Every finding on record at Sterling Rehabilitation and Nursing, LLC

Based on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for two (#4 and #52) of five residents reviewed for pressure injuries out of 45 sample residents. Resident #4, who was at risk for developing pressure ulcers, was admitted on [DATE] and readmitted on [DATE] after a five-day hospital stay. The 4/2/25 wound weekly observation assessment revealed the resident acquired a right heel suspected deep tissue injury (DTI) on 3/21/25, three days after she was readmitted to the facility. The right heel wound measured 3.5 centimeters (cm) in length, 3.5 cm in width and 0.0 cm in depth. The assessment revealed it was the first observation of the wound. The initial treatment orders on 3/22/25 included floating the right heel with a pressure relief boot at all times. -However, the treatment to float the right heel was discontinued on 4/24/25. There was no further documentation to reveal why the treatment order was discontinued or what other offloading measures were added to prevent the pressure ulcer from worsening.On 6/18/25, the wound care physician (WCP) reclassified Resident #4's right heel wound as a stage 3 pressure injury. The right heel wound measured 1.1 cm in length, 1.5 cm in width, and 0.4 cm in depth.On 7/29/25 the WCP documented preventative measures for the resident included heel protectors and wedges.-However, observations during the survey revealed Resident #4 did not have her right heel consistently offloaded in order to prevent the pressure wound from worsening (see observations below).Additionally, Resident #52, who had a DTI to his left heel and a stage 3 coccyx pressure ulcer, did not receive timely interventions to prevent the potential for the development of further pressure wounds, and the facility failed to document the resident's weekly skin check assessments accurately.Specifically, the facility failed to:-Ensure appropriate wound prevention interventions were initiated and consistently implemented in order to prevent further potential pressure injuries from occurring and to promote healing for Resident #4, who had a stage 3 facility-acquired pressure ulcer;-Ensure timely pressure ulcer interventions were implemented after Resident #52 developed a DTI on 6/10/25 and a stage 3 coccyx pressure ulcer on 8/12/25;-Ensure physician's orders for Resident #52's stage 3 coccyx pressure ulcer were obtained in a timely manner after the wound was identified; and,-Ensure Resident #52's weekly skin check assessments were accurate.Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 8/25/25 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Injury Prevention and Management policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 8/20/25 at 5:04 p.m. It read in pertinent part, Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (for example moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to, redistributing pressure such as repositioning, protecting and or offloading heels; minimizing exposure to moisture and keeping the skin clean, especially of fecal contamination; providing appropriate, pressure-redistributing support surfaces; providing non-irritating surfaces; and maintaining or improving nutrition and hydration status, where feasible. Interventions will be documented in the care plan and communicated to all relevant staff. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia, fracture of the unspecified part of the neck of the left femur, and pressure-induced deep tissue damage of the right heel. According to the 7/9/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had an impairment on one lower extremity and required a wheelchair. The resident required set up assistance with eating and oral hygiene. The resident required maximal assistance with showering and personal hygiene. The resident was dependent on rolling left and right, sitting to lying, lying to sitting and sitting to standing. The assessment revealed the resident was at risk for developing pressure ulcers and injuries and had one unstageable DTI that was not present upon admission or reentry. The treatments included a pressure-reducing device for the chair and for the bed, a turning program, a nutrition intervention, and pressure ulcer care. B. Resident interview and observation Resident #4 was interviewed on 8/18/25 at 1:04 p.m. in her room. Resident #4 was sitting in her wheelchair next to her bed in her room. The resident's roommate was also in the room. Resident #4 said she was at the facility because she fell. Resident #4 said she had a pressure wound. Resident #4 said she did not know what the facility was doing to make the pressure wound better. During the interview, Resident #4 did not have any pressure-relieving devices on her right foot. The resident was wearing socks on her feet and a white bandage was sticking out of the top of her right sock. The resident's feet were resting directly on the wheelchair's footrest. There was a large machine next to the resident's bathroom. Resident #4 said she did not know what it was used for. Resident #4's roommate said the machine was used for Resident #4's foot because she had a wound. C. Observations On 8/19/25 from 11:44 a.m. to 12:48 p.m., Resident #4 was in her wheelchair in the dining room. She had her right foot resting on the ground. She did not have any pressure-relieving devices on her right foot. On 8/19/25 at 6:45 p.m. Resident #4's wound care was observed with the WCP and regional clinical resource (RCR) #2. The wound had slight serosanguinous drainage (a thick light pink color and water consistency often indicating the natural healing was underway). The WCP said the wound was improving and was smaller. The wound measured 2.1 cm in length by 1.7 cm in width and 0.8 cm in depth per the WCP. The WCP said the wound was improving and was smaller. The resident did not have any offloading measures on her right foot prior to the WCP beginning the wound care. On 8/20/25 at 9:15 a.m. Resident #4 was sitting in her wheelchair in her room. The resident was observed without any offloading measures on her right foot. Her feet were resting directly on the footrests of her wheelchair. D. Record review Review of Resident #4's skin integrity care plan, initiated 3/21/25 and revised 8/19/25 (during the survey), revealed the resident had a stage 3 pressure ulcer on her right heel. Interventions included encouraging the resident to shift her weight, initiating an air mattress, and providing vaporous hyperoxia therapy (VHT - a non-invasive treatment for chronic wounds that uses a non-contact, low-frequency ultrasonic mist and concentrated topical oxygen to accelerate healing) as needed for wound healing. -The care plan did not include an intervention for the use of assistive heel protectors and wedges (see WCP visit notes below). Review of Resident #4's April 2025 CPO revealed the following physician's orders: Apply skin prep to the right heel, and allow to dry. Float heel with a pressure relief boot at all times two times a day for the wound to the right heel, ordered 3/22/25 and discontinued 4/24/25. Betadine DTI to the right heel daily. Leave it open to air and offload every night shift. Ordered on 4/4/25 and discontinued on 6/4/25. Review of Resident #4's August 2025 CPO revealed the following physician's orders: Monitor DTI to the right heel. Document no if there are no observed abnormalities to the dressing, skin or pain associated with the wound. Document yes if abnormalities or changes to the dressing, skin, or pain associated with the wound are present or observed. If there are abnormalities, document a descriptive note under the nurse's note and notify the physician, ordered 4/4/25. Air mattress: check air mattress for proper function and settings. Settings based on resident range of 130 to 150 pounds or to the resident's preferred comfort level. Notify maintenance if not functioning properly, ordered 4/24/25. Prostat (supplement to promote wound healing). Drink 30 milliliters (ml) twice a day for the promotion of wound healing, ordered 5/2/25. Wound care order: Cleanse the right heel wound with wound cleanser. Apply silver alginate and silicone border dressing. Change three times a week and as needed, ordered 8/20/25. -There were no physician's orders for heel protector boots. A Braden scale (pressure sore assessment risk) assessment, dated 1/19/25, revealed Resident #4 was at risk for pressure ulcers with a score of 19. A Braden scale assessment, dated 3/18/25, revealed Resident #4 was at moderate risk for pressure ulcers with a score of 13. The 4/2/25 weekly wound observation assessment revealed Resident #4 acquired a right heel suspected DTI on 3/21/25. The right heel wound measured 3.5 cm in length, 3.5 cm in width and 0.0 cm in depth. The assessment revealed it was the first observation of the wound. The current treatment plan orders were betadine daily, open to air treatment and offload. The 6/18/25 WCP visit note revealed Resident #4 had a stage 3 pressure injury on her right heel. The right heel wound measured 1.1 cm in length, 1.5 cm in width and 0.4 cm in depth. -Based on the WCP visit note, the right heel wound evolved from a DTI to a stage 3 pressure injury. The 7/9/25 WCP visit note revealed Resident #4 had a stage 3 pressure ulcer on her right heel. The right heel wound measured 1.5 cm in length, 1.5 cm in width and 0.4 cm in depth. The healing was delayed by a local infection. The 7/18/25 nurse note revealed a complete blood count (CBC) lab and wound culture was obtained in the morning for increased wound discharge and foul odor. The resident's vital signs were within normal limits. There were no reports of worsening pain or discomfort. The CBC lab came back with no abnormalities. The July 2025 medication administration record (MAR) revealed amoxicillin-potassium clavulanate 875-125 mg was ordered on 7/19/25. The order read: Take one tablet by mouth every 12 hours for bacterial infection for 10 days. The 7/22/25 weekly wound observation assessment revealed Resident #4's right heel was facility-acquired and was a stage 3 pressure injury. The pressure injury was worsening, there was a foul smell present and there was inflammation present. The wound measured 2.8 cm by 2.0 cm by 0.6 cm. The treatment was to clean with wound cleanser, place gauze soaked with Dakins half strength, border foam, change the dressing daily, and as needed. The resident received VHT with therapy and a new physician's order was given to obtain a culture to rule out osteomyelitis (bone infection). The 7/23/25 nurse note revealed Resident #4 continued on oral antibiotic amoxicillin for a wound infection to the right heel. No adverse reactions were noted. The 7/29/25 weekly wound observation assessment revealed the right heel wound depth was now at the muscle level. The wound culture revealed a light growth of mixed Gram-positive and Gram-negative flora (the sample identified a small amount of various types of bacteria). The 7/29/25, 8/5/25, 8/12/25 and 8/19/25 weekly wound observation assessments revealed that the preventative measures for Resident #4's pressure wound were an air mattress, assistive heel protectors and wedges. -However, there was no documentation prior to 7/29/25 on what preventative measures were in place to prevent the wound from getting worse. -Additionally, observations revealed Resident #4 was not wearing heel protectors (see observations above). E. Staff interviews The WCP was interviewed on 8/19/25 at 7:45 p.m. The WCP said he was concerned when Resident #4's pressure injury first developed that the pressure injury could go to the bone if the facility did not have interventions in place. He said the resident should wear heel protectors when she was in her wheelchair and she should have an offloading measure for her heels when she was in bed, such as a pillow. He said the wedges in the resident's room should not be used directly on the resident's heel. Registered nurse (RN) #1 was interviewed on 8/20/25 at 10:31 a.m. RN #1 said she knew a resident's daily care needs through the physician's orders. She said the physician's orders were documented on residents' MARs and treatment administration records (TAR). She said there was a communication board in the residents' electronic medical record (EMR) system that detailed specific daily care needs. She said she additionally knew a resident's needs through verbal communication. RN #1 said she knew if a resident needed to wear protective boots because it would be on their TAR. She said if a resident declined wearing protective boots, she documented the refusal in the TAR as N for no. She said she asked a CNA to put the boots on the residents. She said if she did not document an intervention in the TAR, she documented it as a progress note. RN #1 said she was familiar with Resident #4. She said she had a pressure ulcer on her right heel. She said she did not remember how long she had the pressure ulcer but she knew she had had it for a long time. She said there was a time when the pressure ulcer was worse and she said she did not see the wound for over a week. She said she did not know what caused the resident's wound, but she said Resident #4 liked to lie in a certain position and that might have been what caused it. She said she did not work at the facility prior to the resident having the pressure ulcer. She said heel protector boots were an intervention to help promote the pressure ulcer to heal. She said she knew because it was on Resident #4's TAR. -However, RN #1 looked at Resident #4's August 2025 TAR during the interview and she said she did not see an order for the heel protector boots. RN #1 said she tried to use a towel instead of a heel protector boot to offload the resident's heel because Resident #4 did not like to wear the heel protector boot. She said it was important to try something to take pressure off the heel to reduce pressure to make the wound better. RN #1 said Resident #4 used the heel protector boot because she had seen the heel protector boot in the resident's room. -However, several observations revealed Resident #4 was not wearing a heel protector boot (see observations above). During the interview, RN #1 went to Resident #4's room. RN #1 found heel protective boots in the resident's closet. Resident #4 was in her wheelchair next to her bed in her room. Resident #4 said she refused to wear the boot at times because of the way it was secured to her foot. -However, there was no documentation in the resident's EMR to indicate the resident had heel protector boots that were to be applied or that she refused to wear them (see record review above). The director of nursing (DON) was interviewed on 8/20/25 at 3:08 p.m. The DON said nurses were responsible for ensuring residents wore heel protector boots to offload heel pressure. She said nurses and certified nurse aides (CNA) knew which residents were supposed to wear heel protector boots based on the resident's care plan, their TAR and the EMR communication board. The DON said if a resident refused to wear a heel protector boot, the nurse should ask another nurse to try to educate the resident on why they should wear the heel protector boot. The DON said if the resident refused to wear the heel protector boots after education attempts by two nurses, then the DON tried to educate the resident on the importance of wearing the heel protector boots. She said if the resident refused to wear the heel protector boot after she provided education, she might ask the social services director (SSD) to talk with the resident. She said she would then discuss the resident's refusals with the interdisciplinary team (IDT), including the physician. The DON said she was familiar with Resident #4. She said the resident had a pressure ulcer on her right heel that was facility-acquired. She said she did not know when the pressure ulcer was identified, what caused it or what interventions were in place prior to the pressure ulcer because the DON said she did not start working at the facility until July 2025. She said Resident #4 had had a right heel pressure ulcer at least since June 2025. The DON said the right heel wound was infected and treated successfully with antibiotics in July 2025. -However, the resident developed the pressure ulcer in March 2025 (see record review above). The DON said the intervention in place for Resident #4's pressure ulcer was an air mattress. The DON said there was no physician's order and no care plan for the resident to wear heel protector boots as an intervention. She said since there was no physician's order and no interventions identified in Resident #4's care plan, the staff did not know what interventions to use to promote the healing of the pressure ulcer. -However, the WCP wound visit notes, beginning 7/29/25, identified the resident should have heel protectors as an intervention (see record review above). The DON said if Resident #4 refused the heel protector boot in the past and IDT determined it was not a successful intervention, the resident's care plan should have been updated to reflect that the resident refused to wear the heel protector boot. IV. Resident #52 A. Resident status Resident #52, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included type 2 diabetes mellitus, bipolar disorder, protein-calorie malnutrition, adult failure to thrive and schizoaffective disorder. The 7/16/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was dependent on staff assistance for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene and all transfers. He required substantial/maximal assistance for rolling side to side. The assessment revealed no behavioral symptoms or rejection of care. The assessment revealed the resident was at risk of developing pressure ulcers and had one unstageable deep tissue injury that was not present upon admission. The assessment revealed the skin and ulcer/injury treatments included a pressure reducing device for his chair, a pressure reducing device for his bed, was on a turning/repositioning program, had a nutrition or hydration intervention to manage skin problems, received pressure ulcer/injury care and had an application of dressings to his feet (with or without topical medications). B. Resident interview and observations On 8/17/25 at 5:59 p.m. Resident #52 was lying on his side in bed with bilateral pressure relieving boots on. An air mattress was in place on the bed. Resident #52 said he had no concerns or complaints. On 8/19/25 at 6:20 p.m. Resident #52's wound care was observed with the WCP and RCR #2. Resident #52's pressure relieving boots were removed and the old dressing, which was dated 8/18/25, was removed from his left heel. The old dressing had moderate serosanguinous (a yellowish, thin, watery discharge with small amounts of red blood) drainage present on it. Resident #52's left heel wound was 6.2 cm in length by 4.5 cm in length by 0.2 cm in depth, per the WCP. The wound was completely covered in 100% (percent) black eschar (a layer of dead, dried tissue that forms over a wound that is typically black or brown in color). The WCP said the left heel wound was considered slightly worsened due to the length of it having increased slightly but it was stable. The WCP applied the contents of a Flagyl capsule (medication used to help control odor in wounds) to the wound prior to applying a new dressing. The WCP next removed the dressing from Resident #52's coccyx wound. The old dressing had very light pink drainage on it. The wound was 0.5 cm in length by 0.7 in width by 0.0 cm in depth, per the WCP. The WCP said the wound was improving. The wound was 100% granulated tissue (a type of new, pink or red tissue that forms in the wound bed during the healing process). The WCP applied a new dressing to the wound. C. Record review Review of Resident #52's skin impairment/pressure ulcers risk for impaired skin integrity care, initiated 4/15/25, revealed the resident was at risk for skin impairment/pressure ulcers related to limited mobility with an existing DTI to his left heel. Interventions included educating the resident about proper skin care to prevent skin breakdown, educating the resident about the proper usage of pressure reducing devices, educating the resident on the importance of keeping skin clean and moisturized, encouraging the resident to frequently shift weight, evaluating the resident's skin and the resident would have pressure relieving boots on when in bed and when up in his wheelchair. -Review of the care plan revealed there had been no new interventions added after Resident #52 developed a left heel DTI on 6/10/25 and developed a stage 3 coccyx pressure ulcer on 8/12/25. Review of Resident #52's potential for pressure ulcer development care plan, initiated on 4/18/25, revealed the resident had the potential for pressure ulcer development related to immobility. Interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness, administering treatments as ordered and monitoring for effectiveness, educating the resident/family/caregivers as to causes of skin breakdown, including transferring/positioning requirements, the importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, following facility policies/protocols for the prevention/treatment of skin breakdown, if the resident refused treatment, conferring with the resident, the IDT and the family to determine why and try alternative methods to gain compliance, documenting alternative methods, informing the resident/family/caregivers of any new areas of skin breakdown and instructing/assisting the resident to shift his weight in his wheelchair every 15 minutes. -Review of the care plan revealed there had been no new interventions added after Resident #52 developed a left heel DTI on 6/10/25 and developed a stage 3 coccyx pressure ulcer on 8/12/25. Review of Resident #52's August 2025 CPO revealed the following physician's orders: May refer to wound consultant for evaluation and treatment as needed, ordered 4/14/25. Monitor blister to left heel. If there are abnormalities, document a descriptive note under the nurses note and notify the physician, ordered 4/14/25. Pressure relieving boot in bed and chair as resident will allow, ordered 4/14/25. Weekly skin and vital sign checks on Monday nights. Document in weekly skin check assessment, ordered 4/14/25. Prostat 30 ml twice per day (BID) for wound diagnosis, ordered 5/9/25. House supplement (generic mighty shake), two times a day as a supplement, ordered 5/9/25. Obtain air mattress per physician, ordered 6/29/25. -However, the facility failed to implement the air mattress intervention and physician's order until 19 days after Resident #52 developed the left heel DTI (on 6/10/25). Obtain bed extender per physician, ordered 6/29/25. Wound care order (left heel): Clean wound with wound cleanser. Apply silver alginate, cover with abdominal (ABD) pad, wrap with kerlix and apply crushed Flagyl for odor control. Change dressing daily and as needed (PRN), ordered 8/20/25. Wound care order (coccyx): Clean wound with wound cleanser. Apply honey gel, border gauze, and change the dressing every other day and as needed (PRN), ordered 8/20/25. -However, a physician's order for wound treatment for Resident #52's stage 3 coccyx wound was not entered into the resident's EMR until eight days after the wound was identified on 8/12/25. The 7/29/25 physician wound tracker form revealed Resident #52 had a left heel DTI. Dimensions were 4 cm in length by 3.9 cm in width by 0.1 cm in depth. Treatment included cleaning the wound with wound cleanser and applying silver alginate and a silicone border dressing. The dressing was to be changed three times per week and PRN. The 8/5/25 physician wound tracker form revealed Resident #52 had a left heel DTI. Dimensions were 4.5 cm in length by 4 cm in width by 0.2 cm in depth. Treatment included cleaning the wound with wound cleanser and applying silver alginate and a silicone border dressing. The dressing was to be changed three times per week and PRN. The weekly wound observation tool, dated 8/5/25 documented Resident #52 had a pressure wound on his left heel that was a DTI and was facility-acquired on 6/10/25. Overall, the wound was improving but had necrotic (dead) tissue present. The wound was documented as 4.5 cm in length by 4 cm in width and 0.2 cm in depth. The 8/12/25 physician wound tracker form revealed Resident #52 had a left heel DTI. Dimensions were 4.7 cm in length by 4.4 cm in width by 0.3 in depth. Treatment included cleaning the wound with wound cleanser and applying silver alginate and a silicone border dressing. The dressing was to be changed three times per week and PRN. Crushed Flagyl was to be applied to the wound daily for odor. Additionally, the form documented the resident had a stage 3 pressure wound to his coccyx. Dimensions were 0.7 cm in length by 0.9 cm in width by 0.1 cm in depth. Treatment included cleaning the wound with wound cleanser, and applying honey gel and a border gauze. The dressing was to be changed every other day and PRN. The weekly wound observation tool, dated 8/12/25, documented Resident #52 had a stage 3 pressure wound to the coccyx that was facility acquired on 8/12/25. This was the overall first observation of the wound and there was necrotic tissue present. The wound was documented as 0.7 cm in length by 0.9 cm in width by 0.1 cm in depth. The 8/5/25 weekly skin check assessment revealed Resident #52 had a current left heel wound and treatment was in progress. The 8/11/25 weekly skin check assessment revealed Resident #52 had a current left heel pressure wound that was dark brown with eschar intact. The surrounding skin of the wound had slight maceration (a condition where the skin becomes soft, white, and soggy due to prolonged exposure to moisture). No drainage was noted with the dressing change and treatment in place. All other skin was warm, dry and intact and there were no new abnormalities observed. -The skin check assessment did not indicate the resident had a wound on his coccyx, however on 8/12/25 (the day after the skin assessment) the WCP discovered a stage 3 pressure ulcer on the resident's coccyx. The 8/18/25 weekly skin check assessment revealed Resident #52 had a left heel skin impairment. The left heel wound was currently receiving daily treatments. No new areas of skin impairment were noted or reported. -However, Resident #52 had a stage 3 coccyx pressure ulcer that was identified on 8/12/25 and was still present during the wound care observation on 8/19/25 (see observations above). D. Staff interviews The DON and the NHA consultant were interviewed together on 8/20/25 at 3:25 p.m. The DON said Resident #52's stage 3 coccyx wound had developed in the facility on 8/12/25. The DON said the facility conducted an IDT meeting for pr

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure uncooked meat was separated from ready-to-eat food; -Ensure food was discarded after the date of expiration; -Ensure food was labeled and dated appropriately; and, -Ensure the kitchen was maintained in a clean manner.Findings include: I. Failed to ensure uncooked meat was separated from ready-to-eat foodA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 8/27/25 read in pertinent part, Food shall be protected from cross contamination by separating raw animal food during storage, preparation, holding, and display from raw ready-to-eat food including fruits and vegetables. (Chapter 3-10)B. Observations On 8/18/25 at 7:36 a.m., during an initial walk through of the main kitchen, the main kitchen's walk-in refrigerator had a large metal basin on the second to top shelf on the right side of the refrigerator. The large metal basin contained a container of lettuce, yogurt, raspberries, blueberries, and a gallon-sized plastic ziplock bag that was opened. The food in the bag resembled raw bacon. There were liquids leaking out of the ziplock bag and onto the other food items in the large metal basin. C. Staff interviews and observationsThe dietary manager (DM) was interviewed during a walk through of the main kitchen on 8/19/25 at 11:10 a.m. The DM observed the leaking plastic ziplock bag of bacon in the metal basin with ready-to-eat food items in the main kitchen's walk-in refrigerator. The DM said the gallon-sized plastic ziplock bag of raw bacon should have been separated from the ready-to-eat food in the large metal basin. The DM said he did not know if it was raw turkey bacon or raw pork bacon. The DM removed the ziplock bag of bacon from the metal basin. The nursing home administrator (NHA) was interviewed on 8/20/25 at 4:12 p.m. The NHA said he was not aware there was raw bacon stored in the same container of ready-to-eat food in the main kitchen's walk-in refrigerator. The NHA said raw animal food should not be stored in the same area with ready-to-eat food. II. Failed to ensure food was discarded after the date of expiration A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 8/27/25, read in pertinent part, The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. (Chapter 3-25)The Hormel Health Labs Code Date and Handling Information for Hormel Vital Cuisine Mighty Shakes Nutritional Shake - Chocolate (2024), page 12, retrieved on 8/27/25 from https://www.lyonshealthlabs.com/wp-content/uploads/HHL-Code-Date_Handling-Sheet-04_2024.pdf, read in pertinent part, Shelf life: Unopened and frozen - 15 months; Refrigerated and thawed - 14 days; opened - up to four hours. B. ObservationsOn 8/18/25 at 7:36 a.m., during an initial walk through of the main kitchen, the main kitchen's walk-in refrigerator had two large cardboard boxes that contained individual Vital Cuisine Mighty Shakes (a nutritional supplement). One was labeled Vital Cuisine Mighty Shakes Vanilla Flavor with a pulled date of 8/13/25 written in black marker. On the sides of the second cardboard box, which was labeled with Vital Cuisine Mighty Shakes Chocolate Flavor, there was a pulled date of 8/1/25 written in black marker. The cardboard boxes contained 28 individual chocolate Mighty Shakes.-The facility failed to discard the Mighty Shakes chocolate flavor 14 days after they were refrigerated and thawed on 8/1/25. C. Staff interview and observationsThe DM was interviewed during a walk through of the main kitchen on 8/19/25 at 11:10 a.m. The DM observed the boxes of Mighty Shakes in the main kitchen's walk-in refrigerator. He said Mighty Shakes could be stored in the refrigerator for three to six months. He said he did not know there were different shelf lives depending on how the Mighty Shakes were stored. He said the cardboard boxes with the Mighty Shakes were labeled based on when the box was moved from the freezer to the refrigerator. He said based on the 14-day thaw shelf life, the box of chocolate Mighty Shakes should be discarded because it had been more than 14 days since the Mighty Shakes had been put in the refrigerator and thawed. The NHA was interviewed on 8/20/25 at 4:12 p.m. The NHA said he did not know the shelf life for Mighty Shakes. He said based on what he was provided from the manufacturer's website for shelf life instructions, the chocolate Mighty Shakes that were labeled with a pulled date of 8/1/25 should have been discarded since it was more than 14 days since the Mighty Shakes had been put into the refrigerator and thawed.III. Failed to ensure food was labeled and dated appropriatelyA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 8/27/25 read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. (Chapter 3-29) B. Observations On 8/18/25 at 7:36 a.m., during an initial walk through of the main kitchen, on the second to top shelf on the left side of the main kitchen's walk-in refrigerator, there was a square plastic container with a white thick substance in it that looked like frosting. The container was not labeled with a date or the name of the food item inside the container. On the right side of the refrigerator, on the third to top shelf, there were four containers. There was a square plastic container with a red thin sauce that looked like tomato sauce. There was a second square plastic container with a broth, noodles and peas that looked like chicken vegetable noodle soup. There was a third square plastic container with a brown thick sauce that looked like gravy. There was a fourth square plastic container with broth and noodles that looked like chicken noodle soup. None of the four containers were labeled with a date or the name of the food item inside the container.On the right side of the refrigerator there was a large metal basin on the second to top shelf. There was a gallon plastic ziplock bag inside the metal basin that was unopened. It appeared to be what looked like raw bacon. The plastic bag was not labeled with what was inside, when it was opened and when it was supposed to be discarded. C. Staff interviewsThe DM was interviewed during a walk through of the main kitchen on 8/19/25 at 11:10 a.m. The DM observed the containers and the ziplock bag that were not labeled in the main kitchen's walk-in refrigerator. He said all food items removed from the original packaging should be labeled with the name of the food, when it was opened and a use-by date. He said the food in the plastic containers should have been labeled with a use-by date and a common name of the food.The DM said he did not know if the food inside the ziplock plastic bag was raw turkey bacon or raw pork bacon. He said the ziplock bag should have been labeled with what the food was, when it was opened and when it should have been discarded. The DM removed the ziplock bag of bacon from the metal basin. The NHA was interviewed on 8/20/25 at 4:12 p.m. The NHA said all food items removed from the original packaging should be labeled with the name of the food, when it was opened and a use-by date. He said the food in the plastic containers observed on 8/18/25 should have been labeled with a use-by date and a common name of the food. IV. Failed to ensure the kitchen was maintained in a clean manner A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 8/27/25 read in pertinent part, Walls and wall coverings shall be designed, constructed, and installed so they are smooth and easily cleanable. (Chapter 6-201) B. ObservationsOn 8/18/25 at 7:36 a.m., during an initial walk-through of the main kitchen, the dish room was observed. The wall of the dishwashing sink, behind the faucet and spray nozzle, had multiple black discolorations that covered an area of approximately twelve inches wide and eight inches long. The wall of the three-compartment sink additionally had multiple black discolorations above the right drainboard of the sink. The black discoloration covered an area of approximately 18 inches wide and 24 inches long. The rest of the wall above the three-compartment sink had brown discolorations on it. C. Staff interviews and observationsThe DM was interviewed during a walk through of the kitchen on 8/19/25 at 11:10 a.m. The DM said during the walk through he would talk to the maintenance director (MTD) about the black discolorations in the dish room. He said previous maintenance directors used white caulking and paint to fix the discoloration. The DM said he had not filled out a form to let maintenance know when he needed maintenance's help in the last six months. The DM said he did not notice the black discoloration or brown discoloration on the walls of the dish room. The DM said the kitchen staff deep cleaned the kitchen and dish room weekly, monthly and as needed. He said based on the observations made today, 8/19/25, the deep cleaning needed to include the walls behind the sinks in the dish room and the three-compartment sink. At 11:32 a.m., during the main kitchen walk through, three large sheet trays were in a dishwashing rack on the right drainboard of the three-compartment sink. The sheet trays were leaning against the wall and water was visible on the top sheet tray. The DM said the sheet trays could have caused the black discoloration on the walls in the dish room. The DM removed the sheet trays from where they were leaning against the wall. The MTD and the NHA were interviewed together on 8/20/25 at 11:30 a.m. The MTD said he was not aware of any work orders for the kitchen. The NHA and the MTD said maintenance work orders were requested by a communication application and in a morning meeting. During the interview, an environmental tour was conducted throughout the kitchen and dish room. The MTD said he was not aware of the black discoloration on the wall in the dish room and on the wall above the three-compartment sink in the kitchen. The MTD and the NHA said they would find a longer lasting solution other than caulking and painting the walls to keep the kitchen clean.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of three medication storage rooms and three of three medication storage carts.Specifically, the facility failed to:-Date residents' insulin pens with the date it was opened;-Label residents' insulin pens with the resident's name; -Discard medication that had expired; and,-Discard open medications from a medication refrigerator for a resident who had been discharged several months earlier. Findings include:I. Professional referenceAccording to the manufacturer Sanofi-Aventis, How to Inject Lantus with a Vial and Syringe, December, 2024, retrieved on 8/26/25 from https://www.lantus.com/how-to-use/how-to-inject, The Lantus vials you are using should be thrown away after 28 days, even if it still has insulin left in it.II. Facility policy and procedureThe Medication Storage policy, revised April 2025, was provided by the nursing home administrator on 8/19/25 at 1:02 p.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. The medication carts and all medication rooms are routinely inspected by the consultant pharmacist or designee for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs policy.III. Observations and interviewsOn 8/18/25 at 3:03 p.m. the East medication cart was observed with registered nurse (RN) #2. The following medications were found:-A used HumaLog insulin pen, which was not labeled with the resident's name. The pen was inside a storage bag which also contained a glucometer for Resident #49.-A used insulin glargine pen and Lispro insulin pen, which were not labeled with the resident's name. The pens were inside a storage bag ,which also contained a glucometer for Resident #34.-A used insulin glargine pen which was not labeled with the resident's name. The pen was stored inside a storage bag which also contained a glucometer for Resident #11.RN #2 said the insulin pens should have been labeled with the residents' names.On 8/18/25 at 3:20 p.m., the medication refrigerator in the East overflow medication storage room was observed with RN #2. A lorazepam (antianxiety medication) two milligram (mg) per milliliter (ml), 30 ml container was found labeled with the name of a resident, who had expired on 6/19/25.RN #2 said the medication should have been removed from the refrigerator within 48 hours of the resident's death.On 8/18/25 at 3:30 p.m., the [NAME] medication cart was observed with RN #3. The following medications were found:-A used Symbicort (inhaler used to treat asthma) 160/4.5 micrograms (mcg) inhaler for Resident #17 was not labeled with the date it was opened. RN #3 said the inhaler should be labeled with the date it was opened.-A used Trelegy Ellipta (inhaler used to treat asthma, bronchitis and emphysema) 100 mcg/62.5 mcg/25 mcg inhaler for Resident #8 was not labeled with the date it was opened. RN #3 said she did not know how long the inhaler could be used once it was opened. RN #3 said the inhaler should have had a date opened label.-A used fluticasone propionate and salmeterol (inhaler used to treat asthma and lung disease)100 mcg/50 mcg inhaler for Resident #5 was not labeled with the date it was opened. RN #3 said she did not know how long the inhaler could be used once it was opened and said it should be labeled with the date it was opened. -A used Lantus Solostar insulin pen, which was not labeled with the resident's name and not labeled with the date it was opened. The pen was inside a storage bag, which also contained a glucometer for Resident #12. RN #3 said the pen should be labeled with the resident's name and the date it was opened. RN #3 said she would notify her supervisor, as she did not know if the pen should be discarded.-A used NovoLog insulin pen and Lantus Solostar insulin pen for Resident #20, which were not labeled with the date they were opened. RN #3 said they should have been labeled with the date opened. -A used NovoLog insulin pen, which was not labeled with the resident's name. The pen was inside a storage bag, which contained Resident #7's glucometer. The NovoLog pen was not labeled with the date it was opened. There was also an opened Lantus insulin pen for Resident #7 that was not labeled with the date it was opened.-A used Lantus insulin pen and HumaLog insulin pen were not labeled with the resident's name. The pens were inside a storage bag which contained Resident #69's glucometer. Both insulin pens were not labeled with the date they were opened.-A used Lantus insulin vial which was not labeled with the resident's name. The vial was in a storage bag which contained Resident #3's name. The Lantus insulin vial had a date opened label of 7/1/25. RN #3 said the medication should have been discarded as it was expired.-An unopened Naloxone Hcl (used to treat opioid overdose) 4 mg package labeled with Resident #3's name, with an expiration date of July 2025. RN #3 said the medication should have been discarded by 8/1/25. On 8/18/25 at 3:50 p.m., the Central medication cart was observed with RN #1 The following medications were found:-A used Lantus Solostar insulin pen for Resident #6, which was not labeled with the date it was opened. RN #1 said the insulin should have been labeled with the date opened. RN #1 said if insulin was used beyond the recommended length of storage, it might not be as effective.-A used Lantus vial for Resident #41, which was labeled with date opened 5/27/25. RN #1 said the insulin was expired and should have been discarded. RN #1 said she was not sure what the facility policy said about the storage of insulin, but her general rule was that the insulin should not be stored longer than 28 days.-A used NovoLog 100 unit vial for Resident #66, which was not labeled with a date it was opened (on the vial or on the box). IV. Staff interviewsThe director of nursing (DON) and regional clinical resource (RCR) #1 were interviewed together on 8/18/25 at 4:30 p.m. The DON said the insulins that dated 5/27/25 and 7/1/25 were both expired and should have been discarded. The DON said all insulins and inhalers should be labeled with the date opened and the resident's name. The DON said medications should be discarded when residents were discharged from the facility. The DON said all medications should be discarded upon expiration.RCR #1 said she was going to review every insulin and inhaler medications on the medication carts to ensure there were no unlabeled, expired or discontinued medications.RCR #1 was interviewed again on 8/18/25 at approximately 5:30 p.m. She said all opened insulin and inhaler medications that were not labeled with resident names and/or the date they were opened had been discarded, medications were removed from the facility for residents who were discharged and expired medications were discarded. RCR #1 said the facility would be providing education to nursing staff regarding medication storage.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) to ensure the highest practicable quality of life and care for four (#23, #65, #8 and #43) out of eight residents reviewed for ADLs out of 45 sample residents. Specifically, the facility failed to provide bathing for Resident #23, Resident #65, Resident #8, and Resident #43 to maintain the residents' personal hygiene. Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADL) policy and procedure, dated 4/11/25, was provided by the nursing home administrator (NHA) on 8/19/25 at 7:37 p.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; eating to include meals and snacks. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will identify resident triggers through the care area assessment (CAA) process to assess causal factors for decline, potential decline or lack of improvement. The facility will maintain individual objectives of the care plan and periodic review and evaluation.II. Resident #23A. Resident statusResident #23, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease (a degenerative disorder that affects the neurons in the brain), diabetes, intracranial injury (head injury) and malnutrition.The 7/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set up assistance with eating and showering, and substantial assistance with personal hygiene and dressing.B. Resident interviewResident #23 was interviewed on 8/18/25 at 9:36 am. Resident #23 said she had not received her showers as scheduled for several weeks because the facility did not have enough staff to complete the showers.C. Record reviewThe activities of daily living (ADL) care plan, revised 4/21/25, revealed Resident #23 had a self-care performance deficit related to her Parkinson's disease process. Interventions included providing a sponge bath when a full bath or shower could not be tolerated, avoiding scrubbing when bathing/showering, patting dry sensitive skin, checking nail length, trimming and cleaning on bath day and as necessary.Resident #23's shower records for the previous eight weeks were provided by the NHA consultant on 8/20/25 at 12:00 p.m. The shower record documented Resident #23 received 10 showers out of 24 scheduled opportunities between 6/25/25 and 8/20/25.D. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 8/20/25 at 9:40 a.m. CNA #6 said Resident #23 was scheduled for her showers three times per week. CNA #6 said there were times residents had to wait until the next day to shower as there was not enough time for staff to complete the showers. CNA #6 said sometimes showers did not get documented, especially on night shift.CNA #4 was interviewed on 8/20/25 at 9:55 a.m. CNA #4 said Resident #23 did not typically refuse her showers. CNA #4 said that most residents were not getting all of their showers as the facility did not typically have enough CNAs to get the showers completed. The director of nursing (DON) was interviewed on 8/20/25 at 3:05 p.m. The DON said Resident #23 should have received her showers as scheduled, however, she did not. The DON said it was important for residents to have showers as scheduled for both hygiene and the residents' well-being.III. Resident #65A. Resident statusResident #65, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, chronic obstructive pulmonary disease (COPD - a lung disease), anxiety and kidney disease. The 6/29/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required set up assistance with eating and moderate assistance with showering, personal hygiene and dressing.B. Resident interview and observationResident #65 was interviewed on 8/17/25 at 3:07 p.m. Resident #65's hair was disheveled. Resident #65 said he was supposed to shower every few days, but it had been about a week since he had showered. Resident #65 said on 8/17/25, he washed himself up as well as he was able to by using the sink in his room.C. Record reviewThe ADL care plan, revised 3/10/25, revealed Resident #65 had a self-care deficit related to dementia. Interventions included providing one person assistance with bathing, allowing sufficient time for dressing and undressing and encouraging the resident to participate to the fullest extent possible.Resident #65's shower records for the previous eight weeks were provided by the NHA consultant on 8/20/25 at 12:00 p.m. The shower record documented Resident #65 received 11 showers out of 24 scheduled opportunities between 6/25/25 and 8/20/25.D. Staff interviewsCNA #6 was interviewed on 8/20/25 at 9:40 a.m. CNA #6 said Resident #65 was scheduled for his showers three times per week. CNA #4 was interviewed on 8/20/25 at 9:55 a.m. CNA #4 said Resident #65 typically did not refuse her showers. CNA #4 said Resident #65 often appeared to have greasy, dirty hair when she arrived at work and it was clear to her that he had not received all of his showers.The DON was interviewed on 8/20/25 at 3:05 p.m. The DON said Resident #65 should have received his showers as scheduled, however, it was clear he had missed showers over the past two months. IV. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included schizophrenia (mental illness), severe obesity, emphysema (lung disease) and Parkinson's disease. The 6/19/25 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS score of nine out of 15. He required supervision with eating and bathing and moderate assistance with personal hygiene and dressing.B. Resident representative interviewResident #8's representative was interviewed on 8/18/25 at 11:29 a.m. The representative said she visited Resident #8 last month and he was not groomed. The representative said his hair was long, disheveled and greasy. The representative said Resident #8 had body odor and the room smelled.C. Record reviewThe ADL care plan, revised 6/3/25, revealed Resident #8 had a self-care deficit. Interventions included extensive assistance of one staff for bathing/showering and to encourage Resident #8 to participate to the fullest extent possible.Resident #8's shower records for the previous eight weeks were provided by the NHA consultant on 8/20/25 at 12:00 p.m. The shower record documented Resident #8 received 11 showers out of 16 scheduled opportunities between 6/25/25 and 8/20/25.D. Staff interviewsCNA #6 was interviewed on 8/20/25 at 9:40 a.m. CNA #6 said Resident #8 was scheduled for his showers two times per week. CNA #4 was interviewed on 8/20/25 at 9:55 a.m. CNA #4 said Resident #8 typically did not refuse his showers. CNA #4 said Resident #8 often appeared to have greasy, dirty hair when she arrived at work and it was clear to her that he had not received all of his showers.The DON was interviewed on 8/20/25 at 3:05 p.m. The DON said Resident #8 should have received his showers as scheduled, however, it was clear he had missed showers over the past two months. V. Resident #43A. Resident statusResident #43, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included spondylosis with radiculopathy (compression in the spinal column causing pain, tingling, numbness in arms and legs), muscle wasting and bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs).The 8/25/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with eating and required moderate assistance with showering, personal hygiene and dressing.B. Resident observation and interviewResident #43 was interviewed on 8/18/25 at 11:35 a.m. Resident #43 appeared to be unshaven with at least one half inch of hair growth on his face. Resident #43 said he was not getting all of his showers. He said he was supposed to have showers on Fridays and Mondays, and he often did not get the Friday shower until Saturday and sometimes did not get the Monday shower at all. Resident #43 said he would like to have his facial hair shaved at least once a week, and it had been several weeks since the facial hair was shaved.C. Record reviewThe ADL care plan, revised 7/21/25, revealed Resident #43 had a self-care performance deficit related to limited mobility. Interventions included providing assistance of one staff for bathing and showering and transferring, and dependence on staff for personal hygiene and oral care. Resident #43's shower records for the previous five weeks since admission were provided by the NHA consultant on 8/20/25 at 12:00 p.m. The shower record documented Resident #43 received seven showers out of 10 scheduled opportunities between 7/12/25 and 8/20/25.D. Staff interviewsCNA #6 was interviewed on 8/20/25 at 9:40 a.m. CNA #6 said Resident #43 was scheduled for his showers two times per week. CNA #4 was interviewed on 8/20/25 at 9:55 a.m. CNA #4 said Resident #43 typically did not refuse any showers and it was likely staff had missed some showers.The DON was interviewed on 8/20/25 at 3:05 p.m. The DON said Resident #43 should have received his showers as scheduled, however, it was clear he had missed showers since his admission. The DON said she and the regional clinical resource (RCR) were evaluating residents' missed showers and were working on a plan to ensure residents were provided showers as scheduled.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#3 and #7) of five residents reviewed for antibiotic use out of 45 sample residents. Specifically, the facility failed to: -Develop and implement an effective facility-wide system to monitor the use of antibiotics; and, -Effectively track and monitor the use of antibiotics for Resident #3 and Resident #7.Findings include:I. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 8/26/25 fromhttps://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html, To track how and why antibiotics are prescribed, providers perform reviews on resident medical records for new antibiotics started to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.II. Facility policy and procedureThe Infection Surveillance policy and procedure, dated 4/25/25, was provided by the nursing home administrator (NHA) on 8/17/25 at 4:33 p.m. It read in pertinent part, The nurses participated in surveillance through assessment of residents and reporting changesin condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. Examples of notification triggers include, but are not limited to a resident developing signs and symptoms of infection, a resident being started on an antibiotic, a microbiology test being ordered, a resident being placed on isolation precautions, whether empirically or by physician order and a microbiology test result showing drug resistance. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: data to be collected, including how often and the type of data to be documented, including the infection site, pathogen (if available), the signs and symptoms, and resident location, including summary and analysis of the number of residents (and staff, if applicable) who developed infections. III. Failed to develop and implement an effective facility-wide system to monitor the use of antibioticsA. Record review The June 2025 through August 2025 infection preventionist's (IP) infection surveillance binder was reviewed and revealed the following: The facility IP's infection surveillance binder was labeled 2025 and had 12 dividers labeled for each month of the year. For June 2025, July 2025 and August 2025, there was a map of the facility. On the bottom of the page in the middle, the following was handwritten: skin, respiratory, urinary, GI (gastrointestinal tract) and other. The June 2025 antibiotic surveillance log revealed the following column headers: date, resident's name, room number, antibiotic order, diagnosis, ordering practitioner, documentation supporting necessity and ordered upon admission. -There were 13 residents identified on the surveillance log. Of the 13 residents identified, one resident did not have the ordering practitioner's name column or the documentation supporting the necessity column filled out. The July 2025 antibiotic surveillance log revealed the following column headers: resident's name, age, room number, unit, date of admission, date of infection, site of infection, symptoms present on admission, pathogen, community or health care associated and comments. -There were 11 residents identified on the surveillance log. Two of the 11 residents did not have the site of infection column filled out. Eight of the 11 residents did not have the pathogen column filled out. Two of the 11 residents did not have the community or health care-associated column filled out. The August 2025 antibiotic surveillance log revealed the following column headers: date, resident's name, room number, antibiotic order, diagnosis, ordering practitioner, documentation supporting necessity and ordered upon admission. There were 10 residents identified on the surveillance log. Nine of the 10 residents did not have the documentation supports the necessity column filled out. B. Staff interviews The IP was interviewed on 8/19/25 at 5:45 p.m. The IP said she was responsible for the facility's infection control and prevention program. She said she had worked as the IP for the past month. She said the process for monitoring and tracking resident infections included checking the physician's orders for the antibiotics. She said the physician's order should have an end date for the antibiotic and a diagnosis that the antibiotic was prescribed for. She said the diagnosis should be appropriate for the antibiotic use. She said there should be a culture and sensitivity completed to check for allergies and appropriateness. She said if a resident had symptoms of an infection, such as a urinary tract infection (UTI), she completed an assessment that included monitoring the resident's vital signs, contacting the physician and determining if cultures and labs were needed. The IP said she monitored residents for adverse reactions from the initial dose of an antibiotic until at least a couple of days after the last day of antibiotic use. She said not every nurse in the facility did it the same way, and there should be an alert in the resident's chart for the nurse to know to monitor for adverse reactions related to antibiotics. The IP said she had not used the antibiotic surveillance log since she started working at the facility. The director of nursing (DON) and regional clinical resource (RCR) #1 were interviewed together on 8/20/25 at 1:10 p.m. The DON said she had just completed her course in IP certification in July 2025. RCR #1 said she was working with the DON and the IP to have a consistent way to track infections and antibiotic use in the facility. RCR #1 said the IP was responsible for the facility's infection control and prevention program. RCR #1 said the IP had been in the IP position since August 2025. The DON said she used an audit tool from the electronic medical record (EMR) system that identified what antibiotics were ordered for residents in the past 24 hours. The DON said she used that to check to see if the nurses used McGeer's criteria (standardized tool used to identify potential infections and guide antibiotic stewardship efforts) or a change of condition evaluation form for the assessment. The DON said the nurse who contacted the physician for an antibiotic order was responsible for completing the assessment. RCR #1 said the IP or the DON checked to make sure an assessment was done by the nurse. RCR #1 said since she started in her role, she had identified that assessments were not completed for all residents who were placed on an antibiotic at the facility. RCR #1 said the IP was responsible for using the antibiotic surveillance log. The antibiotic surveillance logs for June 2025 through August 2025 were reviewed with the DON and RCR #1. The DON and RCR #1 said the surveillance logs were not used to track infections and antibiotic use correctly in the facility. RCR #1 said the facility needed to update the logs to reflect how they tracked infections and antibiotic use. The DON and RCR #1 said the map of the facility had not been used to map infections since they both had started working at the facility. IV. Failed to monitor the use of antibiotics for Resident #3 and Resident #7A. Resident #31. Resident statusResident #3, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included chronic kidney disease with heart failure, chronic respiratory failure, type 2 diabetes mellitus, idiopathic aseptic necrosis of the right hand (condition where the bone tissue in the right hand dies due to a lack of blood supply with no identifiable cause), dependence of renal dialysis, systemic lupus erythematosus, acquired absence of the right leg below the knee, depression and anxiety. According to the 7/15/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had an impairment in one upper extremity and used a wheelchair. She required set up assistance with eating, and she was dependent on staff assistance for toileting and showering. She required substantial assistance with oral hygiene and personal hygiene. The assessment revealed the resident was not on an antibiotic. -However, review of Resident #3's EMR revealed the resident received an antibiotic from 8/14/25 to 8/18/25 (see record review below). 2. Resident interview Resident #3 was interviewed on 8/19/25 at 9:26 a.m. Resident #3 said she had a bandage on her left hand because her fingers and finger tips were contracted and physical therapy taught her an exercise to prevent them from worsening. Resident #3 showed her right hand as she explained what happened and said the yellow circles on the palm of her right hand and the fingernails were bent from her kidney failure. She said her left hand looked the same until she did the exercises. She said she had a cut, and it was infected and was treated with antibiotics. She said she did not know what caused the infection. She said sometimes the bandages were not secure. 3. Record review Review of the skin integrity care plan, initiated 11/26/24 and revised 8/20/25 (during the survey), revealed Resident #3 had altered skin integrity related to limited mobility. She had multiple discolored white areas on her body related to long-term use of triamcinolone (a steroid medication to treat autoimmune and inflammatory diseases). She had an actual skin issue to her left middle finger as of 8/15/25 and discontinued oral antibiotics on 8/19/25. Interventions included following treatment orders as needed, notifying the physician if skin impairment did not respond to the current treatment regimen or the resident experienced an adverse reaction. Review of Resident #3's August 2025 CPO revealed the following physician's order: Amoxicillin-potassium clavulanate (antibiotic) 250-125 milligrams (mg). Take one tablet by mouth two times a day for right-hand wound infection for five days, ordered 8/13/25. -Review of the IP infection surveillance documents from 8/1/25 to 8/19/25 revealed the facility did not identify Resident #3's right-hand wound infection on the infection tracking log. -Review of Resident #3's EMR revealed that the facility was not consistently monitoring for adverse reactions related to the use of an antibiotic. B. Resident #71. Resident statusResident #7, age [AGE], was admitted on [DATE] and readmitted on [DATE], after a four-day hospitalization for acute cholecystitis (inflammation of the gallbladder). According to the August 2025 CPO, diagnoses included type 2 diabetes mellitus, chronic kidney disease, acquired absence of the right leg below the knee, benign prostatic hyperplasia with lower urinary tract symptoms, chronic gastritis and melena.According to the 7/9/25 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He had impairment on one lower extremity. He required a wheelchair. He required set up assistance with eating and oral hygiene. He required maximal assistance with toileting and personal hygiene. He was dependent with showeringThe assessment revealed he was taking an antibiotic and an indication for the antibiotic was noted.2. Record reviewReview of Resident #7's catheter care plan, initiated 12/16/2020 and revised 4/24/25, revealed the resident had a suprapubic catheter related to obstructive and reflex uropathy (a condition where urine flows backward from the bladder up into the ureters and the kidneys). Interventions included checking catheter tubing for kinks when it appeared not to be draining properly, enhanced barrier precautions, observing and documenting for pain and discomfort due to the catheter, observing, recording, and reporting to the doctor for signs and symptoms of UTI.Review of Resident #7's June 2025 CPO revealed the following physician's order: Vancomycin hydrochloride (HCl) (antibiotic) 125 mg. Take one capsule by mouth two times a day for cholecystitis for 21 days, ordered 6/14/25. -Review of the IP infection surveillance documents from 6/1/25 to 8/19/25 revealed the facility did not identify Resident #7's antibiotic use for his cholecystitis on their infection tracking log. -Review of Resident #7's EMR revealed that the facility was not consistently monitoring for adverse reactions related to the use of an antibiotic. -Review of Resident #7's EMR revealed the facility did not care plan the resident's use for an antibiotic from June 2025 to July 2025. C. Staff interviews The IP was interviewed on 8/19/25 at 5:45 p.m. The IP said the facility's process for monitoring and tracking infections and antibiotic use included making sure the McGeer's criteria were met when a new antibiotic was started or a resident was admitted to the facility on an antibiotic. The IP said she discussed antibiotic usage with the medical director when an antibiotic was first ordered, when labs were needed and as needed. The IP said the medical director reviewed antibiotic use as needed if the resident was not improving, to monitor for efficacy and if sensitivity was obtained. The IP said if a resident was started on an antibiotic or if a resident had an infection, it was considered a change in condition and there should be a change in condition assessment completed. The IP said residents should be monitored for adverse reactions and there should be a care plan in place for antibiotic use. The IP said she was familiar with Resident #3 and Resident #7. She said she was not working at the facility when Resident #7 was placed on an antibiotic and she did not know if he was monitored for adverse reactions or if there was a care plan related to the use of the antibiotic. The DON and regional clinical resource (RCR) #1 were interviewed on 8/20/25 at 1:10 p.m. The DON said residents should be monitored for adverse reactions related to antibiotic use once a resident started on an antibiotic until the resident stopped taking the antibiotic. RCR #1 said the facility was not consistent on how to monitor for residents' adverse reactions, and she planned to educate nurses on what to know to monitor for adverse reactions by using an alert charting function in the facility's EMR system. The DON and RCR #1 said the antibiotic use and the type of infection should be documented in the resident's care plan. The DON and RCR #1 said they were familiar with Resident #3 and Resident #7. The DON said Resident #3 and Resident #7 did not have consistent monitoring for adverse reactions related to their antibiotic use. RCR #1 said she reviewed the care plans for Resident #3 and Resident #7 and said they demonstrated the antibiotic use and that the infection was identified. -However, after review of the care plan documents, there was no care plan for Resident #3 and Resident #7's antibiotic use.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the state oversight agency in accordance with state laws for one of three allegations. Specifically, the facility failed to timely report an allegation of resident-to-resident verbal abuse of Resident #5 by Resident #32 to the State Agency.Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, dated 4/11/25, was provided by the nursing home administrator (NHA) on 8/17/25 at 4:33 p.m. It read in pertinent part, Abuse is defined as the willful infliction of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.Alleged violation is a situation or occurrence that is observed or reported by staff, residents, relatives, visitors, or others but has not yet been investigated and, if verified, could be an indication of noncompliance with the federal requirements related to abuse. Possible indicators of abuse include but are not limited to verbal abuse of a resident overheard.The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations.An immediate investigation is warranted when suspicion, or reports, of abuse occur. Reporting of all alleged violations to the administrator, State Agency, adult protective services and to all other required agencies within the specified timeframes. If the event that caused the allegation involves abuse or resulted in serious bodily injury or no later, report within two hours. If the event that caused the allegation does not involve abuse or result in serious bodily injury, report within 24 hours.II. Allegation of verbal abuse of Resident #5 by Resident #32 A. Resident #5 - alleged victim 1. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia, chronic obstructive pulmonary disease and chronic kidney disease. According to the 7/2/25 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She required a wheelchair and set up assistance with eating. She required supervision with eating and moderate assistance with toileting and personal hygiene. She required maximal assistance with showering. The assessment revealed she did not exhibit any physical or verbal behaviors during the look-back period. C. Resident #32 - alleged assailant1. Resident status Resident #32, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, spondylosis (age-related wear and tear of the spinal disks), depression, obsessive-compulsive disorder and anxiety disorder. According to the 8/11/25 MDS assessment, the resident was cognitively impaired with a BIMS score of 11 out of 15. She required a walker and was independent with eating and toileting. She required set-up assistance with oral and personal hygiene and supervision with showering, The assessment revealed she did not exhibit any physical or verbal behaviors during the look-back period. 2. Resident record review The 7/27/25 nurse progress note revealed the nurse was notified by a certified nurse aide (CNA) the resident was verbally aggressive towards her roommate, Resident #5. The CNA reported they heard Resident #32 yelled at her roommate, and so the CNA asked the resident to be kind to her. Resident #32 yelled to Resident #5, Well, my husband is going to come in here and kill you. Resident #32 was asked if she wanted to go to the dining room for coffee. Resident #32 was educated on being polite to others and that threats could not be made. Resident #32 was in the dining room, drinking coffee with purposeful rounds. -On 8/19/25 at 10:41 a.m., the facility was unable to provide documentation that the incident of alleged verbal abuse was reported to the State Agency. III. Staff interviews The NHA and regional clinical resource (RCR) #1 were interviewed together on 8/19/25 at 10:41 a.m. The NHA said he was not familiar with the 7/27/25 nurse progress note for Resident #32. He said he would look into it. RCR #1 said there might be a soft file on the incident. The NHA was interviewed a second time on 8/19/25 at 2:22 p.m. The NHA said he reported the alleged event (during the survey) because, based on what was documented in Resident #32's medical record, it was a reportable event. The NHA said the nurse who wrote the progress note in Resident #32's medical record was not working and he was trying to reach her to gather additional information, including the name of the CNA who witnessed the event. He said while he was investigating the alleged abuse, Resident #32 would be placed on one-on-one staff supervision. He said all staff received education (during the survey) on what abuse was and to contact him, the abuse coordinator, if there was suspected abuse. He said a facility-wide interview had been initiated with all residents to ensure all residents felt safe and were not fearful.The NHA said he was the abuse coordinator. He said the staff had two hours to report possible abuse to him as the abuse coordinator. He said the first thing the staff should do when reporting abuse was to make sure the residents were safe. He said the facility then started the investigation that included interviewing the alleged assailant and victim to determine if there was abuse. The NHA was interviewed a third time on 8/20/25 at 4:34 p.m. The NHA said he did not talk to the nurse who documented the 7/27/25 progress note in Resident #32's medical record. He said the nurse used to work more often but now she worked as needed. The NHA said the nurse would not be allowed to work until she was interviewed about the alleged abuse incident involving Resident #32 and Resident #5. The NHA said he was not able to identify the CNA mentioned in the progress report who reported the alleged abuse to the nurse. He said the facility did an audit of progress notes (during the survey) to see if there were any other residents who could have been affected. The NHA said the other staff who worked on 7/27/25 would be interviewed to ensure a complete and thorough investigation was conducted. He said as of 8/20/25, the investigation into the abuse allegation involving Resident #32 and Resident #5 was ongoing and he had not been able to substantiate or unsubstantiate the alleged abuse. CNA #3 was interviewed on 8/20/25 at 5:49 p.m. CNA #3 said she reported abuse to the NHA because he was the abuse coordinator. She said if she heard a resident have a verbal altercation with another resident, she would try to intervene to keep the residents safe and then she would report the incident to the NHA.

Based on observations, record review and interviews, the facility failed to ensure two (#8 and #39) of two residents reviewed for ancillary services out of 45 sample residents received routine dental care and 24-hour emergency dental care.Specifically, the facility failed to:-Ensure Resident #8 was provided timely dental services to repair his of dentures; and, and-Ensure Resident #39 was provided a routine dental appointment. Findings include: I. Facility policy and procedure The Dental Services policy, revised April 2025, was provided by the chief nursing officer on 8/20/25 at 2:48 p.m. It read in pertinent part, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor, partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, taking impressions for dentures and fitting dentures. For residents with lost or damaged dentures, the facility will refer the resident for dental services within three days. II. Resident #8 A. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included schizophrenia (mental illness), severe obesity, emphysema (lung disease) and Parkinson's disease. The 6/19/25 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He required supervision with eating and bathing and moderate assistance with personal hygiene and dressing. The MDS assessment revealed the resident had no issues with his dentures, including no pain, discomfort or difficulty chewing and no broken or loosely fitting dentures. -However, Resident #8's representative and staff interviews revealed Resident #8 had ill fitting dentures for several months (see interviews below). B. Resident #8's representative interview and observation Resident #8's representative was interviewed on 8/18/25 at 11:39 a.m. The representative said Resident #8 had not been able to wear his dentures for a long time as they did not fit right and they needed to be adjusted. On 8/20/25 at 10:15 a.m. Resident #8 was dressed, groomed and sitting in bed. Resident #8's dentures were in a plastic container located on the sink in his bathroom. C. Record review The dental care plan, revised 6/23/25, revealed Resident #8 had dentures that he often refused to wear. The interventions included dental services to be provided as needed, help Resident #8 brush his dentures, monitoring for pain or discomfort related to dentures and notifying the nurse of any concerns. -A review of Resident #8's care plan did not reveal the dentures were not fitting correctly. Resident #8's last dental consultation was dated 2/13/23 and recommended a follow up visit in one year, or sooner if denture adjustments were needed. -Resident #8 had not been seen for a dental consultation in two and a half years. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 8/20/25 at 9:55 a.m. CNA #4 said Resident #8 had not worn his dentures in months because they did not fit him correctly. CNA #4 said Resident #8 needed a dental appointment to fix the dentures. CNA #4 said the nurses and the scheduler were aware that Resident #8 needed a dental appointment, but the appointment had not been scheduled. The social services director (SSD) was interviewed on 8/20/25 at 10:56 a.m. The SSD said Resident #8's last dental exam was in February 2023. The SSD said she was not aware that Resident #8 did not wear his dentures. She said the facility recently identified many denture wearing residents who were having issues with the fit of their dentures. The SSD said if a resident was having issues with their dentures, she would expect a referral to be initiated within a few days, and the consultation to occur within one month. The SSD said the facility had begun to arrange monthly dental visits onsite. The director of nursing (DON) was interviewed on 8/20/25 at 3:40 p.m. The DON said she had not seen Resident #8 wear his dentures for several months. The DON said she was not certain why Resident #8 did not wear his dentures. The DON said when residents had issues with teeth or dentures, she expected the CNAs to notify the nurse, and the nurse would notify the DON and the SSD to make an appointment. The DON said ancillary services, such as dental appointments, were an area that had been identified in June 2025 by the DON and regional clinical resource (RCR) #1 as needing improvement and the facility was creating a performance improvement plan to address ancillary services issues. The DON said she would confirm the SSD had made a dental appointment for Resident #8. The DON said it was important for residents to have functioning dentures to enable them to eat and promote resident dignity. III. Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included insufficient sleep syndrome (sleep disorder where a person does not get enough sleep), heart failure and type 2 diabetes mellitus without complications. The 7/26/25 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. She required set-up or clean-up assistance with bathing and eating. The MDS assessment documented the resident had obvious or likely had cavities or broken natural teeth. B. Resident interview Resident #39 was interviewed on 8/18/25 at 10:14 a.m. The resident said she had not been able to see a dentist since she was admitted to the facility on [DATE]. She said she had told the nursing staff and had also told the nurse practitioner (NP) six months ago that she wanted to see the dentist, but no one followed up. She said she was sick of no one getting back with her because she wanted to be able to eat salad but could not chew it. She said she received chicken noodle soup instead and could not eat sausage patties because they were too hard. During the interview Resident #39 had teeth that were broken and missing. Resident #39 was interviewed again on 8/19/25 at 3:45 p.m. The resident said it was painful when she ate and her gums swelled up and hurt. C. Record review The care plan initiated 8/7/24, documented Resident #39 had some missing and broken teeth. The goal was for the resident to maintain the ability to eat meals without dental pain or difficulty chewing. Interventions included referring the resident for dental services as needed, assessing for pain or discomfort related to dental issues and monitoring for changes in chewing or eating ability. The August 2025 CPO revealed the following physician's order: Resident may have a podiatrist, ophthalmologist, dentist and an audiologist as needed. ordered 1/22/25. -However, the CPO did not include a specific dental referral, dental consult, or a scheduled dental appointment. The social service progress note, dated 8/19/25 (during the survey), revealed Resident #39 had originally been referred to see a dentist in July 2025. The note documented that the dentist canceled the appointment due to a medical emergency and the appointment was rescheduled for 9/5/25. The SSD met with the resident and asked about discomfort and whether she felt she needed to be seen sooner. The resident denied pain, stating it only hurt when she chewed certain foods. The resident declined an emergency dental appointment but agreed to an urgent referral. The SSD contacted the ancillary coordinator, who sent an urgent referral form for completion. A review of the dental emergency evaluation form, dated 8/19/25, revealed the resident reported pain in the lower right area of her mouth. The form documented swelling was present, the resident reported a pain level of five and a half and the pain had been present for a few months. D. Staff interviews The SSD was interviewed on 8/19/25 at 2:50 p.m. The SSD said residents and their representatives should be offered ancillary services upon admission and every quarter during the care plan conference. She said it should be documented in the progress notes when ancillary services were offered, scheduled, rescheduled or cancelled. She said she was unable to find documentation indicating Resident #39 had been offered dental services since the resident's admission on [DATE]. She said the Resident #39 had an appointment scheduled in August 2025 that was canceled due to the dentist's emergency, but she could not find documentation of that either. She said the process was that staff informed her of residents' dental needs and she recommended those services, either the in-house dentist who came monthly or referral to a community dentist based on the resident's preference. RCR #1 was interviewed on 8/19/25 at 3:05 p.m. She said the in-house dentist had been scheduled to come on 8/15/25 but could not due to a medical emergency and the appointment was rescheduled for 9/5/25. She said she talked with Resident #39 and Resident #39 did not want to go to the emergency room (ER) or be seen by an emergency dentist. She said the facility was in the process of completing a full-house audit of ancillary services, had identified several residents who needed ancillary services or had not seen a dentist and had written a plan of correction. RCR #1 said if paperwork and recommendations are not followed, it affects continuity of care and quality of care. She said she would initiate re-education of the staff. The DON was interviewed on 8/20/25 at 3:50 p.m. The DON said the plan to ensure residents received necessary dental care was to schedule an appointment, with the option of using the in-house dentist or an outside dentist. The DON said this was to help Resident #39 with chewing, addressed cavities, repaired broken teeth and prevented infection or other related dental issues.

Based on observations, record review and interviews, the facility failed to ensure one (#20) of two residents reviewed for insulin administration out of 45 sample residents was kept free from significant medication errors.Specifically the facility failed to ensure insulin pens were primed prior to two insulin medication administrations for Resident #20.Findings include:I. Professional referenceAccording to the manufacturer Novo Nordisk , NovoLog (insulin aspart), February 2023, Instructions for Use, retrieved 8/25/25 from https://www.novo-pi.com/novolog.pdf, Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing:Turn the dose selector to select two units, hold your NovoLog Flex Pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upward, press the push-button all the way in. The dose selector returns to zero. A drop of insulin should appear at the tip.According to the manufacturer Sanofi-Aventis, Lantus Solostar (insulin glargine), May, 2025, Instructions for Use, retrieved on 8/25/25 from https://products.sanofi.us/Lantus/Lantus.pdf, Always do a safety test before each injection to check your pen and the needle to make sure they are working properly and make sure that you get the correct Lantus dose. Select two units by turning the dose selector until the dose pointer is at the two mark. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly.II. Facility policy and procedureThe Medication Administration policy, revised August 2025, was provided by the nursing home administrator (NHA) on 8/19/25 at 1:02 p.m. It read in pertinent part, Administer medication as ordered in accordance with manufacturer specifications.III. Resident #20 A. Resident statusResident #20, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included diabetes and chronic kidney disease.The 5/23/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required set up assistance with eating and dressing, and supervision with toileting and showering. B. Record reviewReview of Resident #20's August 2025 CPO revealed the following physician's orders:NovoLog Injection solution (Insulin Aspart), 100 units per milliliter (ml), inject 24 units subcutaneously with meals for diabetes mellitus type two, ordered 5/13/25.Insulin Glargine subcutaneous solution 100 units per ml, inject 47 units subcutaneously two times per day for diabetes mellitus, ordered 5/6/25.C. ObservationsOn 8/19/25 at 4:55 p.m. registered nurse (RN) #3 was observed preparing two insulin medications for Resident #20, insulin aspart and insulin glargine. RN #3 obtained the resident's insulin pens from the medication cart, cleaned the tip of the insulin aspart pen with an alcohol pad, applied a new needle and then dialed the insulin pen to 24 units. She then cleaned the tip of the insulin glargine pen with an alcohol pad, applied a new needle and dialed the insulin pen to 47 units. RN #3 entered Resident #20's room, advised the resident of the insulin medications, cleaned the resident's abdomen on the left side with an alcohol swab, removed the safety cap and administered the injected medications consecutively. -RN #3 failed to perform a safety test by priming the resident's insulin pens per manufacturer's directions (see professional reference above) prior to administering the medication.Cross-reference F759 failure to ensure the medication error rate was less than five percent. IV. Staff interviewsRN #3 was interviewed on 8/19/25 at 5:10 p.m. RN #3 said she thought she primed the insulin pens prior to attaching the needle tip onto the pens. RN #3 was not able to verbalize the importance of priming the insulin pens.The director of nursing (DON) was interviewed on 8/20/25 at 12:40 p.m. The DON said RN #3 should have primed the insulin pens to make sure there was no air in the pens and to ensure the right dose would be administered to Resident #20. The DON said if insulin pens were not primed, the resident could receive less insulin than what was ordered. The DON said RN #1 should have asked Resident #38 to rinse his mouth with water after he used the inhaler.

Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 11.53 percent, which was three errors out of 26 opportunities for error.Findings include:I. Professional referencesAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment . Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration . To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights : 1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.According to the manufacturer Novo Nordisk , NovoLog (insulin aspart), February 2023, Instructions for Use, retrieved 8/25/25 from https://www.novo-pi.com/novolog.pdf, Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing:Turn the dose selector to select two units, hold your NovoLog Flex Pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upward, press the push-button all the way in. The dose selector returns to zero. A drop of insulin should appear at the tip.According to the manufacturer Sanofi-Aventis, Lantus Solostar (insulin glargine), May, 2025, Instructions for Use, retrieved on 8/25/25 from https://products.sanofi.us/Lantus/Lantus.pdf, Always do a safety test before each injection to check your pen and the needle to make sure they are working properly and make sure that you get the correct Lantus dose. Select two units by turning the dose selector until the dose pointer is at the two mark. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly.II. Facility policy and procedureThe Medication Administration policy, revised August 2025, was provided by the nursing home administrator (NHA) on 8/19/25 at 1:02 p.m. It read in pertinent part, Administer medication as ordered in accordance with manufacturer specifications. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action.III. Observations and record review On 8/19/25 at 11:01 a.m., registered nurse (RN) #1 was observed preparing to administer an inhaler medication to Resident #38.The physician's orders for Resident #38 read, Fluticasone proprionate/salmeterol inhaler 250 micrograms (mcg)/50 mcg, one puff twice a day, rinse mouth with water after use.RN #1 brought the inhaler to Resident #38 to administer the medication. Resident #38 took one puff from the inhaler. RN #1 then walked away from the resident.-RN #1 failed to have Resident #38 rinse out his mouth after taking a puff from the inhaler.On 8/19/25 at 4:55 p.m. registered nurse (RN) #3 was observed preparing two insulin medications for Resident #20, insulin aspart and insulin glargine. The physician's orders for Resident #20 read, NovoLog Injection solution (Insulin Aspart), 100 units per milliliter (ml), inject 24 units subcutaneously with meals for diabetes mellitus type two. Insulin Glargine subcutaneous solution 100 units per ml, inject 47 units subcutaneously two times per day for diabetes mellitus.RN #3 obtained Resident #20's insulin pens from the medication cart, cleaned the tip of the insulin aspart pen with an alcohol pad, applied a new needle and then dialed the insulin pen to 24 units. She then cleaned the tip of the insulin glargine pen with an alcohol pad, applied a new needle and dialed the insulin pen to 47 units. RN #3 entered Resident #20's room, advised the resident of the insulin medications, cleaned the resident's abdomen on the left side with an alcohol swab, removed the safety cap and administered the injected medications consecutively. -RN #3 failed to perform a safety test by priming the resident's insulin pens per manufacturer's directions (see professional reference above) prior to administering the medication.Cross- reference F760 failure to ensure residents were free from a significant medication error.IV. Staff interviewsRN #3 was interviewed on 8/19/25 at 5:10 p.m. RN #3 said she thought she primed the insulin pens for Resident #20 prior to attaching the needle tips onto the pens. RN #3 was not able to verbalize the reason it was important to attach the needle to the pen prior to priming the insulin pen.RN #1 was interviewed on 8/19/25 at 5:30 p.m. RN #1 said she should have asked Resident #38 to rinse his mouth with water after he used the inhaler as the medication tasted bad. The director of nursing (DON) was interviewed on 8/20/25 at 12:40 p.m. The DON said RN #3 should have primed the insulin pens to make sure there was no air in the pens and to ensure the right dose of insulin would be administered to Resident #20. The DON verbalized the process of priming the insulin pen. The DON said if insulin pens were not primed the resident could receive less insulin than what was ordered. The DON said RN #1 should have asked Resident #38 to rinse his mouth with water after he used the inhaler.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA).Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #1, CNA #2 and CNA #3.Findings include:I. Record reviewAnnual performance reviews for CNAs were requested on 8/18/25 at 4:56 p.m. for CNA #1, CNA #2 and CNA #3. The facility was unable to provide annual performance evaluations for CNA #1 (hired 10/25/16), CNA #2 (hired 4/8/22) and CNA #3 (hired 6/26/23). -The CNAs did not have an annual performance review completed and the CNAs did not have an in-service education plan based on the outcome of the review.II. Staff interviewsThe director of nursing (DON) and regional clinical resource (RCR) #1 were interviewed together on 8/19/25 at 2:36 p.m. The DON said the annual performance evaluations should be completed annually. The DON said it was important because if a CNA needed retraining, then she could provide training and also refresh their memory on skills. The DON said a competency assessment during the review was important to ensure the facility was providing the best care to the residents.RCR #1 said the human resources department was looking for the annual performance reviews because the reviews were not kept in her office but she would continue to look.On 8/19/25 at 3:53 p.m. the RCR said the human resources department could not find the annual performance evaluations for CNA #1, CNA #2 and CNA #3.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards for one (#3) of two residents reviewed for dialysis out of 45 sample residents. Specifically, for Resident #3, the facility failed to: -Consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center; and, -Collaborate with the dialysis facility regarding dialysis care and services, specifically acknowledging a recommendation for a gastroenterology referral and medication changes made on the dialysis communication forms. Findings include:I. Facility policy and procedure The Hemodialysis policy and procedure, revised 4/11/25, was provided by the chief nursing officer on 8/20/25 at 3:07 p.m. It read it pertinent part, The facility will coordinate and collaborate with the dialysis facility to assure that there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. The facility will immediately contact and communicate with the attending physician, resident/representative any significant changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications.II. Resident #3A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included chronic kidney disease with heart failure, chronic respiratory failure, type 2 diabetes mellitus, idiopathic aseptic necrosis of the right hand (condition where the bone tissue in the right hand dies due to a lack of blood supply with no identifiable cause), dependence of renal dialysis, systemic lupus erythematosus, acquired absence of the right leg below the knee, depression and anxiety. According to the 7/15/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had an impairment in one upper extremity and used a wheelchair. She required set up assistance with eating, and she was dependent on staff assistance for toileting and showering. She required substantial assistance with oral hygiene and personal hygiene. The MDS assessment indicated the resident received dialysis treatments.B. Resident interview Resident #3 was interviewed on 8/19/25 at 9:26 a.m. Resident #3 said she had abdominal cramping when she went to dialysis. She said the abdominal cramping was so bad that she asked the dialysis center to stop her dialysis early. She said she had had abdominal cramping for about nine months. She said she often asked the dialysis facility to cut her dialysis treatment sessions short because of the abdominal pain. She said she knew she needed dialysis to live, but sometimes she felt it was better not to have dialysis, so she did not have abdominal pain. She said she was supposed to see a gastroenterologist. She said she did not remember when the specialist was recommended, but it had been a while. She said the facility was working on it, and she did not know why it was taking so long to get an appointment with the gastroenterologist. C. Record review Review of Resident #3's dialysis care plan, initiated 1/24/25, revealed the resident received dialysis related to renal failure. Interventions included going to dialysis three times a week, monitoring for any signs and symptoms of infection to the dialysis access site, and working with the resident to relieve discomfort from the side effects of the disease and treatment. -However, the care plan did not include monitoring the resident's vital signs and weights pre- and post-dialysis treatment. Review of Resident #3's August 2025 CPO revealed the following physician's orders related to dialysis: Dialysis - access site central site. Central venous catheter to the right chest, ordered 1/22/25.Resident to have dialysis Monday, Wednesday and Friday and as needed, ordered 1/22/25. Check the graft site (dialysis access site), ordered 1/22/25. Resident #3's dialysis communication forms were reviewed from 7/2/25 to 8/13/25. Each log had three sections on one sheet of paper, which revealed the following: The first section of the communication form was to be filled in by the facility before dialysis with the resident's name, the dialysis date, vital signs, which included temperature, pulse, respirations, blood pressure and oxygen saturation levels and dialysis access site assessment. There was also a section to describe any other concerns. A facility nurse's signature and time the resident left the facility were required.The second section of the communication form was to be filled out by the dialysis center staff. The documentation included the resident's vital signs, the time dialysis started and ended, the resident's weight pre- and post-dialysis, labs drawn, medications given and any other concerns. A dialysis staff person's signature and title were required. The third section of the communication form was to be filled in by the facility after dialysis with the resident's vital signs, dialysis access site assessment, including if the dressing was in place, if there was abnormal bleeding and any other concerns. A facility nurse's signature and the time the resident returned to the facility were required. Review of Resident #52's dialysis communication forms from 7/2/25 to 8/13/25 documented the following: The pre-dialysis section for the dialysis access site assessment and the nurse's signature was left blank on the following dates: 7/4/25, 7/16/25, 7/18/25, 7/23/25 and 7/25/25.The 7/16/25 dialysis section of the form revealed to discontinue Resident #3's milk of magnesia physician's order due to its contraindication in hemodialysis patients and give Miralax or lactulose. It documented milk of magnesia could cause hypermagnesemia, which hemodialysis patients could not clear from their system correctly. The dialysis section of the 7/16/25 communication form further revealed the resident's dialysis treatment ended early due to cramping.The dialysis section of the forms revealed Resident #3 experienced abdominal pain and cramping on the following dates: 7/18/25, 7/25/25, 8/1/25, 8/4/25, 8/6/25, 8/8/25 and 8/13/25. The dialysis section of the forms revealed the resident ended dialysis treatment early on the following dates: 8/1/25, 8/4/25, 8/6/25 and 8/8/25. The 8/4/25 dialysis section of the form revealed Resident #3 ended dialysis treatment 65 minutes early due to abdominal cramping. The resident reported cramping all the time and not just with dialysis. The form instructed that the resident needed a gastroenterology consultation. The post-dialysis section of Resident #3's dialysis communication form was left blank in its entirety on 7/2/25, 7/25/25, 7/28/25, 8/1/25, 8/6/25 and 8/13/25.Review of Resident #3's August 2025 CPO revealed the following physician's order: Milk of magnesia. Take 30 milliliters (ml) by mouth every 24 hours as needed for constipation. Use on day three of no bowel movement, ordered 7/4/25. -A review of Resident #3's electronic medical record (EMR) revealed the facility failed to follow the dialysis center's recommendation to discontinue the resident's milk of magnesia due to its contraindicated use in hemodialysis patients.-A review of Resident #3's EMR failed to identify documentation to indicate the facility was following up on the dialysis center's recommendation to schedule the resident for a gastroenterology consultation due to her persistent abdominal cramping. III. Staff interviews Registered nurse (RN) #1 was interviewed on 8/20/25 at 10:31 a.m. RN #1 said when a resident went to dialysis, they were sent with a folder that included a communication form. She said the communication form had three sections and she said she filled out the top section before the resident went to dialysis. She said she was responsible for obtaining the resident's pre-dialysis vital signs and making sure the dialysis access site was intact. She said she documented the information on the dialysis communication form. RN #1 said the communication form went with the resident to dialysis. She said the dialysis center was responsible for completing the middle section of the communication form. RN #1 said when the resident returned from dialysis, she was responsible for obtaining the resident's vital signs and making sure the dialysis access site was intact. She said she documented the information on the third section of the communication form. She said if the resident came back with new physician's orders or recommendations, she verified the orders with the facility's physician and then entered the orders into the resident's EMR. She said once the dialysis communication form was completed, the form was placed in a file at the nurses' station for the medical records person to pick up so they could scan the form into the resident's EMR. RN #1 said she was familiar with Resident #3. She said Resident #3 went to dialysis. She said Resident #3 ended dialysis early because of abdominal cramping. RN #1 said the abdominal cramping usually resolved on its own or she gave the resident Zofran (an anti-nausea medication). RN #1 said she heard the resident once say if the abdominal pain was going to continue, she did not want to have dialysis. RN #1 said she overheard it in the hallway when she was assigned to another hallway and she did not follow up on the resident's comment. RN #1 said she did not know there was a recommendation from the dialysis facility for a gastroenterology consultation for Resident #3. The director of nursing (DON) was interviewed on 8/20/25 at 4:04 p.m. The DON said when a resident went to dialysis, the resident was sent with a folder that included a dialysis communication form. She said the communication form had three sections and the facility's unit nurse filled out the top section before the resident went to dialysis. The DON said the facility nurse was responsible for obtaining the resident's pre-dialysis vital signs and making sure the dialysis access site was intact. The DON said the unit nurse documented the information on the dialysis communication form. She said the dialysis communication form went with the resident to dialysis. She said the dialysis center was responsible for completing the middle section. The DON said when the resident returned from dialysis, the unit nurse was responsible for obtaining the resident's vital signs and making sure the dialysis access site was intact. The DON said the unit nurse asked how the resident was doing after dialysis and if they needed any medications. The DON said the unit nurse was responsible for reading the dialysis section of the communication form to see if there were any changes to any physician's order, including medications and blood work. She said the dialysis communication form was scanned and uploaded to the resident's EMR by the medical records department. She said if a resident came back from dialysis with new physician's orders or recommendations, the facility nurse verified the orders with the facility's physician and then entered the orders into the resident's EMR. She said once the dialysis communication form was completed, the form was placed in a file at the nurses' station for medical records to pick up so they could scan the form into the resident's EMR. The DON said she was familiar with Resident #3. She said she went to dialysis and she knew she sometimes ended dialysis early because she was nauseous and was vomiting. She said she gave Resident #3 Zofran, offered for the resident to lie down and put a bag next to her bed in case she vomited. The DON said she was aware the resident complained about abdominal pain from dialysis. The DON said the physician was notified of the abdominal pain and orders were given. The DON said she was not aware the dialysis center documented the need to obtain a gastroenterology consultation for Resident #3. She said if there was a gastroenterology consultation recommendation, the nurse who reviewed the dialysis communication form should have entered a physician's order in the resident's EMR for the consultation. She said the physician's order was how the scheduler knew what appointments needed to be made for residents. She said the scheduler made appointments within the same day the physician's order was entered, if not the following day. She said if the dialysis center documented the need for Resident #3 to have a gastroenterology consultation on 8/4/25, the physician's order should have been in the resident's chart by now (8/20/25) and the facility should have known the status of the consultation appointment. The DON said she did not know there was a recommendation to stop Resident #3's milk of magnesia physician's order and she did not know some of the resident's dialysis communication forms were incomplete.

Based on observations, record review and interviews, the facility failed to ensure one (#66) of three residents reviewed for respiratory care out of 45 sample residents were provided respiratory care consistent with professional standards of practice.Specifically, the facility failed to ensure cleaning and proper care of Resident #66's CPAP (continuous positive airway pressure) machine according to manufacturer's instructions and per physician's orders.Findings include:I. Manufacturer's instructionsThe ResMed AirSense 10 CPAP Machine user guide was provided by the nursing home administrator (NHA) on 8/19/25 at 3:08 p.m. It read in pertinent part, Daily cleaning: Disconnect the air tubing and mask, and wash the mask (including cushion and frame) in warm water with mild detergent. Rinse all parts thoroughly and allow to air dry away from direct sunlight. Wipe the exterior of the device with a dry cloth. Empty the humidifier tub daily, rinse it thoroughly in warm water, and allow it to air dry out of direct sunlight. Weekly cleaning: Wash the humidifier tub and air tubing in warm water with mild detergent. Rinse well and allow to air dry out of direct sunlight. Filter maintenance: Check the air filter every month for holes or blockages by dirt or dust. Replace the filter at least every six months, or more often if necessary. The filter is not washable or reusable. Do not use: Bleach, alcohol, chlorine-based solutions, moisturizing or antibacterial soaps, scented oils, or harsh cleaners. Do not place any parts in a dishwasher, washing machine, or expose them to direct sunlight for drying. Replacement schedule (general guidelines): Replace the air filter every six months, the humidifier tub every six months (or as needed if cracked, leaking, or discolored), the tubing every six to 12 months, and the mask system (frame, cushion, headgear) every six to 12 months, depending on wear.II. Resident #66A. Resident statusResident #66, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (low oxygen levels in the blood), obstructive sleep apnea (pauses in breathing during sleep caused by airway blockage) and mild persistent asthma with status asthmaticus (ongoing airway inflammation with episodes of severe asthma attacks).The 8/14/25 minimum data set (MDS) assessment revealed Resident #66 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up or clean-up assistance with eating and oral hygiene. She was dependent on staff for toileting, bathing and dressing. She required moderate assistance with mobility.B. Resident interview and observationsResident #66 was interviewed on 8/17/25 at 4:41 p.m. Resident #66 said her CPAP mask was normally kept in the drawer of her nightstand, but she did not know why there were two other masks on the countertop in the bathroom. She said at night, the staff handed her the CPAP mask and she put it on herself. She said she took the CPAP mask off in the morning, placed it on her bed and the staff put it in the drawer. She said she had not seen the staff wash her CPAP mask.On 8/17/25 at 4:50 p.m. Resident #66's CPAP machine, along with one mask, was observed next to the resident's bed on the nightstand. Two CPAP masks were observed in the resident's bathroom sink in the space next to each faucet handle with no towel underneath. On 8/18/25 at 8:45 a.m., the resident's CPAP mask was observed on the nightstand next to the bed, attached to the CPAP machine. Two other CPAP masks were observed on the side of the bathroom sink. Resident #66 said the staff did not wash the CPAP mask. On 8/19/25 at 8:34 a.m. Resident #66's CPAP mask was observed on the nightstand next to the resident's bed. Two other CPAP masks were observed on the side of the bathroom sink. Resident #66 said she had asked the respiratory therapist the day before how often he changed the mask and tubing, and he told her once a week. She said she had never seen staff wash the CPAP mask. C. Record reviewA review of Resident #66's CPAP care plan, initiated 8/3/23 and revised 10/21/24, revealed the resident had oxygen therapy related to respiratory failure. Pertinent interventions included monitoring for signs and symptoms of respiratory distress. -The care plan failed to include cleaning frequency or instructions for the CPAP machine and its parts.A review of Resident #66's August 2025 CPO revealed the following physician's orders related to the resident's CPAP machine: CPAP 5-20 centimeter (cm) H O (machine delivers airway pressure adjustable between 5 and 20 cm of water pressure) with 2 liters L oxygen at bedtime for obstructive sleep apnea, ordered 8/9/24.CPAP mask cleaning: place in warm, soapy water, soak/agitate for five minutes, rinse and air dry between uses, every day shift, ordered 9/21/24. A review of the June 2025 through August 2025 medication administration record/treatment administration records (MAR/TAR) revealed staff consistently documented completion of daily CPAP mask cleaning.-However, observations and staff interviews revealed the resident's CPAP mask had not been cleaned or washed as ordered (see observations and resident interview above and staff interviews below). -Additionally, Resident #66 said staff did not clean or wash the CPAP mask on a daily basis (see resident interview above).III. Staff interviewsThe director of nursing (DON) was interviewed on 8/19/25 at 12:48 p.m. The DON said the process when a resident was done using the CPAP machine in the morning was for staff to wash the CPAP mask with soap and water and place it on a towel to dry in order to avoid bacterial infection. She said staff should have followed the physician's order for cleaning recommendations for Resident #66's CPAP mask. She said bacteria were important to avoid because they could get into the lungs and cause infections. She said she expected staff to clean Resident #66's CPAP mask daily. She said the respiratory therapist changed the CPAP tubing every Monday. She said she would re-educate staff and train them to wash and clean the resident's CPAP mask daily.On 8/19/25 at 12:50 p.m. the DON observed the CPAP masks in Resident #66's room on the side of the sink and next to the resident's bed. The DON said the storage of the masks was not acceptable and she would educate staff.Certified nurse aide (CNA) #8 was interviewed on 8/20/25 at 9:59 a.m. CNA #8 said she just put Resident #66's CPAP mask on and took it off the resident's face and did not clean it. She said the nurses were responsible for cleaning and completing maintenance for CPAP machines. CNA #5 was interviewed on 8/20/25 at 10:02 a.m. CNa #5 said she was not too familiar with CPAPs and sometimes she put the CPAP mask on and took it off the resident's face. She said she did not know who cleaned the CPAP masks.Registered nurse (RN) #1 was interviewed on 8/20/25 at 10:16 a.m. RN #1 said she first checked if a resident's CPAP mask was clean, and then she checked if there was distilled water in the chamber and if the machine was working properly. She said she helped the resident put the mask on if assistance was needed. For cleaning, she said she checked to see if there was any residue, mucus, or dirt in the CPAP mask. She said if she noticed residue, she cleaned it or replaced it. RN #1 said she tried to pay attention to Resident #66's CPAP whenever she was in the room. She said she did not know how often the mask should have been cleaned. She said in the past two days she had noticed the mask in Resident #66's nightstand and it was clean, but no cleaning had been done in those two days. She said if she noticed dirt or residue on the mask, she used gauze with saline water or distilled water to wipe and clean the mask and then let it air dry. She said she was not aware that there were two CPAP masks in Resident #66's bathroom sink. She said she did not know if Resident #66's CPAP mask should be washed with warm soapy water because she was taught in the hospital not to use tap water, as the water source was unknown and bacteria could build up.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and services to maintain vision abilities for one (#8) of three residents reviewed for vision services out of 45 sample residents.Specifically, the facility failed to ensure Resident #8's new eyeglasses were obtained in a timely manner and the resident was scheduled for a cataract surgery consultation. Findings include:I. Facility policy and procedureThe Hearing and Vision Services policy, revised April 2025, was provided by the chief nursing officer on 8/20/25 at 2:48 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social services designee is responsible for assisting residents, and their families in locating and utilizing any available resources (Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs. Once vision or hearing services have been identified, the social worker/social services designee will assist the resident by making appointments and arranging for transportation.II. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included schizophrenia (mental illness) , severe obesity, emphysema (lung disease) and Parkinson's disease. The 6/19/25 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He required supervision with eating and bathing and moderate assistance with personal hygiene and dressing.The MDS assessment documented the resident had impaired vision requiring corrective lenses.B. Resident observation and resident representative interviewResident #8's representative was interviewed on 8/18/25 at 11:15 a.m. The representative said Resident #8's eyeglasses were very old and needed replacement.On 8/20/25 at 10:15 a.m., Resident #8 was sitting in his bed dressed and groomed. The resident was not wearing glasses.C. Record reviewResident #8's care plan did not reveal documentation regarding Resident #8's visual needs.Resident #8's last eye exam note was dated 8/20/24. The optometrist documented the resident needed to be seen by an ophthalmologist (eye specialist) for a cataract exam. The note documented the resident's glasses improved his vision somewhat, so a prescription would be provided today, but for best visual outcome a cataract surgery may be needed. The exam note documented a new order to dispense the new prescription and a referral for a cataract exam. -Review of Resident #8's electronic medical record (EMR) on 8/20/25 did not reveal documentation to indicate the resident's eyeglasses had been ordered or he had received his new eyeglasses. There was also no documentation indicating a referral had been made to an ophthalmologist for a cataract exam. D. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 8/20/25 at 9:50 a.m. CNA #4 said Resident #8 had old prescription glasses. CNA #4 said the resident had the same glasses for several years. CNA #4 said Resident #8 was unable to see very well.Licensed practical nurse (LPN) #1 was interviewed on 8/20/25 at 10:00 a.m. LPN #1 said Resident #8 used to wear prescription eyeglasses, but she had not seen him wear them in a while.The social services director (SSD) was interviewed on 8/20/25 at 10:56 a.m. The SSD said the facility had recently identified vision services were one of the areas that needed a process correction. The SSD said she had contacted and was working to get optometry services at the facility. The SSD said an audit of residents for ancillary services needs, including vision needs, was completed in June 2025 by the regional clinical resource (RCR). The SSD said she did not know if Resident #8 required a consult for cataract surgery or a new prescription for eyeglasses as she had not seen the 8/20/24 eye exam provider note. The SSD said she was not certain if Resident #8's medical record had been audited for his vision needs. The SSD said she would follow up to determine Resident #8's vision needs. The SSD said residents could experience stress if they could not get new eyeglasses or have their vision corrected in a timely manner.The director of nursing (DON) was interviewed on 8/20/25 at 3:35 p.m. The DON said ancillary services, including vision services were identified as an area of concern for residents by the RCR and herself. She said the facility was developing a performance improvement plan to address the concerns. The DON said when the facility received orders from the vision provider which included a follow up appointment, the next day the scheduler should make arrangements for appointments. The DON said once the facility obtained a prescription for a resident's eyeglasses she would expect to arrange for ordering the eyeglasses within a few days and the resident should expect to receive new eyeglasses in less than a month. The DON said it was important for residents to have eye issues addressed to enhance their well-being and to prevent falls.

Based on observations, record review and interviews, the facility failed to ensure one (#39) of three residents received care and services according to acceptable standards of clinical practice out of 45 sample residents. Specifically, the facility failed to ensure Resident #39 did not receive Excedrin (migraine relief medication) without a physician's order. Findings include:I. Facility policy and procedureThe Medication administration policy, revised 4/16/25, was provided by the nursing home administrator (NHA) on 8/19/25 at 1:02 p.m. It read in pertinent part, Medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Nursing staff are required to ensure the six rights of medication administration, which include:-The right resident;-The right drug;-The right dosage;-The right route;-The right time; and-The right documentation. Nursing staff must review the medication administration record (MAR), compare the medication source with the MAR to verify accuracy, administer medications within 60 minutes before or after the scheduled time unless otherwise ordered, sign the MAR after administration, and report or document adverse side effects or refusals.II. Resident #39Resident #39, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included insufficient sleep syndrome (sleep disorder where a person does not get enough sleep), heart failure and major depressive disorder recurrent severe without psychotic features.A. Resident statusThe 7/26/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up or clean-up assistance with bathing and eating. The assessment documented Resident #39 experienced pain that affected her sleep, therapy participation and day to day activities.B. Resident interviewResident #39 was interviewed on 8/18/25 at 12:41 p.m. Resident #39 said she suffered from migraines and tried to get medication when the pain became severe. She said she was on other migraine medications as a preventative measure, but Excedrin Migraine was the only medication that helped when she had an active migraine. She said registered nurse (RN) #4 was the only nurse who gave her the Excedrin Migraine, and no other nurses administered the medication. She said RN #4 worked the night shift three times per week and gave her Excedrin Migraine on those nights. Resident #39 said about one week ago she experienced a major migraine and suffered throughout the night until RN #4 gave her Excedrin Migraine.Resident #39 was interviewed again on 8/19/25 at 3:45 p.m. She said RN #4 administered two Excedrin Migraine tablets last night (8/18/25) for her migraine headaches and it relieved her pain.C. Record reviewReview of the March 2025 CPO revealed the physician's order for Excedrin Migraine was discontinued on 3/31/25.A nursing progress note, dated 3/7/25, revealed Resident #39 had been administered an Excedrin Migraine oral tablet 250-250-65 milligram (mg) as needed for migraine. The note documented the medication was ineffective and pain was rated 7 out of 10.A nursing progress note, dated 3/10/25, revealed Resident #39 refused her scheduled acetaminophen dose and said she would rather have Excedrin for her headache and the nurse was notified.A nursing progress note, dated 3/29/25, revealed administration of Excedrin Migraine oral tablet 250-250-65 mg. The note documented the as needed (PRN) administration was effective and the pain scale was zero.A physician progress note, dated 4/14/25, documented Resident #39 had a chronic history of headaches and reported Excedrin Migraine had previously helped her. The note documented Excedrin was discontinued because she also took anticoagulants. The physician documented Resident #39 was prescribed acetaminophen and Topamax (medication used to prevent migraine headaches) for pain management.A nursing progress note, dated 7/19/25, revealed the RN brought down two grocery bags containing a rotisserie chicken, a bottle of Tylenol and two bottles of Excedrin Migraine that the resident had purchased. The LPN removed the medications and secured them in the medication room. The RN informed Resident #39 that she could not bring medications into the facility.A behavior note by nursing staff, dated 7/22/25, revealed Resident #39 called her neurology clinic and requested a refill of her sumatriptan (a medication used to treat migraine headaches) and asked the physician to restart Excedrin Migraine. The neurology clinic informed the nurse they would not fill the sumatriptan and would not restart the Excedrin. The nurse documented that she informed the resident's nurse after the call.A physician progress note, dated 7/24/25, documented Resident #39 experienced frequent headaches and that she used sumatriptan for pain relief. The note documented continuation of topiramate, continuation of sumatriptan, use of acetaminophen as needed, and non-pharmacological pain relief.The pain management care plan, revised 8/2/24, documented Resident #39 had acute and chronic pain with episodic comfort concerns. Pertinent interventions included determining the resident's satisfactory pain level, educating the resident or representative on the pain management treatment plan, administering pain medications per order when non-medication interventions were ineffective and administering prescribed medication before activity and therapy.III. Staff interviewsRN #4 was interviewed on 8/19/25 at 4:30 p.m. She said the last time she gave Resident #39 two tablets of Excedrin Migraine was on 8/18/25. She said she usually documented medication administration, but she was busy and did not document it in the electronic medical record record. She said she wrote it on a piece of paper and later shredded it. She said she thought there was a physician's order for Excedrin Migraine and that was why she administered it. She said she was aware that Excedrin Migraine contained acetaminophen and caffeine. Certified nurse aide (CNA) #7 was interviewed on 8/19/25 at 5:13 p.m. She said she had not worked on the side of the hall where Resident #39 resided since the end of July 2025. She said she had administered sumatriptan for Resident #39's migraine symptoms because there was a physician's order. She said Resident #39 had asked her for Excedrin Migraine, but she did not administer it because there was not a physician's order.Primary care physician (PCP) #1 was interviewed on 8/20/25 at 12:04 p.m. She said staff should not give any medication without a physician's order because medications could interact with other prescribed medications. She said an Excedrin Migraine contains caffeine, which could increase heart rate, and contains acetaminophen, which could result in exceeding the resident's daily acetaminophen allowance if administered along with other acetaminophen orders. She said there must be a physician's order even for over the counter medications. She said the Excedrin Migraine was discontinued because it was not appropriate for long-term migraine treatment and the resident had difficulty sleeping when an Excedrin Migraine was administered in the evening. She said the pharmacy also recommended discontinuing the Excedrin Migraine because the resident was on anticoagulant therapy (medication used to prevent blood clots), which increased the risk of prolonged bleeding times. The director of nursing (DON) and regional clinical resource (RCR) #1 were interviewed together on 8/20/25 at 12:45 p.m. The DON said it was not acceptable for a nurse to administer medications without a physician's order. The DON said a physician's order was required because the physician must be aware of the resident's history. She said giving medications without physician's orders could cause interactions with other medications or could cause allergic reactions.RCR #1 said she was not sure why RN #4 administered an Excedrin Migraine without a physician's order and said the facility could not go back in time and fix the incident, but moving forward they would re-educate staff. She said the plan of correction would include educating staff not to give medications without physician's orders, identifying the incident as a medication error, reporting it, and taking disciplinary action. She said medication pass would be monitored and a stat (immediate) prothrombin time/international normalized ratio (PT/INR) (a blood test that measures clotting time) would be completed to ensure the resident was not over-anticoagulated.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one out of three units at the facility. Specifically, the facility failed to provide a bed bath for Resident #55 in a sanitary manner. Findings include: I. Facility policy and procedureThe Bed Bath policy and procedure, dated 4/11/25, was provided by the NHA on 8/19/25 at 7:37 p.m. It read in pertinent part, It is the practice of this facility to assist residents with bed bathing to maintain proper hygiene and help prevent skin issues. Equipment and supplies: gloves, washcloths, several towels, basin half filled with water, plastic trash bag or waste basket, lotion, and protective covering. Remove the resident's blanket and bedspread and place them on a clean surface; place a bath blanket over the top sheet and pull down the top sheet to the foot of the bed, leaving the bath blanket over the resident; Remove resident's clothing under the bath blanket while maintaining privacy and keeping them warm; Fill the basin halfway with water warm to the touch (between 98.6 Fahrenheit to 103 Fahrenheit ). Have the resident feel the water to ensure it is comfortable for them; dip a washcloth into the water and wring out the excess water; form the washcloth into a mitt onto your gloved hand; wash the resident's eyes with water only, starting with the eye that is farther from you. With one corner of the washcloth, wash from the inner corner of the eye out towards the ear. Using another corner of the washcloth, repeat the process on the eye closest to you; wash the resident's face using soap or a facial cleanser only if the resident requests you to do so and rinse off all the soap and pat the skin dry. If the resident is able to assist, allow them to participate; Wash the resident's ears (behind the ears and gently inside the ears) and neck, rinsing and drying the areas; wash, rinse and dry the arms, underarms, and hands starting with the extremity farthest from you, exposing only the extremity you are working on. Repeat on the upper extremity closest to you; place a towel across the resident's chest and pull the bath blanket down to the resident's waist. Wash, rinse and dry the resident's chest and abdomen. Pay attention to the skin under breasts and/or any skin folds. Cover the chest with the bath blanket; expose the leg farthest from you and wash, rinse and dry the leg and foot, not forgetting to wash between the toes. Cover the leg and repeat the process on the leg closest to you, covering the leg when finished; assist the resident to turn to one side, keeping the resident covered with the bath blanket. Expose the back and buttocks and wash, rinse and dry the area; provide a backrub using the lotion, if the resident desires. Assist the resident back onto their back, keeping resident covered with the bath blanket; change the bath water in the basin, obtain a clean washcloth, perform hand hygiene and don new gloves;iIf the resident is able, provide bathing supplies and have them wash and dry perineal area. If unable, gain consent to clean perineal area; for females, expose the perineal area washing the pubic area with downward strokes from the front to the back; for males, expose the perineal area washing the penis from the urethral opening to the base of the penis, then the scrotum. Pull back the foreskin on uncircumcised males and clean under it, gently returning the foreskin; cover the resident with the bath blanket; place soiled linen in a bag for laundering; empty, rinse and dry the bath basin, returning it to its storage location; Remove and discard gloves and perform hand hygiene; apply any moisturizer to the resident's skin as needed; dress the resident in clean clothing; comb or brush the resident's hair; change bed linens; assist the resident to a comfortable position with call light in reach; document the procedure; inspect the skin along the way noting any open areas, bruising, or other signs of skin breakdown and notify the nurse if noted.II. ObservationOn 8/19/25 at approximately 2:00 p.m. CNA #1 and CNA #4 were observed providing a bed bath to Resident #55. The CNAs gathered supplies for the bed bath in advance and talked with the resident about the bath. The CNAs turned the resident side to side to remove bedding and placed a bath blanket under the resident. The CNAs said to Resident #55 at the beginning of the bath, we are going to work from the bottom up. They washed Resident #55's feet first, then his legs. CNA #4 then washed his perineal area including genitals and then washed his chest without changing gloves. CNA #1 washed the resident's back and then his buttocks, she removed a small dressing from his sacral area. After washing his buttocks, CNA #1 reached into the water basin to obtain another washcloth, she ringed out the washcloth and then went to the resident's head of the bed, the washcloth was within a few inches of his face. Upon prompting CNA #1 stopped the bed bath. CNA #1 walked away from the bedside. CNA #1 removed her gloves. She took a towel and went to the bathroom, she used the sink to get it wet. CNA #1 then washed the resident's face and hair. After the bath, the resident said his skin and body were very sensitive to touch and turning.III. Staff interviewsCNA #5 was interviewed on 8/19/25 at 3:47 p.m. CNA #5 said she performed bed baths and learned how to complete a bed bath in CNA school. CNA #5 said she would get supplies first, and get two basins, one with water and one with soap and water and set up an area. CNA #5 said she would start at the head and work to the toes and wash the front of body first. CNA #5 said to use soap first and then rinse with water and dry off. CNA #5 said she would always work top to bottom but would skip the private areas to do last. CNA #5 said she would always end with the bottom area. CNA #5 said she would use lots of different washcloths about five or six and then dry. CNA #5 said she would apply lotion and then either redress or go get the nurse for a skin check if that was needed. The director of nursing (DON) and the NHA consultant were interviewed together on 8/20/25 at 3:05 p.m. The DON said a CNA performed a bed bath by first putting water in the pink bucket and making sure the temperature was good. She said the CNA would then get about 15 washcloths, body wash and prepare the resident. The DON said there should be one wash cloth for each area and to start at the face first working from head to toe. The DON said it was important to work head to toe and with different wash clothes to prevent contamination and be more hygienic. The DON said the CNAs needed to use the body wash first and then to rinse the area with the water. The DON said the water needed to be changed between every body part. The DON said for example one bucket of water for the face, then dump water, then each arm, chest, legs, back, feet and perineal area. The DON said the CNAs needed to always end with the perineal area for hygienic purposes and the bottom very last. The DON said the CNAs who did the bed bath for Resident #55 and started at the feet and worked to the face were not correct and it was not hygienic.

Based on observations and interviews, the facility failed to ensure residents and their representatives had access to the most recent survey findings including survey results, certifications, complaint investigations and plans of correction.Specifically, the facility failed to ensure the survey findings binder was available, ensure staff members were aware of where the binder was located and ensure the binder was accessible for review.Findings include:I. Resident group interviewDuring the resident council group interview on 8/18/25 at 3:00 p.m., Residents, #19, #42, #45 and #61, who were cognitively intact, said they did not know where to access the survey findings binder.II. ObservationsOn 8/18/25 at 2:39 p.m. registered nurse (RN) #1 attempted to locate the survey findings binder at the nurses'station and at the front desk. RN #1 was unable to find the survey findings binder. The infection preventionist (IP) and the nursing home administrator (NHA) additionally attempted to locate the survey findings binder and were unable to find it.III. Staff interviewsRN #1 was interviewed on 8/18/25 at 2:40 p.m. RN #1 said she looked for the survey findings binder and could not find it, so she asked the IP to assist.The IP was interviewed on 8/18/25 at 2:43 p.m. The IP said she looked for the survey findings binder and could not find it.The NHA was interviewed on 8/18/25 at 2:45 p.m. The NHA said the facility was working on putting a survey findings binder together as he had not been able to find one in the facility.The chief nursing officer was interviewed on 8/18/25 at 2:55 p.m. The chief nursing officer said the facility staff had looked for the survey findings binder and could not find it. The chief nursing officer said the facility would resolve the issue and they would place the binder by the main entrance where it would be accessible to everyone.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (#6) of five residents out of nine sample residents. Resident #6 was admitted to the facility on [DATE] with diagnoses of right leg above the knee amputation, left arm paralysis following stroke, peripheral vascular disease (reduced blood flow to limbs), dysphagia (difficulty swallowing), respiratory failure and diabetes. On [DATE] at 6:20 a.m. Resident #6 told the certified nurse aides (CNA) he was experiencing shortness of breath. The CNAs observed the resident was experiencing shortness of breath and informed licensed practical nurse (LPN) #1 of the resident's significant change in condition. LPN #1 failed to collect information regarding Resident #6's condition, notify a registered nurse (RN) to conduct a complete physical assessment of the resident or report Resident #6's concern and significant change in condition to a physician. Resident #6 was later found unresponsive and not breathing. Resident #6 expired at the facility on [DATE] at 9:00 a.m. The facility failed to ensure staff promptly identified and intervened appropriately when Resident #6 experienced a significant change in condition, which resulted in a situation of serious harm. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on [DATE] to [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE]. I. Situation of serious harm On the morning of [DATE] at 6:20 a.m. Resident #6 reported a change of condition (shortness of breath) to the CNAs. The CNAs observed Resident #6's shortness of breath and conveyed the resident's concern and status to LPN #1. LPN #1 failed to collect information regarding Resident #6's condition, notify a RN to conduct a complete physical assessment of the resident or report Resident #6's concern and significant change in condition to a physician. Resident #6 was later found unresponsive and not breathing. Resident #6 expired at the facility on [DATE] at 9:00 a.m. The facility began an investigation immediately following the incident on [DATE]. LPN #1 was suspended on [DATE] following the incident, and terminated from employment at the conclusion of the facility's investigation. II. Facility's plan of correction The corrective action plan implemented by the facility in response to Resident #6's change of condition failure on [DATE] was provided by the regional director of operations (RDO) on [DATE] at 8:30 a.m. The stated purpose of the plan was the facility's immediate action plan to remove the likelihood that serious harm to a resident would occur or recur. The plan revealed the following: 1. Identification of residents affected or likely to be affected. The facility took the following actions to address and prevent any additional residents from suffering an adverse outcome: (Completion date: [DATE]). -The DON or designee notified the facility medical director of the incident. -Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were not identified. -The DON suspended the licensed nurse who was aware of significant change, but did not report it to the physician, pending investigation. 2. Actions to prevent occurrence/recurrence- The facility took the following actions to prevent an adverse outcome from reoccurring: (Completion date [DATE]). -The licensed nurse was terminated on [DATE]. She remained on suspension from [DATE] until termination on [DATE]. -All licensed nurses were educated by the DON/designee on appropriate addressing of urgent changes of condition, physician notification regulations, and facility policy and procedure. -Nurse aides were educated by the DON/designee on escalating resident changes in condition to other licensed nurses in the facility if they do not receive an adequate response from the nurse assigned to the patient. -Staff members were not permitted to work a shift until education was completed. -New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. -The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on physician notification of significant changes. -The PIP resulted in implementation of five times/week DON/designee audits of the 24-hour report and conducting nursing staff huddles to monitor for change in resident condition. -The DON/designee will also complete chart audits as follows, three residents weekly for four weeks then two residents weekly for two weeks then two residents a month for two months. -The regional consultant nurse will visit the facility two times per month to provide general oversight and monitoring of the PIP. Date facility asserts likelihood for serious harm no longer exists: [DATE]. III. Facility policy and procedure The Change in a Resident's Condition or Status policy, revised February 2021, was provided by the RDO on [DATE] at 4:04 p.m. It read in pertinent part, The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change in condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan; and ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the eInteract Change of Condition evaluation form. IV. Facility investigation of incident on [DATE] and education provided in response to incident The facility's plan of correction/performance improvement plan (PIP) binder was provided by the RDO on [DATE] at 8:30 a.m. The binder included a documented interview of LPN #1 which occurred on [DATE]. It read in pertinent part, The nurse reports that she checked on the resident (Resident #6). She said he seemed normal and she measured his oxygen saturation level (level of oxygen in the blood), which read 92% (percent). She admits she did not listen to his heart, lungs, ask him questions, obtain a full set of vital signs (temperature, heart rate, blood pressure and respiratory rate), complete additional assessment or notify the physician. A description of the facility's education and inservice training documents conducted in response to the incident were included in the PIP binder. The documentation included the following, in pertinent part: Interventions that were put into place to help prevent a recurrence: Education as done with all nurses and CNAs prior to their next scheduled shift to ensure they understand policies and procedures regarding resident complaints of acute symptoms. This education was provided by the DON and the ADON (assistant director of nursing) and included a post-education quiz for nurses. CNAs were educated to always report to their nurse the residents' complaints and to escalate the complaint to another nurse, the DON/NHA if their complaint was not properly addressed by their nurse. Additionally, beginning the week of [DATE] and ongoing, all nurses will be evaluated for competency in performing head-to-toe evaluations by the DON/designee. The medical director will conduct additional training with nursing staff related to response to resident changes in condition. New nursing staff will receive this education during orientation. Audits are in place to ensure residents who are experiencing a change of condition have proper follow up. The results of the audits will be reviewed by the QAPI (quality assurance and performance improvement) committee. The [DATE] nursing assessment training document included signed verification of training for 15 nursing staff members. The [DATE] inservice training document for change of condition education provided by the medical director included signed verification of training for 46 facility staff members. Review of 24-hour report audits and resident chart audits revealed the DON audits had been completed through [DATE]. The education record (prior to [DATE]) for LPN #1 was provided by the RDO on [DATE] at 3:40 p.m. It revealed the following: LPN #1 had attended an inservice education regarding residents' change of condition a year prior to the incident, on [DATE]. The inservice education read in pertinent part, A change in a resident's condition may mean that he or she is at risk. Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes, including medical complications, transfer to a hospital or even death. V. Resident #6 A. Resident status Resident #6, age less than 65, was admitted on [DATE] and expired at the facility on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included right leg above the knee amputation, left arm paralysis following stroke, peripheral vascular disease, dysphagia, respiratory failure and diabetes. The [DATE] minimum data sets (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 14 out of 15. He required set up assistance with eating, substantial assistance with hygiene and dressing and was dependent on staff for toileting and showering. B. Record review Review of Resident #6's February 2025 CPO revealed the resident had a physician's order indicating the resident was to be a do not resuscitate (DNR) status, ordered [DATE]. Review of Resident #6's Medical Orders for Scope of Treatment (MOST) form, signed on [DATE], revealed the following: -Resident #6 did not wish to receive cardiopulmonary resuscitation (CPR); -He wished to have selective treatment, which included using intravenous (IV) antibiotics and IV fluids, if indicated, and to transfer to the hospital, if indicated, but avoid intubation and intensive care; and, -The resident wished to receive artificial nutrition by tube for short term/temporary only. A review of Resident #6's electronic medical record (EMR) revealed the following progress notes: A nurse progress note, dated [DATE] at 7:33 p.m., documented Resident #6 was complaining of pain in his left shoulder. The ADON was notified and asked to go visit with him. Resident #6 told the ADON staff rolled him too far on his left side Sunday ([DATE]) and it made his left shoulder pop with pain. Resident #6 was repositioned in bed for comfort control. The ADON asked the nurse to call the PA (physician's assistant). The nurse told the PA about Resident #6's complaint and the PA said she saw the resident yesterday ([DATE]) but he never mentioned his shoulder pain. The PA ordered an MRI (magnetic resonance imaging) of the resident's left shoulder. Resident #6 was encouraged to take Tylenol routinely for pain management prior to initiating something stronger. A nurse progress note, dated [DATE] at 12:30 p.m., documented, a nurse spoke with Resident #6 regarding his MRI and when it would be scheduled. The nurse informed the resident that the physician's order had been faxed to central scheduling and the facility was awaiting a call back. When the nurse entered the resident's room, the resident was moving his fan with his right hand and said his fingers were numb and he could not grab with them. The nurse reported the findings to the nurse practitioner (NP). The NP said it was not an emergent situation. Resident #6 was offered lidocaine patches which he refused. Resident #6 accepted a physical therapy (PT) evaluation and the facility would obtain a MRI as soon as it was scheduled. A nurse progress note, dated [DATE] at 6:30 a.m. and written by LPN #1, documented a CNA reported that Resident #6 was having a difficult time breathing. LPN #1 checked the resident a few minutes later and Resident #6 was breathing at his baseline, with no shortness of breath noted. Resident #6's oxygen saturation level was 92% on room air. Resident #6 did open eyes and said hey to LPN #1. A nurse progress note, dated [DATE] at 7:59 a.m. and written by the DON, documented a CNA contacted the DON and said that Resident #6 was not breathing. Upon assessment, the resident was noted with no heartbeat, breaths or blood pressure. The DON called the resident's representative. The DON attempted to call the representative four times with no answer. The coroner was contacted and Resident #6 was pronounced deceased at 9:00 a.m. Multiple more attempts were made to contact the resident's representative with no answer. Review of Resident #6's vital signs documentation revealed the following: -On [DATE] at 1:41 p.m., the resident's temperature was 97.0 degrees fahrenheit (F); -On [DATE] at 1:41 p.m., the resident's respiration rate was 18 breaths per minute; -On [DATE] at 1:41 p.m., the resident's pulse was 80 beats per minute (bpm); -On [DATE] at 1:41 p.m., the resident's blood pressure was ,d+[DATE] millimeters of mercury (mm/Hg); -On [DATE] at 1:41 p.m., the resident's oxygen saturation was 92% on room air; -On [DATE] at 9:23 p.m., the resident's pulse was 87 bpm; and, -On [DATE] at 9:23 p.m., the resident's blood pressure was ,d+[DATE]. -Review of Resident #6's EMR did not reveal that a full set of vital signs was obtained on the resident on the morning of [DATE]. VI. Staff interviews The NP was interviewed on [DATE] at 1:00 p.m. The NP said she ordered an ultrasound to evaluate Resident #6's right hand on [DATE], and later changed the order on [DATE] to an MRI of his hand for nerve impingement. The NP said sometimes MRI scheduling could take longer in rural locations, and the resident was still waiting for the MRI procedure when he expired. The NP said she was at the facility the day prior to his death. She said she did not examine him at the time, but was told he had the same symptoms on his right side (from [DATE]), including numbness of his right wrist with decreased grip strength. She said he had no new or acute pain on his left side. The NP said Resident #6's roommate at the time said Resident #6 asked a staff person to go to the hospital the day he expired ([DATE]). She said she was not certain if the staff person was LPN #1. The NP said there should have been an immediate call to the provider when Resident #6 said he wanted to go to the hospital, was short of breath or said he could not breathe. The NP said Resident #6 had a do not resuscitate order and the DON called her when he expired and she pronounced his death. CNA #4 was interviewed on [DATE] at 3:07 p.m. CNA #4 said when she arrived for her shift at 6:00 a.m. on [DATE] and received report, the previous CNA told her and CNA #5 that Resident #6 was not feeling well during the night and was awake and used his call light a lot. CNA #4 said she and CNA #5 entered Resident #6's room at 6:20 a.m. ([DATE]) and the resident said he was not feeling well. She said she and CNA #5 observed Resident #6 could not catch his breath, so she elevated the head of his bed and informed LPN #1 of Resident #6's shortness of breath. CNA #4 said LPN #1 did not respond or acknowledge either of the CNAs when they told her of the resident's change in condition. CNA #4 said she repeated the information to LPN #1 and LPN #1 again did not respond to her. CNA #4 said after she reported the information to LPN #1, she and CNA #5 monitored Resident #6's room to see if LPN #1 went to evaluate the resident. She said they did not see LPN #1 enter Resident #6's room. CNA #4 said Resident #6's roommate put his call light on at approximately 7:00 a.m. and told her Resident #6 needed assistance. She said Resident #6 said he felt like he was having a stroke and could not breathe. CNA #4 said she told LPN #1 of Resident #6's statements again at 7:09 a.m. and LPN #1 again did not acknowledge or reply to CNA #4's statements. CNA #4 said LPN #1 just looked at me. CNA #4 said she continued to work together with CNA #5 to assist residents who were getting up for the day. CNA #4 said another CNA (CNA #6) checked on Resident #6 at approximately 7:20 a.m. and told her that he was breathing and appeared to be sleeping. CNA #4 said an additional CNA arrived to work at 7:50 a.m. and CNA #4 asked the CNA to check on the resident. CNA #4 said the CNA checked on Resident #6 and then called out to the DON and said the resident was cold and not breathing. CNA #4 said she had worked with LPN #1 before and LPN #1 never responded to her verbally. She said she and other CNAs were educated after the event with Resident #6 and instructed to go up the chain of command by contacting a registered nurse (RN) or the DON, whether it was day or night, if a nurse did not respond to a resident's change of condition or to their concerns. Resident #6's former roommate, who no longer resided at the facility, (Resident #11) was interviewed on [DATE] at 3:35 p.m. Resident #11 said Resident #6 was not feeling well during the night ([DATE]) and was having difficulty breathing in the morning hours of [DATE]. Resident #11 said he yelled for help several times and the call light was on for an extended period of time. Resident #11 said Resident #6 slowly drifted off after 7:30 a.m. Resident #11 said Resident #6 always had some problems with breathing, but that day it got really bad. Resident #11 said nobody was in the room when Resident #6 died . CNA #5 was interviewed on [DATE] at 12:06 p.m. CNA #5 said Resident #6 was not acting like his usual self and she was told in the shift report that he might be very tired, as he was uncomfortable and awake a lot during the night. CNA #5 said Resident #6 said he could have been having a stroke and she reported this information to LPN #1 and LPN #1 did not respond. CNA #5 said she probably would have told another nurse, but she was concerned that LPN #1 would get back at me. CNA #5 said she thought LPN #1 would ask her to do vital signs, including checking Resident #6's temperature, blood pressure, heart rate and respiratory rate. CNA #5 said LPN #1 did not ask her to do this. CNA #5 said it was possible LPN #1 did go into the resident's room, however, she said she never saw LPN #1 in Resident #6's room. CNA #6 was interviewed on [DATE] at 11:02 a.m. CNA #6 said she was a CNA on a different unit that day ([DATE]), however, she said she stopped over to the nurses station on Resident #6's unit. CNA #6 said CNA #4 and CNA #5 asked CNA #6 to check on Resident #6. CNA #6 said she stood next to the resident for a few minutes and he was breathing, did not appear to be short of breath and appeared to be sleeping. RN #1 was interviewed on [DATE] at 12:41 p.m. RN #1 said she was working when Resident #6 expired. She said she did not know he was having issues or had passed away until after it happened. RN #1 said she had been told LPN #1 should have responded to the CNAs concerns and told her about Resident #6's shortness of breath. RN #1 could not recall who told her this. RN #2 was interviewed on [DATE] at 10:43 a.m. RN #2 said she worked the three nights before Resident #6 expired. RN #2 said she remembered asking Resident #6 if he wanted her to send him to the hospital due to his continued right arm pain and he declined. RN #2 said Resident #6 had complained of right arm pain for a month and was scheduled to have a MRI. RN #2 said Resident #6 did not complain of left shoulder or arm pain on the last night before he expired ([DATE]). RN #2 said after she had given report to the oncoming nurse (on [DATE]), she overheard CNAs tell LPN #1 that Resident #6 was sick to his stomach. RN #2 said she had told LPN #1 in report the resident wanted arthritis cream in more locations than he usually did. She said Resident #6 refused his insulin that night, as he often did. RN #2 said she asked LPN #1 about Resident #6's condition before she left the building and LPN #1 said he was fine. CNA #7 was interviewed on [DATE] at 12:49 p.m. CNA #7 said Resident #6 was a little off that night ([DATE]). She said he could not sleep and was using the call light for things he usually could handle. CNA #7 he could not grab the bar for turning as well as he usually did and it required one more person for repositioning him. She said he was in more pain than usual and became angry, so she told RN #2 about this and RN #2 went to see the resident. CNA #7 said Resident #6 did not complain or appear to have shortness of breath and did not ask to go to the hospital. She said the resident did ask when his MRI was scheduled. The DON and the RDO were interviewed together on [DATE] at 2:06 p.m. The DON said she had arrived at the facility on [DATE] and was called to the resident's room when he expired. She said an investigation was started immediately and she discovered LPN #1 did not respond appropriately to Resident #6's complaints, including his shortness of breath. The DON said Resident #6 did not have any concerning symptoms the day before (on [DATE]) beyond existing right hand numbness/weakness which was ongoing for several weeks, of which the NP was aware. The DON said LPN #1 did not collect data from Resident #6 that was needed to assess the situation. The RDO said LPN #1 should have elevated the concern to a RN and reported the resident's condition change to the provider. The RDO said the CNAs should have reported the concerns to another floor nurse on duty if they were not getting a response from LPN #1. The DON said there were no complete assessments or RN assessments documented in Resident #6's record after he began experiencing a change of condition. She said a RN assessment of the resident should have been conducted. The DON said there was negligence on the part of LPN #1 as she did not collect all of the appropriate information or notify the RN and provider of the resident's change of condition. The DON said the CNAs were educated after the incident with Resident #6 and now understood to go up the chain of command (report to another nurse and the DON) as needed if a resident's concerns were not addressed. The DON said all nursing staff completed nurse competencies regarding change of condition response, including assessment and notification to providers following the incident.

Based on record review and interviews, the facility failed to update the admissions agreement so it did not waive the facilities liability for loss of resident's personal property for one (#3) of two residents out of nine sample residents. Specifically, the facility failed to ensure Resident #3 did not waive her rights for reimbursement for the loss of personal property (five rings) during her stay in the facility. Findings include: I. Facility policy and procedures The Resident Personal Belongings policy, dated 2024, was provided by the nursing home administrator (NHA) on 3/25/25 at 12:48 p.m. The policy revealed this facility protected the resident's right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. The facility would ensure that personal belongings and/or possessions were rightfully returned to the resident, or to the resident's representative, in the event of the resident's death or discharge from the facility. The facility would support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence. All resident personal items would be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. Additional possessions brought in during the duration of the individual's stay should be added to the existing personal belongings inventory listing. The facility would support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence. All resident personal items would be inventoried at the time of admission by the social services designee, or another designated staff member and documentation should be retained in the medical record. Additional possessions brought in during the duration of the individual's stay should be added to the existing personal belongings inventory listing. Following the discharge or death of a resident, all personal clothing and items of a customized personal nature were to be given to the designated resident representative. Inventories of all items were to be reviewed and examined by the Social Services designee and the resident's representative. Recipients of such personal items at the time of discharge or death should sign-off with their legal signature, acknowledging receipt of all personal belongings presented. II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses diabetes mellitus, chronic systolic (congestive heart failure), post-procedural, infection/inflammation due to cardiac and vascular devices, implants and/or grafts. The 10/7/24 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. The resident required substantial/maximal staff (staff did more than half of the effort by lifting or holding the trunk or limbs and provided more than half of the effort) assistance for toileting. The resident required partial/moderate staff (staff did less than half of the effort by lifting, holding or supporting the trunk or limbs less than half of the effort) assistance for upper and lower body dressing. B. Record review Resident #3 signed the Standard Admission Agreement on 10/3/24. The agreement revealed the facility was not responsible for the theft, misplacement, loss or damage otherwise incurred to the resident's personal property and the facility would not be responsible for the repayment or replacement of personal property. Resident #3's admission personal belongings inventory form, dated 10/3/24, revealed the resident entered the facility with five rings. This form was signed by the resident and a registered nurse (RN). The form explained to the resident that all items retained in the resident's possession were the responsibility of the resident. The facility assumed no responsibility for lost or damaged items. A grievance report form, dated 10/31/24, submitted by the resident and their legal representative revealed at discharge the resident reported not having her five rings. One of the rings was her wedding ring. The admission personal belongings inventory form confirmed the resident had five rings on admission. The steps taken to resolve the grievance revealed the staff searched all the rooms the resident resided in during her stay and were unable to locate the rings. The resident and family told facility staff that they would search all of the resident's personal belongings once they got home. The resident and family would let the facility know if they were able to find the rings. On 11/18/24 the facility received a message from the family and they were unable to locate the missing rings. The corrective action portion of the form revealed the facility reported the missing rings as an occurrence related to misappropriation of property on 11/18/24. An event note dated 11/19/24 at 10:00 a.m., revealed it was reported on 11/18/24 by a family member of Resident #3 that the resident was missing five rings that the family was not able to locate. Resident #3 discharged to home on 11/1/24. The risk factors and root cause identification revealed the resident tested positive for a COVID-19 infection during her stay at the community. The resident changed rooms twice during her stay. The resident was encouraged to use the secured lockbox to safeguard her valuables but the resident chose not to. The preventative measures in place prior to the incident revealed the resident discharged home with her family on 11/1/24. Upon admission, residents were being informed and encouraged to use secured to the wall lockboxes that were in each residents' rooms. The new interventions put in place were upon admission, residents were being informed and encouraged to use secured to the wall lockboxes located in residents' rooms. III. Staff interviews RN #1 was interviewed on 3/25/25 at 4:05 p.m. She reviewed Resident #3's admission personal belongings inventory form, dated 10/3/24, and agreed that the resident had five rings listed on the form. She said she completed the discharge summary with Resident #3 when she was discharged from the facility. RN #1 said this included the discharge personal belongings inventory form. She said the resident did not have the five rings at discharge. RN #1 said the resident told her the rings were in a plastic bag. She said to her knowledge the plastic bag containing the five rings was never located. She said she made a copy of the discharge personal belongings inventory form and gave it to the resident. She said the facility was unable to find this form. The SSD was interviewed on 3/26/25 at 9:55 a.m. The SSD said she reviewed the Admission Agreement form with the resident and/or their representative. She said she also asked them if they have any questions about the agreement. She said the agreement explained to the residents that personnel property brought into the facility; the facility was not liable for if it were damaged, missing or stolen. She said the residents were encouraged to keep their valuables locked up and they were offered a metal lock box with a key for their room. The NHA and the regional director of operations (RDO) were interviewed on 3/26/25 at 10:18 a.m. The NHA said the facility was trying to find a compromise with the family regarding the missing five rings. The NHA said according to the admission personal belongings inventory form dated 10/3/24, the resident had five rings upon admission. He said the facility had contacted the family and requested an appraisal or a receipt for the rings. He said the resident had a lock box in the rooms that she resided in during her stay in the facility. He said the facility was unable to find the discharge personal belongings inventory form and asked the family to provide a copy of the form to the facility. The NHA was interviewed again at 12:24 pm. He said the family told the facility the five rings were worth $3,000.00 dollars. The NHA said he asked the family for at least a description of the rings.

Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#4) of seven residents reviewed for behavioral and emotional status out of 14 sample residents. Specifically, the facility failed to coordinate timely necessary behavioral, mental and emotional health care and services for Resident #4 after the resident expressed suicidal ideation. Findings include: I. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE] and discharged to home on 1/23/25. According to the January 2025 computerized physician orders (CPO), diagnoses included alcohol abuse with withdrawal, dementia, psychotic disturbance, mood disturbance, anxiety and hemiplegia and hemiparesis following a cerebral infarction that affected the right dominant side. The 12/30/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The assessment indicated the resident had no behaviors. The assessment indicated the resident had no thoughts that she would be better off dead or of hurting herself in some way, did not feel down, depressed or hopeless and did not have little interest or pleasure in doing things. B. Record review The admit/readmit screener form, dated 12/26/24 at 2:55 p.m., revealed Resident #4 was admitted from the hospital. The form did not reveal the resident had depression or any behaviors. The resident's baseline care plan for social services, dated 12/27/24, revealed the resident had a history of alcohol dependence combined with a diagnosis of dementia. There was a significant concern with suicidal ideation, depression and anxiety. The interventions included frequent checks for 72-hours, referral to the emergency room for a psychological evaluation and referral to behavioral health services for psychological treatment. The care plan also revealed the pertinent initial care plan focus statement, goals and interventions related to mental health needs: the resident had mental health (diagnosis/diagnoses) of (SPECIFY) and requires the use of (SPECIFY: anti-depressant, anti-anxiety, antipsychotic, sedative/hypnotic, mood stabilizer). -The facility failed to develop Resident #4's social services baseline care plan to specify the resident's mental health diagnosis/diagnoses or what medications the resident's mental health diagnosis/diagnoses required for treatment. Additional interventions included administering medication per physician's order, monitoring for side effects and notifying the physician of any adverse or consistent side effects that occurred related to psychotropic drug use, staff were to document target symptoms each shift and notify the physician of any new/worsened symptoms of mental illness that were not effectively managed with current pharmacological and non-pharmacological interventions. If the resident's mental health symptoms became unmanageable in-house or a mental health crisis occurred, staff were to call the crisis line or notify the physician to obtain transfer orders for a psychiatric evaluation in the hospital setting and the psychotropic committee would review medication regimen, target symptoms and side effects at least quarterly and make recommendations as indicated. A Colorado Suicide Lethality Screening Tool (CSLST), dated 1/1/25 at 5:54 p.m., revealed in the past weeks, Resident #4 wished she was dead. In the past weeks, the resident felt she or her family would be better off if she was dead. In the past weeks, the resident had thoughts about killing herself. The resident was currently having thoughts of killing herself right now. The resident told a licensed practical nurse (LPN) that she wished she was dead and if she had a gun, she would shoot herself and if she had a knife, she would stab herself. -There was no documentation in Resident #4's electronic medical record (EMR) to indicate the resident was placed on increased monitoring or that the resident's physician, the nursing home administrator (NHA) or the director of nursing (DON) were notified of the resident's suicidal ideation after the CSLST was completed on the evening of 1/1/25 and identified that the resident expressed wanting to kill herself. The Healthcare Resident Safety Plan was signed by the resident on 1/1/25 (no time documented). The purpose of the safety plan was to identify triggers/warning signs the resident might experience during a mental health crisis. It was also used to remind the resident of helpful activities and people that could help keep the resident safe, if the resident experienced a mental health crisis. A social services note, dated 1/2/25 at 10:00 a.m., revealed Resident #4 was placed on frequent checks for 72 hours. A nurse note, dated 1/2/25 at 10:12 a.m., revealed the resident's primary care physician (PCP) was notified of the resident's suicidal ideations and the PCP would evaluate the resident during today's (1/2/25) rounding. -Review of Resident #4's EMR did not reveal documentation of the 15-minute checks. An eINTERACT situation, background, assessment and recommendations (SBAR) summary for providers note, dated 1/2/25 at 1:44 p.m. by Resident #4's physician, revealed the resident had a change in condition. Nursing observations, evaluations, and recommendations revealed the resident said if she had a way to kill herself, she would. The resident made mention of a gun, knife and pills. The resident said the only thing that was stopping her, was that she had nothing (to help her commit the act). The PCP recommended sending the resident to the emergency room (ER) at the hospital for evaluation and treatment. A nurse note, dated 1/2/25 at 2:25 p.m., revealed Resident #4 was sent to the ER for evaluation and treatment related to recent ideations of self-harm. A call was made to the ER and a report was provided. The resident said that if she had a gun she would shoot herself and if she had a knife, she would stab herself. Resident #4 said if she had medication available, she would take it all. A non-emergent ambulance was called and given the same report. The non-emergent ambulance arrived and left the building at 2:35 p.m. The resident's physician and power of attorney (POA) were notified according to the DON and the social services director (SSD). -The facility failed to send Resident #4 to the ER for a mental health evaluation until almost 24 hours after the resident initially expressed wanting to kill herself. The ER report revealed Resident #4 arrived at the hospital on 1/2/25 at 2:44 p.m., by ambulance. The resident was brought to the ER by emergency medical services (EMS) for an evaluation of depression and verbalizing possible suicidal thoughts. The resident said, on Christmas Eve, she did not have any visitors and was not allowed to participate in the holiday party at the facility. This occurred again on New Year's Eve and she became very depressed. However, she was currently feeling better and did not feel like she wanted to hurt herself. When asked what she would like, she said she wanted to go back to her room at the facility and get into her bed. The resident was discharged from theER on [DATE] at 3:07 p.m., with education materials for depression. A nurse note, dated 1/2/25 at 3:48 p.m., revealed Resident #4 returned to the facility with no new orders. The resident was alert and had no pain or discomfort. The resident made no further ideations. A skilled charting note, dated 1/2/25 at 7:24 p.m., revealed Resident #4 had not made any further ideations of self-harm after returning from the ER. The resident was alert and able to make her needs known. The resident was mobile with the use of a wheelchair. The resident was resting in bed. A history and physical note, dated 1/2/25 at 7:56 p.m. and written by Resident #4's physician, revealed the resident reported suicidal ideations today (1/2/25) to the nursing staff. The resident said if she had a way to kill herself, she would, regardless of the method. The facility sent the resident to the ER for evaluation. The ER physician called this physician and reported that the resident's mood had improved, she was no longer suicidal and the resident wanted to come back to the facility. -However, Resident #4 had reported suicidal ideations to the facility staff on 1/1/25, not 1/2/25 (see above). A physician's order, dated 1/4/25 at 3:40 p.m., revealed to administer Sertraline HCl oral tablet 25 milligrams (mg), one tablet by mouth once a day for anxiety. -The physician's order was not obtained until 1/4/25, three days after Resident #4 expressed wanting to kill herself. Review of Resident #4's baseline care plan for social services, locked on 1/6/25, revealed the resident had mental health needs/behavioral concerns for behavioral health services following suicidal ideations. The interventions to address mental health needs/behavioral concerns were for frequent monitoring. The care plan also revealed the pertinent initial care plan focus statement, goals and interventions related to mental health needs: the resident had a mental health diagnosis of major depressive disorder and required the use of an antidepressant. The interventions further revealed if the resident's mental health symptoms became unmanageable in-house or a mental health crisis occurred, staff were to call the crisis line or notify the physician to obtain transfer orders for a psychiatric evaluation in the hospital setting. Staff were to obtain informed consent for the use of psychotropic medication. The medication regimen included black box warnings that would be reviewed in each care conference meeting. The psychotropic committee would review medication regimen, target symptoms and side effects at least quarterly and make recommendations as indicated. The baseline care plan for social services further revealed the staff should use the following non-pharmacological interventions to help manage the resident's behavioral symptoms of: (SPECIFY symptoms/behaviors that resident displays) (SPECIFY). Additional interventions were to provide opportunities for socialization, provide encouragement, support and active listening, provide reality orientation if appropriate, do not provide reality orientation if the resident was unable to be oriented to reality or it was distressing to the resident and avoid resident's triggers: (specify). -The facility failed to develop Resident #4's social services baseline care plan to specify the symptoms/behaviors the resident displayed that staff should use non-pharmacological interventions for or what the resident's triggers for the behaviors were. A comprehensive care plan focus for Resident #4's history of suicidal ideations was initiated on 1/6/25. The interventions included a behavioral health service referral was to be completed, having a safety plan and suicide contract in place, staff would monitor and manage any undesirable behaviors, if the resident posed a potential threat to injure herself or others, the staff were to notify her provider, if the resident was safe, staff was to allow the resident personal space and if the resident wandered or paced, staff were to initiate visual supervision during the acute episode. -However, there was no documentation in Resident #4's EMR to indicate the facility referred the resident for behavioral health services. Additional interventions included staff were to maintain a consistent schedule with daily rounding, minimize the resident's environmental stimuli, monitor for cognitive, emotional or environmental factors that might contribute to violent behaviors, monitor the resident for signs/symptoms of agitation, offer the resident acceptable alternatives to unacceptable situations, provide clear, simple instructions, provide reorientation to situations and provide verbal feedback to the resident regarding behaviors. -The facility failed to initiate a comprehensive care plan focus for suicidal ideations until 1/6/25, five days after the resident expressed wanting to kill herself. An interdisciplinary team (IDT) event note template, dated 1/6/25 at 9:44 a.m., revealed Resident #4 had suicidal ideations on 1/2/25. The root cause was the resident had a recent hospitalization and a history of alcohol use. The ER physician had cleared the resident from harm/ideations and the new intervention was to refer the resident for behavioral health services. -However, Resident #4 had reported suicidal ideations to the facility staff on 1/1/25, not 1/2/25 (see above). -Additionally, there was no documentation in Resident #4's EMR to indicate the facility referred the resident for behavioral health services. A care conference summary note, dated 1/7/25 at 11:40 a.m., revealed Resident #4 was in attendance and had no nursing or medication concerns. The resident said she had frequent discomfort (pain). The Psychological Assessment, dated 1/9/25 at 10:37 a.m., revealed Resident #4's cognition was moderately impaired. The resident did not require assistance with communicating. The resident had significant trouble adjusting to the facility upon admission but had since adjusted appropriately. The resident had alcohol abuse with severe withdrawals. The resident's psychological factors included mental health conditions, trauma, post-traumatic stress disorder (PTSD), substance abuse, behavioral issues, self-efficacy deficits, and lack of coping skills. The resident's social factors included lack of social support, strained family relationships, social isolation, desire for community involvement, desire for physical/sexual intimacy while in the facility and sexual identity concerns. The resident had diagnoses that included dementia, alcohol abuse, major depressive disorder, anxiety, suicidal ideation, isolation, tearfulness, and suicidal ideation by informing some staff of the ideation while denying the ideation to others. -The facility failed to conduct a Psychological Assessment until 1/9/25, eight days after the resident expressed wanting to kill herself. II. Staff interviews The activity director (AD) was interviewed on 1/27/25 at 10:34 a.m. She said Resident #4 attended the New Year's Eve party on 12/31/24 at 1:30 p.m. She said the resident only stayed at the party for about five minutes and did not mention any suicidal ideations. The SSD was interviewed on 1/27/25 at 11:07 a.m. She said Resident #4 told her, on 1/2/25, that she was actively suicidal, if she had a way to complete the act. She said the resident completed and signed the Healthcare Resident Safety Plan on 1/1/25 (not time documented). She said by signing the safety plan, Resident #4 acknowledged that she would not kill herself. She said the resident's physician assessed the resident on 1/2/25 and completed his note at 7:56 p.m. She said the resident was placed on frequent checks that were documented on a form. She said the resident also had an order for a referral to go to theER on [DATE]. The SSD said she was not made aware of the resident's lethality assessment until the morning of 1/2/25. She said if the lethality assessment was conducted, she should have been notified and if the resident was suicidal, she should have been notified immediately. -However, the facility was unable to provide documentation of the 15-minute checks. LPN #2 was interviewed on 1/27/25 at 11:28 a.m. LPN #2 said she interviewed Resident #4 and completed the Colorado Suicide Lethality Screening Tool (CSLST) on 1/1/25 at 5:54 p.m. She said she searched the resident's room for any type of item that the resident could use to harm herself and nothing was found. She said after the CSLST was completed, the staff rounded on the resident more often. LPN #2 said the resident stayed in her room and slept on and off. She said when the resident woke up, she was in a better mood. She said she started the resident on 15-minute checks and parked the medication cart by the resident's entrance door, so she could watch the resident. She said she told the oncoming registered nurse (RN) #2 for the next shift about the resident's suicidal ideations and handed RN #2 the 15-minute check form. She said she was very busy and did not call the DON or the NHA. She said she told additional staff and the DON about the resident's statements the next day, on 1/2/25. -However, the facility was unable to provide documentation of the 15-minute checks. The regional nurse consultant (RNC) and the DON were interviewed together on 1/27/25 at 11:41 p.m. The DON said she first became aware of Resident #4's suicidal ideations during the 1/2/25 morning meeting. She said after she saw the CSLST, she called the resident's physician at 10:12 a.m. The DON said the frequent checks started when she saw the CSLST. She said frequent checks did not have to be 15-minute checks that were documented on a form. The DON said Resident #4's physician assessed the resident and gave the order to send the resident to theER on [DATE] at 1:43 p.m. She said when staff used the CSLST, she should be notified that the form was used, regardless of the outcome on the form. She said she was not notified that the CSLST had been used to assess Resident #4 and she was not made aware of its findings after it had been completed. RN #1 was interviewed on 1/27/25 at 12:11 p.m. RN #1 said on 1/1/25 at approximately 10:30 a.m., Resident #4 was down the hall and she heard the resident mention suicidal ideations. She said she brought the resident to the nurse's station for one-to-one supervision. She said Resident #4 sat at the nurse's desk for a few hours and did not make any additional comments. She said the resident said she was not happy with her care. RN #2 was interviewed on 1/27/25 at 12:40 p.m. RN #2 said she came to work on 1/1/25 and during the report meeting, LPN #2 said Resident #4 had suicidal ideations and wanted to kill herself. RN #2 said she filled out the 15-minute check form, starting at 1/1/25 at 6:30 p.m. She said the 15-minute check form was continued until there were no more lines on the form. She said she filed the form in a folder at the nurse's station, for the possibility of the checks starting the next day. She said Resident #4 never told her of any suicidal ideations. She said the resident wanted coffee and Tylenol all during the night. She said the next day (1/2/25), LPN #2 came back to work and she already knew what the resident had said. The DON and LPN #2 were interviewed together on 1/27/25 at 1:50 p.m. LPN #2 said she was providing direct supervision of Resident #4 by placing her medication cart outside the resident's room and looking in on the resident during medication administration. She said when she came back to work the next morning, RN #2 did not give her the 15-minute check form. The DON said when a resident expressed suicidal ideations, the resident's physician should be notified and the resident should be placed on one-to-one supervision. The DON said the physician would provide a crisis assessment and/or possibly send the resident to the ER for a mental health assessment. The DON said Resident #4's physician did an assessment on the resident on 1/2/25 and decided he wanted to send the resident to the ER. The DON said the resident was not sent to the ER immediately on 1/1/25, because she was not aware of the resident's statements until the morning meeting on 1/2/25. The social services director (SSD) was interviewed again on 1/29/25 at 10:31 a.m. The SSD said from the time the resident entered the facility on 12/26/24 to 1/1/25, the resident had not exhibited any behaviors. She said she completed the Colorado Suicide Lethality Screening Tool (CSLST) on 1/1/25 for Resident #4. She said after the resident returned from the ER, she denied having any more suicidal ideations. The minimum data set coordinator (MDSC) was interviewed on 1/29/25 at 10:45 a.m. The MDSC said Resident #4's baseline care plan was developed on 12/27/24 and was updated and locked on 1/6/25. She said the admit/readmit screener assessment, dated 12/26/24 at 2:55 p.m., did not mention that the resident had depression or any behaviors. She said the first progress note to mention the resident had behaviors and was on frequent checks was on 1/2/25. She said the resident went to theER on [DATE] and the intervention for the behavioral health services for psychological treatment was on 1/6/25 at 9:44 a.m. The RNC and the SSD were interviewed together on 1/29/25 at 12:01 p.m. The RNC and the SSD said Resident #4 was assessed on admission and had no behaviors until she made the statement of suicidal ideation on 1/1/25. The RNC and the SSD said the resident was on skilled services and staff did a daily nurse assessment on the resident which included monitoring of cognition and mood/behaviors. The RNC and the SSD said until 1/1/25, there was no mention of any behaviors for Resident #4 in the nurse notes. The RNC said before the resident's suicidal ideation statement on 1/1/25, the facility's corporate office had provided training to all the social workers on psychosocial topics and this had been an ongoing process. The RNC said additional audits had been conducted at the facility to review resident progress notes for changes in condition, psychotropic medication orders and PASRR (pre-admission screening and resident review), and five selected residents' daily progress notes were audited for dignity. The RNC said the facility looked to see if any residents had suicidal ideations and if the facility responded appropriately.

Based on record review and interviews, the facility failed to prevent verbal abuse for one (#5) of seven residents reviewed for abuse out of 14 sample residents. Specifically, the facility failed to ensure Resident #5 was free from verbal abuse from Resident #6. Findings include: I. Facility policy and procedure The Abuse Policy, revised 6/11/24, was provided by the regional nurse consultant (RNC) on 1/27/25 at 1:31 p.m. The policy revealed every resident had the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. The facility did not condone resident abuse and would take every precaution to prevent resident abuse. All occurrences of resident abuse, suspected abuse, neglect and injuries of unknown source would be promptly reported to the facility abuse coordinator for investigation. Resident abuse was 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 were necessary to attain or maintain physical, mental or psychosocial well-being. Abuse included any type of abuse that was facilitated or enabled through use of technology or social media. Verbal abuse was the use of oral, written or gestured language that included disparaging or derogatory terms to residents or within their hearing distance, regardless of their ability to comprehend. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property were reported immediately, but no later than two hours, after the allegation was made if the event that caused the allegation involved abuse or resulted in serious bodily injury; or not later than 24- hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provided jurisdiction in long term care facilities and office of long term care ombudsman) in accordance with state law through established procedures. All employees of the facility would immediately report any suspected, observed or reported incidents of resident abuse, neglect, misappropriation of resident property, whether by staff members, family members or any other persons to the administrator or administrator's designee. The administrator served as the abuse coordinator of the facility. The facility permitted the administrator or the administrator's designee to report suspected crimes or allegations of abuse to law enforcement, the State Survey Agency, and/or APS in place of the staff member who witnessed the suspected crime or reported the allegation of abuse. The director of nursing (DON) or designee would ensure that the medical director and resident representative (as applicable) was notified of all incidents or suspected incidents of resident abuse, mistreatment, neglect or injury of unknown source. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator, or his/her designee, would conduct an investigation of the alleged incident. The administrator or designee would interview any staff members, residents, family members or any others who might have knowledge of the incident and document a summary of interviews completed. The administrator or designee would report the results of all investigations to the State Survey Agency within five working days of the incident and other agencies as required by state law or regulation. If the alleged violation was substantiated, the appropriate corrective action would be taken. The facility would ensure that all residents were protected from physical and psychosocial harm during and after abuse investigations, including but not limited to, responding immediately to protect the alleged victim, examining the alleged victim for any sign of injury, including a physical examination and/or psychosocial assessment as indicated, increased supervision of the alleged victim and other residents as indicated, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, protection from retaliation and provide emotional support and/or counseling to the resident during and after the investigation as needed. Residents with aggressive or abusive behaviors would have their care plans written and revised as needed to include approaches to reduce or eliminate the risk for abuse. If one resident jeopardized the safety of another resident, alternative placement might be considered for that resident. II. Incident of verbal abuse between Resident #5 and Resident #6 on 1/1/25. The facility's incident report for verbal aggression, dated 1/1/25 at 8:35 a.m., revealed Resident #6 was yelling obscenities at Resident #5. No physical altercations occurred. The floor nurse immediately intervened and stopped the altercation. Resident #6 was asked to leave the shared room. Resident #6 went back into the room six times and starting yelling at Resident #5. Resident #6 reported being upset because of a shared television. Resident #6 was offered to move rooms and accepted. Resident #5 denied being fearful of Resident #6. Resident #5 stated that she was very upset with the way she was spoken to during the verbal altercation. Resident #5 said that her roommate, Resident #6, was fighting with her over the television channel. Resident #6 was moved out of the shared room, until the staff could decide where the resident could be moved to a different room. No injuries were observed on either resident. The nursing home administrator (NHA) and the director of nursing (DON) were notified and both residents were put on 15-minute checks for 72 hours. The nursing home administrator (NHA) provided typed documentation of the interviews that he conducted on 1/1/25 (no time given). The document revealed the NHA interviewed Resident #5 who said she wanted to finish her television show but Resident #6 wanted to watch another show. Resident #6 argued with Resident #5 but then left the room. Resident #6 continued to come into the room and escalated the conversation. Resident #6 got upset with Resident #5, insulted her by calling her obscenities and pointed her finger at Resident #5. Registered nurse (RN) #1 and some certified nurse aides (CNA) went in to console Resident #5 as she was crying and said she would rather go to her grave. The NHA interviewed Resident #6 who said she asked to watch a television show and Resident #5 wanted to continue to watch her television show. Resident #6 got upset when Resident #5 did not want to change the television show. Resident #6 requested to change rooms. The NHA interviewed RN #1. RN #1 said Resident #5 and Resident #6 were arguing about the television. RN #1 tried to find a compromise but was unable to find one. When the situation between the residents escalated, RN #1 asked Resident #6 if she would come to the nurse's station while a solution could be found. The NHA summarized that the residents were arguing about the television. Resident #6 wanted to watch a television program but Resident #5 wanted to finish the program that she was watching. Both residents starting arguing, which resulted in Resident #5 crying and Resident #6 requesting to have her own room. Resident #6 was immediately given her own room, which alleviated her television frustrations. Mental health services were offered to both residents. The facility concluded that Resident #6 yelled at Resident #5. III. Resident #5 - victim A. Resident status Resident #5, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included schizoaffective disorder, depression, anxiety and metabolic encephalopathy. The 12/2/24 minimum data set (MDS) assessment documented the resident had intact cognitive ability with a brief interview for mental status (BIMS) score of 15 out of 15 with no behaviors. The resident had no impairments in functional ranges of motion. The resident was independent in sit to stand with the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The resident was also independent with chair/bed-to chair transfers and had the ability to transfer to and from a bed to a chair (or wheelchair). B. Resident interview Resident #5 was interviewed on 1/28/25 at 2:07 p.m. Resident #5 said Resident #6 wanted to change the television channel and she did not want her to change the channel to a news station. She said Resident #6 was not yelling at her but only wanted to change the television channel. She said she had no concerns with Resident #6. C. Record review Resident #5's care plan for the potential to be physically aggressive, verbally aggressive and accusatory related to a history of swatting and yelling at staff was initiated on 11/18/23 and revised on 11/5/24. The interventions included providing the resident with positive feedback. The resident escalated toward verbal aggression when staff wanted to wash her clothes, asking about personal hygiene and dentures. The resident's behaviors were de-escalated by calmly walking away, not arguing with the resident, changing the subject and talking about something else. Resident #5's care plan for impaired cognitive function related to developmental delays from birth was initiated on 11/4/23. The interventions included for staff to observe/document/report as needed any changes in cognitive function, specifically, changes in decision-making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and/or mental status. The resident would maintain her current level of decision-making ability by the review date. The staff were to cue, reorient and supervise the resident as needed. The staff were to communicate with the resident/family/caregivers regarding the resident's capabilities and needs. A care plan for a pre-admission screening resident review (PASRR) Level II related to the resident meeting the criteria for major mental illness (MMI) with a primary diagnosis of schizoaffective disorder, depressive type was initiated on 4/30/24. The interventions included allowing the resident to answer questions and to verbalize her feelings, perceptions and fears as needed, encouraging the resident to participate in non-pharmacological interventions based on interests, evaluating the resident's cognitive abilities for participation in recommended services and notifying the physician of any changes. The resident had signed up for behavioral health services for medication management with counseling, which she refused. A care plan, initiated on 1/1/25, revealed to monitor Resident #5 for any signs or symptoms related to verbal abuse for 90 days. The interventions included engaging the resident to express her feelings and monitoring/reporting any signs or symptoms of trauma, such as heightened emotions, to a nurse immediately. A nurse note, dated 1/1/25 at 1:17 p.m. and written by RN #1, revealed she heard a verbal altercation between Resident #5 and her roommate (Resident #6). Resident #5 was watching a television show and Resident #6 began yelling at Resident #5 to change the channel on the television. Resident #6 was using profanities/obscenities at Resident #5. After Resident #5's television show was over, she turned the television to the channel Resident #6 wanted to watch. Resident #6 started yelling at Resident #5 again for not turning the volume up on the television. The television was quite loud when RN #1 entered the room a second time. Resident #6 was asked to leave the room and sat outside of the shared room. RN #1 walked away from the residents' room. About three minutes after RN #1 walked away from the area, Resident #6 went back into the shared room and started yelling at Resident #5 again. RN #1 went into the room and removed Resident #6 from the room, to the nurse's station. The NHA interviewed all that were involved in the incident. A nurse note, dated 1/1/25 at 8:35 a.m. and written by the DON, revealed it was reported that Resident #6 was yelling obscenities at Resident #5. No physical altercation occurred. The floor nurse (RN #1) immediately intervened. Resident #6 reported being upset because of a shared television. Resident #6 was offered to move rooms and accepted. Resident #5 denied being fearful of Resident #6. The DON, the NHA, the social service director (SSD) and the floor nurses were notified and were to monitor the residents. A psychological follow up note, dated 1/2/25 at 9:00 a.m. and written by a nurse practitioner (NP), reiterated RN #1's note on 1/1/25 at 1:17 p.m. It further revealed Resident #5 had good eye contact and was guarded. The resident was depressed and anxious. The resident had appropriate thought processes and associations were logical. The resident had no hallucinations, suicidal ideations or homicidal ideations. A physician's note, dated 1/2/25 at 7:49 p.m., revealed nursing reported that there was resident to resident conflict and that Resident #5 was a victim of verbal abuse by another resident. Resident #5 initially said that she did not want to live but nursing said she had improved since yesterday (1/1/25) when the incident happened. Resident #5 no longer felt that she would be better off dead. IV. Resident #6 - assailant A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included depression, major depression, polyneuropathy, anxiety and chronic pain syndrome. The 12/6/24 MDS assessment documented the resident had intact cognition with a BIMS score of 15 out of 15 with no behaviors. The resident had little interest or pleasure in doing things. The resident felt down, depressed or hopeless. The resident was independent with indoor mobility (ambulation). The resident needed some staff help with functional cognition (planning regular tasks). B. Resident interview Resident #6 was interviewed on 1/28/25 at 3:41 p.m. Resident #6 said she did not want to discuss the verbal altercation involving Resident #5. C. Record review Resident #6's care plan for a mental health diagnosis of depression that required the use of an antipsychotic was initiated on 12/11/24. The interventions included administering medications as ordered, monitoring for any side effects and notifying the physician of any adverse or consistent side effects that occurred related to the use of a psychotropic medication, documenting target behaviors each shift, notifying a physician of any new/worsened symptoms of mental illness that were not effectively managed with current pharmacological and non-pharmacological interventions and the psychotropic committee would review the resident's medication regimen, target symptoms/side effects at least quarterly and make recommendations as indicated. Resident #6's care plan for the potential to be verbally aggressive related to a diagnosis of depression and anxiety was initiated on 1/1/25. The interventions included administering medications as ordered, monitoring/documenting any side effects/effectiveness of medications, behavioral health consults as needed and assisting the resident in developing and providing the resident with a program of activities that was meaningful and of interest. The staff were to encourage and provide opportunities for exercise and physical activity. A nurse note, dated 1/1/25 at 1:17 p.m., and written by RN #1, revealed she heard a verbal altercation between Resident #6 and her roommate (Resident #5). Resident #5 was watching a television show and Resident #6 began yelling at Resident #5 to change the channel on the television. Resident #6 was using profanities/obscenities at Resident #5. After Resident #5's television show was over, she turned the television to the channel Resident #6 wanted to watch. Resident #6 started yelling at Resident #5 again for not turning the volume up on the television. The television was quite loud when RN #1 entered the room a second time. Resident #6 was asked to leave the room and sat outside the shared room. RN #1 walked away from the residents' room. About three minutes after RN #1 walked away from the area, Resident #6 went back into the shared room and started yelling at Resident #5 again. RN #1 went into the room and removed Resident #6 from the room, to the nurse's station. The NHA interviewed all that were involved in the incident. A nurse note, dated 1/1/25 at 8:35 a.m. and written by the DON, revealed it was reported that Resident #6 was yelling obscenities at Resident #5. No physical altercation occurred. The floor nurse (RN #1) immediately intervened. Resident #6 reported being upset because of a shared television Resident #6 was offered to move rooms and accepted. Resident #5 denied being fearful of Resident #6 The DON, the NHA, the SSD and the floor nurses were notified and were to monitor the residents. A follow up note dated 1/2/25 at 7:55 p.m., by a physician revealed this resident was verbally abusive to another resident (her roommate) yesterday. They have since been separated. An event note template, dated 1/3/25 at 9:13 a.m., revealed Resident #6 was verbally aggressive towards another resident (Resident #5). The risk factors/root cause was the television channel. The resident had a diagnosis of major depression disorder and was in a new environment. The residents were separated and provided independent rooms. V. Staff interviews RN #1 was interviewed on 1/28/25 at 1:17 p.m. RN #1 said she was conducting a medication pass and heard a verbal altercation between Resident #5 and Resident #6. Resident #6 was yelling at Resident #5 because she wanted to watch a news channel and Resident #5 wanted to finish watching the program currently on the television. She said there was only one television in the room. She said Resident #6 was yelling foul names and profanities at Resident #5. RN #1 said she asked Resident #6 to step out of the room and talk with the staff. RN #1 said Resident #6 stepped out of the room and she thought the incident had been settled. RN #1 said she continued with her medication administration. She said Resident #6 went back into the room and started yelling at Resident #5 about the volume on the television. RN #1 said she went into the room and asked Resident #6 to leave the room a second time. She said Resident #6 came out of the room and sat down near the nurse's station. She said Resident #6 sat at the nurse's station for about 30-45 minutes to drink a cup of coffee and talk with staff. RN #1 said Resident #5 became very emotional after being verbally attacked by Resident #6. Rn #1 said Resident #6 was told that she would be moved to another room and she was okay with this decision. She said once the residents were in separate rooms, staff started 15-minute checks on both residents. RN #1 said Resident #5 never said she was fearful of Resident #6. The RNC and the DON were interviewed together on 1/28/25 at 4:19 p.m. The RNC said it was reported that Resident #5 and Resident #6 got into a verbal altercation because Resident #6 wanted to watch a news channel. The RNC and the DON said they did not witness any of the altercations. The RNC and the DON said, to their knowledge, this was the first and only altercation between the two residents The NHA was interviewed on 1/29/25 at 10:21 a.m. The NHA said Resident #5 and Resident #6 had a verbal disagreement. He said to his knowledge, this was the first and only altercation between the two residents. The NHA said after the altercation, he came into the facility and started doing interviews of those involved in the incident.

Based on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#4) of four residents out of 15 sample residents. Resident #4, who had diagnoses of type 2 diabetes mellitus with chronic kidney disease and foot ulcers, heart failure and osteomyelitis (infection of the bone) of the left ankle and foot, was admitted from the hospital on 9/16/24 with surgical wounds to both heels following surgical debridement (removal of dead tissue) of his diabetic wounds and placement of a wound vacuum (negative pressure wound therapy) on the left heel. Hospital discharge instructions included the resident was to be non-weight bearing to bilateral lower extremities and Prevalon boots (soft heel protection boots) were to be worn on both feet. However, the facility failed to enter physician's orders for Resident #4's non-weight bearing status or Prevalon boots into the resident's electronic medical record (EMR) upon the resident's admission to the facility. Additionally, the facility failed to include the use of Prevalon boots or Resident #4's non-weight bearing status on the skin and pressure ulcer care plan initiated on 9/17/24. Resident #4 began receiving weekly visits by the wound care physician on 9/18/24. However, documentation revealed the resident was not seen by the wound care physician on 10/1/24, 10/23/24, 11/6/24 and 11/26/24. The 11/20/24 wound care physician visit record revealed the wound on Resident #4's left heel had worsened and increased in size since the last visit on 11/13/24. Resident #4 declined sharp debridement (removing dead or unhealthy tissue) on 11/20/24 and the wound care physician removed the wound vacuum. The wound care physician changed the treatment order and planned to re-evaluate in one week. On 11/24/24 the nursing skin assessment documented Resident #4's left heel wound was improving without the wound vacuum, but had eschar (black, scab-like dead tissue) and a mild odor. There was no documentation the physician was notified of the eschar or odor. The wound care physician did not evaluate the resident's left heel wound on 11/26/24. The nurse documented completing the wound care on 11/26/24 but did not complete a skin assessment or wound progress note on 11/26/24. The nursing progress note dated 11/28/24 documented the left heel wound was described as having a blackened area to the wound bed and as having a foul odor. The wound care physician was contacted and recommended sending Resident #4 to the emergency department for treatment of a worsening wound. Findings include: I. Facility policy and procedure The Wound Care policy, dated 12/19/16, was provided by the regional director of quality and compliance (RDQC) on 12/31/24 at 2:28 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for treatment/wound care to be provided. Dress wounds in accordance with the physician's order. Notify the resident's attending physician if the resident refused wound care. Report other information in accordance with professional standards of practice. II. Resident #4 A. Resident status Resident #4, age 75, was admitted on [DATE] and discharged to the hospital on 11/28/24. According to the November 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with chronic kidney disease and foot ulcers, heart failure, atherosclerotic heart disease (plaque build-up in arteries), atrial fibrillation (irregular heart rhythm) and osteomyelitis of the left ankle and foot. The 9/19/24 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) was not completed. However, a BIMS assessment was completed on 9/26/24 and Resident #4 had a BIMS score of 13 out of 15, indicating his cognition was intact. He required minimal assistance with bed mobility and maximum assistance with transfers. The assessment documented the resident had an infection of the foot, diabetic foot ulcers, other open lesions of the foot and surgical wounds. He had a pressure reducing device for his bed and wheelchair and he was not on a turning or repositioning program. The assessment documented the resident had an application of dressings to his feet (with or without topical medications). B. Record review Review of Resident #4's 9/16/24 hospital discharge instructions revealed the resident was to be non-weight bearing to bilateral lower extremities and Prevalon boots (soft heel protection boots) were to be worn on both feet. The skin and pressure ulcer care plan, initiated 9/17/24, revealed Resident #4 had the potential for altered skin integrity due to limited mobility, had moisture associated skin damage on the buttocks and groin and had open surgical wounds on both heels. Interventions included educating the resident on frequent repositioning, providing treatments per physician's orders and notifying the physician if wounds did not respond to treatment, encouraging good nutrition, monitoring for signs of infection (redness, warmth, odor, pain), providing wound consultation weekly and changing the wound vacuum every Wednesday and Saturday. -The care plan failed to include the use of Prevalon boots or Resident #4's non-weight bearing status. -The care plan did not include an intervention of an air mattress or a pressure reduction mattress (see physician's orders below). Review of Resident #4's September 2024 CPO revealed a physician's order for an air mattress to the resident's bed, ordered 9/17/24. The physician's order did not include air mattress settings or checking to assure the mattress was working every shift. The physician's order was discontinued on 9/20/24. Review of Resident #4's November 2024 CPO revealed the following physician's orders: Change the wound vacuum to the left heel every Wednesday and Saturday, ordered 10/31/24, discontinued 11/12/24, restarted 11/14/24 and discontinued a second time on 11/20/24. Weekly skin checks on Tuesdays, ordered 9/16/24. -Review of Resident #4's October 2024 treatment administration record (TAR) revealed the resident's wound vacuum was not changed on 10/1/24. -There was no documentation to indicate the wound care physician was notified that the resident's wound vacuum was not changed or why it was not changed on 10/1/24. The 10/24/24 at 2:05 a.m. nurse progress note documented the resident refused to have the wound vacuum changed (on 10/23/24) because it was too late and the resident did not want it changed. -However, there was no documentation to indicate the resident's wound vacuum was changed on the following day or that the wound care physician was notified of the resident's refusal to have the wound vacuum changed. -Resident #4's November 2024 TAR revealed no documentation that the resident's wound vacuum was changed on 11/6/24 or 11/13/24. -There was no documentation to indicate the wound care physician was notified that the resident's wound vacuum was not changed or why it was not changed on 11/6/24 or 11/13/24. -Additionally, the November 2024 TAR revealed there was no documentation that weekly skin checks were completed for Resident #4 on 11/19/24 or 11/26/24. A 11/24/24 skin check assessment documented Resident #4's left heel wound was draining serosanguineous fluid (fluid that contains the liquid part of blood and blood and is generally clear/yellowish in color) and the wound edges had thick slough. There was a mild odor noted and eschar was present. -There was no documentation in Resident #4's EMR to indicate that the nurse notified the physician of the changes noted in the resident's left heel wound. Review of Resident #4's wound care physician consultations revealed the resident's left heel wound was not seen by the wound care physician on 10/1/24, 10/23/24, 11/6/24 and 11/26/24. Progress notes revealed the wound care physician was not available on 10/1/24, however, no alternate visit was scheduled. -There was no progress note documenting why the 10/23/24 wound care physician visit did not occur. The 11/6/24 wound care physician visit was cancelled due to bad weather and was not rescheduled. A 11/26/24 progress note revealed the wound care physician came to the facility on [DATE] but did not see any residents because there was not a facility nurse available to make rounds with the physician. The 11/20/24 wound care physician care visit note revealed the wound on Resident #4's left heel had worsened and increased in size from 4.5 centimeters (cm) in length by 4.7 cm in width by 0.2 cm in depth with 100% granulation (healing tissue) and no undermining (erosion under the skin) to 5.2 cm in length by 5.5 cm in width by 0.2 cm in depth with 40% slough (refers to dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material) and 60% granulation (healing tissue) with no eschar (hard scab-like tissue) and 0.6 cm undermining since the last visit on 11/13/24. Resident #4 declined sharp debridement (removing dead or unhealthy tissue) on 11/20/24 and the wound care physician removed the wound vacuum. The wound care physician changed the treatment order to cleanse the wound, apply oil immersion gauze to the wound bed, cover with one-half strength Dakin's solution (wound treatment solution used to prevent infection) soaked gauze and secure with an abdominal (ABD) pad (a highly absorbent, cushioning dressing), kerlix (rolled gauze bandage) and an elastic rolled bandage to secure the wound dressings three times per week. The wound care physician planned to re-evaluate in one week. The wound care physician recommended following up with podiatry if there was no improvement. The 11/26/24 nurse progress note documented the wound care physician was in the building but did not see residents because the facility's wound care nurse was not available to assist with wound rounds. Resident #4 was documented as being very upset because the wound care physician did not see him and the resident was worried his wounds were not healing. The nurse documented completing the wound care but did not complete a wound care progress note on 11/26/24. -There was no documentation in the EMR to indicate the wound care physician was notified that the resident was concerned his wound was not healing. The 11/28/24 nurse progress note documented Resident #4's left heel wound had a blackened area to the wound bed and was noted to have a foul odor. The wound care physician was contacted and the physician recommended sending Resident #4 to the emergency department for treatment of a worsening wound. III. Staff interviews The RDQC, the nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 12/31/24 at 12:07 p.m. The RDQC said Resident #4 was admitted on [DATE] after a two week acute hospital stay. The RDQC said the resident's heel wounds started as diabetic ulcers and the resident had surgical repair, including bone grafts, to both heels. The RDQC said there were inconsistencies in the medical record regarding whether the wounds were caused by pressure or diabetic ulcers. The RDQC said the resident's wounds were stable until approximately 11/8/24 when the resident started declining and wanted to change to comfort care. -However, Resident #4's left heel wound was not seen by the wound care physician on 10/1/24, 10/23/24 or 11/6/24 and the wound vacuum was not changed per the physician's orders on 10/23/24 (see record review above). The RDQC said Resident #4 was wavering on whether to continue the wound vacuum and it was stopped for one day on 11/13/24 and returned to the rental company. The RDQC said the wound vacuum was initiated again on 11/15/24 until the wound care physician decided to discontinue it again on 11/20/24. The RDQC said she was unaware the wound care physician came to the facility on [DATE] and left without seeing residents. The RDQC said timeliness of weekly skin checks was part of a performance improvement plan (PIP) initiated by the facility on 10/15/24. The RDQC said the facility was still working on the accuracy of care plans. -However, despite the initiation of the 10/15/24 PIP, Resident #4's care plan was not updated to include the use of Prevalon boots or the resident's non-weight bearing status. Additionally, weekly skin assessments were not completed for the resident on 11/19/24 or 11/26/24 (see record review above). The DON said she knew the wound care physician was scheduled to visit on 11/26/24 but he was late and when he arrived, the facility did not have a nurse to make wound rounds with him. The DON said if the wound care physician was unavailable she would expect the nurses to do the wound rounds without the physician. The DON said nurses were to notify the wound care physician if there was a change in a resident's wound. The DON said weekly skin assessments should be documented in the EMR. The NHA said if the facility had identified any issues with Resident #4's weekly skin assessments in their audits and reported them to the QAPI committee in November 2024, he would provide the documentation. -There was no documentation indicating Resident #4's weekly skin assessments were discussed at the November 2024 QAPI meeting provided by the NHA by the survey exit on 12/31/24. IV. Additional information The NHA provided the facility's 10/15/24 PIP on 12/31/24 at 12:49 p.m. The PIP indicated resident care plans were to be reviewed and updated by 10/28/24. Weekly audits of skin assessments began on 10/24/24 and findings were to be reported to the quality assurance and performance improvement committee (QAPI) for 12 weeks. -However, Resident #4's care plan was not updated to include the use of Prevalon boots or the resident's non-weight bearing status. Additionally, weekly skin assessments were not completed for the resident on 11/19/24 or 11/26/24 (see record review above).

Based on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for one (#8) of four residents reviewed out of 15 sample residents. Resident #8, who was at risk for developing pressure ulcers and had a history of pressure ulcers, was admitted on [DATE] and readmitted to the facility on [DATE] after a three-day hospital stay. The readmission skin assessment, dated 11/6/24, documented the resident had a 1.0 centimeter (cm) by 1.0 cm scabbed area on his coccyx which the nurse covered with a foam dressing. However, there was no documentation that a treatment order was requested or that the facility's wound nurse or the wound care physician were notified of the skin concern. The 11/6/24 primary care physician's readmission history and physical examination documentation did not indicate Resident #8 had any current skin issues. The weekly nursing skin assessment, dated 11/13/24, documented Resident #8 had a reddened area to his coccyx measuring 1.0 cm by 1.0 cm and a foam dressing was applied for comfort. Again, there was no documentation that a treatment order was requested or that the facility's wound nurse or the wound care physician were notified of the skin concern. The 12/9/24 weekly nursing skin assessment documented Resident #8 did not have redness or any open area to his coccyx. However, the 12/16/24 weekly nursing skin assessment documented the resident had a 1.0 cm round open area on his sacrum/coccyx. On 12/18/24 the wound care physician documented Resident #8 had an unstageable pressure injury to his sacrum measuring 1.6 cm by 1.5 cm by 0.2 cm in depth and covered with 100% slough (refers to dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material). The wound care physician recommended treatment orders to cleanse the wound, apply Medihoney (wound treatment that prevents bacterial growth) and cover with a border gauze every other day and as needed. The facility failed to notify the wound care nurse and the wound care physician of the skin concern noted to Resident #8's coccyx upon his readmission to the facility and obtain appropriate physician's orders for treatment. Due to the facility's failures, the resident's skin concern developed into an unstageable pressure injury to his coccyx which increased in size from 1.0 cm by 1.0 cm on 11/6/24 to 1.6 cm by 1.5 cm by 0.2 cm by the time the resident was assessed by the wound care physician on 12/18/24. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 1/2/25 from https://www.internationalguideline.com/guideline on, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Prevention of Pressure Ulcers/Injuries policy, dated 12/19/16, was provided by the regional director of quality and compliance (RDQC) on 12/31/24 at 2:28 p.m. It read in pertinent part, Newly identified skin impairments should be reported by the licensed nurse to the attending physician to obtain new treatment orders. Routine skin assessments should be performed by the licensed nurse after admission in accordance with the physician's order. III. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE], discharged to the hospital on 11/3/24 and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included bipolar disorder, generalized anxiety disorder, cerebral palsy (a neurological disorder affecting the ability to move, maintain balance and control muscles), hypomagnesemia (low magnesium) and chronic pain syndrome. The 9/29/24 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. The resident was independent or required minimal assistance with bed mobility and dressing and was independent with transfers. The assessment indicated the resident was at risk of developing pressure ulcers. B. Resident interview and observation Resident #8 was interviewed on 12/30/24 at 11:34 a.m. Resident #8 was sitting in his wheelchair. There was no specialty air mattress on his bed. He said he had a sore on his bottom that was caused at the facility because they gave him a new wheelchair cushion that was too hard and thin. Resident #8 pointed out the wheelchair cushion lying near his roommate's dresser. Resident #8 said he was now using his old wheelchair cushion which was thicker and softer. Resident #8 said he had a history of a sore, open to the bone, on his bottom but it was healed. Resident #8 said he should have had a dressing put on the wound on his bottom this morning (12/20/24) after his shower, but the nurse kept putting it off. He said he did not currently have a protective dressing on his bottom. On 12/30/24 at 12:15 p.m. Resident #8 was lying in bed and prepared for wound care by RN #2. Resident #8 did not have a dressing covering the wound. RN #2 cleansed and measured the wound. The wound was covered in yellow slough and measured 1.3 cm by 1.0 cm. C. Record review The skin care plan, initiated 10/17/19 and updated 11/13/24, documented Resident #8 had the potential for skin issues related to limited mobility, with the goal to maintain clean and dry skin through the next review date. -The care plan documented the resident had a history of several pressure ulcers but did not indicate a current pressure injury was present. Care plan interventions included doing skin checks weekly (which he frequently refused), encouraging the resident to lie down during the day to relieve pressure to the coccyx (which he frequently refused), ensuring adequate protein and nutritional intake, observing wound healing (he sometimes removed wound dressings) and providing a pressure relieving cushion in his wheelchair. An update to the care plan interventions was added on 11/13/24 and documented Resident #8 had pain to the tailbone, the area was reddened, and the nurse applied a foam dressing. -However, there was no documentation in Resident #8's electronic medical record (EMR) to indicate the wound care physician was notified or a treatment order was obtained. The December 2024 CPO documented the following physician's orders: Weekly skin checks on Wednesdays, ordered 11/12/24. Cleanse sacrum/coccyx wound, apply Medihoney and cover with a border gauze every other day and as needed, ordered 12/18/24. Review of Resident #8's November 2024 and December 2024 treatment administration records (TAR) indicated the resident refused the weekly skin check on 11/20/24 but no other weekly skin checks were refused by the resident. The readmission skin assessment, dated 11/6/24, revealed Resident #8 had a dry, scabbed over area on the coccyx. The 11/6/24 readmission nursing progress note documented the resident had intact skin except for a 1.0 cm by 1.0 cm area on the coccyx. No further description of the skin concern was documented. -There was no documentation in the resident's EMR to indicate that a treatment order was requested or that the facility's wound nurse or the wound care physician were notified of the skin concern. The weekly nursing skin assessment, dated 11/13/24, documented Resident #8 had a reddened area to his coccyx measuring 1.0 cm by 1.0 cm and a foam dressing was applied for comfort. -There was no documentation in the resident's EMR to indicate that a treatment order was requested or that the facility's wound nurse or the wound care physician were notified of the skin concern. The 12/9/24 weekly nursing skin assessment documented Resident #8 did not have redness or any open area to his coccyx. The 12/16/24 weekly nursing skin assessment documented the resident had a 1.0 cm round open area on his sacrum/coccyx. The nurse documented a change of condition progress note for the physician but there were no recommendations from the physician documented. The 12/18/24 wound care physician documentation revealed Resident #8 had a 1.6 cm length by 1.5 cm width by 0.2 cm depth unstageable pressure injury to the sacrum covered in 100% slough. The wound care physician recommended treatment orders to cleanse the wound, apply Medihoney and cover with a border gauze every other day and as needed. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 12/30/24 at 12:25 p.m. RN #2 said Resident #8 had a shower that morning (12/20/24) at 6:30 a.m. RN #2 said she got busy and was not able to do his wound care and apply the protective dressing following the resident's shower. -Resident #8 did not have a protective wound dressing covering his wound from 6:30 a.m. until 12:15 p.m., almost six hours. The director of rehabilitation (DOR) was interviewed on 12/31/24 at 9:38 a.m. The DOR said she provided a new wheelchair cushion for Resident #8 within the past four weeks. The DOR said Resident #8 kept his previous wheelchair cushion in case he did not like the new one, but she was not aware he did not like it and was not using the new cushion. The RDQC was interviewed on 12/31/24 at 12:07 p.m. The RDQC said a performance improvement plan (PIP) was initiated on 10/15/24 for pressure ulcers. The RDQC said the facility was still working on the accuracy of care plans. -Despite the initiation of the 10/15/24 PIP, Resident #8's care plan was not updated to include the resident's current unstageable pressure injury to his coccyx (see record review above). The director of nursing (DON) was interviewed on 12/31/24 at 12:25 p.m. The DON said a round 1.0 cm open area was found on Resident #8's sacrum on 12/16/24. The DON said Resident #8 had a history of not sleeping in his bed even though staff encouraged him to lie down. The DON said Resident #8 was not using an air mattress because it made it difficult for him to transfer in and out of bed independently. The DON said she was not aware Resident #8 had any skin impairment issues on his coccyx or sacrum prior to 12/16/24. The DON said when the nurse identified Resident #8's skin issue to his coccyx on 11/6/24, the nurse should have notified the physician and requested treatment orders. The DON said the nurses should have notified the wound nurse and communicated the skin issues on the 24-hour report so the resident could have been seen by the wound care physician timely. The DON said Resident #8 should have had a protective dressing covering the wound on his sacrum as soon as possible after his shower on 12/30/24. The DON said she added a physician's order on 12/31/24 for as needed dressing changes for the nurses to document replacing Resident #8's dressing after showers or when soiled. The nursing home administrator (NHA) was interviewed on 12/31/24 at 12:35 p.m. The NHA said Resident #8 received the new wheelchair cushion from the therapy staff on 12/4/24. The NHA said he was not aware Resident #8 was unhappy with the new cushion. V. Additional information The NHA provided the facility's 10/15/24 PIP on 12/31/24 at 12:49 p.m. The PIP indicated care plans were to be reviewed and updated by 10/28/24. The PIP documented the nurses were provided education beginning 10/24/24 on procedures to follow for any new skin issues identified. When a new skin issue was identified, the nurses were to do alert charting for 72 hours, notify the physician and request treatment orders. -However, Resident #8's care plan was not updated to include the resident's current unstageable pressure injury to his coccyx (see record review above). -Despite the nursing education documented on the PIP, Resident #8's skin issue, identified on 11/6/24, was not reported until 12/16/24 and treatment orders were not received until 12/18/24.

Based on record review and interviews, the facility failed to ensure all residents were free from abuse, neglect, and exploitation, for one (#101) of two out of 29 sample residents. Specifically, the facility failed to ensure Resident #101 was not neglected by staff from 8/24/21 to 8/30/21 by providing the care and services the resident required to maintain the highest practicable well-being. The facility failed to implement timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #101 readmitted to the facility following a below the knee amputation (BKA) to her right lower extremity (RLE) on 8/24/21. The facility failed to implement treatment to the surgical wound upon admission. The facility failed to notify the physician and obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #101 was subsequently hospitalized on [DATE] to correct the facility's failure and was treated with a wound VAC (vacuum assisted wound closure), (see record review below). Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/26/22-6/29/22, resulting in the deficiency being cited as past noncompliance with a correction date of 9/7/21. I. Facility policy The Freedom from Abuse, Neglect, and Exploitation policy and procedure, dated 2017, was provided by the nursing home administrator (NHA) on 6/27/22 at 8:00 a.m. It documented, in pertinent part, It is the Facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility shall develop and implement written policies and procedures that: -Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; -Establish policies and procedures to investigate any such allegations; -Include training on preventing abuse, neglect, and exploitation to all staff, service providers and volunteers, consistent with their expected roles. Training must include education on those activities which constitute abuse, neglect, misappropriation of property and exploitation; procedures for reporting relevant incidents; and dementia management and resident abuse prevention. Staff and volunteers shall receive training on preventing abuse, neglect, and exploitation upon hire, annually, and as needed. -Coordinates this policy with quality assurance and performance improvement (QAPI) program; and -Complies with section 1150B of the Social Security Act (requiring facilities to report any suspicion of crime for those in long term care facilities). In response to allegations of abuse, neglect, exploitation, or mistreatment, (name of facility) shall: -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper time frame pursuant to this policy; -Have evidence that all alleged violations are thoroughly investigated; -Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; and -Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 (five) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. II. Resident status Resident #101, age less than 60, was admitted on [DATE] and discharged to the hospital on 3/17/22. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/8/21 minimum data set (MDS) assessment revealed Resident #101 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required one-person limited assistance with most activities of daily living (ADLs) and did not reject care. Resident #101 had one venous/arterial ulcer with application of dressing for treatment. III. Facility investigation The facility investigation was provided by the NHA on 6/28/22 at 2:30 p.m. Review of the facility's investigation revealed on 9/1/21 the facility started an investigation related to Resident #101 being sent to the hospital on 8/30/21 for a wound dehiscence (see record review below). The facility documented they started an action plan as staff did not contact the physician to obtain treatment orders for Resident #101's right stump resulting in a wound dehiscence and infection. It was documented the only order that was obtained to treat Resident #101's surgical site was Iodosorb Gel 9%, an antimicrobial wound gel (see below). The facility interviewed nursing staff who cared for Resident #101 from 8/24/21 to 8/30/21 and revealed staff did not implement treatment orders. Staff were suspended pending the investigation and the DON later fired on 9/3/21. A full house audit was conducted of all residents to ensure treatment orders were in place, care plans were updated to reflect wound care and prevention for wounds. Education regarding skin management and change in condition was initiated on 9/1/21 with the individuals who cared for Resident #101. -However, the education did not include all nursing staff (see interviews below). Additionally, all staff were re-educated on abuse per facility policy above and the facility reported the incident to the State Survey Agency. The facility's investigation concluded that neglect was substantiated. IV. Record review 1. Hospital record The 8/24/21 hospital discharge record revealed Resident #101 had a right BKA on 8/6/21 and a BKA formalization (two-staged amputation) on 8/10/21. Wound care instructions read, Change dressing twice weekly or as needed. Place ABD (absorbent dressing) over the incision line, wrap in figure 8 (eight) pattern with kerlix gauze and re-apply sock and rigid removable dressing. 2. Progress note The 8/24/21 at 11:04 p.m. nursing note documented report was received from the previous shift that Resident #101 admitted to the facility at 1:00 p.m. Resident #101's skin assessment was completed with notation of multiple bruises, skin tears, open area to her left thigh, and incision to her right stump with a staple line incision (measured 4 centimeters) and incision line at the base of the stump which measured 23 cm (centimeters), the dressing was changed due to the wound having increased blood drainage. -However, there was no further documentation of treatment being provided to Resident #101's wound or assessment of the wound from 8/25/21 to 8/30/21 until she was sent to the hospital on 8/30/21 (see below). 3. Admission Data Collection There was no admission data collection on the day of admission 8/24/21. The 8/28/21 admission data collection documented the resident had a most recent admission on 8/28/21. It documented Resident #101 had a non-pressure vascular wound to the front of her left thigh and a non-pressure vascular wound to the front of her right lower leg. Resident #101 had pain in the wound. The acute care plan was blank. 4. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented the Iodosorb Gel 0.9% was applied on 8/25/21 and 8/29/21. On 8/27/21 it was not documented as being applied (see progress note below). 5. Treatment administration record (TAR) Review of the August 2021 TAR revealed no treatment orders for Resident #101's surgical right BKA site. 6. Care plan Review of Resident #101's care plan revealed there was no care plan initiated for her BKA until after the resident was re-hospitalized on [DATE] and returned to the facility on [DATE]. The care plan initiated 9/20/21 and revised on 9/23/21 revealed Resident #101 had an amputation to her RLE and she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to monitor the wound and document any signs and symptoms of infection, drainage, bleeding, impaired circulation, [CONDITION(S)] and pain. Change dressing as ordered, and encourage compliance with treatment. 7. Additional progress notes The 8/26/21 at 1:00 a.m. administration note documented Resident #101 complained of pain to the RLE stump, and pain was not relieved by positioning. The 8/27/21 at 10:52 a.m. administration note documented Resident #101 was picking at her skin and was not cooperative with care. The 8/27/21 at 3:26 p.m. administration note documented waiting at the pharmacy for Iodosorb Gel 0.9%. The 8/30/21 at 1:57 p.m. situation, background, assessment and recommendation (SBAR) summary note documented right BKA dehiscence and possible infection. The wound was very odorous with yellow/light green drainage. The physician and family were notified. The 8/30/21 at 2:18 p.m. nursing note documented the director of nursing (DON) assessed Resident #101's dressing which was intact with yellow/green drainage. The DON removed Resident #101's dressing to her right stump for further inspection and noted the wound to be dehisced at the incision site. The resident was sent to the ER (emergency room ) for evaluation and treatment. Resident #101 readmitted to the facility on [DATE] with a wound VAC to her right BKA. V. Staff interviews The NHA and clinical nurse consultant (CNC) were interviewed on 6/28/22 at 6:50 p.m. The NHA said she started working at the facility in October of 2021. They said they were not involved with the investigation. They contacted the senior vice president of operations (SVPO) for additional documentation of when the action plan was started and completed along with all nursing staff training. VI. Facility follow-up On 6/29/22 at 8:00 a.m. the NHA provided documentation of all staff training, this included 12 additional nurses dated 9/7/21 and quality assurance and performance improvement (QAPI) which was dated 9/7/21. The NHA, CNC and SVPO were interviewed on 6/29/22 at 1:27 p.m. They acknowledged neglect occurred for Resident #101 and corrected the non-compliance prior to the start of survey 6/26/22 to 6/29/22 resulting in the deficiency being cited as past noncompliance with a correction date of 9/7/21.

Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and failed to provide supervision and assistance to prevent falls with injuries. The facility failed to ensure one (#13) of two residents reviewed for smoking safety was safe while in the facility smoking area. The facility further failed to failed to prevent falls for three of five residents (#15, #16, and #19) reviewed for falls out of 29 sample residents. Record review and interviews revealed the facility failed to ensure Resident #13 had adequate access back into the facility after smoking outside in sub-zero temperatures. The resident suffered frostbite to his fingers while outside, and when he attempted to gain entry back into the facility he became stuck between the door and the wall, and waited for approximately 20 minutes before staff found him and assisted him back into the facility. Resident #16 sustained six falls over a period of two months. Two of the falls resulted in major injuries. One fall caused re-opening of the surgical wound on his amputated leg, and another fall resulted in a head injury with subdural hematoma. The facility failed to provide adequate and timely supervision and assistance to prevent multiple falls, resulting in two major injuries for Resident #16. Resident #15 had four consecutive falls in less than one month. The facility failed to put in place interventions to prevent the falls after the third fall. The fourth fall resulted in a fracture of the resident's left arm. Resident #15 was not assessed by an RN for any injuries after the fall. The next morning the resident developed arm discoloration and swelling. She called 911 herself and was transferred to the emergency room for evaluation. The facility failures contributed to the resident's fall with fracture. For Resident #19, the facility failed to properly assess, develop and implement interventions to prevent recurring falls. Fall risk assessments were not consistently documented accurately or timely, neurological checks were not consistently performed, and the resident was not consistently assessed by registered nurses after falls. Findings include: I. Facility policies and procedures The Safe Smoking/Tobacco Use policy and procedure was provided by the director of nursing (DON) on 3/24/21 at 11:00 a.m. and read in pertinent part: The interdisciplinary team (IDT) members determine if a resident may safely use tobacco products or e-cigarettes before the resident is permitted the privilege to do so. -A resident who smokes, uses smokeless tobacco or uses an e-cigarette is evaluated to determine whether the resident is safe or unsafe to use tobacco products or e-cigarettes using the following forms: -Upon admission or readmission: If the Nursing Admission Data Collection (UDS) identifies that the resident uses tobacco or an e-cigarette, then the Safe Smoking/Tobacco Use Evaluation (UDA) is completed. -Quarterly, annually, with significant change of condition, and/or an infraction of facility smoking policy: The Safe Smoking/Tobacco Use Evaluation (UDA) is completed for residents who continue to use tobacco or e-cigarettes. -The degree of supervision is determined based on the Safe Smoking/Tobacco Use Evaluation (UDA), the physical attributes of the smoking area, and other relevant factors. The Incident/Accident Reporting for Residents policy and procedure was provided by the clinical coordinator (CC) on 3/29/21 at 3:46 p.m. and read in pertinent part: All indecent, accidents, and unusual occurrences involving a resident are investigated, documented and reported in accordance with Federal and State law. -Relevant facts regarding the Incident are recorded in the Progress Notes (Electronic Health Record). Relevant facts may include, but are not limited to: the location the resident was found, assessments conducted, care provided, follow-up care provided etc. The Fall Management policy, revised in July 2017, was provided on 3/29/2021 by the nursing home administrator (NHA). The policy read in pertinent part: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and /or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation, with ongoing review. II. Failure to ensure Resident #13's safety by providing access into the facility from the smoking patio A. Resident #13 status Resident #13, age under 60, was initially admitted on [DATE] and most recently readmitted on [DATE]. According to the March 2021 computerized physician orders (CPOs), diagnoses included [CONDITION(S)], chronic pain, [CONDITION(S)] and [CONDITION(S)]. According to the 1/12/21 minimum data set (MDS) assessment, the resident was cognitively intact with the brief interview for mental status (BIMS) score of 15 out of 15. He had behavioral symptoms not directed towards others one to three days during the review period. The resident rejected care for four to six days. He required set-up assistance with eating; one person assistance with locomotion on and off the unit and bed mobility; and two person extensive assistance with transfers, dressing, toilet use and personal hygiene. B. Resident interview The resident was interviewed on 3/24/21 at 10:45 a.m. He said he had been outside smoking on 2/13/21 in late morning or early afternoon, he could not recall, and suffered frostbite to the tips of his fingers on his right hand. The resident said he had gone outside to smoke and it was about zero (0) degrees outside. The resident said he was an independent smoker, and his smoking materials were kept in a locker outside per facility policy. He said when he touched the lock his fingers froze to the lock and he had to pull them off, which caused blisters on his thumb and fingers. He said when he was finished smoking he propelled his wheelchair to the handicap accessible door. He said he used the blue handicap button to open the door, and he made it halfway through the door before it closed with him in between the door jam. He said he was basically stuck inside and outside and it took about 20 minutes before staff found him and assisted him into the facility. The resident said he did not notify staff about his fingers until the following day when the raised blisters formed. He said when staff became aware of the blisters they educated him on the importance of telling staff members when he was going to go outside to smoke. He said they also provided him with two additional pairs of gloves, and made sure he had a winter coat to wear when he was outside. The resident said staff continued to state the frostbite occurred when he touched his wheelchair wheels, but he insisted it happened when he touched the lock on his smoking locker. He said staff replaced the lock on his locker and also placed material on his wheelchair so he was not touching metal when he propelled himself. The resident said he always brought his cellular phone outside when he went to smoke, but he had forgotten it that day. He said he always makes sure he has his phone now, and will go back to his room if he forgets to bring it. C. Record review A 2/14/21 nursing note documented the following: Note Text: Pt (patient) has multiple blisters from his fingers sticking to wheelchair outside in the freezing cold weather. Pt (patient) got stuck outside in the snow and his fingers froze to the wheelchair because it was 0 degrees outside. Educated resident on letting staff know when he goes out to smoke so that staff could set a timer for 15 minutes so that staff can check to see if he is ok. Educated resident to possibly not go out to smoke as often when the temperature drops outside. (name of physician) and wife made aware of the blisters right hand. A 2/14/21 SBAR (situation background assessment recommendation) Communication Form and Progress Note documented the following: This started on 2/13/21, Pt (patient) got stuck outside in the snow and his fingers froze to the wheelchair because it was 0 degrees outside. A 2/14/21 Smoking Injury Investigation documented the following: Nursing description: Pt (patient) had multiple blisters from his fingers sticking to the wheelchair outside in the freezing cold weather. Pt (patient) got stuck outside in the snow and his fingers froze to the wheelchair because it was 0 degrees outside. Resident description: I got stuck at the door try(ing) to get in, I yelled for help and no one came. Immediate action taken: Educated resident on letting staff know when he goes out to smoke so that staff could set a timer for 15 minutes so that staff can check to see if he is ok. Educated resident to possibly not go out to smoke as often when the temperature drops outside. Resident was not taken to the hospital. A 2/15/21 Resident/Family Education Record documented the following: Resident educated on safe smoking in subzero temperatures. Resident is to tell staff when he goes out to smoke so that he will be able to have some help when needed. The skin care plan, last revised on 3/23/21 (during the survey) identified the resident as having frostbite to his right hand from smoking in below zero temperatures. The goal was for the resident's wounds to show signs of healing by the next review. The pertinent interventions included: - Resident agreeing to not go out to smoke if maintenance has not cleared the snow from the ground in the smoking area. - Gloves provided to the resident to wear outside while smoking in below zero temperatures. - Maintenance to move rubber grips to the right wheelchair to ensure the resident does not have to touch cold metal in below zero temperatures. The smoking care plan, last revised 2/15/21, identified the resident as being a smoker. The goal was for the resident not to suffer an injury from unsafe smoking practices. Pertinent interventions included: - Resident agreeing to not go outside if the snow had not been cleared in the smoking area. - Education provided to the resident on risk of smoking outside in below zero temperatures. - Gloves provided to the resident while he is outside smoking in below zero temperatures. - Maintenance to move rubber grips to the right wheel of the residents wheelchair to ensure the resident does not have to touch cold metal in below zero temperatures. D. Staff interviews The staff development coordinator (SDC) was interviewed on 3/24/21 at 1:28 p.m. She said she was the staff member who completed the education to the resident on 2/15/21 regarding safer smoking practices. The SDC said she was part of the investigation and making sure all of the residents who smoke continued to be safe. The SDC said the resident was agreeable to the interventions such as notifying staff when he was going out to smoke and wearing gloves. The SDC said she thought the frostbite occurred from the resident's wheelchair wheels, and when she was completing the investigation she should have asked the resident more questions regarding how he got the injuries. The director of nursing (DON), nursing home administrator (NHA) and clinical coordinator (CC) were interviewed on 3/25/21 at 12:17 p.m. The CC said the facility had identified the concern with the resident following his injury from smoking in sub zero temperatures. The CC said the facility assessed all of the residents who were smokers and had only identified one additional resident who was a smoker, who was not currently smoking as she did not like to smoke when the weather was cold outside. The CC said the facility immediately notified the resident's physician for treatment orders for the blisters from the frostbite. She said they also reviewed the resident's care plan to ensure there were appropriate interventions. Additionally, the maintenance department made sure the smoking area was safe including making sure the door and handicap accessible button were functioning properly. The director of nursing said a safe smoking assessment should have been completed with the resident following the incident, but nursing staff did not complete an updated smoking assessment until 3/23/21, during the time of the survey. The CC said she had educated nursing staff, during the time of the survey, on the facilities policy and procedure of making sure smoking assessments were completed timely. III. Failure to provide adequate supervision and assistance to prevent falls with injuries A. Resident #16 1. Resident status Resident #16, age under 50, was admitted on [DATE]. According to the March 2021 computerized physician orders (CPO), diagnoses included acquired absence of left leg, diabetes type two, end stage [CONDITION(S)], and dependence on [CONDITION(S)]. The 1/18/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident required extensive two person physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He was occasionally incontinent of bowel and bladder. The fall section revealed the resident had at least one fall in the last six months prior to admission that resulted in minor injuries. The behavior section indicated the resident did not resist care, and had no hallucinations, delusions or other types of behaviors. 2. Resident interview The resident was interviewed on 3/23/21. He said he was admitted to the facility after a recent below the knee amputation of his left foot. He said he was very dissatisfied with the care he received in the facility. Specifically, he had multiple falls since he was admitted that complicated his physical condition and resulted in the longer need for care at the facility. He said due to his amputation he was no longer able to use his left leg for ambulation and was dependent on staff for everyday care, such as transfers and bathroom use. He said when he called for assistance, it frequently took 35 to 45 minutes for someone to answer his call lights. He said on multiple occasions he was trying to get to the bathroom and had a fall. He said he complained about the call light response time to the director of nursing (DON) and nurses on the floor, but never received any feedback from anyone. The staff did not discuss falls with him and did not ask him what would help to prevent falls in the future. He felt as if he was treated as an old man who can't remember anything. He said staff kept telling him to use the call light and kept putting signs on the walls as a reminder to use the call light, but that was not the problem. He said the problem was that no one responded to the call light on time, and he ended up transferring independently. He said he felt like no one really cared about anything and was not trying to make things better for him. (Cross reference F725, sufficient nursing staffing.) 3. Record review The admission assessment on 1/13/21 documented the resident was at risk for falls. The care plan for falls was initiated on 1/18/21 (five days after admission, and after two falls on 1/14/21 and 1/17/21), and revealed that the resident was at risk for falls. Interventions included to assist with transfers, make sure call light was within reach and encourage the resident to use it for assistance as needed, and to provide prompt response to all requests for assistance. Fall #1 - 1/14/21 According to the situation, background, assessment report (SBAR) on 1/14/21 resident had an unwitnessed fall in his room. He was assessed by a licensed practical nurse (LPN). The resident stated he was trying to transfer from wheelchair to the recliner and slid to the floor. Resident verbalized difficulty adjusting to left leg amputation. Resident was educated regarding the use of call light. -The SBAR note did not mention what footwear the resident was wearing and if his call light was on or off. -No progress notes were documented that a registered nurse (RN) was contacted to complete the assessment. The fall assessment was completed on 1/14/21, and documented a score of 14 (high risk). The care plan was updated with an intervention Education for resident to remember to call for help when the need to transfer arises. The IDT review was initiated on 1/14/21 and completed (locked) on 1/18/21. The review revealed the resident was able to use the call light correctly, however the intervention was to continue to teach the resident to use the call light. Fall #2 - 1/17/21 According to the SBAR on 1/17/21, the resident had a witnessed fall in his room. He was assisted by a certified nurse aide (CNA) in the bathroom, lost his balance and was lowered to the floor. At that time the incision broke open. Area was cleansed and pressure dressing applied. -The physician was not notified until the next day, 1/18/21 at 8:00 a.m. -The resident per MDS assessment (see above) needed extensive two-person assistance for transfers and toilet use, however it was documented that one CNA performed the transfer. The resident's vital signs were documented by an LPN. There was no evidence that the resident was assessed by an RN. There were no further notes regarding the resident's wounds that opened up. The fall assessment was completed on 1/17/21, and documented a score of 10 (high risk). The care plan was updated with an intervention: Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The IDT review was initiated on 1/18/21 and completed (locked) on 1/26/21. Interventions included to provide two person assistance to the resident. Fall #3 - 1/30/21 According to the SBAR completed on 1/31/21 (one day after the fall), the resident had an unwitnessed fall in his room on 1/30/21. During the fall he bumped his leg that resulted in the dehiscence of the wound. The resident was sent to the emergency room to stop the bleeding. The residents' vital signs and SBAR form were completed by an LPN. There was no evidence that the resident was assessed by an RN. There were no further notes regarding the resident's wound that opened up. The IDT review was initiated on 1/31/21 and completed (locked) on 2/1/21. The note read: resident states, he was sitting in recliner trying to pull the pillow out from under him. Resident states that in the process he somehow 'slid' out of the recliner and bumped his stump as he went to the floor. Interventions included moving the resident closer to the nurses station and conducting frequent checks. The fall assessment was completed on 1/30/21, and documented a score of 12 (high risk). The care plan was updated with an intervention to initiate frequent checks as needed for frequent falls. The emergency room (ER) admission note, dated 1/30/21, revealed that the resident arrived at the ER with a leg injury. Assessment revealed some wound dehiscence, sutures in place, no active bleeding. Wound was redressed and the resident was sent back to the facility. Fall #4 - 2/10/21 According to the SBAR on 2/10/21, the resident had an unwitnessed fall in his room. It was documented that the resident had an unattended fall with no apparent injury. No additional information was documented on the SBAR about where the resident was found, what he was wearing and the status of the call light. The resident's vital signs were documented by an LPN. There was no evidence that the resident was assessed by an RN. The fall assessment was completed on 2/10/21, and documented a score of 10 (high risk). The care plan was updated with an intervention: Bedside commode for shorter distance transfers, resident refuses to use commode. The IDT review was initiated on 2/10/21 and completed (locked) on 2/16/21. The note indicated the resident was found by a CNA during rounds. There were no notes regarding the exact location of the fall, the status of the call light or the resident's footwear. The facility initiated the following intervention: offer bedside commode, resident refuses use of commode. No further clarification was added on why the commode was provided to the resident, the reason for resident refusal of the commode, or any additional interventions. According to the physician note dated 2/24/21, the resident had a dehiscence of amputation stump after the fall on 1/30/21 with re-opening of the surgical incision to the stump. The ortho surgeon started a wound vac on 2/17/21 to promote improved healing. The wound vac was in place, and the resident was followed by a wound care team after 2/17/21 and during the survey. Fall #5 - 2/28/21 According to the SBAR on 2/28/21, the resident had an unwitnessed fall in his room. It was documented, resident found on the floor, stated he fell head first on the floor while trying to transfer. Resident has a knot on the side of the forehead. The physician was notified and the resident was sent to the ER for evaluation. There were no fall risk assessment after the fall on 2/28/21 and there were no IDT notes. The care plan was not updated with any new interventions. The ER admission record dated 2/28/21 documented the resident was admitted with a headache and left stump pain after sustaining a fall at the nursing facility. In the ER he was diagnosed with a subdural hematoma and was admitted to the hospital overnight for observations. Fall #6 - 3/7/21 According to the SBAR on 3/7/21, the resident had an unwitnessed fall in his room. A note documented, Resident attempted to self transfer from wheelchair to recliner, wound vac got caught on wheelchair and resident fell to his knees. The resident's vital signs were documented by an LPN. There was no evidence that the resident was assessed by an RN. The fall assessment was completed on 2/10/21, with a documented score of 10 (high risk). The care plan was updated with an intervention: resident at times refuses to use call light for assist with transfers. Staff to continue to encourage call light use. Staff to offer frequent help with ADL's (activities of daily living). The IDT review was initiated on 3/7/21 and completed (locked) on 3/23/21. The note documented the resident at most times refuses to use call light for assist with transfers. Staff to continue to encourage call light use. Staff to offer frequent help with ADL's. The facility failed to provide supervision and assistance to prevent repeated falls with injuries for Resident #16. 4. Staff interviews CNA #3 was interviewed on 3/29/21 around noon. She said the Resident #16 needed one-person assist with transfers and mobility, and was mostly independent with other tasks. She said the resident was at risk for falls and they were frequently checking on him, making sure his call light was answered promptly. She said the resident did not have behaviors and did not refuse care. LPN #3 was interviewed on 3/29/21 around noon. She said Resident #16 was alert and oriented, and required one person assistance with most tasks. She said the resident was at risk for falls, but had no falls recently. She said the resident used his call light frequently and had no memory problems and no behaviors. She said he did not refuse care. The rehab program manager (RPM) was interviewed on 3/29/21 around 4:00 p.m. She said Resident #16 was currently working with physical therapy (PT) and occupational therapy (OT). He required one person assistance with ambulation and transfers. She said the resident had multiple falls and at times was impulsive. She said he made several attempts to self transfer and sometimes did not use his call light. The MDS coordinator was interviewed on 3/29/21 around 5:00 p.m. She said she was an RN and MDS coordinator. She said she participated in IDT meetings and was responsible for the update of the care plans. Regarding Resident #16, she said she recalled discussing the falls in IDT meetings. She said the resident refused to use his call light and was not cooperative with care. She said Resident #16 was continuously educated to use the call light and the facility came up with many interventions to prevent his falls. She said the resident refused most of the interventions including a bedside commode. She said she did not talk to the resident in person and did not ask him why he was refusing the bedside commode. She said she did not provide direct care to the resident, but heard it from a third party that the resident was refusing care. The director of nursing (DON) was interviewed on 3/29/21 around 5:00 p.m. in the presence of the corporate consultant (CC). She said Resident #16 had several falls and they reviewed all falls in IDT meetings. She said she did not talk to the resident about refusals to use the call light, and she did not know why he would refuse it. She said they continued to educate him and remind him to call for assistance. B. Resident #15 1. Resident status Resident #15, age 81, was admitted on [DATE]. According to the March 2021 CPO, diagnoses included cerebral infarction, [CONDITION(S)], kidney failure, heart failure, hypertension, abnormal weight and mobility. The 1/5/21 MDS assessment revealed the resident was cognitively intact with a BIMS score 13 out of 15. The resident required limited assistance of one person and physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She was occasionally incontinent of bowel and bladder. The fall section revealed the resident had at least one fall in the last six months prior to the admission, that resulted in minor injuries. The behavior section indicated the resident did not resist care, and had no hallucinations, delusions or other types of behaviors. 2. Resident interview The resident was interviewed on 3/23/21 around 3:00 p.m. She said she did not recall having any falls and was doing well. She said she was working with physical therapy and was looking forward to going home. No slings were observed on the resident's arms (see 1/14/21 hospital documentation from record review below). She was able to move her arms and propel herself in a wheelchair. 3. Record review The care plan for falls was initiated on 1/4/21 revealed that the resident was at risk for falls. Interventions included to assist with transfers, make sure call light was within reach and encourage the resident to use it for assistance as needed, and to provide prompt response to all requests for assistance. Fall #1 - 1/5/21 According to the SBAR on 1/15/21, the resident had an unwitnessed fall in her room. She was assessed by an LPN. The note read fall without injury. The SBAR note did not mention where the resident was found, what she said, what footwear she was wearing and if her call light was on or off. No progress notes were located to demonstrate that an RN was contacted to complete the assessment. The care plan was updated with an intervention to place a smaller recliner in her room as the one she had was too big. Fall #2 - 1/7/21 According to the SBAR on 1/7/21, the resident had an unwitnessed fall in her room. Resident found sitting on the floor in her room with a recliner at her backside. Res states, 'I slid out of the chair.' She has some pain in her lower back where the footstool of the recliner would have hit her while sliding out. Presents with no bruising or redness anywhere. No abrasions. Assisted to bathroom and back to the recliner. -The SBAR note did not mention what footwear the resident was wearing and if her call light was on or off. The care plan was updated with an intervention to move the recliner out of the room and replace it with a bed. Fall #3 - 1/14/21 According to the SBAR on 1/14/21, the resident had an unwitnessed fall in her room. Unwitnessed fall in resident room. Complaint of neck pain and left hip pain. -The SBAR note did not mention what footwear the resident was wearing and if her call light was on or off. Vital signs and SBAR assessment were completed by an LPN. No notes documented if the resident was assessed by an RN. The physician was contacted and the resident was sent to the ER for evaluation. The ER notes dated 1/14/21 revealed the resident was brought to the ER after sustaining a mechanical fall. The x-ray of the hip revealed no fractures or other acute abnormalities. The CT scan of the cervical spine showed a compression deformity of the T1 vertebral body with approximately 50 percent height loss and multilevel [CONDITION(S)] changes. IDT notes dated 1/14/21 had no recommendations or interventions. The resident's care plan was not updated with any new interventions. Fall #4 - 1/15/21 There were no SBAR or progress notes related to the resident's fall on 1/15/21. The IDT note completed on 1/16/21 revealed that the resident had a fall on 1/15/21 around 10:00 p.m. Resident found face down in her room, per CNA resident was sitting in a wheelchair before that. Physician and family were notified on 1/18/21. -There were no progress notes to show if the resident was assessed after the fall. No new interventions found on the care plan. The SBAR dated 1/16/21 (the day after the fall) revealed that the resident had a change of condition, where she developed swelling and discoloration to the left hand with decreased range of motion. The resident herself contacted emergency services, and was taken to the emergency room for evaluation. The ER notes dated 1/14/21 revealed the resident presented with extremity injury from nursing home for the second time in less than 48 hours for evaluation after the fall. The most recent fall was last night and she landed on her left side injuring her left shoulder, elbow and wrist. The resident was diagnosed with a left radius fracture, and left shoulder and wrist contusion. The splint sling was provided and the resident was discharged back to the nursing facility. There were no additional IDT notes related to the fall, hospitalization or follow-up treatment above. 4. Staff interviews CNA# 3 was interviewed on 3/29/21 around noon. She said the resident needed one-person to assist with all tasks, and she was able to propel herself independently in a wheelchair. She said the resident was not at risk for falls and had no falls that she was aware of. She said the resident was very cooperative and always used a call light when she needed help. LPN #3 was interviewed on 3/29/21 around noon. She said, the resident was actively working with physical therapy and made good progress. She said the resident had no falls that she knew about and was considered to be a low fall risk. She said the resident was getting ready to be discharged home in a few days. -Regarding falls in general, she said after a fall every resident should be assessed by a nurse and they were instructed to call the DON with every fall. The physician and family should be contacted as well and an SBAR form completed. She said she did not participate in IDT meetings and was not in charge of updating care plans with new interventions. The MDS coordinator was interviewed on 3/29/21 around 5:00 p.m. She said she was an RN and MDS coordinator. It was part of her responsibilities to update care plans. She said she tried to update the care plans timely, but sometimes she got too busy and some interventions were not put on the care plans. The director of nursing (DON) was interviewed on 3/29/21 around 5:00 p.m. in the presence of the corporate consultant (CC). She said the resident did not have any recent falls and was getting ready to be discharged . She said nurses were expected to call her after every fall in the facility and she provided guidance to them over the phone w[TRUNCATED]

Based on interviews and record review, the facility failed to manage the pain of one (#18) of three residents reviewed out of 29 sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. The facility failed to identify when Resident #18 was having increased complaints of pain and failed to perform a current comprehensive pain evaluation to determine the root cause of the resident's increasing complaint of pain and adjust the resident's plan of care to provide optimal pain management. Resident #18 had frequent complaints of moderate sacral pain during her [CONDITION(S)] sessions that were communicated to the facility but were not addressed or treated by the facility. These failures led to the resident ending her [CONDITION(S)] sessions early frequently due to her unresolved pain. Findings include: I. Facility policy and procedure The Pain Management policy and procedure, last revised July 2017, provided by the corporate consultant (CC) on 3/29/21 at 3:00 p.m., revealed in pertinent part, The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and cause (s); determine the type and severity of the pain; and develop a care plan for pain management consistent with the comprehensive care plan and the resident's goals and preferences. An evaluation of pain should be completed when the resident has a new complaint of pain or when pain is suspected to be present. Consult with the resident or resident's representative when developing an individualized care plan related to the signs and symptoms of their pain. Interventions should be focused on approaches that help to control the resident's level of pain, whether it is by managing pain by the use of pain medication or other non-pharmacological approaches. Staff should be proactive to address the resident's pain to aid in achieving relief. Evaluation of pain, implementation of interventions, monitoring the resident response to those interventions, and communicating with the care team regarding pain management strategies are important components of a successful pain management system. II. Resident #18 A. Resident status Resident #18, age 56, was admitted [DATE]. According to the March 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/28/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent or required the extensive assistance of two people for her activities of daily living (ADLs). The resident did not have any complaints of pain during the assessment period. She had one stage 2 pressure ulcer at the time of the assessment and was receiving pressure ulcer care. She had a pressure reducing device for her chair and bed. B. Resident interview and observation Resident #18 was interviewed on 3/24/21 at 4:00 p.m. She said she left [CONDITION(S)] early that day because her bottom hurt. She said it was hurting, even after lying in bed for a while. She said she was not offered any pain medications when she returned from [CONDITION(S)]. She said she rated her pain 3 out of 10 (on a scale of 0 - no pain to 10 - severe pain) at that time because she could lay down, but it was a 6 out of 10 when she was sitting up in the chair at [CONDITION(S)]. She said she could tolerate a pain level of 3 out of 10 but not much more. She said she did not know if she had orders for any pain medications other than Tylenol and it did not work for the pain to her bottom. Observations revealed an approximate two centimeter (cm) diameter, nonblanchable, dark pink, stage 1 pressure area to the resident's coccyx surrounded by approximately 4 cm diameter lighter pink skin that was blanchable. No open areas were seen. The resident was lying on an air mattress and had a pressure relieving cushion in her wheelchair. C. Record review Coccyx and sacral to describe the location of the resident's pain will be used interchangeably throughout the citation. According to the March 2021 CPO, the resident had the following orders for pain management: -Tylenol Extra Strength 500 milligrams (mg) give one tablet by mouth every eight hours as needed for pain, ordered 10/21/2020; and -Observe pain every shift. If pain present, complete pain flow sheet and treat trying non-pharmacological interventions prior to medication if appropriate and document in the progress notes, ordered 10/22/2020. The 10/28/2020 pain evaluation revealed the resident complained of generalized pain, treated with non-medication interventions. It indicated the resident had no complaints of pain during the assessment period and no further evaluation was needed. -Review of the record on 3/25/21 revealed the resident did not have another pain evaluation completed, even after the resident started having new complaints of pain (see below). Review of the [CONDITION(S)] Communication Records from 2/1/21 until 3/25/21 revealed the resident's [CONDITION(S)] session ([CONDITION(S)] sessions are usually four to six hours long) was terminated (termed) early due to the resident complaining of pain on the following days: 2/6/21 - termed one hour and 40 minutes early due to pain; 2/9/21 - termed treatment early due to pain; 2/11/21 - Tylenol given at [CONDITION(S)]; 2/16/21 - resident signed out against medical advice (AMA); 2/18/21- termed early per her request; 2/20/21 - termed treatment two and a half hours early due to pain; 2/25/21 - termed early due to pain; 2/27/21 - resident chose to end treatment 100 minutes early; 3/2/21 - resident only had 50 minutes of treatment done; 3/4/21 - resident termed early for discomfort and signed AMA; 3/9/21 - termed 100 minutes early due to pain; 3/13/21 - resident complained of pain in her coccyx immediately going into the [CONDITION(S)] chair. She was repositioned with no relief and refused Tylenol. She stated she was in too much pain to treat. 3/16/21- termed three hours early per resident request due to her bottom hurting despite repositioning. AMA signed; 3/18/21 - termed early due to pain; 3/20/21 - termed early due to pain; and 3/25/21 - termed early due to pain. A 2/5/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated the resident started routine [MEDICATION(S)] on [CONDITION(S)] days in January (2021) with improvement in compliance. -No new orders were implemented regarding the resident's complaint of pain during [CONDITION(S)]. Review of the progress notes on 3/26/21 revealed the facility frequently documented the resident returned from [CONDITION(S)] early due to pain but did not document any interventions to address the resident's pain. A 2/20/21 nursing progress note revealed the resident terminated [CONDITION(S)] treatment two and a half hours early related to pain and the physician was notified. A 2/27/21 nursing progress note revealed the resident returned from [CONDITION(S)] after she chose to end treatment 100 minutes early and the physician was notified. A 3/4/21 nursing progress note revealed the resident returned from [CONDITION(S)] after requesting to stop treatment early due to being uncomfortable and she signed AMA. It indicated the resident denied any pain or discomfort when she returned to the facility. A 3/13/21 nursing progress note revealed the resident returned from [CONDITION(S)] early after [CONDITION(S)] reported the resident had a complaint of pain in the coccyx area immediately after going into the [CONDITION(S)] chair. It indicated the resident had no complaints of pain after returning to the facility and being put back into bed. A 3/20/21 nursing progress note revealed the resident returned from [CONDITION(S)] early with a complaint of pain. Another 3/20/21 nursing progress note revealed the resident's primary physician made rounds via telehealth and all concerns were addressed. (See physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] A 3/20/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated the resident would be evaluated for optimal pain relief. The plan was to use [MEDICATION(S)] in the wound bed. -Review of the record revealed this did not occur. A 3/23/21 nursing progress note revealed the resident complained of having more pain that day after returning from [CONDITION(S)]. An order was written by the physician on 3/24/21 at 4:15 p.m. that revealed on [CONDITION(S)] days, at least one hour prior to [CONDITION(S)], [MEDICATION(S)] 5% cream was to be applied to the sacral area and covered with a bordered foam dressing to cushion. The dressing was to be removed after the [CONDITION(S)] session on Tuesday, Thursday and Saturday due to sacral pain. -This order was not entered into the electronic medical record (EMR) until the following day, 3/25/21 at 4:41 p.m. so the resident did not get it done prior to going to [CONDITION(S)] on the morning of 3/25/21. A 3/25/21 nursing progress note revealed the resident got off [CONDITION(S)] early due to pain. The February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record revealed the resident was not offered any non-pharmacological pain interventions. The resident did not have a care plan to address her complaints of pain. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/24/21 at 4:25 p.m. She said the resident usually spent most of her time in bed when she was not at [CONDITION(S)]. She said she would get up in her wheelchair for short periods of time and usually did not complain of any pain. The registered nurse (RN) at the [CONDITION(S)] center was interviewed on 3/26/21 at 11:45 a.m. She said the resident received [CONDITION(S)] three times a week for four to six hours at a time. She said when the resident arrived she was transferred into the [CONDITION(S)] chair with the use of a full weight bearing lift. She said the resident had frequently requested to stop her [CONDITION(S)] session early due to complaints of pain to her coccyx. She said she thought it was possible the resident had a pressure ulcer on her coccyx but she was unsure. She said they frequently repositioned the resident but it usually did not help. She said the resident was offered Tylenol but did not want to take it because she had a hard time swallowing pills and the resident said it did not work anyway. She said the [CONDITION(S)] center communicated this information with the facility in hopes that maybe they would be able to pre-medicate her before [CONDITION(S)], or provide some other type of intervention to assist with the resident's pain control. Licensed practical nurse (LPN) #1 was interviewed on 3/26/21 at 10:31 a.m. She said Resident #18 stayed in bed most of the time when she was not at [CONDITION(S)]. She said she would sit up in her wheelchair for short periods of time and did not complain of pain when she was up. She said the resident was frequently sent back from [CONDITION(S)] early due to complaints of pain, but once she got here she never complained of pain so she did not give her anything. She said the physician had seen her last weekend after her [CONDITION(S)] appointment and did not write any orders but the physician was contacted again two days ago (during the survey) and new orders were obtained for [MEDICATION(S)] to be applied before the resident went to [CONDITION(S)]. Certified medication aide (CMA) #1 was interviewed on 3/29/21 at 12:15 p.m. She said she always asked the residents if they were in any pain whenever she had any contact with them. She said if the resident was non-verbal, she tried to use the PAINAD (Pain Assessment in Advanced Dementia) scale to determine if they were having any pain. She said she would offer a non-pharmacological intervention first and if it was not effective, then she would give the resident pain medication. She said if the pain medication was ineffective, she would notify the nurse so a request could be made from the physician for something stronger or a different alternative. She said Resident #18 usually did not complain of pain when she was lying in bed. She said it seemed like the resident only had complaints of pain when she was at [CONDITION(S)]. She said she did not give the resident any pain medication because she did not request it. The director of nursing (DON) was interviewed on 3/29/21 at 6:24 p.m. She said pain evaluations were done upon admission, quarterly and with any change in the residents' complaints of pain. She said a resident's acceptable level of pain should be part of that evaluation. She said the nurse should offer non-pharmacological interventions first then pain medication. If the interventions and medication were ineffective, the physician should be notified. She said the physician was addressing the resident's complaint of pain during [CONDITION(S)]. She said she was not aware the resident was not completing her [CONDITION(S)] sessions due to pain until this past week (during survey).

Based on record review and interviews, the facility failed to provide adequate nutritional and hydration care and services, consistent with the comprehensive assessment, for one (#2) of six residents reviewed of 11 sample residents. Specifically, the facility failed to: -Obtain weekly weights for Resident #2 after admission to monitor for weight loss; and -Monitor Resident #2's significant weight loss and initiate interventions to prevent further weight loss. The facility's failure to timely identify and respond to the resident's unplanned weight loss contributed to the resident's severe 14.6% weight loss within one month of admission. Finding include: I. Facility policy and procedure The Weight Management policy and procedure, last revised July 2017, provided by the medical records staff on 5/12/2020 at 6:53 p.m., included in pertinent part, Weigh all residents upon admission then weigh weekly for an additional three weeks, then monthly or as indicated. Staff should compare the current weight to the previous weight and a resident with a weight variance is reweighed within 48 hours. Weight variances include: a weight change of five pounds or a weight change of three pounds if weight is less than 100 pounds. Significant weight variances are defined as: -5% in one month -7.5% in three months -10% in six months Each resident with weight loss is reviewed weekly by the interdisciplinary team (IDT) at Risk Review Meetings. II. Resident status Resident #2, age 87, was admitted [DATE] and discharged [DATE]. According to the May 2020 computerized physician orders [REDACTED]. The 4/14/2020 minimum data set (MDS) assessment revealed the resident had moderately impaired cognitive function with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required supervision with set up for eating and extensive assistance of one person for all other activities of daily living (ADLs). The MDS documented the resident had a poor appetite with a [DIAGNOSES REDACTED]. The resident's weight was 132 pounds. The resident had no known weight loss and was not receiving speech therapy. III. Family interview The resident's family member was interviewed on 5/8/2020. She said the resident was taken to a physician outside of the facility on 5/4/2020 and was found to have a significant weight loss of approximately 18 pounds in about a month. She said she took her family member out of the facility on 5/5/2020. IV. Record review The 4/5/2020 hospital progress note recorded the resident's weight at 59.7 kilograms (kg) or 131 pounds (lbs). The weights recorded by the facility were: -122 lbs on 4/11/2020 (a nine pound weight loss since being weighed at the hospital on [DATE]); -123 lbs on 4/16/2020; and -105 lbs on 5/5/2020, a 14.6% weight loss in two and a half weeks. No weights were obtained on week three and four after the resident was admitted . According to the 4/14/2020 situation, background, assessment, recommendation (SBAR) the resident's weight was 132 pounds, obtained 4/11/2020 (this weight was not recorded anywhere else in the resident's record). It indicated the resident needed a speech therapy evaluation. It revealed the resident was coughing, had difficulty swallowing, and trouble swallowing pills whole but did better with them crushed in applesauce. The 4/15/2020 speech therapy evaluation and plan of treatment revealed the resident was referred for services related to having difficulty taking medications. It indicated services were warranted to maximize nutrition and hydration with oral motor facilitation, postural control and to minimize the risk of weight loss with swallow analysis. The 4/16/2020 Nutrition Data Collection revealed the resident was on a regular diet with regular textures and thin liquids with his oral intake between 26%-50% and that he ate independently. It revealed he continued to receive a 4-ounce house supplement three times a day and there was no nutritional concern at that time. It indicated no change in weight (it did not address the weight difference between the hospital weight and the facility weight). It did not include laboratory information even though labs had been done on 4/14/2020. The 4/16/2020 Nutrition Registered Dietitian (RD) Assessment revealed the resident had increased calorie needs related to his low body mass index (BMI). The resident had inadequate intake related to his dementia as evidenced by his decreased sensation of thirst and loss of appetite. The rest of the assessment indicated to refer to the care plan. Review of the resident's meal intake on 5/12/2020 revealed from admission through 4/18/2020 the resident was documented to consume 2650% for the majority of meals. Beginning on 4/19/20 the meal intake record documented decreased meal intake of 0-25% for the majority of meals. The April 2020 CPO revealed no orders for interventions for weight loss including the house supplement mentioned in the Nutrition Data Collection above. The nutrition care plan, initiated 4/16/2020, revealed the resident was at a potential nutritional risk related to his diagnoses. Interventions included: -Provide and encourage estimated fluid needs for adequate hydration or physician order. -Offer preferred foods. -Assist with meals as needed. -Offer snacks as needed. -Monitor weights monthly or as indicated. -Monitor labs as available. -Encourage fluids with and between meals, including bedside water. -Remind of meal times and locations. -Registered dietitian (RD) to provide nutrition education as needed. -Refer to RD as needed. -Refer to a speech therapist as needed. -Encourage the resident to request large portions or second portions of foods enjoyed. -Encourage juice and milk with meals for added calories. -Provide house supplement per order. A 5/4/2020 nursing progress note written by the director of nursing (DON) revealed she had spoken with the resident's wife about her concerns over the resident's weight loss. It indicated she would contact the RD and see what interventions could be initiated for the weight loss. The 5/5/2020 speech therapy discharge summary revealed the concerns with difficulty swallowing medications were resolved but the speech therapist had concerns for intake and dehydration. V. Staff interviews The director of nursing (DON) was interviewed on 5/12/2020 at 10:50 a.m. She said the facility had recognized a problem with obtaining weights routinely in March and had initiated a performance improvement plan (PIP). She said the staff had missed doing Resident #1's weekly weights for four weeks and when the weight loss had been brought to her attention, she immediately implemented interventions, however the resident discharged home the next day. She said the weights were now being done by the restorative aide (RA) on Wednesdays and reviewed by the RD on Thursdays. If reweights needed to be done, the RA tried to get them done by Friday for the RD to review the following week. She said all residents were to be reviewed for weight loss weekly and interventions put into place. The surveyor attempted to interview the RD on 5/13/2020, however the RD did not respond.

Based on interviews and record review, the facility failed to ensure 11 (#1, #12, #14, #33, #38, #39, #40, #42, #43, #99 and #148) of 41 sample residents received treatment and care in accordance with professional standards of practice. Specifically: For resident #12, the facility failed to follow physician orders [REDACTED]. As a result, the wound deteriorated, caused the resident severe pain, the resident voiced fear of losing the hand, and ultimately suffered a partial hand amputation. For Resident #38, the facility failed to provide physician-ordered [MEDICATION NAME] for approximately a month. As a result the resident became unstable and delusional, and underwent extra medical testing to determine the cause. Resident #33 received [MEDICATION NAME] without a physician order, which caused the resident to experience decreased control over their hands and legs, to the point where the resident was unable to participate in therapy. Resident #39 did not receive pressure stockings per physician order, and as a result, suffered leg pain and [MEDICAL CONDITION]. The facility further failed to: Communicate [MEDICAL TREATMENT] complications to the physician for Resident #43, who experienced bleeding after [MEDICAL TREATMENT], and Resident #14, who had an occluded fistula; and Follow physician orders [REDACTED]. -Intravenous antibiotics for Resident #148, -Narcotic pain medications for Residents #42 and #1, -[MEDICAL CONDITION] medication for Resident #40 and -Anticoagulant medication for Resident #99. Findings include: I. Failure to follow treatment and MEDICATION ORDERS FOR [REDACTED]. A. Resident #12 status Resident #12, age 64, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/10/19 minimum data set (MDS) assessment revealed Resident #12 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assist with activities of daily living of bed mobility, transfers and personal hygiene. B. Resident interview The resident was interviewed on 4/14/19 at 2:45 p.m. Resident #12 said he fell out of bed months ago, hit his hand on something, maybe the tray table and scraped his knuckles. The resident said the facility ignored it for months. He said the wound got infected, and then ultimately he had to have a partial hand amputation in January. The resident said he did not remember specific information he was told about his wound or exact dates on when events occurred. Resident #12 said if the facility had addressed his wound appropriately, I would probably still have my hand. C. Record review The 8/12/18 Situation, Background, Assessment, Response (SBAR) form revealed the resident had a fall from bed. Injuries from this fall included a left hip externally rotated and a skin tear to his right elbow. He was sent to the emergency room . Per review of his chart, the resident returned on 8/17/18 with a [DIAGNOSES REDACTED]. The 8/17/18 skin assessment documented the resident had: - skin tear to right knuckle (did not specify which): 0.5 cm (centimeters) by 0.5 cm, - skin tear to right knuckle (did not specify which): 1.0 cm by 0.5 cm and - skin tear to right knuckle (did not specify which): 1.0 cm by 0.5 cm. The comprehensive care plan read (Resident #12) has actual impairment to right hand, initiated on 8/20/18. The care plan did not specify what the actual impairment was. Interventions included to monitor the dressing to ensure it was intact and adhering, observe the site for redness, swelling, increased drainage or pain, and provide treatment as ordered. The August, September, and (MONTH) (YEAR) medication and treatment administration records (MARs/TARs) revealed there were no treatment orders related to the resident's right knuckle abrasions. Nursing progress notes and physician documentation from 8/17/18 to 11/5/18 did not mention the right hand wound or specify treatment orders. Daily skilled nursing notes documented there were no changes to the resident's skin integrity. The 9/24/18 skin assessment documented one scab to his right hand measuring 1.0 cm by 1.0 cm. The 10/22/18 skin assessment documented one scab to his right knuckle measuring 1.0 cm by 1.0 cm. The 11/2/18 certified occupational therapy assistant (COTA) note documented the resident had drainage around the scab on his knuckle during an activity for wrist range of motion, and nursing staff and the supervising occupational therapist (OT) were notified. The 11/2/18 OT note documented there was necrotic black tissue on the right hand knuckle which opened with gentle AROM (active range of motion) to wrist and the resident complained of pain with any motion to his hand. The note documented there was minimal discharge, and the wound appeared red, painful and warm around the dark necrosis. The OT wrote that nursing was notified. The OT wrote that AROM activity was stopped to promote healing of the wound and due to the resident's pain. The note documented may indicate infection or worse, nursing is aware. The 11/2/18 and 11/4/18 daily skilled nursing documentation (none completed on 11/3/18) documented the resident had no changes to skin integrity. The 11/2/18 note documented the resident had no pain. Nursing progress notes from 11/2/18 to 11/4/18 did not mention the wound to the knuckles or any follow up that had been completed. The 11/5/18 nursing wound round note documented the resident had thick circular eschar present to his right third knuckle. The note read the resident said the area had been present from his falls a few months ago and recently worsened. The note documented Wound appears to be an avulsion measuring 1.2 x 1.1. Surrounding wound with [DIAGNOSES REDACTED] noted measuring 5 x 2.5. Wound edges flat and attached to wound bed. Unable to assess wound bed as has thick eschar adherent to wound bed. The physician (PCP #1) was notified and the resident was started on keflex (an antibiotic). The skin integrity and infection care plan, revised 11/6/18, was updated to include infected scab to third knuckle on right hand, started on antibiotics. The 11/7/18 PCP #1 telephone order (TO) read staff should clean the eschar daily, and the wound was to be kept dry and protected to promote healing. Review of the medical record revealed the order was entered into the electronic health record system. The 11/10/18 nursing note documented the right hand was worsening, with a streak of redness going up the dorsal hand towards the wrist. PCP #1 was notified. The 11/10/18 TO documented PCP #1 changed the antibiotic from keflex to [MEDICATION NAME]. PCP #1 also recommended the facility to draw a line around the red area and if it expanded to send the resident to the emergency room . The order was updated in the electronic health record system. The 11/12/18 nursing note documented the resident complained of severe pain, and so a cold washcloth was placed on the wound through the night (which contradicted the 11/7/18 physician order [REDACTED]. The note documented the line marking came off of the resident's hand from the washcloth but the nurse did not think the area increased overnight. The 11/13/18 skin/wound note documented the resident was sitting in his wheelchair with a wet washcloth over his hand (which contradicted the 11/7/18 physician order [REDACTED]. The note documented the resident expressed fear of losing his hand. The note documented the resident was educated on treatment options of the wound. The wound showed signs of worsening and the physician was notified. Review of the (MONTH) (YEAR) nursing progress notes and comprehensive care plan did not indicate the resident had preferred to use a wet washcloth to manage pain or that he had been educated on the subject (see interviews below). The 11/13/18 physician assistant (PA) note documented the resident developed a new eschar area to his right hand (5th knuckle) over the weekend and continued on antibiotics for right hand [MEDICAL CONDITION]. The note documented to consider a vascular consult given his new wound. Review of the chart revealed an order for [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed the order to clean eschar daily was not followed on 11/15/18. The 11/15/18 physician TO documented to change the treatment order to clean with normal saline or wound cleanser, apply santyl (a chemical debrider), cover with foam dressing and secure with kerlix. The dressing was to be changed daily and as needed when soiled. The order was changed in the TAR on 11/16/18. The order to keep the wound dry and protected was removed on the same date with the reason documented as new treatment orders. Review of the (MONTH) (YEAR) TAR revealed the treatment order was not documented as followed on 11/16/18 or 11/21/18. The 11/28/18 wound note documented surgical debridement was performed to remove eschar and to promote wound healing. The 12/3/18 TO from PCP #1 documented to change the wound treatment order to cleanse daily, apply an ointment of 1:1 (one to one) mixture of mupirocin (an antibiotic) and Santyl. The wound should be covered with a bandage dressing ([MEDICATION NAME], and changed to [MEDICATION NAME] on 12/14/18) and changed daily or as needed when soiled. The TO also documented the orthopedic specialist (OS) requested a vascular consult. The order for a vascular consult was entered into the electronic health record system on 12/4/18 and marked as completed on 12/5/18. Review of nursing and social services progress notes, and follow up provider documentation, did not indicate that a consult to a vascular specialist had been made. The 12/3/18 history and physical (H&P) completed by another physician (PCP #2) recommended the following laboratory tests be completed: complete blood count with differential (CBC w/ diff), comprehensive metabolic panel (CMP) and C-reactive protein (CRP). Review of the (MONTH) (YEAR) physician orders, progress notes and laboratory results revealed the recommendation had not been addressed by the facility. The 12/4/18 nurse progress note documented there was a new treatment order for the resident's right hand wound and they were awaiting medication at that time. The (MONTH) (YEAR) TAR revealed the order had been updated in the electronic health record system on 12/4/18. The medication was documented as administered with wound treatment on 12/4/18, 12/5/18 and 12/6/18. The pharmacy services consultant (PSC) provided documentation which showed the order for the 1:1 mupirocin/Santyl ointment had not been faxed to the pharmacy until 12/7/18 at 3:42 p.m. The PSC provided the delivery slip to show the ointment had been delivered to the facility on [DATE] at 5:07 p.m. Nursing progress notes in (MONTH) (YEAR) and the (MONTH) (YEAR) TAR did not indicate what ointment was used on the resident's wound treatment for [REDACTED]. The 12/11/18 PA note documented the 1:1 ointment was not started as planned until 12/7/18. The 12/11/18 PCP#1 note documented the resident had increased pain and redness and the wound was worsening after completing a round of antibiotics the previous week. The note documented the wound continued to progress, and had thin necrotic eschar and worsening [MEDICAL CONDITION], so [MEDICATION NAME] was restarted. The (MONTH) (YEAR) TAR revealed the treatment orders to cleanse wound, apply the 1:1 ointment, and cover the wound were not completed on 12/24/18 and 12/26/18. The 12/26/18 PA note documented the resident's wound to right hand had exposed tendons. The note documented that staff indicated the resident did not have his dressing changed on 12/24/18, and now there was increased tendon exposure and a foul odor. The note read that a vascular consult was requested on 12/3/18. The 12/27/18 PA note documented the resident had increased tendon exposure and the resident was manipulating his dressing and the wound. The note also documented the resident had high blood glucose levels which could have affected his healing, and so changes to his insulin regimen were made. A recommendation was made to check his CMP, CBC and CRP laboratory tests. An order was placed on 12/27/18 to check these labs. PCP #1 provided internal documentation that she had received labs from the facility dated 12/28/18. There was no resident name listed on the labs. PCP #1 had written she had asked for clarification as the resident was on [MEDICAL TREATMENT], and his lab values for glomerular filtration rate and creatinine (GFR and Cr, tests to measure kidney function) were not reflective of residents who were on [MEDICAL TREATMENT]. PCP #1 wrote that she had received the labs from a nurse at the facility, and had contacted the [MEDICAL TREATMENT] center for clarification. The physician wrote on 1/4/19 that she had yet to hear from [MEDICAL TREATMENT] regarding the labs. The 1/4/19 PA note documented that according to staff, the resident continued to manipulate his bandages, however the resident denied doing so. The note documented there was some improvement in his wound as the resident now had a proper dressing on his wound which was helpful to optimize wound healing. The note documented there was continued concern for vascular issues as discoloration was not improving with antibiotics. She documented a vascular consult had been requested on 12/3/18. The PA wrote to consider referral to wound care specialist given the overall worsening of the wound and an order was given to refer to the OS for examination of the right hand wound with tendon exposure. The 1/9/19 PA note documented the wound care nurse had notified her that the resident's wound was dry and improperly dressed. The PA wrote the tendons were also dry today. The note further read that wound care orders were not consistently being followed, and now wound bed is dry/deteriorating. The 1/10/19 PA note documented that wound care orders were not consistently being followed. The note also read the resident continued to manipulate his dressings and the resident had concerns about wanting a brace as he was unintentionally bumping his hand on the wall at times. The note read the PA and his nurse discussed an alternative way of fashioning his gauze dressing to make it more like a glove, improve circulation and make it more difficult to remove. The note further read the resident's vascular consult was never ordered as recommended by the OS. The PA wrote that she had explained to staff that despite the fact he had a normal arterial ultrasound (completed on 11/21/18), a vascular consult had been recommended by the OS as there was concern for microvascular disease. The note read that facility staff would reach out to the OS to see if the vascular consult was still necessary given the extent to which the wound had deteriorated. Review of the (MONTH) (YEAR) and (MONTH) 2019 nursing progress notes and comprehensive care plan did not indicate the resident had behaviors of removing his dressing or that he had been re-educated by nursing staff when these instances occurred. The 1/11/19 TO from the PA read to schedule an appointment to see a vascular specialist as soon as possible. The 1/11/19 social services note documented the OS office was notified and the resident had an appointment with the OS on 1/15/19 and it would be determined at that appointment to see if a vascular consult was still necessary. The 1/15/19 OS note documented the resident no longer required a vascular consult and required an urgent referral for a hand surgeon. The 1/16/19 hand surgeon note documented the resident had developed eschar overlying his fourth and fifth metacarpophalangeal (MCP) joints, which had sloughed off to reveal the tendons. The note documented the resident had limited range of motion with his fourth and fifth joints and the fingers were nonfunctional. The MCP wrote the fastest way to heal the wound was a partial hand amputation. review of the resident's medical record revealed [REDACTED]. D. Staff interviews Registered nurse (RN) #1 was interviewed on 4/17/19 at 10:20 a.m. RN #1 said the resident had fallen back in (MONTH) (YEAR) and scraped his hand. She said the wound worsened due to the resident's uncontrolled diabetes. She said the wound got swollen and infected. She said from what she remembered, in (MONTH) there was an order to keep the wound dry and the resident should not have been given a wet washcloth to keep on his wound. The PSC was interviewed on 4/17/18 at 10:57 a.m. She said she had received a phone call on 12/7/18 from a staff member at the facility inquiring about the ointment. The PSC said the pharmacy had not received the order for the mupirocin ointment until 12/7/18 and the ointment was delivered the same day. The PSC said the ointment would not have been available at the facility otherwise to administer as it was a compound mixture specially made by the pharmacy. The wound care registered nurse (WCRN), no longer employed by the facility, was interviewed on 4/17/18 at 1:40 p.m. The WCRN said when the resident had a fall resulting in a [MEDICAL CONDITION], he had also obtained an abrasion to his hand which scabbed over and deteriorated rapidly. The WCRN said there were no treatment orders to the resident's wound in August, but staff was monitoring the area. By November, the area had worsened and became infected. The WCRN said the resident had an order to keep the wound dry and there was one time where the nurse told him to keep a wet washcloth on the wound. The WCRN said this could cause the wound to get macerated. The WCRN said she saw the resident's wound on weekly wound care rounds and that nurses were responsible for completing daily treatments. The WCRN said there were other times when she saw the dressings on wound rounds and treatment orders were completed incorrectly. The WCRN said she had seen the dressing not changed for a day or two (had a date from one or two days prior) though orders were to change the dressing daily, or the dressing was undated. The WCRN said there was another time where the resident received a dry dressing with no ointment and the wound dried out. The WCRN said she did not recall specific dates for these instances. The WCRN said there was a delay with the resident receiving the 1:1 mupirocin/santyl ointment as the order had not been sent to the pharmacy, so she had called the pharmacy and faxed the order and they delivered the ointment the same day. The WCRN said that the documentation on the TAR that the ointment had been administered on 12/4/18, 12/5/18 and 12/6/18 was misdocumentation, as the ointment was not available in the facility as there were no other residents who required that compound. She said the medication should have been marked as unavailable on the TAR. The WCRN said she believed the resident had received a vascular consult but she did not know the name of the physician or when he did, but that she thought she had heard that in verbal report from PCP #1. The WCRN said she stopped working at the facility in January. The PA was interviewed on 4/17/18 at 3:48 p.m. The PA said she got the sense at times that treatment orders were not being followed for Resident #12. The PA said when she visited the facility, there was one visit earlier in his care where the dressing was really soiled and the resident had orders to change the dressing as needed when soiled, and visits later in the progression of his wound where he had no dressing and staff said he had removed it. The PA said in December, the resident did not receive the correct treatment order for four days as the order was not sent to the pharmacy timely. She said that there would not have been a 1:1 mupirocin/santyl ointment available for the facility staff to use otherwise. The PA said she had communicated frequently with facility nursing staff and PCP #1 regarding concerns with the resident's wound treatments. The PA said the OS had requested a vascular consult in the beginning of (MONTH) (YEAR). The PA said she had noticed a month later the facility had not made the referral for the resident and she had pointed it out. The PA said at that point the wound had worsened badly and the OS had requested an urgent referral to the hand surgeon instead. The PA said that there would normally be a couple of weeks of turnaround time for the resident to get an appointment with the vascular specialist given the facility's rural location, but the order could have been expedited. The medical director (MD) was interviewed on 4/17/19 at 5:03 p.m. The MD said he was not familiar with Resident #12's wound but he said the resident was likely mentioned at the monthly quality assurance and performance improvement (QAPI) meetings when wounds were discussed. The MD said he had not collaborated with the resident's physicians regarding his wound care. PCP #1 was interviewed on 4/17/19 at 5:52 p.m. PCP #1 said the resident's wound deteriorated rapidly in early (MONTH) as it had become infected and he was at higher risk due to the resident's chronic conditions of end stage [MEDICAL CONDITION] and type 2 diabetes. She said prior to that, nursing staff were monitoring the wound and she had not heard of any concerns of pain or the wound worsening from nursing or therapy staff. PCP #1 said she would frequently hear from the WCRN or the PA regarding issues with treatment orders being followed. She said she had written an order to keep the wound dry and heard the resident had a wet washcloth on the hand. She said this could cause the wound to become macerated and would not promote wound healing. PCP #1 said she had heard of other times throughout the resident's treatments that the resident's dressings were done incorrectly and nursing staff had been re-educated by the WCRN and PA. She said she believed the WCRN brought concerns to the attention of the director of nursing (DON) and nursing home administrator (NHA). PCP #1 said the resident had been treated with multiple rounds of antibiotics at the facility, and also had received [MEDICATION NAME] at the [MEDICAL TREATMENT] center as ordered by the nephrologist. PCP #1 said the resident had an arterial ultrasound completed on 11/21/18 which showed no issues with vasculation of major arteries, but the OS had concern for the resident having issues with microvasculature given the complexity of his situation, such as a history of uncontrolled diabetes, bilateral leg amputations, and the wound was on the same arm as his [MEDICAL TREATMENT] fistula. She said a consult with a vascular specialist had been requested but not followed up on. PCP #1 said the former social worker was responsible for scheduling appointments, and when the PA had noticed the consult had not been made, the social worker said she was not aware that there had been an order in early December. PCP #1 said there was a delay in the resident receiving the 1:1 mupirocin/santyl ointment as the order was not sent to the pharmacy by the facility. She said the resident's wound looked worse after this and she was not sure what treatments the nurses were administering during the time the ointment was not available in the facility. PCP #1 said at that point in early January, the wound had deteriorated to the point where an amputation was necessary. PCP #1 said she had heard the resident had behaviors of picking at his own bandages and he had been educated by the WCRN and other nursing staff on this. PCP #1 said it was hard to say if the resident would have had a different outcome given his multiple chronic conditions, but she said some treatment decisions were based on trying to accommodate that treatments were not being followed consistently, so perhaps the resident could have had less complications or have delayed the surgery. PCP #1 said given the resident's chronic medical conditions, it was even more important for the facility staff to adhere to wound treatment orders and recommendations strictly. PCP #1 said there may have been alternative options for treatment as well if the resident had seen a vascular specialist timely. Licensed practical nurse (LPN) #3 was interviewed on 4/18/19 at 8:46 a.m. LPN #3 said she did not recall the resident's wound in much detail. LPN #3 said the resident's knuckles were fine and then rapidly declined. She said she did not remember seeing any wound treatment orders followed incorrectly. LPN #3 said she did not recall exactly what was put on the wound when the ointment was unavailable but documented as administered, and said it was likely [MEDICATION NAME] ointment. LPN #3 said she did not know if the vascular consult was made as the former social worker was in charge of that. LPN #3 said Resident #12 would remove or play with his dressing and that he would be re-educated. She said there was probably documentation in the resident's chart regarding this. The director of nursing (DON) was interviewed on 4/18/19 at 3:12 p.m. The DON said the resident's wound was not present when she began working at the facility at the end of September, but said it had declined rapidly shortly after. The DON said Resident #12's wound was followed on wound rounds but the DON did not always attend wound rounds. The DON said the former WCRN followed the resident's wound more closely than she did and the DON had only seen the resident's wound once or twice. The DON said she had only heard of one or two times where the resident's wound treatments were not followed. She said one time, the resident received a dry dressing and the bandage had dried onto the wound and had to be soaked off. Another time she had been notified the wound had been dated a previous day and she had re-educated staff on following wound treatment orders daily. The DON said the resident preferred to have the wet washcloth on his hand as it helped alleviate the pain and she was not aware Resident #12 had an order to keep the wound dry. The DON said she could not speak to what happened with the delay in receiving the 1:1 ointment as she was not aware of the situation. The DON said once the order was entered into the electronic health record system, the nurse who entered the order should fax the order to the pharmacy. The DON said the former social worker was in charge of scheduling appointments and she was not aware a vascular consult had not been made for the resident timely. The DON said the resident's wounds were discussed in their wound meetings and monthly QAPI meetings so she was informed on the progression of the resident's wound. II. Failure to transcribe discharge medication instructions correctly when Resident #38 was readmitted to the facility, resulting in Resident #38 not receiving his antipsychotic medication for approximately one month. A. Resident #38 status Resident #38, age 75, was admitted on [DATE]. According to the (MONTH) 2019 (CPO), [DIAGNOSES REDACTED]. The 3/20/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required extensive assistance of two people with transfers, and one person physical assistance with all other activities of daily living (ADLS). The resident was receiving an antipsychotic medication seven days a week. B. Record review The care plan, initiated on 5/27/18, identified the resident as receiving an antipsychotic medication ([MEDICATION NAME]) due to his [DIAGNOSES REDACTED]. The goal was for the resident to remain free from [MEDICAL CONDITION] related complications including: movement disorder, discomfort and cognitive/behavioral impairment. The pertinent approaches included administering the medication ([MEDICATION NAME]) as ordered by the physician and monitoring for effectiveness and side effects every shift. The hospital discharge medication instructions dated 12/5/18 revealed Resident #38 was to continue taking his [MEDICATION NAME] ([MEDICATION NAME]) 20 milligram tablet one time every day. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the med error/incident report, provided by Resident #38's primary care physician (PCP), revealed the following: resident returned from the hospital after SOB (shortness of breath) without significant medication changes, however his [MEDICATION NAME] ([MEDICATION NAME]) was not resumed at the facility .Upon discharge reconciliation, the medication was continued but never showed up in the first list of medication instructions (which are also considered admission orders [REDACTED]. Therefore, the patient has been delusional at the facility, with extra testing being performed to figure out why he is delusional. C. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 4/18/19 at 10:12 a.m. She said the resident was having increased behaviors during (MONTH) (YEAR). She said he would frequently yell out at nothing in particular, he would get on the phone and would think he was talking to his wife and would yell at the phone. She stated he just seemed more agitated during that time. The primary care physician (PCP) #1 was interviewed on 4/17/19 at 6:22 p.m. She said he was having increased behaviors after he returned from the hospital in (MONTH) of (YEAR). The PCP said he was yelling out frequently, and she also noted a change in his speech, where it felt pressured. She said they tested the resident for a urinary tract infection, which came back negative. The PCP said she began investigating the resident's change in behavior because prior to his hospitalization (MONTH) (YEAR), he had been very stable. The PCP began looking into his medication and that was when she noted the [MEDICATION NAME] had not been continued when the resident returned from the hospital. The PCP said she immediately restarted the medication, but it took about a month for the resident to get stabilized. The director of nursing (DON) was interviewed on 4/18/19 at 3:00 p.m. She said the admitting nurse should be reviewing all of the documentation that came from the hospital with a resident. She said she was not aware that medication orders could be in two separate locations on the hospital discharge paperwork. The DON said she needed to get a different system into place to ensure all of the resident's medications were being transcribed correctly onto the medication administration record. III. Failure to manage [MEDICAL CONDITION] for Resident #39 A. Resident #39 status Resident #39, age 73, was admitted on [DATE]. According to the (MONTH) 2019 (CPO), [DIAGNOSES REDACTED]. The 3/22/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required limited assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. He required set-up help only with eating. B. Record review A stop and watch early warning tool dated 4/4/19 documented the following change in skin condition for Resident #39, therapy noted [MEDICAL CONDITION] in patient's lower extremities. Not new condition. A stop and watch early warning tool dated 4/9/19 documented the lower extremity [MEDICAL CONDITION] and that the resident may benefit from compression hose/stockings. C. Resident interview Resident #39 was interviewed on 4/14/19 at 4:38 p.m. He said he had been in the facility about a month and had been struggling with swelling in his lower legs. He said a therapy staff member said the facility was ordering stockings for him

Based on observation, record review, and staff interviews, the facility failed to ensure for four (#96, #29, #18, and #101) of six residents received care consistent with professional standards of practice to promote healing of pressure injuries out of 41 sample reviewed. The facility contributed to Resident #96 developing pressure ulcers, who was an at risk resident. The facilities actions contributed to Resident #96 prior wounds to worsen and the development of new pressure wounds. This is evident by the facility failing to assess and accurately document wounds in its entirety on admission and thereafter, identify and monitor prior wounds and new wounds that developed for healing and or deterioration, notify the physician of the wounds to obtain orders timely, implement the treatments prior to the residents discharged home with hospice care. Moreover, the facility did not notify the responsible party of the new wounds and failed to inform and coordinate care of the pressure ulcers with hospice to ensure continuity of care. Hospice received Resident #96 with five wounds and no current treatment orders in place. The facility contributed to a delay in wound treatments services for Resident #29 who had compromised skin integrity and a history of pressure ulcer development. Resident #29 sustained two pressure ulcers to his buttocks and after these wounds were identified the facility failed to obtain orders, initiate treatment orders timely and according to professional standards, notify the wound clinic of the two new areas, revise the person centered care plan to reflect the stage 2 pressure ulcers. As a result, the residents pressure ulcers were not treated from the initial day of observation (4/12/19) until the resident was seen at the wound clinic (4/17/19), this action contributed to the residents delay in adequate care and appropriate initial healing response time. Furthermore, the facility failed to communicate with staff and implement the orders from the wound clinic timely. Additionally, the facility failed to: -Obtain physician orders timely to treat Resident #18's stage 2 pressure ulcer; and -Obtain physician orders timely and follow the physicians order and provide treatment to Resident #101's unstageable pressure ulcer. Cross-reference F725 the facility failed to provide sufficient nursing staff to meet the needs of the residents. Findings include: I. Professional reference A. The National Pressure Ulcer Advisory Panel (2016) NPUAP Pressure Injury Stages, retrieved from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages revealed the following pertinent information: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. -A stage 2 pressure injury is partial-thickness skin loss with exposed dermis. -An unstageable pressure injury is an injury with obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. -A deep tissue pressure injury (DTPI) is a persistent non-blanchable deep red, maroon or purple discoloration resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. B. The National Pressure Ulcer Advisory Panel (2016) NPUAP Pressure Injury Stages, retrieved from: http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf revealed interventions for prevention and treatment of [REDACTED]. Assess the pressure ulcer initially and re-assess it at least weekly. Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection) should be addressed immediately. -Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. II. Facility policy and procedure The Skin Management policy, revised (MONTH) (YEAR), was provided by the nursing home administrator (NHA) on 4/16/19 at 4:00 p.m. It read in pertinent part, Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition. -Appropriate preventative surfaces (e.g., beds, wheelchairs) will be implemented for residents identified at risk. Interventions are documented on the care plan. -Residents admitted with skin impairments will have: Interventions implemented to promote healing; a physician's order for treatment; wound location and characteristics documented in the Nursing Admission Data Collection Set, and notification of the presence of skin impairment to the resident's representative and attending physician and documentation in the Nursing Admission Data Collection Set or progress notes. -A care plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address, but is not limited to the following: hydration, nutrition, physical activity, pain management, positioning requirements, and proper alignment. -If a new pressure ulcer is identified, either upon admission, readmission, or during the resident's say, the wound is, assessed and documented on the weekly pressure ulcer record. The licensed nurse will document daily monitoring of pressure ulcers on the Treatment Administration Record (TAR). A physician's order will be written to monitor each pressure ulcer and documentation on the TAR will reflect the status of the dressing, surrounding skin color and skin and pain associated with the wound. -At-Risk Review Meetings will be conducted to review/discuss: new admissions, residents identified at risk or with skin integrity compromise, treatment modalities and interventions, recommendations based on interdisciplinary evaluation. -The nurse will initiate treatment, interventions, care plan, and the appropriate skin documentation records in a timely manner according to the practice guidelines. Pressure ulcers are measured and staged in accordance with the practice guidelines. III. Resident #96 A. Resident status Resident #96, age 73, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician orders (CPO), he had a [DIAGNOSES REDACTED]. The 2/6/19 minimum data set (MDS) assessment revealed the resident required extensive one-person assistance with bed mobility, dressing, transfers, and toilet use. He was frequently incontinent of bowel and bladder. He did not exhibit any behaviors or resist care. It was documented Resident #96 did not have any unhealed pressure ulcers. His discharge goal was to return to the community with family. His cognitive status was not documented. B. Hospice interview Throughout the review process multiple skin documents failed to reveal the wounds were assessed in their entirety to include: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. The hospice social worker was interviewed on 4/17/19 at 8:39 a.m. She said when Resident #96 was discharged home on hospice (February 2019) they were not informed he had five wounds and he did not have treatment orders in place. She provided the documentation of his wounds from his home admission on the hospice physical assessment form (see below). C. Record review The baseline care plan, initiated 1/31/19 revealed the resident required assistance with activities of daily living (ADLs) due to [MEDICAL CONDITION] and he needed end of life care. Interventions included to notify the physician and/or hospice for potential changes or needs for treatment changes. Provide comfort measures as indicated when end of life is imminent. -There was no documentation indicating whether the resident planned to stay at the facility or discharge home, and there was no documentation of Resident #96's pressure wounds. Review of the CPO for (MONTH) 2019 revealed there were no treatment orders for Resident #96' wounds. Review of the (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. The 1/30/19 Braden Scale for Predicting Pressure Score Risk revealed the resident was at risk for developing pressure ulcers with a score of 17 (score of 15-18=At risk, 13-14=Moderate risk, 10-12=High risk, and 9 or below=very high risk). The 1/30/19 Nursing Admission Data Collection form revealed the resident was alert and oriented to person, place and time. He had pressure ulcers to his coccyx and to his left buttock. -There was no documentation of how many wounds Resident #96 had to his coccyx or his left buttock. It was documented there were two small sores dark and black in color. The physical characteristics or measurement of the wounds was not documented. Review of the Nursing Daily Skilled Charting form from 1/31/19 through 2/6/19 revealed no changes in Resident #96's skin integrity except on 2/5/19; it revealed there were changes in Resident #96's skin integrity; documented was a small open area in between buttock on the right side. -There were no physical characteristics of the wound documented. -There was no documentation of the physician being notified of Resident #96's wounds in the clinical record. The 1/31/19 nurses note at 2:19 p.m. revealed Resident #96 had 3+ (plus) [MEDICAL CONDITION] to his bilateral lower extremities. -The 2/1/19 nurses note at 8:05 p.m. revealed Resident #96 had open area to his bilateral medial fissure (long narrow opening or slit to the coccyx), the area was cleansed and barrier cream was applied. -There was no documentation in the clinical record of the physician or family being notified of the wound or any physical characteristics of the wound. -The 2/7/19 Nutrition Data Collection (facility form) revealed Resident #96 had pressure wounds (stage 1) to his left buttock and his coccyx. The hospice physical assessment form dated 2/7/19 at 10:00 a.m. revealed Resident #96 had five pressure ulcers including a diagram of their location (see below). It was also documented per family report Resident #96 developed his pressure wounds in the past 10-days. -The superior rectal crease (midline) wound measured 3 cm (centimeters) x (by) 1 cm depth was unknown. It was unstageable pressure ulcer with eschar (necrotic tissue) and slough (dead tissue) with a small amount of drainage, the periwound (skin around the wound) was intact. -The lateral buttock (lateral rectal crease) wound measured 1 x 0.7 x < (less than) 0.2 cm. It was a stage II (2) pressure ulcer with partial thickness and clear serous (thin watery plasma) drainage, the periwound was tender. -The (lateral left rectal crease) inferior to the wounds above, over a bony prominence was denuded (excoriated) it measured 1.5 cm x 1.6 cm x < 0.2 cm with a small amount of serosanguineous (plasma and red blood cells) drainage. It was a stage II and appeared pink/black/yellow and white, the periwound was tender and firm. -The right lateral rectal crease (lateral to mid buttock) wound measured 1.6 cm x 1.6 cm x < 0.2 cm. It was a stage II and appeared pink/white with slough, the periwound was tender. -The inferior right gluteal peri-area near the right testicle was denuded. It was a stage II that measured 2.3 cm x 2.0 cm x < 0.2 cm. with a small amount of serosanguineous drainage and appeared pink/white/yellow and brown, the periwound was dark pink and intact. -It was also documented the resident had weeping [MEDICAL CONDITION] to his bilateral lower extremities. D. Staff interview The director of nursing (DON) was interviewed on 4/18/19 at 2:09 p.m. She said the facility did not have a protocol they followed for wound care. She said the nursing staff should notify the physician or nurse manager on call when a wound was identified. She said Resident #96' condition was reported to his wife; however, could not provide any evidence that she was aware. She said Resident #96 should have had treatment orders for his wounds prior to discharge. IV. Resident #29 A. Resident status Resident #29, age 72, was admitted on [DATE], and readmitted [DATE]. According to the (MONTH) 2019 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 2/6/19 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required extensive assistance of two or more people with all activities of daily living. He was always incontinent of bowel and bladder. He was identified at risk for pressure ulcers. The resident had existing stage IV pressure ulcer and was receiving treatment. He had pressure reducing device in bed. He was not on a turning and repositioning program. B. Wound care observation and staff interview On 4/17/19 at 1:46 p.m. Resident #29 was in bed during wound care provided by licensed practical nurse (LPN) #2 and the director of nursing (DON). The resident was positioned on his back with the head of the bed elevated to 35 degrees. The resident was lying on an air mattress. The resident had one small dressing on the right plantar surface (sole of the foot) and it was dated 4/17/19. The dressing was clean and not saturated. -On the left plantar surface he had three small dressings dated 4/17/19. The DON said the resident returned from the wound clinic one hour ago and all of his dressings were changed at the clinic. The DON said the resident' skin was intact except for the wounds on the resident' feet. -When the resident was repositioned onto his side, two large pink foam dressings were observed covering the right and left buttocks. The DON stated those dressings were placed by the wound clinic as the facility did not have pink foam dressings. The dressings did not have dates on them. The DON removed both dressings and stated both dressings were Vaseline impregnated gauze. She said it was not appropriate treatment for [REDACTED]. (see DON interview on 4/18/19 at 4:45 p.m.) Two large wounds were observed on the resident' buttocks with extensive redness and irritation that covered 90% of the residents buttocks. The wound on the right buttock measured 2.5 centimeters (cm) width by 1.0 cm length with redness around the wound measured 11.6 cm width by 6 cm length. The wound on the left buttock measured 1.5 cm width by 0.5 cm length with redness around the wound was 14.7 cm width by 6.5 cm length. Both wounds were pink to red in color, clean with no slough, and no discharge. After cleaning both wounds with the wound cleanser the DON applied absorbent adhesive dressings to both wounds. The DON was interviewed immediately after the wound observation. She said she was not aware that Resident #29 had wounds on his buttocks. She said she just learned about those wounds when she stepped out of the room to get the dressing supplies when the floor nurse showed her a note from the wound clinic that described the wounds. She said she did not recall observing any skin problems for this resident last week on the last wound round. She could not recall on what date last wound round was conducted. However, the wound was first observed on 4/12/19 see situation background assessment recommendation (SBAR) below. C. Record review The skin integrity care plan, initiated 4/5/16 and revised 4/14/19, identified the resident was at risk for developing skin problems due to psoriasis, scratching self, and incontinence. The resident was readmitted with pressure areas and one stage IV (4) wound to the plantar foot. Interventions included wound clinic visits weekly starting on 4/9/19, air mattress in bed, float heels when resident in bed, turn and reposition, and to notify physician about healing of present wounds and emergence of new. -However, the care plan did not address the two existing stage 2 pressure ulcers on the resident' buttocks. The 4/12/19 SBAR form revealed Resident #29 had open blister to left and right bottom cheek. Treatment included treatment cream, repositioned side to side, and good peri care. Assessment revealed that resident is incontinent of bowel and bladder. Bedridden, dependent with repositioning, ADLs. A note indicating that resident' physician was notified. The 4/12/19 Skin Assessment documented two abrasions on the right and left buttocks. There were no previous or further documentation regarding the left and right buttocks skin condition, treatment orders that were implemented or the DON being notified of the newly developed pressure ulcers. On 4/17/19, the same day as the two new wounds were observed with the DON, a physician order for [REDACTED]. On the 4/17/19 the note by the wound care clinic physician read in pertinent part, Right/left buttock, Vaseline gauze, foam, daily and (as needed). No description or measurements of the wounds were available. There were no other wound notes between 4/12/19 (time wounds were first identified) and 4/17/19 after the wound clinic treated them. D. Resident observations revealed that the majority of the time the resident was left lying on his back. On 4/14/19 at 12:10 p.m. resident was observed in bed on his back. -at 2:15 Resident #29 observed in same position, he was awake watching TV. Did not respond to questions, made short eye contact and continued to watch TV. -at 4:56 p.m. Resident #29 was positioned on his back. On 4/15/19 at 9:23 a.m. Resident #29 was in bed on his back, the resident was watching TV. -at 11:21 a.m. the resident was lying on his back, asleep. -at 3:51 p.m. the resident was lying on the back, awake watching TV. -at 5:36 p.m. the resident was in bed in the same position, watching TV. On 4/16/19 at 10:01 a.m. the resident was in his bed lying on his back, awake, watching TV. -at 1:23 p.m. he was in the same position, but asleep. -at 4:43 p.m. he in the same position watching TV. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 4/17/19 at 2:45 p.m. She said she was new to the facility. She said she was assigned to do wound rounds with the DON. She said at times the DON was not available for the wound rounds and it was done by another nurse from the sister facility. She said Resident #29 had two wounds on his buttocks which were new and she did not know the resident had the wounds. She did not know what treatment the resident had for his buttock wounds currently. The director of nursing (DON) was interviewed again on 4/18/19 at 4:45 p.m. She said at the time of the wound observation she did not know the resident had wounds on his buttocks. She did not know he developed them. She said she talked to nurses and they communicated to her that the resident' physician was contacted on 4/12/19 and he did not respond back regarding what treatment to initiate. She said they did not have any standing orders regarding wound treatments. She said nurses should have called physician again and reminded him to clarify the order. She said the resident did not receive any care for his buttock wounds between 4/12/19 and 4/17/19. -This would be a delay in treatment for [REDACTED]. DON reviewed the current physician orders and confirmed that physician order stated to apply Vaseline impregnated gauze to both wounds. She said it was not the dressing she applied during wound care observation as she thought it was not an appropriate dressing for wounds. She said she did not read the physician' order prior to starting the wound dressing and she did not clarify it with the physician after she applied a different dressing (if she thought it was an appropriate dressing). V. Resident #18 A. Resident status Resident #18, age 82, was admitted on [DATE]. According to the (MONTH) 2019 CPO [DIAGNOSES REDACTED]. The 1/15/19 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive one-person assistance with bed mobility, transfers, and toilet use. She was frequently incontinent of bladder and continent of bowel. The resident was at risk for developing a pressure ulcer. B. Observation and staff interview On 4/17/19 at 2:50 p.m. Resident #18's wound care to her coccyx was being provided by the director of nursing (DON) and licensed practical nurse (LPN) #2. The resident was observed in bed with her pants and brief on. The DON and LPN #2 used ABHR (alcohol based hand rub) and donned gloves. The DON helped Resident #18 reposition and lie on her right side. LPN #2 removed a soiled dressing with a moderate amount of serosanguineous drainage. The minimum data set coordinator (MDSC) came into the room with CNA #3 to assist with care. They used ABHR and donned gloves. CNA #3 helped assist the DON in keeping Resident #18 positioned on her right side while the MDSC measured the wound. She said the measurement to the wound was 4 cm x 0.5 cm x 0.1 cm. The MDSC said when she measured the wound a week prior the wound was smaller and circular in size and now appeared more as a slit and it was superficial. The wound bed was red, pink and brown with discoloration. The DON said the wound was a stage 2. She said the resident had a history of [REDACTED]. The DON said the treatment orders were for an absorbent dressing. LPN #2 cleansed the wound with wound cleanser and the DON applied an [MEDICATION NAME] (absorbent) dressing to the resident's buttocks and placed her in a comfortable position. C. Record review The nutrition care plan, initiated 11/30/15 and revised on 4/9/19 revealed the resident had a history of [REDACTED]. The pressure ulcer care plan, initiated 5/21/16 and revised on 4/14/19 revealed the resident had a pressure ulcer to her buttock interventions included an air mattress initiated on 4/15/19, encourage the resident to turn and reposition, preventative care as ordered and provide wound care per physician orders. The 1/30/19 Braden Scale for Predicting Pressure Score Risk revealed the resident was at risk for developing pressure ulcers with a score of 16. The SBAR (situation, background, assessment, and recommendation) form dated 3/28/19 revealed Resident #18 had an open area to her coccyx. There was no documentation of any new orders received. -There were no physical characteristics of the wound documented on the SBAR. The nurses note dated 3/28/19 at 11:51 p.m. revealed the coccyx wound measured 0.5 cm x 0.5 cm. and a foam dressing was applied to the wound. There were no physician orders for treatments until 4/12/19 (see below). The nurses note dated 4/9/19 at 4:25 p.m. revealed Resident #18 had an open wound to her coccyx which was left open to air and was pinpoint in size. The skin assessment dated [DATE] revealed Resident #18 had an opened wound to her coccyx which measured 0.2 cm x 0.2 cm. The 4/11/19 Nutrition status review revealed the resident had a pinpoint area to her inner left buttock (per the facilities skin report 4/3/19). The weekly pressure ulcer record form dated 4/12/19 revealed Resident #18 had a stage 2 wound to her left buttock which measured 0.25 cm x 0.25 cm x 0.1 cm. The wound bed was pink, the surrounding skin was intact, and there was no odor, no drainage, or signs of infection. The telephone order dated 4/12/19 read, Apply [MEDICATION NAME] to open area on left buttock twice daily and as needed. Review of the (MONTH) and (MONTH) 2019 treatment administration record (TAR) revealed an order for [REDACTED]. Although the facility had treatment orders in place for Resident #18's wound to her left buttocks during the survey, observations revealed Resident #18's wound had deteriorated and progressed to a stage 2 pressure ulcer, there was a delay in obtaining treatment orders as noted in the documentation above. D. Staff interview The director of nursing (DON) was interviewed on 4/18/19 at 2:09 p.m. She said she was told Resident #18's wound was healed, and she had no response to the delay in obtaining treatment orders. VI. Resident #101 A. Resident status Resident #101, age 85, was admitted on [DATE] and was discharged or was not in the facility during the survey. According to the (MONTH) 2019 CPO [DIAGNOSES REDACTED]. The 12/21/18 MDS assessment revealed the resident was cognitively impaired with a BIMS score of one out of 15. She required extensive two-person assistance with bed mobility, transfers, and toilet use. She always incontinent of bladder and frequently incontinent of bowel. She was at risk for developing pressure ulcers. B. Record review The skin integrity care plan, initiated on 3/29/18 and revised on 3/11/19 revealed the resident had a pressure ulcer. Interventions included to observe the site for redness, swelling, increased drainage and pain, pressure relieving device to bed and chair, and provide treatment as ordered. The 12/19/18 Braden Scale for Predicting Pressure Score Risk revealed the resident was at risk for developing pressure ulcers with a score of 15. The Pain Evaluation form dated 3/4/19 revealed Resident #101 had no pain was not on a scheduled pain management regimen, did not receive any as needed pain medication and did not receive non-medication intervention for pain. The nurses note dated 3/4/19 at 9:33 a.m. revealed Resident #101 had a wound to her coccyx. -There were no physical characteristics of the wound documented or treatment orders obtained. The nurses note dated 3/5/19 at 1:36 a.m. revealed Resident #101 had clean, dry, and intact dressing to her coccyx. -There were no orders for treatment from the physician documented until 3/6/19 (see nurse note below). The nurses note dated 3/6/19 at 11:17 a.m. revealed the physician ordered treatments for Resident #101's coccyx wound; however, the orders were not transcribed into Resident #101' TAR until 3/7/19 at 11:06 a.m. (three days after the documented wound observation). The Head to Toe Skin Checks form dated 3/7/19 revealed Resident #101 had a pressure wound to her coccyx. The Weekly Pressure Ulcer Record form dated 3/7/19 revealed Resident #101 had an unstageable pressure ulcer to her coccyx. The wound measured 3.5 cm x 2.5 cm and the depth was unknown. The wound was black, there was no drainage, no odor, and the wound edges were normal for skin and the area was slightly larger in size. Review of the TAR for (MONTH) 2019 revealed an order dated 3/7/19 at 11:06 a.m. which read in pertinent part, Cleanse wound to coccyx with normal saline then pat dry, apply santyl (a medicine used to remove dead tissue from wounds) to wound bed and cover with [MEDICATION NAME] dressing. The time documented for the treatment of [REDACTED]. Review of the TAR for 3/7/19, 3/8/19, and 3/9/19 revealed Resident #101 treatment was held due to her condition. No documentation the physician or family was notified the treatments were not being done during this time. On 3/10/19 it was documented the treatment was held (see progress notes). Review of the 3/10/19 progress notes revealed Resident #101 was declining. Although the facility received treatment orders for Resident #101 there was a delay in treatment and there was no documentation of the treatments being provided consistently per the physician orders or monitoring the wound for infection or deterioration. C. Staff interviews The medical director was interviewed on 4/17/19 at 4:38 p.m. He said the staff should notify the physician of any wounds and follow treatment orders even if a resident is declining. The director of nursing (DON) was interviewed on 4/18/19 at 2:09 p.m. She said the nurses should have provided treatment to Resident #101's wound, and it was not an acceptable reason to hold treatment because a resident was declining. She acknowledged treatment could have been provided to Resident #101 during incontinent care or with repositioning because of the location of the wound.

Based on observations, staff and resident interviews and record review, the facility failed to maintain an environment as free from accident hazards as possible for the 34 residents residing on the East hall, and two of 65 sample residents (#9 and #20). Specifically: I. The facility failed to maintain an audible and effective call light system to ensure the safety of residents, including the safety of 34 residents currently residing on the East hall, 13 of whom required one to two person assistance with activities of daily living (ADLs) and eight of whom were total dependent on staff for ADLs. (Cross reference F166; grievances). Activation of the call lights revealed on the East hall, rooms 2-29 call lights were not audible. Staff reported the call lights on the hall had not been audible for about two years and they relied on a light bar and a large ceiling light to alert staff a call light had been turned on. However, the light bar was not visible from rooms 17-29 and the large light, visible throughout the East hall, only operated occasionally. Observations further revealed 16 bathrooms on the East hall were equipped with a call light button, rather than a call light cord, which was placed between the toilet and the sink and likely out of a resident's reach from the toilet or from the floor after a fall. Interviews revealed the facility knew of the deficiencies above in the call light system on the East hall and that until recently (5/16/17), the call light on the West hall, too, was deficient. However, the facility had not acted promptly to develop an interim plan to ensure the residents' ability to communicate their potential need for urgent assistance. This failure created a situation of immediate jeopardy for serious harm for the residents on East hall. II. The facility failed to clarify for the resident and staff, the parameters of the resident's smoking practices after admission. III. The facility failed to monitor and address resident #20's elopements from the facility. III. The failed to Findings include: I. Call light system A. Immediate Jeopardy (IJ) 1. Imposition of IJ On 5/18/17 at 7:03 a.m. the nursing home administrator (NHA) and the nurse consultant (NC #2) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to provide an audible and effective call light system on the East hall left the facility residents vulnerable and created a situation of immediate jeopardy for serious harm. 2. Facility Response to the IJ On 5/18/17 at 2:15 p.m., the facility's plan to abate the IJ was accepted. It read: May 18, 2017 Immediate Jeopardy Abatement Plan for F323 The call light system is not audible, but the light globes above each resident room door illuminate, as determined with an audit of the function of the globes above the resident room doors. A hand-held bell has been distributed to each resident on the East side of the facility, which includes rooms numbered 2 through 29. A staff member is assigned to the East hallways to monitor for the room light illumination and listen for the ringing of the hand-held bells supplied to the residents. The staff member will only be responsible for monitoring the East hallway during the assigned times and informing the care providers of the residents' needs. The staff monitoring the East Hall will be educated regarding their responsibilities while monitoring the East Hall. The residents who reside on the East hallways will be evaluated on the ability to physically hold and shake the call bell. The residents who are able to hold and shake the bell will be able to understand the purpose of the bell through the education provided at the time of the evaluation. The bathroom call lights will be audited to determine which rooms have a call button and which have a call cord. The call buttons will be replaced with a call cord style or a TABs type alarm, which will be within resident's reach until the new system installation is completed. A face-lock panel will be purchased and installed by the Maintenance Director, preventing access to the call light panel unauthorized staff on 5/18/2017. (Company name) Communication are currently attempting to complete temporary repairs on the existing call light system, until the new system can be installed. The Capital Purchase Request for the call light system was approved on May 16, 2017. The Installer of the new system completed an onsite assessment May 17, 2017. The install Vendor will be on premise May 19, 2017 to begin the install of the new call light system. Residents residing on the East Side will be interviewed daily to ensure their call light or handheld bell is being answered timely and needs are met, until the call light system is restored or replaced. Residents residing on the East Side will be interviewed by the Nursing Home Administrator or designee weekly for one month and then bi-weekly for one month to ensure their call lights are answered timely and need(s) are being met, after the call light system is restored/replaced. A random sample of 10 residents residing on the East Side will be interviewed by Social Services or designee weekly for 2 months to ensure their call lights are answered timely and needs are being met. Education will be provided to each staff member prior to starting their assigned shift, with all staff educated by May 19, 2017 regarding the room call lights and bathroom call lights and the temporary system (hand-held bells and hall monitoring assignments), until the call system is repaired or replaced. Maintenance Director and Maintenance Staff will be educated to not disconnect the sound of the call light system by (Senior Nursing Home Administrator name). An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting will be held on May 18, 2017. The results of the audits will be present(ed) by the Nursing Home Administrator and reviewed at the QAPI meeting for 3 months. 3. IJ removed On 5/18/17 at approximately 2:30 p.m., after a hand held bell was given to each resident on the East hall and a staff member was assigned to monitor all call lights, the NHA and NC #2 were informed the IJ was removed. However, deficient practice remained at an E level. B. Facility Policy The policy titled Equipment Repair or Replacement, revised June 2007, read in pertinent part: - Essential/Critical Equipment is defined as equipment whose failure would pose a threat to the safety or welfare of residents or staff. Examples include the following: Nurse Call Equipment - Emergency Repairs: 6.Implement temporary emergency procedures; 7. Contact appropriate vendor/contractor for repair/replacement. C. Facility failure to maintain an effective call light system to ensure resident safety. 1. Review of Facility Census and Conditions Review of the facility census and conditions, dated 5/18/17, revealed 13 residents required assistance of one or two staff for ADLs and eight residents were totally dependent on staff for ADLs. 2. Observations and Interviews 5/18/17 - Prior to facility notification of IJ Activation of the call lights on the East hall revealed the call lights were inaudible and the call light system (push button) in 16 East hall resident bathrooms was placed out of residents' reach. Interviews revealed these deficiencies, as well as inaudibility of the call light system on West hall until recently, were known, longstanding, and not timely addressed to ensure resident safety. a. On 5/18/17 at 5:25 a.m., call lights above the doors of room #2, #8 and #6 on the East hall were illuminated but no call lights were audible. Observations of the bathrooms in rooms #2/#3 (shared bathroom), #4, #7, #11, #12, #13, #14, #15, #16, #17, #18/#19 (shared bathroom), #20, #22, #23, #24, and #28/#29 (shared bathroom) revealed no emergency call cords but rather emergency call buttons located between the toilet and the sink, a location difficult to reach from either the toilet or the floor. b. On 5/18/17 at 5:35 a.m., the certified nurse aide (CNA #3) came around the corner and observed the illuminated call lights above rooms #2, #8 and #6. She said nursing was supposed to be watching the call lights because the nurses can observe the light bar at the end of the hall when a call light has been turned on. She said if she is in a room with a resident, she would not know the call light was on as the call lights did not sound. She said the call lights had not been audible for a couple of years. c. On 5/18/17 at 6:00 a.m., licensed practical nurse (LPN #3), working on the West hall was interviewed. -She said the maintenance supervisor (MS) had made the West hall call light system audible, but the former NHA had it turned off because he did not like the noise and thought the call light sound was disruptive when nurses were on the phone. LPN #3 said she had begged administration to make the call light system audible again; she said without the sound, it was difficult to know a call light was going off when a nurse was charting or a CNA was in the room with another resident. She said the sound for the call light system on the West hall was finally turned back on 5/16/17; however, she said on the East hall, the call light system was old and it remained inaudible. d. On 5/18/17 at 6:10 a.m. registered nurse (RN) and LPN #4 were interviewed, while both were in the nurse charting room preparing for change of shift. They said when they work nights they will assist the CNAs in answering the call lights. They said when they are in the nurse charting room, they will rely on the light bar, which works inconsistently, but could be seen from the door of the nurses' station and a large ceiling light which flashed to alert staff a call light had been turned on. However, they said (and observations confirmed) the light bar was not visible from rooms 17-29 and the large light, although visible throughout the East hall, only operated occasionally. e. On 5/18/17 at 6:15 a.m., the NHA was interviewed. She said she had been working on getting the call light system fixed and had turned in a capital expense request when she first started at the facility on 1/23/17. She said that at that time, she also had asked the MS to activate the West hall call lights sound system but the system had not been activated. She said she asked the MS again on 5/16/17, the same day the sound system had been activated on the West hall. She did not identify any other attempts to have the MS activate the sound system. Likewise, she did not identify any temporary or interim plan developed by the facility to ensure the residents' ability on the West hall prior to 5/16/17 or the residents' ability on the East hall currently, to communicate their potential need for urgent assistance. Review of the facility's 2/10/17 Capital Project Approval Request (CPAR), the capital expense request referenced by the NHA above, revealed the following information: The CPAR dated 2/10/17 documented the following: - The nurse call system replacement was being requested; - The description documented Existing nurse call system in one wing is very old and in need of update; - The total amount requested was $16,477; and - The call light system is outdated and experiencing issues. Approval signatures included: - The Division Vice President of Operations (DVPO) approved on 2/17/17; - The CIO approved on 2/17/17; - The Division Vice President of Finance (DVPF) approved on 5/5/17; and - The CEAC approved on 5/16/17. f. On 5/18/17 at 6:20 a.m., the resident assistant (RA #4) was interviewed. She said the only way you would know on the East hall if a call light was on was when someone came down the hall to check and saw the light bar at the end of the hall. Otherwise, there was no way to know. C. Observation, Interviews and Record Review - After facility notification of IJ Interviews after facility notification of IJ confirmed the facility's inaudible, ineffective call system was long-term and inadequately addressed to ensure resident safety. 1. On 5/18/17 at approximately 7:20 a.m., the resident care management director (RCMD) was observed distributing hand-bells to residents. 2. On 5/18/17 at 7:51 a.m., the rehabilitation program manager (RPM) was interviewed He said he was monitoring call lights currently. He said the call lights on the East hall had been sketchy for a while. 3. On 5/18/17 at 7:59 a.m., the MS was interviewed. She said when she completed the call light audits on the West hall, she would check the room light, listen for the sound and watch on the board at the nurses' station. -She said the previous NHA had her shut off the audible part of the call light system because he said it bothered the nurses at the nurses' station. She said additionally, when he would call the nurses at the nurses' station he could hear the call lights and that bothered him. She said the former NHA had asked her to disable the sound at one point and she did not but he asked her again and was angry because she had not done it yet. She said she knew it was wrong, but said she opened the faceplate on the call light system and unplugged the audio power cord. She said if another administrator ever asked her to do that she would call the Senior NHA. She confirmed she was asked about turning the call lights back on after the new NHA started and said she forgot to do so on the West hall until 5/16/17 (but she was not able to activate the East hall system). She confirmed that even without the sound, the call lights on the East hall worked inconsistently. -She said she had replaced some of the push buttons in the bathrooms on the East hall. She said there are push buttons in many of the East hall bathrooms and she was slowly replacing the push buttons with a pull string. She agreed, during a tour of the East hall bathrooms, that it would be difficult for some residents to reach the push button given its location on the wall between the sink and the toilet. She agreed it would be impossible for a resident to reach the push button if he or she had fallen to the floor. -She said she randomly selected which bathroom call light push buttons to replace next. She said she had been trying to get all of the push button call lights replaced with a string but currently she only had the hardware to replace three. She said she was unable to complete too many because reach replacement cost $55 - $100. She said she also had to check what kind of wiring the call light had to determine whether she could change it or an electrician had to be called. She said the bathroom call lights on the West hall all had been replaced. -She said if one needed to be changed promptly, a therapist would usually have assessed the resident and would let her know that the resident needed a pull cord. She said usually the therapist would walk by and tell her of the need and she would write it down to ensure the call light was changed. 4. On 5/18/17 at 8:30 a.m., resident #7, who resided on the East hall, was interviewed. She said her bathroom had a call light push button. She agreed that if she were to fall in her bathroom she would be unable to reach the push button. 5. Review of resident grievances filed with the facility revealed repeated complaints about call light response times. See F166 for details. D. Observations, Further Interviews and Record Review- After facility notified of IJ 1. On 5/18/17 at 10:50 a.m., the MS, along with the NHA and SNHA demonstrated the call light board on West hall. The MS removed three screws from the call light faceplate and pointed to a small black wire which could be removed to disable the audible portion of the call light system. The MS, SNHA and the NHA agreed to install a lock on the faceplate to ensure no one could disable the call light sound system. 2. On 5/19/17 at 8:13 a.m., the customer service coordinator (CSC) was interviewed. She said the main concern with residents about the current operation of the call light system was the long wait time for staff to respond. She said she had wondered why the call lights on the East hall were not making any noise. She said she understood the call light system was going to be fixed at some point. She said she thought the response time would be quicker if the call lights were audible. 3. On 5/19/17 at 10:23 a.m., the NHA was interviewed. She said she talks to the SNHA at least weekly, but had not shared with him her concerns related to the call light system or talked with him about developing a temporary, interim plan to ensure resident safety. She said she knew the MS had discussed the call light concerns with the regional maintenance director; however, she did not provide documentation of these discussions and the MS had not referenced such discussions during her interview (see above). 4. Record Review a. Review of the Nurse Call System Test on the East hall from 2/7/17 to 5/16/17 revealed the facility was aware of issues with the call light system since 2/7/17. Call lights were tested on the East hall documented: - 2/7/17, same issues exist - 2/14/17, call lights still having same issues - 2/22/17, issues still exist - 3/1/17, same issues present - 3/7/17, same issues exist - 3/15/17, issues still exist - 3/27/17, same issues exist - 4/4/17, issues still persist - 4/11/17, issues still persist on east wing - 4/18/17, issues still remain in building - 4/25/17, same issues exist - 5/2/17, same issues exist - 5/9/17, same issues - 5/16/17, issues still exist on East wing b. A Communication Service - Service Order 5/18/17 documented: We found the east side nurse call system not ringing when a call was placed we had to replace the bell and redesign the power input and restore the system we also installed a couple of new bathroom stations. c. A. Restroom Call Light Access Audit, provided by the NC #1 on 5/18/17 revealed 16 resident bathrooms on the East hall with a push button and six resident bathrooms with a pull string. II. Smoking safety A. Facility Policy The Safe Smoking/Tobacco Use Policy, revised January 2017, documented in pertinent part: - The purpose: To help to ensure the safety of all residents, staff and visitors at facilities which permit smoking and tobacco use. - An evaluation is conducted for all resident who use tobacco products. - Residents who are determined to be unsafe smokers are required to wear a protective smoking vest/apron and are supervised at all times while smoking. B. Resident #9 1. Resident status Resident #9, under the age of 50, was admitted to the facility on [DATE]. According the May 2017 medication review report, [DIAGNOSES REDACTED]. According to the 5/15/17 nursing admission note, the resident was alert and able to make needs known. She required extensive assistance with most ADLs. Two smoking assessments were completed after the resident's admission. The first Safe Smoking Evaluation dated 5/16/17 documented the resident was unable to light and smoke a cigarette while demonstrating safe techniques and the resident required a lighter with no flame. The Second Safe Smoking Evaluation the next day (5/17/17) documented the resident had been reassessed with [REDACTED]. The resident's smoking care plan, initiated 5/17/17 and revised on 5/18/17, documented the resident was a smoker. The care plan goal was to ensure the resident did not suffer injury from unsafe smoking practices. Interventions included instruct resident about smoking risks, notify charge nurse immediately (if) resident was suspected to violate facility policy (initiated 5/17/17), the resident can smoke unsupervised (initiated 5/17/17) and utilize flameless lighter (initiated 5/18/17). 2. Record review and Interview a. Record review Record review revealed that notwithstanding the smoking assessment dated [DATE], resident #9 exhibited unsafe smoking practices and expressed a determination to smoke on her terms. -A nursing progress note, dated 5/16/17 and written at 7:30 a.m., documented the resident was smoking in her room and refused to give the nurse her cigarettes and lighter. -A social services progress note, dated 5/16/17 and written at 1:18 p.m. documented, The resident enjoys reading and smoking. She has no intention of stopping. -A wound nurse progress note, dated 5/16/17 and written at 6:37 p.m. documented the resident would only allow staff to complete her treatment if she would be allowed to smoke afterwards. The wound nurse informed the resident who her nurse was and the resident refused to answer any further questions until she was allowed to go outside to smoke. -A nursing progress note, dated 5/16/17 and written at 11:33 p.m. documented, Nurse observes resident for safety with lighting and smoking cigarette. Resident is unsafe with lighting own cigarette. Flame of lighter is too close to resident's clothing. b. Interview On 5/17/17 at approximately 5:30 p.m., the resident was interviewed. She said the reason she smoked in her room was because the staff would not get her up and she had to wait too long in bed. She said she was aware one of the facility rules was no smoking in bed but now they know if they do not get me up (timely) I will smoke in my room. She said, I'm not stupid, I'm very smart . they don't need to take my cigarettes. 3. Failure to clarify for the resident and staff the parameters of the resident's smoking practices after admission. a. Staff interview Staff interviews indicated it was unclear to staff whether resident #9 required supervision while smoking or just assistance with lighting a cigarette or if the resident was a safe smoker if a safer lighter was provided. On 5/17/17 at 5:45 p.m., LPN #3 was interviewed. She said she had talked with resident #9 and identified she needed a flameless lighter in order for her to smoke safely. She said she had provided the resident her fameless lighter to use. She said the resident had cigarettes and a lighter in her room and had been educated that she must turn in her cigarettes and lighter when she comes back inside from smoking. The LPN said she was loaning the resident her flameless lighter until the resident obtained one. She did not specify when the resident would obtain her own flameless lighter or how the resident would light her cigarette when the LPN was not working and was unable to loan the resident her flameless lighter. On 5/17/17 the Social Services Manager (SSM) was interviewed at 5:55 p.m. and again at 6:08 p.m. - She said there were 12 smokers in the building and only one required supervision; she did not identify resident #9 as a supervised smoker or as a smoker who required special equipment to smoke safely. -She said if a new admission was a smoker, the facility would determine whether they were a safe smoker on admission. But see above; resident #9's smoking assessment was not finalized until two days after her admission. She said, initially, resident #9 was deemed a safe smoker, although see above, she had been found smoking in her room on 5/16/17. She said she was aware the resident needed a different lighter without a flame and agreed staff needed education to ensure they were aware the resident gave staff her cigarettes and lighter after she was done smoking. b. Record Review Record review revealed directives to staff failed to identify the parameters identified as necessary to ensure the resident smoked safely. An undated Education to Staff on Specific Smoking Residents documented resident #9 required supervision to light cigarette, can safely hold a cigarette once lit by staff member, and was able to smoke safely. This staff education did not include any supervision needs related to resident #9 who required a flameless lighter or for staff to ensure the resident turned in her lighter and cigarettes after smoking. The Supervised Smoking Times form documented there were eight times (every two hours), the resident could safely smoke from 7:00 a.m. until 9:00 p.m. The form documented Resident (resident #21) needs to be supervised entire duration of smoking break. Resident also needs to wear protectant apron, This form did not include any supervision needs related to resident #9 who required a flameless lighter or for staff to ensure the resident turned in her lighter and cigarettes after smoking. See the resident's care plan above. The care plan failed to alert staff of the resident's history of smoking in her room and her determination, per interview and progress notes above, to smoke on her terms. Moreover, the care plan did not include instructions to staff to ensure the resident turned in her lighter and cigarettes after smoking. 4. Action taken during survey A staff training attendance dated 5/17/17 documented 22 staff members received training regarding safe smoking. The training was completed by the SSM. The list of safe smokers (10) and unsafe smokers (2) was attached. It listed resident #9 as an unsafe smoker. On 5/18/17 at 6:10 a.m. registered nurse (RN) and LPN #4 were interviewed. They confirmed they both had received training referenced above, related to the residents who required supervision during smoking. LPN #4 said she had received a phone call the night before and received the training. She said she had been told only resident #21 required supervision. III. Elopement (Cross-reference F250 and F309). A. The facility's elopement policy, revised in August 2012, was provided by the NHA on 5/19/17 at 8:30 a.m. The policy read in pertinent part, The facility strives to provide a safe environment and preventive measures for elopement. Personnel must report and investigate all reports of missing residents .Facility creates a photographic directory of residents identified at risk for elopement .stored printed photographs, labeled with resident name and room number in binder . Upon return of the resident to the facility, the director of nursing (DON) and administrator should make recommendations regarding safety measures to the Quality Assurance and update the resident's care plan with preventive interventions . B. Resident #20 1. Resident #20, age 67, was admitted to the facility on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 3/5/17 MDS assessment, the resident was cognitively impaired with daily decisions. His brief interview for mental status (BIMS) was 15 of 15. The resident was independent with all activities of daily living (ADLs). He received antipsychotic medications for past seven days during observation period. Review of the resident's medication and treatment records and care plan revealed no reference to pass privileges and review of the resident's care plan revealed only that the resident likes to go on independent outings. 2. Record review According to a progress notes dated 5/6/17 at 9:01 p.m., the resident was not seen in the facility after 2 p.m. Resident #20 was not signed out on any signed out sheets at both nurses' stations. An incident report provided by the NHA on 5/19/17 at 8:30 a.m., revealed the resident had been missing. He had not signed the outing book. The other residents had seen him getting on the bus around noon on 5/6/17. The incident report was filed out at 9:00 p.m., nine hours after the resident left the facility. There was inconsistency in medical records regarding where and when the resident was seen last. -According to the medication administration record the nurse administered resident's medication Gabapentin 300 mg capsule at 4:00 p.m. -According to the progress notes, the facility proceeded with the missing person protocol at 10:00 p.m. -A social services note dated 5/15/17, nine days after the resident eloped, noted the resident's power of attorney (POA) had not heard from the resident and he was worried. There were no other follow up notes in the medical record. 3. Staff interviews According to the resident assistant (RA #2) in an interview on 5/19/17 at 9:05 a.m., resident #20 was leaving the facility on daily basis after lunch and was gone for two - three hours running his errands and everyone in the facility was aware of it. In interview with LPN #2 on 5/19/17 at 9:20 a.m., she said the resident was out of the facility often; however, he always returned to the facility before dinner. She said there were no issues in the past, the resident had always returned to the facility and he was not classified as a risk for elopement. She said before her shift change, she always checks to see if all residents are present and accountable. According to the CNA #5, in interview on 5/18/ 17 at 11:15 a.m., the resident was gone from the facility at noon on 5/6/17 and never returned to the facility before her shift ended. 4. Facility failures Record review revealed no evidence the facility investigated the incident on 5/6/17 or made recommendations regarding safety measures to the Quality Assurance as expected per the facility's elopement policy (see above) to address the safety of other independent residents in the future who frequently left the facility. Review of the resident #20's plan of care revealed the facility lacked a comprehensive care plan addressing the resident leaving facility on daily basis and how and when the facility should be concerned about his failure to return. In addition, there was no evidence on 5/6/17 that nursing staff accounted for the resident prior to the shift change, and there was no investigation why the nurse signed medications in medication administration record as administered on 5/6/17, even though the resident was not present in the facility, per record review and staff interview.

Based on observations, staff and resident interviews and record review, the facility failed to ensure all portions of the facility's resident call light system were functioning to allow residents to call directly to a staff member or to a centralized staff work area for assistance. This facility failure currently affected 34 of 65 sample residents, all of whom resided on the East hall. (Cross-reference F323 and F166). Specifically: The facility failed to maintain an audible and effective call light system to ensure the safety of residents, including the safety of 34 residents currently residing on the East hall, 13 of whom required one to two person assistance with activities of daily living (ADLs) and eight of whom were total dependent on staff for ADLs. Activation of the call lights revealed on the East hall, rooms 2-29 call lights were not audible. Staff reported the call lights on the hall had not been audible for about two years and they relied on a light bar and a large ceiling light to alert staff a call light had been turned on. However, the light bar was not visible from rooms 17-29 and the large light, visible throughout the East hall, only operated occasionally. Interviews revealed the facility was aware all portions of the facility resident call system were not working properly at least as early February, 2017. The facility failed to act promptly to correct the system to ensure the residents' ability to communicate their potential need for urgent assistance. This failure created a situation of immediate jeopardy for serious harm for the residents on East hall. Findings include: I. Immediate Jeopardy (IJ) A. Imposition of IJ On 5/18/17 at 7:03 a.m., the nursing home administrator (NHA) and the nurse consultant (NC #2) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to ensure an audible and effective call light system on the East hall left the facility residents vulnerable and created a situation of immediate jeopardy for serious harm. B. Facility Response to the IJ On 5/18/17 at 2:15 p.m., the facility's plan to abate the IJ was accepted. It read: May 18, 2017 Immediate Jeopardy Abatement Plan for F463 The call light system is not audible, but the light globes above each resident room door illuminate, as determined with an audit of the function of the globes above the resident room doors. A hand-held bell has been distributed to each resident on the East side of the facility, which includes rooms numbered 2 through 29. A staff member is assigned to the East hallways to monitor for the room light illumination and listen for the ringing of the hand-held bells supplied to the residents. The staff member will only be responsible for monitoring the East hallway during the assigned times and informing the care providers of the residents' needs. The staff monitoring the East Hall will be educated regarding their responsibilities while monitoring the East Hall. The residents who reside on the East hallways will be evaluated on the ability to physically hold and shake the call bell. The residents who are able to hold and shake the bell will be able to understand the purpose of the bell through the education provided at the time of the evaluation. The bathroom call lights will be audited to determine which rooms have a call button and which have a call cord. The call buttons will be replaced with a call cord style or a TABs type alarm, which will be within resident's reach until the new system installation is completed. A face-lock panel will be purchased and installed by the Maintenance Director, preventing access to the call light panel unauthorized staff on 5/18/2017. (Company name) Communication are currently attempting to complete temporary repairs on the existing call light system, until the new system can be installed. The Capital Purchase Request for the call light system was approved on May 16, 2017. The Installer of the new system completed an onsite assessment May 17, 2017. The install Vendor will be on premise May 19, 2017 to begin the install of the new call light system. Residents residing on the East Side will be interviewed daily to ensure their call light or handheld bell is being answered timely and needs are met, until the call light system is restored or replaced. Residents residing on the East Side will be interviewed by the Nursing Home Administrator or designee weekly for one month and then bi-weekly for one month to ensure their call lights are answered timely and need(s) are being met, after the call light system is restored/replaced. A random sample of 10 residents residing on the East Side will be interviewed by Social Services or designee weekly for 2 months to ensure their call lights are answered timely and needs are being met. Education will be provided to each staff member prior to starting their assigned shift, with all staff educated by May 19, 2017 regarding the room call lights and bathroom call lights and the temporary system (hand-held bells and hall monitoring assignments), until the call system is repaired or replaced. Maintenance Director and Maintenance Staff will be educated to not disconnect the sound of the call light system by (Senior Nursing Home Administrator name). An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting will be held on May 18, 2017. The results of the audits will be present(ed) by the Nursing Home Administrator and reviewed at the QAPI meeting for 3 months. C. IJ removed On 5/18/17 at approximately 2:30 p.m., after a hand held bell was given to each resident on the East hall and a staff member was assigned to monitor all call lights, the NHA and NC #2 were informed the IJ was removed. However, deficient practice remained at an E level. II. Facility Policy The policy titled Equipment Repair or Replacement, revised June 2007, read in pertinent part: - Essential/Critical Equipment is defined as equipment whose failure would pose a threat to the safety or welfare of residents or staff. Examples include the following: Nurse Call Equipment - Emergency Repairs: 6.Implement temporary emergency procedures; 7. Contact appropriate vendor/contractor for repair/replacement. III. Facility failure to ensure all portions of the facility's resident call light system were functioning to allow residents to call directly to a staff member or to a centralized staff work area for assistance. A. Observations and Interviews 5/18/17 - Prior to facility notification of IJ Activation of the call lights on the East hall revealed the call lights were inaudible. Interviews revealed this deficiency, as well as inaudibility of the call light system on West hall until recently, were known, longstanding, and not timely addressed to ensure resident safety. 1. On 5/18/17 at 5:25 a.m., call lights above the doors of room #2, #8 and #6 on the East hall were illuminated but no call lights were audible. 2. On 5/18/17 at 5:35 a.m., the certified nurse aide (CNA #3) came around the corner and observed the illuminated call lights above rooms #2, #8 and #6. She said nursing was supposed to be watching the call lights because the nurses can observe the light bar at the end of the hall when a call light has been turned on. She said if she is in a room with a resident, she would not know the call light was on as the call lights did not sound. She said the call lights had not been audible for a couple of years. 3. On 5/18/17 at 6:00 a.m., licensed practical nurse (LPN #3), working on the West hall was interviewed. She said the maintenance supervisor (MS) had made the West hall call light system audible, but the former NHA had it turned off because he did not like the noise and thought the call light sound was disruptive when nurses were on the phone. LPN #3 said she had begged administration to make the call light system audible again; she said without the sound, it was difficult to know a call light was going off when a nurse was charting or a CNA was in the room with another resident. She said the sound for the call light system on the West hall was finally turned back on 5/16/17; however, she said on the East hall, the call light system was old and it remained inaudible. 4. On 5/18/17 at 6:10 a.m. the registered nurse (RN) and LPN #4 were interviewed while both were in the nurse charting room preparing for change of shift. They said when they work nights they will assist the CNAs in answering the call lights. They said when they are in the nurse charting room, they will rely on the light bar, which works inconsistently, but could be seen from the door of the nurses' station, and a large ceiling light which flashed to alert staff a call light had been turned on. However, they said (and observations confirmed) the light bar was not visible from rooms 17-29 and the large light, although visible throughout the East hall, only operated occasionally. 5. On 5/18/17 at 6:15 a.m., the NHA was interviewed. She said she had been working on getting the call light system fixed and had turned in a capital expense request when she first started at the facility on 1/23/17. She said that at that time, she also had asked the MS to activate the West hall call lights sound system but the system had not been activated. She said she asked the MS again on 5/16/17, the same day the sound system had been activated on the West hall. She did not identify any other attempts to have the MS activate the sound system. Review of the facility's 2/10/17 Capital Project Approval Request (CPAR), the capital expense request referenced by the NHA above, revealed the following information: The CPAR dated 2/10/17 documented the following: - The nurse call system replacement was being requested; - The description documented Existing nurse call system in one wing is very old and in need of update; - The total amount requested was $16,477; and - The call light system is outdated and experiencing issues. Approval signatures included: - The Division Vice President of Operations (DVPO) approved on 2/17/17; - The CIO approved on 2/17/17; - The Division Vice President of Finance (DVPF) approved on 5/5/17; and - The CEAC approved on 5/16/17. 6. On 5/18/17 at 6:20 a.m., the resident assistant (RA #4) was interviewed. She said the only way you would know on the East hall if a call light was on was when someone came down the hall to check and saw the light bar at the end of the hall. Otherwise, there was no way to know. B. Observation, Interviews and Record Review - After facility notification of IJ Interviews after facility notification of IJ confirmed the facility was aware the East hall call light system was an inaudible, ineffective call system. 1. On 5/18/17 at 7:51 a.m., the rehabilitation program manager (RPM) was interviewed. He said he was monitoring call lights currently. He said the call lights on the East hall had been sketchy for a while. 2. On 5/18/17 at 7:59 a.m., the MS was interviewed. She said the previous NHA had her shut off the audible part of the call light system. She said she had opened the faceplate on the call light system and unplugged the audio power cord. She confirmed she was asked about turning the call lights back on after the new NHA started and said she forgot to do so on the West hall until 5/16/17 (but she was not able to activate the East hall system). She confirmed that even without the sound, the call lights on the East hall worked inconsistently. 3. Review of resident grievances filed with the facility revealed repeated complaints about call light response times. - A grievance dated 3/7/17 read resident #71, who resided on the East hall, reported it had taken over 30 minutes for her call light to be answered. - A grievance dated 3/26/17 read resident #72, who resided on the East hall, had been sitting on the commode and waiting for more than 30 minutes for assistance. Follow up occurred on 3/27/17 and read, Call light functioning issues. Once call light was reset it has been functioning properly. Staff educated to frequently check on resident while in bathroom and not depend on call light. - A grievance dated 4/20/17 read resident #67, who resided on the East hall, reported she waited over 30 minutes for the call light to be answered on the evening shift. - A grievance dated 4/25/17 read resident #13, who resided on the East hall, reported she was upset because her husband/roommate's (resident #14) alarm was going off and her call light was on and no one came to assist her. - A grievance dated 4/28/17 read resident #15, who resided on the East hall, reported she had her call light on for 15 minutes and peed my bed. See F166 for further details on residents' grievances regarding call light response. 4. On 5/18/17 at 10:50 a.m., the MS, along with the NHA and Senior NHA (SNHA) demonstrated the call light board on West hall. The MS removed three screws from the call light faceplate and pointed to a small black wire which could be removed to disable the audible portion of the call light system. The MS, SNHA and the NHA agreed to install a lock on the faceplate to ensure no one could disable the call light sound system. 5. On 5/19/17 at 8:13 a.m., the customer service coordinator (CSC) was interviewed. She said the main concern with residents about the current operation of the call light system was the long wait time for staff to respond. She said she had wondered why the call lights on the East hall were not making any noise. She said she understood the call light system was going to be fixed at some point. She said she thought the response time would be quicker if the call lights were audible. 6. On 5/19/17 at 10:23 a.m., the NHA was interviewed. She said she talks to the SNHA at least weekly, but had not shared with him her concerns related to the call light system. She said she knew the MS had discussed the call light concerns with the regional maintenance director; however, she did not provide documentation of these discussions and the MS had not referenced such discussions during her interview (see above). C. Record Review 1. Review of the Nurse Call System Test on the East hall from 2/7/17 to 5/16/17 confirmed the facility was aware of issues with the call light system since 2/7/17. Call lights were tested on the East hall documented: - 2/7/17, same issues exist - 2/14/17, call lights still having same issues - 2/22/17, issues still exist - 3/1/17, same issues present - 3/7/17, same issues exist - 3/15/17, issues still exist - 3/27/17, same issues exist - 4/4/17, issues still persist - 4/11/17, issues still persist on east wing - 4/18/17, issues still remain in building - 4/25/17, same issues exist - 5/2/17, same issues exist - 5/9/17, same issues - 5/16/17, issues still exist on East wing 2. A Communication Service - Service Order 5/18/17 documented: We found the east side nurse call system not ringing when a call was placed we had to replace the bell and redesign the power input and restore the system .

Based on observation, record review and interview, the facility failed to ensure three of 16 sample residents (#1, #2, #3) received the care and services necessary to address resident #1 and #2's change in condition and resident #3's pain. Record review revealed resident #1 sustained a shearing injury (abrasion) on her left posterior thigh during a Hoyer (mechanical) transfer on or about [DATE]. The abrasion became a wound, more than doubling in size, draining like a river, and emitting a foul odor. Wound treatments were changed but the wound failed to improve and the resident was not seen by either a physician or a wound specialist. On [DATE], staff determined the resident's condition required further assessment and requested orders to transfer the resident to the hospital. No orders were received, no further action was taken by the facility to secure the resident's transfer, and the resident was found unresponsive on [DATE]. The facility's failure to ensure the resident was seen by a physician or wound specialist when her wound failed to improve despite treatment changes, and its failure act to secure resident #1's transfer after determining her condition required further assessment on [DATE], created a situation of immediate jeopardy for serious harm. Findings: I. Immediate Jeopardy A. Imposition of Immediate Jeopardy On [DATE] at 3:48 p.m. the nursing home administrator (NHA) and director of nursing (DON were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to adequately assess and monitor resident #1's wound and secure a hospital transfer on [DATE] after recognizing a change in the resident's condition created a situation of immediate jeopardy for serious harm. B. Facility Response and Removal of the Immediate Jeopardy On [DATE] at approximately 7:30 p.m., a plan was submitted by the facility to CDPHE. It read: - Resident living in Sterling Living Center have the potential to be affected by this alleged deficient practice. - Nursing staff currently working at Sterling Living Center have been educated that when they see any type of skin concern they are to notify their nurse of the skin concern immediately. Education will include identification of skin issues and reporting of skin issues. Nurses will be educated on practice guidelines for skin management to include head to toe assessment of skin. Braden Scale for predicting pressure sore risk, documentation of identified skin issues, care plan development and notification of physician and family. - Remaining nursing staff and newly hired nursing staff members at Sterling Living Center will be trained on the practice guidelines for skin management during orientation and or prior to working the floor per scope of practice. - The DON and nurses on shift are completing a full house audit of resident to identify any other skin issues. Physicians will be notified of finding as appropriate and orders obtained for treatment as needed. - The NHA will bring all skin management audits to an Ad Hoc Quality Assurance meeting weekly for one month then monthly for three months and then quarterly or as needed to review all outcomes and applicable action plan. On [DATE] at 9:53 p.m., the NHA, Director of Nurses (DON) and the Regional Clinical Director (RCD) were notified the above plan was accepted and the immediate jeopardy was removed. However, based on observation, interview and record review, deficient practice remained at a D level, isolated with the potential for more than minimal harm. II. Facility failures in assessment, monitoring, and responding to findings A. Change of Condition 1. Resident #1, age 62, was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The resident expired at the facility on [DATE]. a. Resident Status [DATE] to [DATE] The [DATE] minimum data set (MDS) assessment identified the resident had clear speech, made self understood and was able to understand others. The brief interview for mental status (BIMS) score was 15 out 15 which indicated intact cognition. The resident was totally dependent and required physical assistance of two persons for bed mobility, dressing, toilet use and personal hygiene. She used wheelchair for mobility and although at risk of developing pressure ulcers, at the time of the assessment there were no ulcers noted. The weekly skin assessments dated [DATE] and [DATE] revealed the resident's skin was intact. However, the resident's care plan documented on [DATE] that the resident had an open area on the left posterior thigh due to shearing during mechanical (Hoyer) lift transfer. Staff were to observe skin weekly and document findings and complete a full body check weekly and document. Progress notes revealed a note [DATE], documenting the abraded area to left posterior thigh was not healing well, the physician was called and orders were obtained for different treatment. Review of the treatment record revealed an order for [REDACTED]. b. Resident status [DATE] to [DATE] Review of progress notes and skin assessments revealed the resident's open wound worsened and the resident's condition declined. Orders to transport to the hospital for a wound evaluation were requested but when not obtained, the facility took no further action to secure the resident's transfer for evaluation and treatment. A [DATE] skin assessment documented the top layer of the skin on the left posterior thigh sheared off and the cause was the (Hoyer) sling. The open area measured 4x5 cm and was described as superficial abrasion, red wound bed and duoderm reapplied. Another abrasion was noted to the resident's left knee which measured 3.5x4 cm. A [DATE] nursing note documented, in pertinent part, IDT (interdisciplinary team) skin review: Abrasion to left post(erior) upper thigh is 4.5 cm x 6cm with drk (dark) area where bleeding occurred. New tx (treatment) ordered (silver alginate replacing calcium aginate on [DATE]). Up in w/c (wheelchair) since this a.m. A [DATE] nursing note documented, in pertinent part, Abrasion continues to have grayish thick tissue to outer edge where has blood blister, no bleeding noted. The rest of wound is red, silver alignate utilized and changed Q (every) day. Air mattress on bed and cushion in w/c. lays on back in bed. Doctor and (family member) notified of what wound looked like, no new orders noted. No wound measurements were documented and there was no documentation further assessment of the wound by a wound specialist or the physician was considered. A skin assessment dated [DATE] was not located in the resident's record. However, review of the treatment record revealed the wound orders were changed on [DATE] to Santyl ointment (QD and PRN). A progress note dated [DATE] and [DATE] revealed the resident had fevers ranging from 102.5, 101.8, and 100.3. There was no documentation the resident was experiencing symptoms of Norovirus (nausea, diarrhea) present in other facility residents at this time. A skin assessment dated [DATE] documented the abrasion to the left (rear) thigh was 15 cm x 8 cm and was unstageable. -The note read the wound bed was black with black eschar to the center. The wound had a moderate amount of drainage/exudates, was serosanguineous and a foul odor was present. The wound edges were pink without [MEDICAL CONDITION]. The note read, area is larger than it was and black eschar noted. Utilized silver alignate and now santyl to debride to see what is under eschar. The assessment read the resident's response to treatment had deteriorated and treatment would be continued. -The note further read, Awaiting call back from (physician) to see if can send to wound nurse at hospital, and documented the responsible party/family member was notified. A progress note dated [DATE], written at 10:45 a.m., read in part, Wound to left posterior thigh is 15 cm x 8 cm black eschar. Slight foul odor noted, serasangerous drainage noted. Santyl utilized to debride, lays on back in bed. Has had flu like s/s (signs/symptoms) and has been staying in bed all week, air mattress on bed. Was using silver alignate then changed to santyl to debride eschar off wound. Wound is an abrasion from sling. Doctor's (name) nurse and sister (name) notified of the wound is bigger, foul odor. Asked to send to hospital for wound nurse to see. Awaiting return call. c. Resident status ,[DATE] to [DATE] Review of the progress notes revealed no documentation of further calls to the physician on ,[DATE] or [DATE] until 5:50 p.m., no assessment of the wound by the DON, and no further steps taken by the facility to transfer the resident to the hospital for evaluation and treatment although there was no indication the resident's condition had improved. A progress note dated [DATE], written at 5:32 a.m. read, the wound had brownish drainage noted, which runs out of wound like a river. Has black color to wound bed with a black color in a line from wound down buttock toward rectum area. A decrease in odor was noted. Another note at 2:46 p.m. read the resident requested to stay in bed due to the wound. A progress note dated [DATE], written at 2:50 p.m., read in bed all shift per resident request. A progress note dated [DATE], written at 4:30 p.m, read in part, Alert and oriented. Requested sister to be called again to come for a visit. Call placed to on-call doctor at 1750 (5:50 p.m.). Called to room by CNA at 1800 (6:00 p.m) d/t (due to) patient being unresponsive. 911 called, DNR given to EMS's upon their arrival. EMT called ER Doctor (name). Pronounced at 1812 (6:12 p.m.). Called on-call doctor back at 1820 (6:20 p.m.). Received order from Doctor (name) for coroner to pronounce and release body. Sister (name) notified at 1830 (6:30 p.m.) Sister arrived at 1850 (6:50 p.m.). d. Staff interviews Staff interviews confirmed when the resident's wound failed to improve, the resident was not seen by either a physician or a wound specialist. Moreover, on [DATE], when staff determined the resident's condition required further assessment and failed to receive orders to transfer the resident to the hospital, no further action was taken by the facility. The MDS Coordinator/Registered Nurse (MDSC/RN) was interviewed on [DATE] at several different times. She said she was delegated to assess/measure, document and implement proper treatments for wounds in the facility. She was responsible to communicate with physicians and the local hospital wound clinic. She was not sure when the resident's skin injury actually occurred or how long it was left untreated. She said she never treated the resident's wound as a pressure wound because the wound, which was caused by sling during the Hoyer transfer, appeared very superficial; therefore, she did not monitor this particular wound weekly. She did not indicate she had sought an evaluation by the physician or wound specialist when the resident's wound failed to improve. The Nursing Home Administrator (NHA) was interviewed on [DATE] at 3:48 p.m. and stated the facility has hired a RN who will be taking over all skin issues and will complete skin rounds and confirmed that prior to this, all wound care was the MDSC/RN's responsibility. The DON, NHA and Regional Clinical Director were interviewed on [DATE] again at 9:45 p.m. They reported that everything facility staff had completed regarding skin issues was in the medical record. The DON, NHA, former DON and MDSC/RN were interviewed again on [DATE]. The MDSC/RN was interviewed at 1:30 p.m. and she and the DON, former DON and NHA were interviewed at 1:47 p.m. -The MDSC/RN reported that because the wound had gotten bigger on [DATE], she decided she wanted the doctor to see it. She said she did not receive a return phone call after leaving a message and left for the day. She said when she returned the facility after the weekend, the resident had expired. -The former DON reported the MDSC/RN would always notify her if she needed to contatct the doctor to send a resident out to the hospital. She stated she had seen the wound in different stages and was aware it had gotten bigger, was changing and had opened. The former DON said she expected staff to continue to contact the doctor if they had not received a response to an order they had requested. -The MDSC/RN said she had told the resident's nurse that she was waiting for a call from the doctor and confirmed that when she left the faciity on [DATE], she had not heard from the doctor. -The former DON reported that since it was the weekend and they had still not heard from the doctor, the clinical manager on duty was ultimately responsible for contacting the doctor and obtaining the orders. The former DON reported if staff did not hear from the doctor they should obtain paperwork, call the hospital, notify them of their concerns with the resident and send the resident to the hospital whether doctor's orders are obtained or not. There was no documentation in resident #1's record that any of the above steps were taken on [DATE]. e. Responsible party/family member, physician, and mortician interviews The responsible party/family member, physician and mortician interviews confirmed the resident's decline, as well as the facility's failure to adequately communicate the resident's change of condition and seek further evaluation and treatment. The responsible party/family member was interviewed on [DATE] at 10:21 a.m. She said she went to visit the resident on [DATE]. She stated the resident did not say she was not feeling well. She said she returned to the facility on [DATE] and was told by staff that isolation had started throughout the facility and facility staff did not want the family member visiting the resident. She reported she called the facility on [DATE] to find out if the facility was still under isolation. The facility staff confirmed isolation continued. -The responsible party/family member said on [DATE] at approximately 4:30 p.m. the licensed practical nurse (LPN) called and reported the resident's catheter had come out, her blood pressure was fluctuating and she was asking for the family member. She said the LPN said he was going to call the hospital because of the fluctuating blood pressure. She said the LPN recommended she visit the resident at the hospital. She said she then received a phone call at approximately 6:20 p.m. and the LPN said the resident had passed away. She stated she went into the facility and entered the resident's room. She reported the resident looked pale and the room smelled bad, so bad I had a mask on. -The responsible party/family member said she had never seen the wound on the resident's thigh but had been told about it several days after the injury occurred. She said staff told her it was a small scrape caused by the lift sling and they would put medicine on it and a band aid. She said they also told her they would use a towel during transfers. She said the resident said the CNAs told her the wound was getting black. She said when she would ask the wound nurse about the color, the wound nurse would say it was because of the medicine and the CNAs should not be telling the resident about her wound. -The responsible party/family member stated no one at the facility had talked about sending the resident out to the hospital for wound treatment. She said she knew the wound was getting worse because the resident was staying in bed more and more. The physician was interviewed on [DATE] at approximately 3:10 p.m. He stated he was aware of the resident's wound but was not aware the facility had called on [DATE] to have the resident sent to the hospital for wound treatment. He stated the community did not have a wound nurse who would come to the facility for wound evaluation and care; the resident would either go to the hospital or be sent to another city which was about 100 miles away. The certified mortician science practitioner (CMSP) was interviewed on [DATE] at 2:35 p.m. He reported the medical doctor was the certifying physician who pronounced the resident's death. He stated, upon review of the documents related to the resident's death, that while the cause of death was pneumonia, contributing causes included the sacral decubitus ulcer and diabetes. He said he went to the facility on the night of the resident's death. The odor in the room was strong and there was approximately one pint of drainage under the resident; the sheet was soaked. He said he could not see the entire wound but was able to see the margins which were very deep. 2. Resident #2, age 87, was admitted to the facility on [DATE]. The resident was hospitalized from [DATE] until [DATE]. According to the facility face sheet, her [DIAGNOSES REDACTED]. According to the [DATE] minimum data set (MDS) assessment, the resident had clear speech, made self understood and was able to understand others. The Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated her cognition was intact. The resident required extensive assistance of two persons for bed mobility, dressing, toilet use and personal hygiene. The resident had an indwelling urinary catheter and had occasional pain level of 2 (out of 10 with 10 being the most severe). The care plan, dated [DATE] identified the resident received pain medication therapy. The goal was the resident would be free of any discomfort or adverse side effects from pain medication. Interventions included; administer [MEDICATION NAME] as ordered, observe/ document effectiveness on every shift. Observe, document and report adverse reactions such as altered mental status, anxiety, lack of appetite, nausea, vomiting, and [MEDICAL CONDITION]. Observe closely, follow therapeutic regimen if pain control is not adequate- changes required. a. Record Review According to the ,[DATE] Medication Administration Record [REDACTED]. Nursing progress notes were reviewed and documented the resident began experiencing pain more frequently and at a higher intensity, beginning [DATE]. Specifically: -[DATE] at 7:48 p.m. resident stated that she has not had a bowel movement in 3 (three) days. PRN (as needed) [MEDICATION NAME] administered. -[DATE] at 12:57 a.m. resident complained of abdominal pain. No tenderness, redness, no N/V bowel sounds active. PRN Tylenol given - ineffective. -[DATE] at 9:35 a.m. Resident also had temperature of 100.0 degrees F. -[DATE] at 6:11 p.m. Tylenol administered at 1600 (4:00 p.m.) for complaint of pain rated at a 5 on ,[DATE] scale PRN effective. -[DATE] at 2:21 a.m. resident complaint of right side pain. Resident denies chest pain or shortness of breath. -[DATE] at 3:22 a.m. PRN Administration was: Unknown resident resting with eyes closed. -[DATE] at 2:29 p.m. Resident requesting IV (intravenous) fluids. Resident was informed that we just can't give IV fluids without an order. Resident's body temperature was 99.5 degrees. She complained of nausea. -[DATE] at 5:56 p.m. patient requested medication for pain rated at 8 on scale ,[DATE]. -[DATE] at 8:00 p.m. resident to be sent to ER for eval of right side pain and nausea. Ambulance called gave report to (name) in the ER (emergency room ) of pt (patient) arrival. There was no further information in the record documenting an assessment of the resident's condition after [DATE], including a description of the location, intensity, and duration of the resident's pain, as well as any associated symptoms. Review of the [DATE] consulting physician's report revealed it read, This is an [AGE] years old . presented with right upper quadrant pain for one week associated with diarrhea. She had been feeling fatigued. I believe she had some nausea and vomiting as well. The patient presented to the emergency room and was found to have [MEDICATION NAME]. Part of the reason for her delayed presentation was that there has been an outbreak of Norovirus at the facility .the patient presented with some degree [MEDICAL CONDITION] and [MEDICATION NAME]. Diagnosis: [REDACTED]. According to the hospital documentation, the resident underwent [REDACTED]. b. Interviews The resident was interviewed on [DATE] at 5:50 p.m. She said she reported to the staff that she had an abdominal pain starting [DATE] on a daily basis. She was unable to eat and drink, she was nauseated and in pain. The facility staff told her to stay in her room because they had an infection in the facility and everybody was sick. She said that after six days of not being able to eat and drink, she asked the nurse for IV fluids and was sent to the hospital. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 2:10 p.m. in presence of the Director of Nursing (DON). LPN #2 said when the resident asked her for IV (intravenous) fluids, and reported pain of 8 in the scale of ,[DATE], she called the physician's office for orders. According to the LPN #2, she checked the resident's condition; however, she did not ask the registered nurse to assess the resident or document her findings in the nurses' notes. The DON, while confirming most residents had gastrointestinal symptoms from [DATE] to [DATE] due to a Norovirus outbreak, said resident #2 was not appropriately and timely assessed. B. Pain Management Facility policy reads in part, Assess and reassess resident's pain and respond appropriately. 1. Resident #3 was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, his [DIAGNOSES REDACTED]. According to the [DATE] MDS assessment, the resident's cognition was severely impaired. He required extensive and total assistance of two staff members for bed mobility, transfers, eating, toileting and personal hygiene. The care plan, updated on [DATE], identified the resident had pressure ulcers on right and left iliac crest, and undermining coccyx area related to nutritional impairment and incontinence. Approaches included: air mattress on bed, turn and reposition frequently to decrease pressure, provide wound care, and treat infections to wound as ordered. The pain care plan dated [DATE] identified the resident had potential for pain related to the [DIAGNOSES REDACTED]. Approaches included: monitor for pain and pain medications as ordered, administer pain medication prior to treatments and therapy, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. 2. Record Review Review of physician orders [REDACTED]. The resident also had orders for [MEDICATION NAME] sulfate solution 20 mg/ml. Give 0.5 ml via Peg- tube every two hours as needed for pain (order date [DATE]) The pain evaluation assessment dated [DATE] noted the resident was unable to answer questions related the pain and received pain medication as needed. The controlled drug administration record was reviewed and revealed the resident received [MEDICATION NAME] ,[DATE] times a day from [DATE] to [DATE]. The next administrations were noted to be on [DATE] at 5:00 a.m. and [DATE] at 5:00 a.m. The remained amount in the vial on [DATE] was noted to be 10 ml. No further administration of [MEDICATION NAME] was noted for resident #3. 3. Observation, interviews and further record review On [DATE] at 4:30 p.m., a certified nurse aide (CNA) asked LPN #1 to change the resident's dressings which were soaked with urine, feces and blood. The dressing on the resident's right hip was dated [DATE] with no time specified. Observation of the dressing change at 4:32 p.m. by LPN #1 in the presence of the facility assistant DON (ADON), revealed each time the LPN #1 cleaned, or touched resident's right hip wound, the resident became aggressive and tried to grab her hand. LPN #1 did not to assess resident's pain but rather continued to clean the wound and apply a new dressing. When LPN#1 was asked if the resident had an order for [REDACTED]. Following the above observations, the resident's MAR indicated [REDACTED]. Likewise, there was no documentation on the narcotic sheet and notation in progress notes to show that pain medication had been administered on [DATE]. On [DATE] at approximately 5:00 p.m. the DON and the Nursing Home Administrator (NHA) were informed of the findings above. The DON confirmed the resident's dressings had not been changed for two days and nursing staff had not followed the physician orders [REDACTED]. The NHA said the resident should have been pre-medicated prior to dressing change and the medication administration should be recorded. She said when the resident appeared uncomfortable or in pain during dressing change, the nurse should stop the dressing change immediately.

Based on observation, record review, and interview, the facility failed to ensure three (#7, #92, #49) of 37 residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically: --Resident #7's pain related to wounds was not addressed and treated; --An open area on resident #92's leg was not identified, assessed, and treated in a timely manner; and --Resident #49 did not receive timely toileting assistance and, after being left on the toilet for a prolonged amount of time, was not thoroughly and timely assessed. The findings include: Facility Policy According to the facility's pain management policy, in pertinent part: " ...The staff will implement the care plan, monitor the resident and administer therapeutic interventions for pain, if ordered." 1. Resident #7 a. According to the face sheet, the resident was an [AGE] year-old female originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] and readmitted [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], showed the resident's cognition was severely impaired. She required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident received as needed pain medications and non-medication intervention for pain but denied the presence of pain at the time of the assessment. The resident had an unstageable pressure ulcer. The pressure ulcer care plan, dated 11/22/13, showed the resident had an actual pressure ulcer on 12/18/13 related to moisture/incontinence, decreased activity, and impaired mobility. Approaches included: --Apply pressure reduction mattress to bed --Apply pressure reduction cushion to chair or wheelchair --Reposition in chair frequently --Turn and reposition frequently while in bed --Treatment as ordered --Foam booties on at all times. The pain care plan, dated 11/22/13 and last reviewed on 5/1/14 showed the resident had a potential for pain related to a chronic disease process. Her pain goal was zero. Approaches included: --Positioning/support as she chooses --Administer [MEDICATION NAME] as ordered --See physician orders --Observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other) every shift --Notify physician if interventions are not consistently effective. b. Record review On 4/26/14, a resident transfer form showed the resident was to the hospital due to, "No response to clinical treatment of [REDACTED]. (Physician) would like eval(uation) and treat to (rule out) ([MEDICAL CONDITION] based on lab results from 4/26/14." The hospital history and physician showed the resident was hospitalized from [DATE] - 5/1/14. She presented to the hospital with worsening left leg [MEDICAL CONDITION] and the discharge [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE]. According to the readmission physician orders, dated 5/1/14, the resident was ordered the following, pertinent medications and treatments: --Tylenol 500 milligrams every four hours as needed for pain --Irrigate left heel wound with sterile saline pack lightly with silver aliginate cover with foam form with adhesive. Change every 2 days or as needed The 5/1/14 readmission pain assessment showed the resident had pain/hurting related to left lower extremity [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The resident was unable to complete the pain evaluation. The resident's location of pain/hurting was a wound/ulcer, back pain, and she complained of pain when touching the left lower extremity (LLE). Timing and contributing factors to pain included the resident's wound dressing change and when completing activities of daily living. The resident's manner of expressing pain included verbalization, expressions of anger/agitation, resistance with cares, and "Res(ident) says ouch when LLE touched." The May 2014 Medication Administration Record [REDACTED]. Her pain goal was zero. The resident's pain was documented as above zero on the following dates: -5/2/14: 4 -5/3/14: 2 -5/4/14: 4 -5/5/14: 4 and 3 -5/6/14: 2 -5/7/14: 4 -5/8/14: 4 -5/9/14: 2 -5/10/14: 2 -5/11/14: 3 -5/12/14: 2 -5/13/14: 2 The May 2014 MAR indicated [REDACTED]. The resident's nursing progress notes were reviewed back to 5/1/14 and revealed, in pertinent part: --5/3/14: "Dressing changed to area (left) inner heel. Has faint odor, minimal drainage. Skin is peeled off of top of foot. Is moist between swollen toes ...Res(ident) is angry while (treatment) being done." --5/4/14: "...Dressing to L(eft) heel intact. Ankle to toes remain dark red with skin peeling off. No (complaint of) pain except with movement or touching LLE ..." --5/5/14: "Dressing to L heel intact. (Complains of) pain to LLE only." --5/7/14: "...Is cheerful but does (complain of) pain when L leg is touched or moved ..." --5/9/14: "...LLE remains red - warmer to touch c/o (complains of) pain only when area touched." --5/11/14: "...C/O pain with cares to LLE. LLE remains reddened. Skin remains to peel from foot ..." --5/12/14: "...Angry with staff while dressing change done, but did not C/O pain..." On the dates the resident expressed pain to her LLE and it was noted by the nursing staff, there was no evidence in the documentation to show pain relief was offered. The weekly pressure ulcer records were reviewed back to 5/1/14. The records revealed the resident had an unstageable pressure ulcer to her left heel. The records documented: --5/1/14: Pain related to wound - Yes --5/10/14: Pain related to wound - Yes --5/12/14: Pain related to wound - Yes Despite the resident's pain related to her wound and the pain to the left lower extremity related to [MEDICAL CONDITION] and [MEDICAL CONDITION], the resident's pain and pressure ulcer care plans were not updated to include this onset of pain with individualized interventions. c. Resident Observation --On 5/14/14 at 2:25 p.m., the resident was observed in her room. She was seated in a wheelchair and she was wearing heel protectors on her feet. --On 5/14/14 at approximately 2:45 p.m., the resident was observed lying in bed. Her wound dressing was removed and the licensed practical nurse (LPN #3) was about to complete her wound treatment. The wound, located on the resident's left heel, was approximately one half inch wide with yellow slough in the wound bed. As LPN #3 began the wound treatment, the resident began breathing deeply, grimacing, and putting up her hands. LPN #3 said, "I'm sorry (resident #7). The resident said, "What are they doing to my heel?" while grimacing. The resident said, "Please don't hurt me anymore." LPN #3 responded with, "I'm not." The resident said, "I didn't do anything bad. I love you." Shortly after, as her foot was being wrapped with gauze and taped she said, "Oh oww! What was that?" LPN #3 did not stop and offer pain medication during the treatment. --On 5/20/14 at 10:30 a.m., the resident was observed lying in bed. The resident's heel was undressed and exposed pending treatment from LPN #3. The wound base contained whitish, gray slough. It was approximately half an inch wide. The resident was asked if she was in pain and said, "All the time. It hurts something awful." LPN #3, who was in the room, smiled and said, "This morning she claimed her legs were broken." d. Staff Interview --On 5/14/14 at approximately 3:00 p.m., LPN #3 and the wound care registered nurse (RN #1) were asked about the resident's pain. LPN #3 and RN #1 stated it was normal for the resident to complain of pain during her dressing change. LPN #3 said the resident would sometimes threaten to call her attorney but would in the same sentence say she loves her." LPN #3 was asked if she had ever attempted to pre-medicate the resident prior to her dressing change. She said she had not. --5/15/14 at 9:19 a.m., the director of nursing (DON) was informed of the 5/14/14 observation of the resident's wound treatment. She said, "They should have tried pre-medication. I've been down and watched them and sometimes she tolerates it very well but there's sometimes she will say," ow," and they tell her what they're doing and it stops immediately." The DON stated, however, if the resident was expressing pain, "They need to address that and take care of it." 2. Resident #49 a. Resident Status Resident #49, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His MDS dated [DATE] revealed that he was usually understood and could usually understand others. His cognition (decision making ability) was 12 out of 15 on the brief interview for mental status (BIMS) indicting a mild cognitive deficit. He needed extensive assist with all activities of daily living except eating. He needed extensive assist with transfers. He was frequently incontinent of urine and was always continent of bowel. b. Resident Interviews The resident was interviewed 5/14/14 at 9:17 a.m. He was asked if anyone in the facility had ever abused him. He stated he was abused. He elaborated by stating he was left on the toilet for more than two hours. He also stated the call light cord was broken: it was frayed and short and he could not pull the string. He thought it occurred about two weeks ago. He stated that he had not informed staff and would just, "Let it go." The resident was interviewed on 5/20/14 at approximately 1:45 p.m. He was asked if he remembered the incident with the toilet. He stated he did. He stated he hurt while he was waiting. He stated it hurt his hip and buttocks. He then stated he was angry at the end. c. Facility investigation The Nursing Home Administrator (NHA) and the Former Interim Nursing Home Administrator (FINHA) were informed of the incident on 5/14/14 at approximately 12:00 p.m. The FINHA stated he would start the investigation right away. He acknowledged this would be neglect. The facility's investigation revealed the resident was left on the toilet for at least 30 minutes and was unable to seek assistance due to a frayed call light cord. The facility was not aware of the incident as the two staff members involved did not report it to upper management. Further, the resident did not have a documented assessment or progress note following the incident. Cross reference F224 - prohibition of mistreatment, neglect, and misappropriation of property for further pertinent information and interviews. 3. Resident #92 a. Sample Resident #92, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His MDS dated [DATE] revealed mild cognitive loss, needed extensive assist for transfers, toileting, and personal hygiene. He needed human assistance with walking. He had no venous/arterial ulcers and no open [MEDICAL CONDITION] on his body. The Care plan for non pressure ulcer skin impairment, dated 4/30/14 showed a potential for skin impairment. Co-morbid conditions included thin, fragile skin. There was no goal noted. The approaches were: observe skin weekly and document findings, document observation of any non-pressure related skin impairments on the facility Non- Pressure Ulcer Wound document, and wound care as ordered. b. Interview On 5/13/14 at approximately 3:45 p.m. the resident stated he had he had an open area on his leg. He stated it [MEDICAL CONDITION]. He lifted up his pants and a bandage on his right inner aspect of the right lower leg was visible. His assigned nurse was interviewed on 5/13/14 at approximately 4:05 p.m. There was no mention of any skin problems. c. Record review The medical record was reviewed on 5/14/14. A review of the Head to Toe Skin Checks sheet undated (4/19/14 was the admitted ) showed multiple bruises, scabs and a denuded area measuring 3 x 2.5 cm on his right shin. On 4/24/14 it was noted on the sheet, the bruises noted above were fading, "Dressing intact to top of head." There was no mention of the area on his shin. On 5/2/14, a head to toe skin check noted, "The dressing was intact to top of head, fading bruises." There was no mention of the area on his shin. An undated head to toe skin check (noted after 5/2/14 and before 5/15/14) noted in pertinent part, "The dressing intact to the top of the head." There was no mention of the area on his shin. A 5/15/14 a head to toe skin check noted, "The dressing intact to top of the head: dressing intact on right ankle and excoriation peri-area. " A Non Pressure Skin Condition Record was initially dated 5/14/14. It noted the physician, family, and dietary were notified 5/14/14 of a skin issue. The site was noted on the right lower extremity. The following was from the Non Pressure Skin Condition Record. --The size of the wound was 2.1 x 1.3 cm the depth (illegible) The wound was described as having a yellow center. The area with redness surrounding it measured 5.5 x 6.0 cm. -- 0.8 x0.3 cm yellow scab -- 0.8 x 0.9 cm yellow scab, with dark center (this was a second open area) -- 0.5 x 0.4 cm dark area (This was the third area on the lower leg.) The bottom of the foot was noted as having: --1. 2 x 3 cm callous --2. 2 x 1.5 cm callous area --3 0.1 x 0.1 with 0.3 x 0.3 redness surrounding Review of the nurses' notes from 5/5/14 had no mention of the denuded area until 5/10/14 which noted the resident complained [MEDICAL CONDITION] in the leg. [MEDICATION NAME] was administered. There was no indication the area was examined or assessed. --5/12/14 the licensed nurse noted the dressing was changed. Area cleansed with saline and foam dressing applied. Review of the physician's order [REDACTED]. --5/13/14 the licensed nurse noted the dressing was intact for the area on the right leg. --5/14/14 the licensed nurse noted the dressing to the leg was removed. Wound nurse present, area noted and charted on Non Pressure Skin Condition record by the registered nurse. Physician notified. --5/16/14 the licensed nurse noted the dressing was changed with minimal redness to the surrounding area. It further noted a small open area to the right buttocks which was treated as ordered. The document noted the family was notified. --5/17/14 the nurse's note revealed a dressing to right leg was intact: Dressing clean and dry. --5/18/14 the nurse's notes revealed the dressing was replaced to the inner leg with no signs/symptoms or inflammation. Small open area was noted as clean and dry. Foam dressing was applied over areas. A review of the physician's orders [REDACTED]. On 5/15/14, an order to cleanse with Wound Cleanser, apply Aqauacil, cover with foam and secure was made. d. Interviews The registered nurse who did wound care and the charge nurse for the resident's unit had no explanation why the wound was not reported to them. There was also no explanation why the resident's wound was treated without a physician's orders [REDACTED].

Based on record review and interviews, the facility failed to ensure three of 24 sample residents (#36, #4 and #49) received the care and services necessary to attain/maintain their highest practicable level of well being. Specifically, the facility failed to ensure the residents' pain was addressed in a timely manner. The facility's failure contributed to resident #36 experiencing unrelieved pain at a level of 7. The findings include: 1. Resident #36, age 84, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. a. Resident Status - Pain and Pain Management Plan The 3/17/13 Minimum Data Set (MDS) scored the resident as a 12 on the cognitive exam (moderate impairment) and noted that she occasionally had pain with the intensity rated as 4 on a 0 to 10 scale. The 3/28/13 care plan noted a potential for pain with a goal that the resident would verbally express satisfaction with pain control over the next 90 days. The approaches included administering [MEDICATION NAME] as ordered, implementing a pain management flow sheet and monitoring the resident's pain every shift. Staff was to notify the physician if the pain interventions were not effective. Pain assessments, on 3/7/13, revealed a change of condition with a new onset of unspecified joint pain. This form was not completed and a second pain assessment was initiated on 3/17/13. -The resident stated that she had pain over the previous five days that was almost constant, the pain made it difficult to sleep and had limited her day to day activities. -The resident rated the current pain as a 7 on a 0 to 10 pain scale, stated that the pain had reached a 10 and the best pain level was a 4. The resident's acceptable pain level was not documented nor was the response to the question of, "Are you satisfied with the current level of pain control?" Review of physician orders [REDACTED]. -[MEDICATION NAME] 325 mg and directions to take two tablets every six hours as needed for pain with a start date of 10/12/12. -[MEDICATION NAME] 50 mg two tablets every six hours for severe pain with a start date of 1/28/13. -Topical Aspercream listed on the 4/13 MAR stated that the resident may apply to right shoulder three times a day as needed for pain. (Start date 3/14/13) b. Increasing Pain Review of physician notes revealed that beginning 2/1/13, the resident complained of increasing arm and shoulder pain. The 3/6/13 physician note addressed pain in right shoulder. See also the pain assessment above on 3/17/13, documenting the resident complaining of almost constant pain that interfered with sleep and activities of daily living. Review of the medication administration record (MAR) revealed pain assessments were recorded three times a day with pain levels at 2 or higher on the day shift from 4/1/13 through 4/24/13. The pain scale monitoring documentation order was started on 10/12/12. The 4/13 log revealed the resident was experiencing increasing pain beginning in mid-April. Specifically: 4/1/13 10 p.m. - 6 a.m. pain score, score was 2 6 a.m. - 2 p.m. pain score, score was 2 2 p.m. - 10 p.m. pain score, score was 0 4/2/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 2 2 p.m. - 10 p.m. pain score, score was 0 4/3/13 10 p.m. -6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 3 2 p.m. - 10 p.m. pain score, score was 0 4/4/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 3 2 p.m. - 10 p.m. pain score, score was 0 4/5/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 2 2 p.m. - 10 p.m. pain score, score was 0 4/6/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 2 2 p.m. - 10 p.m. pain score, score was 0 4/7/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 2 2 p.m. - 10 p.m. pain score, score was 0 4/8/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 4 2 p.m. - 10 p.m. pain score, score was 0 4/9/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 2 2 p.m. - 10 p.m. pain score, score was 0 4/10/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 2 2 p.m. - 10 p.m. pain score, score was 0 4/11/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 3 2 p.m. - 10 p.m. pain score, score was 0 4/12/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 4 2 p.m. - 10 p.m. pain score, score was 0 4/13/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 3 2 p.m. - 10 p.m. pain score, score was 0 4/14/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 3 2 p.m. - 10 p.m. pain score, score was 0 4/15/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 4 2 p.m. - 10 p.m. pain score, score was 9 4/16/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 4 2 p.m. - 10 p.m. pain score, score was 0 4/17/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 3 2 p.m. - 10 p.m. pain score, score was 4 4/18/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 7 2 p.m. - 10 p.m. pain score, score was 4 4/19/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 6 2 p.m. - 10 p.m. pain score, score was 0 4/20/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 4 2 p.m. - 10 p.m. pain score, score was 3 4/21/13 10 p.m. - 6 a.m. pain score, score was 8 6 a.m. - 2 p.m. pain score, score was 6 2 p.m. - 10 p.m. pain score, score was 4 4/22/13 10 p.m. - 6 a.m. pain score, score was 5 6 a.m. - 2 p.m. pain score, score was 6 2 p.m. - 10 p.m. pain score, score was 5 4/23/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 5 2 p.m. - 10 p.m. pain score, score was 2 4/24/13 10 p.m. - 6 a.m. pain score, score was 0 6 a.m. - 2 p.m. pain score, score was 5 A review of the MAR revealed [MEDICATION NAME] had been given once in April, on 4/20/13. A review of the 4/21/13 nurse's notes stated that Tylenol had been given at 3:30 a.m. and a dose of [MEDICATION NAME] at 5:00 a.m. Tylenol had been administered 13 times on: 4/1/13- Tylenol administration 4/2/13- Tylenol administration 4/3/13- Tylenol administration 4/4/13- Tylenol administration 4/5/13- Tylenol administration 4/10/13- Tylenol administration 4/11/13- Tylenol administration 4/15/13 Tylenol administration 4/17/13- Tylenol administration 4/18/13 -Tylenol administration (twice) 4/20/13- Tylenol administration (Times of administration and effectiveness not documented). An interview with resident, on 4/18/13 at approximately 3:30 p.m., revealed a physician appointment to have the resident's pain evaluated at the physician's office on 4/23/13 at 2:30 p.m. c. Failure of the facility to ensure ordered interventions to evaluate and address the resident's pain were implemented timely (1) Pain Medication Review of the resident's physician orders [REDACTED]. The resident was interviewed on 4/23/13 at approximately 4:30 p.m., and stated she was in pain at a level 6. She stated that her right shoulder hurt as well as her knee. She said she had returned from her physician appointment at 3:30 p.m. She said the physician had ordered new pain medication during her visit to his office, as well as ordering x-rays of her arm and shoulder. She further stated the new pain medication was not in the facility; it was to be delivered from the pharmacy. Review of the MAR revealed the resident had not received any pain medication on 4/23/13; specifically, no [MEDICATION NAME], no Tylenol, and no Aspercream, either before or after her physician visit. On 4/24/13 at 1:45 p.m., an observation of the medication cart revealed the resident's [MEDICATION NAME] 5/325 mg had been received from the pharmacy and a narcotic log sheet had been created; however, the medication had not been administered. The licensed practical nurse (LPN), who was responsible for the resident's care, stated that the resident had not asked for pain medicine. She further stated the resident had not been informed the medication had been delivered to the facility. On 4/24/13 at 1:50 p.m., resident #36 was interviewed. She rated her arm and shoulder pain as a 7 on a 0 to 10 pain scale (10 being the worst) and stated that she had not had pain medication that day. Her pain had been documented on pain assessment log as a 5 for the 6:00 a.m. to 2:00 p.m. shift. Per MAR review at 1:50 p.m., the resident had not received any prn pain medications on this date at this time. On 4/24/13 at 2:00 p.m., the director of nursing (DON) was interviewed. -She stated her expectation was that a resident who complained of pain would receive the medications that were ordered. -During the interview, the DON examined the medication administration record and the documented pain scales for April 2013. She agreed that the resident had documented pain scores with no documentation of medication administration. She agreed that topical Aspercream, Tylenol and [MEDICATION NAME] ([MEDICATION NAME]) pain medications had been available for the month of April and appeared to not be administered or offered in relationship to the documented pain scores. -She said the facility policy stated pain medicine would be offered and documented in the medical record. She stated that she would investigate the reason for the resident not receiving pain medication as ordered. On 4/24/13 at 2:30 p.m., following the above interview with the DON, the resident was interviewed again. She said the nurse had administered a pain pill ([MEDICATION NAME] 5mg /325 mg) to her a few minutes before. Review of the MAR and narcotic record revealed [MEDICATION NAME] was administered at 2:15 p.m. (2) Ice Pack Review of the resident's physician orders [REDACTED]. Review of the resident's MAR and treatment administration record (TAR) revealed the ice pack had not been documented on the 4/13 MAR, and there was no documentation in the nurses' notes or elsewhere in the record that the resident had received the ice packs for ten minutes per hour as ordered. d. X-rays ordered 4/23/13 were completed 4/25/13. The radiology report stated that the resident had "very severe [MEDICAL CONDITION] changes of the right shoulder with a high riding shoulder that is indicative of chronic rotator cuff tear." 2. Resident #49, a [AGE] year female, was admitted to the facility on [DATE]. According to the facility admission record, her [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], the resident was coded as a 12 (moderately impaired 8-12) on the BIMS (Brief Interview for Mental Status). a. Resident Status Review of the pain care plan, dated 4/22/13, revealed the resident had the potential for pain related to migraines. The approaches included; -Relaxation -Administer [MEDICATION NAME] as ordered -Implement pain management flow sheet -Observe resident for signs and symptoms of pain, include verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other) -Notify physician if interventions are not consistently effective. According to the physicians orders for April 2013 the resident had the following orders; -[MEDICATION NAME] 5 mg three times a day at 5:00 a.m., 2:00 p.m. and 8:00 p.m. -[MEDICATION NAME] 50 mg PRN (as needed). Review of the quarterly Pain Evaluation, dated 1/10/13, reflected the resident had experienced occasional pain in the past five days. The pain had made it hard for her to sleep and limited her day to day activity. The resident's current pain level was a 2 (out of 10). The worst the pain got was a 6 out of 10. The best the pain was a 1 or 2. The resident's goal for managing pain was a one. Review of the quarterly Pain Evaluation, dated 4/6/13, reflected the resident had experienced almost constant pain in the past five days. The pain had made it hard for her to sleep and limited her day to day activity. The resident's current pain level was 5. The worst the pain got was a 10 (out of 10). The best the pain was a 2 or 3. Review of the January 2013 pain scale on the medication administration record and the PRN Pain Medication Administration Record revealed that the resident had documented pain that went untreated/unaddressed on the following days: -On 1/13 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record, -On 1/15 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 4 and there is no entry on the PRN flow record, -On 1/16 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record, -On 1/17 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 1/19 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record, -On 1/20 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 1/21 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, and during the 2 p.m. - 10 p.m. shift, pain was recorded as a 4 and there was no entry on the PRN flow record, -On 1/22 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 1/23 during the 6 a.m. - 2 p.m., the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 1/24 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record, -On 1/25 during the 6 a.m. - 2 p.m., the resident's pain was recorded as a 2 and there was no entry on the PRN flow record and during the 2 p.m. - 10 p.m. shift, pain was recorded as a 6 and there was no entry on the PRN flow record, -On 1/26 during the 10 p.m. - 6 a.m. shift, the resident's pain was recorded as a 5 and there was no entry on the PRN flow record and during the 6 a.m. - 2 p.m. pain was recorded as a 2 and there was no entry on the PRN flow record, -On 1/28 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 5 and there was no entry on the PRN flow record and during the 2 p.m. - 10 p.m. shift, pain was recorded as a 4 and there was no entry on the PRN flow record, -On 1/29 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record, -On 1/30 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 5 and there was no entry on the PRN flow record, -On 1/31 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record. Review of the nurse's notes (NN) for January 2013 revealed there were no entries related to the above documented pain. Review of the February 2013 pain scale on the medication administration record and the PRN Pain Medication Administration Record revealed the resident had documented pain that went untreated/unaddressed on the following days: -On 2/8 during the 6 a.m. - 2 p.m., the resident's pain was recorded as a 2 and there was no entry on the PRN flow record, -On 2/13 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 2 and there was no entry on the PRN flow record and during the 2 p.m. - 10 p.m. pain was recorded as a 4 and there was no entry on the PRN flow record, -On 2/14 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record, -On 2/15 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 2 and there was no entry on the PRN flow record, -On 2/20 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 2 and there was no entry on the PRN flow record, -On 2/26 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record, -On 2/27 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 2 and there was no entry on the PRN flow record, -On 2/28 during the 6 a.m. - 2 p.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record. Review of the NN for February 2013 revealed that there were no entries related to the above documented pain. Review of the March 2013 pain scale on the medication administration record and the PRN Pain Medication Administration Record revealed that the resident had documented pain that went untreated/unaddressed on the following days: -On 3/6 during the 10 p.m. - 6 a.m. shift, the resident's pain was recorded as a 6 and during the 2 p.m. - 10 p.m. shift it was at a 2 and there was no entry on the PRN flow record, -On 3/7 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 5 and there was no entry on the PRN flow record, -On 3/8 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 2 and there was no entry on the PRN flow record. -On 3/20 during the 10 p.m. - 6 a.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 3/21 during the 10 p.m. - 6 a.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 3/28 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 3/29 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 3 and there was no entry on the PRN flow record, -On 3/30 during the 2 p.m. - 10 p.m. shift, the resident's pain was recorded as a 4 and there was no entry on the PRN flow record. Review of the NN for March 2013 revealed there are no entries related to the above documented pain. Review of the April 2013 medication administration record (MAR) revealed there was no pain scale monitoring. Review of the NN for April revealed there was no documentation related to the resident's increased pain noted on the pain evaluation. There was no documentation reflecting that the physician was notified of the resident's increased pain. b. Interviews On 4/24/13 at 11:27 a.m., the resident was interviewed. She stated she received scheduled pain medication and if they offered her the [MEDICATION NAME] she would take it. On 4/24/13 at approximately 11:45 a.m., a licensed practical nurse (LPN) was interviewed. She said there was no specific time that they asked residents about pain or recorded the findings on the MAR. She indicated that she asked the resident about pain with the morning medication pass. She also said that question could be asked several times in the shift. If the answer was different and the resident received a PRN medication she would document it on the MAR/PRN sheet. On 4/25/13 at 9:06 a.m., a LPN who cared for the resident regularly was interviewed. She said the resident often complained of pain. She indicated that she would offer her [MEDICATION NAME] or try alternate treatment like positioning. She indicated that the floor nurses completed the quarterly pain assessments. She indicated that when she did them, she compared them to the previous one. If there was a change or a concern, she would notify the physician and chart any communication with the doctor. On 4/25/13 at approximately 9:45 a.m., the director of nursing (DON) was interviewed. She said the nurses' first encounter with the residents was when they completed the pain assessment that was documented on the MAR. She said it was her expectation that if there was a change in the quarterly pain assessment or the resident's daily pain, the nurse notified the physician. She indicated that the nurses should document any follow up with the physician in the nurses' notes. She indicated that alternative treatment could be tried and if it was, it should be documented also. 3. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Symptoms of post polio include muscle weakness, fatigue, and pain from joint degeneration and increasing skeletal deformities. See generally: National Institute of Neurological Disorders and Stroke, NIH, www.ninds.nih.gov/disorders/post_polio/detail_post_polio.htm <http://www.ninds.nih.gov/disorders/post_polio/detail_post_polio.htm> a. Resident Status The resident's Minimum Data Set, dated dated [DATE], revealed she could understand and be understood. She had minimal decline in cognitive ability and needed extensive assist with transfers, dressing, toileting, personal hygiene and bathing. The MDS revealed the resident was on a scheduled pain medication. The resident's pain was frequent with an intensity of 8 on a scale of 1-10. Review of physician orders [REDACTED]. Review of the Medication Administration Record (MAR) revealed: -In 3/13, the resident received her scheduled [MEDICATION NAME] four times a day, in addition to [MEDICATION NAME] 1000 mg on 22 days for pain. -In 4/13 (through 4/24/13), the resident received her scheduled [MEDICATION NAME] four times a day in addition to [MEDICATION NAME] 1000 mg on 13 days. The resident's care plan for pain, dated 3/21/13, read under problems, that the resident had the potential for pain due to a history of seeking pain meds. -The goal was the resident would verbally express increased satisfaction with pain control. -The approaches in pertinent part included: Hot pack application; positioning; computer games; administering [MEDICATION NAME]; implementation of pain control sheet; observing for signs/symptoms of pain; and notifying the physician if interventions were not effective. b. Interviews The resident was interviewed, on 4/18/13 at approximately 11:00 a.m. and again on 4/23/13 at 1:25 p.m. -She stated she had pain now and stated she had pain at times in her legs causing burning, tingling and spasms. She stated she had asked for an increase in her pain medications and nothing was happening. -The resident was asked to rate her pain, and during both interviews, said her pain level was a 5 on a scale of 0 to 10. She stated a 4-5, but also stated the medication was not always helpful. Moreover, see MDS above; there were times the resident's pain was at a higher level. The Medical Director was interviewed, on 4/24/13 at 4:45 p.m. He stated he was no longer resident #4's primary physician, but had been until January 2013. He stated he had heard from the staff the resident was asking for an increase in her pain medication and he did not agree with increasing it. He stated he knew that pain was whatever the resident said it was, but he did not think increasing her pain medication would be beneficial, stating it could lead to an increase in falls. The pharmacist and social service director were interviewed on 4/24/13 at approximately 9:30 a.m. -The pharmacist said she had her notes showing there was a request for the resident's pain medication to be increased, which the primary physician denied. -Both stated the resident's demeanor had changed since her family member had been admitted to the facility. The resident, who had stayed in her room for 1.5 years, was now eating in the dining room and attending a few activities. They were afraid an increase in pain medication would further depress the resident and make her less social.

Based on observations, record review and interviews, the facility failed to ensure one of ten sample residents (#2) was free from abuse by another resident (#5). Specifically, the facility failed to ensure resident #2 was protected from physical assault with injuries, caused resident #5 who had a psychiatric [DIAGNOSES REDACTED]. The findings include: 1. Resident Demographics a. Resident #2 Resident #2, an [AGE] year-old female, was admitted to the facility on [DATE]. Diagnoses, according to the face sheet included in pertinent part, schizoaffective and depressive disorders. The resident's daily medications for treatment included Seroquel, Zoloft and Aricept. The 4/2/11 Minimum Data Set (MDS) documented the Brief Interview for Mental Status (BIMS) score was 11, indicating the resident had moderate cognitive impairment. The 1/2/11 comprehensive care plan, updated 4/7/11, documented the resident exhibited verbal and physically abusive behaviors; scratching at staff, pulling staff hair, cussing at staff, and having conversations with people inside her head. Approaches included: -use firm gentle voice identify self to individual prior to initiating care, -simple clear directions, -check for pain, -allow choices, -be alert for triggers of potential evidence of pending behavioral episodes, -notify MD as needed, and administer medications as ordered. b. Resident #5 Resident #5, a [AGE] year-old male, was admitted to the facility on [DATE]. According to the 2011 history and physical, [DIAGNOSES REDACTED]. The MDS, dated [DATE], revealed the resident scored a 13 on the BIMS (a score of 13-15 indicates the resident was cognitively intact). The resident's daily medications for treatment included Prolixin and Cogentin. The 5/24/11 psychoactive medication evaluation documented targeted behaviors for the Prolixin were, cusses at staff, refuses care, verbally aggressive towards staff and other residents. A pharmacy review report, dated 5/25/11, documented the resident was, "becoming aggressive with residents." The recommendation was for the physician to consider increasing the Prolixin. The physician agreed. The comprehensive care plan, updated 5/10/11, documented the resident was socially inappropriate/disruptive at times; picks on residents who he thinks did something to him, multiple delusions from gun powder in his legs to heroin in his teeth. Approaches listed were the same as for resident #2 (above), with additional approaches to: -monitor closely around others, -give prn medication (Prolixin) for behaviors, -call (name of) mental health center when increased agitation noted, -every 15 minute checks on resident. 2. Record Review a. Review of resident #2's medical revealed that on 6/15/11 at 5:00 p.m., resident #5 was seen backing out of resident #2's room into the hallway. Resident #5 had a belt and blood on his hands. Resident #2 was found on the floor on her right side. Noted injuries included large bruising to the left side of her face, two large gashes to the back of her head, bite marks to her left upper arm and a cut to her left upper lip. The ambulance was called and the resident was transported to the hospital. According to the hospital record, dated 6/15/11, the impression (for resident #2) was: "extensive trauma to head and face, including several superficial lacerations and extensive ecchymosis and swelling. Her left eye was completely swollen shut. Because of the type of injuries, it was felt that she should probably be admitted to the hospital and observed." Review of a knee x-ray taken on 6/16/11 revealed, "Somewhat suspicious for a possible fracture of the medial tibial plateau, cross sectional imaging could be considered." b. Review of resident #5's medical record revealed on 6/15/11, after the resident exited resident #2's room and proceeded down the hall, he stated, "Don't worry, I didn't kill her." Review of resident #2's room by staff showed there was hair and blood on the floor. Resident #5 was placed on one to one supervision and the police were called. During their investigation at the facility, resident #5 stated to the staff and the police, "I did that to her because she killed my brother and sister." The resident was then discharged to the hospital at 7:50 p.m. 3. Documented Behavioral History a. Resident #2 Nursing and physician documentation was reviewed the afternoon of 6/30/11. -On 4/1/11, nurses' notes in the nursing summary documented the resident had a schizoaffective disorder and was noted to strike out, kick, bite, scratch with cares, and talk frequently about someone trying to kill her. -On 5/9/11, "proceeded to throw juice at this nurse and yelled, 'get the hell out.'" -On 5/11/11 at 8:15 p.m., she was hitting and verbally abusive at bath time. -On 5/12/11 at 10:20 a.m., resident pinched, hit, scratched and verbally abused staff. At 9:00 p.m., cursed at the nurse. -On 5/13/11 at 9:00 p.m., combative with cares. -On 6/7/11 at 9:00 p.m., resident was noted punching, screaming, kicking, cursing and biting at staff. -On 6/13/11 at 9:00 p.m., the resident "frequently throws fluids on dining room floor at meals." The next entry was dated 6/15/11 when the resident was found with the multiple injuries. She was transferred back to the facility following hospital treatment and observation. b. Resident #5 Nursing and physician documentation was reviewed the afternoon of 6/30/11. -On 4/9/11 at 9:30 p.m., "From nurses' station, I hear resident yelling, 'get outta my room,' over and over. Another resident was yelling 'don't hit me.' I witnessed resident #5 with his hands on the other resident's hands, squeezing them. I yelled for the resident to let go and stop hurting the resident, but he ignored me. He let go after 30 seconds, and I pulled the resident out of the room. As I did this resident #5 grabbed the other resident's hat and slammed the door." -On 4/12/11 at 7:30 a.m., "resident (#2) sitting at her table. Coffee cup were noted on floor under the table. Resident (#2) had thrown coffee cup with coffee in it at resident (#5). Resident #2 stated stated that resident #5 had hit her on her hand. Resident #5 stated he knew resident #2 was going to throw the coffee at him. Stated, 'that was pretty smart of her.'" A dietary note entry at the same time documented, "Back of dining room resident #5 and resident #2 having a shouting match, 'I saw both residents slapping at each other arms, then resident (5) had his fist drawn, but did not hit resident (2).'" -The 4/12/11 interdisciplinary team review notes documented resident #5 was agitated in the dining room (DR). Another female resident was walking by him and they had a verbal exchange. He grabbed her right arm as she was leaving the DR, let go when nurse walked by. -On 4/18/11, "has had delusional ideation." -The 4/20/11 physician's history and physical documented the resident's speech was, "tangential and vulgar at times, paranoid schizophrenia." -A nurses' note, dated 5/1/11 at 9:00 p.m., documented, "Reported from pm nurse that resident grabbed peer by wrist in dinning (sic) room." -On 5/2/11 at 1:30 p.m., "Watching resident for agitation towards other residents." -On 5/2/11 (no time) the interdisciplinary team review documented the resident was agitated in the DR. Another female resident was walking by him, they had a verbal exchange, and he grabbed her right arm as he was leaving. -On 5/4/11 at 1:30 p.m., "Is very delusional, no increasing agitation today." At 9:00 p.m., the resident was witnessed by the nurse, hitting at his right knee quite hard, telling the nurse his leg won't work." -On 5/4/11, late entry for 4/30/11, documented the resident was agitated, and when another female resident walked by, "I looked over, I saw this resident grab female resident, raised his right arm as she was leaving. Resident #5 had very firm grip on her wrist, did let go as this nurse approached." -On 5/11/11 at 10:15 a.m., "Resident #5 did raise his hand but did not strike the other resident," who attempted to pass by resident #5. -On 5/24/11 at 4:30 a.m., "Resident #5 went down to peers room and yelled at peer to shut up and that if peer didn't shut up, resident (5) would go in and make him shut up." -Another interdisciplinary team review dated 6/(sic)/11, no time, documented the resident continued to have delusions per usual. (Resident) "Told IDT that he grabbed her due to her killing 200 (expletive) and burning them." -On 6/11/11 at 1:00 p.m., in the dining room, after resident #5 walked past his place at the table, he stated, "I need to go after someone." -On 6/14/11 at 10:00 a.m., the resident continued to have delusional ideation, "People are sneaking in and taking blood out of his legs and giving him Montezuma's revenge." Review of the behavioral monitoring records for Prolixin, showed behaviors being tracked included refusing bath, meds or to eat, bizarre Ideations, calling staff and peers [***] es. The number of episodes documented on the records was zero, while the (above)narrative documentation showed evidence of such behaviors. The next entry, dated 6/15/11, described the assault towards resident #2. A 6/sic/11 interdisciplinary review, documented resident #5 was to be placed on 10 minute checks for 48 hours. 4. Observations Resident #5 was no longer at the facility. On 6/30/11 at 5:15 p.m., resident #2 was observed seated at a table in the dining room. Her face was covered, largely, with fading yellowish/green/purple bruising. In an attempt to interview the resident, she did not respond to verbalization. 5. Interviews On 6/30/11 at 1:30 p.m., the director of nursing (DON) was interviewed. -She stated the facility had monitoring in place for resident #5 when he exhibited behaviors, which included every 15 minute checks. She said resident #2 was found with severe injuries from an attack by resident #5. She said resident #5 was then placed on every 15 minute checks, and mental health was contacted. -She reported the resident had a case worker who responded to the facility when the resident, "got out of hand." -She said resident #2 frequently talked in other voices, would become agitated with staff during cares, and she was recently assaulted and then returned from the hospital. -At the time of the survey, the DON said, "She (resident#2) is the same, and will direct staff to leave her room at times. She has a new baby, a doll she keeps with her all the time, we got her a new one." During the same interview, the DON was queried about resident #5. She stated that he had been at the facility since 2006 and she had not known him to exhibit any aggressive outbursts. On 6/30/11 starting at 2:10 p.m., six staff members who routinely cared for/interacted with both residents were interviewed separately. Regarding behaviors exhibited: Staff member (#1) stated resident #5 exhibited no behaviors/physical abuse and she had not seen him argue with resident #2, however, she witnessed him argue with others. Staff (#2) said she was witnessed resident #5 coming out of resident #2's room stating, "Don't worry, I didn't kill her, I did hit her." She further stated resident #5 had been in a verbal argument and she witnessed him arguing with resident #2. Staff member (#3) stated she had witnessed resident #5 arguing. Staff member (#4) stated she was working at the time of the above assault, and was documenting in care tracker at the time. She was called to help and found resident #2 on the floor bleeding. Resident #5 was in the hallway, "looking blank." Staff member #6 stated she was the first one to arrive after the attack on resident #2. She witnessed resident #5 backing out of resident #2's room. Staff member #7 stated she arrived after the attack. She said she had not witnessed behaviors from either resident #2 or resident #5 and she was not familiar with any previous negative interactions. Staff member #5 stated resident #5 experienced delusional thoughts, like, he was the owner of Vegas, and of another nursing home. He was paranoid that others were taking his things. He was diagnosed with [REDACTED]. She reported she did not think resident #5 "was necessarily arguing," rather he would laugh, and it bothered other residents. However, she said one week prior to the attack on resident #2, another confused resident entered resident #5's room. He thought that resident was pulling a gun so he grabbed the resident's wrists. The DON reported there had been a previous incident between resident #2 and #5 that occurred in the dining room. She said there was a cup on the floor; however, it was unclear whether resident #2 threw it at resident #5, so the residents were separated. She reported that resident #5 did have orders for as needed (prn) Prolixin for escalating behaviors, in addition to the scheduled doses. However, sometimes he would not take it. She said she thought he exhibited no changes in his behaviors, he continued having hallucinations, yet no acts of violence. On 6/30/11 at 6:15 p.m., the Social Worker (SW) was interviewed and asked about resident #5's behaviors, monitoring and review. She stated the facility currently did not have a system in place for routine review of psychotropic medications and behaviors. When asked about specific triggered behaviors that would alert facility staff for possible needs to review the resident, behaviors and medications, she said resident #5 had an outside case worker who saw the resident every other week. If the resident exhibited changes, they could contact the case worker. In summary, the facility was aware of resident #5's behaviors; however, documentation regarding his behaviors had been inconsistent -There was no documentation found to show the resident was monitored every 15 minutes following negative encounters with other residents, including resident #2, as care planned. -Failure to effectively monitor resident #5's behaviors following negative encounters with residents, including resident #2, contributed to the severe injuries resident #2 suffered after being assaulted by resident #5.

Based on observations, record review, and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being for three (#6, #7 and #10) of 12 sample residents. Specifically, the facility failed to ensure: -Resident #6 had timely treatment interventions for a fractured right leg, -Resident #7 had assessments and interventions for bowel movements, and -Resident #10 had a functional [MEDICAL CONDITION] (continuous positive airway pressure) machine as the physician ordered. The findings include: I. Failure to Provide Timely Treatment Interventions for [MEDICAL CONDITION] 1. Resident Failure Sample resident #6, [AGE] years old, was admitted to the facility on [DATE]. The face sheet documented the resident had the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment, dated 9/13/10, documented the resident was independent with daily decision-making. The resident required extensive assistance from staff with bed mobility and dressing. The resident required limited assistance from staff with transfers, toileting, and personal hygiene. The resident had fallen in the past 30 to 180 days. a. Record Review A fall risk assessment, dated 9/8/10, documented the resident scored a "10" (high risk). An 11/10 physician's orders [REDACTED]. An 11/11/10 care plan (CP) documented the resident had two falls on 10/19/10 and one fall on 10/21/10. The CP did not document the resident had a fractured femur or utilized a right leg brace (see the 11/10 physician's orders [REDACTED]. Fall #1 A nurse's note (NN) written on 10/19/10 at 1:55 p.m. documented a housekeeper called the writer (nurse) to the dining room where the resident was found lying on her left side. Blood was noted to her forehead and under her head. The resident was seizing, which lasted for approximately five to seven minutes. An ambulance was called and the resident was sent to the emergency room . The resident's physician and family were notified. A head to toe skin check completed on 10/19/10 at 2:15 p.m. documented a skin tear/laceration to the resident's forehead. The interdisciplinary post fall review, dated 10/20/10, documented the resident had an unwitnessed fall on 10/19/10 at 1:55 p.m. The resident received a laceration to her forehead. A housekeeper called the nurse to the dining room where the resident was found lying on her left side. Blood was noted to her forehead and under her head. The resident was seizing. The summary of the interdisciplinary team documented the resident was refusing medications and had a grand mal [MEDICAL CONDITION] in the dining room. Her vital signs were taken and the physician and family were notified. The 10/19/10 resident transfer form documented the resident was sent to the emergency room for a [MEDICAL CONDITION] with head trauma. It also documented, "resident has been refusing all medications." Fall #2 A NN written on 10/19/10 at 7:15 p.m. documented the writer (nurse) was called to the dining room where the resident was found on left side with pool of blood on the floor and seizing. Pressure was applied to the previous laceration (see above). The [MEDICAL CONDITION] lasted approximately five to seven minutes. The resident left the facility via ambulance. The nurse was unable to contact the resident's physician. Her family was notified. A head to toe skin check completed on 10/19/10 at 7:30 p.m. documented a pin hole to the left temple. The 10/20/10 interdisciplinary post fall review dated documented the resident had an unwitnessed fall on 10/19/10 at 7:15 p.m. The resident reopened the laceration to her forehead. The nurse was called to the dining room where the resident was found on her left side with a pool of blood under their head and seizing. The summary of interdisciplinary team documented the resident had no knowledge of the incident. The resident was refusing medications. She was sent to the emergency room for evaluation. Her vital signs were taken and her physician and family were notified. Discharge instructions (DI) written on 10/19/10 at 11:11 p.m. from the emergency room documented the resident had a [MEDICAL CONDITION] disorder with medication non-compliance. The DI documented the resident had a laceration (location not documented) with five stitches. The DI also documented the resident had a urinary tract infection. NN written on 10/20/10 at 04:30 a.m. documented the resident returned from the hospital via ambulance with sutures intact to her left forehead at the hair line. There was no [MEDICAL CONDITION] activity noted this shift. NN written on 10/20/10 at 1:00 p.m. documented the resident remained in bed all shift. The resident had turned herself from lying on their right side onto her back. When the resident's legs were moved by the nurse during care, the resident yelled, "Ouch, my leg!," referring to the right leg. The resident had external rotation of the right leg, but had moved the leg by herself earlier in the shift. Bruising was noted to her left knee cap, right inner knee, and faint bruising to the shoulder. Sutures were in place to the left hairline with visible dried blood. The interdisciplinary falling star program care plan dated 10/20/10 documented, "Will continue on program due to history of falls: had two falls due to [MEDICAL CONDITION]. Resident refusing to take medications at times. Resident gets up by self without calling for staff." The program did not document the resident experienced pain when the nurse moved the resident's right leg. The program also did not document the resident had an externally-rotated right leg. Though the resident complained of pain in her right leg upon movement and her leg was externally rotated, there was no evidence in the medical record the nurse notified the physician and facility administration of this information, assessed the leg for a possible fracture, or provided any interventions to address the pain. Fall #3 NN written on 10/21/10 at 8:15 a.m. documented the resident was found on the floor on her right side next to the bed. No [MEDICAL CONDITION] activity was noted. The resident was observed to have a laceration to the right ear. Vital signs were taken and were within normal limits. The physician's office was notified at 9:00 a.m. At 11:30 a.m., the physician ordered the resident be sent to the emergency room to have the laceration to the ear treated. The facility van provided transportation for the resident to the emergency room . A head to toe skin check sheet was not completed after the fall on 10/21/10 at 8:15 a.m. The 10/22/10 interdisciplinary post fall review documented the resident had an unwitnessed fall on 10/21/10 at 8:15 a.m., and received a laceration to the right ear. The resident was found on the floor on the right side next to the bed. No [MEDICAL CONDITION] activity noted. The summary of the interdisciplinary team documented the resident did not know what happened and staff stated the resident was found on the floor with half of her body on the fall mat and half of her body on the room floor. The team recommended a lipped mattress, mat on the floor, low bed, and a pressure alarm on at all times. The physician and family were notified. Discharge instructions (DI) written on 10/21/10 at 2:36 p.m. from the emergency room documented the resident had fallen. The DI documented the resident had a head injury with the skull and/or brain affected. The DI also documented the resident had a fractured femur. The DI further documented the resident was to utilize a knee immobilizer - a soft brace with stiff bars on its sides used to keep the knee from bending. The DI stated the resident was to be non-weight-bearing. A 10/21/10 x-ray report (right knee three views) documented a [MEDICATION NAME] impaction [MEDICAL CONDITION] right femur. The report was faxed to the facility on [DATE]. NN written on 10/21/10 at 10:00 p.m. documented the resident came back from the emergency room with a fractured femur. The physician on call for the resident was notified of the fractured leg on 10/21/10 at 10:00 p.m. A total of 33 hours had elapsed since the resident experienced right leg pain and had a visible externally-rotated right leg. NN written on 10/22/10 at 4:30 a.m. documented the brace was intact to the right leg. Sutures were intact to the forehead hairline. At 9:30 a.m., NN documented the brace was intact to the right lower extremity and the leg was externally rotated. The resident was non-weight-bearing on the right leg and transferred without complaint of pain. A right extension pedal was placed on the resident's wheelchair to support the right leg. The resident had a 2.5 cm (centimeters) by 1 cm purple bruise to the right facial area now. Sutures and staples were intact to area on left upper forehead at hairline. The interdisciplinary falling star program care plan, dated 10/26/10, documented the resident had three falls this month due to [MEDICAL CONDITION]. The resident refused to take medications at times. Safety devices were added and new medications were adjusted. The care plan was reviewed and updated. The program did not document the resident had a fractured femur and did not document the resident utilized a knee immobilizer. The interdisciplinary falling star program care plan, dated 11/11/10, documented the resident was to remain on the program. The last incident was on 10/21/10. The resident fell three times in two days. The program did not document the resident had a fractured femur and did not document the resident utilized a knee immobilizer. The resident's care plan had not been updated to address her fractured femur and need for a knee immobilizer (cross-reference F279: Comprehensive Care Plan). b. Staff Interviews On 11/17/10 at 2:15 p.m., the Director of Nursing (DON) stated she was not made aware of the resident's externally rotated right leg and the pain upon movement by nursing staff. She stated if she had known, she would have called the resident's physician for an x-ray order. The DON stated she had not read the NN on 10/21/10 regarding the resident experiencing leg pain or the externally rotated leg prior to being questioned about the NN by the state surveyor on 11/15/10. The DON stated she received the complete Emergency Physician Records (10/19/10 [MEDICAL CONDITION], 10/19/10 [MEDICAL CONDITION], and 10/21/10 facial/scalp laceration) on this date (11/17/10 at 10:53 a.m.), and this was the first time she had read all of the hospital reports. The DON stated there was no head to toe skin check for the fall on 10/21/10; however, one should have been completed by nursing staff. The DON stated the NN for 10/21/10 did not document a complete head to toe skin assessment after the fall on that day. The DON stated the facility does not complete fall risk assessments after each unwitnessed fall. The DON stated there was no documentation in the resident's clinical record that the resident's physician was notified of the resident's leg pain and externally rotated leg. The DON stated the physician on call for the resident was notified of the fractured leg on 10/21/10 at 10:00 p.m. The DON stated the facility had not conducted any investigations regarding the origin of the fracture; it was assumed the leg fractured during a [MEDICAL CONDITION]/fall. The DON stated there was no documentation in the interdisciplinary falling star program notes regarding the resident's fractured leg or use of a knee immobilizer. The DON stated there was no care plan for the resident's fractured leg or that the resident utilized a knee immobilizer. The DON stated it was her expectation nursing staff tell her about signs and symptoms of a resident with a suspected leg fracture. On 11/17/10 at 3:21 p.m., the Nursing Home Administrator (NHA) stated she was unaware of the resident's fractured femur until the x-ray report was faxed to the facility from the emergency room (on 10/26/10, five days after the resident returned from emergency room - see above). The NHA stated if she had known about the resident's pain in the right leg upon movement and externally-rotated leg, she would have sent the resident to the emergency room immediately. The NHA stated it was her expectation nursing staff contact her when they suspect a resident had a fracture. II. Failure to Perform Neurological Assessments Per Facility Policy 1. Facility Policy The facility's neurological assessment policy documented neurological checks should be recorded every hour for four hours, every four hours for twenty-four hours, and every eight hours for the remaining seventy-two hours or as ordered by a physician. 2. Resident Failure a. Record Review Sample resident #6, see above, experienced three falls in 10/10, on 10/19/10 at 1:55 p.m. and 7:15 p.m. and once on 10/21/10 at 8:15 a.m. A neurological record (NR) was started after the first fall on 10/19/10 at 1:55 p.m. and continued after the resident returned from the emergency room . The NR was re-started after the second fall on 10/19/10 at 7:15 p.m. The NR for the second fall documented assessments were done on 10/20/10 at 3:30 a.m.; however, NN documented the resident did not return from the emergency room until 10/20/10 at 4:30 a.m. The NR did not document any neurological assessments (level of consciousness, pupil reaction, eye signs, eye responses, motor responses, or verbal responses) for 10/20/10 at 7:30 p.m. The resident had a third fall on 10/21/10 at 8:15 a.m., and was sent to the emergency room . The resident had hit her head and received a laceration to the ear. The resident returned from the emergency room at 10:00 p.m. Neurological assessments were not started upon her return. The NR did not document any neurological assessments for 10/21/10 and 10/22/10, a total of 32 hours. On 11/15/10 at 3:15 p.m., NN were reviewed. There was no documentation in the NN regarding neurological assessments (level of consciousness, pupil reaction, eye signs, eye responses, motor responses, or verbal responses) for 10/21/10 and 10/22/10, following the third fall. b. Staff Interviews On 11/17/10 at 2:15 p.m., the DON stated a new NR (assessments) should have been started after the fall on 10/21/10 using the frequency on the NR policy. The DON observed/agreed the NR for 10/21/10 and 10/22/10 did not document any neurological assessments (level of consciousness, pupil reaction, eye signs, eye responses, motor responses, or verbal responses) after the third fall. III. Failure to Provide Assessments/Interventions for Constipation 1. Reference According to the Health Professional's Drug Guide, 2007-2008, by Shannon, Wilson, Shields, and Stang, the following medications had constipation or fecal incontinence as a possible side effect/adverse reaction: [MEDICATION NAME] (p. 1106), [MEDICATION NAME] (p. 901), [MEDICATION NAME] (p. 505), [MEDICATION NAME] (p. 724), and [MEDICATION NAME] (p. 942). 2. Resident Failure Sample resident #7, [AGE] years old, was admitted to the facility on [DATE]. The face sheet documented the resident had the following Diagnoses: [REDACTED]. The 10/28/10 MDS assessment documented the resident was severely impaired with daily decision-making. The resident rarely/never made self understood in verbal content and rarely/never understood others in verbal content. The resident had both short- and long-term memory problems. The resident required extensive assistance from staff with toileting, personal hygiene, bed mobility, transfers, and dressing. The MDS documented the resident was always incontinent of bowel. a. Record Review The 10/28/10 care plan addressing bowel elimination documented the resident had the potential for alteration in bowel function due to decreased mobility, disease process, and no perception of bowel urgency. The approaches for this problem included: administer medications as ordered, observe for bowel pattern to ensure adequate bowel elimination, and notify the physician as indicated/needed. The 11/10 physician's orders [REDACTED]. -[MEDICATION NAME], 2.5 mg (milligrams) each day for dementia with agitation; -[MEDICATION NAME], 10 mg each day for rhinitis due to pollen; -[MEDICATION NAME], 10 mg each day for [MEDICAL CONDITION]; -[MEDICATION NAME], 1 mg each night for hypertension; -[MEDICATION NAME], 10 mg twice a day for dementia with behaviors; -Milk of Magnesia, 30 ml (milliliters) as needed for bowel regime; and -[MEDICATION NAME], 10 mg suppository as needed if no bowel movement in three days in a row. On 11/16/10 at 9:00 a.m., the resident's clinical record was reviewed. After completion of the review, a request was made to the facility for documentation of the resident's bowel movements for the past three months. The facility provided a copy of the resident bowel and bladder by shift chart (RBBSC) from 8/15/10 through 11/13/10. There were no documented bowel movements in the RBBSC for 9/14/10 shift one through 9/18/10 shift two, a total of thirteen shifts (4 days and 1 shift) and for 10/11/10 shift one through 10/16/10 shift three, a total of eighteen shifts (5 days). Further review of the resident's clinical record did not provide any documentation in the NN regarding bowel assessments, bowel auscultations, or bowel interventions for 9/14/10 shift one through 9/18/10 shift two and for 10/11/10 shift one through 10/16/10 shift three. A review of the medication administration records (MARs) for 9/10 and 10/10 did not provide any documentation the resident was administered any as-needed bowel regime medications for the dates 9/14/10 through 9/18/10 and 10/11/10 through 10/16/10. On 11/17/10 at 9:00 a.m., certified nurse aide (CNA) #1 stated she documented bowel movements in "Care Tracker" (CT, a CNA documentation tool) as soon as possible after helping a resident. She stated she sometimes wrote herself notes so she would not forget to document bowel movements, as she was busy with other duties. The CNA stated the documentation in CT might not be accurate because staff may forget to place information in CT. At 9:50 a.m., CNA #2 stated she documented bowel movements in CT as soon as she could after helping a resident; sometimes it could be ? to 1 hour after the event because she was helping other residents. The CNA stated she thought the information in CT was accurate. At 9:55 a.m., a licensed practical nurse (LPN) stated she did not know whether the documentation of bowel movements in CT was accurate; but the information "had to be taken at face value unless an alert and oriented resident made a statement contrary to the documentation" in CT. On 11/17/10 at 10:28 a.m., the DON stated there was no documentation in the RBBSC for 9/14/10 shift one through 9/18/10 shift two a total of thirteen shifts (4 days and 1 shift) and for 10/11/10 shift one through 10/16/10 shift three a total of eighteen shifts (5 days). The DON stated there was no documentation in the resident's clinical record regarding bowel assessments, bowel auscultations, or interventions for 9/14/10 through 9/18/10 and 10/11/10 through 10/16/10. The DON stated she generated the "No Bowel Movements for Nine Shifts Report" on a daily basis, provided the report to the day nurse, and directed the necessary bowel regime for each resident on the report. The DON stated for some reason, resident #7 did not trigger (was not documented) on the No Bowel Movements for Nine Shifts Report for those dates. The DON stated the facility did not have specific policy/protocols on bowel movements and did utilize physician standing orders for bowel interventions. On 11/17/10 at 3:31 p.m., the Nursing Home Administrator (NHA) stated it was her expectation nursing staff document bowel movements in Care Tracker (CT) timely and accurately. The NHA stated nursing staff were trained on how to document in CT at the time of hire. IV. Failure to Administer [MEDICAL CONDITION] as ordered 1. References According to C-Pap learning center via <http://www.[MEDICAL CONDITION].com/[MEDICAL CONDITION]-faq/New-[MEDICAL CONDITION]-User.html> : "- Obstructive Sleep Apnea (OSA) is a condition in which a patient's muscles and tissues in the throat and air passage relax while sleeping, and this impedes the flow of air into the lungs due to a blockage of the airway. This can occur many times per night in the sleep cycle and especially during the REM sleep stages. Apnea is Greek for "without breath." -The scientific standard of an apneic event is the patient must stop breathing for at least 10 seconds per event and have an overall blood oxygen desaturation level of 3-4 % along with certain potential changes in EEG frequencies and data. If a person has 5 or more of any type of events per hour of sleep then they can be clinically diagnosed with [REDACTED]. This cycle leads to the patient being unable to get the needed quantity of restful sleep and results in: constant fatigue, difficulty focusing and irritability. -Untreated Sleep Apnea is potentially fatal and frequently results in the following serious health problems: [MEDICAL CONDITIONS], high blood pressure and diabetes. [MEDICAL CONDITION] therapy is the most recommended and the most effective treatment for [REDACTED]. [MEDICAL CONDITION] therapy provides a constant airflow which holds the airway open so that uninterrupted breathing is maintained during sleep. This eliminates sleep apnea events and allows the patient to get a restful sleep. -The pressure of the air is determined during your sleep study and your doctor will prescribe you a [MEDICAL CONDITION] machine at that pressure. -[MEDICAL CONDITION] therapy is traditionally provided through a nasal mask that seals around the nose. However, more innovative and comfortable options are available and advances in the delivery of [MEDICAL CONDITION] therapy are continually occurring. -A failure to use [MEDICAL CONDITION] therapy may increase your risk for conditions linked to untreated OSA: hypertension (OSA increases your risk of hypertension by up to five times), stroke and [MEDICAL CONDITIONS]. -Hypopnea can be characterized by recurrent episodes of upper airway obstruction during sleep. They are commonly associated with the so called recurrent oxyhemoglobin desaturation (frequent, persistent pulse oximetry reading less than 90%) and frequent arousals from sleep." According to the American association of critical care nurses via <http://www.aacn.org/WD/Practice/Docs/ch_14_PO.pdf>: "Oxygen saturation (SaO2) is an indicator of the percentage of hemoglobin saturated with oxygen at the time of the measurement. The reading, obtained through pulse oximetry, uses a light sensor containing two sources of light (red and infrared) that are absorbed by hemoglobin and transmitted through tissues to a photodetector. Normal oxygen saturation values are 97% to 99% in the healthy individual. An oxygen saturation value of 95% is clinically accepted in a patient with a normal hemoglobin level..." 2. Resident Failure Sample resident #10 was admitted on [DATE] with diagnoses, according to the face sheet, including [DIAGNOSES REDACTED], asthma, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], high blood pressure, [MEDICAL CONDITION], diabetes insipidus, [MEDICAL CONDITION], hemorrhoids and nephriti[DIAGNOSES REDACTED]. His most recent MDS assessment, dated 9/3/10, disclosed he had no problems with memory or decision-making. He was understood and able to understand others. The resident required extensive assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing and was totally dependent on staff for transfers. He had limited range of motion in his legs and feet. a. Record Review Review of sleep study results, dated 2/16/10, disclosed the following: -Baseline results: the longest event of 49 second obstructive hypopnea with minimum SaO2 of 79%. -Impression: moderate to severe obstructive sleep apnea. -Recommendations: be prescribed [MEDICAL CONDITION]. Review of 11/10 physician orders [REDACTED]. -4/29/10: "[MEDICAL CONDITION] wear while in bed, heater is set on 2. Machine is set on 9 until further notice. Check for proper settings every bedtime before turning on machine." -4/29/10: "Wash [MEDICAL CONDITION] filter every week in clear water then replace." -4/29/10: "Rinse humidifier chamber well with clean water before refill. Fill with reverse osmosis water to full line every evening." -4/29/10: "Wash mask to [MEDICAL CONDITION] every bedtime before applying. Dry well to make sure mask has good seal." Review of the resident's care plan disclosed the following: -1/18/10: "Respiratory risk-[MEDICAL CONDITION] at bedtime, care for [MEDICAL CONDITION] as ordered, administer oxygen as ordered, monitor breath sounds as needed, and monitor vital signs as needed." Review of information documented on [MEDICAL CONDITION] equipment revealed the [MEDICAL CONDITION] mask could be requested every 6 months. There were other [MEDICAL CONDITION] items on the list that revealed the equipment could re-ordered periodically. Review of 11/10 nurses' notes revealed there was no mention of the [MEDICAL CONDITION] machine or assessment of respiratory status. Copies of the 11/10 medication administration record/treatment administration record (MAR/TAR), resident's face sheet, and information on re-order of [MEDICAL CONDITION] equipment was requested from the medical records director on 11/17/10 at 11:00 a.m.; however, they were not provided prior to the end of the survey. b. Observation On 11/17/10 at 12:20 p.m., observation and interview disclosed the resident in a wheelchair in his room. There was a [MEDICAL CONDITION] machine next to his bed and a mask stored on the toilet tank. The resident stated the mask had been broken for several days. He explained that he told several staff, could not recall which staffs, but no one had given him a new mask. He revealed breathing was uncomfortable at night. The resident stated he was not given oxygen at night and his breathing was not assessed by staff at night. He added the facility did not have a back -up (secondary) mask for him. c. Staff Interviews On 11/17/10 at 2:30 p.m., a licensed nurse disclosed no one had told her the resident needed a new [MEDICAL CONDITION] mask. The DON stated in an interview on 11/17/10 at 3:00 p.m., that she had not been informed the resident needed a new [MEDICAL CONDITION] mask. There was no evidence the facility ensured they had the back-up equipment for resident #10, ensured licensed nurses followed physician orders [REDACTED].