly through the next review. -The interventions read to provide a regular/regular diet with regular fluids. Offer him snacks at bedtime and as needed. Offer food alternatives for the foods he disliked. Monitor his lab reports, weights and oral intakes. Assist at mealtimes as needed. Provide fortified pudding twice a day at lunch and dinner for added kilocalories and protein started on 12/14/16. Provide four ounces of house supplement each morning-started on 1/13/17. Encourage the resident to come to breakfast on a regular basis for added kilocalories and protein to aid with weight stabilization started on1/25/17. A physician's orders [REDACTED]. A PO dated 1/13/17 noted to provide four ounces of house supplement each morning and to document the percentage consumed. The medication administration records (MARs) dated 1/1/17, 2/1/17, and 3/1/17 noted the resident usually consumed 100% of the four ounces of supplement once a day started on 1/13/17. Weight records: The resident's clinical weight record noted the resident had a weight on 9/5/16 at 20:14 (8:14 p.m.) of 161 pounds and a weight of 142 pounds on 3/11/17 at 14:38 (2:38 p.m.). This was a 19-pound weight loss (13.4 percent) in 180 days representative of a severe weight loss. The resident's clinical weight record noted additional weights (recorded in pounds) with specific dates and times: -3/11/17 at 14:38 (2:38 p.m.) a weight of 142, -3/5/17 at 18:39 (6:39 p.m.) a weight of 146, -3/1/17 at 13:55 (1:55 p.m.) a weight of 144, -2/26/17 at 10:41 a.m., a weight of 144, -2/16/17 at 14:46 (2:46 p.m.) a weight of 144, -2/11/16 at 11:47 a.m., a weight of 143, -2/2/17 at 19:49 (7:49 p.m.) a weight of 144, -2/1/17 at 13:23 (1:23 p.m.) a weight of 144, -1/28/17 at 14:14 (2:14 p.m.) a weight of 144, -1/14/17 at 15:47 (3:47 p.m.) a weight of 143, -1/4/17 at 18:09 (6:09 p.m.) a weight of 147, -12/24/16 at 14:05 (2:05 p.m.) a weight of 151, -12/21/16 at 17:38 (5:38 p.m.) a weight of 150, -12/7/16 at 16:09 (4:09 p.m.) a weight of 150, -11/1/16 at 18:29 (6:29 p.m.) a weight of 156, -10/1/16 at 21:00 (9:00 p.m.) a weight of 159, and -9/5/16 at 20:14 (8:14 p.m.) a weight of 161. Nutrition - amount eaten sheet (NAES) records: The nutrition - amount eaten sheet (NAES) dated 9/1/16 to 9/30/16 documented the resident consumed 51-75% of his breakfast one time and 76-100% of his breakfast 26 times. It also documented his total monthly meal consumption was 51-75% seven times and 76-100% 82 times. The NAES dated 10/1/16 to 10/31/16 documented the resident consumed 76-100% of his breakfast 29 times. It also documented his total monthly meal consumption was 51-75% seven times and 76-100% 85 times. The NAES dated 11/1/16 to 11/30/16 documented the resident consumed 51-75% of his breakfast one time and 76-100% of his breakfast 26 times. It also documented his total monthly meal consumption was 0-25% two times, 26-50% seven times, 51-75% seven times and 76-100% 68 times. The NAES dated 12/1/16 to 12/31/16 documented the resident consumed 76-100% of his breakfast 28 times. It also documented his total monthly meal consumption was 26-50% two times, 51-75% 13 times and 76-100% 78 times. The NAES dated 1/1/17 to 1/31/17 documented the resident consumed 51-75% of his breakfast one time and 76-100% of his breakfast 30 times. It also documented his total monthly meal consumption was 51-75% ten times and 76-100% 83 times. The NAES dated 2/1/17 to 2/28/17 documented the resident consumed 51-75% of his breakfast three times and 76-100% of his breakfast 23 times. It also documented his total monthly meal consumption was 51-75% 13 times and 76-100% 67 times. The NAES dated 3/1/17 to 3/14/17 documented the resident consumed 76-100% of his breakfast 13 times. It also documented his total monthly meal consumption was 51-75% two times and 76-100% 38 times. Nutrition status review and notes: The quarterly nutrition status review, dated 10/25/16 at 6:16 p.m., noted the resident had a weight of 159 pounds. He had a usual body weight of 160 pounds. His body mass index (BMI) was 23.6. He had no change in his weight status. His breakfast average consumption was 50%, his lunch average consumption was 50% and his dinner average consumption was 50%. A bedtime snack was available three times a day. His morning supplement/snack average intake was 50%. His evening supplement/snack average intake percentage was 50%. His bedtime supplement/snack average intake percentage was 50%. There were no lab values for this resident for the past 90 days. The resident had no nutritional concerns at this time and will continue to monitor as needed. The nutrition note dated 12/14/16 at 12:36 p.m., noted follow up due to weight changes. The resident's current weight was 150 pounds on 12/7/16 and 156 pounds on 11/12/16 indicating continued gradual weight decrease noting at the end of 11/16 he had several days where he did not feel well with nausea/vomiting which could have affected his weight. Further weight loss was undesirable at this time given his history of weight decrease noting past weight decrease did not put him at increased nutritional risk with good oral intakes and his BMI remained within normal limits of 22.1 at current weight. Re-established weight goal of 150 plus or minus five pounds. Start fortified pudding twice daily for added kilocalories and protein to aid with weight maintenance within newly established goal. His care plan was updated to reflect current goal. The nurse note dated 12/29/16 at 16:32 (4:32 p.m.) noted the interdisciplinary team (IDT) met to review the resident's management. The resident gained one pound over the last week. The interventions were effective with fortified pudding for kilocalories and protein to aid in weight consistency. His weight goal was 150 plus or minus five pounds and his BMI remained at 22.1. The resident's skin was intact. His appetite was 76-100% at meals. The resident had good hydration. No new orders or concerns at this time. Will monitor and continue for weight maintenance. The nurse note dated 1/11/17 at 13:21 (1:21 p.m.) noted the IDT met to review the resident's weight loss. The resident refused to eat breakfast in the morning bud did eat lunch and dinner very well. The resident received fortified foods at all mealtimes. The resident had lost 9.5 pounds since 11/16. Will continue to monitor resident as needed. The nutrition note dated 1/13/17 at 8:59 a.m., noted follow up due to weight changes. The resident's current weight trends were 147 pounds on 1/4/17, 151 pounds on 12/24/16 and 150 pounds on 12/7/16 indicating the resident remained within re-established weight goal of 150 plus or minus five pounds. However, he continued to show a gradual decrease. His oral intakes remained good at lunch and dinner. The resident refused breakfast as per his choice; otherwise, his appetite and intakes were good. Will start four ounces of house supplement each morning when he woke up for his breakfast. Continue with weekly weights and his care plan was updated to reflect current goals. The vitals note dated 1/13/17 at 9:04 a.m., noted a weight warning of 147 pounds. The MDS noted a minus ten percent change over the past 180 days (11.2%). Nutrition continued to follow up due to weight changes. The resident's current trends were 147 pounds (1/4/17), 151 pounds (12/24/16) and 150 pounds (12/7/16) indicating he remained within re-established weight goal of 150 plus or minus five pounds. However, he continued to show gradual decrease. His oral intake remained good at lunch and dinner. However, breakfast was refused as per his choice; otherwise, his appetite and intakes were good. Will start four ounces of house supplement provided in the morning when he woke up for his breakfast. Continue with weekly weights and his care plan was updated to reflect current goals. The nurse note dated 1/18/17 at 13:19 (1:19 p.m.) noted the IDT met to review the resident's weight loss. The resident had lost 3.5 pounds since the last review. The resident received four ounces of house supplement once a day. The resident did not eat breakfast bud did eat lunch and dinner very well. The resident did eat breakfast if he woke up early sometimes. Will continue to monitor as needed. The nurse note dated 1/25/17 at 13:17 (1:17 p.m.) noted the IDT met to review the resident's weight loss. The resident did refuse to get his weight taken this week but will continue to try for next week. The resident started to eat breakfast at least three times a day (week). The resident also received fortified foods at each meal to help with weight gain. The resident received four ounces of house supplement a day. Will continue to monitor the resident as needed. The nurse note dated 2/3/17 at 11:47 a.m., noted the IDT met to review the resident's weight loss. The resident was offered snacks throughout the

Based on observation, staff/resident interviews and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of 28 sample residents (#38, #7 and #61). Specifically the facility: -Failed to adequately assess and evaluate pain after a fall for resident #38. -Failed to assess and monitor skin condition for resident #7. -Failed to properly assess skin condition and obtain orders for treatment for [REDACTED]. 1. Failure to Appropriately Address Pain for Resident #38 Resident #38 was a [AGE] year old female who was admitted to the facility on [DATE]. According to the 1/2013 computerized physician orders, the resident had the following diagnoses; [MEDICAL CONDITION], dementia with behavior disturbances, depression,[MEDICAL CONDITION](high blood pressure), lack of coordination and [MEDICAL CONDITION]. According to the most recent quarterly minimum data set (MDS), dated [DATE], the resident was coded as scoring 14/15 on the brief interview for mental status (BIMS) which indicated no cognitive impairment. The resident had no behaviors and was independent with all activities of daily living (ADLS). The resident was coded as not being steady with balance while walking and turning around and facing the opposite direction while walking, but was able to stabilize without human assistance. During this assessment period the resident had been receiving occupational and physical therapy services. Care Plan According to the care plan, dated 1/19/13, the resident had the potential for pain/discomfort related to a recent fall and an ankle fracture (occurred in December 2012). The goals were for the resident to have reduced pain as measured by verbal expression and/or decreased behaviors associated with pain, increased function ADL abilities associated with decreased pain and resident will verbalize increased satisfaction with pain control. The approaches included, in pertinent part: -Relaxation beads, -Administer [MEDICATION NAME] as ordered, -See physician orders, -Implement pain management flow sheet, -Monitor for pain every shift, -Notify physician if interventions are not consistently effective, -Medicate resident for pain prior to treatments and therapy if indicated. There was no care plan for pain documented prior to survey entrance on 1/16/13. Nurse's Notes -Notes dated 12/9/12 (no time) documented the resident was limping to the dining room holding on to the railing, and reported that her right foot hurt as she had fallen yesterday. Staff was not aware of the fall and the physician was notified and would be in to examine the resident in the morning. The nurse noted that the top of the right foot, inner foot and ankle were slightly swollen. -On 12/9/12 a change of condition form noted the resident had a severe limp when she put weight on her right leg. It was noted the resident had pain and limping when bearing weight and when she was sitting or lying down her symptoms were better. The resident reported that she fell but no staff were aware of a fall. The resident's vital signs were within normal limits and she did not have any confusion/agitation or lethargy. The nurse documented that she was not sure what the problem was, but there was an acute change in condition. An X-ray was requested and the physician was to examine the resident on the following day. -On 12/10/12 at 5:00 a.m., notes documented, "Right foot remained swollen, resident was up to the bathroom twice and continues to refuse to bear weight on her foot." She noted signs of bruising to outer ankle and the inner arch area. Resident reported that it was very painful and she reported she was getting out of bed and fell this morning. -Notes dated 12/10/12 at 9:00 a.m., documented the right ankle remained swollen and the resident refused to walk on it. The nurse further noted that when the resident thought nobody was watching her, she ambulated without difficulty. There were signs of bruising, very faint and they would have the physician exam her. -Notes dated 12/10/12 at 4:00 p.m., documented an order was received for X-ray of right ankle; resident being transported via facility vehicle. -Notes dated 12/10/12 at 8:30 p.m., documented the on call physician was called regarding the X-ray results for resident #38. Orders were received to send the resident to the emergency room to be evaluated and treated for [REDACTED]. Family was notified and report was given to the registered nurse. -Notes dated 12/10/12 at 9:00 p.m., documented the resident was instructed by the emergency room physician to call staff for assistance with transfers. Staff wheeled her to her room. Staff later responded to a commotion and resident was found on the floor. Range of motion to the ankle was normal, but there was no documentation showing which ankle and that neuro checks were initiated. The resident denied pain. The resident was in bed, a fall mat was down, call light was within reach and resident was being checked on frequently and reminded to call for assistance. The resident was able to demonstrate use of call light. -Notes dated 12/11/12 at 5:00 a.m., documented the resident was up to the bathroom three times, and she walked on the heel of her foot without difficulty. The resident stated that it was painful; noted that bruising continued. There was no evidence the resident's pain was assessed for severity, or evidence to show any pain medication was offered or administered. -Notes dated 12/11/12 at 2:00 p.m., documented the resident required assist of 1-2 persons for transfers, there were no complaints of pain, ice was applied per order and the bruising remained. An order was received for an orthopedic consult and the resident was at the appointment. -Notes dated 12/11/12 at 3:30 p.m., documented the resident returned from the orthopedic doctor and was non-weight bearing (touch down with transfers) and orders for cast care were received. Radiology Report A 12/10/12 radiology report documented the reason for the exam was a right ankle injury. The report read; "Examination of the right ankle demonstrated a non-displaced oblique [MEDICAL CONDITION] fibular shaft. Soft tissue [MEDICAL CONDITION] noted. No medial or posterior malleolar injury identified. The impression was non-displaced oblique fracture the distal fibular shaft. No medial or posterior malleolar injury seen." Incident Report There was no incident report dated for 12/9/12 when the facility became aware of the injury. There was also no documentation to show neuro checks were initiated, and no assessment was found for 12/9/12, regarding the resident's report of a fall the night before. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the December 2012 MAR indicated [REDACTED]. The resident was monitored every shift for pain and the MAR indicated [REDACTED]. Physician Telephone Orders There were no orders for pain medication found in the chart regarding the resident's right leg fracture. Resident Interview On 1/22/13 at 3:15 p.m., the resident reported that although her leg was (currently) better, she had a lot of pain in the beginning and did not get anything for the pain. Staff Interview On 1/23/13 at 2:19 p.m., the certified nurse aide (CNA) stated the resident had casually mentioned that her ankle was sore or that it hurt, but the CNA did not recall her complaining a whole lot about it. On 1/23/13 at 2:33 p.m., the nurse on duty stated that if a resident was having pain, they would identify where the pain was, get a severity rating, and offer different types of pain interventions. He stated that he would follow what the physician ordered and if there were no medications for pain, he would call the physician and request an order. He said when a resident complained of pain the nurse should be documenting the pain in the nurse's notes and recording the severity rating on the MAR. The nurse stated the first time resident #38 complained of pain someone should have looked into it and addressed her pain. On 1/23/13 at 3:05 p.m., the director of nursing (DON) stated that if a resident complained of pain she would expect the nurse to notify the physician for something to help the resident with pain. 2. Failure to Assess/Monitor Skin for Resident #7 Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. According to the January 2013 computerized physician orders [REDACTED]. According to the most recent annual minimum data set (MDS), dated [DATE], the resident was coded as having both long and short term memory problems. The resident was moderately impaired for cognitive skills for daily decision making. The resident at times could be verbally aggressive towards others and was coded as being short tempered or easily annoyed. The resident was totally dependant with all activities of daily living, but was limited assistance with eating. Care Plan The comprehensive care plan identified the resident had a potential for skin impairment related to sensory perception. The goal was for the resident to be free of further skin impairment related to risk factors, through the next review. The approaches were; -Observe skin weekly and document findings as indicated, -Document observations of any non-pressure related skin impairments on facility Non-Pressure Ulcer Wound documentation form, -Observe safety needs with transfers. Observation On 1/16/13 at 11:16 a.m., the resident was observed to have a scratch on the side of her left nostril. On 1/22/13 at 4:45 p.m., the resident was observed eating in the dining room; she had a scab to her left nostril. On 1/23/12 at 9:30 a.m., the resident was observed sitting in her room eating a donut. The resident still had a small scab on the left nostril. On 1/23/13 at 11:27 a.m., the resident was sleeping in her room, her thumb nails were a little long and jagged. The nurse looked at her nails and agreed they were a little long and she would attempt to cut them later. The "resident has been combative and refusing care this day." Treatment Administration Records (TAR) Review of the January 2013 TAR revealed there was no documentation regarding the scab on the resident's left nostril. Staff Interview On 1/23/12 at 9:29 a.m., the nurse stated she was not aware of any scab on the resident's left nostril. She looked in the treatment administration record (TAR) and stated she did not see anything documented. She stated there was a scab and she would have the CNA's look at it. On 1/23/13 at 9:35 a.m., the CNA stated the resident scratches herself. She noticed the scab on her nose approximately 2 weeks ago and reported it to the day nurse. On 1/23/13 at 9:38 a.m., the nurse stated the procedure for injuries of unknown origin, was that once staff notified them of an injury, the nurse started an incident report, made appropriate notifications, started a skin sheet, charted in the nurse's notes and started an investigation. She stated that plus an incident report should have been done for the resident when it was reported. However, that had not been done and she said she would "start an incident report now." On 1/23/13 at 9:50 a.m., the DON stated that if a CNA noted an injury she expected them to fill out a "stop and watch sheet" and notify the nurse. The DON stated if they did not fill one out, the nurse was to remind them to. However, the nurse was responsible to begin the incident and skin sheet to monitor the area, regardless of whether or not the "stop and watch sheet" got filled out. 3. Failure to Assess and Treat Skin Tears for Resident #61 According to the facility admission record resident #61 was an [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record Review According to a non-pressure ulcer skin impairment care plan, dated 11/29/12, the resident had the potential for skin impairment. The resident had an abrasion to his nose. The approaches included: -Observe skin weekly and document findings as indicated, -Document observation of any non-pressure related skin impairment on facility non-pressure Ulcer Wound documentation Form, -Observe for safety. According to the nurse's progress note (NN), dated 1/14/13 at 4:30 p.m., the resident was involved in an altercation. The note revealed, in pertinent, that the resident had a skin tear to his right cheek, his middle finger on his right hand and bruising to his right hand. The skin tear was well approximated. It was cleansed, steri-stripes applied and wrapped with gauze. The physician was notified. Review of the resident's treatment administration record (TAR) for January and telephone orders from 1/14/13 to 1/23/13 (survey exit date) revealed there was no order written related to treatment and monitoring of the skin tear. Review of the non-pressure sheet, dated 1/14/13, revealed the resident had a skin tear to his right third digit. It was 2.5 centimeters (cm) in size. The next entry was dated 1/21/13. It revealed the skin tear was still 2.5 cm in size. Observation On 1/16/13 at 10:54 a.m., the resident was observed to have a scabbed area to the third finger on his right hand. It was approximately 2.5 cm x 1.0 cm in size. It was oozing red drainage at the edges of a scab. On 1/17/13 at 2:30 p.m., observations revealed the third finger on the resident's right hand was bleeding at the scabbed area and had a band-aid wrapped loosely around it. However, the band-aid was not touching the skin tear and there was a scabbed area visible, approximately 2.5 cm x 2.5 cm in size. On 1/22/13 at 11:48 a.m., observations revealed the scabbed area to the third finger on his right hand was approximately 2.5 cm x 2.5 cm in size. There was not a dressing or bandage on the finger. Interviews On 1/22/13 at 11:19 a.m., the licensed practical nurse (LPN) was interviewed. He indicated that a non-pressure skin sheet should be completed on all skin tears and bruises. He indicated that the nurses on the floor were to initiate the sheet and then notify the director of nursing (DON). On 1/22/13 at approximately 11:30 a.m., the LPN was interviewed. He indicated that he was unaware if there were any standing orders for treatments or if he needed to obtain and write an order for [REDACTED]. On 1/23/13 at 9:02 a.m., the DON was interviewed. She indicated that all dressings and treatments had orders. The nurses needed to call the physician and obtain an order. She indicated that she had seen the resident's skin tear when it first happened and it was well approximated. However, the DON said the resident picked at it and it had gotten worse. She indicated the non-pressure sheets should be used and correctly reflect the appearance of the skin tear. She indicated that she had seen the resident's skin tear and verified it was approximately 2.5 cm x 2.5 cm.

Based on observations, record review, and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for one of 9 sample residents (#2) who had recently ([DATE]) sustained a fall at the facility that resulted with neck injuries. Specifically: The facility failed to assess, monitor, address and timely communicate changes in the resident's condition that took place following a fall in the facility [DATE]. The resident was sent to the hospital on [DATE] and was diagnosed with [REDACTED]. She was admitted unresponsive to another facility on Hospice on [DATE] and expired three days later on [DATE]. The findings include: 1. Resident #2, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], revealed the resident scored a 5 on the BIMS (Brief Interview for Mental Status exam), indicating severe impairment. The resident was coded as needing extensive assistance of two staff members for all activities of daily living. The resident also was coded as having behavioral symptoms such as verbal abuse, being socially inappropriate and could resist care. The resident was at risk for falls and had a lap buddy restraint. Review of the ,[DATE] Computerized physician's orders [REDACTED]. -[MEDICATION NAME] 15 mg for weight loss (ordered [DATE]), -[MEDICATION NAME] 2 mg twice a day for [MEDICAL CONDITION] (ordered [DATE]), Decreased to 3 mg daily on [DATE], -[MEDICATION NAME] 50 mg IM every 3 weeks for [MEDICAL CONDITION] (ordered [DATE]), -[MEDICATION NAME] 25 mg twice a day for hypertension with parameters to hold if blood pressure was below 160 or heart rate was below 60 (ordered [DATE]), -Med Pass 2.0, 6 ounces three times a day, a supplement (ordered [DATE]), -Tylenol Extra strength 500 mg, two tablets every six hours as needed for pain not to exceed 3000 mg in 24 hours (ordered [DATE]), -Regular Pureed Nectar thick liquids 2. Resident Status a. Fall [DATE] Record review revealed the resident fell from her wheelchair (w/c) when she removed her lap buddy on [DATE]. This fall resulted in a cervical (C2) fracture. b. Status on Readmission The resident was readmitted to the facility on [DATE] with a neck collar in place. New orders on readmission included: -[MEDICATION NAME] 0.5 mg every six hours as needed for anxiety and agitation (ordered [DATE]), Increased to twice a day and prn on [DATE], -[MEDICATION NAME] ,[DATE] one-half tablet every four hours as needed for pain and may repeat one half tablet every four hours as needed for pain (sic), not to exceed 4 gm Apap in 24 hours (ordered [DATE]), -Cervical collar on at all times, may remove briefly to clean if resident is laying flat. A Medical Nutrition Therapy Review completed [DATE], revealed the resident's intakes appeared to meet her estimated nutritional needs of 1267 calories per day and 45 gms/kg per day. Nutritional support included [MEDICATION NAME] 15 mg, Med Pass 2.0, 6 ounces three times a day, and Regular Pureed Nectar thick liquids. 3. Declines After Readmission - Facility Failures On [DATE] at 8:10 a.m., a family member was interviewed. The family member stated the resident was doing fine until she fell and broke her neck on [DATE]. S/he continued that the resident then became ill and never recovered. The resident was placed on Hospice and expired approximately a month after the fall. Record review and interviews confirmed the resident's decline following her fall [DATE], and confirmed the facility failed to assess, monitor, and timely communicate changes in the resident's condition, as well as follow and/or clarify physician orders. (1) Skin Breakdown See orders above for cervical collar on at all times. According to the nurses' notes, after readmission the resident was given showers with the cervical collar on. -On [DATE], nurses' notes documented the resident was noted with an abrasion to left lower jaw. -On [DATE], a 3 cm x 2.5 cm abraded area was noted on the resident's chin; the nurse documented the collar was rubbing the resident's chin due to her constant chewing motion. Physical therapy and physician were notified; no treatment changes were made. -On [DATE], the area was documented as "very excoriated with a white concave center. At this time, 4 x 4 padding was placed on the neck collar. On [DATE], an order was received for [MEDICATION NAME] to "raw area on chin" to address itching. (2) Syncopal episodes [DATE] Review of the resident's nurses' notes and neuro-check sheets revealed on [DATE] at 6:40 p.m., the resident's blood pressure was ,[DATE]. Her pulse was 84. The resident was unresponsive and sent to the emergency room (ER), and diagnosed , per ER record, with "likely [MEDICAL CONDITION] from using toilet with brief post-syncopal [MEDICAL CONDITION]. [DATE] Review of the resident's nurses' notes and neuro-check sheets revealed on [DATE] at 9:00 p.m. the resident's blood pressure was ,[DATE] and her pulse 80. She was documented to have another syncopal episode. Facility Failures -Review of the resident's medication administration records (MARs) for ,[DATE] and [DATE] revealed that on both dates the resident had received [MEDICATION NAME], an antihypertensive, at 7:30 a.m. and 4:30 p.m. Contrary to orders (hold [MEDICATION NAME] if blood pressure less than 160 and pulse less than 60) there was no documentation in the resident's record (MAR, neuro-check sheet, nurses' notes) that blood pressures were taken on these dates prior to administration of [MEDICATION NAME]. -Following the resident's second syncopal event on [DATE], orthostatic blood pressures were order to be taken for three days on each shift. There was no documentation in the resident's record (MAR, neuro-check sheet, nurses' notes ,[DATE] - [DATE]) that this was done as ordered. The ,[DATE] MAR revealed documentation that the was completed only on the 10 p.m. to 6 a.m., shift on ,[DATE] and ,[DATE]. There were only initials in dated squares for the 6 a.m. to 2 p.m. shift on ,[DATE], ,[DATE], and ,[DATE] and for the 2 p.m. to 10 p.m. shifts on ,[DATE] and [DATE], however there were no documented blood pressures readings. (3) Physical and Behavioral Changes Review of the nurses' notes dated ,[DATE] through [DATE] revealed the resident was up in the wheelchair with lap buddy for meals, fed herself, responded to verbal and tactile stimulus, spoke with staff, alert with confusion, and ate fairly well. On [DATE] at 10:00 a.m., a nurse documented that the resident was fed and ate most of her breakfast. Review of the ,[DATE] MAR indicated [REDACTED]% seven times, with one entry lacking documentation. Change in Condition: [DATE] On [DATE] at 9:30 p.m., a nurse documented the resident was leaning to the left and refused the evening meal. The nurse documented the resident spit out her medication. Review of the neuro-check sheet revealed (no time documented) an elevated pulse of 105 with blood pressure ,[DATE]. Failures [DATE]: Record review revealed no documentation staff reported the resident was leaning to left (documented in nurses' notes [DATE] at 9:30 p.m.) and had an elevated pulse. MAR review [REDACTED]. Although the resident's blood pressure was low (,[DATE]) There was no documentation staff considered notifying the physician to clarify continuation of this order. [DATE] On [DATE] at 4:45 a.m., the nurse documented the resident complained of general pain, was restless, grabbing onto staff and was crying out. The resident was medicated with [MEDICATION NAME]. Another nurse documented at 1:00 p.m., the resident spit out food instead of swallowing and was refusing appropriate fluids. According to the Meal Detail Report, the resident had refused breakfast, lunch, dinner and the bedtime snack on ,[DATE]. The physician's office was notified of the refusal of medications. Failure: Although physician notified [DATE] of medication refusal, there was no documentation that other behavior changes documented [DATE] (grabbing onto staff, crying out) were assessed and communicated to the physician. [DATE] On [DATE] at 10:00 a.m., the nurse documented the resident was lethargic and not taking in oral food or fluids. The physician was notified and orders were received for lab work, including a CBC (complete blood count), a BMP, and a UA (urinalysis). -Review of the neuro-check sheet revealed the resident's blood pressure at 1:00 p.m. was ,[DATE] with pulse of 84. -At 2 p.m., a nurse documented the resident was up for lunch, however "spit out anything po" (oral). According to the Meal Detail Report, the resident had refused breakfast, ate 100% of lunch, refused dinner and refused the bedtime snack on [DATE]. Failure: -Record review revealed no documentation the UA or BMP were collected [DATE] (see below; UA collected [DATE]. No results from the BMP ordered [DATE] were located in the resident's record). -Record review revealed was no documentation the resident's continued refusal of food and fluids was communicated to the physician. [DATE] On [DATE] at 5:30 a.m., the nurse documented the UA was collected per catheter. According to the Meal Detail Report, the resident had refused breakfast, lunch, dinner and the bedtime snack on [DATE]. -The resident's blood pressure and pulse at 10:30 a.m. were ,[DATE] and 60. -The resident's blood pressure and pulse at 9:30 p.m. were ,[DATE] and 71. Failure: -There was no evidence that the physician was notified of the resident's refusal of oral intake. -MAR review [REDACTED]. Although the resident's blood pressure was low (,[DATE]), there was no documentation staff considered notifying the physician to clarify the continuation of this order. [DATE] According to the Meal Detail Report, the resident ate 100% of breakfast, refused lunch, refused dinner and accepted the bedtime snack on [DATE]. -At 10:00 a.m., the neuro-check sheet documented the resident's blood pressure was ,[DATE] and pulse of 62. -At 9:35 p.m., a nurse documented that she could not obtain a blood pressure, the resident was documented as unresponsive, and the pulse was 100. The son was notified of the resident's condition. Failure: -Record review revealed no documentation the physician was notified of the resident's vital signs on [DATE] and continued food and fluid refusals. [DATE] On [DATE] at 4:20 a.m., a nurse documented the resident complained, 'Don't feel good,' had slow, shallow respirations, and noted there was mottling of both the hands and feet. -The resident's blood pressure was documented on the neuro-check sheet at 4:20 a.m. as ,[DATE] and pulse of 74. -The resident's blood pressure was documented on the neuro-check sheet at 10:30 a.m. as ,[DATE] and pulse 60. At 9:45 p.m. a nurse charted the resident's pulse was 164, the resident complained of pain all over, had not voided the entire shift, and the oxygen saturation level was 87% on room air. Failures: Even though the resident had been complaining of pain, refusing food and fluids since [DATE], there was no evidence the physician was notified of the resident's documented changes in condition from ,[DATE], until [DATE] 9:45 p.m. after the resident's pulse was recorded as 164. The on call physician ordered a chest x-ray, oxygen to keep her saturation levels above 90% and labs, including a CBC and BMP to be done on the next lab day. Oxygen was applied at 2L/M liters per minute and the resident's oxygen saturation level rose to 96%. [DATE] On [DATE] at 2:45 a.m., a nurse documented the resident's pulse ranged from 62 to 162. Review of the neuro-check sheets revealed at 10:00 a.m., the resident's blood pressure was ,[DATE] and her pulse 161. Nurses' notes at 10:00 a.m. documented the resident remained lethargic and still was not taking food or fluids. The nurse also documented the resident's extremities were cool to touch. [MEDICATION NAME] was given for general discomfort. At the family member's request, the resident was transferred to the hospital. Failure: Even though nurses documented the resident was lethargic on ,[DATE] through [DATE], medications with potential side effects of [MEDICAL CONDITION] ([MEDICATION NAME] and [MEDICATION NAME]), drowsiness ([MEDICATION NAME] and [MEDICATION NAME]) and respiratory depression ([MEDICATION NAME]) were administered as follows: [MEDICATION NAME] [MEDICATION NAME] 0.5 mg was documented as given per the narcotic sign out sheet: -On ,[DATE] at 5:35 a.m., -On ,[DATE] at 5:45 a.m. and at 5:00 p.m., -On ,[DATE] at 6:00 a.m., -On ,[DATE] at 5:45 a.m., and -On [DATE] at 5:45 a.m. There was no documentation that the medication was wasted. [MEDICATION NAME] [MEDICATION NAME] ,[DATE] ? tablet was documented as given per the narcotic sign out sheet on ,[DATE] at 8:40 a.m. and at 5:30 p.m., and on ,[DATE] at 7:30 a.m. There was no documentation that the medication was wasted. [MEDICATION NAME] Review of the ,[DATE] MAR indicated [REDACTED] 4. Status On and After [DATE] a. Labs The [DATE] BMP revealed a BUN/Creatinine ratio of 63 and a critical level of sodium. According to http://www.livestrong.com/article/ 1-dehydration-and-sodium-levels/#ixzz24o0qnhuB <http://www.livestrong.com/article/ 1-dehydration-and-sodium-levels/>, " [MEDICAL CONDITION], or high blood sodium, results from having too little water in the body. In other words, dehydration causes an increase in the level of sodium in the blood stream. . . . According to the Penn State Milton S. Hershey Medical Center, [MEDICAL CONDITION] can also affect your brain cells, resulting in confusion and fatigue, and eventually can result in coma and death." b. ER and Hospital Records According to the emergency room and hospital records, the resident was lethargic, unresponsive, and in critical condition on [DATE]. The hospital [DIAGNOSES REDACTED]. The "patient clearly has what looks to [MEDICAL CONDITION] secondary to possible urinary tract infection." (2) Dehydration - "Bun elevated." (3) [MEDICAL CONDITION] with rapid ventricular response. "Secondary to the dehydration." The resident was put on comfort measures and expired on [DATE]. 5. Staff Interviews The Director of Nurses (DON) was interviewed on [DATE] at 7:54 a.m., 8:11 a.m., and again at 8:32 a.m. -When asked for the BMP results ordered on [DATE] that could not be located in the medical record, the DON first replied the hospital was looking for a copy to send and then later verified that the lab had not been done. The DON explained that the night nurse double checks the physician's orders [REDACTED]. -The DON also explained that the physician had reviewed the [DATE] UA results and had decided not to treat the resident at that time for the urinary tract infection.

Based on observations, staff interviews and record review, the facility failed to provide adequate care and services for pressure ulcer prevention and management for one (#1) of 11 sample residents. Specifically, the facility: -Failed to accurately assess and document facility acquired pressure sores. -Failed to consistently implement identified preventative measures to promote healing when ulcers developed and prevent the development of new ulcers. -Failed to timely notify the physician of new pressure sores, until it was brought to the facility's attention during the survey. The findings include: A. Professional Reference The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines, found at the website: http//www.npuap.org provided the following definitions: "Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction . . . Pressure Ulcer Stages -Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . . . -Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister . . . -Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." B. Facility Policy The facility skin management policy was requested and was provided by the Director of Nursing (DON) on 2/22/12. The policy indicated the following in pertinent parts: "When a pressure sore is identified, the licensed nurse (Registered Nurse) will document in the progress notes and on the weekly Pressure Ulcer Record. Documentation to include size, stage, location, drainage, odor and pain; obtainment of treatment orders, initiation of care plan, and notification of interdisciplinary wound team including dietician ...The licensed nurse will document daily monitoring of all pressure ulcers to include status of dressing, surrounding skin, presence of possible complications ...The licensed nurse will communicate all identified pressure ulcers to the attending physician and resident's family ...The licensed nurse will document notification ...in the residents medical record and care plan ...a care plan will be developed, implemented, evaluated to treat actual pressure ulcers and reduce further pressure ulcers." The policy further indicated in pertinent parts, "A licensed nurse (Registered Nurse) or therapist measures wounds to assist with wound healing assessment and treatment. Wound measurement must be precise, consistent, and completely documented ...Stage I: a defined area of persistent redness in lightly pigmented skin ...Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater." C. Resident Failures 1. Resident #1 Resident #1, a [AGE] year-old female, was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment, dated 11/5/11, revealed the resident understood others and others understood the resident. On the Brief Interview for Mental Status (BIMS), the resident scored 99 (unable to complete one or more questions of the interview). The resident had short- and long-term memory problems. The resident's behavioral symptoms included inattention and disorganized thinking. -She required extensive assistance of two persons for bed mobility, transfer, dressing, personal hygiene, toileting and bathing. The resident was non-ambulatory and required limited one-person assistance for locomotion. -She used a wheelchair; was incontinent of bowel and bladder. -She was coded with no risk for pressure sores and was coded without pressure ulcers. a. Pressure Ulcer Risk Assessment On 10/12/11, the skin breakdown assessment tool for resident #1 indicated a score of 12, (specifically scores of or below 12 on the Braden's scale were indications of high pressure sore risk). On 1/17/12, the resident scored 13, respectively, indications of mild pressure sore risk, yet physician telephone orders (PTO) dated 2/16/12 read in pertinent parts, "Apply [MEDICATION NAME] dressing to (L) left inner buttox (buttocks) site Q 3 days," indication of actual skin breakdown. b. Care Plans Resident #1's plan of care, dated 1/29/12, read in pertinent part, "Braden score: 13 ...potential ...Related to (r/t): Moisture/Incontinence ...Decreased activity ...impaired mobility ...nutrition/Hydration risks ...Friction and shearing problems ...refusal of care/treatment ...Hx (history) of healing pressure ulcer [MEDICATION NAME] drsg (dressings) to buttocks for prev. (prevention) pressure ulcers and excoriation prevention." The goals for the care plan read, in pertinent parts, "Will have intact skin without signs of skin breakdown through next review ...90 days." The approaches included treatment (Tx) as ordered, weekly skin assessments which were to be documented and frequent repositioning in chair and bed. The resident's bed had a pressure reduction mattress, a pressure reduction cushion in the chair and wheelchair (w/c), specifically, "a roho cushion in the recliner." The resident was to be provided with incontinence care after each incontinent episode. The care plan indicated there were no referrals for dietitian (although the most recent Braden's scale indicated that the resident's nutritional status was poor). Although the resident had actual skin breakdown by 2/16/12 and was observed with actual skin breakdown on 2/22/12, the care plan indicated no actual skin breakdown or treatment for [REDACTED]. c. Physician Orders Physician's Telephone Orders (PTO) and Medication Administration Records (MARs)/treatment record administration (TARs), dated 1/18/12, read in pertinent parts, "Clarification: Apply [MEDICATION NAME] drsg (dressing) to (L) left Ischia site ... (change) Q (every) 3 days & PRN (as needed). Dx (diagnosis).., Preventative Pressure Ulcer." Further PTO notes, dated 1/18/12, read in pertinent parts, "Clarification: Change [MEDICATION NAME] dressing to (L) Ischia site Q (every) 7 days & prn (as needed)." The PTO, dated 2/16/12, read in pertinent parts, "Apply [MEDICATION NAME] dressing to (L) left inner buttox (buttocks) site Q 3 days." d. Progress Notes Nurses' notes and weekly pressure ulcer record (WPUR), dated 1/3/12, indicated skin breakdown. Nursing notes, dated 1/3/12 at 7:00 a.m., read in pertinent parts, "(with) cares this A.M., small reddened area noted to left buttock 2 cm x 1 1/2 cm, [MEDICATION NAME] (pressure sore dressing) applied. Heels ...reddened, skin protectant applied to feet." The physician (MD) and medical power of attorney (MPOA) were notified appropriately on that date. Interdisciplinary (IDT) care conference attendance record (form), dated 2/2/12, read in pertinent parts, "pressure ulcer healed." Nurses' notes, dated 2/16/12 at 3:00 a.m., read in pertinent parts, "[MEDICATION NAME] to (L) buttocks ... (changed). Noted 3 small circular red areas ...cleaned prior to new dressing applied." Licensed Practical Nurse (LPN) notes, dated 2/16/12 at 1:00 p.m., read in pertinent parts, "noted an abrasion 6 cm long x 0.5 cm wide." The notes indicated no signs and symptoms (s/s) of infection and a [MEDICATION NAME] (pressure sore dressing) was applied to the area per physician orders. In addition, the notes indicated no location of that new abrasion. The MD and MPOA were notified of those new findings. The WPUR which indicated "non-pressure" wounds, dated 2/16/12, read, "non-pressure" skin breakdown. In pertinent parts, the non-pressure wound record read, "(L) side inner buttocks ...Stage 2 ...6 cm x 0.5 cm ...EXODATE TYPE ...Serous ...scant." The form further read, in pertinent parts, "abrasion noted on (L) side of inner buttox. Area open as top layer of skin is removed [MEDICATION NAME] dressing applied." After the surveyor and director of nursing (DON) observed the resident with multiple stage II (crater) shaped pressure ulcers to both buttocks, on 2/22/12, the DON documented additional notes on that same 2/16/12 form. The notes read in pertinent parts, "Addendum area noted located in gluteal fold, excoriation not P.U. (pressure ulcer)." However, the observations revealed four undocumented stage II pressure sores on 2/22/12. The non-pressure record, dated 1/18/12, indicated the progress of skin breakdown. In pertinent parts, the non-pressure progress record read, "bottom ... Stage 2 ...6 cm x 1 cm total area ...EXODATE TYPE ...Serosanguinous ...small." The form further read, in pertinent parts, "Area has healing stage Dressing intact... interventions ...Bed type ...Air ...W/C Cushion ....Other ...Recliner Cushion." Nurses' notes, dated 1/18/12, indicated the pressure sore to the (L) ischia was resolved and a [MEDICATION NAME] dressing was to be continued as a preventative measure, in accordance with physician orders. A form entitled, "Nursing Weekly/Monthly Summary," dated 2/18/12, was reviewed. Under the subtitle, "Skin Turgor," the form indicated no abrasions, no excoriation, no pressure ulcers, no preventative skin care, no pressure relieving or reduction mattress or chair reduction pad use. All those boxes were left blank on that form. Under the subtitle, "Additional Comments," the RN notes read, in pertinent parts, "incontinent of B & B (bowel and bladder). Now has dressing to buttocks for skin breakdown ...(with) staff aware of repositioning ...does not like to lay down on bed ...cont (continue) ...roho pressure relieving cushion mattress." No further documentation of skin breakdown abrasions or of the multiple stage II pressure sores to the resident's buttocks was noted until it was brought to the facility's attention by the surveyor on 2/22/12 during wound care observations. e. Observations On 2/21/12 at 12:40 p.m., the resident was observed as she sat in a wheelchair. A specialized (customized) pressure reduction cushion was in the seat of the chair, however, it was covered with a thick cloth pad which was folded four times. This created multiple layers on top of the cushion therefore, reduced its effectiveness. On 2/21/12 at about 1:30 p.m., the resident stated to two certified nurse aides (CNAs) that she wanted to lie down. The two CNAs were observed to transfer the resident from her w/c to the bed. Observations revealed seven layers had been placed under the resident as she lay down. The resident's mattress was covered with two sheets, a draw sheet (which was folded four times), a pad, a cloth pad on top of the draw sheet, a thick bedspread, another thick pad on top of the thick bedspread. Furthermore, the resident was wearing incontinent pads underneath her trousers, creating another layer between the resident and the mattress. On 2/21/12 at 2:30 p.m., 2:40 p.m. and 3:00 p.m., the resident was observed as she sat in her recliner chair at the bedside. The recliner chair was covered with a thick incontinent pad, which was folded four times. No cushion was observed in the chair. On 2/22/12, between 12:10 p.m. and 1:00 p.m., the DON and the facility's wound care nurse LPN (WCLPN), were observed during wound care. The DON acknowledged the LPN was the wound care nurse, however, the LPN was not a Registered Nurse (RN) or licensed to assess wounds. The DON stated the WCLPN worked under the supervision of the DON. The DON was then responsible for wound care assessments after the LPN collected the necessary wound data. During the observation, the WCLPN removed two dressings. She stated that one was a proactive dressing to cover an old pressure sore and the second old dressing covered a resolving abrasion (that dressing was observed with a date of 2/21/12 per WCLPN and surveyor observation) When the old dressings were removed, multiple stage II pressure sores were observed. More specifically, observations and assessment on that date and time revealed the following undocumented wounds: A. Left Gluteal: Wound #1 stage II - located to left gluteal fold, measured 0.3 x 0.3 cm. Wound #2 Stage II - located to left center of gluteal fold, measured 0.5 x 0.4 cm. Wound #3 - stage II - located to left lower gluteal fold, measured 1.5 x 0.5 cm. B. Right Gluteal: Wound #4 - stage II - located to right lower gluteal fold, measured 0.5 x 0.5 cm. None of the above wounds were documented. Moreover, the DON, MD and family members were unaware of the findings, even though the LPN had observed those pressure sores prior to pressure sore observations done by the surveyor on 2/22/12. The pressure sores were not measured or documented prior to surveyor's request. On 2/22/12 at 2:30 p.m., the WCLPN and a consulting administrator, who was also a RN (NHARN), were interviewed at the same time. The WCLPN stated, "I saw small area (gluteal pressure sores) but I did not document them ...it was a few days ago ...last week ...I passed on to the shift nurse ...I did not document ...nurses are supposed to document ...they (stage II wounds) have been already open for a while." The NHARN stated, "There was failure to document the new pressure sores, failure to (timely) notify the physician and family ...The MD and MPOA were unaware of the pressure sores." On 2/22/12 at 5:30 p.m., the DON was interviewed. After the facility was informed of the findings, the DON obtained physician orders [REDACTED]. The DON stated an investigation was conducted and revealed the facility's WCLPN, "Had seen the open areas a couple days ago (no dates were quoted or given) and did not document when she first noticed them ...She (WCLPN) should have documented ...Should have notified me (DON) immediately, then I would have assessed the skin breakdown ...I agree with you that those were stage II pressure ulcers (craters)." The DON further stated, "I followed up ...I called the MD and notified him. The process is to call and notify the MD right away." The DON then stated she would follow up by educating the staff.