Every finding on record at Stillwater Post-Acute

Based on observation, interview, and record review, the facility did not develop patient centered care plans for one of seven residents reviewed for care plans. (Resident 8). As a result, Resident 8 wandered into Resident 7's room and had an altercation (angry dispute between two people).Findings: On 8/7/26 at 9 A.M., an unannounced onsite visit at the facility was conducted related to a reported resident to resident altercation. Resident 7 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental illness that causes people to lose touch with reality) and Parkinson's disease (brain disorder that causes uncontrollable movements and difficulty with balance and coordination) according to the facility's admission Record. Resident 8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) and dementia (an impairment of brain function, such as memory loss and judgment) according to the facility's admission Record. During a review of Resident 8's SBAR [Situation, Background, Assessment and Recommendation- a communication tool used in healthcare to relay critical patient information] & INITIAL COC [change of condition]/ALERT CHARTING & SKILLED DOCUMENTATION [clinical record that shows the resident needed a licensed professional for care], dated 7/18/26, the SBAR indicated an altercation between Resident 8 and Resident 7. The SBAR indicated a Certified Nurse Assistant (CNA) reported that Resident 8 was seen walking out of Resident 7's room and heard Resident 7 who stated, I told you not to come to my room. The SBAR indicated CNA separated the residents and while walking with Resident 8 to the nurses' station, Resident 7 attempted to reach over the CNA to strike Resident 8. An interview on 8/7/26 at 10:51 A.M. with CNA 3 was conducted. CNA 3 stated Resident 7 preferred to stay in his room all day and was bothered when other residents wandered into his room. CNA 3 stated if a resident wandered in Resident 7's room, Resident 7 would ask the resident to leave but if the resident persisted in entering, Resident 7 would raise his voice. CNA 3 stated Resident 8 wandered to different resident rooms which caused altercation between Resident 7 and Resident 8. During an interview on 8/7/26 at 11:05 A.M. with Resident 7, Resident 7 stated Resident 8 was the only resident who wandered into his room. Resident 7 stated Resident 8 invaded my privacy. An interview and joint record review on 8/7/26 at 11:11 A.M. with the Assistant Director of Nursing (ADON) 2. ADON 2 reviewed Resident 8's care plans in the electronic medical record (EMR). ADON 2 stated Resident 8 had care plans regarding the use of psychotropic medication, risk for elopement and the altercation on 7/18/26 with Resident 7. ADON 2 stated there was no care plan regarding Resident 8's wandering into other residents' rooms. ADON 2 stated Resident 8's wandering into other residents' rooms should be care planned because it was a behavior which needed to be addressed. During an interview on 8/7/26 at 2:09 P.M. with the Director of Nursing (DON), the DON stated care planning was important to have interventions and prevent Resident 8 from entering other residents' rooms. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised December 2016 was conducted. The P&P indicated, The Interdisciplinary Team [IDT-team members with various areas of expertise who work together toward the goals of their residents], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The comprehensive, person-centered care plan will.incorporate identified problem areas.reflect treatment goals, timetables and objectives in measurable outcomes. A review of the facility's P&P titled, Resident-to-Resident Altercations, dated September 2022 was conducted. The P&P indicated, If two residents are involved in an altercation, staff.make any necessary changes in the care plan approaches to any or all of the involved individuals.

Based on observation, interview, and record review, the facility failed to ensure appropriate corrective action for an abuse allegation when an alleged victim (Resident 5) was not protected from the alleged perpetrator (offender) (Resident 3).This failure had the potential to affect Resident 5's safety and well-being. Findings:On 8/7/26 at 9 A.M., an unannounced onsite visit at the facility was conducted related to a reported resident to resident altercation.Resident 5 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition in which the heart does not pump or fill blood as well as it should) and weakness according to the facility's admission Record.Resident 3 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental illness that causes people to lose touch with reality) according to the facility's admission Record.An interview with Certified Nurse Assistant (CNA) 1 was conducted on 8/7/26 at 9:36 A.M. CNA 1 stated he heard about Resident 3 touching Resident 5. CNA 1 stated Resident 5's room was in the same hallway as Resident 3. CNA 1 stated after breakfast, Resident 3 roamed around the halls or watched TV at the nursing station. CNA 1 stated Resident 3 needed to be separated from Resident 5 because touching a female resident was considered sexual abuse.An observation and interview with Resident 5 was conducted on 8/7/26 at 9:53 A.M. Resident 5 was at the activity room sitting on a wheelchair. Resident 5 stated a male resident touched her chest area. Resident 5 stated she was coming back from a smoke break at 200 hall when the male resident coming from the opposite direction, got close to her wheelchair and touched her chest area. Resident 5 stated she reported the incident to staff. Resident 5 stated she still saw the male resident because their rooms were in the same hallway. Resident 5 stated she felt afraid every time she saw the male resident in the halls. An interview and joint record review was conducted on 8/7/26 at 11:43 A.M. with the Assistant Director of Nursing (ADON) 2. ADON 2 reviewed the care plans for Resident 3 in the electronic medical record (EMR). ADON 2 stated Resident 3 had a care plan for wandering and for the use of antipsychotic (a medication that work to alter brain chemistry to reduce symptoms of disconnection from reality) medication for believing people were trying to harm him. ADON 2 stated a care plan dated 7/19/26 indicated Resident 3 had physical contact with a peer and the interventions included monitoring Resident 3 for 72 hours. On 8/7/26 at 11:55 A.M. ADON 2 reviewed care plans for Resident 5. ADON 2 stated Resident 5 had no behaviors. ADON 2 stated a care plan dated 7/19/26 indicated Resident 5 was a victim of physical contact. ADON 2 stated interventions included to monitor Resident 5 daily for 72 hours whereabouts/activities of involved residents. ADON 2 stated close supervision for both Resident 3 and Resident 5 should be documented exceeding 72 hours to keep both residents safe psychologically and physically.During an interview with the Director of Nursing (DON) on 8/7/26, at 2:09 P.M., the DON stated Resident 3 should have continued monitoring to prevent emotional distress for Resident 5.A review of the facility's policy and procedure (P&P) titled, Resident-to-Resident Altercations, dated September 2022 was conducted. The P&P indicated, Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents.d. review the events with the nursing supervisor and director of nursing services, and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents.f. make any necessary changes in the care plan approaches to any or all of the involved individuals; g. document in the resident's clinical record all interventions and their effectiveness.

Based on observation, interview, and record review, the facility did not develop a patient centered care plan for one resident reviewed for care planning (Resident 4). This deficient practice had the potential for Resident 4 to not meet her needs for safety and well-being.Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a brain disorder that causes uncontrollable movements and difficulty with balance and coordination) and anxiety disorder (a mental health disorder characterized by worry or fear that interferes with daily functioning) according to the facility's admission Record. An interview on 3/19/26 at 9:55 A.M. was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 4 was discharged to a board and care on 3/17/26 but had complained about a Certified Nurse Assistant (CNA) on 3/11/26. LN 1 stated Resident 4 observed with a purplish, quarter sized discoloration on top of Resident 4's hand between the forefinger (2nd finger) and the thumb. LN 1 stated Resident 4 made the report to the Assistant Director of Nursing (ADON) for the unit. An interview on 3/19/26 at 10:15 A.M. was conducted with ADON. The ADON stated Resident 4 was at the nursing station by the snack bin when he observed a quarter sized, dark purplish discoloration on Resident 4's right top of hand between the forefinger and thumb. During an interview on 3/19/26 at 12 P.M. with the Director of Nursing (DON), the DON stated Resident 4 had the tendency to tightly hold and rub her hands when Resident 4 was upset. The DON demonstrated with her hands how Resident 4 repeatedly held her hands tightly and rubbed them. The DON stated there was no documentation or care plan to reflect Resident 4's behavior of tightly rubbing her hands. During an interview on 3/24/26 at 2:02 P.M. with the DON, the DON stated there should have been a care plan regarding Resident 4 squeezing her hand when upset or when spoken to. The DON stated it was important to have a care plan to observe and monitor Resident 4. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022 was conducted. The P&P indicated, The interdisciplinary team [IDT- team members with various areas of expertise who work together toward the goals of their residents), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, for four of 37 sampled residents (148, 163, 92, 141) the facility failed to: 1. Notify the doctor of high blood sugar readings, 2. Develop a careplan for a palm guard splint, 3. Develop a careplan for supervision during dining, and 4. Ensure a care plan was implemented for foot care. As a result, there was not a consistent approach by staff to address residents' care needs. Findings: 1. Per the facility's Admission Record, Resident 148 was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus (abnormal blood sugar levels). Per the facility's Medication Administration Record, dated April 2025, Resident 148 had an order to notify the physician if his blood sugar (BS) was greater than 350 milligrams per deciliter (mg/dl). The following BS readings in April 2025 were greater than 350 mg/dl: 4/4 6:30 A.M., BS 356 mg/dl. 4/5 6:30 A.M., BS 380 mg/dl. 4/8 11:30 A.M., BS 517 mg/dl. 4/13 11:30 A.M., BS 410 mg/dl. 4/16 11:30 A.M., BS 378 mg/dl. On 4/17/25 a review was conducted of Resident 148's medical record. There were no progress notes on 4/4, 4/5, 4/8, 4/13, or 4/16 regarding high BS or notifying the physician of high BS. On 4/17/25 at 1:16 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated, she did not always document when she notified the physician of high BS. LN 2 was not available for interview. On 4/18/25 at 9 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, the LNs should have notified the physician of the high BS readings for Resident 148, and they should have documented the notification. The DON further stated, if notifying the physician was not documented, then the notification did not happen. Per the facility's policy, titled Change in a Resident's Condition or Status, revised May 2017, .The nurse will notify the resident's Attending Physician .when there has been .specific instruction to notify the Physician of changes in the resident's condition . 48263 Cross-Reference F688 2. A review of Resident 163's Admission Record indicated Resident 163 was readmitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (brain attack known as stroke when the blood flow to part of the brain is interrupted) of the left side. A record review of Resident 163's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/16/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points, which indicated Resident 163 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 4/17/25 at 8:15 A.M., an observation and interview was conducted with Resident 163, in Resident 163's room. Resident 163 had on a palm guard splint (medical device that stabilizes a part of your body and holds it in place to protect from injury) on his left hand. Resident 163 stated he was only able to move his right hand. On 4/17/25 at 8:31 A.M., an observation and interview was conducted with Resident 163, in Resident 163's room. Certified Nursing Assistant (CNA) 25 stated she did not know the care for Resident 163's palm guard splint and was not sure when Resident 163's palm guard splint was supposed to be taken off. On 4/17/25 at 8:35 A.M., an interview was conducted with Resident 163, in Resident 163's room. Resident 163 stated he wore his palm guard splint on his left hand because he was unable to move it due to contractures (the shortening of muscles). Resident 163 stated he had his palm guard splint on the whole day yesterday and the other day. Resident 163 stated he could not remember when they took off his palm guard splint. Resident 163 stated there was no set time when they removed his palm guard splint. On 4/17/25 at 8:38 A.M., an interview and clinical chart review was conducted with Restorative Nurse Assistant (RNA) 27 of Resident 163's RNA charting. RNA 27 stated that he was involved with RNA programs for all residents that had splints. RNA 27 stated that he documented under RNA FOR ADL (activities of daily living) and WEEKLY RNA SUMMARY in the facility's electronic chart [e-chart]. RNA 27 stated Resident 163's palm guard splint was usually removed at the end of the shift about four hours and documented. RNA 27 stated he was unable to find documentation when Resident 163's palm guard splint to his left hand was removed or when care instructions were provided. RNA 27 stated it was important to provide the proper care on Resident 182's left hand with the palm guard splint to stretch his mobility and trying to prevent from further contracture. RNA 27 further stated you wanna [sic] take off the palm protector to check for skin care and any changes and having the palm protectors [palm guard splint] can cause skin breakdown. On 4/17/25 at 8:51 A.M., an interview and clinical chart review was conducted with Licensed Nurse (LN) 21. LN 21 stated she was not aware Resident 163 had a palm guard splint to his left hand. LN 21 stated there was no care plan in place for the palm guard splint to communicate with the nursing staff for when it should be on and off and/or additional instructions for monitoring. LN 21 further stated without proper physician's (MD) orders and a care plan for Resident 163's palm guard splint could lead to improper care and complications of Resident 163's left hand contracture. On 4/17/25 at 9:01 A.M., an observation, and interview was conducted with LN 21 and Resident 163, in Resident 163's room. Resident 163 stated he had been using the palm guard splint for a while about three months. Resident 163 stated RNA 26 was the one who put the palm guard splint on his left hand. On 4/17/25 at 12:57 P.M., an interview and clinical chart review was conducted with Licensed Nurse (LN) 23. LN 23 stated it was important that we monitor the use of Resident 163's palm guard splint to prevent skin breakdown and provide skin care and to include the frequency of when it should be on and off. LN 23 stated that a care plan for Resident 163's palm guard splints were just put in today in the in the care plan [sic] but did not indicate further instructions with frequency. On 4/17/25 at 1:11 P.M., an interview and clinical chart review was conducted with Assistant Director of Nursing (ADON) 3. ADON 3 stated Resident 163's care plan was updated today with a new intervention dated 4/17/25 that indicated .May use palm protector for prevention of skin breakdown and contracture . ADON 3 stated Resident 163's care plan was not personalized to the care and monitoring of Resident 163's palm guard splint and should have been focused on Resident 163's comprehensive care plan during the time Resident 163 started using the palm guard splint to prevent improper care and complications. On 4/17/25 at 1:46 P.M., a record review was conducted on Resident 163's clinical chart. Resident 163's MDS dated [DATE] section GG, indicated Resident 163 had an upper side impairment to one side. On 4/17/25 at 4:18 P.M., an interview and clinical chart review was conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated she updated Resident 163's care plan today after finding out from RNA 27 that Resident 163 was using hand protectors [palm guard splint] and not hand rolls (hand towels rolled) that did not need an MD order. The MDSN stated Resident 163's care plan should have been updated and screened by the rehab team from when Resident 163 started using the palm guard splint (three months ago). The MDSN stated a care plan for the use of the palm guard splint was a way to communicate to the staff on the proper use and monitoring of Resident 163's palm guard splint. The MDSN further stated improper care and monitoring of Resident 163's palm guard splint could lead to complications such as skin breakdown and the worsening of contractures. On 4/18/25 at 2:33 P.M., an interview was conducted with the Director of Nursing (DON), in the conference room. The DON stated Resident 163 should have been screened two to three months ago to get the proper MD order if indicated and care planned personalized to include the use of the palm guard splint. The DON stated RNA 27 should not have put on Resident 163's palm guard splint without an MD order because the nursing staff would not have known that they should be providing the proper care and monitoring for the use of the device. The DON stated complications to not providing the proper care and monitoring of the palm guard splint could have resulted in skin injuries, pain and worsening of contractures. A review of the facility's policy and procedure titled CARE PLANS, COMPREHENSIVE PERSON-CENTERED revised 2016 indicated, .Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to .Participate in determining the type, amount, frequency and duration of care . 51452 3. Resident 92 was readmitted to the facility on [DATE], with the diagnosis which include Parkinson's Disease (a progressive neurological disorder characterized by gradual loss of movement-related symptoms like tremors, slowness of movement, and stiffness), Dysphasia (Difficulty with swallowing), a stroke causing left non-dominant side hemiplegia and hemiparesis (weakness and paralysis of one side of the body) per facility's Admission Record. On 4/17/25 at 1:23 P.M., an observation and interview with Resident 92 and Certified Nursing Assistant (CNA) 54 was conducted. The resident was eating his lunch in his bed, the meal ticket indicated chopped meat and soft fruit plate. The resident was observed to be eating without dentures but stated, I'm fine without them. CNA 54 stated that he was from another unit and was supervising the resident during mealtime to help the resident reach drinks and chop meat into smaller pieces if needed. CNA 54 stated this was his second time to supervise the resident. On 4/18/25 at 8:29 A.M., an observation was conducted in the hallway outside of Resident 92's room. Resident 92 was heard attempting to cough loudly. Resident 92 was in his bed with his breakfast tray on the bedside table in front of him. The breakfast tray had scrambled eggs, cubed potatoes, fruit cup, cream of wheat and thin beverages. Resident 92's head of bed was up, and he was slightly slanted over to his left side. His face was red. Resident 92 was asked if he was choking and the resident nodded while trying to breathe and cough. No staff were present in the room. Licensed Nurse (LN) 53 and Assistant Director Of Nursing (ADON) 66 were called to the resident's room. The nurses were observed assisting the resident. ADON 66 stated she had assigned a CNA to supervise the resident for his breakfast. ADON 66 stated the CNA should have been there. ADON 66 stated Resident 92 required RNA (Restorative Nursing Assistant) DINING (a trained nursing staff to supervise a resident with meals while focusing on aspiration risk) and she was going to discuss it with the physician. On 4/18/25 at 10:22 A.M., an observation was conducted at the nurses' station. There was a white board that indicated, 4/17/25 Feeders [Resident 92] (supervision). On 4/18/25 at 10:30 A.M., an interview and record review with ADON 66 was conducted. ADON 66 stated CNA supervision was required during mealtime for Resident 92 because the resident was identified as at risk for aspiration, and he coughs with food and drinks. ADON 66 stated the Resident 92 was known to inhale food and gulp as he drank. ADON 66 reviewed Resident 92's clinical record and stated she did not find a care plan related to aspiration, swallowing precautions, or providing supervision during mealtime. ADON 66 stated there should have been a care plan that addressed providing supervision to Resident 92 during meals to prevent aspiration and choking. On 4/18/25 at 3:15 P.M., an interview with the Director Of Nursing (DON) was conducted. The DON stated if LNs identified residents at risk for aspiration, they could initiate meal supervision without orders. The DON stated Resident 92 should have been supervised during meals when ADON 66 identified the concern for aspiration. DON stated care plan for aspiration/swallow precaution should have been developed at the time the problem was identified, because it was important to communicate the resident's required supervision to all staff. A review of the facility's policy titled Care Plans, Comprehensive Person - Centered revised December 2016, indicated, .8. The comprehensive, person-centered care plan will . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, ad psychosocial well-being .g. Incorporate identified problem areas 51541 4. Resident 141 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease (having to do with the blood vessels and circulation), hereditary and idiopathic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and insulin dependent diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During an interview and observation on 4/15/25 at 8:55 A.M., Resident 141 stated he had long toenails and a fungal condition, and had been on a list to see the podiatrist (healthcare provider specializing in foot care) for months. Resident 141 was observed to have long, thick toenails that were approximately a quarter inch in length. Resident 141 also had dry, cracked feet. During an interview and record review on 4/18/25 at 9:50 A.M., the assistant director of nursing (ADON) 66 reviewed Resident 141's care plan for podiatry dated 6/1/24. The care plan indicated, Podiatry care every other month and PRN (as needed). The ADON 66 stated the last time Resident 141 was seen by Podiatry was on 9/5/24. The ADON 66 stated Resident 141's care plan was not followed. During an interview on 4/18/2025 at 3 P.M., the Director of Nursing (DON) stated Resident 141's care plan should have been followed and implemented for podiatry care. A review of the facility's policy and procedure, titled Care Plan, Comprehensive Person-Centered, revised December 2016, indicated, .Receive the services and/or items included in the plan of care

Based on observation, interview, and record review, the facility failed to provide the minimum required staffing to adequately care for all 248 residents to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident This deficient practice placed all residents at risk for unmet care needs, including delayed assistance, missed treatments and potential harm due to insufficient nursing staff. Findings: A review of the facility's Payroll Based Journal (PBJ) fiscal year (FY) quarter (QTR) one 2025 (October 1, 2024 - December 31, 2024) indicated, .Excessively Low Weekend Staffing . Survey team observations conducted on 4/15/25 included: - 9:00 A.M., Sometimes there is a long wait. Roommate stated he had poop since 7:30 A.M. - 11:15 A.M., Soiled diapers were changed about an hour ago. - 3:05 P.M., Waits for staff for over an hour every time he called then yelled out. Waited for pain management for a long time. - 9:55 A.M., 3-11 shift that it takes a long time to answer call light due to not having enough staff - 10:58 A.M., Don't answer call lights for hours. On 4/17/25 at 9:47 A.M., an interview was conducted with the Staffing Coordinator (SC). The SC stated there were weekend shortages during the holidays along with the month of January and February and staff call offs due to sickness. On 4/17/25 at 1:30 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 22. CNA 22 stated during staff shortage that this definitely affected resident care. CNA 22 stated the facility residents would complain about getting changed and yell out. On 4/18/25 at 7:45 A.M., an interview was conducted with Resident 37, in Resident 37's room. Resident 37 stated there aren't enough staff that run the facility which stressed the nursing staff having to fill in for the shortage. Resident 37 stated she did not think the facility scheduled enough people to care for residents because they had nursing staff who floated from other sections and were overworked to cover a shortage. Resident 37 stated that influenced how the care was unmet when she waited hours to get changed. Resident 37 stated meals were always given an hour late and thought the kitchen staff may also have been short staffed. Resident 37 stated that happened on all shifts and all days. On 4/18/25 at 7:51 A.M., an interview was conducted with Resident 47, in Resident 47's room. Resident 47 stated she had fallen out of bed twice because there was no one by her bedside to help her when she needed it. Resident 47 stated the first time she fell her physician (MD) told her she required two person to assist her with transfers and mobility. Resident 47 stated that the second time she fell was in the middle of being changed while she was in bed and fell to the floor that required four people to help her from the fall. Resident 47 stated that she had not been changed all night and further stated they assume that I don't need to be changed. Resident 47 stated this had affected her care and other residents care due to call lights not being answered because they [nursing staff] call in sick, no show or whatever and that's just detrimental for them [nursing staff] and neglect for us[residents]. On 4/18/25 at 8:33 A.M., an interview was conducted with CNA 23. CNA 23 stated he worked when they were short-staffed and when they were short-staffed we have more work to do. CNA 23 stated they were more short during the weekends with staff calling out. CNA 23 stated he helped out when he could by doing double shifts but also had another CNA job elsewhere. On 4/18/25 at 8:37 A.M., an interview was conducted with CNA 24. CNA 24 stated that residents would complain about night shifts not providing care that they needed. On 4/18/25 at 10:41 A.M., an interview was conducted with Resident 21, in Resident 21's room. Resident 21 stated that a certain CNA during night (NOC) shift did not care to answer call lights. Resident 21 stated staff called in sick during the weekends and it had been difficult for CNA's picking up more work. Resident 21 stated that being short-staff had affected her care because she was not turned every two hours when she needed to be turned for skin maintenance, does not get changed timely and meals delivered late. Resident 21 stated during NOC shift her roommate stinks because she was unable to advocate for herself when she needed an incontinent change. On 4/18/25 at 10:45 A.M., an interview was conducted with the SC. The SC stated being short-staff could have affected resident care and increased complaints by residents with their call lights. The SC stated they used registry but some complaints from residents were due to registry staff either missing or late or taking long to answer lights. On 4/18/25 at 2:13 PM an interview with the Director of Nursing (DON) was conducted, in the conference room. The DON stated that when they were short-staff, they would use registry as a last resort. The DON stated her expectations were for the Director of Staff Development (DSD) and the SC to work together to communicate with the call-ins and communicate this with the Administrator (ADM). The DON stated wait times for call lights could increase and necessary care could be delayed, compromising the care given for the residents. A review of the facility's policy and procedure titled STAFFING revised October 2017 indicated, .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care .

Based on observation, interview and record review, the facility failed to ensure food served to all residents was in a palatable, flavorful manner that maintained the nutritional value of the menu items served when they: 1. Did not take resident's preferences and tastes into account for meals, 2. Did not follow recipe for pureed garden meat loaf, 3. Did not follow recipe for garden meat loaf. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 248. Findings: 1. During a dining observation and interviews with residents on 4/15/25 from 9:00 A.M. to 12:45 P.M., residents' food concerns included: . I don't eat the food, sometimes I don't get food I like . . Food sucks. Alternates suck . . Food is lousy .Small Portions .No seasoning .No variety . . Always chicken .always dry . . Calls it Slop, poured lots of gravy . Food-sometimes too salty, sometimes no flavor . . Food is bland . . Does not like Asian food . . No variety in meals .always chicken .always dry . . Food is not good, so-so . .Too many sandwiches .repeated meals over and over again . food bland On 4/16/25 at 10:29 A.M., a meeting of the Resident Council was conducted. Six out of six residents at the Resident Council Meeting complained about food. Food complaints during Resident Council included: . Sometimes run out of snacks . . No coffee at dinner time . . Breakfast this morning was Ice Cold . More variety and more vegetables; vegetables were 'mushy', overcooked . . Menu most time is not being followed . . Alternative menu sometimes items not available due to ordering . . Fresh eggs not available, eggs are usually scrambled . . More dessert variety . Review of the facility's menu dated 4/16/25 indicated the regular diet meal for lunch was, Garden Fresh Meatloaf, Mashed Potatoes, Spinach Augratin, and Garlic Bread. The Pureed Diet was served pureed versions of regular diet. On 4/16/25 between 11:45 A.M. and 2:05 P.M. an observation of trayline was conducted. Resident tray distribution was observed on last unit (Unit 4). On 4/16/25 at 2:09 P.M., an observation of two test trays (Pureed and Regular) and interview with the Registered Dietician (RD) was conducted. Test tray items temperatures were taken by the RD prior to sampling. The RD and surveyor sampled all items on test trays. The following were the surveyor's observations of the test trays: Regular Tray - visually: test tray items appeared appetizing, but lots of gravy. Meatloaf- 128 F.Taste: well seasoned, slightly salty, warm. Mash Potatoes 134.6 F.Taste: well seasoned, slightly salty, warm. Spinach Au Gratin- 130.F.Taste: bland, no cheese tasted, slightly mushy Puree Tray - visually multiple large scoops of pureed food, covered in gravy. Meatloaf 146.9 F. Taste: well seasoned, slightly, salty warm. Mashed Potatoes 146.5 F. Taste: well seasoned, slightly salty, warm. Spinach Au Gratin-140.4 F.Taste: bland, no cheese tasted, did not look appetizing. On 4/17/25 at 3:30 P.M., an interview with Registered Dietician (RD) was conducted. The RD stated that the expectation was that optimal temperature for food served off tray line for residents should be close to holding temperature of 140 F. The RD stated the importance of having hot palatable meals was to encourage residents to eat their meals and promote good nutrition. The RD stated that it was important for residents to have their preferences met to encourage them to eat their meals and meet nutrition goals. Review of policy titled FOOD PREPARATION, dated 2023, indicated .7. Hold foods prior to service for as short time as practical. A maximum 1 hour holding time is recommended. Hot food should be held prior to service at 140 F or above . Review of facility policy titled FOOD PREFERENCES, dated 2023, indicated Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group .Food preferences can be obtained from the resident, family or staff members. Updating of food preferences will be done as the residents' needs change . 2. On 4/16/25 at 9:17 A.M., an observation of [NAME] 14 and [NAME] 15 preparing meatloaf puree was conducted. [NAME] 14 was observed cooking ground beef and other ingredients for meatloaf on a tilt skillet (a large, shallow pan with a tilting mechanism that allows for easy tilting to pour out contents) prior to making Garden Meatloaf puree. [NAME] 15 moved the ingredients cooked by [NAME] 14 to a large food processor. [NAME] 15 stated that the puree recipe indicated to, Complete regular recipe prior to pureeing. [NAME] 15 stated that cooking the meatloaf ingredients in the tilt skillet prior to pureeing was not the same as baking the meatloaf by provided recipe. Review of recipe titled, RECIPE: GARDEN FRESH MEATLOAF, dated 2024, indicated Directions: .4. Add sauteed vegetables and herbs to meat mixture, and press into loaves. 5. Bake 1 1/2 to 2 hours at 325 F . Review of recipe titled, RECIPE: PUREED (DDSI-LEVEL 4) MEATS, dated 2024, indicated .Directions: 1. Complete regular recipe On 4/17/25 at 3:30 P.M., an interview with Registered Dietician (RD) was conducted. The RD stated that the expectation was that the cooks should follow the recipe to ensure meal quality and to meet residents' nutritional needs. Review of policy entitled FOOD PREPARATION, dated 2023, indicated .1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific as to portion, yield, method of preparation, quantities of ingredients, and time and temperature guidelines . 3. On 4/16/25 at 9:45 A.M., an observation of [NAME] 14 preparing meatloaf and interview was conducted. [NAME] 14 was observed mixing ground beef and breadcrumbs in a large bowl. [NAME] 14 was observed pouring breadcrumbs directly into bowl from container without measuring. The recipe book was observed closed on the table and multiple containers of breadcrumbs were open. [NAME] 1 refused to answer when asked if he had measured the breadcrumbs. [NAME] 14 refused to answer when asked if he was following the recipe for Garden Meatloaf he was preparing. [NAME] 14 continued to mix unmeasured breadcrumbs into bowl with meat loaf ingredients. [NAME] 14 stated that it was important to follow the recipe, so the residents get the nutrition from the dish as per recipe. Review of recipe titled, RECIPE: GARDEN FRESH MEATLOAF, dated 2024, indicated Directions: .Ingredients: .Serves 120 .Soft bread crumbs 2 Qts(Quarts) 2 cups . On 4/17/25 at 3:30 P.M., an interview with Registered Dietician (RD) was conducted. The RD stated that the expectation was that the cooks should follow the recipes to ensure meal quality and to meet residents' nutritional needs. Review of policy titled FOOD PREPARATION, dated 2023, indicated .1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific as to portion, yield, method of preparation, quantities of ingredients, and time and temperature guidelines .

Based on observation, interview, and record review the facility failed to ensure: 1. Frozen biscuits, hash brown potatoes, and chicken breast were in a sealed, labeled, and dated container in facility's walk in freezer. 2. One food services worker wore a beard restraint not completely over his full beard and mustache during tray line service. These failures had the potential for food borne illness related to poor quality food or contamination by facial hair. Findings: 1. On 4/15/25 at 7:45 A.M., during initial tour of the kitchen, an observation of the walk-in freezer and interview with Registered Dietician (RD) was conducted. Frozen biscuits, potato hash browns, and chicken breast were observed in unsealed, unlabeled, and undated plastic bags. The RD stated that this was, Unacceptable, and that she would in-service dietary staff about proper food storage in the freezer. On 4/17/25 at 3:30 P.M., an interview with the RD was conducted. The RD stated that food in the freezer should be sealed, labeled and dated. The RD stated the importance of proper food storage was for maintaining food quality and preventing contamination of residents' food. Review of facility policy titled, PROCEDURE FOR FREEZER STORAGE, dated 2023, indicated .5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. 6. All frozen food should be labeled and dated . 2. On 4/16/25 at 11:55 A.M., an observation of tray line service was conducted. Dietary Supervisor (DS) was observed with a full beard and mustache not completely covered by beard restraint. The DS was about to plate the first tray and the beard restraint was covering just his chin and not the upper beard and mustache. The tray line service was paused until the DS fixed beard restraint. The DS stated that the expectation was that facial hair should be completely covered with beard restraint. The DS stated that facial hair falling into food can be unsanitary and could contaminate food. On 4/17/25 at 3:30 P.M., an interview with the RD was conducted. The RD stated any facial hair needs to be covered completely. The RD stated that the importance of beard restraints was to prevent contamination of residents' food by facial hair. Review of facility policy titled DRESS CODE, dated 2023, indicated .8. If applicable, beards and mustaches (any facial hair) must wear a beard restraint . Review of facility policy titled PREVENTING FOODBORN ILLNESS-EMPLOYEE HYGIENE AND SANITARY PRACTICE, dated November 2022, indicated .15 .Beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens .

Based on interview, observation, and record review, the facility failed to provide adequate supervision to prevent choking during mealtimes for one sampled resident (Resident 92). As a result of this deficient practice, the resident experienced a choking episode while eating breakfast without supervision (cross reference F656 #3). Findings: Resident 92 was readmitted to the facility on [DATE], with the diagnosis which include Parkinson's Disease (a progressive neurological disorder characterized by gradual loss of movement-related symptoms like tremors, slowness of movement, and stiffness), Dysphasia (Difficulty with swallowing), a stroke causing left non-dominant side hemiplegia and hemiparesis (weakness and paralysis of one side of the body) per facility's Admission Record. On 4/17/25 at 1:23 P.M., an observation and interview with Resident 92 and Certified Nursing Assistant (CNA) 54 was conducted. The resident was eating his lunch in his bed, the meal ticket indicated chopped meat and soft fruit plate. The resident was observed to be eating without dentures but stated, I'm fine without them. CNA 54 stated that he was from another unit and was supervising the resident during mealtime to help the resident reach drinks and chop meat into smaller pieces if needed. CNA 54 stated this was his second time to supervise the resident. CNA 54 also stated that although the resident could answer questions appropriately, he noticed the resident was confused at times. On 4/18/25 at 8:29 A.M., an observation was conducted in the hallway outside of Resident 92's room. Resident 92 was heard attempting to cough loudly. Resident 92 was in his bed with his breakfast tray on the bedside table in front of him. The breakfast tray had scrambled eggs, cubed potatoes, fruit cup, cream of wheat and thin beverages. Resident 92's head of bed was up, and he was slightly slanted over to his left side. His face was red. Resident 92 was asked if he was choking and the resident nodded while trying to breathe and cough. No staff were present in the room. Licensed Nurse (LN) 53 and Assistant Director Of Nursing (ADON) 66 were called to the resident's room. The nurses were observed assisting the resident. ADON 66 stated she had assigned a CNA to supervise the resident for his breakfast. ADON 66 stated the CNA should have been there. ADON 66 stated Resident 92 required RNA (Restorative Nursing Assistant) DINING (a trained nursing staff to supervise a resident with meals while focusing on aspiration risk) and she was going to discuss it with the physician. On 4/18/25 at 10:22 A.M., an observation was conducted at the nurses' station. There was a white board that indicated, 4/17/25 Feeders [Resident 92] (supervision). On 4/18/25 at 10:30 A.M., an interview with ADON 66 was conducted. ADON 66 stated CNA supervision was required during mealtime for Resident 92 because the resident was identified as at risk for aspiration, and he coughs with food and drinks. ADON 66 stated the Resident 92 was known to inhale food and gulp as he drank. ADON 66 stated she told CNA 55 before breakfast that Resident 92 needed supervision with meals. ADON 66 stated she handed Resident 92's breakfast tray directly to CNA 55 and instructed her to supervise Resident 92 because he coughs with food. On 4/18/25 at 10:53 A.M., an interview with CNA 55 was conducted. CNA 55 stated she was from the registry (nursing staff provided by an agency) and Resident 92 was eating fine without supervision last time she worked at the facility. CNA 55 stated that she was not aware of Resident 92's need for mealtime supervision and did not remember ADON 66's instruction to supervise the resident for breakfast. CNA 55 stated she wasn't focused. CNA 55 stated it was very important to listen to the direction of the nurses because a resident's condition could change at any time. On 4/18/25 at 3:15 P.M., an interview with the Director Of Nursing (DON) was conducted. The DON stated it was important to provide supervision for Resident 92 when CNA 55 was instructed to do so. The DON stated if LNs identified residents at risk for aspiration, they could initiate meal supervision without orders. The DON stated it was important for all CNAs to follow the LN's instructions to avoid an incident like this. The DON stated Resident 92 should have been supervised during meals when ADON 66 identified the concern for aspiration. A review of the facility's policy titled Accidents and Incidents - Investigating and Reporting revised July 2017, did not provide guidance related to providing supervision to prevent aspiration/choking. A review of the facility's policy titled Assistance with Meals revised July 2017, indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident

Based on interview and record review, the facility failed to create a comprehensive care plan for one of 37 sampled residents (Resident 183). This failure caused Resident 183's medication to be unmonitored. Cross Reference F757 and F881. Findings: Resident 183 was admitted to the facility on [DATE] with a diagnosis of aftereffects of a cerebral infarction (Stroke- lack of blood flow to the brain). Additional diagnoses included metabolic encephalopathy (brain dysfunction due to the body's inability to filter toxins). During a concurrent interview and record review on 4/18/25 at 1:55 P.M., with the Director of Nursing (DON), the DON stated, Care plans drive the resident care, they should be resident specific. The DON further stated, if it [a resident's care plan] is not specific, the resident might not get the appropriate care. Resident 183's care plans were reviewed. The DON stated there is no care plan for antibiotic monitoring. There should be one. During an interview on 4/18/25 at 2:10 P.M., with the Infection Preventionist (IP), the IP stated Resident 183 has been on this medication since admission. The IP further stated Yes, the care plan is not specific to this medication. It should be. During a review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2016, the document indicated .8. The comprehensive, person-centered care plan will aid in preventing or reducing decline in the resident's functional status and/or functional levels .

Based on observation, interview, and record review, the facility failed to evaluate the use of palm guard splints for one of four reviewed residents (Resident 163) according to professional standards of practice. These deficient practices placed Resident 163 at risk for improper care and worsening of hand contractures (a shortening of muscles). Cross-Reference F656 Findings: A review of Resident 163's Admission Record indicated Resident 163 was readmitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (brain attack known as stroke when the blood flow to part of the brain is interrupted) of the left side. A record review of Resident 163's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/16/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points which indicated Resident 163 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 4/17/25 at 8:15 A.M., an observation and interview was conducted with Resident 163, in Resident 163's room. Resident 163 had on a palm guard splint (medical device that stabilizes a part of your body and holds it in place to protect from injury) on his left hand. Resident 163 stated he was only able to move his right hand. On 4/17/25 at 8:31 A.M., an observation and interview was conducted with Resident 163, in Resident 163's room. Certified Nursing Assistant (CNA) 25 stated she did not know the care for Resident 163's palm guard splint and was not sure when Resident 163's palm guard splint was supposed to be taken off. On 4/17/25 at 8:35 A.M., an interview was conducted with Resident 163, in Resident 163's room. Resident 163 stated he wore his palm guard splint on his left hand because he was unable to move it due to contractures. Resident 163 stated he had his palm guard splint on the whole day yesterday and the other day. Resident 163 stated he could not remember when they took off his palm guard splint. Resident 163 stated there was no set time when they removed his palm guard splint. On 4/17/25 at 8:38 A.M., an interview and clinical chart review was conducted with Restorative Nurse Assistant (RNA) 27 of Resident 163's RNA charting. RNA 27 stated that he was involved with RNA programs for all residents that had splints. RNA 27 stated that he documented under RNA FOR ADL (Activities of Daily Living) and WEEKLY RNA SUMMARY in the facility's electronic chart [e-chart]. RNA 27 stated Resident 163's palm guard splint was usually removed at the end of the shift about four hours and documented. RNA 27 stated he was unable to find documentation when Resident 163's palm guard splint to his left hand was removed or when care instructions were provided. RNA 27 stated it was important to provide the proper care on Resident 182's left hand with the palm guard splint to stretch his mobility and trying to prevent from further contracture. [sic] RNA 27 further stated you wanna [sic] take off the palm protector to check for skin care and any changes and having the palm protectors [palm guard splints] can cause skin breakdown. On 4/17/25 at 8:51 A.M., an interview and clinical chart review was conducted with Licensed Nurse (LN) 21. LN 21 stated she was not aware Resident 163 had a palm guard splint to his left hand. LN 21 stated Resident 163 did not have Physician's (MD) orders for a palm guard splint for his left hand. LN 21 stated there was no care plan in place for the palm guard splint to communicate with the nursing staff for when it should have been on and off and/or additional instructions for monitoring. LN 21 further stated without proper MD orders and a care plan for Resident 163's palm guard splint could lead to improper care and complications of Resident 163's left hand contracture. On 4/17/25 at 9:01 A.M., an observation, and interview was conducted with LN 21 and Resident 163, in Resident 163's room. Resident 163 stated he had been using the palm guard splint for a while about three months. Resident 163 stated RNA 26 was the one who put the palm guard splint on his left hand. On 4/17/25 at 12:57 P.M., an interview and clinical chart review was conducted with LN 23. LN 23 stated there was no MD orders in place for Resident 163's palm guard splint to his left hand. LN 23 stated that any splints required MD orders because these were medical devices that could cause immobility issues if not properly monitored or cared for. LN 23 stated it was important that we monitored the use of Resident 163's palm guard splint to prevent skin breakdown and provide skin care and to include the frequency of when it should have been removed. LN 23 stated that a care plan for Resident 163's palm guard splints were just put in today in the in the care plan [sic] but did not indicate further instructions. On 4/17/25 at 1:11 P.M., an interview and clinical chart review was conducted with Assistant Director of Nursing (ADON) 3, at station three nursing station. ADON 3 stated that the RNA supervisor which was the Minimum Data Nurse (MDSN) stated they did not need an order for a palm guard splint. ADON 3 stated that Resident 163 did not have an order for a palm guard splint. ADON 3 stated an MD order was needed for their [Resident 163's] care and to know how to care for them. ADON 3 stated Resident 163's palm protector splint should have had a frequency to the MD order to be removed to check for skin injury cause it can cause device related pressure injuries and skin tears. ADON 3 was unable to find documentation by the RNA charting for the proper care and monitoring of Resident 163's palm guard splint. ADON 3 stated Resident 163 had an updated intervention in place dated 4/17/25 that indicated .May use palm protector for prevention of skin breakdown and contracture . ADON 3 stated Resident 163's care plan was not personalized to the care and monitoring of Resident 163's palm guard splint and should have been focused on Resident 163's comprehensive care plan during the time Resident 163 started using the palm guard splint to prevent improper care and complications. On 4/17/25 at 1:46 P.M., a record review was conducted on Resident 163's clinical chart. Resident 163's MDS dated [DATE] section GG, indicated Resident 163 had an upper side impairment to one side. On 4/17/25 at 4:18 P.M., an interview and clinical chart review was conducted with the MDSN. The MDSN stated that RNA 27 thought it was a hand roll [rolled hand towel] and not a palm guard splint (hand protector) and the reason I said we did not need an order but when I looked at Resident 163's left hand it was a hand protector [palm guard splint] and not a hand roll. The MDSN stated Resident 163 did not have an MD order for the palm guard splint and that an order was indicated for the use and monitoring of the medical device. The MDSN stated RNA 27 should not have applied the palm guard splint without an MD order. The MDSN stated an MD order and a care plan for the use of the palm guard splint was a way to communicate to the staff on the proper use and monitoring of Resident 163's palm guard splint. The MDSN further stated improper care and monitoring of Resident 163's palm guard splint could have lead to complications such as skin breakdown and the worsening of contractures. On 4/18/25 at 2:33 P.M., an interview was conducted with the Director of Nursing (DON), in the conference room. The DON stated Resident 163 should have been screened three months ago to get the proper MD order if indicated and care planned personalized to include the use of the palm guard splint. The DON stated RNA 27 should not have put on Resident 163's palm guard splint without an MD order because the nursing staff would not know that they should have been providing the proper care and monitoring for the use of the device. The DON stated complications to not providing the proper care and monitoring of the palm guard splint could result in skin injuries, pain and worsening of contractures. A review of the facility's policy and procedure, titled SPLINTS and POSITIONING DEVICES, revised July 2017 indicated, .any resident with a need to be screened by the Rehab team including a qualified specialist in Rehab devices .if a device is ordered other than a simple hand roll, an in-service will be given to the RNA and any other appropriate staff on the use of the device, to ensure proper application .This device will be applied daily as ordered and documented on the resident Care plan and daily RNA notes .

Based on observation, interview, and record review the facility failed to maintain the dignity of one resident out of thirty-seven sampled residents (Resident 227) when she was asked by staff to have a bowel movement in her brief. This failure had the potential to affect this Resident 227's dignity and mental health. Findings: Review of Admission Record for Resident 227 indicated resident was admitted on [DATE] for diagnoses which included Cervical(relating to the neck) Disc Disorder with Myelopathy (disease of the spinal cord), Spinal Stenosis (condition where the spinal canal narrows, causing compression of the spinal cord), Chronic Kidney Disease (a condition where the kidneys are damaged and cannot effectively filter waste and fluid from the blood), Congestive Heart Failure (a condition where the heart can't pump enough blood to meet the body's needs), and Respiratory Failure (condition where the lungs struggle to transfer enough oxygen into the blood). Review of Minimum Data Set (MDS-a standardized assessment tool used in nursing homes) section C-Cognitive (thinking processes) Patterns indicated that Resident 227 had a Brief Interview for Mental Status (BIMs-a quick assessment tool used to evaluate cognitive function) score of 14, which indicated intact cognitive abilities. Review of MDS section GG-Functional Abilities, indicated Resident 227 was dependent for self-care, independent for Self-Cognition (thinking processes), and dependent for toileting hygiene. On 4/15/25 at 10:18 A.M., an observation and interview with Resident 227 was conducted during initial pooling. Resident 227 was observed to be very pleasant and alert and oriented x4 (a person is fully alert and oriented to person, place, time, and event). Resident 227 stated that she was bedbound with leg strength at time of interview. Resident 227 stated that she was constipated and that before she was hospitalized , she could use the commode, but probably could not at this time because of the weakness of her legs. Resident 227 further stated that she was feeling, backed up and that the night staff had told her to move her bowels in the diaper, and they would clean her up after. Resident stated that staff did not offer her a bedpan. On 4/17/25 at 8:45 A.M., an interview with Resident 227 was conducted. Resident 227 stated she had still been constipated and they had been putting her on the bedpan mostly, but night shift staff still asked to have a bowel movement in her diaper and did not offer her a bedpan. On 4/17/25 at 9 A.M., an interview with Certified Nursing Assistant (CNA 11) was conducted. CNA 11 stated Resident 227 was alert enough to ask for a bedpan when she had to move her bowels. CNA 11 stated the expectation for alert residents who cannot use commode, or bathroom should be offered a bedpan to maintain the resident's dignity. On 4/17/25 at 9:20 A.M. an interview with Licensed Nurse 12 (LN 12) was conducted. LN 12 stated that Resident 227 was alert enough to ask for bedpan when she had to move her bowels. LN 12 stated the expectation for alert residents who cannot use commode, or bathroom should be offered a bedpan. LN 12 stated the importance was to maintain the resident's dignity. On 4/17/25 at 9:30 A.M., an interview with Charge Nurse 13 (CN 13) was conducted. CN 13 stated that Resident 227 was alert enough to ask for bedpan when she had to move her bowels. CN 13 stated the expectation for alert residents who cannot use commode, or bathroom should be offered a bedpan. CN 13 stated the importance was to maintain the resident's dignity and allow for resident's right to choose. On 4/18/25 at 9:45 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation for alert residents who cannot use commode, or bathroom should be offered a bedpan to maintain the resident's dignity and allow for resident's right to choose. Review of facility policy titled QUALITY OF LIFE, dated 2020, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, feeling of self-worth and self-esteem .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example .b. Promptly responding to a resident's request for toileting assistance . Review of facility policy titled RESIDENT RIGHTS, dated December 2016, indicated Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: 1. a dignified existence; b. be treated with respect, kindness, and dignity .

Based on observation and interview, the facility failed to provide a blanket after showering to one of 37 sampled residents (148). As a result, Resident 148 felt cold. Findings: Per the facility's Admission Record, Resident 148 was admitted to the facility on [DATE] with diagnoses to include heart failure and absence of right ankle. On 4/15/25 at 10 A.M., an observation and interview was conducted with Resident 148. Resident 148 was observed lying on his bed wearing only a disposable brief, and was not covered by any linens. Resident 148 stated, when Certified Nursing Assistant (CNA) 3 brought him back to his bed at 9 A.M. after his shower, he asked her to cover him with a blanket. Resident 148 further stated, CNA 3 told him she would come back to give him a blanket, but he had been waiting an hour for her to return. Resident 148 stated he was cold. On 4/15/25 at 12:54 P.M., an interview was conducted with CNA 3. CNA 3 stated, she finished providing a shower to Resident 148 at about 9 A.M., and returned him to his room. CNA 3 further stated, she was delayed in bringing him his blanket because she was busy. On 4/18/25 at 9 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, the blankets should have already been ready when CNA 3 returned Resident 148 to his bed, and he should not have had to wait for his blanket after returning from the shower. Per the facility's policy, titled Homelike Environment, revised February 2021, .Residents are provided with a safe, clean, comfortable and homelike environment .clean bed and bath linens .comfortable and safe temperatures .

Based on interview and record review, the facility failed to complete a mental health screening accurately for one of 37 sampled residents (17). As a result, Resident 17 may not have received necessary mental health services. Findings: Per the facility's Admission Record, Resident 17 was admitted to the facility on [DATE] with diagnoses of bipolar disorder (a mental health disorder with mood swings). Per the facility's Preadmission Screening and Resident Review (PASRR) Level 1 screening, dated 11/30/24, the screening was negative and a level 2 mental health evaluation was not required. The document also directed the facility to resubmit a new level 1 screening in 31 days. On 4/17/25 at 10 A.M., a concurrent interview and record review was conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated, Resident 17's latest PASRR was completed on 11/30/24, and it indicated Resident 17 had bipolar disorder, but it did not direct them to complete a level 2 PASRR evaluation. The MDSN stated the 11/30/24 PASRR was inaccurate and it should have triggered a level 2 PASRR evaluation. The MDSN further stated, a new PASRR screening should have been completed within 30 days of the screening on 11/30/24. On 4/18/25 at 9 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, if a resident had bipolar disorder, then the PASRR should have triggered a level 2 PASRR evaluation. The DON further stated, the facility should have submitted a new level 1 PASRR within 30 days of the evaluation completed on 11/30/24. Per the facility's policy, titled Admission Criteria, revised March 2019, .If the level I screen indicates that the individual may meet the criteria .he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process .

Based on observation, interview, and record review, the facility failed to initiate an initial activities care plan within 48 hours for one of 11 reviewed new admitted residents (Resident 570). This deficient practice placed all newly admitted residents at risk for depression (a mood disorder that causes a persistent feeling of sadness) and missed opportunities to take part in enjoyable activities that supported their emotional and mental well-being. Findings: A review of Resident 570's Admission Record indicated Resident 570 was admitted to the facility on [DATE] with diagnoses which included a history of depression. A clinical chart review of Resident 570's initial Activities assessment dated [DATE] indicated, Resident 570 was alert and oriented x1 [only oriented to person] with severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 4/15/25 at 11:52 A.M., an observation and interview was conducted with Resident 570, in Resident 570's room. Resident was non-verbal and was unable to answer simple yes or no questions. Resident 570 was frowning and a bit teary eyed while lying in bed with a startled-like appearance while clenched on her blanket. On 4/16/25 at 9:12 A.M., an observation and attempted interview was conducted with Resident 570, in Resident 570's room. Resident 570 was lying in bed and was unable to verbalize. Resident 570 just stared and looked confused to verbal communication and was unable to answer simple yes or no questions. On 4/16/25 at 1:26 P.M., a clinical chart review was conducted on Resident 570's initial care plan. Resident 570's initial care plan for activities was initiated on 4/14/25. Resident 570's activities care plan indicated .Encourage participation during group programs .Inform and offer out of room activities . On 4/18/25 at 8:20 A.M., an interview was conducted with Licensed Nurse (LN) 26. LN 26 stated Resident 570 does not talk to me but according to the family she was just real scared of being in the facility and if you get too close, she can get reactive (e.g. physically hit someone). LN 26 stated Resident 570 was verbal and understood English and Spanish according to a staff interview. On 4/18/25 at 9:51 A.M., an interview and clinical chart review was conducted on Resident 570, with the Activities Director (AD). The AD stated that there was always someone representing the activities department on the weekends that did initial evaluations for new admissions. The AD stated Resident 570's activities care plan was initiated on 4/14/25. The AD stated they evaluated and documented under ACTIVITIES-Initial Assessment in Resident 570's electronic clinical chart (e-chart) to initiate the activities care plan that included how Resident 570 communicated (e.g. verbal, non-verbal methods) and preferred language to provide proper activities. On 4/18/25 at 9:58 A.M., an interview and record review was conducted with Activities Assistant (AA) 1. AA 1 stated they were responsible to put in a baseline care plan within 48 hours for all new admissions. AA 1 stated Resident 570 was admitted on Friday (4/11/25) and that she was working on Sunday (4/13/25). AA 1 stated she did not evaluate Resident 570 until 4/14/25 as the reason why she did not initiate the activities care plan for Resident 570. AA 1 stated Resident 570 can say bad words only when she wants but had not heard Resident 570 verbally talk to her. AA 1 stated Resident 570's care plan was not initiated timely and further stated we would not be able to provide resident [Resident 570] activities and delay her care. She would be in her bed doing nothing. On 4/18/25 at 10:02 A.M., an interview was conducted with the AD. The AD stated that the baseline care plan should have been initiated by the activities department regarding Resident 570's status to avoid delaying activities that Resident 570 likes to do because that's important. The AD stated if Resident 570 was unable to verbalize her preference with activities that they [activities department] should have communicated with the family and make sure communication preferences were updated with the baseline care plan to better communicate with Resident 570 if she was not able to verbalize her needs. The AD further stated the baseline care plan helped to communicate with other staff involved with Resident 570's care on her activities preferences and communication. On 4/18/25 at 2:45 P.M., an interview with the Director of Nurse (DON) was conducted, in the conference room. The DON stated her expectations was for all members of the interdisciplinary team (IDT) to include the activities department's input with Resident 570's immediate care needs should include communication preferences, and activities preferences that promotes participation with activities and overall psychosocial well-being. A review of the facility's policy and procedure titled CARE PLANS BASELINE, revised 2016 indicated, .The Interdisciplinary Team will review the healthcare practitioner's orders .and implement a baseline care plan to meet the resident's immediate care needs .

Based to observation, interview and record review, the facility failed to provide individualized therapeutic and/or social activities according to their plan of care for one of seven reviewed residents (Resident 67) that promotes their highest physical, mental, and psychosocial well-being. This deficient practice placed Resident 67 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Findings: A review of Resident 67's Admission Record indicated Resident 67 was readmitted to the facility on [DATE] with diagnoses which included a history of adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and dementia (a progressive state of decline in mental abilities). Observations were conducted during the following days in Resident 67's room: - 4/15/25 at 9:49 A.M., Resident 67 was in bed resting with a blanket wearing a facility gown and was not verbal staring blankly at the ceiling. - 4/15/25 at 3:48 P.M., Resident 67 was in bed resting wearing a facility gown and was not verbal staring blankly at the ceiling. - 4/17/25 at 8:29 A.M., Resident 67 was in bed asleep. - 4/17/25 2:21 P.M., Resident 67 was in bed resting wearing a facility gown and was not verbal staring blankly at the ceiling. - 4/18/25 8:29 A.M., Resident 67 was in bed resting wearing a facility gown and was not verbal staring blankly at the ceiling. On 4/16/25 at 7:54 A.M., a record review was conducted on Resident 67's Activities care plan with activities. The Care plan initiated on 4/5/24 indicated, .will have 1:1 room visits activities to reduce BPSD [Behavioral and Psychological Symptoms of Dementia (loss of mental abilities)] episodes 3x [three times] per week . On 4/16/25 at 2:03 P.M., a record review was conducted on Resident 67's Activities participation tasks documentation for the month of January 2025-April 2025. Resident 67's activity participation task for individual and social activities conducted 3x per week indicated: - 1/1/25 thru 1/7/25: Activities conducted two times on 1/4/25 and 1/6/25. - 1/8/25 thru 1/14/25: Activities conducted two times on 1/9/25 and 1/13/25. - 1/22/25 thru 1/31/25: No activities conducted. - 2/1/25 thru 2/28/25: No activities conducted. - 3/1/25 thru 3/7/25: Activities conducted one time on 3/6/25. - 3/8/25 thru 3/14/25: Activities conducted one time on 3/13/25. - 3/15/25 thru 3/21/25: Activities conducted two times on 3/18/25 and 3/21/25. - 3/22/25 thru 3/28/25: Activities conducted one time on 3/23/25. - 3/29/25 thru 3/31/25: Activities conducted one time on 3/31/25. - 4/1/25 thru 4/6/25: Activities conducted two times on 4/5/25 and 4/6/25. - 4/8/25 thru 4/14/25: Activities conducted two times on 4/9/25 and 4/12/25. On 4/18/25 at 10:17 A.M., an interview and record review was conducted with the Activities Director (AD). The AD stated Resident 67 liked music and would sing with her when they did a music activity. The AD stated Resident 67 would also enjoy participating with lotion massage, listening to music on the radio and participate with balloon toss. The AD stated she was aware that resident was not getting activities three times a week within the last month and stated she was on leave at the beginning of the year to audit. The AD stated she planned on training one of the Activities Assistant (AA) to help her when she was unavailable to help with audits and do more initial evaluations and care plans. The AD stated Resident 67 did participate in social events in the past and stated they should try and have Resident 67 participate more with social events. The AD stated if Resident 67 did not engage with activities according to his plan of care that Resident 67 could have declined and became more depressed (mental disorder with continuous sadness) and lonelier. On 4/18/25 at 2:52 P.M., an interview with the Director of Nursing (DON) was conducted, in the conference room. The DON stated for dependent residents like Resident 67 they should have been visited regularly per their plan of care because it was their right to participate with activities. The DON stated not engaging with activities according to their [facility residents] plan of care could have caused depression that did not promote their highest physical, mental and psychosocial well-being. A review of the facility's policy and procedure, titled ACTIVITIES ATTENDANCE, revised June 2018 indicated, .Records are reviewed on a regular basis, and at least quarterly, to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review .

Based on observation, interview, and record review, the facility failed to ensure one of 37 sampled residents (Resident 141) received foot care and treatment as ordered by the physician. This failure resulted in missed appointments and treatment aimed to prevent complications from conditions such as diabetes, peripheral vascular disease, or immobility Findings: Resident 141 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease (having to do with the blood vessels and circulation), hereditary and idiopathic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During an interview and observation on 4/15/25 at 8:55 A.M , Resident 141 stated he had long toenails and a fungal condition and had been on a list to see the podiatrist (healthcare provider specializing in foot care) for months. Resident 141 was observed to have long, thick toenails that were approximately a quarter inch in length. The resident also had dry, cracked feet. A record review was conducted on 4/16/25. Resident 141's physician's order dated 2/9/24, indicated podiatry every 2 months and PRN (as needed) for mycotic (something related to, caused by, or of a fungus), hypertrophic (excessive growth) nails, corns and calluses (thickening of or a hard thickened area on skin). During an interview on 4/18/25 at 8:20 A.M , Certified Nursing Assistant (CNA) 69 stated CNAs could not cut or file toenails. CNA 69 stated CNAs could only clean the residents' feet in the shower or in bed with a towel, and clean between the toes. CNA 69 stated CNAs had to let the nurse know about residents' toenails when they were long. During an interview on 4/18/25 at 8:20 A.M., CNA 68 stated toenail care included cleaning between the residents' toes and using a cuticle stick to clean under the nail. CNA 68 stated CNAs were not allowed to cut or file the residents' toenails. CNA 68 stated if the residents' nails needed to be cut, it had to be reported to the nurse. During a concurrent interview and record review on 4/18/25 at 8:50 A.M., Assistant Director of Nursing (ADON) 66 stated if the residents' toenails were long, the CNA would need to report it to nurse. ADON 66 stated the nurse would contact Social Worker (SW) 65 in person or by phone to let them know to put the patient on the list to be seen by podiatry. ADON 66 stated the podiatrist came once a month to the facility. ADON 66 stated the last time Resident 141 was seen by Podiatry was on 9/5/24. ADON 66 went into Resident 141's room and assessed the resident's feet. ADON 66 came out of Resident 141's room and stated, Yeah, that's bad and [Resident 141] should have been seen immediately and placed on list [for podiatry]. During an interview on 4/18/25 at 9:15 A.M., SW 65 stated she handled the referrals for podiatry and had a spreadsheet with every resident on the list that was to see podiatry. SW 65 stated that was a rolling schedule that cycled every 90 days. SW 65 stated she was not aware Resident 141 had an order to be seen every two months or as needed and did not have him on the rolling schedule to be seen by the podiatrist. SW 65 stated Resident 141 should have been seen regularly as his orders indicated. During an interview on 4/18/25 at 3 P.M., the Director of Nursing (DON) stated Resident 141's order for podiatry care every two months should have been followed and implemented. A review of the facility's policy and procedure, titled Foot Care, revised October 2022, indicated, .5. Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals .

Based on observation, interview, and record review, the facility failed to follow nutrition orders for two of 37 sampled residents (Resident 82, Resident 208) with tube feedings (TF: nutritional intake via tube) when: 1. Resident 82's TF was not started timely. 2. Resident 208's TF was not ran at the ordered rate. These deficient practices placed all residents on TFs at risk for malnutrition. Findings: 1. A review of Resident 82's Admission Record indicated Resident 82 was readmitted to the facility on [DATE] with diagnoses which included a history of protein calorie malnutrition (the body does not get enough calories and protein from their diet). A record review of Resident 82's MDS (Minimum data set: nursing facility assessment tool) dated 2/7/25 indicated that Resident 82 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. On 4/15/25 at 12:07 P.M., an observation, and interview, was conducted with Resident 82, in Resident 82's room. Resident 82 was unable to verbalize clearly but was able to answer simple yes or no questions. Resident 82 pointed to his TF when asked if he ate breakfast. Resident 82's TF was stopped and a bag of TF formula was still hung on the TF pole with 100 ml (milliliters) remaining labeled 4/14/25. On 4/15/25 at 3:35 P.M., a clinical chart review was conducted on Resident 82's diet/nutrition orders. Resident 82's orders indicated .(Brand name of TF) 2.0 at 55 cc[ml]/hr [per hour] x 20 .TURN ON AT 1400 [2 P.M.] & OFF AT 10:00 [10 A.M.] OR AFTER THE DOSE IS COMPLETED . On 4/15/25 at 4:14 P.M., an observation was conducted in Resident 82's room. Resident 82 was in bed asleep. Resident 82's TF was not turned on and the same bag of TF dated 4/25/25 with 100 ml remaining was still hung on Resident 82's TF pole. On 4/17/25 at 9:03 A.M., an interview and clinical chart review was conducted with LN (Licensed Nurse) 21, on Resident 82's diet orders. LN 21 stated Resident 82's TF orders indicated, .(Brand name of TF) 2.0 at 55 cc/hr x 20 .TURN ON AT 1400 & OFF AT 10:00 OR AFTER THE DOSE IS COMPLETED . LN 21 observed pictures of Resident 82's TF taken at 12 P.M. and 4:13 P.M. with Resident 82's name and remaining 100 ml TF bag still hung on Resident 82's TF pole. LN 21 stated that the TF should have been discarded and should have been re-hung as ordered at 2 P.M. on 4/15/25. LN 21 stated it was important to follow Resident 82's physician's (MD) orders to prevent malnutrition and weight loss. On 4/17/25 at 9:10 A.M., an interview and clinical chart review was conducted with LN 22, on Resident 82's diet orders. LN 22 stated Resident 82 was NPO [no intake by mouth]. LN 22 stated Resident 82's TF orders indicated, .(Brand name of TF) 2.0 at 55 cc/hr x 20 .TURN ON AT 1400 & OFF AT 10:00 OR AFTER THE DOSE IS COMPLETED . LN 22 stated at 10 A.M., Resident 82's TF bag should have been stopped and discarded. LN 22 stated that Resident 82's TF should have been started at 2 P.M. and not late (given at 4:15 P.M.) per the Medication Administration Record (MAR). LN 22 stated Resident 82 had a history of malnutrition and was at increased risk of malnutrition. LN 22 stated Resident 82 required a TF to get all his nutritional needs because that was his food and giving the TF late could have been harmful for Resident 82 because he was not getting sufficient nutrition that could have lead to weight loss. On 4/18/25 at 2:27 P.M., an interview with the Director of Nursing (DON) was conducted, in the conference room. The DON stated it was her expectations that the LN's followed Resident 82's diet order for his TF intake. The DON stated that complications for not giving Resident 82's TF timely could have caused complications with weight loss, especially for dependent residents. A review of the facility's policy and procedure, titled ENTERAL FEEDINGS-SAFETY PRECAUTIONS, revised May 2024 indicated, .The facility will remain current in and follow accepted best practices in enteral nutrition . 39448 2. Per the facility's Admission Record, Resident 208 was admitted to the facility on [DATE] with diagnoses of malnutrition (not enough nutrients), dementia (mental and physical decline), and dysphasia (difficulty swallowing). On 4/15/25 at 10:48 A.M., an observation was conducted of Resident 208's TF. The TF was running at 50 Milliliters per hour (ml/hr). On 4/16/25 a review was conducted of Resident 208's record. There was an order for TF at 65 ml/hr. On 4/16/25 at 1:02 P.M., an observation and interview was conducted with Licensed Nurse (LN) 5. LN 5 stated, she refilled Resident 208's TF that morning and it was her responsibility to ensure the TF was running as ordered. LN 5 stated, Resident 208 had an order for the TF to run at 65 ml/hr. The TF was observed to be running at 50 ml/hr and LN 5 stated, that it was incorrect and should have been running at 65 ml/hr. On 4/17/25 at 2:10 P.M., an interview was conducted with the Registered Dietician (RD). The RD stated, if a TF was ran at the incorrect rate, it could potentially have contributed to weight loss. On 4/18/25 at 9 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, the LNs should have checked the order to ensure the TF was running at the correct rate. The DON further stated, running a TF at a lower rate than ordered could have contributed to weight loss. A review of the facility's policy and procedure, titled ENTERAL FEEDINGS-SAFETY PRECAUTIONS, revised May 2024 indicated, .The facility will remain current in and follow accepted best practices in enteral nutrition .

Based on observation, interview, and record review, the facility failed to label and change a peripheral intravenous access (IV, location to administer medication into the blood stream) for one of 37 sampled residents (179) based on professional standards of practice. As a result, Resident 179 was placed at an increased risk of infection and medical complications. Findings: Per the facility's Admission Record, Resident 179 was admitted to the facility on [DATE] with diagnoses of Amyotrophic Lateral Sclerosis (a nerve disorder causing loss of movement). On 4/15/25 at 10: 38 A.M., an observation and interview was conducted with Licensed Nurse (LN) 4 of Resident 179. The IV to Resident 179's right hand was observed to be unlabeled. Resident 179 stated that the IV had been in his right hand for one week. LN 4 stated the IV needed to be changed. On 4/17/25 a review was conducted of Resident 179's medical record. There were no orders to monitor or change the IV prior to 4/15/25. There was an order on 4/8/25 (seven days before the observation of the unlabeled IV) for Resident 179 to have gentamycin (an antibiotic) IV. On 4/18/25 at 9 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, the LN should have dated Resident 179's IV, and they should have entered an order to insert the IV and an order to change the IV at a specific frequency. The facility's policy, titled Peripheral and Midline IV Catheter Flushing and Locking, revised March 2022, did not direct staff to label their IVs, or change them at a specific frequency.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to professional standards of practice for three of seven residents (37, 81, 92) reviewed for pharmacy services when: 1. Resident 81's pantoprazole (a prescribed medication to treat acid reflux) was dispensed and left at the resident's bedside for the resident to self-administer. 2. The manufacturer's instructions for Advair Diskus (an inhaled steroid medication) were not followed when the medication was administered to Resident 92. 3. A controlled medication (drugs with high abuse potential) prescribed to Resident 37 could not be accounted for. As a result: -Resident 81 self-administered his pantoprazole at the wrong time and not according to the physician's order. -Resident 92 was at risk of developing thrush (a fungal infection). - The facility was unable to readily identify potential loss and/or drug diversion (illegal distribution or abuse of prescription drugs). Findings: 1. A review of Resident 81's Admission Record indicated the resident was readmitted to the facility on [DATE]. A review of Resident 81's physician orders dated 7/28/24, indicated the resident was to receive pantoprazole 40 milligrams once a day before breakfast. The medication was scheduled to be administered at 6:30 A.M. A review of Resident 81's medication administration record (MAR) indicated the resident's pantoprazole was administered to the resident on 4/15/25 at 6:30 A.M. On 4/15/25 at 9:45 A.M., an observation and interview was conducted with Resident 81 while inside the resident's room. Resident 81 was observed in bed. There was a yellow, oblong tablet in a medication cup next to the resident on the resident's overbed table. Resident 81 was asked about the observed medication in the medication cup. Resident 81 quickly self-administered the tablet and then stared at the wall without answering the question. On 4/15/25 at 10:29 A.M., a joint observation, interview, and record review was conducted with licensed nurse (LN) 52. LN 52 stated he was the nurse currently assigned to Resident 81. LN 52's medication cart was inspected and Resident 81's medication cards were observed. Resident 81's pantoprazole matched the tablet in the medication cup which was observed at 9:45 A.M. LN 52 stated he just dispensed and administered Resident 81's medications that were scheduled for 9 A.M. LN 52 stated he did not give the resident pantoprazole. LN 52 stated Resident 81's pantoprazole was a medication that the night shift nurse gave to the resident at 6:30 A.M. LN 52 stated he did not work the night shift. LN 52 reviewed Resident 81's clinical record and stated the resident did not have an order to self-administer medications. LN 52 stated Resident 81 ate breakfast approximately an hour ago, and when the resident self-administered his pantoprazole, it was not taken at the correct time and before breakfast as was ordered. On 4/18/25 at 3:10 P.M., an interview was conducted with the director of nursing (DON). The DON stated pantoprazole should not have been left at Resident 81's bedside for the resident to self-administer. The DON stated Resident 81 did not have an order to self-administer his medications. The DON stated the pantoprazole was administered late and not according to physician's order. The DON stated her expectation was for LNs to stay with residents until the residents took all their medications. The DON stated LNs should be checking the residents' mouths to ensure medications were swallowed. 2. A review of Resident 92's Admission Record indicated the resident was readmitted on [DATE]. On 4/17/25 at 9:50 A.M., a medication administration observation was conducted with licensed nurse (LN) 53. LN 53 was observed preparing and dispensing medications for Resident 92. At 10:05 A.M., LN 53 was observed administering an oral inhalation of Advair Diskus to Resident 92. LN 53 then had Resident 92 drink water and take oral medications. The Advair Diskus packaging indicated, .Instructions for using ADVAIR DISKUS .Step 3. Inhale your medicine .Put the mouthpiece to your lips. Breathe in quickly and deeply through the DISKUS .Step 5. Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it On 4/17/25 at 10:13 A.M., an interview and record review was conducted with LN 53. LN 53 reviewed the Advair Diskus packaging (for Resident 92's Advair). LN 53 stated he did not follow the manufacturer's instructions when administering the Advair to Resident 92. LN 53 stated he should have instructed the resident to rinse his mouth with water and spit it out. On 4/18/25 at 3:10 P.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 92's Advair Diskus manufacturer's instructions should have been followed. The DON stated LN 53 should have instructed the resident to rinse his mouth with water and spit it out. The DON stated this was to prevent oral thrush. A review of Patient Information Advair Diskus for oral inhalation use, revised January 2019, indicated, .Advair Diskus can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Advair Diskus to help reduce your chance of getting thrush 51541 3. Resident 37 was admitted to the facility on [DATE] per the facility's Admission Record, with diagnoses to include femur (upper leg bone) fracture. During a record review on 4/17/25, Resident 37's physician's order, controlled drug record (CDR), and medication administration record (MAR) was reviewed. Resident 37's physician's order dated 1/14/25, indicated the resident was to receive hydrocodone-APAP 5/325mg (medication used to relieve pain) one tab every four hours as needed for pain. A review of Resident 37's CDR indicated two doses of the resident's hydrocodone-APAP 5/325 had been removed from the locked supply on 2/8/25 and 2/28/25. Resident 37's MAR for hydrocodone-APAP 5/325mg had blank entries on 2/8/25 and 2/28/25 and it could not be determined if the medication had been given to the resident. During an interview on 4/18/25 at 7:40 A.M., Licensed Nurse (LN) 64 stated LNs had to sign controlled medications out on the CDR and document on the MAR when the medication was given to the resident. LN 64 stated that it was important to keep track of controlled medications so that other LNs knew when the medication was given. During an interview on 4/18/25 at 7:45 A.M., the Director of Nursing (DON) stated Resident 37's hydrocodone-APAP 5/325mg was not documented on the resident's MAR on 2/8/25 and 2/28/25. The DON stated her expectation was for the LN to sign the CDR when controlled medications were removed from the locked drawer and then for the LN to document on the resident's MAR once the medication was given to the resident. During another interview on 4/18/25 at 3:15 P.M., the DON stated the Assistant Directors of Nursing (ADON) were supposed to conduct weekly random audits of controlled medications for five random residents. The DON stated these weekly audits had to be documented and submitted to the DON. The DON stated the weekly audits of controlled medications were not being done. The facility's policy and procedure, titled Medication Reconciliation, revised July 2017, did not provide guidance related to reconciling and accounting for controlled medications.

Based on observation, interview, and record review, the facility failed to complete a monthly medication reconciliation (reviewing and creating an accurate list of all medications a resident is taking if appropriate to continue, hold or stop) review (MRR) for one of 20 sampled residents (Resident 183) receiving antibiotics. This deficient practice placed residents at risk for unnecessary medication use, side effects, and harm due to lack of proper review. Cross-Reference F881 and F657. Findings: A review of Resident 183's Admission Record indicated Resident 183 was admitted to the facility on [DATE] with diagnoses which included a history of metabolic encephalopathy (a brain disorder that causes problems with the body's chemistry due to lack of oxygen, blood sugar level and essential nutrients). On 4/15/25 at 2:46 P.M. a clinical chart review was conducted on Resident 183's physician's order sheet (POS). Resident 183 was taking Rifaximin (an antibiotic medication that worked by killing the bacteria and preventing its growth) for encephalopathy ordered 3/4/24. On 4/18/25 at 7:06 A.M., a record review was conducted on Resident 183's MRR. There was no MRR conducted on Resident 183's medication for Rifaximin for the month of January 2025-March 2025. On 4/18/25 at 8:49 A.M., an interview and record reviews were conducted on Resident 183's clinical chart and MRR with the Infection Control Prevention Nurse (ICPN). The ICPN stated Resident 183 was no longer on antibiotic. The ICPN stated she tracked the infection control log/antibiotic tracking to determine which residents were on antibiotics. The ICPN reviewed Resident 183's POS and stated Resident was on Rifaximin for encephalopathy ordered on 3/4/24. The ICPN reviewed the MRR for the month of January 2025-March 2025 and stated Resident 183's Rifaximin was not reviewed. The ICPN stated that she only kept track on residents with infections as part of her antibiotic stewardship log as to why Resident 183's antibiotic was not tracked. The ICPN stated Resident 183's Rifaximin should have included routine monitoring for the medication use and appropriateness to be included monthly. The ICPN stated antibiotics (such as Rifaximin) were used for bacterial infections but Resident 183 was using the medication for encephalopathy and that there was no stop date for the medication. The ICPN stated she was unable to find any side effect monitoring or documentation in Resident 183's clinical chart for Rifaximin. The ICPN stated we should have been monitoring the side effects for Resident 183's antibiotic use and indications so that the physician could have reassessed with the information gathered to determine appropriateness of long term use. The ICPN stated complications from taking antibiotics for long term use could have lead to antibiotic resistance and caused other infections. On 4/18/25 at 2:55 P.M., an interview with the Director of Nursing (DON) was conducted, in the conference room. The DON stated that her expectations was for the ICPN to track all antibiotics short term and long term and be reviewing all antibiotics for indication of use and be included in the care plan. The DON stated, the ICPN should have followed up with the MRR and recommendations with antibiotic appropriateness and continued use monthly. The DON stated complications to include antibiotic resistance to infections, disease progressions, and multi-drug resistance organisms (MDRO: germs that have evolved to survive against multiple antibiotics) complications A review of the facility's policy and procedure, titled MEDICATION REGIMEN REVIEWS, revised May 2019 indicated, .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example .potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences .

Based on interview and record review, the facility failed provide one to one (1:1) feeding (when a staff member assist the resident throughout the meal, with verbal queing), according to the facility's policy and the physician's order for RNA (restorative nursing assistant-a certified nursing assistant {CNA} with advanced training and skills such as feeding residents at high risk for aspiration), feeding for one of five residents (Resident 1), reviewed for Quality of Care. As a result, Resident 1 expired after she was left unsupervised to eat her lunch, and she aspirated (when food enters the lung), food into her lungs causing asphyxiation (deprived of oxygen). Findings: Resident 1 was readmitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), and failure to thrive (weight loss, decreased appetite and poor nutrition), per the facility's Resident Face Sheet. According to the physician's History and Physical, dated [DATE], Resident 1 did not have the capacity to understand and make decisions. Per the admission Registered Dietician (RD) Nutritional Observation notes, dated [DATE], the resident's hospital weight was 81 pounds, and the resident was consuming ,d+[DATE]% of her meals. Multiple pressure ulcers (breakage of skin from prolonged pressure) were present, and interventions were implemented which included Speech Therapist (ST- a specialist who assist residents with difficulty talking, swallowing and chewing) evaluation, and high protein supplements, and vitamins. According to the ST Evaluation and Plan of Care, dated [DATE], Resident 1's plan of care included speech therapy treatments two times a week for dysphagia (difficulty swallowing) related to dementia. Resident 1's diet was downgraded to pureed solids (a smooth textured modified diet, to assist with easy swallowing) and thin liquids. The ST 1 recommended strict aspiration/swallowing precautions, with 1:1 assistance during all meals. The ST documented the resident's caregivers were educated on safe swallowing precautions. Per the ST Treatment Encounter note, dated [DATE], the resident was evaluated for a trial mechanical soft diet (foods that are soft and easy to chew/swallow). ST 2 documented Resident 1 took large rapid bites, was holding bolus (food mixed with saliva and held in mouth), with prolonged/slow mastication (chewing food). The ST 2 recommended strict aspiration/swallowing precautions, with 1:1 assistance with all meals. The ST 2 documented, .training to staff was re-enforced for continued safe swallowing precautions. According to the Physician's Order Report, dated [DATE] through [DATE], (discontinue date) .Diet: mechanical (extra nutrients added), soft textured, ground meat/thin liquids. 1:1 assistance. Strict aspiration and swallow precautions. Special Instructions: RNA FEEDING **Awaiting DC {discontinued- meaning the discontinue date for RNA assistance with feeding pending verification from the physician and speech therapist after an evaluation could be conducted} verification (DC dated [DATE]) . Per the ST Treatment Encounter note, dated [DATE], ST 1 documented Resident 1 was occasionally taking multiple bites prior to swallowing, however she did eventually clear her oral cavity (mouth). ST 1 recommended diet upgrade to regular solids with continued 1:1 feeding assistance and continued supervision throughout meals. According to the Physician's Order Report, dated [DATE] through [DATE], (discontinue date) .Diet: Fortified, Regular textured/thin liquids 1:1 assistance. Strict aspiration and swallow precautions. RNA FEEDING **Awaiting DC verification {meaning the discontinue date for RNA assistance with feeding pending verification from the physician and speech therapist after an evaluation could be conducted} verification DC dated [DATE]) . Per the ST Treatment Encounter note, dated [DATE], the ST 2 documented, .turkey sandwich with graham cracker and water via cup .Pt (patient) with multiple bites prior to swallow and benefited from verbal/visual cues to slow down/finish one bite first . Continue with ST plan of care, provided instructions to nursing staff in safe swallow strategies specifically, one bite at a time, slow rate, alternate solid/liquids, upright position. According to Resident 1's care plan titled, Requires RNA feeding program due to weight loss and required feeding assistance, dated [DATE], indicated, .communicate with RNA of resident needing assistant during feeding .verbal ques such as Take a bite or Pick-up the spoon. There was no documented evidence of a 1:1 feeding listed as an intervention on the RNA care plan. Additional care plans were reviewed to include Speech Therapy, dated [DATE] and Nutritional Status, dated [DATE], both of which were not revised to include documentation of 1:1 feeding. According to the Resident Progress Notes dated [DATE] at 1:24 P.M., Licensed Nurse 1 (LN 1) was notified by Certified Nursing Assistant 1 (CNA 1) something was wrong with Resident 1. LN 1 documented Resident 1 had a grayish tint, with a clenched jaw, and was struggling to catch her breath. 911 was called and LN 1 lifted Resident 1 up in her chair by her arms, in attempts to clear the resident's airway. LN 1 documented Resident 1 coughed and then clenched her jaw again and showed signs of difficulty breathing. The resident's oxygen saturation (an external device which measures the amount of oxygen in the blood) was 35% (normal 98%). Resident 1 was transported to the hospital at 1:15 P.M., and the family was notified. The next Resident Progress Note, date [DATE] at 3:48 P.M., LN 2 documented the hospital called informing them Resident 1 had expired. On [DATE] at 1:08 P.M., an interview and record review was conducted with the Dietary Services Supervisor (DSS). The DSS printed out Resident 1's meal ticket for [DATE], which was listed as Fortified regular diet texture with thin liquids RNA 1:1 feeding assistance. The lunch calendar was reviewed for [DATE]. The lunch meal consisted of White chili with chicken, salad, cornbread, and an apple brown betty desert. The facility's Registered Dietician (RD) was not available for an interview on [DATE]. On [DATE] at 12:48 P.M., an interview was conducted with LN 1. LN 1 stated she was approached by CNA 1, who said something was wrong with Resident 1. LN 1 stated she entered Resident 1's room with CNA 1. LN 1 stated Resident 1's color was gray. LN 1 stated she attempted to open Resident 1's mouth, but the resident's jaw was clenched. LN 1 yelled for help and lifted the resident up by both arms to re-position her in the wheelchair. LN 1 stated Resident 1's color improved, she coughed, then she re-clenched her jaw. LN 1 stated two respiratory therapists (RTs) arrived about that same time. The RTs moved the resident to her bed and placed a non-rebreather mask, (special medical device that helps provide oxygen in emergencies) on Resident 1, as she sat up in bed. LN 1 stated the resident remained awake, but lethargic (sluggish) until the paramedics arrived about ,d+[DATE] minutes after placed in bed. LN 1 stated she did not perform the [MEDICATION(S)] maneuver, (a first-aid procedure for dislodging an obstruction or food from a person's windpipe, which is performed by applying a thrust to the upper abdomen) because the resident was breathing, and her color had improved after she was re-positioned in the wheelchair. LN 1 stated Resident 1's color started to slightly change again to a gray tint, but she was still breathing on her own with the oxygen mask on, and they could not suction her because her jaw remained clenched. LN 1 continued, stating if a resident was on RNA 1:1 feeding, that meant an RNA should be doing the feeding. LN 1 stated RNAs had more training than CNAs, along with extra certifications. LN 1 stated if a resident was identified as an RNA or regular staff 1:1 feeding, then it should be in their care plan, so all staff were aware of the care being provided. LN 1 stated she would also expect to see the 1:1 feeding listed in the RD's nutritional care plan. LN 1 stated Resident 1's RNA 1:1 feeding should have also been listed in the Facility's Special Needs book, which was a reference tool for the CNAs. LN 1 stated the facility's Special Needs book was updated daily by the unit charge nurse and a new sheet was printed out weekly by the Minimum Data Set Nurse (MDS-a clinical assessment tool, performed by a licensed nurse). LN 1 continued, stating Resident 1's food tray, which had been in front of her at the time she entered the room contained soup, which looked like chicken stew with two spoons in the bowl, a chopped salad, corn bread and an apple crumble desert. LN 1 stated Resident 1 had no previous problems when eating. The staffing assignments were reviewed for Resident 1's unit on [DATE]. CNA 1 was listed as 1:1 for Residents 1 and her two roommates, (Residents 5 and 6), on [DATE]. On [DATE] at 1:28 P.M., an interview and record review was conducted with ST 1. ST 1 stated she initially evaluated Resident 1 and recommended puree diet with thin liquids, due to her dementia and forgetting to swallow her food. ST 1 stated she recommended 1:1 feeding because the resident was an aspiration risk. ST 1 stated she educated the CNAs on the unit, to provide cueing and verbalization to the resident and to remind the resident to take small bites, chew, and then swallow, before ingesting any more food. ST 1 stated she discussed the plan of care with the resident's physician, who agreed with the 1:1 feeding for supervision and cueing. ST 1 reviewed Resident 1's ST Progress Reports and stated on [DATE], the resident's diet was upgraded after discussing the resident's progress with the physician, to a fortified mechanical soft diet with thin liquids. ST 1 stated the resident was still considered an aspiration risk and 1:1 feeding was continued. ST 1 stated Resident 1 continued to improve with the twice a week evaluation and was developing better eating patterns with small bites and chewing her food. ST 1 continued to review Resident 1's ST Progress Reports and stated on [DATE], Resident 1's diet was upgraded again by the physician to a fortified regular textured diet with 1:1 assistance for all meals and strict aspiration and swallow precautions were to be followed. ST 1 stated Resident 1 was doing extremely well, her weight was up, and the resident was feeding herself, but she still required cueing and verbalization because she could not remember the task at hand. ST 1 stated she documented the staff were educated and trained, whenever a change was made in Resident 1's ST treatment plan. ST 1 stated the training would be verbally provided to CNAs who were working that specific day. ST 1 stated she did not have documentation of who she educated each time. ST 1 stated if staff were working on different days, evenings, or the night shifts, they did not receive the training, only the staff who was there on that day of training. ST 1 stated she only educated staff for general 1:1 training, such as small bites, swallowing food before the next bite, when it was requested by management. ST 1 stated RNA 1:1 feeding was considered a specialized feeding, due to swallowing challenges and high risk of aspiration, so she never trained CNAs to perform this specialized feeding, only general 1:1 feeding. ST 1 stated RNAs had additional training and certification for performing 1:1 feeding, which was not a part of the ST department's training. ST 1 stated she had never provided training for the new hire CNAs for general 1:1 feeding. ST 1 reviewed Resident 1's ST Progress Reports again and stated she recommended 1:1 feeding, but she did not request RNA feedings, because that order came directly from the physician. ST 1 stated when the physician entered the RNA feeding order, a care plan should have been developed or revised to reflect the RNA 1:1 feeding with the specific diet ordered. ST 1 stated the LNs were responsible for care plan updates and revisions to reflect RNA feeding, due to weight loss or swallowing difficulty. ST 1 stated she probably would have kept Resident 1 on 1:1 feeding indefinitely, due to her declining memory loss. On [DATE] at 2 P.M., an interview was conducted with CNA 1. CNA 1 stated she usually worked the P.M. shift (3 P.M. to 11:30 P.M.) and had taken care of Resident 1, maybe twice before on the P.M. shift and she could not recall if Resident 1 was a 1:1 RNA feed at that time. CNA 1 stated [DATE], was her first time working on the day shift. CNA 1 stated she was told in the morning huddle she was assigned to three residents in the room closest to the nurse's station, and all three residents in that room were on 1:1 room supervision. Resident 6 was in the first bed and she could feed herself with supervision. Resident 1 was in the second bed and was an RNA 1:1 feeding, and Resident 5 was in the third bed, who was a general 1:1 feeding. CNA 1 stated when breakfast came that morning, she fed Resident 5. When she finished the 1:1 breakfast feeding with Resident 5, she noticed Resident 1's tray was still there and covered. CNA 1 said she went to the nurse's station and was told by an unknown CNA there were no available RNAs that day. CNA 1 stated she took it upon herself to feed Resident 1, without asking anyone if it was alright. CNA 1 stated she did not inform the charge nurse that the RNA had never arrived to feed Resident 1. CNA 1 stated she was still sitting with Resident 1, who was finishing her breakfast, when another CNA, who she could not identify, passed by the resident's room and said Resident 1 was no longer a 1:1 feeding, and was now considered a supervised feeding. CNA 1 continued, stating supervised feeding meant the CNA must be around or nearby, in case the resident needed assistance. CNA 1 could not name the CNA who told her this, and could not describe the person, saying she could not even recall if it was a male or female who told her it was now a supervised feeding. CNA 1 stated she did not verify this information with the unit charge nurse, and she did not check the CNA Communication book which contained Special Instructions for care. CNA 1 continued, stating the next meal on [DATE], was lunch and remembered preparing Resident 1's tray by uncovering her soup, salad, and drinks and tearing up the resident's cornbread into little pieces. CNA 1 stated she left Resident 1 in her wheelchair to feed herself and went to the next bed to feed her roommate, Resident 5. CNA 1 stated she was feeding Resident 5, with her back to Resident 1, when she heard noises coming from behind her. CNA 1 stated she turned her head to look over her shoulder at Resident 1 and determined Resident 1 did not look right. CNA 1 stated she left the resident's room to get help. CNA 1 returned to Resident 1's room within seconds with LN 1. CNA 1 stated LN 1 lifted Resident 1 up in her wheelchair, which seemed to help for a few seconds, but then Resident 1 started to have trouble breathing. CNA 1 stated she remembered looking at Resident 1's food tray and could tell the resident ate some soup, but she could not tell if anything else had been consumed from the tray. On [DATE] at 2:10 P.M., an interview was conducted with CNA 2. CNA 2 stated 1:1 staff feeding meant the CNA needed to sit with the resident throughout the entire meal. CNA 2 stated 1:1 staff feeding meant the resident required feeding assistance, because they were at risk for choking or aspiration. CNA 2 stated if someone told her a resident was no longer a 1:1 feeding, she would need to check the physician orders or ask the charge nurse, because it was the CNAs responsibility to verify the change in the order. On [DATE] at 2:25 P.M., an interview and record review was conducted with the Minimum Data Set Nurse 1 (MDSN 1- MDS-a clinical assessment tool, performed by a licensed nurse). The MDSN 1 stated she was responsible for the RNAs and for maintaining the facility's Special Needs book weekly. The MDSN 1stated the Special Needs book was designed for the CNAs, as a communication tool and endorsement hand-off during shift changes. The MDSN 1 stated the Special Needs book contained residents with 1:1 feeding, and fall precaution as an example. The MDSN 1 reviewed the Special Needs book and located Resident 1 listed as a Fall risk only. The MDSN 1 stated the facility's Special Needs book was updated every week by her and the 1:1 feeding must have been missed. According to the facility's Job Description for Restorative Nursing Aide, undated, .Duties: .4. Feeding Program . The facility's RNA job description did not provide specific guidance for how RNAs performed 1:1 feeding for residents. According to the facility's Job, Title for Certified Nursing Assistant CNA, undated, .2. Monitoring of fluid and food intake .3.oral feedings, positioning . The facility's CNA job description did not provide specific guidance for how CNAs performed 1:1 feeding for residents. On [DATE], CNA 1's employment file was reviewed. CNA 1 was hired [DATE], with documented training on hire, for Feeding Special Problems, Feeding-Serving Trays-D/R (dining room) Procedures, and Choking-[MEDICATION(S)] Maneuver. No additional training regarding resident 1:1 feeding. On [DATE] at 3:05 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated RNAs had special training to do range of motion (ROM) and additional tasks. The ADON stated CNAs and RNAs could do the same tasks along with 1:1 feeding, and there was no additional training required. The ADON stated CNAs were trained on feeding residents when hired. The ADON stated 1:1 feeding meant the staff stayed with the resident during the meal and focused on nothing but the resident and how they were eating, chewing, and swallowing. The ADON stated the resident should be positioned properly, have dentures in, have the correct diet, and that staff should be right there with a constant visual, to ensure choking and aspiration risk were low. The ADON stated she expected staff to remain sitting with the resident until the meal was finished. The ADON continued, and stated if a 1:1 feeding order was changed, she expected it to be discussed in the shift change huddle by the LNs and it should also be documented in the Special Needs book by the unit charge nurse. The ADON stated if a CNA was unsure of a feeding, the CNA should go to the charge nurse for clarification or check the Special Needs book On [DATE] at 3:20 P.M., an interview was conducted with the Administrator's Assistant (ADM-A). The ADM-A stated 1:1 feeding assistance meant sitting and feeding just one resident at a time. The ADM-A stated if RNA feeding was ordered, then an RNA should be providing the feeding, not a CNA. The ADM-A stated if a CNA was feeding an RNA feeding resident, she would expect the physician to be notified, and it was documented in the resident record the physician had agreed. The ADM-A stated the facility's Special Needs binder was kept at every nursing station and contained information for the CNAs on those residents that required special instructions, such as fall risk, and 1:1 feeding. The ADM-A stated she would expect to see Resident 1 listed in the facility's Special Needs book since she was a 1:1 feeding and a fall risk. On [DATE], Resident 1's hospital medical records were reviewed for treatment received on [DATE]. According to the ED (emergency department) Note, Resident 1 arrived in the emergency room unresponsive with agonal respirations (abnormal breathing). A chest x-ray revealed an obstruction in the left lung. An emergency fiberoptic bronchoscope (a medical tool that allows visualization of the lungs) was performed, which showed a collapsed left lung. The bronchoscope found fruit embedded in the left mainstem bronchi (a major air passage to the lung) which was completely occluded (blocked). Parts of fruit were removed from the bronchi, which resembled a peach slice. During the procedure, Resident 1's heart rate dropped, and death was pronounced at 2:22 P.M., on [DATE]. On [DATE] at 12:50 P.M., an interview and record review was conducted with the Registered Dietician (RD). The RD. printed out the dessert menu served at lunch time on [DATE]. The desert recipe titled, Apple Brown Betty Crumble, included canned slices of apple. On [DATE] at 9:25 A.M., an interview was conducted with the Medical Examiner (ME) who performed an external (outside) exam of Resident 1. The ME stated an internal (inside) autopsy was not required since the hospital visualized and removed food from left mainstem bronchi using a bronchoscope The ME stated Resident 1's cause of death was listed as an Accident, due to food aspiration into the left lung, resulting in asphyxiation. On [DATE] at 11:10 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she provided training to all new CNAs during their orientation. The DSD stated one of the standard trainings was assisting residents with eating and 1:1 feeding. The DSD stated the training she provided was verbal and she started with the basics such as, the dentures were placed, protective clothing was worn if needed, the resident was in an upright position, ensuring the diet tray was checked by a licensed nurse first and double checking the diet ticket for accuracy, along with all the different types of diets, such as puree, mechanical soft, etc. The DSD continued, stating staff were also instructed on the [MEDICATION(S)] maneuver. The DSD stated she instructed staff verbally and then provided a demonstration. The DSD had staff return the [MEDICATION(S)] demonstration to her. The DSD stated she expected CNAs to perform the [MEDICATION(S)] maneuver first if a resident was choking and then call for help. The DSD stated if a resident had a clenched jaw and was choking, she still expected the staff to still perform the [MEDICATION(S)] maneuver. The DSD stated after the orientation training, she sent the CNAs over to the Rehabilitation Department, to provided additional training for 1:1 feeding, but she was not sure. The DSD continued, stating if a CNA was assigned to provide 1:1 feeding to three residents for one meal, she expected the CNA to assist one resident at a time, such as finish with the first one and then heat up the second resident's food, feed that resident, and then go to assist the third resident. The DSD stated 1:1 feeding meant staff were to stay with the resident throughout the meal. The DSD stated 1:1 feeding should be care planned, so all staff knew what the plan of care was, for consistency. The DSD stated care plans were developed and revised by the LNs. The DSD stated a CNA could not do what an RNA did, because the RNA had additional specialized training. The DSD stated if a physician ordered RNA feeding, then the feeding should be performed by an RNA, not a CNA. The DSD stated if a CNA was confused about a physician's order or performing a specific function, the DSD expected the CNA to verify the order with a LN or check the facility's Special Needs book. The DSD stated the facility's Special Needs book was a communication tool for the CNAs regarding residents with special instructions, such as assistive devices, falls, behavior, and 1:1 feeding. The DSD stated the facility's Special Needs book was updated continuously by the unit's charge nurse and a MDSN printed out a new copy each week. On [DATE] at 12:04 P.M., an interview and record review was conducted with MDSN 2. MDSN 1 was unavailable for a follow up interview and would not be returning to the facility for another three weeks. MDSN 2 stated the MDSNs were responsible for supervising the RNAs. MDSN 2 stated the facility currently had 5 to 6 RNAs. MDSN 2 stated RNAs could do CNA work, but CNAs could not do RNA work, due to the RNAs having additional training with specialized certification. MDSN 2 stated if a physician ordered RNA 1:1 feeding there was a reason, so the feeding should only be performed by an RNA. MDSN 2 stated thefacility's Special Needs book was updated weekly by a MDSN. MDSN 2 stated if a change of condition or a new order came in during the week, it was the expectation of the facility for the unit's charge nurses to updated the facility's Special Needs book. The facility's Special Needs book was utilized by the CNAs. MDSN 2 stated MDS assessments for section K, titled Swallowing/Nutritional Assessments were completed by reviewing then physician orders, ST notes, RD Observation Notes and nursing notes. MDSN 2 reviewed Resident 1's MDS, dated [DATE], for Section K-0100, Swallowing Disorder had nothing documented, for a 7-day look back period because Resident 1 was not on a 1:1 feeding at that time. Resident 1's MDS, dated [DATE] listed as Discharge to Hospital was reviewed by MDSN 2. The MDSN 2 stated Resident's 1's weight was up to 100 pounds. The MDSN 2 stated nothing was listed in Section K-0100, because it was not a requirement on discharges. MDSN 2 stated Section K ,d+[DATE] was only required for quarterly and annual assessments, so that was why nothing was listed. On [DATE] at 12:30 P.M., an interview was conducted with the Respiratory Therapy Supervisor (RTS). The RTS stated she responded to Resident 1's room, along with RT 1, after a code blue (an overhead announcement indicating cardiopulmonary arrest in a specific room) was called. RTS stated she recalled the resident sitting in a wheelchair in the second bed, closest to the door. RTS stated the resident's color was strange, but she was not choking. RTS stated they placed the resident back in bed, in an upright sitting position and placed a non-rebreathing oxygen mask, over the resident's nose and mouth. The RTS stated the resident remained awake and her color improved, but she did not talk, and she appeared subdued. The RTS stated she stayed in the room with the resident until the paramedics arrived. RTS stated she could not say how much time had passed from when she arrived until the time the resident was taken to the hospital. The RTS stated a [MEDICATION(S)] maneuver was never performed because the resident was not choking at the time. The RTS could not recall if a food tray was present or if any food had been consumed. On [DATE] at 12:42 P.M., an interview was conducted with RT 1. RT 1 stated he remembered a code blue was called overhead and he responded with his supervisor. RT 1 stated when he arrived the resident was sitting up in a wheelchair and looked okay. RT 1 stated a lot of staff were in the room, and he could not figure out why a code blue had been called. RT 1 stated they assisted the resident back into bed and placed a non-rebreathing mask on the resident until the paramedics arrived. RT 1 stated it took ,d+[DATE] minutes for the paramedics to arrive and the resident remained sitting up in bed and did not appear in any discomfort. On [DATE], the secured unit's CNA schedule was reviewed. Seven CNA's (CNA 1, 4, 5, 6, 7, 8, 9), were working 7 A.M. to 3:30 P.M., on [DATE]. With an additional CNA (CNA 3) assigned as a 1:1 sitter (sits and supervises one resident throughout the entire shift) for one specific resident. On [DATE] at 1:17 P.M., an interview was conducted with CNA 4, who was working the day shift on [DATE]. CNA 4 stated she was in one of her assigned rooms, feeding a resident when she heard the code blue called overhead. CNA 4 stated Resident 1's room was always assigned to one CNA as a 1:1 supervision room, because the three residents in that room were confused and required constant supervision. CNA 4 stated she could not recall which residents in CNA 1's assigned room that day required 1:1 feeding. CNA 4 stated if all the residents were 1:1 feeding, then the CNA should only feed one resident at a time, before moving on to the next resident. CNA 4 stated if a CNA was confused about their assignment, they should check with the unit's charge nurse. CNA 4 stated additional information about residents, such as feeding, falls, behaviors were listed in the Special Needs book kept at the nursing station. CNA 4 stated the CNAs could refer to this book if they were not sure of what the resident's special requirements were. CNA 4 continued, stating she received 1:1 training for feeding in CNA school and additional in-services from the facility over the past three years. CNA 4 stated if a resident was an RNA 1:1 feed, she would feel comfortable feeding that resident, without an RNA being present. On [DATE], a subsequent interview was conducted with the RD. The RD stated she conducted an RD Observation for Resident 1 on [DATE]. The RD stated the resident was sent out on [DATE] and returned on [DATE], less than 24 hours later. The RD stated if the return was less than 24 hours, a repeat RD Observation was not required. The RD stated she was following Resident 1's weekly weights and a dietary update was documented on [DATE]. The RD stated she updated the nutritional care plan whenever diets were change. The RD stated she did not update Resident 1's care plans to include 1:1 RNA feeding as ordered by the physician. On [DATE] at 1:40 P.M., an interview was conducted with LN 2, who was the unit's charge nurse on [DATE]. LN 2 stated she had staff huddles (stand-up meetings), every morning with the staff before they started caring for residents. LN 2 stated these huddles were important for assignments, who required supervision, 1:1 feeding, falls from the night before, behavior monitoring and things like that. LN 2 stated Resident 1's room was next to the nursing station, with three residents, who all required supervision due to their confusion. LN 2 stated Resident 6, who was in the first bed could feed herself, Resident 1 in the second bed was on an RNA feeding, and Resident 5 in the third bed was a staff 1:1 feeding. LN 2 stated an RNA was usually assigned to each unit and the trays would sit, until the RNA arrived to feed the resident. LN 2 stated if the RNA was not available, they would usually send over another RNA to assist. LN 2 was unaware if an RNA arrived for Resident 1's feeding on [DATE], stating she did not track when they arrived or left. LN 2 stated if there was a problem with an RNA not arriving, she expected the CNAs to notify her, so she could make a phone call, requesting an RNA to assist in the unit. LN 2 continued, stating CNAs had a Special Needs communication book where they could get resident's special requirements. LN 2 stated she was responsible for adding or deleting information from the Special Needs book as resident conditions changed. LN 2 stated she verified everything was correct in the book every Friday afternoon, and the MDSN printed out a new version every Monday morning. LN 2 stated it was her responsibility to make sure everything in the book was accurate. LN 2 stated she was unaware Resident 1's 1:1 feeding with RNA was not in the Special Needs book on [DATE], and it should have been. LN 2 stated the facility's Special Needs book was a communication tool for the CNAs. LN 2 stated Resident 1's RNA 1:1 feeding should have been documented in the RNA care plan or the Nutritional care plan. LN 2 stated whoever received the new physician's order was the one responsible for adding it and revising the care plan. LN 2 continued, stating she was not on the unit at the time of Resident 1's feeding and returned after her lunch when the resident had already been transported to the hospital. On [DATE] at 1:59 P.M., an interview was conducted with CNA 5. CNA 5 stated he was working on [DATE]. CNA 5 stated he had training with feeding residents when he started at the facility 9 months prior. CNA 5 stated the training included positioning, having their dentures in, and verifying the meal ticket. CNA 5 stated if the resident was listed as an RNA feed, you had to wait for the RNA to arrive and they would feed the resident. CNA 5 stated if he was not sure of a feeding assignment, he would ask the charge nurse.

Based on observation, interview and record review, the facility failed to ensure three of three residents (Resident 1, Resident 2, and Resident 3) were free from abuse when: 1. Certified nursing assistant (CNA) 5 became upset with Resident 1 and pushed the resident into the wall. In addition, CNA 5 forced care upon Resident 1 when the resident was refusing care. 2. CNA 10 yelled at Resident 2 and told the resident not to speak. 3. CNA 10 yelled at Resident 3 and slapped the resident's legs. These deficient practices resulted in: -Resident 1 experiencing rough handling and sustaining a head injury that caused pain and required a hospital evaluation. -Resident 2 feeling upset, having a knot in my stomach, and reliving previous abuse committed by her mother. -Resident 3 experiencing abusive treatment. Findings: 1. A review of Resident 1's undated Resident Face Sheet, indicated the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set Assessment (an assessment tool), dated 4/22/21, indicated the resident scored two out of 15 on the cognitive assessment (a score of two meant the resident had severe cognitive impairment). On 7/22/21 at 12:25 P.M., an interview was conducted with CNA 3. CNA 3 stated she had recently reported an incident of abuse that she had witnessed (on 6/24/21). CNA 3 stated on the day of the incident (6/24/21), it had been her second day on the job. CNA 3 stated she had been orienting (learning the routine from an experienced staff) with CNA 5. CNA 3 stated Resident 1 had been one of their assigned residents. CNA 3 stated Resident 1 was confused, hard of hearing, and did not fluently speak English. CNA 3 stated she spoke the same native language as Resident 1. CNA 3 stated Resident 1 had been having episodes of diarrhea (loose stools) that day. CNA 3 stated Resident 1 had reached into her brief during each episode of diarrhea, and had smeared the diarrhea all over herself, bed linens, and on the wall next to the bed. CNA 3 stated it was a little after 10 A.M when Resident 1 had a fifth episode of diarrhea and had smeared it around all over again. CNA 3 stated when she and CNA 5 entered Resident 1's room and closed the door to provide care, CNA 5 saw the mess and became angry and yelled at the resident, What did you do? CNA 3 stated Resident 1 was sitting on the bed and appeared to hear and recognize CNA 5's voice. CNA 3 stated Resident 1 responded to CNA 5 in the foreign language, It's you, [expletive]. CNA 3 stated CNA 5 walked over to Resident 1 and grabbed the resident under the armpits and pushed the resident into the wall. CNA 3 stated Resident 1's head hit the wall with an audible thud and the resident immediately grabbed the left side of her head and covered her left eye. CNA 3 stated Resident 1 cried out in pain and said in the foreign language, It hurts. Pain. CNA 3 stated she told CNA 5 to stop and said, It's not proper to do that [to the resident]. CNA 3 stated CNA 5 responded back with, Don't tell me what to do! CNA 3 was asked to clarify if the incident happened while repositioning the resident. CNA 3 stated, No, she [CNA 5] did it on purpose. She was mad at the resident. CNA 3 stated the resident was not in the process of being repositioned and the action had not been necessary. CNA 3 stated This wasn't an accident. CNA 3 stated CNA 5 started cleaning Resident 1 who was resisting and it looked like the resident was fighting with CNA 5. CNA 3 stated CNA 5 was rough with Resident 1 because the resident was resisting care. CNA 3 stated while CNA 5 was cleaning Resident 1, she cleaned up the resident's linens and soiled items. CNA 3 stated when the resident and the room were clean, they left, and she told licensed nurse (LN) 2 about the incident. A review of Resident 1's Resident Progress Notes dated 6/24/21, indicated, At approximately 430 [4:30 P.M.] it was reported to charge nurse by staff that resident has a bump on the left side of forehead. Charge nurse proceeded to assess resident, resident with expressions of discomfort at site, Tylenol administered, small bump noted with no bleeding or open area .new orders to send resident out to .ER [emergency room ] for further eval [evaluation] and treatment .RP [responsible party] . made aware. A review of Resident 1's hospital Emergency (Department) Documentation dated 6/24/21 at 8:30 P.M., indicated, .Chief Complaint: Fall .The patient is a [AGE] year old female who presents to the emergency department with [MEDICATION(S)] head trauma . Patient resides at a skilled nursing facility, has severe uncontrolled and ongoing dementia .She was found to have a hematoma to the left side of her scalp, was presumed she had some trauma and she was sent here. Occurred today, otherwise spontaneous in onset without clear inciting event, moderate severity, without any other associated symptoms or modifying factors A review of Resident 1's Resident Progress Notes dated 6/25/21, indicated, Resident skin assessed .resident noted with . Bump above left eye, intact with discoloration On 8/12/21 at 11:15 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated CNA 3 came and reported the incident she witnessed between Resident 1 and CNA 5 on 6/24/21 toward the end of the day shift (around 3 P.M.). The DSD stated CNA 3 had reported the incident to both the DSD and assistant DSD. The DSD stated CNA 3 told them CNA 5 had been angry and frustrated with Resident 1 after having several bowel movements, in which the resident had made a mess of the bowel movements. The DSD stated CNA 3 told them CNA 5 had lifted Resident 1 under the armpits and pushed the resident into the wall hitting the resident's head on the wall. The DSD stated CNA 3 told them this incident was not accidental and had been done in anger. The DSD stated he notified the administrator (ADM) that there had been an abuse allegation made by CNA 3, and he went to go see if Resident 1 had any injury as a result of the incident. The DSD stated he noticed a bump over Resident 1's left eyebrow that was a little smaller than a quarter in size. The DSD stated the injury looked like it had been caused from some kind of forceful impact. The DSD stated he notified the ADM of his observations of the resident's injury. The DSD stated he taught abuse prevention training for staff, and that CNA 3 had followed her training. The DSD stated what CNA 3 described to them as having occurred between Resident 1 and CNA 5 sounded like abuse. The DSD stated a staff handling a resident roughly while frustrated, angry, or stressed was unacceptable. The DSD stated a resident sustaining an injury from such an event was physical abuse. The DSD stated he considered CNA 3 to be a credible witness. On 8/12/21 at 2:37 P.M., an interview was conducted with LN 2. LN 2 stated he was Resident 1's nurse on 6/24/21. LN 2 stated he had been unaware of any situation involving Resident 1 until the DSD informed him of an incident the afternoon of 6/24/21. LN 2 stated he went to assess Resident 1 and saw a bump and swollen area over the resident's left eyebrow area that was reddish in color. LN 2 stated that had been a new injury to that area of the resident's head. LN 2 stated during his assessment, he could tell Resident 1 was in pain as he knew the resident well. LN 2 stated, She seemed out of sorts. LN 2 stated Resident 1 had a behavior of sometimes refusing care and there were occasions where the resident smeared her feces. LN 2 stated Resident 1's language barrier, cognition, and hearing issues could contribute to those behaviors. LN 2 stated even if residents were confused, they still had the right to refuse care. LN 2 stated a resident who could not communicate effectively would hit or push staff away as a way of refusing. LN 2 stated staff were expected to stop what they were doing and try again later if a resident were refusing care. LN 2 stated forcing care on a resident who was resisting or refusing care was abuse. LN 2 stated staff were also expected to step away and not provide care if they felt angry or upset with a resident. LN 2 further stated nothing stood out from earlier in the day of the incident. LN 2 stated a CNA did tell him Resident 1 had a few episodes of diarrhea, but he could not recall who told him that. LN 2 stated he recalled working again the following day after the incident (6/25/21) and Resident 1's left eye was bruised and the eyelid was slightly swollen. LN 2 stated Resident 1's left eye area had puffiness and discoloration that lasted for about one to two weeks after the incident. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and on 6/26/21 at 11:38 A.M. On 8/12/21 at 3:16 P.M., a telephone call was placed to CNA 5. CNA 5 did not answer the call. A review of CNA 5's employee file indicated CNA 5's employment with the facility was terminated on 7/1/21 following immediate suspension after the incident on 6/24/21. On 8/13/21 at 9:05 A.M., an interview was conducted with CNA 4. CNA 4 stated she had provided regular care to Resident 1 for about the last four months. CNA 4 stated Resident 1 spoke a foreign language and that staff who also spoke the foreign language said the resident often did not make sense. CNA 4 stated she had no problems taking care of Resident 1 and that the resident did not resist or refuse care from her. CNA 4 stated Resident 1 could participate in turning and repositioning. CNA 4 stated, I point, and she'll turn. CNA 4 stated, I've never had to use draw sheet [used to reposition a resident who could not participate in positioning] or pull her up. She can do it. CNA 4 stated she was not working on 6/24/21, but she recalled Resident 1 in the days after. CNA 4 stated Resident 1 had a black eye, and described the resident's left eye as swollen and bruised. CNA 4 stated she had seen no injury to the resident's left eye and forehead area prior to the incident on 6/24/21. On 8/13/21 at 9:30 A.M., an interview was conducted with CNA 19. CNA 19 stated she had not provided care to Resident 1 but knew who all the residents on the unit were. CNA 19 stated she recalled Resident 1 had an injury in June 2021. CNA 19 pointed to her own left eye and stated, She [Resident 1] had a black eye. On 8/13/21 at 9:35 A.M., an interview was conducted with CNA 7. CNA 7 stated she had provided care to Resident 1. CNA 7 stated Resident 1 can be resistive to care and will at times grab at and pinch at staff. CNA 7 stated It's not all the time just on her bad days. CNA 7 stated Resident 1 had the right to refuse care and that staff were expected to stop trying to deliver care, leave, and to try again later if the resident was refusing. On 8/17/21 at 10:30 A.M., an observation and joint interview was conducted in the facility's conference room with Resident 1, the resident's responsible party (RP), and family member (FM). Resident 1 sat in her wheelchair and fidgeted with the zippers on her pants. Resident 1 did not participate in the interview or respond to interview questions that were translated by FM and the RP into the resident's language. At the time of the interview, no injury to the left eye or left side of the head was visible. The RP stated she recalled seeing Resident 1's injury to the left side of the head and eye area. The RP stated the injury had faded discoloration that was still visible during a July 2021 visit. The RP stated she received a call from the facility on or around 6/24/21, notifying her Resident 1 was being sent to the hospital to be evaluated for a fall. The RP stated the facility never communicated with her on how the fall occurred or what had been done after the fall or the plan to prevent further falls. The RP and FM stated they thought Resident 1 would refuse care from staff at times because she was afraid and could not understand what was happening or what staff were trying to do. A review of CNA 5's written statement dated 6/25/21, indicated, .Incident for 6/24/21 While providing care to [Resident 1] she had loose bowel movement x5 [five times]. Patient combative while providing care. She was standing and when I was assisting her to sit on a bed for brief change, she sat down quickly and hit the back of her head lightly on the wall while trying to lay down. Orientee reported to [LN 2] about the bruise on elbow and [MEDICATION(S)] stool while I'm still with the resident. I told her to get [LN 2] so we can show him. Patient was combative and she even scratch the orientee and orientee mentioned to me On 8/17/21 at 12:56 P.M., a second interview was conducted with CNA 3. CNA 3 recounted her statements of witnessed events that took place on 6/24/21 with CNA 5 and Resident 1. CNA 3's interview statements of the incident were consistent with the previous interview conducted on 7/22/21. CNA 3 stated she reported the incident she witnessed that occurred on 6/24/21 because It was abuse. CNA 3 stated she had worked at other facilities to include dementia care units and had not seen staff treat a resident like that before. CNA 3 stated it was the first time she had to report an incident of abuse. CNA 3 stated she did not know CNA 5 prior to 6/24/21 as it was her second day working at the facility, and she had nothing against CNA 5. Elements from CNA 5's written statement dated 6/25/21 were reviewed with CNA 3. CNA 3 stated Resident 1 was sitting in the middle of her bed and was playing in the poo [feces] and wiping it everywhere when both she and CNA 5 entered the resident's room. CNA 3 stated at no time during the incident was Resident 1 standing. CNA 3 stated Resident 1 did not sit down quick and hit the back of her head. CNA 3 stated that did not happen. CNA 3 stated Resident 1 had been actively resisting care from CNA 5. CNA 3 stated CNA 5 cleaned up Resident 1 and CNA 5 kept telling the resident don't fight me. CNA 3 stated again that CNA 5 had been rough with the resident because Resident 1 was resisting care. CNA 3 stated she herself was not scratched or injured by Resident 1. CNA 3 stated that was not true. On 8/17/21 at 2:03 P.M., an interview was conducted with the assistant director of staff development (ADSD). The ADSD stated she was present when CNA 3 reported the incident on 6/24/21. The ADSD stated CNA 3 reported that CNA 5 had been upset Resident 1 made another mess of the diarrhea and yelled at the resident. The ADSD stated Resident 1 seemed to recognize CNA 5's voice and called her an expletive in another language. The ADSD stated CNA 3 told her CNA 5 pushed the resident into the wall in anger. The ADSD stated CNA 3 told her the incident was not an accident, and was an unnecessary move that had been done in anger. The ADSD stated what CNA 3 had described to her sounded like abuse. The ADSD stated a witness's statement was very important as it may be the only way to know what happened especially if a resident could not speak for themselves. The ADSD stated Resident 1 was cognitively impaired and could not explain what happened. The ADSD further stated CNA 3 had not reported any other complaints against any other staff and there were no complaints about CNA 3. The ADSD stated she was familiar with CNA 5 and that she had heard don't tell me what to do before . The ADSD stated CNA 5 did not want anyone to correct her. On 8/17/21 at 2:45 P.M., an interview was conducted with LN 8. LN 8 stated she was the unit manager, and on 6/24/21, she had been notified by the DSD and ADSD that there had been an incident involving Resident 1. LN 8 stated she went to assess Resident 1 and noticed the resident had a bump about the size of a golf ball in diameter toward the left side of her head. LN 8 stated Resident 1 did not appear to be in distress at the time, but an injury like that would have hurt. LN 8 stated she did not recall any injury to that area of Resident 1's head before the incident, and that the injury looked recent like it had happened on 6/24/21. LN 8 stated she did not recall any injury to the back of the resident's head. LN 8 stated no staff had reported any concerns to her on 6/24/21 and no one had requested assistance with Resident 1. LN 8 stated Resident 1 had to be sent to the hospital on 6/24/21 because of the head injury. LN 8 stated she did not recall what information she provided to Resident 1's RP about the incident. LN 8 stated Resident 1 was confused and would refuse care at times. LN 8 stated even confused residents had the right to refuse care. LN 8 stated being combative during care was considered refusing care. LN 8 stated forcing care on a resident who was refusing care was abuse. LN 8 stated she expected staff to immediately stop providing care if a resident refused and to try again later. LN 8 stated staff were expected to tell the nurse and take a break if they became frustrated or stressed with a resident's behavior. LN 8 stated it was that individual staff's responsibility to self-identify when they felt stressed or upset. On 8/17/21 at 4:04 P.M., a telephone interview was conducted with CNA 5. CNA 5 stated she had been really stressed on 6/24/21. CNA 5 stated she had been assigned too many duties, and aside from her own assigned residents, had to closely monitor five additional residents. CNA 5 stated that with Resident 1's frequent episodes of diarrhea and a new orientee, It was too much. CNA 5 stated she was in her sixties and could not remember if there had been a staffing shortage or call-outs that day. CNA 5 stated the lead CNA made her take on the orientee (CNA 3) when she had too many duties. CNA 5 was asked if she had reported her concerns regarding having too many duties to the LN. CNA 5 stated she did not remember and changed the topic away from the allegation. CNA 5 was redirected back to discussing the allegation. CNA 5 stated Resident 1 had episodes of diarrhea five times that morning and had been painting it [diarrhea] all over. CNA 5 denied feeling in any way upset during this time and described herself as feeling fine and happy. CNA 5 stated Resident 1 had been kneeling on the floor mattress and then stated, She's very combative. CNA 5 stated she was holding on to Resident 1 when the resident was standing, and the resident was also holding on to her. CNA 5 stated Resident 1 fell back hard on to the bed and lightly bumped the back of her head on the window wall. CNA 5 stated she forgot to tell the LN that Resident 1 had fallen back and bumped her head. CNA 5 changed the topic away from the allegation. CNA 5 was redirected back to discussing the allegation. CNA 5 was asked if Resident 1 had hit her face or the left side of her head. CNA 5 stated I can't remember. CNA 5 stated, Resident 1 was fighting me. CNA 5 was asked if Resident 1 was resisting and refusing care. CNA 5 changed the subject away from the allegation. CNA 5 was redirected back to the allegation and was asked if care should have continued if Resident 1 was fighting against it. CNA 5 stated, She [Resident 1] needed care. CNA 5 changed the topic away from the allegation. CNA 5 was redirected back to the allegation. CNA 5 was asked if care should have stopped and been offered later. CNA 5 stated, I can't come back she was full of poo. CNA 5 was asked if Resident 1 had the right to refuse care. CNA 5 changed the subject. CNA 5 as redirected back to the allegation. CNA 5 denied pushing Resident 1 into the wall and causing the resident's head to hit the wall. CNA 5 stated she would not do something like that. CNA 5 stated she had asked CNA 3 to go get LN 2 so they could show him Resident 1's diarrhea, and CNA 3 left to get LN 2. CNA 5 stated LN 2 should have come to see Resident 1 because then this wouldn't have happened . CNA 5 was asked if either she or CNA 3 had been injured in any way during the course of the incident. CNA 5 stated that she was in her sixties and could not remember. On 8/18/21 at 8:50 A.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated eye witness statements of an abuse incident were important as they helped the facility know exactly what happened and who was involved. The ADON stated residents had the right to refuse care at any time. The ADON stated residents who had trouble communicating with staff would express refusals by resisting the care. The ADON stated if any resident resisted care, staff were expected to immediately stop providing care and to come back later and offer care again. The ADON stated forcing care upon a resident while they were resisting, It is abuse because they don't want to be touched. The ADON further stated forcing care upon a resident was, Fighting the resident and that's abuse. The ADON stated forcing care on a resident would also be considered rough handling and rough handling was abuse. The ADON stated staff were responsible to self-identify when they felt frustrated or upset with a resident, and the facility's expectation was for staff not to engage with the resident at that time. The ADON stated staff being stressed could lead to resident abuse. The ADON further stated staff should notify the LN about feeling frustrated with a resident or stressed, take a break, or request to have a change in resident assignment. On 8/18/21 at 11:10 A.M., an interview was conducted with the facility's administrator (ADM) and director of nursing (DON). The DON stated all residents had the right to refuse care. The DON stated staff were not allowed to force care upon a resident as that was considered abuse. The ADM stated, We were under the impression that this was an accident. The ADM stated CNA 3 made the incident sound accidental and that the resident's head injury occurred when the resident had been turned and repositioned. The ADM was informed that CNA 3 had witnessed Resident 1 refusing care from CNA 5 and described that part of the incident as CNA 5 fighting with the resident. The ADM was further informed that CNA 5 had made a statement that Resident 1 had been fighting me. The ADM stated residents had the right to refuse care and staff fighting with a resident to provide care was abuse. The ADM stated Resident 1 refusing care from CNA 5 was new information. The ADM stated, I would have substantiated the allegation of abuse with the new information. The ADM stated the incident that occurred with Resident 1 and CNA 5 was abuse. The DON was asked what a reasonable person would have felt to have gone through the incident that occurred on 6/24/21 as described by CNA 3. The DON stated, It would be traumatic. On 8/18/21 at 12:35 P.M., an interview was conducted with the ADM, DON, assistant administrator, and CNA 3. CNA 3 stated the incident she witnessed on 6/24/21 between CNA 5 and Resident 1 that resulted in the resident sustaining a head injury was not accidental. CNA 3 stated CNA 5 had been stressed and was upset after Resident 1 had a fifth episode of diarrhea in which the resident smeared the feces all around. CNA 3 stated CNA 5 did an unnecessary move while upset with the resident and that it was not part of turning or repositioning. CNA 3 stated This was no accident. 2. A review of Resident 2's Resident Face Sheet, dated 5/27/21, indicated the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's Resident Face Sheet, dated 5/27/21, further indicated the resident was her own responsible party (medical decision maker). A review of Resident 2's Minimum Data Set Assessment (an assessment tool) dated 2/17/21, indicated the resident scored 13 on the Brief Interview for Mental Status (a score of 13-15 indicated the resident was cognitively intact). On 7/21/21 at 3:10 P.M., an interview was conducted with certified nursing assistant (CNA) 10 to discuss a facility reported incident of alleged abuse between CNA 10 and Resident 2 which occurred on 6/27/21. CNA 10 stated she knew Resident 2 well and regularly took care of the resident. CNA 10 stated she and Resident 2 had, [A] way of talking to each other and an understanding. CNA 10 stated Resident 2 started treating her like a slave and being a bit mean lately. CNA 10 stated she asked the lead CNA (CNA 12) to not assign her to provide care to Resident 2 anymore. CNA 10 stated CNA 12 told her she could not change the assignment. CNA 10 stated on the day of the incident (6/27/21), she asked CNA 14 to help Resident 2 take a shower. CNA 10 stated that she had Had enough of [Resident 2]. CNA 10 stated that she helped prepare Resident 2 for a shower by assisting the resident into the mechanical lift [used to move a resident who could not move independently] with CNA 14. CNA 10 stated Resident 2 was upset that CNA 14 would be the CNA giving her a shower. CNA 10 stated Resident 2 then told her that she (CNA 10) had a lot of problems. CNA 10 stated she told the resident back that it was not right for her (Resident 2) to say that. CNA 10 stated CNA 14 was present and had misinterpreted her relationship with Resident 2 and the interaction between them. Resident 2's clinical record was reviewed for documentation related to the incident on 6/27/21. There was no documentation of the incident. On 7/22/21 at 11:20 A.M., an interview was conducted with CNA 14. CNA 14 stated on 6/27/21, she was newly hired and had been orienting (learning the routine from an experienced staff). CNA 14 stated on 6/27/21 she had helped CNA 10 by providing Resident 2 with a shower. CNA 14 stated when she entered Resident 2's room to help with care, CNA 10 and Resident 2 were arguing. CNA 14 stated Resident 2 told her that CNA 10 was always miserable. CNA 14 stated CNA 10 responded to Resident 2 with a loud and ugly attitude, 'Me miserable? At least I have someone [who cares].' CNA 14 stated there was a lot of arguing and she could not understand everything that was said in the argument. CNA 14 stated, It was a loud and inappropriate interaction. CNA 14 stated Resident 2 told her during shower care that she was used to CNA 10 treating her that way. CNA 14 stated Resident 2 stated that she did not understand why someone would always come to work with an attitude like that. CNA 14 stated it seemed to her like Resident 2 was accustomed to being treated in that way by CNA 10. CNA 14 stated the incident was rude, disrespectful, and it was verbal abuse. CNA 14 stated, I was shocked and reported the incident. CNA 14 stated the next day Resident 2 thanked her for reporting the incident. On 7/22/21 at 4:25 P.M., an interview was conducted with Resident 2. Resident 2 stated she had an incident on Sunday (6/27/21) with CNA 10. Resident 2 stated CNA 10 had provided care to her on a regular basis for the last two years. Resident 2 stated CNA 10 frequently would tell her not to speak during the care and that made her feel bad. Resident 2 stated CNA 10 was, Very controlling and things have to be done her way. Resident 2 stated CNA 10 would twist her hair up as part of hair care. Resident 2 demonstrated with her hands arranging her hair up into a hairdo. Resident 2 stated there were times she would take her hair down after CNA 10 fixed it up because she wanted her hair to be down. Resident 2 stated CNA 10 would yell at her for taking her hair down. Resident 2 stated She [CNA 10] yells at me when I don't do what she wants. Resident 2 stated CNA 10 could be mean. Resident 2 stated, I would get a knot in my stomach when she [CNA 10] gets upset with me. Resident 2 stated that if she started talking during care, CNA 10 would throw up her hands and yell, I can't take it, and walk out of the room. Resident 2 stated CNA 10 was domineering and reminded her of her mother. Resident 2 stated she grew up in an abusive home where her mother would pull her across the floor by her hair, yell at her, and demean her. Resident 2 stated she ran away from home at [AGE] years old to get away from her abusive mother. Resident 2 stated CNA 10's treatment reminds me of my mother. Resident 2 stated on Sunday (6/27/21), CNA 10 did not want to do her shower. Resident 2 stated CNA 14 did her shower. Resident 2 stated when CNA 14 was bringing her to the shower room, CNA 10 yelled in the hall, There's miserable [Resident 2's name]! Resident 2 stated, I know the residents don't know who [Resident 2] is, but I didn't like that said so everyone could hear. Resident 2 stated it made her feel embarrassed and hurt. Resident 2 stated, It was then I had enough of her [CNA 10] treatment. Resident 2 stated she had had enough of CNA 10 telling her that she was difficult, and no one wanted to take care of her. Resident 2 stated she talked to CNA 12 and told her she did not want CNA 10 to take care of her anymore. Resident 2 stated she did not feel CNA 10's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 further stated it was not abuse because CNA 10 did not hit her. Resident 2 acknowledged there were different types of abuse. Resident 2 stated if how CNA 10 treated her was done to a resident who could not speak for themselves then that would be abuse. Resident 2 stated again that she did not want CNA 10 to lose her job or get in trouble. A review of CNA 14's written statement of the incident dated 6/28/21, indicated, .[CNA 10] was scheduled to do [Resident 2's] shower . I was going to help her with the transfer so we were getting everything ready. I walked into the room and [CNA 10] was arguing back and forth with [Resident 2]. She was telling her not to talk that she didn't want to hear her or talk to her anymore. She [CNA 10] also told the patient [Resident 2] that she was probably miserable because she didn't have anyone. She [CNA 10] is very rude to the patients and she talks back to them it's been a couple times I have heard her screaming or talking rudely to the patients. Other CNAs/LVNs [licensed vocational nurses] have heard her as well A review of CNA 12's written statement of the incident dated 6/28/21, indicated, . I [CNA 12] was making my rounds when [Resident 2] told me that [CNA 10] told her to shut up! [Resident 2] was telling me she is tired of her [CNA 10] talking to her like that and her mood swing [sic]. And hard [sic] [CNA 10] telling outher [sic] staff that she [Resident 2] is to [sic] much and she [NAME], & doesn't [sic] want to take care of her. So [Resident 2] told me she doesn't [sic] wan't [sic] [CNA 10] caring for her On 7/23/21 at 11:37 A.M., an interview was conducted with CNA 12 with the director of nursing (DON) present. CNA 12 stated CNA 10 did not inform her of any difficulties providing care to Resident 2. CNA 12 stated CNA 10 had not asked for her assignment to be changed. On 8/24/21 at 2:50 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON stated the incident that occurred between CNA 10 and Resident 2 was unacceptable. The DON stated staff were not allowed to speak to residents like CNA 10 had done to Resident 2. The DON reviewed Resident 2's clinical record and stated there had been no documentation related to the incident with CNA 10. The DON stated all allegations of abuse substantiated or not substantiated should be documented in a resident's medical record. The DON stated this was important in order to monitor for any emotional distress related to the event. The DON further stated it was the facility's practic [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure reported allegations of abuse were reported according to mandated reporting timeframes of 24 hours, when: 1. Certified nursing assistant (CNA) 1, reported an incident of verbal and physical abuse occurring between one resident (Resident 3) and CNA 10, approximately two months after witnessing the event (Cross reference F600 # 2 and #3). 2. The acting administrator (AA) failed to report an allegation of physical abuse that was allegedly witnessed by a resident's (Resident 5) family member (FM) 2 to the California Department of Public Health (CDPH-regulates the facility for compliance) within 24 hours of having knowledge of the allegation. These failures to report abuse allegations delayed the facility's identification of CNA 10's abusive behavior and did not prevent further abuse which then occurred to Resident 2. In addition, failure to report abuse allegations to CDPH had the potential to compromise the safety of all residents currently in the facility by exposing them to potential unreported abuse. Findings: 1. A review of Resident 2's Resident Face Sheet (basic information related to the resident such as address, insurance, responsible party), dated 5/27/21, indicated the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's Resident Face Sheet, dated 5/27/21, further indicated the resident was her own responsible party (medical decision maker). A review of Resident 3's Resident Face Sheet, dated 8/20/21, indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's Minimum Data Set Assessment (an assessment tool), dated 6/23/21, indicated the resident scored zero out of 15 on the cognitive assessment (a score of zero meant the resident had severe cognitive impairment). On 7/21/21 at 3:10 P.M., an interview was conducted with certified nursing assistant (CNA) 10 to discuss a facility reported incident of alleged abuse between CNA 10 and Resident 2 which occurred on 6/27/21. CNA 10 stated she knew Resident 2 well and regularly took care of the resident. CNA 10 stated she and Resident 2 had, [A] way of talking to each other and an understanding. CNA 10 stated Resident 2 started treating her like a slave and being a bit mean lately. CNA 10 stated on the day of the incident (6/27/21), she asked CNA 14 to help Resident 2 take a shower. CNA 10 stated that she had Had enough of [Resident 2]. CNA 10 stated that she helped prepare Resident 2 for a shower by assisting the resident into the mechanical lift [used to move a resident who could not move independently] with CNA 14. CNA 10 stated Resident 2 was upset that CNA 14 would be the CNA giving her a shower. CNA 10 stated Resident 2 then told her that she (CNA 10) had a lot of problems. CNA 10 stated she told the resident back that it was not right for her (Resident 2) to say that. CNA 10 stated CNA 14 was present and had misinterpreted her relationship with Resident 2 and the interaction between them. Resident 2's clinical record was reviewed for documentation related to the incident on 6/27/21. There was no documentation of the incident. On 7/22/21 at 11:20 A.M., an interview was conducted with CNA 14. CNA 14 stated on 6/27/21, she was newly hired and had been orienting (learning the routine from an experienced staff). CNA 14 stated on 6/27/21 she had helped CNA 10 by providing Resident 2 with a shower. CNA 14 stated when she entered Resident 2's room to help with care, CNA 10 and Resident 2 were arguing. CNA 14 stated Resident 2 told her that CNA 10 was always miserable. CNA 14 stated CNA 10 responded to Resident 2 with a loud and ugly attitude, 'Me miserable? At least I have someone [who cares].' CNA 14 stated there was a lot of arguing and she could not understand everything that was said in the argument. CNA 14 stated, It was a loud and inappropriate interaction. CNA 14 stated Resident 2 told her during shower care that she was used to CNA 10 treating her that way. CNA 14 stated Resident 2 stated that she did not understand why someone would always come to work with an attitude like that. CNA 14 stated it seemed to her like Resident 2 was accustomed to being treated in that way by CNA 10. CNA 14 stated the incident was rude, disrespectful, and it was verbal abuse. CNA 14 stated, I was shocked and reported the incident. CNA 14 stated the next day Resident 2 thanked her for reporting the incident. On 7/22/21 at 3 P.M., an interview was conducted with CNA 1. CNA 1 stated about two months ago (in or around May 2021) she had assisted CNA 10 with turning and repositioning Resident 3. CNA 1 stated while attempting to turn and reposition Resident 3, CNA 10 became frustrated when Resident 3 could not participate in the turning. CNA 1 stated that CNA 10 yelled at Resident 3 to turn and then slapped her legs hard which made an audible sound when the resident did not move. CNA 1 stated the slap had left a temporary red mark on Resident 3's leg. CNA 1 stated she did not report the incident at the time it occurred because she was afraid of retaliation as CNA 10 had many friends in the facility including management. CNA 3 stated she came forward now because she did not want what happened to Resident 3 to happen to other residents. CNA 1 stated remaining silent about what she witnessed CNA 10 do to Resident 3 had bothered and concerned her. CNA 1 stated what she witnessed was verbal and physical abuse. CNA 1 stated she had no problems or disagreements with CNA 10. CNA 1 stated she knew failing to report what she witnessed CNA 10 do had been wrong. CNA 1 stated she had not followed her abuse prevention training as a mandated reporter. On 7/22/21 at 4:25 P.M., an interview was conducted with Resident 2. Resident 2 stated she had an incident on Sunday (6/27/21) with CNA 10. Resident 2 stated CNA 10 had provided care to her on a regular basis for the last two years. Resident 2 stated CNA 10 frequently would tell her not to speak during the care and that made her feel bad. Resident 2 stated CNA 10 was, Very controlling and things have to be done her way. Resident 2 stated She [CNA 10] yells at me when I don't do what she wants. Resident 2 stated CNA 10 could be mean. Resident 2 stated, I would get a knot in my stomach when she [CNA 10] gets upset with me. Resident 2 stated that if she started talking during care, CNA 10 would throw up her hands and yell, I can't take it, and walk out of the room. Resident 2 stated CNA 10 was domineering and reminded her of her mother. Resident 2 stated she grew up in an abusive home where her mother would pull her across the floor by her hair, yell at her, and demean her. Resident 2 stated she ran away from home at [AGE] years old to get away from her abusive mother. Resident 2 stated CNA 10's treatment reminds me of my mother. Resident 2 stated on Sunday (6/27/21), CNA 10 did not want to do her shower. Resident 2 stated CNA 14 did her shower. Resident 2 stated when CNA 14 was bringing her to the shower room, CNA 10 yelled in the hall, There's miserable [Resident 2's name]! Resident 2 stated, I know the residents don't know who [Resident 2] is, but I didn't like that said so everyone could hear. Resident 2 stated it made her feel embarrassed and hurt. Resident 2 stated, It was then I had enough of her [CNA 10] treatment. Resident 2 stated she had had enough of CNA 10 telling her that she was difficult, and no one wanted to take care of her. A review of CNA 14's written statement of the incident dated 6/28/21, indicated, .[CNA 10] was scheduled to do [Resident 2's] shower . I was going to help her with the transfer so we were getting everything ready. I walked into the room and [CNA 10] was arguing back and forth with [Resident 2]. She was telling her not to talk that she didn't want to hear her or talk to her anymore. She [CNA 10] also told the patient [Resident 2] that she was probably miserable because she didn't have anyone. She [CNA 10] is very rude to the patients and she talks back to them it's been a couple times I have heard her screaming or talking rudely to the patients On 7/23/21 at 9:29 A.M., another interview was conducted with CNA 1. CNA 1 repeated what she had witnessed occur with CNA 10 and Resident 3, and her statements were consistent with her previous interview on 7/22/21. CNA 1 stated she was concerned her employment would be terminated and that she would receive disciplinary action to included possible revoking of her CNA certificate for failure to report witnessed abuse in a timely manner. CNA 1 stated that she knew she would be facing disciplinary action and that her statements about what she witnessed happen between CNA 10 and Resident 3 had been accurate. On 7/23/21 at 9:45 A.M., a joint interview was conducted with the acting administrator (AA) and the director of nursing (DON). The AA acknowledged the facility was cited in May 2021 for failure to report an allegation of abuse. The DON stated since the citation was issued (in May 2021) the facility had conducted extensive trainings and built awareness of recognizing potential signs of abuse and of reporting requirements. The DON stated there was a facility confidential compliance line if staff were worried about retaliation. The AA stated the facility had learned from past mistakes and was taking abuse allegations seriously. The DON stated it was difficult to learn that CNA 1 failed to report an incident of witnessed abuse that happened approximately two months ago between Resident 3 and CNA 10. The DON stated CNA 1 should have immediately reported the incident to the DON or AA. The DON further stated CNA 1's failure to report witnessed abuse had potentially allowed an alleged perpetrator of abuse to continue to abuse residents for two months. The DON stated the incident on 6/27/21 that occurred with CNA 10 and Resident 2 could have been prevented had CNA 1 reported the incident immediately. The DON stated CNA 10 would be suspended again. On 7/23/21 at 12:15 P.M., a joint observation and interview was conducted with Resident 3 and the residents responsible party (RP) 1. Resident 3 sat in her wheelchair and wore clothing that covered her arms and legs. RP 1 stated he went to the facility almost every day to feed Resident 3 lunch. RP 1 stated Resident 3's memory was poor, and she could not recall events. RP 1 interpreted the conversation to Resident 3. Resident 3 was asked, how was her care? Resident 3 stated Yes. Resident 3 did not participate further in the interview. On 8/12/21 at 11:15 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated he was responsible for providing the facility's abuse training and supervised the facility's CNAs. The DSD stated CNA 1 had not followed her abuse reporting training by reporting an incident of suspected abuse immediately. The DSD stated due to CNA 1's failure to report what she witnessed, residents were not protected from the possibility of further abuse. The DSD stated there were no known problems or issues between CNA 10 and CNA 1. On 8/27/21 at 8:29 A.M., a telephone interview was conducted with CNA 10. CNA 10 stated she got along well with her coworkers and did not have any issues or problems with anyone. CNA 10 denied slapping or yelling at Resident 3. CNA 10 stated she had resigned after hearing she had another accusation against her. CNA 10 stated she was on friendly terms with management and that management misses me. On 10/12/21 at 3:15 P.M., a joint interview was conducted with the DON and acting administrator (AA). The DON stated the incident between CNA 10 and Resident 3 was abuse. The DON stated the incident between CNA 10 and Resident 2 was abuse. The DON stated CNA 10's behavior was a pattern of abuse. The AA stated she agreed with the DON's statements. Both the DON and AA stated that abuse was harm. A review of CNA 1's employee training indicated CNA 1 received training on abuse identification and mandated abuse reporting on 8/4/20 and 5/18/21. 2. A review of Resident 5's Resident Face Sheet, dated 9/23/21, indicated the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/17/21, CDPH received a written complaint from Resident 5's health plan provider (HP) indicating, .[FM 2] reported safety concerns to [HP] on 9/17/21 over the phone . [FM 2] also reports [Resident 5] complained a few months ago about one nurse hitting him. [FM 2] reports she witnessed [Resident 5] being hit on his face by a .nurse when she was outside of his window and nurse was unaware that [FM 2] was there On 9/21/21 at 12 P.M., a telephone interview was conducted with FM 2. An official language translator service was utilized. FM 2 stated she could not give an exact date or time of the incident, but she was at Resident 5's window for a window visit when she observed a female nurse slap Resident 5 in the face to wake him up. FM 2 stated the nurse proceeded to slap Resident 5 along his upper body and legs. FM 2 stated she banged on Resident 5's window and the nurse ran away. FM 2 stated she could not clearly describe the nurse she saw. FM 2 attempted to describe the nurse and then said she would be able to identify her if she saw her again. FM 2 stated what she saw the nurse do was abuse. FM 2 stated she reported the incident to Resident 5's HP. On 9/23/21 at 9:30 A.M., an interview was conducted with the acting administrator (AA) and director of nursing (DON). The AA stated the facility's social worker received a call on 9/21/21 from Resident 5's HP alleging an abuse incident had taken place and had been witnessed by FM 2. The DON stated FM 2 alleged she witnessed a staff member slapping Resident 5's body. The DON stated FM 2 also told the facility of other concerns involving missing items and visitation. The DON stated the facility was taking the abuse allegation seriously and was still investigating it. The DON stated the facility planned another care conference with FM 2 to further discuss the abuse allegation as well as FM 2's other concerns. The AA was asked if the facility had reported the allegation of abuse to CDPH, and she stated, No. Both the AA and DON stated the abuse allegation should have been reported to the State agency. The AA stated she would go now and report the incident to the State Agency. On 9/23/21 at 2:20 P.M., an interview was conducted with the AA. The AA stated she had finished the care conference with FM 2. The AA stated, We decided to keep the allegation as a grievance [internal facility dispute process]. We decided not to report it. The AA was reminded that federal and state regulations required all allegations of abuse to be reported as per regulation. The AA then stated she would report the allegation of abuse. On 9/24/21 at 10:07 A.M, an interview was conducted with the AA and DON. The DON stated his part of the facility's abuse process was the clinical component such as interviewing residents and updating care plans. The DON stated he was not involved in receiving the abuse allegation or reporting the allegation to appropriate agencies. The AA stated the abuse allegation should have been reported within 24 hours of the facility being aware of the allegation. The AA acknowledged the facility had been aware of the abuse allegation on 9/21/21. The AA stated the facility's reporting process had not happened as usual. The AA stated, We made the decision to keep it as a grievance and not report. The AA was asked to clarify who we were. The AA stated we included the social services director (SSD), DON, and the AA. On 9/24/21 at 10:48 A.M., a telephone interview was conducted with HP case manager (HPCM). The HPCM stated she called the facility on 9/17/21 to report FM 2's concerns and to report an allegation of abuse to the facility. The HPCM stated she had to leave a generic voice message for the social worker. The HPCM stated she then proceeded to report the allegation of abuse to CDPH. The HPCM stated she called the facility again on 9/21/21 and reported FM 2's concerns to the social worker. The HPCM stated, I spoke in great detail, and reported all FM 2's concerns including the allegation Resident 5 had been slapped by a nurse. FM 2 stated she made it clear to the facility there was an allegation of physical abuse. On 9/24/21 at 11:20 A.M., an interview was conducted with the DON. The DON stated he had no part in the decision not to report FM 2's allegation of abuse. The DON stated, I always tell them report everything. The DON stated the AA was currently the facility's abuse prevention coordinator and it was her decision of what and when to report. The DON stated when HP reported to the facility an allegation of abuse on 9/21/21 that the facility should have then reported the allegation to CDPH. The DON stated the facility had reported the allegation of abuse late. On 9/24/21 at 3:33 P.M., an interview was conducted with the AA and DON. The AA was asked to clarify the situation of the facility's decision to not report the allegation of abuse. The AA was asked whose decision it had been to not report the abuse allegation and to instead make the abuse allegation a facility grievance. The AA stated, The decision was mine. A review of the document titled Report of Suspected Dependent Adult/Elder Abuse SOC 341(a legal form), form dated 11/18, indicated, .Reporting party definitions, Mandated Reporter . Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult .including administrators, . and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, . is a mandated reporter . If the abuse occurred in a LTC [long-term care] facility, was physical abuse, but did not result in serious bodily injury, report by telephone to the local law enforcement agency within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse . Send the written report to .[CDPH] . within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse A review of the facility's policy titled Abuse Investigation and Reporting, revised December 2016, indicated, .All reports of resident abuse, . shall be promptly reported to local, state and federal agencies . Reporting 1. All alleged violations involving abuse, .will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency . 2. Suspected abuse, . will be reported within two hours . 3. Alleged abuse, . a. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours

Based on observation, interview and record review, the facility failed to ensure care was provided to one of three residents (Resident 4) in a manner consistent with the Resident 4's comprehensive assessment and according to professional standards of nursing practice, when: 1. Certified nursing assistant (CNA) 13 did not receive report (information about a resident's level of care) prior to providing care to Resident 4. 2. CNA 15 did not perform Resident 4's bed mobility (how a resident moves to and from lying position and turns side to side while in bed) with two or more staff as indicated in the resident's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) and according to professional standards of practice. In addition, CNA 13 and CNA 15 did not communicate the care provided to Resident 4 in a language he could understand. As a result of these deficient practices, Resident 4 stated he received care he felt was rough and this caused him to experience pain and fear. Findings: A review of Resident 4's Resident Face Sheet, dated 9/30/21, indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS, dated [DATE], indicated the resident was totally dependent on staff to perform activities of daily living (self-care activities such as bathing, eating, toileting, and grooming) to include bed mobility. The MDS further indicated Resident 4 required two or more staff to perform his bed mobility. A review of Resident 4's physician's history and physical exam, dated 6/23/21, indicated, .General Appearance: weak, lying in bed .Neuro-muscular: minimal movement of legs/feet, minimal movement of arms/hands . This resident has the capacity to understand and make decisions A review of Resident 4's physician's progress note, dated 7/6/21, indicated, .Patient is still very weak and has minimal movement of his legs . Both arms are still very weak. He is able to move his fingers . he is functionally quadriplegic [partial or complete paralysis of all four limbs] A review of Resident 4's physician's progress note, dated 8/5/21, indicated, .Patient is now able to shrug her [sic] shoulders and momentarily lift his arms off the bed while lying supine [on his back]. He can lift his left leg against gravity but the right leg he moves the ankle only .nowhere near being able to get out of bed or walk On 9/23/21 at 2:50 P.M., an interview was conducted with CNA 20 who was the P.M. shift (3 P.M. to 11 P.M.) lead CNA (had responsibilities that included creating CNA assignments and supervision over other CNAs). CNA 20 stated she was familiar with Resident 4 and spoke the same foreign language as he did. CNA 20 stated on or around the time of Resident 4's admission to the facility (6/22/21), the resident told her that CNA 13 had been rough with him during care and had placed his call light (device used to signal for assistance) where he could not reach it and use it to ask for help. On 9/23/21 at 3:51 P.M., an observation and interview were conducted with Resident 4 while inside the resident's room. CNA 20 was present and translated the interview. Resident 4 stated he was able to move his hands and arms now, but when he was first admitted to the facility (6/22/21), he was only able to move his head. Resident 4 stated he had a specialized call light that was placed on his pillow that he could activate with his head or face. Resident 4 stated he did not recall the exact date, but on the day he was admitted or the day after, he had activated his call light and CNA 13 had responded to it. Resident 4 stated he felt CNA 13's care was rough and that she had moved him around by pushing and pulling on him. Resident 4 stated CNA 13's actions had caused him pain and discomfort. Resident 4 stated CNA 13 then placed his call light up on the corner of his mattress where he could not access it. Resident 4 stated he had not been capable of raising his arm to retrieve the call light. Resident 4 stated he told CNA 20 about the incident and he did not see CNA 13 again. Resident 4 stated he also experienced care he felt was rough when CNA 15 provided care to him. Resident 4 stated CNA 15 would pull the blanket off him, turn him over in bed, and insert pillows behind him and all this caused him pain and discomfort. Resident 4 stated he did not tell anyone about how CNA 15 provided care to him. Resident 4 stated he tried to forget the incidents that happened with CNA 13 and CNA 15. Resident 4 stated he still received care from CNA 15. Resident 4 was asked how the care provided to him from CNA 13 and CNA 15 made him feel. Resident 4 became tearful, wiped his eyes with his hand and tried to hide his face in the pillow. Resident 4 paused, took a deep breath, blinked his eyes, cleared his throat, and then apologized for crying. Resident 4 stated the incident with CNA 13 had made him feel vulnerable because he could not move at all. Resident 4 stated he felt taken advantage of because staff did not speak his language and he could not say anything about the way he was treated because he did not speak English. Resident 4 stated he called his brother after the incident with CNA 13 and told him, I don't want to be here. Resident 4 stated the incident with CNA 13 made him feel afraid. Resident 4 stated he felt other CNAs would treat him in the same manner because he could not move at all or fully communicate his needs. Resident 4 stated the incidents with CNA 13 and CNA 15 made him hesitate to ask staff for help. On 9/23/21 at 4:16 P.M., an interview was conducted with CNA 20. CNA 20 stated she had never seen Resident 4 become emotional and cry. CNA 20 stated Resident 4 was not someone who complained to her. On 9/23/21 at 4:35 P.M., an interview was conducted with CNA 13. CNA 13 stated she remembered the incident with Resident 4 while working on the P.M. shift on or around the time of his admission (6/22/21). CNA 13 stated she remembered going to answer Resident 4's call light and being surprised to see Resident 4. CNA 13 stated she had expected a different resident to be in Resident 4's bed. CNA 13 stated she did not know anything about Resident 4, but assumed he was a new admission. CNA 13 stated she straightened him out, by herself and then checked his brief to see if it was wet. CNA 13 stated all nursing staff were expected to get a report about their residents. CNA 13 stated she did not get a report before providing care to Resident 4, and that she knew nothing about him. CNA 13 stated she had explained the care to Resident 4 but he did not answer her. CNA 13 stated she did not think he understood what she was saying. CNA 13 stated she did not speak Resident 4's language. CNA 13 stated she had adjusted Resident 4's pillow before leaving the resident's room. CNA 13 stated she did not know Resident 4 was paralyzed and did not know he had a specialized call light or that it needed to be placed in his pillow. On 9/23/21 at 5:13 P.M., an interview was conducted with CNA 15. CNA 15 stated she knew Resident 4 well and last provided care to the resident on 9/22/21. CNA 15 stated she did not speak or understand Resident 4's language and the resident did not speak English except for one or two words. CNA 15 stated as a way of communicating, she and Resident 4 mostly pointed at stuff. CNA 15 stated Resident 4 required total care as he could not turn or sit up on his own. CNA 15 was asked how many staff were required to turn and position Resident 4 in bed. CNA 15 stated, I can do it myself. CNA 15 stated it would be safer and more comfortable to Resident 4 if there were two staff to turn and reposition him. CNA 15 stated she turned and repositioned Resident 4 by herself because everyone was too busy to help. CNA 15 stated she had to push and pull Resident 4 to turn and reposition him as the resident could not participate in the activity. CNA 15 stated she would not have to push or pull on Resident 4 if two staff performed the resident's bed mobility. On 9/24/21 at 12:57 P.M., a joint interview was conducted with CNA 2 and CNA 6. CNA 2 stated it was important to get report on the residents so staff providing care would know how to properly provide care to them. CNA 6 stated she agreed with CNA 2's statement. CNA 6 further stated she usually worked on the P.M. shift and that shift did not give report to CNAs. On 9/24/21 at 1:35 P.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated all direct care staff were expected to receive a report on the residents who were in their care. LN 1 stated direct care staff had to understand the residents they were assigned to provide care for and had to be aware of any special needs or ways to deliver care. LN 1 stated receiving report was a standard of practice. On 9/24/21 at 2:11 P.M., an interview and record review was conducted with LN 9. LN 9 reviewed Resident 4's clinical record and stated residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LN 9 stated based on that alone, Resident 4 should have received care such as turning and repositioning by two staff to ensure the care was delivered in a manner that would be comfortable to the resident. LN 9 stated since Resident 4 could not participate in the turning and repositioning, one staff turning him would be uncomfortable as they would have to push or pull on the resident to move him without the help of another staff. LN 9 stated all direct care staff providing care should know their residents. On 9/30/21 at 7:16 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated he was familiar with Resident 4 and the resident required two or more staff to turn and reposition him. The DSD stated turning and repositioning should always be provided by two or more staff for residents who were totally dependent on the staff. The DSD stated this was a basic standard of practice. The DSD stated CNAs should not provide care to a resident without first getting report about the resident. The DSD further stated he had not been aware of Resident 4's complaint of receiving rough care when it had been reported to CNA 20. The DSD stated when residents complained to CNAs about the quality of care provided to them, those complaints needed to be reported to him and tracked. The DSD stated this needed to be done so any perceived rough handling or care issues could be readily addressed. On 9/30/21 at 9:30 A.M., an interview and record review was conducted with the MDS nurse (MDS 1). MDS 1 reviewed Resident 4's MDS assessment dated [DATE] and stated she performed the resident's assessment for functional status and determined the resident required two or more staff for bed mobility. MDS 1 stated at the time of her assessment, the resident could not participate with bed mobility in any way. MDS 1 stated Resident 4 required total care and full staff performance to be able to do many of his ADLs including bed mobility. On 9/30/21 at 3:46 P.M., an interview was conducted with the director of nursing (DON). The DON stated it was the facility's expectation for direct care staff to know the care needs of their assigned residents. The DON stated it was his expectation that all direct care staff received report on their residents before providing care to them. The DON stated the expectation was for two staff to work together to provide care to residents requiring total or extensive assistance with turning or repositioning and other related care tasks. The DON stated this was to be done to ensure resident care was provided in a safe and comfortable manner. A review of the undated, facility document titled, Job Description Job Title: Certified Nursing Assistant (CNA), indicated, . Essential Responsibilities and Job Functions . 12. Shift reports/Notes: Exchanges and communicates resident care information via charge nurse and shift report A review of the facility's undated, policy titled Avoidance of Rough Handling, indicated, .This facility will provide care to residents in a manner that avoids rough handling and prevents injury .h. Assist with care as appropriate/indicated

Based on observation, interview and record review, the facility failed to protect one of 2 residents (Resident 2) from potential abuse when Resident 2 was transferred to Resident 1's room after Resident 1 was involved in an altercation with previous roommate (Resident 5). Resident 1 was identified by staff as unpredictable and territorial and had been involved in 3 resident to resident altercations. This failure had the potential to result in an altercation between Resident 1 and Resident 2 which may result in a serious injury, harm, impairment, or death to Resident 2. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Event Reports and Interdisciplinary Team (IDT- an approach that involved team members from different disciplines) Conference Record for the months of June, July and August 2021 was conducted. According to these records, Resident 1 was involved in three resident to resident altercations. Per the records, the first altercation occurred on 6/1/2021 which involved Resident 3; The second altercation occurred on 6/27/2021 which involved Resident 4; The third altercation occurred on 8/18/2021 which involved Resident 5. Resident 1's Electronic Health Records indicated the following: First altercation (6/1/2021) A review of Resident 1's Event Report, dated 6/1/2021 at 3:52 P.M., indicated that on 6/1/2021 at 12:45 P.M., Resident 1 was involved in a resident to resident altercation with Resident 3. The document indicated Resident 1 stated, I pushed him on his chest I didn't want him in my room. A review of Resident 1's Care Plan Problem Start Date 6/2/2021 indicated (Resident 1's name) was involved in resident to resident event on 6/1/2021. Per the same care plan, one of the interventions developed for this problem was Separate both residents immediately. Second Altercation (6/27/2021) A review of Resident 1's IDT Conference Record, dated 6/29/2021 at 3:16 P.M., indicated that a resident to resident altercation occurred on 6/27/2021 at 2:25 P.M. inside Resident 1's room. Per the IDT note, EVENT: Licensed nurse noted another male resident (Resident 4) with an abrasion to his left lower eye. Resident (Resident 1) stated to staff that he pushed other male resident (Resident 4) and scratched the other resident (Resident 4) on the face for wandering into his (Resident 1) room. Both residents were separated immediately . A review of Investigation summary for the incident that occurred on 6/27/2021 completed by the Administrator (ADM), dated 7/2/2021 indicated, Resident 4 entered Resident 1's room. The report indicated Resident 1 scratched Resident 4's face which resulted in a scratch that measured 1 centimeter long. Per the same report, A stop sign has been placed in front of (Resident 1's) room to deter residents from wandering in. Third Altercation (8/18/2021) A review of Resident 1's Event Report, dated 8/18/2021, indicated that an allegation of physical abuse was reported by Resident 5 against Resident 1 on 8/18/2021 at 5:30 P.M. A review of Resident 1's Progress Note, dated 8/18/2021 at 7:12 P.M., written by Licensed Nurse (LN) 2, indicated Resident to Resident: Writer approach by the certified nursing assistant (CNA) and this Res. (Resident 1) in the nursing station reporting that this resident (Resident 1) admitting that he (Resident 1) hit the other res. (Resident 5) on his right leg while in the room sitting on his W/C (wheelchair). A review of Resident 1's IDT Conference Report, dated 8/19/2021 at 1:53 P.M., indicated the incident between Resident 1 and Resident 5 occurred inside the residents' room (Resident 1 and Resident 5 were roommates). Per the same IDT report, Accelerated Measures: Separated residents, Reassured safety, Investigate, Notified ADM (Administrator), MD (medical physician)/RP (responsible party)/SSW (Social Worker) notified. A review of Resident 5's undated Facesheet indicated that Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's IDT Conference Report, dated 8/19/2021 at 2:21 P.M., indicated that the incident between Resident 1 and Resident 5 occurred on 8/18/21 at 5 P.M. inside both Resident 1 and Resident 5's room. Per the same IDT report, Root Cause: Upon interviewing Resident (Resident 5) he stated that roommate (Resident 1) was upset. He (Resident 1) was angry because the staff asked him to wait for his shower. He (Resident 5) said the resident (Resident 1) pulled back the curtain and kicked him (Resident 5) in the right leg he (Resident 5) got up in his w/c and went to staff and told them what happened they checked him (Resident 5) out and moved him (Resident 5) and his (Resident 5) belongings to another room. Per nurses note: At 5:30 pm pt (patient) (Resident 5) and CNA made this writer aware that he (Resident 5) was hit on his right leg by his roommate (Resident 1). Patient (Resident 5) was immediately assigned to a new room for safety purposes. MD, supervisor and administrator made aware of incident. Patient (Resident 5) shows no signs of emotional distress at this time. Will continue to monitor. A review of Investigation Summary faxed to the California Department of Public Health on 8/25/2021 indicated, During dinner on 8/18/21 (Resident 5) and (Resident 1) were in their room. (Resident 1) was sitting by the window and (Resident 5) was sitting on his bed. When dinner was completed (Resident 1) was going to take a shower he had to get what he needed and had to step around (Resident 5). Resident 5 immediately after wheeled out of his room reporting that (Resident 1) had hit his leg the (LN 2), charge nurse asked (Resident 1) if this had occurred, and he did say yes. The roommates were separated into different rooms at the time of the incident, there was no injury, and there have been no issues since then. The incident is substantiated. A review of Resident 5's Census (a record that shows the resident's rooms while at the facility) indicated that on 8/18/2021 at 9:49 P.M., Resident 5 was transferred from his current room to another resident room. A review of Resident 2's Census indicated that on 8/18/2021 at 9:49 P.M., Resident 2 was transferred from his current room to Resident 5's previous room, as Resident 1's new roommate. Resident 2 was admitted in the facility on 5/24/2021 for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels, and behaves) per the undated Face sheet. On 7/21/2021 at 10 A.M., an observation was conducted outside of Resident 1's room. The door of the room was closed, and a STOP sign was posted outside of Resident 1's door. On 7/21/2021 at 11:07 A.M., an observation and interview of Resident 1 were conducted. Resident 1 laid in bed with his eyes open and was facing the wall of his room. Resident 1 stated, in an unwelcoming tone, I am fine. I'm okay. Bye. On 7/21/2021 at 11:35 A.M., an interview with Certified Nurse Assistant (CNA) 1 was conducted. CNA 1 stated, Resident 1 preferred to be alone. CNA 1 stated, Resident 1's door was closed all the time. CNA 1 stated, Resident 1 did not want anyone close to his space. On 8/13/2021 at 9:21 A.M., a telephone interview with CNA 3 was conducted. CNA 3 stated Resident 2 was ambulatory, confused and wandered to other resident rooms/areas all the time. On 8/27/2021 at 3:35 P.M., an interview with CNA 2 was conducted. CNA 2 stated, Resident 1 had a territorial behavior. On 8/27/2021 at 3:39 P.M., an interview with CNA 2 was conducted. CNA 2 stated, Resident 1 always stayed in his room. CNA 2 stated Resident 1 wanted to be alone. CNA 2 stated Resident 1 was unpredictable. CNA 2 stated she did not know what could trigger resident 1's behavior. On 8/27/2021 at 4:05 P.M., an interview with LN 2 was conducted. LN 2 stated, Resident 1 stayed in bed in his room most of the time. LN 2 stated Resident 1's bedroom door was closed most of the time to prevent other residents from entering Resident 1's room. On 8/27/2021 at 3:15 P.M. until 4:07 P.M., Resident 1 and Resident 2's bedroom door was observed closed. On 8/27/2021 at 5:55 P.M., the survey team called an Immediate Jeopardy (concern that crisis situations in which the health and safety of individuals are at risk and needed resolution as quickly as possible) with the Director of Nursing (DON) and Assistant Administrator (Asst. ADM) related to the facilities failure to protect Resident 2 from potential physical abuse when, Resident 2 was moved in the same room as Resident 1, a resident who was known to staff as being unpredictable and territorial. Resident 2 was placed in the same room as Resident 1 prior to the completion of the facility's abuse investigation which involved Resident 1 and Resident 5. The facility began to create a Plan of Correction to remove the immediacy of the Immediate Jeopardy. The facility's Corrective Action Plan was reviewed. The Corrective Action Plan included: - .Resident 1 and Resident 2 were separated immediately. The assistant administrator and DON initiated room arrangement for Resident 2 immediately. Resident 1 was continued to place on Q (every) 15 minutes checks. - .Resident 2 was moved to (another room) . - .notified to the attending physician and received an order 'Transfer Resident 1 to (name of hospital) at 6:30 PM on 8/27/2021. - IDT will review and determine roommate compatibility on the following day of admission and/or prior to room change. On 8/27/2021 at 11 P.M., the DON and the Asst. ADM were notified that the facility's Corrective Action Plan was accepted by the survey team on-site, and the Immediate Jeopardy was removed. On 9/1/2021 at 12:40 P.M., an interview was conducted with Director of Social Services (DSS). The DSS stated, Resident 1 had a territorial behavior. The DSS stated, on the day of the incident between Resident 1 and Resident 5 (8/18/2021), Resident 1 was upset due to a delay in taking his shower. The DSS stated, Resident 1 was unprovoked when Resident 1 hit his roommate Resident 5. The DSS stated, she would not have moved Resident 2 in the same room as Resident 1. The DSS stated, moving Resident 2 was not a good decision. The DSS stated, the move was a recipe for disaster. On 9/1/2021 at 5:50 P.M., an interview with the DON, Asst. ADM, ADM and Nurse Consultant (NC) 1 was conducted. NC 1 stated that vulnerable resident and a resident with a behavior should not be placed in the same room with the door closed. NC 1 stated that the combination of a resident with behavior and a resident who was vulnerable was not a good combination. A review of the facility's Policy and Procedure titled Abuse and Neglect - Clinical Protocol, revised in December 2016, was conducted. The policy indicated, . (6) The healthcare practitioner and staff will help identify potential or actual abuse or neglect within the facility, for example: a. Significant numbers of residents/patients with unmanaged problematic behavior; . A review of the facility's Policy titled Abuse Investigation and Reporting, revised in December 2016, was conducted. The policy indicated, . (5) The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented.

Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment to prevent the development and worsening of pressure ulcers (localized damage to skin and/or underlying soft tissue usually over a bony prominence (a part of the body with limited fatty tissue over a bone, such as the heels and tailbone)) for three of eight sampled residents (63, 359, 134), reviewed for pressure ulcers, when: 1. a. Resident 63 skin wounds were not accurately and completely assessed. b. Resident 63's medical doctor was not accurately informed of the resident's skin condition, the cause of the resident's pain, nor the resident's refusal to turn and reposition. c. Resident 63's pain management was not addressed related to re-positioning and wound care. d. Resident 63's initial admission, wound assessments, and weekly wound assessments were not completed by qualified staff. As a result, Resident 63's wound developed to a stage three pressure ulcer (an open wound in which damage had occurred into the subcutaneous level (fatty layer) and may be painful). 2. a. Resident 359's wound did not have a written plan of care developed. b. Resident 359's physician treatment orders were not consistently carried out. c. Resident 359 did not receive accurate assessments. As a result, Resident 359 developed a painful pressure ulcer which became infected and required surgical debridement (removal of dead tissue) down to the bone. 3. Resident 134 was not turned every 2 hours, as indicated in the resident's plan of care. This failure had the potential for Resident 134 to develop pressure ulcer. Findings: 1. Resident 63 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 63 was assessed to have excoriation (surface injury to the skin caused by scratching or an abrasion) on the coccyx (tailbone), per the facility's Admission Assessments, dated [DATE]. On [DATE] at 11:06 A.M., an observation and interview was conducted with Resident 63. Resident 63 was observed lying on a regular mattress in his room. Resident 63 stated he had a sore on his bum, and the he was uncomfortable and experienced pain. Resident 63 stated he could not fully turn or reposition himself without assistance from staff. On [DATE], a record review was conducted. Resident 63's MDS (Minimum Data Set) assessment (an assessment tool) Section C, dated [DATE], indicated the resident scored 14 on the BIMS (Brief Interview of Mental Status, a score of ,[DATE] indicated the resident was cognitively intact). Section G of the MDS indicated Resident 63 required extensive assistance from staff to move and turn side to side while in bed. On [DATE] at 11:26 A.M., an interview was conducted with licensed nurse (LN) 4, a licensed vocational nurse. LN 4 stated he was the full-time wound treatment nurse and cared for Resident 63's wound regularly. LN 4 stated he had assessed and classified Resident 63's sacrococcyx wound as excoriation (a superficial evenly distributed scraping of skin). On [DATE] at 8:47 A.M., a concurrent wound observation and interview with Resident 63, LN 4 (treatment nurse), and CNA 5 was conducted. CNA 5 assisted Resident 63 into a side lying position in his bed. Resident 63 was observed with a large, defined reddened area over the sacrococcyx, and the wound was open and actively bleeding on the coccyx (tailbone) area. Resident 63 stated, Ouch, what are you doing back there? when LN 4 touched the wound. LN 4 stated Resident 63 had an opening in the wound which measured 3.5 cm (centimeters) by 2 cm, and the wound bed was composed of 20% (percent) slough (devitalized tissue with a yellow or white appearance). LN 4 further stated the entire wound (opened and closed area) measured 13 cm by 14 cm. LN 4 was not observed to have assessed or measured the depth of Resident 63's wound. On [DATE] at 9:10 A.M., an interview was conducted with CNA 5. CNA 5 stated Resident 63's sacrococyyx wound looked worse today ([DATE]) compared to when she took care of him in (MONTH) (YEAR). CNA 5 stated, This is really big now and has a big opening. CNA 5 further stated Resident 63 had complained of pain and did not like to be turned or repositioned. On [DATE] at 9:33 A.M., a joint interview and record review of Resident 63's medical record was conducted with LN 4. LN 4 stated he told the physician on [DATE] Resident 63 had excoriation on the sacrococcyx. LN 4 reviewed his nursing note on [DATE] at 1:05 P.M., .MD (medical doctor) made aware of wound condition with new treatment to excoriation to coccyx . LN 4 stated another LN had told him Resident 63 had excoriation to the coccyx when he was admitted , so I kept it as excoriation. LN 4 reviewed his documentation and stated the wound was assessed to be excoriation to the coccyx and he did not perform measurements of the site. Resident 63's Weekly Non-Ulcer Skin Reports from [DATE] through [DATE] indicted, .Description (Include Size/Extent): excoriation to site, pink/red in color. No signs and symptoms of infection noted . LN 4 stated as the wound treatment nurse, he was supposed to do thorough skin assessments to include measurements. LN 4 stated, I wish I had been more thorough. LN 4 further stated he was the regular wound treatment nurse for Resident 63 since the resident's readmission on [DATE]. LN 4 reviewed Resident 63's initial admission assessment and initial wound treatment assessment dated , [DATE] and stated both assessments were incomplete. LN 4 stated the assessments did not indicate if the reddened excoriated coccyx area was checked for being blanchable (a technique to check for return blood flow to skin and tissues). LN 4 stated the facility's procedure was to check for blanching skin when there was abnormal, reddened, or excoriated skin over a bony prominence in order to rule out a pressure ulcer. The wound doctor's Physician's Progress Notes, dated [DATE], were reviewed and indicated Resident 63 had a Stage 3 pressure ulcer of cocyx (sic) with periwound [DIAGNOSES REDACTED] (redness) . 1) ulcer 3.5 x (by) 2 x 0.2 cm . 20% slough yellow 2) [DIAGNOSES REDACTED] 13 x 16 cm . On [DATE] at 8:33 A.M., an interview was conducted with CNA 6. CNA 6 stated Resident 63 was alert. CNA 6 stated Resident 63's pain to his sacrococcyx area prevented him from wanting to turn and reposition. CNA 6 stated Resident 63 could not independently turn or reposition himself in bed. CNA 6 stated he cared for Resident 63 on a full time basis (,[DATE] days per week) and he had never seen Resident 63 out of bed. CNA 6 further stated when he assisted Resident 63 with positioning during wound treatments, the resident would complain of pain during the treatments. CNA 6 stated Resident 63 would say, Ouch, Ouch, what's going on there? On [DATE] at 8:53 A.M., a joint observation and interview was conducted with Resident 63. LN 4 was present at the bedside. Resident 63 was observed lying on a low air loss mattress (specialized mattress designed to prevent and treat pressure wounds). Resident 63 stated he did not know the wound on his coccyx was open or had become worse. Resident 63 stated he was told his wound had been improving. Resident 63 stated the wound had been there a long time and it hurts like (expletive). Resident 63 stated the pain was concentrated in his butt and lower back area. Resident 63 stated he could not move in bed due to the pain in his sacrococcyx area. Resident 63 further stated he had been told by staff the reason he needed to reposition and turn every two hours in bed was to get air to his coccyx area because his wound was caused by too much moisture. Resident 63 pointed to his bedspread and blankets and stated, air can't get under all these blankets, it didn't make sense. Resident 63 stated he had not been educated to turn and reposition every two hours to relieve pressure to his sacrococcyx. Resident 63 stated he got a new mattress (low air loss mattress) on [DATE]. Resident 63 stated from his admission to the facility ([DATE]) through [DATE], he suffered a good amount of pain while using his old mattress. A review of Resident 63's Pain Assessment Flowsheets for (MONTH) (YEAR) through (MONTH) (YEAR) was conducted. Resident 63 was recorded as having pain and receiving pain medication 145 times. Of the 145 times, 68 times the pain was documented as located in the back, buttock or wound area and the pain was rated between 5 to 10 out of 10. A review of Resident 63's Clinical Documentation-Weekly Summaries, LNs documented: On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] Resident 63 had pain located in his back or coccyx area. On [DATE] at 9:11 A.M., a joint interview and record review was conducted with LN 4. LN 4 stated Resident 63 refused to turn and reposition every two hours due to pain. LN 4 stated the MD should have been notified Resident 63 refused to turn and reposition because of pain. LN 4 reviewed Resident 63's written care plan for Non-Compliance: Resident resists care ( .turning and repositioning .) dated [DATE]. LN 4 stated he had known Resident 63 was not consistently turned and repositioned since [DATE] because Resident 63 often complained of pain when he moved. LN 4 reviewed Resident 63's written plan of care and stated, the plan did not address Resident 63's, problem, decreased bed mobility from [DATE] to [DATE]. LN 4 reviewed Resident 63's medical record and stated there was no LN documentation Resident 63 refused to be turned or moved due to pain from [DATE] to [DATE]. LN 4 reviewed Resident 63's nursing note on [DATE], .resident with complaints of pain to the sacral-coccyx area. Resident noted with existing excoriation to site. Upon assessment wound is no change in size from previous measurement . LN 4 stated Resident 63's area of excoriation was not defined and had not been measured. LN 4 reviewed his documentation and stated without complete data from wound measurements, he would not be able to determine if the wound declined, plateaued (stayed the same), or improved. LN 4 (licensed vocational nurse) further stated as the wound treatment nurse, he did all of the weekly wound assessments independently and not under the direct supervision of a Registered Nurse. On [DATE] at 11:51 A.M., an interview was conducted with Resident 63. Resident 63 stated he was very concerned and upset about his sacrococcyx wound. Resident 63 stated he had not been informed previously that his wound was as bad as it is. Resident 63 stated he had been told frequently, it was getting better and smaller. Resident 63 stated now that he was aware his wound had not improved he asked the LN to create a schedule to turn him every two hours. On [DATE] at 2:43 P.M., a joint interview and record review was conducted with LN 6, a registered nurse. LN 6 reviewed her documentation on [DATE], . Skin and Body Assessment (Indicated site, wound description, and size) Pressure ulcer stage 1 on the sacrum area . LN 6 stated she had performed a dressing change because Resident 63's dressing had become dislodged. LN 6 stated on [DATE], she performed Resident 63's wound assessment, and determined the wound was a stage 1 pressure ulcer. LN 6 stated she did not include a measurement in her [DATE] wound assessment for Resident 63. LN 6 demonstrated with her hands the size of Resident 63's wound size to be approximately 10 x 6 cm. LN 6 stated Resident 63's wound on [DATE] was not excoriation, but a pressure ulcer. LN 6 further stated Resident 63 complained of pain to the sacrococcyx wound and the pain had increased during the month of (MONTH) (YEAR). LN 6 stated Resident 63's pain had prompted her to call the nurse practitioner on [DATE]. LN 6 stated on [DATE] she had not informed the nurse practitioner Resident 63 pain was related to being repositioned. A review of Resident 63's CNA Daily Charting Forms were reviewed. The form indicated, .Positioned q (every) 2 hours and prn (as needed)? Yes (Y) No (N) . for each shift (night shift, day shift and PM (3 to 11 P.M.) shift on each day of the month. On [DATE] through [DATE]: Resident 63 was not turned and repositioned every 2 hours for 23 shifts. On [DATE] through [DATE]: Resident 63 was not turned and repositioned every 2 hours for 69 shifts, and there was no documentation in the medical record the Resident 63 refused. On [DATE] through [DATE]: Resident 63 was not turned and repositioned every 2 hours for 28 shifts, and there was no documentation in the medical record the Resident 63 refused. On [DATE] at 3:44 P.M., a joint interview and record review was conducted with LN 1, a wound treatment nurse. LN 1 reviewed Resident 63's CNA Daily Charting Forms and stated the LNs should have documented the reason the resident was not turned and what was done about it. LN 1 stated all pressure ulcers and reddened, excoriated areas over a bony prominence should have been measured on the initial admission assessments. LN 1 stated the initial skin assessment was important when establishing a baseline for pressure ulcers. On [DATE] at 7:23 A.M., a joint interview and record review was conducted with the subacute (specialized level of care for medically fragile patients) manager (SM) 1. SM 1 stated accurate communication was expected when a LN conveyed information to the physician. SM 1 stated on [DATE], LN 4 should have informed the physician Resident 63 had a pressure ulcer not excoriation. LN 4 stated the MD used the assessment information from the LN's when deciding which treatment would be best for different wounds. SM 1 further stated the facility practice was for a licensed vocational nurse to consult the registered nurse during the wound assessment. SM 1 stated a licensed vocational nurse by scope of practice was not supposed to do assessments independently without the registered nurse. SM 1 reviewed the admission assessment dated [DATE], .5 [MEDICAL CONDITION] (dime size) sore on coccyx . and the wound physician's note dated [DATE], . Stage 3 pressure ulcer of cocyx (sic) . 1) ulcer 3.5 x 2 x 0.2 cm . 2) [DIAGNOSES REDACTED] 13 x 16 cm . SM 1 stated Resident 63's wound had become a lot bigger since his readmission on [DATE]. SM 1 stated, It's worsened. SM 1 stated Resident 63's sacrococcyx wound should have been measured weekly since admission on [DATE]. SM 1 stated Resident 63's wound should have been discussed with the team. On [DATE] at 9:57 A.M., an interview was conducted with the director of nursing (DON). The DON stated LNs 4 and 5 who cared for Resident 63's wound had not been certified in wound care and were not registered nurses. On [DATE] at 10:42 A.M., an interview was conducted with LN 7. LN 7 stated licensed vocational nurses could not perform assessments without the direct supervision of the registered nurse. LN 7 stated a complete admission assessment, initial skin or wound assessment should have been completed by a registered nurse, not a licensed vocational nurse. On [DATE] at 11:15 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated initial admission and initial skin or wound assessments had to be done by a registered nurse. The DSD stated, It's not within the scope of an LVN (licensed vocational nurse) to perform initial assessments. On [DATE] at 12:22 P.M., an interview was conducted with LN 1. LN 1 stated the facility had a skin committee that was called an IDT (interdisciplinary team) wound management. LN 1 stated because Resident 63's skin issue was mis- identified as excoriation from [DATE] through [DATE], it was not brought to the IDT for wound management review. On [DATE] at 2:30 P.M. and 3:28 P.M., a telephone interview was conducted with MD 1, Resident 63's primary physician. MD 1 stated excoriation was not the same as a pressure ulcer. MD 1 stated he was not informed Resident 63 had increased pain affecting turning and repositioning in bed. MD 1 stated he should have ordered Resident 63 a specialty bed, a low air loss mattress, sooner if he had received a more accurate assessment from the LN's. MD 1 stated the LN's should have informed him Resident 63 needed pain medication to encourage repositioning in bed. On [DATE] at 3:06 P.M. and [DATE] at 8:03 A.M., a joint interview and record review was conducted with the registered nurse supervisor (RNS). The RNS stated if a resident was at risk for developing a pressure ulcer and complained of pain with turning and repositioning, he should have attempted to obtain an order from the facility's pain doctor. The RNS reviewed Resident 63's CNA Daily Charting Forms. The RNS stated there were several shifts when Resident 63 did not receive turning and repositioning every two hours. The RNS stated when it was noticed Resident 63 had multiple episodes of not being turned and repositioned every two hours, it should have been investigated as to why. The RNS stated there should have been a written, individualized care plan created for Resident 63. The RNS further reviewed the admission assessment dated [DATE], .5 [MEDICAL CONDITION] (dime size) sore on coccyx . and the wound physician's note dated [DATE], . Stage 3 pressure ulcer of cocyx (sic) . 1) ulcer 3.5 x 2 x 0.2 cm . 2) [DIAGNOSES REDACTED] 13 x 16 cm . The RNS stated the wound had not gotten better, it had gotten worse since [DATE]. The RNS stated had Resident 63's wound been completely assessed and measured weekly by the LN's, the worsening of the wound would not have been missed. The RNS further stated, licensed vocational nurses could not completely or thoroughly assess something they were not qualified by licensure to assess or scope. The RNS stated, things got missed. The RNS stated Resident 63's wound should have been assessed on admission and during weekly wound assessments by a registered nurse. On [DATE] at 2:35 P.M an interview was conducted with the DON. The DON stated it was her expectation LNs measure all wounds. The DON stated LN 4 should have measured Resident 63's sacrococcyx wound weekly. The DON stated licensed vocational nurses could not stage any pressure ulcers, as it was not within their scope of practice. A review of the In-Service Record and Attendance, dated [DATE] - [DATE], for Pressure Sore (ulcer)/Skin Management, indicated one of the instructors was LN 4, a licensed vocational nurse who was not wound certified and was not qualified to provide education to other staff. A review of the facility's Job Description for Licensed Vocational Nurse (LVN) indicated, . Essential Responsibilities and Job Functions . Resident Admission Assessments: Performs and accurately documents the resident admission assessment . under the supervision of the RN. Resident Re-assessments: Consistently and accurately performs reassessments .under the supervision of the RN . Other Resident Assessments: Completes other assessment tools . under the supervision of the RN . Per the facility's undated policy titled, Pressure Ulcers/Skin Breakdown Prevention and Monitoring, .h. Routinely assess and document the condition of the resident's skin . i. Report any signs of developing pressure ulcer to the physician and inform resident and/or responsible party . 2. Resident 359 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Face Sheet. On [DATE] at 8:26 A.M., a joint interview and record review was conducted with licensed nurse (LN) 1, a licensed vocational nurse. LN 1 stated she was a wound treatment nurse at the facility. LN 1 stated the admissions nurse performed a quick assessment of the skin on newly admitted residents, and documented their findings. LN 1 stated the wound treatment nurse performed a complete assessment of the residents' skin and of any wounds or skin issues within 24 hours of a resident's admission to the facility. LN 1 stated the wound treatment nurse, based on their assessment, would inform the physician of what they saw and obtain a treatment order. LN 1 stated she assessed the wounds for new admissions and weekly wound assessments. LN 1 stated she would ask for help from a registered nurse or the wound care director (WCD) if there was something she felt she could not identify. LN 1 further stated as the wound treatment nurse, she did not take any pictures of the residents' wounds. LN 1 stated, We aren't allowed to take pictures of wounds. LN 1 reviewed Resident 359's electronic and paper medical record. Resident 359's Admission assessment on [DATE] had an anatomical picture and there was no skin issue documented on the residents, buttocks, coccyx, or sacrum (a triangular bone at the end of the spine between the hips and coccyx). LN 1 stated there was no skin issue on Resident 359's sacrococcyx (where the sacrum and coccyx meet) on admission. LN 1 reviewed the Wound Nurse Body Observation, dated [DATE], and stated she was the nurse who performed that assessment. LN 1 stated Resident 359 had wounds on both of her heels, but the resident's skin was clear and intact on her buttocks and sacrococcyx on admission to the facility. LN 1 reviewed Resident 359's Wound Nurse Body Observation dated [DATE], SDTI (suspected deep tissue injury, a persistent non-blanchable (a technique to check for return blood flow to skin and tissues) deep red or purple discoloration that may progress to a stageable pressure ulcer) to the right lateral heel . LN 1 stated residents with an SDTI usually had a low air loss mattress (LAL, specialized mattress designed to prevent and treat pressure ulcers). LN 1 reviewed Resident 359's physician's orders [REDACTED]. LN 1 reviewed Resident 359's treatment administration record (TAR). Resident 359's treatment for: Cleanse Left heel surrounding drainage tube. Pat dry and apply dry dressing every day. The TAR was blank on [DATE] and [DATE]. Monitor dressing integrity daily . The TAR was blank on [DATE] and [DATE]. Monitor pressure sore/wound daily . The TAR was blank on [DATE] and [DATE]. Apply skin prep to right lateral heel wound f/b (followed by) dry dressing then wrap with rolling gauze every 3rd day . The TAR was blank on [DATE]. LN 1 stated a blank on the TAR meant the treatment was not done. LN 1 stated treatments were physician's orders [REDACTED]. LN 1 stated Resident 359's treatments should have been carried out as ordered by the physician. LN 1 reviewed Resident 359's physician's orders [REDACTED]. LN 1 reviewed the TAR and stated, there was an X from [DATE] through [DATE]. LN 1 stated X meant the treatment was not done. LN 1 reviewed Resident 359's nursing notes, and stated there was no documentation the resident's heels were elevated in bed. LN 1 reviewed certified nursing assistant (CNA) charting and stated there was no documentation Resident 359 had her heels elevated while in bed. LN 1 stated Resident 359 should have had her heels floated to prevent further development or worsening of pressure ulcers. LN 1 reviewed Resident 359's Non-Pressure Sore (pressure ulcer) Skin Problem Report, dated [DATE], Other was marked with a description, moisture related sheering (sic) Location: coccyx. LN 1 stated she conducted the assessment for Resident 359's new skin issue. LN 1 stated moisture related sheering was an area of skin where heavy moisture from urine or sweat had removed the first layer of skin. LN 1 stated with moisture related sheering the skin was pink or red and intact. A record review was conducted on [DATE]. Resident 359's physician's orders [REDACTED]. Pat dry and apply [MEDICATION NAME] ointment (a medicated ointment) every shift . On [DATE] at 10:55 A.M., an interview was conducted with CNA 1. CNA 1 stated if a resident had an incontinence (inability to control urine or stool) rash she would tell the nurse. CNA 1 stated the nurses would give her a cream to put on the rash when she changed the resident's soiled brief. CNA 1 stated she could not recall the name of the cream. On [DATE] at 11:25 A.M., an observation and interview was conducted with CNA 2. CNA 2 stated if she noticed a resident having a moisture related rash, she would apply an ointment stored in the nurse's locked treatment cart. CNA 2 stated the nurse would give the ointment to her to apply to the resident's moisture rash. CNA 2 stated the ointment she used was currently in a resident's room. CNA 2 retrieved the ointment from the resident's room. The medication label read, [MEDICATION NAME] Skin Protectant Paste (a medicated ointment). CNA 2 stated, I put it on her (the resident), not the LN. On [DATE] at 11:37 A.M., an interview was conducted with CNA 3. CNA 3 stated she was told by the LNs to apply [MEDICATION NAME] ointment to residents with incontinence rashes. CNA 3 stated she obtained the [MEDICATION NAME] ointment from the LNs. CNA 3 stated she had been a CNA for about two and a half years and had not seen the medication nurses change a resident's soiled brief or apply any ointment. CNA 3 stated she had witnessed the wound treatment nurse change residents' soiled briefs and apply ointments. On [DATE] at 11:50 A.M., an interview was conducted with LN 1. LN 1 stated the [MEDICATION NAME] ointment was a medication. LN 1 stated the ointment should be applied by LNs not CNAs since it was a medication. On [DATE] at 12 P.M., an interview was conducted with LN 2. LN 2 stated if a resident needed a moisture barrier cream like [MEDICATION NAME], it was more convenient to give it the CNA since they were the one changing the resident's brief. LN 2 stated, Wait, I think I'm supposed to do the cream. I'm not sure. On [DATE] at 12:20 P.M. and 2:50 P.M., an interview was conducted with the WCD. The WCD stated it should have been the LN who applied the [MEDICATION NAME] ointment because it was a medication. The WCD stated it should not be the CNA who does it. The WCD reviewed Resident 359's Non-Pressure Sore (pressure ulcer) Skin Problem Report, dated [DATE], Other was marked with a description, moisture related sheering (sic) . Location: coccyx Description (include size/extent) 1.5 x (by) 1.5 cm (centimeters) . The WCD stated moisture related sheering was not an accurate description of a wound. The WCD stated there was no such thing as moisture related sheering. The WCD stated the assessment was not complete because the LN did not rule out if the wound was a pressure ulcer. The WCD stated LNs were expected to check any redness over a bony prominence for blanching (when a person's skin loses redness with pressure applied indicating adequate blood flow to tissues) which would aid the LN in determining if the wound was a pressure ulcer. The WCD further reviewed Resident 359's TAR and stated wound treatments were not done on [DATE] and [DATE]. The WCD stated the TAR should be signed by the LN when they complete the physician ordered treatment. The WCD stated, There's no proof it was done. On [DATE] at 3:07 P.M., an interview was conducted with the director of nursing (DON). The DON stated [MEDICATION NAME] barrier cream was considered a medication and had to be administered by a LN. The DON stated [MEDICATION NAME] should not be administered by CNAs. On [DATE] at 10:30 A.M., an interview was conducted with Resident 359's responsible party (RP). The RP stated Resident 359 was a resident of the facility for about 2 weeks. The RP stated Resident 359 had a stroke and was sent to the facility for rehabilitation. The RP stated Resident 359 did not have an infection, was not at the end of life, and was expected to make improvements. The RP stated, They (the facility) took horrible care of my mother. The RP stated Resident 359 had not been consistently turned and repositioned. The RP stated every time she or family members visited Resident 359, the resident was soaked with urine and feces. The RP stated she had to ask a family member who lived nearby to stay at the facility in order to ensure Resident 359 was repositioned regularly and had her soiled brief changed timely. The RP stated Resident 359 had rashes everywhere down there. The RP stated Resident 359 was in pain from the rashes and would cry when we helped change her soiled brief. The RP stated we tried to put ointment on the rashes and were told not to because the doctor did not order it. The RP stated, they (nurses) never put ointment on it (rashes). The RP stated the facility never told her what all the rashes were. The RP stated she believed they were from not cleaning or turning Resident 359. The RP stated Resident 359 would scream when the rashes were touched. The RP stated Resident 359's skin was very damaged, bleeding, red. The RP stated Resident 359 had surgery in the hospital for the rash on her upper butt. The RP stated, She (Resident 359) suffered a lot and on (MONTH) 24th (YEAR) she died . A review of the Resident 359's Resident Progress Notes, dated [DATE] at 3:03 P.M., indicated, .CNA noted pt (patient) open area to coccyx getting worse and notified writer . Open area noted on coccyx with foul smell . Resident 359's Resident Progress Notes, dated [DATE] at 6:23 A.M., indicated, .open area to coccyx, showing signs of getting worse. Open area noted on coccyx with foul smell . Resident Progress Notes, dated [DATE] at 7:59 A.M., indicated, Res (resident) noted having labored breathing after peri-care (cleaning of the perineum and groin area), and positioning. O2 (oxygen) @ (at) 3LPM (liters per minute) via n/c (nasal cannula, a tube delivering oxygen to the nose). SPO2 (blood oxygen saturation level) checked 84% (normal range between ,[DATE]%) . 911 called . Res transported to general acute care hospital (GACH) 2 ER (emergency room ) via 911 . Resident Progress Notes, dated [DATE] at 4:16 P.M., indicated, Call placed to GACH 2, . resident was admitted with DX. (diagnosis) [MEDICAL CONDITION] (blood infection). A review of GACH 2's physician's History & Physical, dated [DATE] at 1:58 P.M., indicated, .Pt (patient) was reevaluated 6 hrs (hours) after in SICU (Surgical Intensive Care Unit) . She had a coccygeal (coccyx area) decubitus ulcer (pressure ulcer) present under dressing. Unable to evaluate . A review of GACH 2's Wound/Ulcer Assessment, dated [DATE] at 8 P.M., indicated Resident 359 had a suspected unstageable pressure ulcer (full thickness tissue loss in which the extent of damage within the ulcer cannot be confirmed because it is obscured by dead tissue) with a moderate amount of foul smelling, yellow discharge, and the surrounding skin was denuded (skin that is eroded). A review of GACH 2's Social Work Initial Note, dated [DATE], indicated, .RP (name omitted) expressed concern about wound on pt's (patient's) coccyx which she said was not there when pt was in hospital at GACH 1. DTR (daughter, RP) is not wanting her to return to facility (name omitted). She st (states) that her mother would not refuse care .DTR does not feel pt was changed in a timely manner . A review of GACH 2's physician's Consultation Note, dated [DATE], indicted, .Reason For Consultation: Sacral (area around the sacrum) pressure ulcer with infected wound and [MEDICAL CONDITION] . She (Resident 359) was brought to GACH 2ER on [DATE] with [MEDICAL CONDITION] related to her pressure ulcer . Plan: The patient will be taken to the OR (operating room) for debridement of the sacral pressure ulcer .The flap closure will be done at a later date . A review of GACH 2's phy (TRUNCATED)

Based on observation, interview, and record review, the facility failed to consistently implement fall preventative measures, thoroughly investigate all fall incidents, and implement new fall preventative measures after each fall incident for five of 30 sampled residents (Residents 175, 87, 243, 232, 154) and three of five non-sampled residents (134, 152, 166). Failure to implement new fall interventions, after a fall, did not help prevent the residents from further falls. Findings: 1. Resident 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of Resident 175 on 9/27/16 at 12:30 P.M., was conducted. Resident 175 sat in her wheelchair in the dining room eating lunch. Resident 175 had a chair alarm (an alarm that alerts staff when the resident gets up unassisted) on her wheelchair. A review of Resident 175's nurses notes, dated 5/5 to 8/24/16, was conducted. These notes indicated Resident 175 had incidents of fall or suspected of fall on the following dates: 6/17, 6/22, 8/12, and 8/19/16. A review of Resident 175's Fall Risk Assessment, dated 5/2, 6/17, 6/21, and 6/22/16, were conducted. Resident 175 was identified as high risk for fall respectively. A concurrent interview and record review of Resident 175's Fall Risk care plan, dated 5/9/16, was conducted with licensed nurse (LN) 12 on 9/29/16 at 7:50 A.M. The interventions included, Provide adequate lighting, and keep call light within reach . LN 12 stated these were the interventions in place for Resident 175. A review of Resident 175's clinical record was conducted. This documentation indicated that on 6/17/16, Resident 175 had an unwitnessed fall in Station 4. A review of Resident 175's X-ray (Imaging test that view the inside of the body to determine the extent of injuries) report, dated 6/17/16, was conducted. This report indicated Resident 175 had an acute left hip fracture (broken bone). An interview with licensed nurse (LN) 10, Station 4 unit manager on 10/3/16 at 9:20 A.M., was conducted. Per LN 10, on 6/17/16, Resident 175 went inside another resident's room and was pushed causing her to fall. For Resident 175, LN 10 stated a tab alarm was already in place. LN 10 stated, They should have heard the tab alarm (an alarm that alerts the staff when the resident gets up assisted), it should sound when the resident got up from the wheelchair. This was contrary to the Resident's 175's Fall Risk care plan, dated 5/9/16. There was no documented intervention on the resident's care plan, dated 5/9/16, related to the use of a tab alarm. A concurrent interview and record review of Resident 175's Medication Administration Record (MAR) dated 6/1 to 6/30/16 was conducted with LN 10 on 10/3/16 at 9:45 A.M. LN 10 reviewed the MAR and did not find evidence of documentation that tab alarm was monitored for placement from 6/1 to 6/30/16. Resident 175 had an incident of fall on 6/17/16. LN 10 further stated, I'm not sure if it was done since I can't find it here. A review of Resident 175's clinical record was conducted. This record indicated that on 6/21/16, Resident 175 was readmitted to a different station in the facility (Station 1) with [DIAGNOSES REDACTED]. S/P (status [REDACTED]. Upon further review, the record also indicated that on 6/22/16, one day after the resident returned to the facility, Resident 175 was found by a certified nursing assistant (CNA) on the floor next to bed. A record review of Resident 175's physician order, dated 6/22/16, was conducted. This record indicated an order for [REDACTED]. A concurrent interview and review of Resident 175's record titled, Fall Risk Care plan, dated 6/22/16, was conducted with LN 11, unit manager Station 1 on 10/3/16 at 9:45 A.M. LN 11 stated on 6/22/16, she received a report that Resident 175 was found on the floor by a CNA. LN 11 did not know the CNA who worked that shift. LN 11 further stated that interventions which included landing mat and pressure sensor were ordered, And monitored for placement. LN 11 looked through Resident 175's chart and was not able to find documentation that these interventions were done. LN 11 stated, I didn't see it in here. LN 11 acknowledged that it was important to document pressure sensor pad and mat placement checked every shift to ensure Resident 175's safety. LN 11 also acknowledged that the resident's care plan related to fall risk was not developed until the next day after admission. LN 11 stated that the incident on 6/22/16 was not investigated thoroughly and it should have been. A review of Resident 175's nurses note, dated 7/1/16, was conducted. Per this note, Resident 175 went to the orthopedic (bone doctor) appointment and was sent to the hospital for another surgery. A review of Resident 175's (name of hospital) History and Summary, dated 7/3/16, was conducted. This document indicated, .The x-rays in the office showed that she had a left hip .dislocation . It was felt that this is actually a chronic dislocation, at least 1 week old. She was admitted to (name of hospital ) on 7/1/16 was taken to the operating room on 7/2/16 . Resident 175 was readmitted to the facility on [DATE] to a different station in the facility (Station 3). A review of Resident 175's physician orders, dated 8/17/16, was conducted. This record indicated an order for [REDACTED]. A review of Resident 175's treatment flowsheet, dated 8/17 to 8/30/16, was conducted. This flowsheet indicated, on 8/19/16 during 3 to 11 P.M. shift, the check box next to landing mat, pressure sensor alarm in bed and wheelchair did not have a staff initial, which indicated these placements were not checked. An interview was conducted on 10/3/16 at 1:35 P.M., with CNA 7. CNA 7 stated she was familiar with Resident 175. CNA 7 further stated, She likes to climb out of the chair and bed even with the bed alarm and the chair alarm. She also likes to slide down from the bed. She was a fall risk. A concurrent interview and record review of Resident 175's record was conducted on 9/28/16 at 9:50 A.M., with licensed nurse (LN) 2. LN 2 stated that he was familiar with Resident 175 and was aware of her history of falling. LN 2 further stated, I know when she (Resident 175) was in Station 4, another resident knocked her over, fell and had a fracture. The second time it was when she got out of her wheelchair. Third time was when she fell out of her bed. An interview with LN 2 was conducted on 9/28/16 at 9:55 A.M. LN 2 stated Resident 175 had episodes of falls on 8/12 and 8/19/16, where staff found her on the floor. LN 2 did not know what had happened he just received a report that she was on the floor. LN 2 also stated She had safety measure such as landing mat, bed alarm and (wheel) chair alarm. Staff was supposed to check and initial on the treatment administration record when they check for placement. LN 2 also stated,I don't remember hearing the bed alarm. If there was a bed alarm, I would have heard it because it is loud. For Resident 175, LN 2 acknowledged there were no evidence of documentation that placement for landing mat, bed alarm and chair alarm was checked as ordered and incident of falls were not investigated thoroughly. A concurrent interview and review of Resident 175's record on 10/3/16 at 10:30 A.M., with LN 12, unit manager for Station 3 was conducted. LN 12 stated Resident 175 was readmitted to the facility on [DATE] to Station 3. Per LN 12, Resident 175 was found on the floor on 8/12 and 8/19/16. LN 12 stated, She (Resident 175) likes to move around in bed and maybe that's why she ended up on the floor. LN 12 acknowledged the incident was not investigated thoroughly and it should have been. A phone interview was conducted on 9/28/16 at 4:05 P.M., with Resident 175's responsible party (RP). The RP stated, (Resident's name), was always very mobile, walked a lot. I got a phone call that another resident pushed her, fell and fractured her hip. She had surgery on 6/19/16 then returned to facility on 6/21/16. After that, I got another phone call on 6/22/16 about mom was found sitting on the floor. A week after that she was kicking the staff when they try to provide care for her so I took her the the doctor on 7/1/16. The doctor said her hip was dislocated so she was back to hospital for surgery on 7/5/16. Then I got another phone call about mom was found out of bed again a month ago, but they called me a week after the fact. I just don't want her to hurt again. An interview was conducted with the director of nursing (DON) on 10/4/16 at 5 P.M. The DON stated that Resident 175's care plan related to fall should have been updated on the day of the re-admission. The DON also stated that fall interventions should have been implemented and followed. The DON stated that the resident's falls should have been investigated thoroughly to determine the cause of fall and to help determine the appropriate intervention. The DON acknowledged for Resident 175, this was not done. 2. Resident 134 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the same record, Resident 134 did not have the capacity to understand and make decisions. A review of Resident 134's nurses progress notes, was conducted. This record indicated that on 3/23/16, Resident was found on floor, unable to explain why he was on floor but resident usually moves and turned himself around when awake . There was no further documentation regarding this incident. A review of Resident 134's nurses progress notes, was conducted. This record indicated on 3/25/16, .Pt (patient) attempted to amb (ambulate) without assistance and had a fall, from standing landed on buttocks then hit his left side of chin on bed rail. Observed by CNA . There was no evidence of documentation found in Resident 134's chart for further investigation regarding this incident. A review of Resident 134's nurses progress notes, was conducted. This record indicated on 4/6/16, Noted with purplish discoloration on left .thigh & (and) left hip . Claimed he fell but unable to state when . There was no evidence of documentation found in Resident 134's chart for further investigation regarding this incident. A concurrent interview and record review of Resident 134's record with licensed nurse (LN) 12 was conducted on 10/4/16 at 1:25 P.M. LN 12 stated Resident 134 had multiple incidents of fall and that the last incident, Resident 134 had a hip fracture (broken hip). LN 12 acknowledged these incidents of falls were not thoroughly investigated and it should have been. In addition, LN 12 stated that the fall risk care plan was not updated to show new interventions to address Resident 134's fall. A concurrent interview and record review of Resident 134's record titled, Incident Report SBAR (situation, background, assessment, request) . with LN 12 was conducted on 10/4/16 at 1:30 P.M. LN 12 stated nurses were responsible to fill out the incident report after a fall incident. On the reports dated 3/25, 3/26, and 4/6/16, the assessments and request sections were not completed. LN 12 further stated, It is important to complete these portions so we know why and how the incident happen and what happen to the resident. LN 12 acknowledged it should have been completed but was not. An observation on 10/4/16 at 3:05 P.M., was attempted. Resident 134's door was closed, staff provided care at this time. An interview was conducted with the director of nursing (DON) on 10/4/16 at 5 P.M. The DON stated it was her expectation for every incident of fall to be investigated thoroughly to determine the cause of fall and to help determine the appropriate intervention for the resident. The DON also acknowledged that Resident 134's care plan in place for the prevention of fall was not effective and was not updated with new interventions to prevent the reoccurrence of falls. A review of the facility's policy, dated 9/04, titled Fall/Accident Mitigation and Intervention, indicated, .Procedure 2. Residents at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. A review of facility policy titled, Fall Risk Assessment, Identification and Reduction, dated 10/14, was conducted. This policy indicated, . Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the individual risk factors. 3. Resident 152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No opportunities for observation of Resident 152 were available as he had been transferred to the hospital and had not returned as of 10/5/16. On 10/4/16 at 3:30 P.M., a review of Resident 152's SBAR (situation, background, assessment, report) /Actual or Suspected Fall, dated 8/30/16, indicated a witnessed fall. Further review of the SBAR indicated that Resident 152 slid to the floor from his bed while being turned and landed on his feet and his bottom. The physician was notified, no new orders received. A concurrent interview and record review of Resident 152's care plans, dated 5/30 and 8/30/16 with licensed nurse (LN 12) was conducted on 10/4/16 at 3:35 P.M. LN 12 acknowledged that there was no evidence that the care plan had been updated to reflect new information after the fall. An interview with certified nursing assistant (CNA) 13 was conducted on 10/5/16 at 8 A.M. CNA 13 stated that, Resident 152 did not fall, but slipped off his bed. CNA 13 stated that the resident required a Hoyer lift (a mechanical device to help move patients) to transfer and could not stand up. CNA 13 further stated that the resident required extensive assist with his activities of daily living. Per CNA 13, a student was with her in the resident's room. CNA 13 stated that she stood next to the bed, where Resident 152 laid. CNA 13 stated that she was changing the resident's incontinent briefs and had the resident turn to his side, facing the wall. CNA 13 stated that the resident had a low air loss mattress (LAL - a special mattress to help with pressure). CNA 13 stated that in the past, the LAL would become faulty and the maintenance fixed it. CNA 13 stated that the LAL mattress would create a V shape and the resident would end up in the lower tip of the V shape mattress. CNA 13 stated that on the day of the incident (8/30/16), the LAL mattress was faulty again and created the V shape on the mattress. CNA 13 stated that she turned to check on the student, and when she turned to look at the resident, the resident was on the floor, in between the bed and the wall. CNA 13 stated that the resident was sitting on the floor. CNA 13 stated that the resident slipped off the bed due to the faulty LAL mattress. Per CNA 13, she told the charge nurse about the LAL mattress. A concurrent interview and record review with LN 12 was conducted on 10/5/16 at 8:20 A.M. LN 12 was asked about Resident 152's fall on 8/30/16. LN 12 stated, As far as I remember, I spoke with CNA 13 and he (Resident 152) slid off the bed; he was fine the rest of the shift. LN 12 stated that she was not aware that the resident's LAL mattress was faulty on the day of the incident. LN 12 reviewed the Post Fall Assessment record, dated 8/30/16. LN 12 stated that, as a result of the fall, a new intervention was added to the resident's care plan. This care plan indicated, 2 staff assist during care. It was explained to LN 12 that when the incident happened, there were two people assisting the resident, CNA 13 and the student. LN 12 acknowledged that the new fall intervention developed for Resident 152 which indicated, 2 staff assist during care, would not be an effective response for the resident's fall incident, since the resident fell while being cared for by two people. LN 12 stated that the investigation regarding the resident's fall was not thorough in order to identify and develop appropriate interventions to address fall. An interview with the director of nursing (DON) was conducted on 10/4/16 at 4:50 P.M. The DON stated that her expectation was that care plans should be developed to prevent further falls; and it was important to investigate falls thoroughly in order to determine the correct interventions. A review of the facility's policy, dated 9/04, titled Fall/Accident Mitigation and Intervention, indicated, .Procedure 2. Residents at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. A review of facility policy titled Fall Risk Assessment, Identification and Reduction, dated 10/14, was conducted. This policy indicated, . Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the individual risk factors. 4. Resident 87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 87 was observed on 9/27/16 at 7:20 A.M., in bed, eating breakfast. Resident 87 was dressed, with her right leg drawn up toward her chest, and a landing mat was on the floor. A review of Resident 87's nurse notes, dated 5/12/16, was conducted. The note indicated, Resident was found on the floor sitting and leaning by the side of the bed A review of Resident 87's SBAR (situation, background, assessment, request): Actual/Suspected Fall indicated an unwitnessed or suspected fall on 5/12/16 at 12 P.M. A review of Resident 87's Fall Risk Evaluation, dated 3/11/16, indicated a score of 14. The Fall Risk Evaluation, dated 5/12 and 5/26/16, indicated a score of 22; Per the scoring instruction, a score of 10 or above represents high risk. A concurrent interview and record review was conducted with licensed nurse (LN) 13 on 10/4/16 at 2:50 P.M. LN 13 stated that Resident 87's fall risk was high and that Resident 87 had two falls; one in 3/16 (no injury) and one on 5/12/16. A review of the nurses notes, dated 5/12/16, indicated that Resident 87 was found sitting on the floor by her bed. Per the nurse's notes, the resident stated she was not hurt and a physical assessment was conducted and no injuries noted. Further review of the nurse's notes indicated that on 5/22/16, Resident 87 was grimacing and refused to move her legs up and down. Per the nurse's notes, the physician and responsible party were notified and Resident 87 was transported to the acute care hospital on [DATE] at 10:50 A.M. Resident 87 returned from the hospital on [DATE] at 5:30 P.M. The final report from the emergency room indicated a mildly displaced acute right greater trocanter (hip bone) fracture (broken bone). LN 13 reviewed the resident's current medical record and did not locate a fall risk care plan that addressed that resident's risk for falls. LN 13 acknowledged that the resident's fall risk care plan was located in the medical record thinning. LN 13 stated that a fall risk care plan should have been available in Resident 87's current medical record, especially since the resident was identified as a high fall risk. LN 13 also stated that new interventions should have been initiated in response to the resident's fall on 5/12/16 to help prevent further falls. An interview with director of nursing (DON) was conducted on 10/4/16 at 4:50 P.M. The DON stated that Resident 87 should have had a fall risk care plan in her current medical records. The DON also stated that new interventions should have been initiated after the fall to help prevent further incidents of fall. A review of the facility's policy, dated 9/04, titled Fall/Accident Mitigation and Intervention, indicated .Procedure 2. Residents at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. A review of facility policy titled Fall Risk Assessment, Identification and Reduction, dated 10/14, was conducted. This policy indicated, . Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the individual risk factors. 5. Resident 243 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/29/16 at 9:55 A.M., Resident 243 was observed wheeling himself down the hallway in his wheelchair. The resident stopped by the door to the outside, leaned forward in his chair and the sensor pad alarm went off. The staff responded and assisted the resident back into his wheelchair. A review of Resident 243's record titled Fall Risk Assessment, dated 4/25/15-8/5/16, indicated Resident 243 was high risk for falls, (Total score of 10 and above indicated high risk) with the exception of 6/7/16 (score of 9). A review of Resident 243's Fall Risk Care Plan, dated 4/24/15, indicated that the resident had risks for falls and injuries. The interventions included, Provide adequate lighting, observe for side effects of meds, keep call light within reach, encourage use of call light, observe for unsteady gait and balance, instruct to avoid sudden position changes, assess toileting needs, provide verbal safety cues, keep personal belongings within reach, Provide/Reinforce use of assistive devices: Wheelchair, provide/Reinforce use of non-skid footwear., PT Eval (Physical therapy evaluation) and treat if indicated, OT Eval (Occupational therapy evaluation) and treat if indicated, ST Eval (Speech therapy evaluation) and treat if indicated. There were no other interventions noted on this care plan. A review of Resident 243's nurses notes, dated 5/4/15 at 9:30 A.M., indicated, .Had incident of witness fall, seen attempting to stand up from his w/c (wheelchair) but slip & (and) fall on the floor in between the footrest . A review of Resident 243's record titled Post Fall Assessment, dated 5/5/15, was conducted. This assessment indicated that Resident 243 required alarm in w/c as a supportive device to prevent falls. A concurrent interview and record review was conducted with licensed nurse (LN) 12 on 10/3/16 at 11:30 A.M. LN 12 was unable to locate a fall care plan regarding Resident 243's fall on 5/4/15. LN 12 acknowledged that the resident's long term fall risk care plan was not updated or accelerated after the 5/4/15 fall. LN 12 stated that according to the 5/5/15 post fall assessment, Resident 243 required a wheelchair alarm. LN 12 acknowledged that recommendation had not been implemented. A concurrent interview and record review was conducted with LN 10 on 10/3/16 at 12:05 P.M. LN 10 stated that after a fall, LNs were supposed to update and accelerate the resident's care plan. LN 10 acknowledged that Resident 243's care plan had not been updated or accelerated after his fall on 5/4/15. A review of Resident 243's nurses notes, dated 8/7/15 at 9:50 P.M., indicated, At 2020 (8:20 P.M.), pt (patient- resident) was found on floor. Pt states 'I was turning on my TV and fell and hit my head, but I'm ok.' . A review of Resident 243's record titled Post Fall Assessment, dated 8/10/15, was conducted. Per this record, there was no intervention needed because it was an, Isolated incident. Cont (continue) to enc (encourage) resident to ask for assistance PRN (as needed). A review of Resident 243's Post Fall care plan, dated 8/7/15, was conducted. This care plan had interventions which included, .Document base-line vital signs and conduct physical assessment. Provide for any immediate needs. Monitor VS (vital signs) and resident's condition over the next 72 hours. Assess for pain and other signs of physical injury/trauma. Complete neurological assessment . There were no evidence of documentation that additional intervention was added and no dates for re-evaluation of the care plan. A concurrent interview and record review was conducted with LN 12 on 10/3/16 at 11:30 A.M. LN 12 acknowledged that the resident's long term fall risk care plan was not updated or accelerated after the 8/7/15 fall. LN 12 acknowledged that there were no new interventions added to help prevent the resident from further falls. A concurrent interview and record review was conducted with LN 10 on 10/3/16 at 12:05 P.M. LN 10 stated that the wheelchair alarm that was recommended by the interdisciplinary team (IDT- a group of individuals coordinating a resident's plan of care), after Resident 243 fell on [DATE], had not been implemented prior to the resident's second fall on 8/7/15. LN 10 acknowledged that new interventions related to fall were not added to the resident's care plan to help prevent the resident from further falls. A review of Resident 243's clinical record, dated 8/5/16, indicated that Resident 243 was found on the patio outside. This record also indicated that Resident 243 was sent to (hospital name). On 8/10/16, Resident 243 returned to the facility per the facility's Face Sheet. A review of Resident 243's record titled Fall Risk Assessment, dated 8/10 - 9/16/16, indicated that Resident 243 was a high risk for fall with a score of 16 (Total score above 10 represents HIGH RISK). A review of Resident 243's Fall Risk Care Plan, dated 8/11/16, indicated that the resident was at risks for falls and injuries. The care plan listed interventions which included tab alarm for bed and wheelchair. There were no other interventions documented on care plan. A concurrent interview and record review of Resident 243's nurses note was conducted with LN 10 on 10/3/16 at 10:40 A.M. Per this note, Resident 243 was found sitting on the bathroom floor. LN 10 reviewed Resident 243's record and was not able to find new interventions initiated after the resident's third fall on 8/13/16. LN 10 acknowledged there were no new interventions initiated to help prevent the resident from further falls. A review of Resident 243's physician orders, dated 8/17/16 at 11:30 A.M., indicated, Low bed, sensor alarm in bed, chair sensor alarm in w/c. A concurrent observation of Resident 243 and an interview with LN 19 was conducted on 9/29/16 at 5:27 P.M. Resident 243 was in the dining room sitting in a chair at a table, his wheelchair was next to him. LN 19 stated that the resident transferred himself from his wheelchair to the chair, and that the wheelchair alarm was turned off while he was in the dining room. An interview with LN 20 on 10/3/16 at 11:13 A.M. was conducted. LN 20 stated that Resident 243 was able to turn off the sensor alarm on his wheelchair, and that he usually used his wheelchair like a cart, storing his belongings on the seat while he pushed the wheelchair from behind. A concurrent interview and record review with LN 12 was conducted on 10/3/16 at 11:30 A.M. LN 12 stated that the alarms for Resident 243 were not realistic since the resident was able to remove and turn off the alarms. A concurrent interview and record review was conducted with LN 10 on 10/3/16 at 12:25 P.M. LN 10 acknowledged that the care plan developed for Resident 243 on 8/11/16 related to falls was not sufficient in addressing the resident's risk for falls. LN 10 further stated that she was not aware that Resident 243 was able to turn off alarms. LN 10 further acknowledged that since Resident 243 had the ability to turn off alarms that intervention was not effective. An interview was conducted with the director of nursing (DON) on 10/4/16 at 4:50 P.M. The DON stated her expectation was for care plans to be updated and accelerated for residents after a fall. The DON further stated that she expected a thorough investigation of the cause of a fall to help determine the appropriate interventions. The DON stated that if the IDT made recommendations, the nurses need to follow through. A review of the facility's policy titled Fall Risk Assessment, Identification and Reduction, dated 10/14, indicated, Purpose: To reduce risk for fall. Procedure: .2. Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the individual risk factors . 4. The facility nursing staff and/or the IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or related incident. 6. Resident 232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/26/16 at 4:21 P.M. Resident 232 was observed standing next to her bed talking to her roommate. The bed was in a low position, no sensor alarm was noted on the bed, and there were no landing mats on the floor. On 9/27/16 at 3:53 P.M., Resident 232 was observed lying on her back under the covers with her eyes closed. The bed was in low position, but no sensor alarms were on the bed, and no landing mats were seen on the floor. An interview was conducted with certified nursing assistant (CNA) 15, on 9/27/16 at 3:56 P.M. CNA 15 stated that Resident 232 had a fall before, but there were no landing mats or sensor alarms in place. CNA 15 stated that Resident 232 was ambulatory on her own, and did not use a cane, walker or wheelchair. CNA 15 stated, We just keep an eye on her and help her when she gets up. An interview was conducted with CNA 16, on 9/28/16 at 7:52 A.M. CNA 16 stated that he had worked at the facility for two years and was familiar with Resident 232. CNA 16 stated that he was not aware that Resident 232 had any falls, and stated that she was not on any fall precautions. A review of Resident 232's record titled Fall Risk Assessment, dated 11/11/15 - 9/9/16, was conducted. These assessment indicated Resident 232's score was 12-14 and was high risk for fall (total score above 10 represents high risk). A review of Resident 232 nurses progress notes indicated that the resident fell on [DATE] at 4:10 P.M., 9/8/16 at 11:40 A.M., and on 9/9/16 at 9 P.M. A review of Resident 232's Post Fall Assessment, dated 8/5/16, indicated that Resident was found sitting on the flr (floor), according to the resident, she's going to use the bathroom but foot twisted. A review of Resident 232's Post Fall Assessment, dated 9/8/16, indicated that Resident was ambulating in the rm (room), increase agitation when (sic) she loss her balance and fell , trip over her sandals. A review of Resident 232's Post Fall Assessment, dated 9/9/16, indicated that Resident was standing on the hallway talking to other resident when she loss her balance and fell . A review of Resident 232's Fall Risk Care Plan, dated 11/11/15, indicated that Resident 232 was at risk for falls and injuries. This care plan had Interventions which included, .Tab alarm w/c (wheelchair), pressure sensor pad in bed, mat at bedside when in bed and Low bed. There were no documented evidence that new interventions were added and initiated after the resident fell on [DATE], 9/8/16, and 9/9

Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse and injury of unknown origin for two of 30 sampled resident (175, 134). In addition, the facility failed to notify the officials in accordance with State law through established procedures (including to the state survey and certification agency). For Resident 175, the failure to thoroughly investigate an allegation of abuse had the potential to affect physical and psychosocial well-being of the resident. For Resident 134, failure to investigate the injury of unknown origin with a fracture had the potential for increase resident injury. Findings: 1. Resident 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 175's record titled, Post Fall Assessment, dated 6/17/16, was conducted. This record indicated, Resident was found laying on the flr (floor) in front of Rm (room-number) as per investigation resident went inside that rm . she (another resident) pushed the res (resident) out and she landed on the flr. An interview with licensed nurse (LN) 10 was conducted on 10/3/16 at 9:20 A.M. LN 10 stated that the incident happened during the night shift. LN 10 stated that Resident 175 went inside another resident's room. Per LN 10, the other resident told Resident 175 to go but Resident 175 did not understand the other resident. The other resident pushed Resident 175 causing her to fall. An interview with the Administrator (Admin) and the Assistant Administrator was conducted on 10/4/16 at 5 P.M. The Admin stated she remembered this particular incident. The Admin stated, It wasn't noted until later in the afternoon, so we dropped the ball. We probably should have investigated more. The Admin acknowledged all resident to resident physical altercations should have been investigated thoroughly and reported to the Department of Public Health and police department. A review of the facility's policy titled, Unusual Occurrence, dated 9/14, was conducted. This policy indicated, Occurrences such as .major accidents . and unusual occurrences which threatens the welfare, safety or health of patients . shall be reported by the facility within 24 hours either by telephone . to the local health office and the Department . 2. Resident 134 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the same record, Resident 134 did not have the capacity to understand and make decisions. A review of Resident 134's nurses progress notes, dated 4/6/16, was conducted. This note indicated, Noted .purplish discoloration on left posterior (back) thigh & (and) left hip . Claimed he fell but unable to state when . There was no other evidence of documentation for this incident. A review of Resident 134's transfer record, dated 4/6/16, was conducted. This record indicated the following reason for transfer, -CNA (certified nursing assistant) found a bruise, -Ordered x-ray -X -ray showed left [MEDICAL CONDITION]. A concurrent interview and record review with licensed nurse (LN) 12 was conducted on 10/4/16 at 1:25 P.M. LN 12 stated she went to see Resident 134 after the CNA reported bruising on the left hip, purple in color. LN 12 further stated, Resident 134 was alert but confused, he complained of pain and had facial grimacing. LN 12 also stated, He is non ambulatory. An interview with LN 12 was conducted on 10/4/16 at 2:15 P.M. LN 12 stated, I remember investigating the incident and asking the nurses what happen but I don't remember the result of that investigation. There was no other documentation found in Resident 134's record regarding this incident. LN 12 stated that Resident 134's injury of unknown origin should have been reported to the abuse coordinator and should have been investigated thoroughly, but was not. A concurrent interview and record review with the facility's Administrator (Admin) and the Assistant Administator (AA), was conducted on 10/4/16 at 4:25 P.M. The Admin stated all injuries of unknown origin should be investigated. The Admin reviewed records of abuse allegations in the facility. The Admin acknowledged that there was no record or documented evidence that Resident 134's injury of unknown origin was reported to the department of public health or the police in accordance with state law. The Admin stated,l know I didn't report it and looking back we probably should have. A review of the facility's policy titled, Unusual Occurrence, dated 9/14, was conducted. This policy indicated, Occurrences such as .major accidents . and unusual occurrences which threatens the welfare, safety or health of patients . shall be reported by the facility within 24 hours either by telephone . to the local health office and the Department .

Based on observation, interview and record review, the facility failed to ensure that 1of 2 sampled residents (A) received supervision and assistance necessary to prevent an accident and injury. A strap of the mechanical lift sling became loose during transfer and Resident A fell and sustained multiple fractures. Findings: Resident A was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessment ((MDS) dated [DATE], indicated that Resident A had no problems with short term and long term memory. The same MDS indicated that the resident was totally dependent on staff for bed mobility, transfers and had functional limitations in the range of motion of the upper extremity (shoulder, elbow, wrist, hand) and the lower extremity (hip, knee, ankle, foot) on both sides. Additionally, the MDS documented the Resident A had occasional pain that did not interfer with sleep or activities of daily living. On a scale of 0-10, with 10 being the worst pain, Resident A's pain was described as 4. The 1/12/12 Resident Care Plan for decline in basic activities of daily living and mobility indicated the a hoyer (mechanical) lift with 2 person assist was to be used for all transfers. The 1/12/12 Resident Care Plan for risk for falls/injury goal was the the resident would not fall or have injuries related to a fall for 90 days. The Licensed Nurses (LN) Progress Notes, dated 4/9/12 at 8:25 P.M., indicated: " (Resident A) fell from the sling of the Hoyer (mechanical) lift ...by the CNA (certified nurse assistant) ...Pain at right shoulder and left leg with a scale of 8/10 ...called 911 ... " The same notes, dated 4/9/12 at 10:50 P.M., indicated, " ...asked again what happened was told that sling on one end came off and resident slipped to floor ...Per CNA " resident was being transferred from wheelchair to bed and sling from Hoyer came off and resident slipped to floor ... " On 5/16/12 at 3:55 P.M., an interview with Resident A was conducted. The resident stated it was not the wrong lift or the wrong mesh sling, everything was just right. She stated, "If the sling was put on correctly, I would not be laying here broken. " She stated, " I felt my left shoulder go and said, Oh my gosh, I am falling, I fell backwards. " She stated that her bones were "shattered with 2 broken hips, right clavicle, and fractured neck, fractured both femurs, left tibia and left ankle." She stated there was trauma to her chest area. She stated that she landed face down, hitting hard on the chest. Resident A further stated that staff had to turn her over as she couldn't breathe. Resident A stated that she had a surgical repair of the right hip fracture with pins placed. Resident A stated that she could no longer feed herself, her teeth were no longer in alignment and she may lose them. On 6/7/12 at 2:15 P.M., a review of Resident A ' s acute care hospital record was conducted. The physician ' s discharge summary dated 4/13/12 indicated: " ...FX femur (fracture) neck R (right), closed FX of R clavicle, closed FX of vertebra, cervical C6-7 ...[DIAGNOSES REDACTED]. On 4/19/12 at 3:45 P.M., an interview was conducted the Resident A ' s physician. He stated that with the resident ' s history of osteoporosis, it would " an uphill battle to heal fractures. " He stated that the surgeon used screws to repair the right hip fracture but did not know if they would hold due to the resident ' s softened bones. On 4/19/12 at 5:30 P.M., CNA 2 was inteviewed. CNA 2 assisted with Resident A's transfer on 4/09/12. CNA 2 stated that resident was in the sling in the air approximately 20-30 seconds when the left top loop (head area) came off and the resident fell to the floor. CNA 2 stated that the sling did not rip. CNA 2 stated that CNA 3 had said the resident was ready to be transferred. On 5/16/12 at 3:05 P.M., an interview was conducted with CNA 3. She stated that she was assigned to the resident on 4/09/12, the day of the fall. She stated at approximately 8:20 P.M. she needed to transfer the resident from wheel chair to bed and CNA 2 assisted. CNA 3 stated that the resident was seated in a wheel chair on a mesh lift sling with the middle white loops attached to the mechanical lift. CNA 3 stated that CNA 2 operated the remote and raised the lift. CNA 3 held the resident ' s legs and that the resident faced the lift when going up then turned in the sling towards door (left side of bed). CNA 3 stated that CNA 2 moved the wheel chair for more space. When CNA 2 started to move the lift towards the bed, one the left shoulder hook of the sling of mesh sling came off the hook. CNA 3 stated that when the shoulder strap came unhooked, resident rolled out of sling onto the floor, face down. 4/13/12, physician redamission orders indicated Tylenol 325 milligrams (mg) every 4 hours as needed for pain. On 4/25/12, a new physician order [REDACTED]. Medication Adminstration Records (MARs) indicated that Resident A reported severe pain ranging from 4-10 on a scale of 10 for 26 days from 4/13/12 - 5/08/12 and 28 days from 5/09/12 - 6/05/12. The pain was described as generalized body, back and leg pain. The 4/20/12 MDS assessment documented that Resident A was in almost constant pain, had to limit daily activities, and pain intensity was described as 7 out of 10.