Every finding on record at Storybrook Care & Rehabilitation

Based on record review and interviews, the facility failed to provide emergency basic life support and cardiopulmonary resuscitation (CPR) when needed for one (#59) of three residents reviewed for advance directives out of 30 sample residents.Resident #59 was admitted to the facility on [DATE] with a history of acute and chronic respiratory failure.On [DATE], the Resident #59 completed and signed a Colorado Medical Orders for Scope of Treatment (MOST) form. The MOST form documented Resident #59 desired to receive CPR with full treatment in the event it was required. On [DATE], a physician's order was entered into Resident #59's electronic medical record (EMR) that identified Resident #59 was a full code and should receive CPR. On [DATE] at 2:42 a.m. licensed practical nurse (LPN) #3 documented Resident #59 was found to be absent of vital signs. She had no blood pressure, no pulse and no respirations. The resident was blue in color and cool to the touch. Emergency medical services (EMS) were contacted. Upon arrival to the facility, EMS pronounced the resident's death. The progress note did not indicate that CPR was provided to the resident before the arrival of EMS. -However, Resident #59's code status indicated the resident wanted CPR.Specifically, the facility failed to provide CPR for Resident #59, who had a full code status, until relieved by EMS personnel.Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #59's code status prior to the onsite investigation on [DATE] to [DATE], which resulted in the deficiency being cited as past non-compliance with a correction date of [DATE].I. Situation of serious [NAME] [DATE], the Resident #59 completed and signed a Colorado MOST form. The MOST form documented Resident #59 desired to receive CPR with full treatment in the event it was required. On [DATE], a physician's order was entered into Resident #59's EMR that identified Resident #59 was a full code and should receive CPR. On [DATE] at 2:42 a.m. LPN #3 documented Resident #59 was found to be absent of vital signs. She had no blood pressure, no pulse and no respirations. The resident was blue in color and cool to the touch. EMS was contacted. Upon arrival EMS pronounced the resident's death. -The progress note did not indicate that CPR was provided to the resident before the arrival of EMS. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #59's CPR incident on [DATE] was provided by the nursing home administrator (NHA) on [DATE] at 5:45 p.m. The facility became aware of the issue on [DATE] and developed a performance improvement plan (PIP) in response to Resident #59 not receiving CPR. The facility completed education to all clinical staff and audits of MOST forms for all residents in the facility.On [DATE], the facility provided in-service training for all nursing staff, including LPN #3, on the facility policy and when to initiate CPR.The facility continued to audit the MOST forms weekly to ensure each resident's advanced directive wishes were being honored.III. Facility policy and procedureThe Medical Emergency Response policy, revised [DATE], was provided by the NHA on [DATE] at 11:10 a.m. The policy read in pertinent part,The employee who first witnesses or is first on the site of a medical emergency, that is trained, will initiate immediate action, including CPR as appropriate, basic first aid, and summon for assistance. CPR will continue unless:-There is a DNR order in place;-There are obvious signs of clinical death; or,-Initiating CPR could cause injury or peril to the rescuer. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR prior to the arrival of the emergency medical services.IV. Resident #59A. Resident statusResident #59, age less than 65, was admitted on [DATE] and passed away at the facility on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included acute respiratory failure and morbid obesity. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. B. Record reviewThe progress note, dated [DATE], documented that at approximately 2:00 a.m., Resident #59 was found unresponsive by LPN #3. The nursing progress note documented Resident #59 did not have heart rate, blood pressure or respirations. The resident appeared cyanotic (blue in color) and cool to the touch. The nurse contacted EMS providers for assistance as the resident had a full code status.-However, the note did not document that LPN #3 attempted CPR for Resident #59. The EMS report, dated [DATE], documented that upon arrival to the facility, EMS determined Resident #59 had expired and resuscitation was not attempted. The resident's cause of death was documented as cardiac arrest at 2:54 a.m. by EMS. V. Staff interviewsLPN #3 was interviewed on [DATE] at 4:25 p.m. LPN #3 said she was the nurse who found Resident #59 unresponsive (on [DATE]). LPN #3 said she did not perform CPR on the resident because the resident appeared to have signs of death. She said she received education on when to start and stop CPR the same day on [DATE].Registered nurse (RN) #1 was interviewed on [DATE] at 5:01 p.m. RN #1 said CPR must be initiated when a resident was found unresponsive with absent vital signs. He said CPR could be stopped when EMS arrived. He said cyanosis and being cool to the touch were signs that CPR must be initiated. He said signs of immediate death would be stiffness of the body. The medical director was interviewed on [DATE] at 9:45 a.m. The medical director said cyanosis, coolness to touch and absence of vital signs were indications to start CPR. She said she reviewed the medical record for Resident #59 and LPN #3 should have initiated CPR on the resident on [DATE]. She said due to Resident #59's comorbidities, the CPR was unlikely to be successful; however, CPR should still have been initiated. The director of nursing (DON) was interviewed on [DATE] at approximately 10:30 a.m. The DON said the facility identified on [DATE] that CPR was not initiated by LPN #3 for Resident #59, who had a full code status. She said immediate education to all clinical staff and LPN #3 was provided to ensure staff understood signs of immediate death and signs when CPR should be initiated. She said she continued to audit MOST forms. She said following the education on [DATE], the facility had had another medical emergency where CPR was appropriately initiated by staff.

Based on observations, record review and interviews, the facility failed to protect the resident's rights to privacy regarding providing a private area to meet with clinicians, family members and friends. The deficient practice had the potential to affect all 53 residents who resided in the facility. Specifically, the facility failed to provide a dedicated area where residents could meet with clinicians, family members, friends and conduct resident council meetings.Findings include: I. Facility policy and procedure The Resident Right to Privacy in Communication, revised January 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 12:03 p.m. It read in pertinent part, It is the policy of this facility to support and facilitate a resident's right to privacy in communications with individuals and entities within and external to the facility.II. Observations During an initial facility walk-through on 6/22/26 at 9:45 a.m., there was no room observed to be designated as a conference room. The social services office was observed to be located next to the NHA's office and the door to the social services office was replaced with a curtain. The director of nursing's (DON) office was observed to be shared with the business office manager. The dining room was observed with no doors separating the dining room from the hallway to the rest of the building. The resident group interview was requested to be in a private space. The NHA provided the dining room. During the group interview, there were three black partitions dividing the dining room from the rest of the building (see group interview below). -However, there was space above the partitions which did not provide complete privacy as requested. On 6/25/26 at approximately 11:08 a.m. Resident #17 was talking to a nurse practitioner (NP) in the hallway in front of her room. The NP and Resident #17 were talking about the itching the resident was experiencing all over her body. The conversation could be clearly heard by others in the vicinity of Resident #17's room.III. Resident interviewsResident #17 was interviewed on 6/22/26 at 3:02 p.m. Resident #17 said she did not have privacy during her care conferences. She said care conferences took place in the dining room. She said it was not private, but there was nowhere else to go for them in the facility. A group interview was conducted on 6/24/26 at 10:30 a.m. with five residents (#13, #30, #32, #1, and #54) who were identified as alert and oriented through facility and assessment. All five residents said they did not have a private room to conduct care conferences, physician visits and family visits. The residents said they usually met outside on the porch or in the dining room. All five residents said they would like a dedicated room for private meetings. IV. Staff interviews The NHA was interviewed on 6/25/26 at 3:24 p.m. The NHA said residents' care conferences were held in the social services office, on the outside patio, in the NHA's office, in the DON's office or in the secured unit. She said if residents wanted to meet with family members and friends privately, they could meet in her office, the dining room, their room, or the outside patio. The NHA said no one had asked her to meet with providers privately. The NHA said residents knew where they could meet privately by going to resident council meetings and when they were admitted . The NHA said she knew not all residents attended resident council meetings and she was not sure it was documented at admission where they could meet. The NHA said she knew the social services office did not have a door so it was not completely private and the DON's office was shared with the business office manager. The NHA said the facility had long-term plans to make it easier for residents to meet privately and she would work with her team to come up with a short-term plan to ensure residents had a place to meet privately.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of three medication carts and one of one medication room.Specifically, the facility failed to: -Ensure that insulin and Turberculin vials were labeled with the dates the medications were opened;-Ensure ophthalmic solutions and inhalers were labeled with the date when the medications were opened; and, -Ensure there were no loose pills in the bottom of the medication cart drawers.Findings include:I. Professional referenceThe Food and Drug Administration's (FDA) Insulin Storage and Effectiveness (revised 9/19/17), retrieved on 6/30/26 from fda.gov/drugs/emergency-preparedness-drugs/information- regarding-insulin-storage-and-switching-between-products-emergency. It read in pertinent part, Insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 degrees F (Fahrenheit) and 86 degrees F for up to 28 days and continue to work.The Heath Direct Pharmacy Service's Did You Know? Ophthalmic Medication Beyond Use Date Guide (revised April 2024) was retrieved on 6/30/26 fromhttps://www.hdrxservices.com/wp-content/uploads/2024/04/799-[NAME]-Ophthalmic-Medication-Beyond-Use-Date-Guide-Apr-2024-Final.pdf. It read in pertinent part, Once the ophthalmic drops are opened, current practice guidelines recommend discarding the medication after 28 days due to concerns of stability and sterility. The Allergen Inc., the manufacturer of Refresh Tears, drug facts were retrieved on 6/30/26 from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=329d1fe0-4432-4565-b7b1-65666bd86526. It read in pertinent part, Refresh Tears: discard 90 days after opening.According to the manufacturer's recommendations for Systane (2025), retrieved on 6/30/26 from https://systane.myalcon.com/en-ca/products/systane-hydration-preservative-free/, Systane eye drops are good for 90 days after opening. According to the manufacturer's recommendations for Pataday ophthalmic solution (revised June 2020), retrieved on 6/30/26 from https://www.novartis.com/sg-en/sites/novartis_sg/files/Pataday-July_2020.SIN-App050221.pdf#:~:text=Results%20from%20clinical%20studies%20up,symptoms%20of%20allergic%20conjunctivitis%20and, Pataday Olopatadine Ophthalmic Solution 0.2%. Store at 2 degrees Celsius (C) to 25 degrees C (36 degrees F to 77 degrees F). Discard four weeks after opening. According to Drugs.com (1/23/25) Can You Use An Expired Albuterol Inhaler?, retrieved on 6/30/26 from https://www.drugs.com/medical-answers/you-expired-albuterol-inhaler-3556003/, An albuterol inhaler should be discarded after it passes its expiration date. It should be thrown out even sooner if it has been 13 months since it was removed from its foil packaging.According to Drugs.com (10/10/24), Tuberculin (PPD) Purified Protein Derivative (Interdermal) (monograph), retrieved on 6/30/26 fromhttps://www.drugs.com/monograph/tuberculin-purified-protein-derivative-interdermal.html#:~:text=for%20intradermal%20injection.-,Administration,Mantoux%20Test, Tuberculin PPD, diluted (Aplisol), is supplied as multi-dose vials containing 5 Tuberculin Units (TU) per 0.1 milliliters (ml) for intradermal injection. Store vials at 2 to 8 degrees C (36 to 46 degrees F); do not freeze; protect from light. Vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.According to the manufacturer's recommendations for Flonase, retrieved on 6/3026 from https://www.flonase.com/products/sensimist/faqs/, Flonase Sensimist: A 60-spray bottle will last you two weeks and a 120-spray bottle will last you four weeks. Standard Flonase/Fluticasone Propionate is good for up to 60 days after opening. According to Health Direct Pharmacy Services (6/30/26), RX Guides: Select Medications with Shortened Expiration Dates., retrieved on 6/30/26 fromhttps://www.hdrxservices.com/rx-guides-select-medications-with-shortened-expiration-dates/, Ipratropium Albuterol discard three months after first actuation or when the device locks out. Breo Ellipta 200 mcg/25 mcg inhaler, discard six weeks after removal from foil tray pouch or when counter reads 0.II. Facility policy and procedureThe Medication Storage policy, dated 10/26/24 and revised 1/1/26, was received from the nursing home administrator (NHA) on 6/23/26 at 4:20 p.m. It read in pertinent part, All medications housed on our premises will be stored in the medication room and medication carts according to the manufacturer's recommendations and sufficient to ensure proper temperature. All medications requiring refrigeration are stored in refrigerators. All medication rooms and carts are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.III. ObservationsOn 6/23/26 at 11:30 a.m. the Salana medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:-One vial of Lispro insulin was marked with an open date of 1/28/25; -One vial of Glargine insulin was marked with an open date of 4/21/26; -One bottle of Pataday olopatadine ophthalmic solution was not marked with the date it was opened;-One bottle of refresh tears was marked with an open open date of 8/25/25;-One vial of Tubersol (tuberculin PPD) was dated with an open date of 5/3/26. Additionally, the medication had a manufacturer's expiration date of 6/3/26 and the medication was not refrigerated; and,-There were five loose medication tablets in the first and second drawers of the medication cart.On 6/23/26 at 12:30 p.m. the Spruce medication cart was observed with registered nurse (RN) #1. The following items were found:-Four bottles of fluticasone propionate nasal spray 50 mcg were not labeled with the date they were opened; -Two Albuterol sulfate inhalers with no open date;-One Breo Ellipta 200 mcg/25 mcg inhaler was marked with an open date of 11/20/25;-One Breo Ellipta 200 mcg/25 mcg inhaler was not marked with an open date;-One bottle of Systane eye drops was not marked with an open date;-One bottle of Pataday eye drops was not marked with an open date;-One bottle of Refresh tears was marked with an open date of 1/24/26;-One bottle of Refresh tears was not marked with an open date; and, -There were five loose medication tablets in the first and second drawers of the medication cart.On 6/23/26 at 2:30 p.m. the medication room was observed with LPN #1. The following item was found:-One opened vial of Tuberosol (tuberculin PPD) was not marked with an open date. IV. Staff interviewsLPN #1 was interviewed on 6/23/26 at 11:50 a.m. LPN #1 said every nurse was responsible for cleaning the medication cart. She said every nurse on their shift should check the expiration dates of medications when administering the medication. LPN #1 said when opening a new medication, the date should be written on the package. She said giving expired medication may not be effective.RN #1 was interviewed on 6/23/26 at 12:50 p.m. RN #1 said when the nurses were working, they should check the medication carts for expired medications. He said when the nurse opened the medication, an open date should be clearly marked on the medication. RN#1 said administering expired medications was not in accordance with professional standards.The director of nursing (DON) was interviewed on 623/26 at 4:00 p.m. The DON said every nurse working on the medication cart is responsible for the medication and cleaning. She said the nurses should be checking expiration dates prior to medication administration. The DON said when a new medication was opened, the date should be clearly marked on the package. She said the pharmacy provided the medication sticker with an open and expiration date area to mark. The DON said the pharmacy consultant was monitoring the medication carts once a month for expired medications to take out of circulation.

Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications and treatments was clinically appropriate for two (#17 and #9) of two residents reviewed for self-administration of medications out of 30 sample residents. Specifically, the facility failed to: -Ensure a self-administration assessment was completed for Resident #17 to provide urostomy care by herself; -Ensure a self-administration assessment was completed and that Resident #9 was reevaluated to use his TENS unit (transcutaneous electrical nerve stimulation - a pocket-sized, non-invasive device that sends low-voltage electrical currents through the skin to relieve acute and chronic pain) for pain management by himself; -Ensure a self-administration assessment was completed for Resident #9 to administer his own insulin; and, -Ensure the self-administration of urostomy care for Resident #17 and the self-administration of a TENS unit and insulin administration for Resident #9 were care planned.Findings include: I. Facility policy and procedure The Resident Self-Administration of Medication policy, revised January 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 12:03 p.m. It read in pertinent part, A resident may only self-administer medications after the facility's interdisciplinary team has determined whichmedications may be self-administered safely. The results of the interdisciplinary team (IDT) assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR (medication administration record). A re-assessment for safety at a minimum, should be considered by the interdisciplinary team for the following significant changes in the resident's status and medication errors occur.II. Resident #17 A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included surgical aftercare following surgery on the genitourinary system (the organs of the urinary tract and the reproductive system), attention to the artificial openings of the urinary tract, stage 3 chronic kidney disease and malignant neoplasm of unspecified ureter (cancerous tumor of two thin, muscular tubes that carry urine from the kidneys to the urinary bladder).According to the 6/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental (BIMS) score of 13 out of 15. She used a walker and was independent with eating, oral hygiene, toileting, showering, and personal hygiene.B. Resident interviewResident #17 was interviewed on 6/22/26 at 3:03 p.m. Resident #17 said she had an urostomy because she had stomach cancer and they removed her stomach as part of her treatment. She said the tape used around the urostomy stoma (a surgically created opening on the surface of the body that connects to an internal organ) irritated her skin and she thought she was allergic to the tape. C. Record review Review of Resident #17's June 2026 CPO revealed the following physician's orders: Urostomy care: change appliance two times a week. 2 1/4-inch medium wafer, 2 1/4-inch urostomy pouch. Measure stoma so that no more than a sliver (about 1/16 of an inch) of skin is showing between the stoma and wafer. Replace foley catheter bag with each change due to nephrostomy infection every day shift every Monday and Thursday. Document in nurses notes or skilled notes any teaching or training provided, ordered on 4/30/26 and discontinued on 6/22/26. Urostomy care: change appliance two times a week. 2 1/4-inch medium wafer, 2 1/4-inch urostomy pouch. Measure stoma so that no more than a sliver (about 1/16 of an inch) of skin is showing between the stoma and wafer. Replace foley catheter bag with each change due to nephrostomy infection every day shift every Monday and Thursday. Resident independent with changing. Document in nurses notes or skilled notes any teaching or training provided, ordered on 6/25/26 (during the survey). Urostomy care: empty when the pouch is one third full. Record output every shift. Every shift for outputs, ordered 4/7/26. Review of Resident #17's May 2026 and June 2026 MARs revealed the 5/4/26, 5/11/26, 5/18/26, 6/4/26 and 6/18/26 dates of administration for the urostomy care were documented with the number 9, indicating to see the nurse notes. The notes revealed the urostomy did not need to be changed because the urostomy appliance was not soiled or had been changed the previous day. -However, there was no documentation that education or teaching was provided to the resident. The 4/10/26, 4/12/26, 4/14/26, 4/20/26, 4/24/26, 4/25/26, 4/28/26, 4/29/26, 5/1/26, 5/4/26, 5/8/26, 5/9/26, 6/2/26 and 6/17/26 nurse progress notes revealed the urostomy bag was emptied by the resident. -A review of Resident #17's electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #17 was able to safely change her urostomy bag and empty her urostomy pouch. III. Resident #9 A. Resident status Resident #9, age less than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included type 2 diabetes mellitus, chronic pain syndrome, hereditary and idiopathic neuropathy (unknown underlying cause of nerve damage).According to the 6/10/26 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene.B. Observation and interview On 6/23/26 at 9:43 a.m. four insulin pens were observed in Resident #9's refrigerator door. Resident #9 said he kept the insulin pens there because sometimes the nurses did not administer his insulin in a timely manner and he administered his insulin himself. During the interview, Resident #9 said he had pain in his left foot and he pointed to his left foot. Resident #9 said pain medications, such as gels, creams and oral medications helped him with his pain. C. Record review Review of Resident #9's June 2026 CPO revealed the following physician's orders: TENS unit to feet three times a day for one hour at a time. Tens unit is in the room and resident may self administer as needed for pain, ordered 2/3/25. -However, a review of Resident #9's EMR did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #9 was able to safely administer his own TENS unit.-A review of Resident #9's EMR did not reveal a physician's order or other documentation that indicated the resident was able to self administer his own insulin. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 6/25/26 at 11:08 a.m. LPN #4 said medications and treatment supplies could never be left at a resident's bedside unless an assessment was completed to determine if the resident could self-administer the medication or treatment. LPN #4 said she was familiar with Resident #17. She said Resident #17 kept her urostomy supplies in her room because she changed her own urostomy on the days she showered. LPN #4 said Resident #17 was quick to change her urostomy and she never talked about the tape irritating her skin. LPN #4 said when she saw the urostomy site it was red. LPN #4 said there should have been an assessment completed for Resident #17 to change her own urostomy bag. LPN #4 said she was familiar with Resident #9 and she was not familiar if he had a TENS unit. She said if the physician's order was for as needed use, Resident #9 should have had an assessment that indicated he was educated to tell the nurse when he used the TENS unit so the nurse could document on the MAR that the resident had used it as a pain intervention. She said he did not have a self-administration assessment to indicate he could self-administer his own insulin.The director of nursing (DON) and the regional nurse consultant were interviewed together on 6/25/26 at 3:39 p.m. The DON said medications and treatment supplies could be left at a resident's bedside if there was a physician's order, a self-administration assessment and there was a care plan indicating the resident could self administer medications. The DON said residents were re-evaluated quarterly and as needed because she wanted to make sure the resident could still safely administer the medication or treatment. The DON said if there was a physician's order for an as needed treatment that was self administered, the resident was educated to notify the nurse when they used the medication or treatment so the nurse could document on the MAR or TAR. The DON said she was familiar with Resident #17. She said Resident #17 did not have an assessment to self administer her urostomy bag. The DON said she should have had an assessment and a care plan indicating she could self-administer the urostomy care. The DON said she was familiar with Resident #9. She said she was not aware of the TENS unit or if the resident was still using it. The DON said she knew the resident had insulin in his refrigerator. She said he bought his own insulin sometimes and he refused to give the insulin to the nurses. The DON said the resident did not self administer the insulin but stored the insulin in his room. The DON said she should have had some documentation to ensure the resident was educated on how to store medication safely. The DON said she did not know Resident #9 self-administered his own insulin at times and she would check to ensure the resident was only storing the medication.The DON and the regional nurse consultant were interviewed a second time on 6/25/26 at 4:50 p.m. The regional nurse consultant said therapy was the department who assessed Resident #9 for the TENS unit in February 2025. She said the therapy assessment should have been in the resident's chart and the resident should have been re-evaluated at least quarterly to determine if the resident should have been self-administering the TENS unit.

Based on record review and interviews, the facility failed to ensure one (#44) of three residents reviewed for abuse out of 30 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #44 from physical abuse by Resident #12.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised April 2026, was provided by the nursing home administrator (NHA) on 6/22/26 at 3:04 p.m. It read in pertinent part, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse during and after the investigation.II. Incident of physical abuse by Resident #12 towards Resident #44 on 6/5/26 A. Facility investigationThe facility investigation, dated 6/5/26, was provided by the NHA on 6/23/26 at 9:50 a.m. The investigation revealed that Resident #44 came into physical contact with Resident #12 on 6/5/26.Resident #44 was interviewed on 6/5/26 after the incident. Resident #44 said she was alright. Resident #12 was interviewed but did not respond to questions. After the incident Resident #12 was placed on one-to-one staff monitoring. Resident #44 was assessed and no immediate skin injuries were noted. Resident #44 was re-evaluated on the day of the incident (6/5/26) and transferred from the secure unit to another unit, as she no longer met the criteria for the secure unit.According to the facility's investigation, the facility did not substantiate the allegations of physical abuse because the outcome of the investigation revealed no intentional, knowing or reckless action resulted in bodily injury. The contact made (to Resident #44) was not intentional (by Resident #12) and did not result in fear for either resident. The facility could not substantiate the abuse because it did not meet the criteria for intention. -However, abuse occurred because Resident #12 made physical contact with Resident #44.-Additionally, interviews with staff during the survey revealed that Resident #44 and Resident #12 had a previous altercation on the morning of 6/5/26 (see interviews below).B. Resident #441. Resident statusResident #44, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and anxiety. The 6/6/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial assistance from staff for most activities of daily living (ADL).The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.2. Resident's representative interviewResident #44's representative was interviewed on 6/22/26 at 2:40 p.m. The resident's representative said Resident #44 was kicked and pushed by another resident (Resident #12) on 6/5/26. She said the first incident occurred in the morning in the garden, and the second incident occurred in the evening in the dining room. She said she was on the phone with Resident #44 in the evening when she heard yelling and screaming, the phone was dropped and the call was discontinued. She said she attempted to call back, but Resident #44 did not respond. She said she was later called by the facility staff and learned that Resident #44 was attacked by another resident on the unit. 3. Record reviewThe progress note, dated 6/8/26, documented Resident #44 was seen for follow-up after being assaulted twice over the weekend. Xrays were reviewed and no acute injury was identified. The resident reported no pain and no acute concerns at the time.-Review of Resident #44's electronic medical record (EMR) revealed no other progress notes related to the 6/5/26 incident with Resident #12. C. Resident #121. Resident statusResident #12, age less than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included early onset Alzheimer's dementia and cognitive communication deficit.The 6/19/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident required supervision and was independent with most ADLs.The MDS assessment documented the resident had hallucinations and had verbal behaviors directed at others. 2. Record reviewThe behavioral care plan, initiated on 4/26/26, revealed Resident #12 had physical behaviors towards herself, such as hitting her head on the wall and was on several psychotropic medications. -The behavioral care failed to document that the resident had behaviors towards other residents and that the resident was on one-to-one staff supervision. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/24/26 at 12:31p.m. LPN #1 said Resident #12 was mostly calm but did have spontaneous outbursts of anger. She said she had not observed Resident #12 hitting other residents, but she had observed the resident trying to grab and lift a metal chair on the patio during one of her outbursts.Certified nurse aide (CNA) #3 was interviewed on 6/24/26 at 12:40 p.m. CNA #3 said she was supervising Resident #12 today (6/24/26), to make sure she did not go too close to other residents, as she had a history of aggression. LPN #3 was interviewed again on 6/24/26 1:25 p.m. LPN #3 said she was aware of the incident between Resident #44 and Resident #12 (on 6/5/26). She said she did not witness the event but was aware that after the incident, Resident #44 was moved out of the secure unit. She said Resident #44 was never physically aggressive. CNA #2 was interviewed on 6/24/26 at 1:27 p.m. CNA #2 said a couple of physical altercations occurred between Resident #12 and Resident #44 at the beginning of June 2026. She said after the second incident, Resident #44 was moved out of the secure unit. She said she was with Resident #12 right after the 6/5/26 evening incident and provided one-to-one monitoring of the resident. She said Resident #12 's aggression was not always predictable. She said she did not know what Resident #12 did (to Resident #44), but she knew she did try to hurt Resident #44. She said Resident #44 was tearful and emotional after the incident. She said she was not sure if Resident #12 was placed on one-to-one supervision right after the morning incident on 6/5/26. CNA #4 was interviewed via phone on 6/24/26 at 2:30 p.m. CNA #4 said she did not witness the 6/5/26 morning incident between Resident #44 and Resident #12 because she was working an evening shift that day. She said in the evening (6/5/26)around dinner time, she was giving report to another CNA when Resident #12 came outside to the garden and kicked the plant that was on the patio. CNA #4 said as she was trying to pick up the plant, she observed Resident #12 charging at Resident #44 who was sitting in the dining room with a phone in her hand. CNA #4 said Resident #44 grabbed the phone and threw it on the floor. She said other CNAs in the unit intervened, but it was hard to see if Resident #44 got hurt. She said Resident #12 made attempts to kick and hit Resident #44 during the incident. CNA #5 was interviewed via phone on 6/24/26 at 2:50 p.m. CNA #5 said on the morning of 6/5/26, Resident #44 was in the garden holding a plant. She said Resident #12 came to the patio and grabbed the plant from Resident #44. CNA #5 said Resident #44 yelled my plant and Resident #12 hit her on the shoulder. She said both residents were separated. The director of nursing (DON) was interviewed on 6/25/26 at 4:30 p.m. The DON said she was not in the building at the time of the incident on 6/5/26 between Resident #44 and Resident #12. She said the incident was reported to her later. She said she did not recall the 6/5/26 morning incident between the residents in the garden. She said after the 6/5/26 evening incident, the residents were separated and Resident #12 was put l on one-to-one supervision for aggressive behaviors. She said Resident #12 was still on one-to-one supervision.The NHA was interviewed on 6/25/26 at 4:30 p.m. The NHA said she thought only one incident occurred between Resident #12 and Resident #44 on 6/5/26. She said she was not aware of the morning incident on 6/5/26. She said she did not know what interventions were put in place after the first incident. She said she would provide immediate education to staff to ensure that all altercations between residents were reported. The NHA said she did not investigate the 6/5/26 incident between Resident #44 and Resident #12 because she was not aware of it. She said she investigated the 6/5/26 evening incident and placed Resident #12 on one-to-one supervision. She said Resident #12's medications were currently being reviewed and adjusted to address her aggressive behaviors.

Based on record review and interviews, the facility failed to ensure residents received the nutritional care and services necessary to maintain their highest practicable level of well-being for two (#17 and #24) of three residents out of 30 sample residents. Specifically, the facility failed to follow physician-ordered nutritional interventions for Resident #17 and Resident #24.Findings include: I. Professional referenceAccording to the National Institutes of Health (NIH), National Library of Medicine, Effects of high-protein supplementation during cancer therapy: a systematic review and meta-analysis (December 2024), retrieved on 6/30/26 from https://pmc.ncbi.nlm.nih.gov/articles/PMC11619795/#abs0010, High-protein supplementation mitigates weight loss, improves muscle strength, and lowers hospitalization rates in patients undergoing cancer therapy. These positive clinical outcomes, along with a favorable safety profile, suggest that high-protein supplementation may be a valuable addition to medical practice.According to [NAME], Ensure Regular, retrieved on 6/30/26 from https://www.nutrition.[NAME]/ca/en/adult/ensure-regular Ensure provides complete, balanced nutrition and protein, which helps build strong muscles and antibodies. Patients can drink Ensure Regular with or between meals. For patients with or at risk of malnutrition.II. Resident #17 A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included surgical aftercare following surgery on the genitourinary system (the organs of the urinary tract and the reproductive system), attention to the artificial openings of the urinary tract, stage 3 chronic kidney disease, malignant neoplasm of unspecified ureter (cancerous tumor of two thin, muscular tubes that carry urine from the kidneys to the urinary bladder), unspecified protein calorie malnutrition, muscle weakness and long term drug therapy. The 6/24/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview mental (BIMS) score of 13 out of 15. She used a walker and was independent with eating, oral hygiene, toileting, showering, and personal hygiene. The assessment revealed she was at risk for malnutrition. She was 63 inches tall and weighed 131 pounds (lbs). She was not on a therapeutic diet. B. Resident interview Resident #17 was interviewed on 6/22/26 at 3:03 p.m. Resident #17 said she had lost weight since she was admitted to the facility and the facility had not talked to her about interventions on how to not lose weight. She said she had cancer and she expected to lose weight due to the disease. She said a physician recommended protein shakes to help prevent her from losing weight. She said she had to buy her own protein shakes and she kept the shakes in her room. She said no one reviewed the shakes she bought on her own to see if they were the right type of shakes to help her not lose weight. She said she bought different types of shakes each time she ran out of shakes. C. Record review The nutritional care plan, initiated 10/1/25 and revised 10/16/25, revealed Resident #17 had nutritional problems related to cancer, chronic kidney cancer, anxiety, depression, gastroesophageal reflux disease (GERD), hyperlipidemia and hypothyroidism. Resident #17 was at risk of malnutrition with a mini nutritional assessment score of eight out of 14. Interventions included inviting the resident to activities that promoted additional intake, monitoring, recording and reporting to the physician as needed for signs and symptoms of malnutrition and providing diet as ordered. According to the June 2026 CPO, Resident #17's diet order was a regular diet, regular texture and thin consistency, ordered 3/13/26. -There were no physician's orders for protein shakes (see record review below).The 4/6/26 nurse note revealed Resident #17 returned from a urology oncology appointment with new physician's orders for two protein shakes per day for nutrition support indefinitely. The resident provided a copy to the kitchen staff. The nurse placed a copy in the dietary box.-However, the physician's order from the oncologist was not entered into the resident's electronic medical record (EMR) -A review of Resident #17's EMR revealed no documentation that protein shakes were administered to the resident from 4/6/26 to 6/24/26. The 4/15/26 social services progress note revealed Resident #17's protein needs were discussed. Shakes, supplements and options to increase protein intake were reviewed. The note documented that suggestions and education were provided for the resident. -However, there was no documentation of what suggestions and education were given to the resident for increasing protein intake. The 4/17/26 care plan meeting revealed Resident #17's diet and protein shakes were reviewed. The social services director (SSD), physical therapist, activities director and a licensed practical nurse (LPN) were present at the meeting, along with the resident. -However, a review of Resident #17's EMR revealed there was no documentation to indicate that the shakes were discussed as an intervention and a decision was made not to implement them. The 6/20/26 nutritional assessment revealed the following weights as follows: -On 12/28/25, the resident weighed 140 pounds; -On 5/25/26, the resident weighed 133 pounds; and, -On 6/14/26, the resident weighed 131 pounds, which was a 9 lb weight loss or a 6.43% in a six-month period. The 6/20/26 nutritional assessment documented the registered dietitian (RD) would not trigger the weight loss as significant due to the weight loss not being a concern, per the resident. Resident #17 could be at nutritional risk due to cancer, chronic kidney disease, anxiety, depression, GERD, hyperlipidemia, hypothyroidism, and surgery. She was at risk of malnutrition due to a mini nutritional assessment score of eight out of 15. Medications could affect appetite, intake and weight. Resident #17 was receiving chemotherapy treatment which could affect appetite, intake and weight. Resident #17 could order outside foods at times and had snacks in rooms. The resident's intake appeared adequate to meet her nutritional needs at the time. -However there was no documentation that the RD discussed the weight loss of the intervention of protein shakes with the resident. III. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included hypertensive heart disease with heart failure, unspecified protein calorie malnutrition, pulmonary hypertension, and GERD. The 5/7/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He used a wheelchair. He was independent with eating and he required set up assistance with oral hygiene. He was dependent on toileting. He required partial assistance with personal hygiene and showering. The assessment revealed he was at risk for malnutrition and required a mechanically altered diet. B. Resident interview Resident #24 was interviewed on 6/22/26 at 3:20 p.m. Resident #24 said he saw a nephrologist and the nephrologist told him he ordered two protein shakes. Resident #24 said he had not received any protein shakes from the facility. Resident #24 said his nephrologist ordered the protein shakes because he wanted him to have extra protein. C. Record reviewThe nutritional risk care plan, initiated 9/17/25 and revised 6/3/26, revealed Resident #24 was at nutritional risk due to congestive heart failure GERD, sepsis and hypertension. Resident #24 was considered malnourished based on a mini nutritional assessment score of six out of 14. He had a desired weight loss of 200 lbs and was non-compliant with diet texture recommendations. Interventions included monitoring for malnutrition, IDT referrals as needed, providing nutritional education as needed and RD to evaluate and make diet change recommendations as needed. According to the June 2026 CPO, Resident #24's diet order was a regular diet, regular texture and thin consistency, ordered 5/12/26.-There were no physician's orders for protein shakes (see record review below).The 4/8/26 nephrology note revealed Resident #24 was seen as a new patient. The assessment revealed Resident #24 had chronic hyponatremia in the setting of CHF and hypertension. He had possible protein energy malnutrition. He had hypertension and was on blood pressure medication medications. He had type 2 diabetes mellitus and was on Jardiance (a medication for diabetes). The physician's orders and patient education included starting on Ensure two cans a day. -However, a review of Resident #24's EMR revealed the order from the nephrologist was not entered into the resident's EMR as a physician's order. -There was no documentation in the resident's care plan or EMR to indicate not ordering the protein shakes was discussed as an IDT team or with the resident. IV. Staff interviews LPN #4 was interviewed on 6/25/26 at 11:08 a.m. LPN #4 said she knew a resident had an appointment because the facility's EMR had a dashboard that showed all the appointments for the day and what time the resident had to leave the facility. LPN #4 said when the resident returned from an appointment, the floor nurse or charge nurse was responsible for reviewing the paperwork the resident brought back to see if there were any new physician's orders. LPN #4 said if there were any new physician's orders, she called the facility's physician to review the orders and then entered the order in the resident's EMR. LPN #4 said she initiated and dated the paperwork and entered a progress note summarizing the outside physician's visit. LPN #4 said if a community physician ordered Ensure or protein shakes, it was considered a physician's order. LPN #4 said the RD was responsible for entering nutritional orders. LPN #4 said she did not have any residents in her unit who had protein shakes. LPN #4 said she was familiar with Resident #17 and Resident #24 and neither of them had physician's orders for Ensure or protein shakes. The RD was interviewed on 6/25/26 at 2:36 p.m. The RD said if a community physician ordered Ensure or protein shakes, it was considered a physician's order. The RD said her role in regards to supplemental shakes was to interview the resident or the resident's family to determine the resident's need. The RD said the newest research showed there were chemicals in Ensure and other supplements. She said the chemicals caused more problems than it was worth. The RD said the first route for nutritional interventions was food. She said examples included fortified food, such as fortified cereal, fortified milk, pudding, large protein, scheduled snacks or extra glasses of milk. The RD said nutritional shakes were the last resort and for residents who were cachetic (very thin), unable to eat, or did not have a lot of teeth. The RD said she was familiar with Resident #17. She said the resident talked to her about protein shakes based on her oncologist's recommendations. The RD said she provided the resident with education on the risk and the downfalls of consuming shakes. The RD said she told Resident #17 if she wanted shakes, she could have them, but she (the RD) would not order them. The RD said she did not talk to the resident's oncologist and she did not talk to the rest of the IDT team about her discussion with Resident #17. The RD said she was familiar Resident #24. She said the resident talked to her about the Ensure recommended by his nephrologist. She said the Ensure contradicted his goals of losing weight. She said there was not a progress note about their conversation and she did not talk to his nephrologist after their discussion. She said she did not talk to the IDT about their conversation regarding not starting the Ensure shakes. The director of nursing (DON) and the regional nurse consultant on 6/25/26 at 3:39 p.m. The DON said when a resident returned from a community physician's appointment, the floor nurse or charge nurse reviewed the paperwork that came back with the resident. The DON and the regional nurse consultant said the nurse initialed, dated and wrote the time on the paperwork and wrote a progress note describing the physician's appointment and if there were any new physician's orders discussed with the physician. The DON said the nurse verified and clarified any physician's orders with the facility's physician and then entered the orders in the resident's EMR. The DON and the regional nurse consultant said if a community physician ordered Ensure or protein shakes, it was considered a physician's order. The DON said she was familiar with Resident #17 and was not aware there was a physician's order from the resident's oncologist for protein shakes in April 2026. The DON said she was familiar with Resident #24. The DON said Ensure shakes for the resident was mentioned to her verbally and it was not recommended due to his weight being stable. The DON and the regional nurse consultant said there should have been documentation from the RD as to why the physician's order was not followed for the Ensure shakes and the IDT team should have discussed the Ensure orders as a team.

Based on record review and interviews, the facility failed to provide tube feeding management according to professional standards for one (#28) of one resident out of 30 sample residents.Specifically, the facility failed to ensure the correct amount of tube feeding formula and water were administered for Resident #28.Findings include: I. Facility policy and procedureThe Appropriate Use Of Feeding Tubes policy, revised February 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 11:04 a.m. It read in pertinent part, Feeding tubes (naso-gastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. II. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician's orders (CPO), diagnoses included unspecified severe protein-calorie malnutrition, and liver and kidney transplant.The 4/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 of 15. The MDS assessment indicated the resident received nutrition via feeding tube and was receiving hospice care servicesB. Record reviewReview of Resident #28's June 2026 CPO revealed the following physician's orders:Resident is to be NPO (nothing by mouth), only tube feeds, ordered 9/11/25.Enteral Feed Order: Two times a day Isosource 1.5 at rate of 350 milliliters (ml) gravity bolus (a method of delivering liquid nutrition or medication directly into the stomach using a syringe, mimicking a regular mealtime schedule) via PEG (percutaneous endoscopic gastrostomy - a medical device inserted directly through the abdomen into the stomach) four times a day. Flush tube with 50 milliliters (ml) water before and after administration, ordered 6/11/26.Enteral Feed Order: four times a day for hydration, ordered 6/17/26.-The physician's order did not document the amount of water that was to be administered with each hydration administration.Review of Resident #28's June 2026 medication administration record (MAR) revealed the following: Resident #28's Isosource 1.5 tube feedings had been documented as administered two times a day, not four times a day as was ordered since 6/11/26.Resident #28's water hydration administrations had been documented as administered four times per day.-However, the hydration administrations did not document how much water was administered each time.-Additionally, according to the registered dietitian's (RD) evaluation (see evaluation below), the resident should have been receiving hydration administrations every four hours (six times per day). The RD evaluation, dated 4/6/26, indicated Resident #28 was to receive 350 ml of formula (Isosource 1.5) four times a day and 150 ml of water every four hours (six times a day). III. Staff interviews Registered nurse (RN) #2 was interviewed on 6/25/26 at 12:30 p.m. RN #2 said she administered today's (6/25/26) feeding via bolus for Resident #28. She said for hydration, she administered 15 ml of water to the resident. She said it was not clear how much water to give to the resident, so 15 ml is what she administered. Licensed practical nurse (LPN) #4 was interviewed on 6/25/26 at 12:36 p.m. LPN #4 said Resident #28's physician's orders for hydration and tube feeding did not make sense and needed clarification. She said the water amount and the frequency was missing and the bolus order for the formula was not clear if it should be given four times per day or two times per day. RN #3 was interviewed on 6/25/26 at 12:40 p.m. RN #3 said she was a charge nurse on the unit. She said the physician's orders for Resident #28's tube feeding and hydration were incomplete and unclear and should have been clarified. She said she did not know how much water the resident had received since 6/11/26 because there was no amount specified in the physician's order. The RD was interviewed on 6/25/2026 at 12:45 p.m. The RD said she reviewed Resident #28's physician orders and said the orders in the resident's June 2026 CPO were not what she documented the resident should be receiving on her last evaluation in April 2026. She said the hospice care services team sometimes changed physician's orders and did not notify her. The director of nursing (DON) was interviewed on 6/25/26 at 1:49 p.m. The DON said Resident #28's physician's orders for tube feeding and hydration were not complete and should have been clarified with the RD and the physician. She said she believed the orders were changed by a hospice care services team member, but she had no documented records as to who changed the orders and when. She said she did not know why the amount of water to administer was missing from the physician's order. She said she would provide education to the nursing staff to always clarify incomplete physician's orders. The DON said Resident #28 would be assessed and monitored for dehydration.

Based on record review and interviews, the facility failed to ensure residents received medically related social services for one (#23) of five residents out of 30 sample residents. Specifically, the facility failed to ensure Resident #23 was followed by behavioral health services, as was recommended by the primary care physician.Findings include:I. Resident #23A. Resident statusResident #23, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included aphasia after stroke, anxiety, and depressive episode. The 3/31/26 minimum data set (MDS) assessment revealed Resident #23 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment for depression indicated the resident had moderate depression with a score of 10. B. Resident interviewResident #23 was interviewed on 6/22/26 at 11:17 a.m. During the interview, Resident #23 was pausing and searching for words and was tearful. Resident #23 was able to say who she was, and what type of facility she was living in. Resident #23 said she was anxious and upset about her current situation. She said about a year ago, before her stroke she was able to run her business and manage her life independently. She said after the stroke, she was appointed a conservator who was managing her business and a guardian who was deciding her medical and everyday needs for her. She said she did not wish for any of that and wished to manage her life on her own. She said she was deemed incompetent and was not able to make decisions on her own, however she believed that she was competent and was able to make decisions about her health and finances. Resident#23 said she was stressed out about the conservator and guardianship situation and did not know who could help her. She said it was currently being reviewed, but no court date was scheduled. C. Record reviewThe social care plan, initiated 4/23/26, revealed that Resident #23 was independent for meeting her emotional, intellectual, physical, and social needs. Review of court documents revealed that immediately after Resident #23's stroke in July 2025, Resident #23 was appointed a permanent conservator to manage her business. On 1/14/26 she was appointed a temporary guardianship that was to expire on 7/13/26.The 5/6/26 psychologist evaluation note revealed Resident #23 was evaluated by a psychologist as a court ordered assessment in order to see if temporary guardianship should be switched to permanent. Permanent conservatorship was not evaluated as it was permanent.The psychologist recommended antidepressant medication; however, the psychologist documented that side effects may outweigh the benefits of the medication for Resident #23. The primary care physician note, dated 5/29/26 documented Resident #23 had major depressive disorder, single moderate episode. The resident expressed sadness and discontent with her current facility stay and desired to be home with her animals. The primary care physician documented that Resident #23 was being followed by behavioral health/psychiatry services. Social services was working with the resident to explore discharge options with home caregiver support given the resident's functional improvement (the resident was now requiring only one-person assist to transfer). -However, review of Resident #23's electronic medical record (EMR) revealed no behavioral health services documentation. II. Staff interviewsRegistered nurse (RN) #2 was interviewed on 6/25/26 at 3:21 p.m. RN #2 said she did not know Resident #23 well because she rarely worked with her. She said she had not observed the resident being tearful or wanting to leave. Certified nurse aide (CNA) #4 was interviewed on 6/26/26 at 3:45 p.m. CNA #4 said Resident #23 was frequently tearful and upset when she was searching for words. CNA #4 said for the most part, the resident was alright.CNA #2 was interviewed on 6/26/26 at 4:00 p.m. CNA #2 said Resident #23 was tearful and many times said that she wished to be home. The social services assistant was interviewed on 6/24/25 at 4:20 p.m. The social services assistant said Resident #23 was not able to express herself and was appointed a guardian. She said the resident's guardianship was currently being reviewed. She said the resident was not followed by any behavior health services. She said she did not know why. She said the resident was happy to be in the facility and never expressed any concerns about her guardianship or conservator.-However, according to the primary care physician's note, the resident was not happy with her stay at the facility and wanted to be home with her animals (see physician's note above). The primary care physician was interviewed via phone on 6/25/26 at 5:00 p.m. The primary care physician said Resident #23 had expressive aphasia after her stroke. She said she recommended behavioral health services because the resident was very frustrated with her conservator/guardianship situation. She said she was under the impression that the resident was receiving behavioral health services in the facility. She said she did not know that the resident had not received any behavioral health services. The primary care physician said she had not been included in the guardianship review for Resident #23, but felt that she should have been. She said Resident #23 had shown improvement since her initial admission and she was able to express herself well.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of eight residents reviewed for medications out of 30 sample residents.Specifically, the facility failed to ensure Resident #1's oxybutynin ER (extended release), a medication used to treat bladder spasms, was administered in the correct dosage form per the physician's orders.Findings include:I. Professional referenceAccording to Drugs.com's prescribing information for oxybutynin ER tablets(1/20/26), retrieved on 7/1/26 from https://www.drugs.com/pro/oxybutynin-er-tablets.html, Oxybutynin chloride extended-release tablets must be swallowed whole with the aide of liquids, and must not be chewed, divided, or crushed. Oxybutynin relaxes bladder smooth muscle. Oxybutynin chloride exerts a direct antispasmodic effect on smooth muscle and inhibits the muscarinic action of acetylcholine on smooth muscle. Overdosage with oxybutynin chloride has been associated with anticholinergic effects including central nervous system excitation, flushing, fever, dehydration, cardiac arrhythmia, vomiting, and urinary retention.II. Facility policy and procedureThe Medication Administration policy, dated 10/16/24 and revised 1/1/26, was received from the nursing home administrator (NHA) on 6/25/26 at 4:15 p.m. The policy read in pertinent part, Administer medication as ordered in accordance with manufacturer specifications. Crush medications as ordered. Do not crush medications with 'do not crush' instructions.III. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included infection and inflammatory reaction due to a urinary catheter, multiple sclerosis, flaccid neuropathic bladder (large bladder volume), and muscle spasms. B. ObservationOn 6/24/26 at 9:44 a.m. licensed practical nurse (LPN) #1 was observed administering medications to Resident #1. LPN #1 dispensed the resident's medications, including an oxybutynin ER tablet, and proceeded to crush all of the tablet medications in applesauce for ease of administration to the resident.-However, per manufacturer's instructions (see professional reference above) and the physician's order for the medication (see record review below), oxybutynin ER tablets should not be crushed.C. Record reviewReview of Resident #1's June 2026 CPO revealed the following physician's order:Oxybutynin chloride ER oral tablet extended release 24-hour 15 mg; give one tablet by mouth one time a day for a spastic bladder. This medication is an extended-release medication that should not be crushed, ordered 5/5/26.IV. Staff interviewsLPN #1 interviewed on 6/24/26 at 1:00 p.m. LPN #1 said she always crushed all of Resident #1's medications. She said the resident had some liquid medications. She said the resident's medication capsules were opened and sprinkled into applesauce, along with the crushed medication tablets. LPN #1 opened Resident #1's electronic medical record (EMR) and read the physician's order for oxybutynin ER. After reading the physician's order, LPN #1 said she made a mistake and should not have crushed the resident's oxybutynin ER. LPN #1 said consuming oxybutynin ER in a crushed form released all of the medication at once, instead of over a 24-hour period. LPN #1 said crushing the medication instead of administering it in a whole form was a medication error. She said she would complete a medication error report, call the physician and get a new medication order that could be crushed. LPN #1 said she should follow the physician's orders for medications.The director of nursing (DON) was interviewed on 6/24/26 at 1:05 p.m. The DON said oxybutynin ER should not be crushed. She said that administering the medication in a crushed form was a medication error. The DON said she expected LPN #1 to complete a medication error report. The DON said LPN #1 would call the physician, write a progress note, and monitor Resident #1 for any symptoms of a reaction to administering the medication in the wrong form.The physician was interviewed on 6/25/26 at 1:40 p.m. The physician said LPN #1 had called her about Resident #1's medication error for the oxybutynin ER tablet. The physician said she ordered for the nurse to monitor the resident. She said administering the oxybutynin ER crushed was not ideal and could cause potential harm to the resident. The physician said administering oxybutynin ER in a crushed form could cause an elevated heart rate, tremors and dry mouth. She said she changed the medication order to a medication form that could be crushed to prevent errors in the future.

Based on observations, record review and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one (#7) of two residents out of nine sample residents. Specifically, the facility failed to ensure professional standards were followed when completing a peripherally inserted central catheter (PICC) line dressing for Resident #7.Findings include:I. Professional referenceThe University of California Los Angeles (UCLA) Health's Care and Maintenance of Peripherally Inserted Central Catheters (PICC) (2026), retrieved on 1/5/26 from https://www.uclahealth.org/medical-services/radiology/clinical-services/clincal-programs/peripherally-inserted-central-catheters-picc/care-and-maintenance, read in pertinent part, PICC line dressing steps: -Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 20 seconds;-Apply clean gloves;-Apply mask to patient or ask patient to turn head away from catheter site;-Apply personal protective equipment (PPE) such as gown and cap per protocol;-Remove dressing and dispose in waste container;-Remove gloves and dispose in waste container;-Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 20 seconds;-Apply sterile gloves;-Pinch the wings on the Chlorhexidine-70% alcohol applicator to break the ampule and release the antiseptic onto the sponge pad;-Clean area approximately two inches around the catheter exit site with the chlorhexidine applicator. Use a back and forth motion for 30 seconds to clean site;-If using alcohol and povidone iodine, clean in a circular motion from the PICC exit site outwards approximately two inches in diameter;-Allow the area to air dry for 30 seconds;-Secure catheter with Advance CHG Tegaderm and/or suture-less securement device; -Note date, time and initials on dressing; and,-Document the date and time of the procedure and assessment of the site in the patient's medical record. Sterile fields must always be kept in sight to be considered sterile. Sterile fields must always be kept in sight throughout the entire sterile procedure. Never turn your back on the sterile field as sterility cannot be guaranteed.II. ObservationsOn 12/22/25 at 1:14 p.m. registered nurse (RN) #1 was observed performing a PICC line dressing change for Resident #7. RN #1 was observed turning his back on the sterile field several times during the PICC line dressing change. RN #1 left the resident's room to grab additional supplies after removing the PICC line dressing, leaving the resident's PICC line exposed. RN #1 cleaned the distal (far end) section of the PICC line first, and then proceeded to clean the insertion site last with the chlorhexidine sponge for less than the recommended 30 seconds (see professional reference above). -RN #1 failed to measure the length of the catheter to monitor for migration (the unintended shifting of the catheter from its ideal position often due to patient movement, coughing or change in body position). RN #1 wore gloves and a mask during Resident #7's PICC line dressing change, however RN #1 failed to don a protective gown during the PICC line dressing change. Cross-reference F880 for failure to ensure enhanced barrier precautions (EBP) were followed during a PICC line dressing change. III. Record reviewThe employee file for RN #1 was reviewed on 12/22/25 at 4:15 p.m. RN #1's employee file did not contain documentation that he had completed training and competency to show he was able to demonstrate skills and techniques necessary to perform an appropriate PICC line dressing change.IV. Staff interviews RN #1 was interviewed on 12/22/25 at 2:17 p.m. RN #1 said he had worked at the facility for less than two months. RN #1 said he had experience with changing PICC line dressings from his previous employment. RN #1 said he had not received any formal training on PICC line dressing changes from the current facility. RN #1 said he would like education and training from the facility. RN #1 said he was nervous while performing Resident #7's PICC line dressing change and that is the reason he failed to complete the procedure in the appropriate steps (see observation above). RN #1 said he knew that he was not supposed to leave the resident's PICC line exposed and instead should have used the call bell to request other staff members to bring him additional supplies. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 12/22/25 at 3:47 p.m. The IP said he also performed the role of the staff development coordinator and was in charge of nursing training. The IP said the facility was in the process of initiating a new training platform for all nursing staff. The IP said competency training had not yet started on the new training platform. The IP said the manner in which RN #1 completed the PICC line dressing change for Resident #7 was not the standard of care. The IP said it was important to follow the standard of care to prevent infections, protect resident safety and promote consistent high quality care. The DON said she had two nurses currently working in the facility. The DON said neither of the nurses had received training for PICC line management. The DON said all nursing staff should be properly trained and demonstrate competency for nursing skills tasks prior to performing resident care. The DON said this was important to maintain resident safety and ensure professional and reliable healthcare practices.The regional nurse consultant was interviewed on 12/22/25 at 4:18 p.m. The regional nurse consultant said she would conduct in-house training for PICC line management for nursing staff starting that day (12/22/25).

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to ensure enhanced barrier precautions (EBP) were followed during a peripherally inserted central catheter (PICC) line dressing change.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 12/30/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.II. Facility policy and procedureThe Transmission Based Precaution policy, implemented 10/16/24, was received from the director of nursing (DON) on 12/22/25 at 2:10 p.m. The policy read in pertinent part, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Airborne precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Transmission-based precautions (also known as Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact and droplet) in order to prevent or control infections. The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Facility staff will apply transmission-based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission.-However, the policy failed to mention or address enhanced barrier precautions (EBP).III. Observations and resident interviewOn 12/22/25 at 12:00 p.m. there was a sign on Resident #7's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. Resident #7 was interviewed on 12/22/25 at 12:05 p.m. Resident #7 said he came to the facility for antibiotic treatment and intravenous (IV) management. He said the nurses were really nice but they never wore gowns or a mask when giving him his IV antibiotics. He said he was unsure if there were any requirements for the nurses to wear gowns or masks when he would get his IV medication. On 12/22/25 at 1:14 p.m. registered nurse (RN) #1 was observed performing a PICC line dressing change for Resident #7. -RN #1 wore gloves and a mask during Resident #7's PICC line dressing change, however RN #1 failed to don a protective gown during the PICC line dressing change. On 12/22/25 at 1:45 p.m. certified nurse aide (CNA) #2 was assisting Resident #7 with transferring from his wheelchair to the private toilet in his room. -However, CNA #2 failed to put on a protective gown prior to providing incontinence care to Resident #7.IV. Staff interviews CNA #2 was interviewed on 12/22/25 at 2:08 p.m. CNA #2 said Resident #7 needed staff assistance to get out of his bed into his wheelchair and from his wheelchair onto the toilet. She said Resident #7 was on EBP because of his IV line. She said there were no special precautions for her because she did not have to do any care with his IV line. She said she only needed to wear gloves when assisting the resident with personal care. RN #1 was interviewed on 12/22/25 at 2:30 p.m. RN #1 said he had worked at the facility for less than two months. RN #1 said he forgot to don a gown when he was changing Resident #7's PICC line (see observation above) because he was focused on the dressing change. RN #1 said he should have had a gown, gloves and mask on to protect the resident from acquiring an infection from the dressing change.The DON and the infection preventionist (IP) were interviewed together on 12/22/25 at 3:47 p.m. The IP said he also performed the role of the staff development coordinator and was in charge of nursing training. The IP said all of the facility nursing staff were trained on enhanced barrier precautions. The IP said CNA #2 should have donned a gown and gloves prior to assisting Resident #7 with the chair to toilet transfer. The IP said RN #1 was required to don a gown along with a mask and gloves while performing PICC line care for Resident #7. The IP said he would conduct reeducation on EBP for both RN #1 and CNA #2. The DON said RN #1 and CNA #2 should have followed the precaution requirements for EBP when providing direct care for Resident #7, which included wearing gowns and gloves with high-contact resident activity.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (#7 and #5) of seven residents reviewed for quality of care out of 10 sample residents.Specifically, the facility failed to:-Ensure Resident #7 and Resident #5 were assessed by a registered nurse (RN) following falls; and,-Ensure Resident #7, who was on anticoagulant medication (a class of medications that prevent or slow down blood clotting and can increase the risk of bleeding), received consistent and increased monitoring following a fall on 7/25/25 where the resident hit her head. The resident was transported to the emergency room three days post-fall, where she was diagnosed with a significant subdural hemorrhage (bleeding in the brain). Resident #7, who was known to be at risk for falls, was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur, atrial fibrillation, muscle weakness and difficulty in walking. Resident #7 was taking Eliquis (an anticoagulant, blood thinner) for atrial fibrillation (a condition where the upper chambers of the heart (atria) beat irregularly and rapidly, which disrupts the normal rhythm of the heart and can lead to complications, such as blood clots and stroke).On 7/25/25 Resident #7 sustained a fall in the early morning hours where she hit her head. After the fall, a licensed practical nurse (LPN) evaluated the resident and the resident was determined not to have any injuries from the fall. However, review of Resident #7's electronic medical record (EMR) failed to reveal that a RN had assessed the resident at the time of the fall or that a RN was consulted regarding the resident's fall. Resident #7 began complaining of a headache and neck pain later in the morning on 7/25/25, however, the facility did not send the resident out to the emergency department for further evaluation, despite the fact that the resident was on anticoagulant medication and had hit her head during her fall. Documentation did not indicate the facility increased monitoring for Resident #7 for potential signs of bleeding in the brain after she hit her head during the fall, aside from implementing the facility's normal neurological assessment protocol.Interviews during the survey revealed the facility's process for neurological assessments included monitoring residents for 72 hours post-fall. However, review of the implemented neurological assessments for Resident #7 revealed neurological assessments on 7/26/25 and 7/27/25 were not completed consistently as scheduled.On 7/28/25, three days after the fall, Resident #7 was transported to the emergency department for uncontrolled pain in the back of her head and vomiting. A computed tomography (CT) scan conducted at the hospital revealed the resident had sustained a significant subdural hemorrhage from the fall.The facility's failures to frequently and consistently monitor Resident #7, who was on anticoagulant medication, following a fall where she hit her head resulted in the delay of the resident being transferred to the hospital where it was identified that she had sustained a significant brain bleed.Additionally, the facility failed to ensure Resident #5 was assessed by a RN prior to being moved from the floor after the resident's fall on 4/8/25.Findings include: I. Professional referenceAccording to Nurse Journal's Licensed Practical Nurses (LPN) Versus Registered Nurses (RN), (8/27/24), retrieved on 10/15/25 from https://nursejournal.org/resources/lpn-vs-rn-roles/, LPNs and RNs both monitor patients, administer medications, perform wound care, help patients with basic tasks like bathing and feeding, and often educate and support patients and their loved ones. However, there are differences in the education requirements and scope of practice between RNs and LPNs. LPNs perform vital work in collaboration with RNs, physicians and other healthcare professionals. LPNs work alongside or under the supervision of RNs to deliver care and support to patients. This role also requires gathering patient data, which other licensed healthcare providers later interpret. Unlike RNs, LPNs typically do not have state authorization to make health assessments, create nursing care plans or triage patients. Compared to LPNs, RNs generally operate independently. RNs use their specialized judgment, skills, and knowledge to provide direct patient care in various settings. Generally speaking, only RNs provide initial assessments. Therefore, an RN must perform all tasks that require close monitoring and frequent assessment, such as initiating blood products, the first round of antibiotics, and initial patient assessments.According to Science Direct's Brain hemorrhages in traumatic brain injury and the excess burden conferred by anticoagulants and antiplatelets (10/19/24) retrieved on 10/22/25 from https://www.sciencedirect.com/science/article/pii/S2589238X24000457, Geriatric trauma patients along with their preexisting comorbidities are often on anticoagulants that increase their risk for complications, bleeding, mortality in the setting of even minor traumas. With a geriatric population, less severe injuries and minimal trauma may result in a higher mortality rate and worse outcomes. Injury from falls has surpassed motor vehicle collisions as the leading cause of injury leading to hospitalization. Trauma is the fifth leading cause of death in elderly with ground falls as the most common cause which can cause devastating and life altering injuries in frail patients who have decreased physiologic reserve and impaired ability to withstand stresses to their body. The otherwise underwhelming mechanism of ground level fall is potentiated by baseline coagulopathy as well as the use of anticoagulants in elderly patients. Under-triage of geriatric trauma patients occurs with head trauma where an accurate assessment of neurologic function can be difficult in older trauma patients. Geriatric patients can sustain a significant intracranial injury and yet often initially manifest no neurologic deficits on examination. This is especially complicated by neurological comorbidities such as dementia or changes such as reduced sensation that are part of normal aging. In addition, history of anticoagulant use may be missed when patients and family do not know which medications they take. In view of these pre-existing comorbidities and resultant complications, geriatric trauma patients should be transported to centers with a higher geriatric volume who are more familiar with and equipped to handle such patients. Antiplatelet and anticoagulant use confers additional morbidity in trauma patients in the form of brain hemorrhages, especially patients over the age of 55. The current study demonstrates that these medications impose an added burden in the form of intracranial hemorrhage leading to neurosurgical intervention, additional hospital and ICU (intensive care unit) days, return visits following discharge, as well as in hospital death and death within three months. For this reason, a history of antiplatelet and anticoagulant use should be considered a significant risk factor in trauma patients who suffer head injury.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of the right femur, type two diabetes, atrial fibrillation, muscle weakness, epilepsy and difficulty in walking. The 6/18/25 minimum data set (MDS) assessment revealed Resident #7 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The assessment further revealed Resident #7 was independent for most of her activities of daily living (ADL) and was independent with her transfers. B. Record reviewResident #7's fall care plan, initiated 2/6/25, documented she was at risk for falls related to her seizure disorder medication side effects. Pertinent interventions included encouraging the resident to participate in activities that promoted exercise and physical activity for strengthening and improved mobility (initiated 2/6/25), ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in her wheelchair (initiated 2/6/25), following the facility fall protocol (initiated 2/6/25), reminding the resident to utilize her call light for assistance with transfers (initiated 3/17/25) and ensuring the resident's nightlight was on in the evening (initiated 7/25/25). The fall risk evaluation, dated 3/16/25, documented Resident #7 was a high fall risk. A review of Resident #7's electronic medical record (EMR) revealed the following progress notes:A nurse's note, dated 7/25/25 at 2:45 a.m., documented that Resident #7's roommate alerted the licensed practical nurse (LPN) that Resident #7 was on the floor. The note documented that Resident #7 was found on the floor, flat on her back across from her bed with urine underneath her and her wheelchair was across from the resident, next to the bed in the locked position. The note documented that Resident #7 told the nurse that she was trying to get to the bathroom and missed her wheelchair. The note documented that the nurse did a head-to-toe assessment and no injuries were found and no first aid was needed. The note documented that the nurse and certified nurse aide (CNA) assisted the resident back into bed. The note documented that the nurse notified the on-call person, physician and the resident's representative and neurological checks were started. -However, the note did not document that a RN completed an assessment or was consulted regarding the fall. A situation, background and recommendation (SBAR) summary note for providers, dated 7/25/25 at 2:45 a.m., documented that Resident #7 had a fall and that there were no changes noted. The note documented that Resident #7 was not on an anticoagulant medication.-However, Resident #7 was on anticoagulant medication (see below). -The note did not document that the resident was assessed for pain. Review of Resident #7's July 2025 medication administration record (MAR) revealed Resident #7 was taking Eliquis (anticoagulant medication) oral tablet 5 milligrams (mg) twice a day for atrial fibrillation. The resident was documented as receiving the medication on 7/25/25, 7/26/25, 7/27/25 and 7/28/25. An interdisciplinary team (IDT) risk management note, dated 7/25/25 at 9:24 a.m., documented the incident on 7/25/25 as an unwitnessed fall and found the root cause to be that the resident was self-transferring in the dark. The note documented that there was no injury and the new intervention was to ensure a night light was on in the evening. An administration note, dated 7/25/25 at 10:07 a.m., documented Resident #7 was given tramadol (pain medication) for a headache and neck pain. An administration note, dated 7/25/25 at 1:49 p.m., documented Resident #7's incentive spirometer (a device to help measure deep breaths) was put on hold due to the resident's recent fall causing discomfort while performing incentive spirometer and acapella (a device that mobilizes lung secretions and helps clear airways). An administration note, dated 7/26/25 at 5:52 p.m., documented Resident #7 was given tramadol (pain medication) for neck pain.A fall follow-up nurse's note, dated 7/26/25 at 11:55 p.m., documented Resident #7 did not show any signs or symptoms of distress or shortness of breath. The note documented that there was no delayed onset of bruising or bleeding. It documented that Resident #7 did complain of pain of a 2 out of 10 in the back of her head. -There were no progress notes documented between 7/26/25 at 11:55 p.m. and 7/28/25 at 7:25 a.m. to indicate the resident continued to be monitored for 72-hours following the resident's fall on 7/25/25. An administration note, dated 7/28/25 at 7:25 a.m., documented Resident #7 was given tramadol (pain medication) for pain.An alert note, dated 7/28/25 at 11:39 a.m., documented that Resident #7 continued to complain of a headache of 9 out of 10. The note documented that she was given as-needed tramadol and scheduled Tylenol which were not effective. The note documented that Resident #7 was feeling nauseous and was administered as-needed Zofran (anti-nausea medication). The note documented that a message was left for the physician and they were waiting for a response. A nurse's note, dated 7/28/25 at 12:02 p.m., documented a new physician's order was obtained to send Resident #7 to the emergency department for evaluation. A nurse's note, dated 7/28/25 at 12:35 p.m., documented that emergency medical services (EMS) arrived and Resident #7 was taken to the hospital. Review of Resident #7's July 2025 MAR revealed the resident received tramadol 50 mg one tablet every eight hours as needed as follows:-Administered on 7/25/25 at 10:07 a.m. for a pain level of 6 out of 10;-Administered on 7/25/25 at 6:27 p.m. for a pain level of 6 out of 10;-Administered on 7/26/25 at 8:09 a.m. for a pain level of 5 out of 10;-Administered on 7/26/25 at 5:52 p.m. for a pain level of 7 out of 10; and,-Administered on 7/28/25 at 7:25 a.m. for a pain level of 3 out of 10.Further review of the resident's July 2025 MAR revealed the resident received Tylenol Extra Strength tablets 500 mg, two tablets orally three times a day and the resident consistently reported a pain level of 0-5 out of 10, with multiple documentations of a pain level of 0 out of 10.-However, following the resident's fall on 7/25/25, Resident #7's pain levels for the administration of the scheduled Tylenol were consistently documented as a pain level of 3-6 out of 10, with only one administration documented for a pain level of 0 out of 10. On 7/28/25, the 12:00 p.m. administration dose was documented as a pain level of 8 out of 10.Review of Resident #7's neurological assessment evaluations following the 7/25/25 fall revealed the following: -The 7/26/25 at 7:30 a.m. neurological assessment was not completed;-The 7/26/25 at 11:30 a.m. neurological assessment was not completed; and,-There were no neurological assessments completed for more than 24 hours, between 7/27/25 at 3:30 a.m. and 7/28/25 at 11:30 a.m. (just prior to when the resident was transferred to the hospital for uncontrolled pain and nausea/vomiting).-The facility failed to consistently and appropriately monitor Resident #7 for a full 72 hours following the 7/25/25 fall where she hit her head.The hospital note, dated 7/29/25, documented Resident #7 had a concern of left parietal headache and had an unwitnessed fall two days prior and was not brought to the emergency department for evaluation and was on Eliquis. The note documented the CT the resident had a very large 17 millimeter (mm) acute left frontotemporal subdural hemorrhage (blood that gathers between the brain and the brain's outermost protective layer) and a rightward midline shift (significant pressure inside the skull which pushes the brain off center) of 11 mm with narrowing of the right ambient cistern (cerebrospinal fluid-filled space to the right of the midbrain). III. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the October 2025 CPO, diagnoses included cerebral atherosclerosis (hardening and narrowing of the arteries in the brain), dementia, muscle weakness, difficulty walking and cognitive communication deficit. The 5/16/25 MDS assessment revealed Resident #5 had severe cognitive impairment with a BIMS score of zero out of 15. She needed supervision or touching assistance with most of her ADLs. She was independent with transfers and ambulating short distances. B. Record reviewResident #5's fall care plan, initiated 4/8/25, documented she was at risk for falls due to deconditioning, unawareness of safety needs and a right hip fracture. Pertinent interventions included anticipating and meeting the resident's needs (initiated 4/8/25), ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair (initiated 4/8/25), following facility fall protocol (initiated 4/8/25), reminding the resident to use walker when appropriate (initiated 4/8/25), using a night light in the room (initiated 4/8/25) and increasing rounding every shift every day to assist with toileting (initiated 5/27/25). The nursing fall risk evaluation, dated 4/8/25, documented that Resident #5 was a high fall risk. A review of Resident #5's EMR revealed the following progress notes: An alert note, dated 4/8/25 at 3:48 a.m., documented that staff alerted the LPN on duty that Resident #5 had fallen and was bleeding. The note documented she was laying on her right side beside her bed, she was wearing nonskid socks. She was found to have a two centimeter (cm) gash on her right forehead and a large skin tear on her right forearm. The note documented Resident #5 was very agitated and was trying to pick herself off the floor. The note documented that wound care was given and that the resident was assisted to a sitting position and then assisted to standing and ambulated to her bed and laid down. EMS was called and Resident #5 was taken to the hospital. -However, the note did not document that a RN completed an assessment or was consulted regarding the fall. An alert note, dated 4/8/25 at 5:35 a.m., documented that a report was called into the facility from the emergency department. The note documented Resident #5's imaging scans came back clear and stitches were put in Resident #5's forehead and her right arm was dressed. The note documented that Resident #5 returned to the facility at 5:05 a.m. and neurological checks were started. The IDT risk management note, dated 4/8/25 at 9:35 a.m., documented that Resident #5 had a fall early in the morning which resulted in a laceration to her right temporal lobe and a skin tear to her right forearm. The root cause was documented as her room being dark. New interventions were repositioning her bed in her room and providing a night light for the evening. IV. Staff interviewsRN #2 was interviewed on 10/14/25 at 9:21 a.m. RN #2 said when a resident fell, a full assessment was completed, which included vital signs, skin assessment, range of motion (ROM) and assessment of altered mental status. She said if a resident was on blood thinners or if they hit their head, that was an automatic call to EMS. She said then EMS would come and assess the resident and determine if the resident should be taken to the emergency department. She said neurological checks were started right away and the nurse would call the director of nursing (DON), the resident's representative, the physician, and the manager on duty. She said the RN on duty would do the assessment. -However, there was no documentation to indicate a RN completed an assessment for Resident #7 or Resident #5 following their falls, or that EMS was called following Resident #7's fall, despite the resident being on a blood thinner (anticoagulant) medication.LPN #1 was interviewed on 10/14/25 at 9:32 a.m. LPN #1 said when a resident fell, the RN on duty completed the assessment of the resident right away. She said the assessment was done while the resident was still on the floor. She said the assessment should happen before the resident was moved. She said if a resident was on blood thinners, then EMS was called. -However, there was no documentation to indicate a RN completed an assessment for Resident #7 or Resident #5 following their falls, or that EMS was called following Resident #7's fall, despite the resident being on a blood thinner (anticoagulant) medication.Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 10/14/25 at 9:35 a.m. CNA-Med #1 said she reported to the RN that was on duty. She said that if the RN on duty was busy, then she reported to the DON and then the nursing home administrator (NHA). She said if a resident fell, she would have the CNA sit with them and she would go find the RN. She said the RN would do the resident assessment. RN #2 was interviewed a second time on 10/14/25 at 9:47 a.m. RN #2 said a resident who had an unwitnessed fall with a head injury should never be moved before a RN assessed them. She said you never knew what kind of injury the resident could have. She said if there was anything in question, the facility would call EMS. RN #3 was interviewed on 10/14/25 at 12:11 p.m. RN #3 said if a resident had a fall with a head injury, a RN should do the assessment. She said a LPN did not have the scope of practice to do an assessment and move a resident after they had fallen. The DON and the NHA were interviewed together on 10/14/25 at 1:08 p.m. The DON and the NHA said if a RN was not working at the time of a resident's fall, then the DON would do the resident assessment. The NHA said that at the time of Resident #7 and Resident #5's falls, there was not a RN in the building. The NHA and the DON were unable to find any documentation that a RN completed the fall assessments for either of the residents. The DON said that a RN should do an assessment on all falls and that if a resident who fell was on an anticoagulant medication, the nursing staff should call EMS. LPN #1 was interviewed a second time on 10/14/25 at 1:33 p.m. LPN #1 reviewed the progress note she documented on 4/8/25 for Resident #5's fall. She said she was the nurse who assessed Resident #5 when she fell. She said the CNA had told her that Resident #5 had fallen. She said Resident #5 was bleeding and agitated and was crawling on her hands and knees and trying to get up. She said she and the CNA assisted her up because she was not going to stay on the floor. She said she was the nurse on duty at the time.

Based on record review and interviews, the facility failed to ensure one (#6) of four residents were kept free from physical abuse out of 10 sample residents.Specifically, the facility failed to ensure Resident #6 was kept free from physical abuse by Resident #3. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, implemented on 10/16/24, was provided by the nursing home administrator (NHA) on 10/13/25 at 9:54 a.m. The policy revealed the facility would provide protections for the health, welfare and rights of each resident by developing, implementing written policies with procedures that prohibited and prevented abuse, neglect, exploitation and misappropriation of resident property. The term abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident-to-resident altercations.Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse included, but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment.The facility would develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility would establish policies and procedures to investigate any such allegations; include training for new and existing staff on activities that constituted abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and establish coordination with the quality assurance performance improvement (QAPI) program.The facility would designate an Abuse Prevention Coordinator in the facility who was responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility would provide ongoing oversight and supervision of staff in order to assure that its policies were implemented as written.The facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. The facility would identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property was more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents. The facility would assure that the staff assigned had knowledge of the individual residents' care needs and behavioral symptoms; the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.The facility would have written procedures to assist staff in identifying the different types of abuse mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This included staff to resident abuse and certain resident-to-resident altercations. Possible indicators of abuse included, but were not limited to the observations of physical abuse of a resident.II. Incident of physical abuse between Resident #3 and Resident #6 on 7/23/25A. Facility investigationThe 7/23/25 at 6:28 p.m. alleged abuse risk report revealed Resident #3 struck the arm of Resident #6. The residents were immediately separated. Resident #3 was oriented to her person. Skin assessments were completed and no injuries were observed.The investigation revealed the outcome of the investigation found no intentional, knowing or reckless actions resulting in bodily injury. The investigation documented Resident #6 was unable to recall the incident. Resident #6 resided in the memory care unit and had severe cognitive impairment. Resident #6 voiced no concerns at the time of the interview on 7/24/25 by the NHA. Resident #6 was asked by the NHA if she felt safe and Resident #6 answered yes. The investigation documented Resident #3 was interviewed on 7/24/25 by the NHA. Resident #3 resided in the memory care secure unit and had severe cognitive impairment. The resident was unable to recall the altercation. The investigation documented the facility could not substantiate the abuse because it failed to meet criteria.-However, abuse occurred due to Resident #3 striking Resident #6's arm.B. Resident #3 - assailant1. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included adult failure to thrive, bilateral hearing loss, major depression, difficulty in walking, spinal stenosis in the lumbar region and dementia without behavioral, psychotic, mood or anxiety disturbances.The 9/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident did not exhibit any behaviors. The resident required substantial/maximal assistance with staff providing more than half of the effort. Staff lifted or held the resident's trunk or limbs and provided more than half the effort for toileting, upper body dressing, lower body dressing, personal hygiene, and chair/bed-to-chair transfers.2. Record reviewResident #3's care plan for a behavioral problem (delusions, anxious fixations (related to dementia progression was created on 10/13/25 (during the survey). The interventions included administering medications as physician ordered, monitoring/documenting for side effects and effectiveness of the medications, anticipating the resident's needs, providing a program of activities that was of interest and accommodated the resident's status, redirecting the resident by asking her to come with staff, get a snack, show her to her room and remove the resident from the area.The care plan for secure unit placement, initiated on 10/10/25, revealed Resident #3 was on the secured unit due to being an elopement risk/wanderer related to disorientation to place, a history of attempting to leave the facility unattended, impaired safety awareness, wandering aimlessly and significantly intruding on the privacy or activities. The interventions included for staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and/or a book and providing structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes.A nurse note, dated 7/23/25 at 6:27 p.m. and written by registered nurse (RN) #3, revealed Resident #3 was agitated and aggressive during the afternoon. Resident #3 hit Resident #6. Resident #3's daughter was called to try to calm the resident. Resident #3 was not calmed by this conversation. Resident #3 was redirected and placed in her room where her behaviors improved slightly.The incident report, dated 7/23/25 at 6:28 p.m., revealed Resident #3 struck the arm of Resident #6. The residents were immediately separated with skin assessments completed. Resident #3 was oriented to her person.C. Resident #6 - victim1. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included senile degeneration of the brain, dementia with agitation and adult failure to thrive. The 10/3/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15 and had no behaviors. The resident was dependent on staff for toileting, showering, upper body dressing, lower body dressing, personal hygiene and putting on/taking off footwear.2. Record reviewThe behavior care plan, revised on 10/30/24, revealed at times the resident could display behaviors that included cursing at all persons within her immediate vicinity, hitting during activities, hitting during cares, kicking, shouting, screaming and the refusal of care. The care plan documented at times, the resident ran into others with her wheelchair as she ambulated down the hall and the resident prevented others from coming around the area in front of her room entrance or going into her room. The interventions included attempting interventions before the behaviors began, staff were not to position the resident near others that disturbed the resident, positioning the resident in her favorite place to sit, helping help the resident avoid situations or others that upset the resident, notifying the resident's physician if her behaviors were interfering with her activities of daily living, offering diversional activities and reporting to her physician as appropriate, telling the resident what was going to happen before the activity/care was initiated and speaking with the resident unhurriedly and in a calm voice.The care plan for elopement risk/wandering, revised on 10/30/24 revealed Resident #6 was at risk for elopement related to impaired safety awareness and dementia. The interventions included staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and/or a book.The care plan for secure unit placement, initiated on 10/10/25, revealed Resident #6 was an elopement risk. The care plan documented the resident was disoriented to place, had a history of attempts to leave the facility unattended, had impaired safety awareness and wandered aimlessly. The interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and/or a book, the resident liked drinking coffee with pastry and enjoyed dolls, identifying the patterns and triggers of wandering tendencies, understanding the resident's triggers for wandering/elopement and the methods for de-escalation the resident.On 10/14 25 at approximately 3:00 p.m. the resident's electronic medical record (EMR) was reviewed. -The EMR did not contain progress notes related to the physical altercation with Resident #3 on 7/23/25.III. Staff interviewsRN #3 was interviewed on 10/14/25 at 11:27 a.m. RN #3 said she remembered the event that occurred on 7/23/25. RN #3 said Resident #3 hit Resident #6 on the upper arm. She said the residents were in the dining room area and she did not know what caused the altercation. RN #3 said the residents might have been too close to each other and Resident #3 was agitated at the time of the altercation. RN #3 said she assessed Resident #6. RN #3 said neither resident said they were afraid of each other at that time.The NHA and the director of nursing (DON) were interviewed together on 10/14/25 at 3:35 p.m. The NHA and the DON agreed with the documentation in the residents' medical records and on the investigation reports. The NHA was unable to provide any skin assessments for Resident #6.

Based on record review, observations and interviews , the facility failed to provide a safe, clean, comfortable and homelike environment for the residents on two out of three hallways and one out of two dining rooms. Specifically, the facility failed to: -Ensure there were enough clean linens; and, -Maintain clean floors in the residents' rooms, hallways and main dining room. Findings include: I. Failure to ensure there were enough clean linens A. Facility policy and procedure The Laundry policy, dated October 2025 was provided by the nursing home administrator (NHA) on 6/3/25 at 2:30 p.m. It read in pertinent part, The facility launders linens and clothing in accordance with current CDC (Center for Disease Control and Prevention) guidelines to prevent transmission of pathogens. Laundry will be removed from washers promptly and will not be left in the machines overnight. B. Resident interviews Resident #5 was interviewed on 6/2/25 at 11:49 a.m. She said she did not get a shower last week, because the facility did not have any clean linens. Resident #7 was interviewed on 6/2/25 at 3:17 p.m. She said it seemed like the facility did not have enough linens. She said there had been times when she did not get her bed bath due to not having any linens. Resident #2 was interviewed on 6/3/25 at 9:58 a.m. She said the facility never had enough linens or towels and it has been an ongoing issue. C. Record review The facility census was provided by the NHA on 6/2/25 at 10:41 a.m. The census documented that the facility had a total census of 52 residents. D. Observations On 6/3/25 at 10:32 a.m. the linen storage closet was stocked with three flat sheets, two large washable chucks pads, four hand towels, four pillow cases, twelve wash cloths, a small shelf of regular towels, five blankets and zero fitted sheets. On 6/3/25 at 10:46 a.m. the washer and dryers in the laundry room were running. There were no clean linens being folded or stored anywhere in the room. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/3/25 at 10:32 a.m. She said the facility did not have enough linens. She said she noticed the lack of linens when the facility was purchased by a new company. She said there were never any linens after Friday. She said that staff always tried to give the residents their showers even when there were not any towels. She said they would have to get creative and would use the hospital blankets and regular blankets. Laundry aide (LA) #1 was interviewed on 6/3/25 at 10:46 a.m. She said she was not sure if the facility was low on linens. She said the facility had ordered blankets and fitted sheets a few months ago. The maintenance supervisor (MS) was interviewed on 6/3/25 at 11:15 a.m. He said he began working at the facility two months ago. He said he recently discovered that there had been stains on the linens and the staff had been throwing the linens away. He said he had not been taught to order linens and was not sure if he would be taking over that duty. He said the NHA was the person who was in charge of ordering the linens. He said the NHA was aware of the situation. He said the NHA had not ordered any more linens, since they discovered the staff was disposing of the stained linens. The director of nursing (DON) was interviewed on 6/3/25 at 12:02 p.m. She said she was not aware that the residents had not been receiving their showers due to the shortage of linens. She said the lack of linens had been an ongoing issue. She said there had been times when she had to go to the laundry room and grab linens so that the floor staff would have enough for their shift. She said the laundry staff needed more education regarding cleaning the linens. She said the laundry staff needed education regarding washing the sheets to see if the stains could be removed prior to disposing of them. The NHA was interviewed on 6/3/25 at 12:15 p.m. She said the facility did not have a shortage of linens. She said there was a lack of awareness of where linens were being held. She said the laundry staff was supposed to stock the linen closets but sometimes they did not stock it enough. She said the floor staff did not go downstairs to get more linens. She said that the laundry room was locked on the weekends and there was a disconnect between the laundry staff and the floor staff. She said the facility had an upcoming meeting with the linen supplier to go over par levels. She said she did not know the current par levels for linens. II. Failure to maintain clean floors in the residents' rooms, hallways and main dining room. A. Observations On 6/2/25 at 11:00 a.m., during the initial walk-through of the facility, the main hallway floors on all the units had wrappers from snacks, wheelchair tracks on the floors, spots where liquids were dropped and then dried and dust in the corners. In room [ROOM NUMBER] there were wheelchair tracks and dried liquid spots were on the floor. In room [ROOM NUMBER] there was black debris that outlined the resident's personal belongings that were placed on the floor. In room [ROOM NUMBER] the floor had dust in the corners and spills that had dried. The dining room had food and beverage spills on the floor and visible wheelchair tracks. B. Staff interviews Housekeeper (HK) #1 was interviewed on 6/3/25 at 11:06 a.m. She said she began working at the facility two months ago. She said there were two housekeepers during the week and one on the weekends. She said the facility hired a new housekeeper that was starting sometime that week. She said there were paper schedules that documented which rooms they were supposed to clean. She said the schedules were where they were supposed to document what they cleaned and if there were any needed repairs. She said they cleaned the dining room, shower rooms, employee and guest bathrooms every day. She said they cleaned the long hall and short hall every other day. The MS was interviewed on 6/3/25 at 11:15 a.m. He said that the residents' rooms and dining room were cleaned every day. He said everything was tracked on paper schedules. He said he was unsure how often the residents' rooms should be deep cleaned. He said he was not sure when the housekeepers cleaned the dining room, but he often saw them there in the mornings. He said he did not know if the housekeepers swept and mopped the dining room after each meal. He said he had three full-time employees. He said Sunday through Tuesday there were two housekeepers. He said on Wednesday there were three housekeepers and Thursday through Saturday there was one employee. He said he did not think that one employee would be able to clean all the residents' rooms, bathrooms, shower rooms and dining room by themselves.

Based on interviews, observations, and record review, the facility failed to ensure one (#5) of two residents reviewed for pressure injuries out of 19 sample residents received the necessary treatment and services to prevent the development of pressure injuries. Resident #5, who had a diagnosis of multiple sclerosis (an immune disease that disrupts nerve communication between the brain and the body) and generalized muscle weakness, was admitted to the facility on [DATE] for ongoing medical management and rehabilitation after a tibial and fibular fracture. Resident #5 was admitted to the facility with intact skin of the feet and heels. On 4/25/24 Resident #5 was assessed for risk of developing pressure injuries and was identified as moderate risk due to a history impaired mobility and bowel incontinence. The facility initiated a skin care plan for pressure injury risk, however, the care plan did not include specific interventions to prevent pressure injuries from developing on the resident's feet. On 6/3/24 a physician's order was obtained for Resident #5 to wear off-loading boots on both feet at all times. However, multiple observations during the survey (from 9/16/24 to 9/19/24) revealed staff was not consistently implementing the intervention (see observations below). On 8/23/24 Resident #5 was noted to have an unstageable pressure injury to the plantar surface of her left foot. Due to the facility's failure to implement timely and effective pressure injury interventions and ensure that staff were consistently implementing Resident #5's offloading boots, the resident developed a facility-acquired unstageable pressure injury to the plantar surface of her left foot. Findings include: I. Professional reference A. Classification of pressure injuries According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://internationalguideline.com/2019 on 9/23/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin Assessment policy and procedure, dated January 2023, was provided by the regional clinical resource (RCR) on 4/19/24 at 4:00 p.m. It read in pertinent part, It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. A head to toe skin assessment will be conducted by a licensed or registered nurse (RN) upon admission, readmission, daily for three days, and weekly thereafter. The Wound Treatment Management policy and procedure was provided by the RCR on 4/19/24 at 4:00 p.m. It read in pertinent part, To promote wound healing it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. III. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis, generalized muscle weakness and myoclonus (sudden involuntary muscle spasms). The 6/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident was a substantial/maximal status and required two staff assistance for transfers with a hoyer lift. The MDS assessment revealed Resident #5 was at risk for the development of pressure injuries. B. Resident observations and interviews On 9/16/24 at 9:40 a.m. Resident #5 was lying in bed. The resident's feet and heels were not off-loaded. Her off-loading boots were on the dresser. Resident #5 said she developed a wound on her left foot after her admission to the facility. Resident #5 said she had seen a wound care doctor regularly since she developed the wound. On 9/16/24 at 12:52 p.m. Resident #5 was sitting in her wheelchair in the dining room with her feet resting on the foot pedals of the wheelchair. The resident was wearing an offloading boot on her left foot. The resident's right foot did not have an offloading boot on it. -However, according to the September 2024 CPO, Resident #5 was supposed to wear offloading boots on both feet at all times (see physician's order below). On 9/17/24 at 10:51 a.m. Resident #5 was lying in bed. Her feet and heels were not off-loaded and her off-loading boots were on the dresser. On 9/17/24 at 1:04 p.m. Resident #5 was sitting in her wheelchair in the dining room with her feet resting on the foot pedals of the wheelchair. The resident was wearing an offloading boot on her left foot. The resident's right foot did not have an offloading boot on it. -However, according to the September 2024 CPO, Resident #5 was supposed to wear offloading boots on both feet at all times (see physician's order below). On 9/18/24 at 9:53 a.m. Resident #5 was lying in bed. Her feet and heels were not off-loaded and her off-loading boots were on the dresser. Resident #5 said she developed a blood blister on her left foot after admitting to the facility. Resident #5 said she was supposed to wear special off-loading boots while she was out of bed in her wheelchair. On 9/18/24 at 11:20 a.m. Resident #5 was lying in bed. Her feet and heels were not off-loaded and her off-loading boots were on the dresser. Registered nurse (RN) #2 entered the resident's room to perform wound care on the resident's left foot wound. The wound was located on the ball of Resident #5's left foot, just under her toes and was an oval shaped area of skin, dark purple in color, approximately the size of an egg. Resident #5 said she had limited sensation in her legs and feet which felt like pins and needles with a burning sensation. C. Record Review Resident #5's skin care plan, updated 8/30/24, revealed the resident was at risk for pressure ulcer development related to impaired mobility and bowel incontinence. Interventions included following policies and protocols for the prevention of skin breakdown (initiated 5/5/24), following treatment orders for the left plantar pressure ulcer (initiated 8/30/24), following with the wound care provider (WCP) until wound healed (initiated 8/30/24), and providing a supplemental protein to promote wound healing (initiated 8/30/24). -The care plan did not document specific interventions for offloading the resident's feet to prevent pressure injury development. Review of Resident #5's August 2024 CPO revealed the following physician's order: Barrier cream to wound on left foot, cover with foam dressing, ordered 8/23/24 and discontinued 8/29/24. Review of Resident #5's September 2024 CPO revealed the following physician's orders: Offloading boots at all times to bilateral feet every shift, ordered 6/3/24. Wound on bottom of left foot: cleanse with wound cleaner, apply xeroform and bordered dressing. Change one time every other day or as needed if dressing becomes soiled/dislodged, ordered 8/31/24. Protein supplement 30 milliliters (ml) twice daily for wound healing, ordered 8/31/24. Review of Resident #5's treatment administration record (TAR) from 7/1/24 to 9/19/24 revealed staff documented the resident's offloading boots were on every shift. -However multiple observations throughout the survey revealed Resident #5's offloading boots were on the dresser while she was in bed or she was only wearing one boot on the left foot while she was sitting in her wheelchair (see observations above). A physician's progress note dated 8/26/24 documented Resident #5 had a new lesion on her foot. The note documented barrier cream, foam and gauze would be applied to the wound and the wound would continue to be monitored. A physician's progress note dated 8/28/24 documentedResident #5 had a new lesion on her foot with no signs of infection. A physician's progress note dated 9/11/24 documented Resident #5's foot wound was not healing very fast. There were no signs of infection and the wound care physician was to follow the wound. A wound progress note dated 8/29/24 documented Resident #5 had an unstageable full thickness skin or tissue loss, depth unknown, pressure ulcer which measured 3.5 centimeters (cm) by 3.5 cm by 0 cm on the left plantar foot surface. The wound was unresolved and was present after admission. A wound progress note dated 9/5/24 documented Resident #5 had an unstageable full thickness skin or tissue loss, depth unknown, pressure ulcer which measured 3.5 cm by 3.5 cm by 0 cm on the left plantar foot surface. The wound was unresolved and was present after admission. A wound tracker form signed by the WCP on 9/12/24 documented Resident #5 had an unstageable full thickness skin or tissue loss, depth unknown, pressure ulcer which measured 3.5 cm by 3.5 cm by 0 cm on the left plantar foot surface. D. Staff interviews RN # 2 was interviewed on 9/19/24 at 12:20 p.m. RN #2 said Resident #5 had a protein supplement and protein shake ordered for wound healing. RN #2 said that Resident #5 wore the offloading boots as ordered, which was all of the time. -However multiple observations throughout the survey revealed Resident #5's offloading boots were on the dresser while she was in bed or she was only wearing one boot on the left foot while she was sitting in her wheelchair (see observations above). Certified nurse aide (CNA) #2 was interviewed on 9/19/24 at 12:24 p.m. CNA #2 said Resident #5 was unable to turn herself in bed. CNA #2 said Resident #5 required two staff members to assist with the hoyer lift to transfer her. CNA #2 said Resident #5 never refused to wear her offloading boots and wore them as ordered. -However multiple observations throughout the survey revealed Resident #5's offloading boots were on the dresser while she was in bed or she was only wearing one boot on the left foot while she was sitting in her wheelchair (see observations above). The RCR was interviewed on 9/19/24 at 12:54 p.m. The RCR said she was covering for the director of nursing who was absent at the time of the survey. The RCR said a skin assessment was completed upon a resident's admission to the facility. She said the admission nurse completed a skin assessment within 24 hours of admission. The RCR said Resident #5's left foot wound had not been present upon admission to the facility. She said Resident #5 had a moderate risk score for the development of skin breakdown. The RCR said all of the facility mattresses were pressure reducing mattresses. The RCR said Resident #5 had a history of wounds on her feet and the development of the heel wound had been unavoidable. She said Resident #5 had an order to wear offloading boots at all times but the resident refused to wear the boots every night. -However, there was no documentation in Resident #5's electronic medical record (EMR) to indicate the resident refused to wear the offloading boots and staff interviews indicated the resident did not refuse to wear the boots. RN #2 was interviewed again on 9/19/24 at 2:28 p.m. RN #2 said a complete skin assessment was completed on all newly admitted residents. RN #2 said after any skin concern or wound had been assessed, the nurse would call the WCP and fill out a wound tracker sheet. RN #2 said the WCP assessed the left heel wound that Resident #5 developed as an unstageable pressure injury. RN #2 said she did not know how the wound developed because Resident #5 was supposed to wear the off-loading boots at all times. RN #2 said Resident #5 never refused wearing the off-loading boots. RN # 2 said if Resident #5 had refused to wear the boots it would be documented in a nurses note. -An interview was requested with the WCP on 9/19/24, however, the WCP was unavailable for an interview during the survey. IV. Facility follow-up On 9/23/24 (after the survey exit) the facility provided the following information via email: A pressure injury worksheet dated 8/23/24, documented in pertinent part, Wound prevention interventions in place (for Resident #5) were offloading boots, repositioning every two hours, protein supplement, wound care with WCP. The cause of the foot wound was because the resident had been rubbing the bottom of her foot on the foot rest of her wheelchair. The wound was unavoidable related to disease progression, even though interventions were in place. -However, there was no documentation in Resident #5's EMR to indicate turning and repositioning was initiated or being completed, the protein supplement was not ordered until 8/31/24 ( seven days after the wound developed), and the WCP did not assess the resident's wound until 8/29/24. -Additionally, multiple observations throughout the survey revealed Resident #5's offloading boots were on the dresser while she was in bed or she was only wearing one boot on the left foot while she was sitting in her wheelchair (see observations above).

Based on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to: -Allow the resident council to meet without a staff member present; -Provide a private space for resident council; and, -Provide a response, action and rationale for food concerns. Findings include: I. Facility policy and procedure The Resident Council Meetings policy, revised June 2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, The facility shall act upon concerns and recommendations of the council, make attempts to accommodate recommendations to the extent practicable, and communicate its decision to the council. II. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five residents (#11, #14, #17, #31 and #35), who were identified as alert and oriented through facility and assessment. Resident #31 and Resident #11 said the resident council meeting was held in the large dining room. Resident #11 said the door was left open. Resident #11 said staff, visitors and residents came in and out of the room during the meeting. Resident #31 said the facility staff attended the meeting and they were not given an opportunity to talk without staff present at resident council meetings. Resident #31 said the staff listened to their concerns but did not provide an action to resolve their concern. Resident #31 said she was a vegetarian. She said the facility did not provide a lot of vegetarian protein choices for her meals. Resident #31 said she was served a lot of grilled cheeses as her meals. Resident #11 and Resident #17 said there were not a lot of desserts that were appropriate for a diabetic diet. Resident #17 said she had a lot of jello and pudding. Resident #11 said she wanted sugar free pies, cakes and cookies. Resident #17 and Resident #35 agreed with Resident #11. Resident #11, Resident #17, Resident #31 and Resident #35 said the food was overcooked and watery. The residents said they did not feel the facility provided prompt resolutions to their concerns. III. Resident council notes The July 2024 resident council meeting notes were requested. A resident council concern form was provided. It revealed residents wanted more food varieties and consistency. The staff response section revealed the dietary manager (DM) would attend the resident council meetings. -The recommendation and solution section was left blank. The resident council approval date section was left blank. -There was no documentation indicating the residents were offered the opportunity to meet without staff present. The 8/7/24 resident council meeting notes revealed the residents said the food was awful, there was too much seasoning and the soup was watery. It also documented the residents requested more diabetic dessert options and would like sugar free hot chocolate. The response for more diabetic desserts indicated the (DM) would look into adding more diabetic desserts to the menu. The DM said there was sugar free hot chocolate, but the residents had to ask for the sugar free hot chocolate. The DM said they would speak to the cooks and come up with suggestions on how to improve the food. The dietary response for the watery soup was the residents would tell the DM when they received watery soup so she could see who was cooking and educate the cook. -However, there was no documentation indicating the residents approved the food concerns brought up in the 8/7/24 resident council meeting. - There was no documentation the residents were offered the opportunity to meet without staff present. Resident council notes from 9/4/24 revealed residents said there was too much pepper in the food, soup was water, roasts too tough, wanted more fresh fruit and sugar free ice cream. The recommendation section said the dietary manager was notified. The staff response section said the DM would talk to staff about less pepper. The DM said the soup was not too watery because it was soup and not a stew. The DM said she would see if fresh fruit could fit in the budget, would look into sugar free ice cream and residents could buy their own food and keep the food at the nurse's station refrigerator and freezer. -However, there was no documentation residents approved the 8/7/24 food concern. -There was no documentation residents were offered the opportunity to meet without staff present. V. Staff interviews The activities director (AD) was interviewed on 9/19/24 at 11:29 a.m. The AD said she had been in her position for approximately three months. She said the NHA and the clinical resource consultant (CRC) helped her coordinate the resident council meeting. The AD said the resident council agenda started with the residents talking about dietary comments, concerns or suggestions. She said the meeting continued with a topic such as what was resident council, then she asked for general comments, concerns or suggestions. She said the topic was provided by the NHA and the last resident council topic was the purpose of resident council. The AD said the resident council meeting was held in the dining room and the dining room doors are left open. The AD said she did not ask if the residents wanted to meet without staff present. She said when a resident brought a concern up during resident council meeting she told the department head and asked what the timeline was to resolve the concern. The AD said she went over the department's response in the next resident council meeting. The AD said she did not ask the resident council if they approved the response. The AD said the food concerns were not resolved. The AD said there was no documentation indicating the resident council approved the food concern responses. The DM was interviewed on 9/18/24 at 12:14 p.m. The DM said she e was aware of the concerns residents brought up at the recent resident council meeting. The DM said the resident council did not approve the responses she provided to their concerns. The DM said she would follow up with the residents to come up with a solution. The NHA was interviewed on 9/19/24 at 11:57 a.m. The NHA said the AD was responsible to coordinate the resident council meeting. He said the agenda consisted of covering a topic, such as what was resident council. He said the residents were given an opportunity to voice their concerns. He said resident council were offered to meet without staff present and the dining room door should be closed. The NHA did not know the AD did not provide the residents the opportunity to meet without staff present and the door was not closed. He said the resident council concerns were reviewed in the morning meeting the day after resident council was held. He said the department head had five days to resolve the concern. The NHA said the AD went to the resident council's president to ensure the resolution was approved. The NHA said he did not know the AD did not go over the concerns with the president. The NHA said he reviewed the 7/3/24 resident council concern form. The NHA said the form should have been completed to ensure the resident council approved the residents concerns. The NHA said he reviewed the 8/7/24 resident council minutes. The NHA said there was no documentation the residents were offered to meet without staff present and the resident council approved the staff response to the residents concerns. The NHA said he reviewed the 9/4/24 resident council minutes. The NHA said there was no documentation the residents were offered to meet without staff present and the resident council approved the staff response to the residents' concerns. The NHA said he would work with the AD to ensure the residents were offered the opportunity to meet without staff present and to ensure the dining room door is closed during the resident council. The NHA said he would work with the AD to ensure the resident council approved the staff response to the residents' concerns.

Based on record review and interviews, the facility failed to provide ongoing communication to residents about their rights; and failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Specifically, the facility failed to provide ongoing communication and discussion to the resident's about their rights and responsibilities. Findings include: I. Facility policy and procedure The Resident Rights policy, revised August 2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, Information about resident rights and responsibilities will be given to the resident both orally and in writing. II. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five residents (#11, #14, #17, #31, and #35), who were identified as alert and oriented through facility and assessment. Resident #11, Resident #17, Resident #31 and Resident #35 said the facility did not provide ongoing discussion to review and explain their resident rights and responsibilities. The residents who attended the group meeting said they did know their rights as residents. The residents said they did not know the resident rights were posted on a wall in the facility. The rights were posted on the wall on the left side of the doors to the dining room. The residents said they wanted to know what their rights were so they could ensure the facility honored their rights. III. Record review The resident council monthly minutes from July 2024 through September 2024 were provided by the activities director (AD) on 9/18/24. The minutes revealed there was no documentation indicated the rights of residents were discussed and reviewed. IV. Staff interviews The AD was interviewed on 9/19/24 at 11:29 a.m The AD said she did know when resident rights were reviewed with residents. The AD said she assisted in running the resident council meetings monthly. She said the resident rights were not reviewed during resident council. The NHA was interviewed on 9/19/24 at 11:57 a.m. The NHA said the resident rights were reviewed verbally and in writing with the resident and the family at admission. He said there was a big poster on the wall next to the dining room. He said resident rights were not discussed at the resident council. The NHA said he would work with the AD to ensure rights were reviewed on an ongoing basis and documented in the resident council minutes.

Based on observations, record review, and interviews the facility failed to provide a prompt effort to resolve grievances for one (#28) and the resident group out of 19 sample residents. Specifically, the facility failed to: -Follow through on grievances for lost/stolen items for and #28; and, -Ensure the residents had information on how to file a grievance. Findings include: I. Facility policy and procedure The Resident and Family Grievances policy and procedure, dated January 2023, was provided by the regional clinical resource (RCR) on 9/19/24 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances with prompt effort to resolve. Information on how to file a grievance or complaint will be available to the resident. The Resident Personal Belongings policy and procedure, dated April 2022, was provided by the regional clinical resource (RCR) on 9/19/24 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to protect the resident's right to possess personal belongings. All resident personal items will be inventoried at the time of admission. Additional possessions brought into the facility shall be added to the existing personal belongings inventory listing. The facility will exercise reasonable care for the protection of the resident's property from loss or theft. II. Failure to address Resident #28's grievances A. Resident #28 1. Resident status Resident #28, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included epileptic seizures and major depressive disorder. The 6/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. 2. Resident interview Resident #28 interviewed on 9/16/24 at 11:00 a.m. Resident #28 said he had a local sports team sweatshirt stolen out of his closet. Resident #28 said he also had a cotton towel stolen from off of his bed. Resident #28 said he had cash stolen from his room twice totaling $100.00. Resident #28 said many of his shirts go out to the laundry and do not come back. Resident #28 said he had filed many grievances without resolution. 3. Record Review The resident personal belongings inventory, dated May 2024, was provided by the nursing home administrator (NHA) on 9/18/24 at 9:00 a.m. It indicated the resident had eyeglasses, upper and lower dentures, chase debit card, one pair of gloves, one hat, five sweatpants, seven shirts, one pair white sneakers, eight pairs of socks, seven jackets/flannels, three shorts, one suitcase, one wooden box, one blanket, one dodge caravan, one fossil kit, one broken laptop and one model car. The September 2024 resident council meeting notes dated 9/4/24 provided by regional clinical resource (RCR) on 9/18/24 at 9:00 a.m. The notes revealed Resident #28 had reported on 9/4/24 during the resident council meeting that he had some clothing that had been stolen from his room. The notes documented social services notified. Grievances related to missing/stolen items for Resident #28 were requested on 9/17/24 for Resident #28. The facility did not provide documentation indicating they had attempted to resolve the resident's concern regarding missing clothing (see interview below). B. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 9/18/24 at 3:33 p.m. CNA #1 said if a resident reported missing items she would look in the trash can, dirty laundry and linen. CNA #1 said she would fill out a grievance form for social services. CNA #2 was interviewed on 9/18/24 at 3:35 p.m. CNA #2 said if property was reported missing or stolen she would notify the nurse and administration. The RCR interviewed on 9/19/24 at 12:54 p.m. The RCR was covering for the DON who was on vacation at the time of the survey. The RCR said she did not believe that any items had been missing or stolen from Resident #28. The RCR said we could not show he ever had the items. The RCR said the facility could not show the items went missing either. The RCR said Resident #28 had a current increase in external stressors and had become fixated on items. 48112 III. Failure to ensure residents had information on how to file a grievance A. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five residents (#11, #14, #17, #31 and #35), who were identified as alert and oriented through facility and assessment. Resident #11, Resident #17, Resident #31 and Resident #35 said they did not know how to file a grievance. After the group interview, Resident #17 and Resident #31 saw where the grievance form and grievance policy were located. Both residents said they did not know the grievance forms were in front of the social services office. Resident #31 said the grievance policy's font was too small to read. B. Observations On 9/16/24 at 8:30 a.m. an observation was conducted throughout the facility. There was a grievance policy located on the wall between the NHA's office and the social services office. The policy was in four frames sized eight and a half by 11 inches. The font size was approximately 10 to 12. The policy was displayed vertically from the ceiling to the middle of the wall, approximately at eye level for someone in a wheelchair. There was a wire mesh wall file on the left side wall of the social services office. There were grievance forms in the wall file. There were no signs around the wall file to say what the papers in the wall file were for. On 9/19/24 at 11:00 a.m. a sign was posted above the grievance forms to the left of the social services office on how to file a grievance form. C. Staff interviews The NHA was interviewed on 9/18/24 at 9:54 a.m. The NHA said there was not a sign next to the grievance forms (see observations above). The NHA was interviewed again on 9/19/24 at 11:57 a.m. The NHA said the social services director (SSD) was for managing grievances. The NHA said the SSD was unavailable to interview due to illness during the survey period. He said there should have been a sign next to the grievance form to indicate the mesh file held grievance forms. He was not aware the residents said the policy posted was too small to read. The NHA said he would fix it.

Based on record review, and interviews the facility failed to assist residents in obtaining routine or emergency dental services, as needed for three (#10, #11 and #17) of five residents reviewed for dental services out of 19 sample residents reviewed. Specifically, the facility failed to replace Resident #10, Resident #11 and Resident #17's dentures in a timely manner. Findings include: I. Facility policy and procedure The Dental Services policy and procedure, dated August 2024, was provided by regional clinical resource (RCR) on 9/19/24 at 4:00 p.m. It read in pertinent part, For residents with lost or damaged dentures, the facility will refer the resident for dental services within three days. The resident and/or representative shall be kept informed of all arrangements. II. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physicians order (CPO), diagnoses included dementia and dysphagia (difficulty swallowing). The 7/5/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment indicated the resident had no dental issues or concerns. -However, the resident had missing lower dentures. B. Resident interview Resident #10 was interviewed on 9/16/24 at 11:47 a.m. Resident #10 said her lower set of dentures went missing in February 2024. Resident #10 said she filed a grievance form. Resident #10 said she has not seen a dentist and her dentures had not been replaced. C. Record review A review of Resident #10's comprehensive care plan did not reveal the resident's dental concerns were addressed. A grievance form, dated 2/14/24, was provided by the RCR on 9/18/24 at 9:00 a.m. The grievance form indicated Resident #10 reported her lower dentures were missing on 2/14/24. The grievance said the resident reported the dentures had been missing for one week. The form documented the resident had increased confusion and this may not have been accurate. It indicated the resident was on the list to be seen by a dentist. A request was made for dental visit notes for Resident #10 on 9/17/24. The RCR said the resident had not been seen by the dentist since she submitted a grievance form on 2/14/24 reporting her dentures were missing (see interview below). III. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included unspecified dementia. The 7/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment indicated the resident had no dental issues or concerns. -However, the resident was missing her lower dentures. B. Resident interview Resident #11 was interviewed on 9/17/24 at 9:42 a.m. Resident #11 said she had upper and lower dentures upon admission. Resident #11 said she no longer had her bottom set of dentures. Resident #11 said she had not seen a dentist and had not had the lower set replaced. Resident #11 said it changed which foods she chose to eat. C. Record review The nutritional care plan, revised 9/11/23, revealed the resident had missing lower dentures and often chose food she could easily chew with only upper dentures. Pertinent interventions included providing the resident with a dental consult. -However, there was no documentation indicating the resident was seen by the dentist to address her missing dentures. A request was made for dental visit notes for Resident #11 on 9/17/24. The facility did not provide documentation indicating the resident had been seen by the dentist. IV. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included dysphagia. The 8/29/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment indicated the resident had no dental issues or concerns. B. Resident interview Resident #17 was interviewed on 9/17/24 at 10:25 a.m. Resident #17 said that her lower dentures were not fitted correctly. Resident #17 said even after she had glued the dentures in, they popped out during meals. Resident #17 said she had been told by the facility that a dentist would be back to look at the fit. Resident #17 said she had not seen a dentist since October 2023. C. Record review A review of the resident's comprehensive care plan did not reveal information regarding the resident's dental status. A dental note, dated 10/5/23, documented an impression was taken with a custom tray. A request was made for dental follow up notes for Resident #17 on 9/17/24. The facility did not provide documentation indicated the resident had been seen by the dentist for follow up. V. Staff interviews Registered nurse (RN) #2 was interviewed on 9/18/24 at 11:49 a.m. RN #2 said if a resident had missing dentures she reported the missing dentures to the social services department. She said the social services director (SSD) would work with the family and the resident to get the dentures replaced. Certified nurse aide (CNA) #1 was interviewed on 9/18/24 at 3:33 p.m. CNA #1 said she was not aware of any residents that had missing dentures. CNA #1 said if a resident reported missing dentures she would look in the trash can and the linen for the dentures. CNA #1 said she would fill out a grievance form and give it to the social services department if the dentures were not found. CNA #2 was interviewed on 9/18/24 at 3:35 p.m. CNA #2 said some residents refused to wear their dentures, but she was not aware of any missing dentures. CNA #2 said if dentures were reported missing she would notify the nurse and the administration. The RCR was interviewed on 9/18/24 at 4:05 p.m. The RCR said if dentures were reported missing, a search should be conducted through the trash and laundry. The RCR said a report should be made by the staff to the social services department. The RCR said the SSD should have followed up with the residents in a timely manner and scheduled dental appointments as needed. The RCR said a resident should have an appointment set within 30 days. The RCR said the grievance for Resident #10 was overdue for a resolution. The RCR said there should be documented interventions while the dentures were missing to include diet accommodations. The RCR said if dentures had become ill-fitting the nursing staff should inspect the mouth for sores, swelling, a cause for the ill-fit. The RCR said the facility should have followed up timely when the residents reported their dentures were missing. The RCR said the SSD should have followed up with an appointment to get the dentures corrected and documentation indicating the steps that were taken. The RCR was interviewed again on 9/19/24 at 9:53 a.m. The RCR said Resident #10 had received a dental appointment on 7/9/24. -However there was no documentation that indicated the resident had a dental appointment on 7/9/24 (see record review above). The RCR said Resident #10 had a new appointment scheduled for 10/7/24. The RCR said she spoke to Resident #17's daughter regarding the ill-fitting dentures. The RCR said Resident #17 had been taken to multiple dentists and there was not anything further to be done about the lower dentures. The RCR said there should have been documentation with interventions, provider assessment, speech assessment and diet evaluation in the resident's electronic medical record.

Based on interviews, observations, and record review, the facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance. Findings include: I. Facility policy and procedure The Food Preparation Guidelines policy, revised 4/2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, Food should be palatable, attractive, and at a safe and appetizing temperatures. II. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five (#11, #17, #31, #35 and #14) residents, who were identified as alert and oriented through facility and assessment. Resident #11, #17, #31 and #35 said the food was not palatable. The residents said the food was overcooked and watery. II. Individual resident interviews Resident #5 interviewed on 9/16/24 at 9:40 a.m. Resident #5 said sometimes the food was overcooked causing her to order take-out. Resident #17 was interviewed on 9/17/24 at 10:25 a.m. Resident #17 said the food was not very good. Resident #17 said the food was served overcooked, dry, or very bland. Resident # 17 was interviewed on 9/18/24 at 10:03 a.m. Resident #17 said the facility needed to serve more fresh fruit. He said he did not like the canned fruit, because it was all the same texture. III. Record review The July 2024 resident council meeting notes were requested. A resident council concern form was provided. It revealed residents wanted more food varieties and consistency. The staff response section revealed the dietary manager (DM) would attend the resident council meetings. The 8/7/24 resident council meeting notes revealed the residents said the food was awful, there was too much seasoning and the soup was watery. It also documented the residents requested more diabetic dessert options and would like sugar free hot chocolate. The response for more diabetic desserts indicated the DM would look into adding more diabetic desserts to the menu. The DM said there was sugar free hot chocolate, but the residents had to ask for the sugar free hot chocolate. The DM said they would speak to the cooks and come up with suggestions on how to improve the food. The dietary response for the watery soup was the residents would tell the DM when they received watery soup so she could see who was cooking and educate the cook. Resident council notes from 9/4/24 revealed the residents said there was too much pepper in the food, soup was water, roasts too tough, wanted more fresh fruit and sugar free ice cream. The recommendation section said the DMwas notified. The staff response section said the DM would talk to staff about less pepper. The DM said the soup was not too watery because it was soup and not a stew. The DM said she would see if fresh fruit could fit in the budget, would look into sugar free ice cream and residents could buy their own food and keep the food at the nurse's station refrigerator and freezer. IV. Observations During a continuous observation during the lunch meal on 9/18/24, starting at 12:14 p.m. and ending at 1:32 p.m., the following was observed: The bread rolls were in a medium metal container in the food steamer. The rolls in the bottom of the container were sticking together and were smashed. The rolls did not maintain the shape. The lemon and thyme chicken was in a large metal container in the food steamer. The liquid surrounding the chicken was watery. The almond rice pilaf was in a large metal container. The rice on the edges were dark brown. A test tray for a carbohydrate-controlled diet was evaluated by three surveyors immediately after the last resident had been served their meal for lunch on 9/18/24 at 1:40 p.m The menu was grilled chicken breast with lemon and thyme, almond rice pilaf, sugar snap peas, bread or roll and butter, and spiced peaches. The test tray consisted of grilled chicken breast with lemon and thyme, almond rice pilaf, sugar snap peas, roll and spiced peaches. -The chicken was dry and did not taste like there was lemon or thyme; -The almond rice pilaf was bland and did not taste almondy; -Sweet green peas were served instead of the sugar snap peas; -The roll was squished; and, -The spiced peaches tasted like canned peaches with cinnamon. V. Staff interviews The dietary manager (DM) and the NHA were interviewed together on 8/19/24 at 1:50 p.m. The DM said the grilled chicken breast with lemon and thyme should have tasted like there was lemon thyme. She said the chicken should not have been dry. The DM said the almond rice pilaf should have tasted like there was almond in the rice pilaf. The DM said they did not put almonds in the rice pilaf. She said the rolls should not be squished. She said the peas should have been sugar snap peas like the menu indicated. She said it was important for the food to be palatable to reduce complaints and for the residents to have a well-rounded nutrition. The NHA said d he would work the DM to ensure the food was palatable for the residents.

Based on record review and interviews, the facility failed to ensure one (#30) of four residents reviewed for accidents out of 28 sample residents remained as free from accident hazards as possible. Resident #30, who was identified as a high fall risk, had numerous predisposing factors which included dementia, confusion, unsafe sleeping habits and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from falling on multiple occasions. Due to the facility's failures, the resident sustained a fracture to her right femur (hip) subsequent to a fall on 12/5/22, requiring hospital treatment. Findings include: I. Facility policies and procedures The Fall Prevention policy, revised 4/1/19, was provided on 4/11/23 by the nursing home administrator (NHA). The policy read in part: The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate, or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator (such as star, color coded sticker) on the nameplate to the resident's room. iii. Place Fall Prevention Indicator on the resident's wheelchair. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or resident education ix. Therapy services referral. II. Resident #30 A. Resident status Resident #30, age 82, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included metabolic encephalopathy, (a problem in the brain caused by a chemical imbalance in the blood), and severe dementia with anxiety. The 2/14/23 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with poor decision making and supervision required. The resident required extensive assistance with transfers, walking in the room, eating, dressing, toileting and personal hygiene. Falls were not indicated on the assessment. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. B. Resident observations The resident was observed on 4/10/23 at 9:25 a.m. The resident was laying at the edge of the bed with her closed eyes. The resident's bed was not fitted with bed canes, there was no fall mat next to her bed and body pillows on the side of the bed (as indicated in the care plan, see below). C. Record review The resident was assessed for fall risk on several occasions since 11/10/22. Specifically, she was assessed on 11/23/22, 12/2/22 and 12/5/22. She consistently scored high risk for falls. Upon admission, she was referred to a physical and occupational therapy (PT/OT) program. The care plan for activities of daily living (ADLs), initiated on 11/10/22 and revised on 2/22/23, revealed that the resident had potential for self care related deficit due to cognitive deficit. Interventions included to provide extensive assistance with one staff with bed mobility, transfer, dressing, toileting, personal hygiene, bathing, eating and locomotion. The care plan for falls, initiated on 11/10/22 and revised on 2/22/23, revealed the resident was at risk for falls due to cognitive status, poor safety awareness, and history of falls. Interventions included to make sure call light was within the reach and encourage resident to use it, and to maintain an uncluttered environment. Interventions including bilateral bed canes for increased mobility, transfers, and positioning, as well as mat on floor by bed, keep bed in low position, body pillow both sides of bed, and close supervision were added 12/11/22 (after fall #4, see below). -There were no interventions added to the care plan for the resident after her fall #1, #2 and #3. After fall #4 (which resulted in femur fracture), interventions were put into place six days after the incident occurred. 1. Fall #1 on 11/23/22 The incident report dated 11/23/22, revealed Resident #30 sustained a fall on 11/23/22. Resident was observed by OT sitting on the floor near the head of bed. Resident stated she fell and hit her head. Resident was assessed by a registered nurse and staff assisted the resident to her wheelchair. Predisposing factors for the fall were listed as weakness, and ambulating without assistance to get out of bed. The incident report included intervention from the care plan to anticipate and meet the resident's needs. -No other interventions were noted. The therapy team assessed her fall on 11/23/22 and noted that they would continue with PT/OT/speech therapy (ST) to address deficits and increase safety. -The interdisciplinary team (IDT)/Risk Management review did not occur after the fall to discuss the incident or any further interventions. -The resident's care plan was not updated with any further interventions. 2. Fall #2 on 12/2/22 The incident report dated 12/2/22, revealed Resident #30 sustained a fall on 12/2/22. Resident #30 was witnessed self-propelling down hallway per baseline behavior. She rolled toward the handrails on the wall and pulled herself to a standing position. She lost balance and fell back into a seated position in her wheelchair and then laid-back rolling to her right side onto the floor. -Predisposing factors were not identified in the report. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. -The IDT/Risk Management review did not occur after the fall to discuss the incident or any further interventions. -The resident's care plan was not updated with any further interventions. 3. Fall #3 on 12/5/22 The incident report dated 12/5/22, revealed Resident #30 sustained a fall on 12/5/22. Resident was sitting in a wheelchair in front of the TV (television) in the living room watching TV. She was leaning back in her wheelchair, as she routinely does. Resident slid out of her chair slowly and fell to the floor on her bottom and laid back. It was witnessed by the certified nurse aide (CNA) and RN (registered nurse). Resident was lying on the floor perpendicular to the two chairs facing the TV between those chairs and the refrigerator with her head toward the hallway. Resident was assessed by a registered nurse with no adverse findings. Full assessment completed with vital signs, pain assessment, and range of motion assessment. Patient returned to wheelchair where she immediately began rolling away self-propelled. -Predisposing factors were not identified in the report. The incident report documented immediate interventions included continued PT/OT/ST, ST and activities team to collaborate on a structured activity for resident's cognitive level. 4. Fall #4 on 12/5/22 (second fall in the last 24 hours) The incident report dated 12/5/22, revealed Resident #30 sustained another fall on 12/5/22 at 11:00 p.m. (this was her second fall in less than 24 hours). Resident was sitting in her wheelchair, when she suddenly stood up and promptly fell to the floor, as she was reaching for another chair. CNA stated that she was not more than 10 feet from the resident but was unable to reach the resident in time to prevent the fall. Registered nurse immediately assessed resident eliciting a strong pain response, upon palpation of the right hip/thigh area. The on-call physician was notified, as well as the emergency contact. The resident was transported via emergency medical services (EMS) to hospital. X-ray results from the hospital showed a fracture to the right hip. Predisposing factors were identified as resident was high risk for falls due to gait and balance problems, incontinence, poor communication and comprehension, and unaware of safety needs. -The incident report did not include any new immediate interventions that were put in place to prevent any further falls. -The IDT review on 12/6/22 determined the cause was poor safety awareness resulting in the resident attempting to stand unassisted where she lost her balance and fell . -The resident's care plan was not updated with any specific interventions based on the cause of fall. III. Staff interviews CNA #4 was interviewed on 4/10/23 at 10:30 a.m. She said she was familiar with the resident's care but was not at the facility before the resident fell . She said the only fall interventions she was aware of was the resident had safety checks while the resident was in bed. She said the resident was effective at propelling herself in her wheelchair. RN #1 was interviewed on 4/10/23 at 11:00 a.m. She said the resident was confused due to her dementia diagnosis. She said the resident was hospitalized and diagnosed with a femur fracture. She said she did not work the shift when the fall occurred. She said for her fall prevention staff were checking on the resident frequently due to her unsafe gait and safety awareness and always performing two person transfers with the resident to ensure safety. She said the resident occasionally refused care but was easy to redirect after a couple attempts. She said she was not aware that the resident required bed canes since the fall with injury on 12/5/22 and she had not seen any devices installed on the resident's bed. She said the resident had a fall mat next to her bed starting before the fall with injury on 12/5/22. -However, the fall intervention was not in place until 12/11/22. In addition, no fall mat was observed (see above). The director of rehabilitation (DOR) was interviewed on 4/11/22 at 1:00 p.m. She said the resident was receiving physical, speech, and occupational therapy services since arriving at the facility last November 2022. She said after the fall with injury on 12/5/22, the resident was recommended to have bilateral bed canes installed and a fall mats for safety measures. She said it was not the therapy department's responsibility to ensure that those interventions were installed/implemented. Once the order was written, it went to the maintenance staff to install and then on to the nursing staff to ensure the order was carried out. In addition, the resident received education on safely operating her wheelchair and was being evaluated for wheelie bars for her wheelchair to prevent her from falling back. The director of nursing (DON) was interviewed on 4/11/23 at 12:00 p.m. She said after every fall the resident had, the IDT team concluded that no further interventions were necessary until the resident's fall with injury on 12/5/22. She said upon arriving at the facility, residents were assessed for fall risk and immediately placed on standard fall risk protocols. She said that Resident #30 was a high risk for falls when she admitted however the resident was not placed on high risk protocols or interventions according to the facility's fall prevention policy.

Based on observations, record review and staff interviews, the facility failed to ensure one (#30) of six residents observed for nutrition out of 28 sample residents to maintain acceptable parameters of nutritional status. The facility failed to provide meal supplements per registered dietitian (RD) order and provide assistance during meal times. Resident #30, who was identified as having a significant weight loss, had numerous predisposing factors which included dementia, lack of appetite and confusion. She was admitted to the facility on [DATE] with a weight of 126 pounds. Due to the facility's failures, the resident sustained a weight loss of 10.4% in six months. Resident #30 sustained a weight loss of 10.4% (14 lbs) from admission on 11/9/22 through 4/1/23 which was considered significant. Observations revealed that the nutritional interventions were not consistently implemented. Findings include: I. Resident status Resident #30, age 82, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and severe dementia with anxiety. The 2/14/23 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with poor decision making and supervision required. The resident required extensive assistance with transfers, walking in the room, eating, dressing, toileting and personal hygiene. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. II. Observations On 4/5/23 at 10:30 a.m. the resident was observed drinking a shake in the dining area. She was not offered ice cream with the shake as per RD orders. The resident drank less than half of the shake and did not finish it. -However, the nurse charted the resident drank 100% of the shake in the electronic medical record. At 12:20 p.m. Resident #30 was in the memory care dining room for lunch. She was placed at the table and her tray was brought to her with no cueing to begin her meal and no assistance was offered through the entire meal. She received honey roasted chicken, wild rice blend, julienne carrots and dinner roll with butter. For dessert she was given a cookie. By the end of the meal, the resident only ate her chicken and cookie. She covered her plate with a paper napkin and drank a cup of coffee and less than half a glass of orange juice. The resident was not offered an alternative meal or encouraged to eat more. On 4/6/23 at 11:36 a.m. Resident #30 was given a health shake with crushed medications mixed in. She was not offered ice cream as per RD orders (see below). At 12:14 p.m. Resident #30 was in the memory care dining room for lunch. She was placed at the table and her tray was brought to her with no cueing to begin her meal and no assistance was offered through the entire meal. She received glazed ham steak, skillet fried potatoes, zucchini medley and dinner roll. For dessert, she was given a slice of chocolate mousse pie. By the end of the meal, the resident only ate her ham, dinner roll and dessert. She drank a cup of coffee during the meal. The resident was not offered an alternative meal. On 4/10/23 at 11:54 a.m. resident was in the memory care dining room for lunch. She was placed at the table and her tray was brought to her with no cueing to begin her meal and no assistance was offered through the entire meal. She received barbecued pork chop, macaroni and cheese, steamed spinach, and dinner roll. For dessert, she was given caramel apple pudding. By the end of the meal, the resident only ate her dinner roll and dessert. The resident was not offered an alternative meal. -The resident was not offered assistance with meals as indicated by the MDS assessment and her nutrition care plan. III. Record review The nutrition care plan was initiated on 12/15/22 and revised on 2/3/23, revealed Resident #30 was at risk for weight loss due to the history of weight fluctuations and gradual weight loss. Goals included to maintain adequate nutritional status as evidenced by maintaining weight within five percent of current weight, consume at least 50% for most meals, no signs or symptoms of malnutrition, and no signs or symptoms nutrition related skin breakdown. Interventions included to provide a liberalized diet as ordered which offers adequate calories and protein for estimated needs. Interventions revised on 1/25/23 included to provide supplements as ordered: four ounces health shake three times a day and offer with ice cream, appetite stimulant order as mirtazapine, assist with meals and set up as needed, remind of meal times and locations, and offer meal alternates and/or snacks as needed. The activities of daily living (ADL) functional care plan was initiated on 11/10/22 and revised on 12/1/22, revealed Resident #30 required extensive assistance with one staff member for eating. The weight record demonstrated Resident #30 had lost 13.1 pounds (10.4 percent) in a period of six months. The resident's weight was 126 pounds in November 2022, and most current weight in April 2023 was 112.9 pounds. This demonstrated a loss of 10.4 percent from her usual weight, which was considered significant. The nutritional assessment on admission was conducted by the registered dietitian (RD) on 11/10/22. Recommendations were regular diet, regular texture, and thin liquids. Her average meal intake was around 50% with prompting. Staff to encourage eating and drinking fluids at and between meals as the resident was a potential nutritional risk due to diagnosis of dementia, anxiety, and hypothyroidism. The RD completed an updated nutritional assessment on 12/15/22. At that time, the resident's weight was 120.6 pounds (six pounds less than her weight in November 2022). The RD assessment indicated that the resident had a 4.8% weight loss in 30 days, and her average meal intake was around 25 percent. The resident required extensive assistance with meals at this time per nursing. Recommendations included supplement shake twice a day while working on self-feeding and improved intakes at meals. According to the April 2023 CPO: -Provider order for health shake three times a day for weight loss, offer with one container ice cream initiated on 12/30/22. -Medication order for Mirtazapine 15 mg was initiated on 1/24/23. Prescribed as one time a day for appetite stimulation. IV. Staff interviews Certified nurse aide (CNA)#5 was interviewed on 4/10/23 at 11:00 p.m. She said that she was unaware the resident was on any particular nutritional plan. She said that when the resident was assisted to the dining area, she would eat by herself. She said the resident did not need any assistance at meal times. She said that CNAs were responsible for documenting the intakes of the residents in the electronic medical record. Registered nurse (RN) #1 was interviewed on 4/10/23 at 11:00 a.m. She said that the resident usually slept in until around 10:30 a.m. every day. She said that lunch was usually the resident's first meal of the day. She said that she offered the resident health shakes with ice cream at least twice a week. She said the resident did not require any assistance at meal times. -However, the health shake with ice cream was supposed to be offered three times per day. The director of nursing (DON) was interviewed on 4/11/23 at 11:37 a.m. She said that the resident only required assistance with dining as needed but the staff should have been providing extensive assistance according to the resident's care plan. She said extensive assistance would include sitting with the resident and verbally cueing the resident to eat. Staff could assist the resident with bites to ensure the resident was getting the appropriate nutrition intake. She said that the resident should have been receiving assistance with eating as well as receiving supplement shakes according to the provider's orders and by not doing so could have contributed to the resident's weight loss. The RD was interviewed on 4/11/23 at 2:29 p.m. She said she had been in the position since March 2023. She said she reviewed residents' nutritional status on admission, quarterly and when weight loss was noticed. She said Resident #30 had a significant weight loss of 10% in the past six months. She said she did not observe her meal intake in person, but looked at the intake log in the computer. She said if the resident had received the interventions of extensive assistance when eating and having the health shakes with the ice cream that the weight loss could have been avoidable. She said that the care plan should have been updated in a more timely manner after significant weight loss was noted to ensure effective nutritional interventions.

Based on observations, record review and interviews the facility failed to provide effective pain management during wound care for one (#10) of three out of 28 sample residents. The facility failed to assess Resident #10 for pain after he developed two stage 3 pressure injuries. Nursing staff did not offer pain medication to the resident prior to the dressing changes. The resident experienced severe pain during dressing changes and refused the care due to the pain. In addition, nursing staff did not follow up with the physician regarding pain management and did not obtain an order for pain control prior to wound care and continued to provide dressing changes without offering pain medication. Resident #10 frequently refused care and his wounds deteriorated. Findings include: I. Facility policies and procedures The Pain Management policy, updated [DATE], was received from the director of nursing (DON) on [DATE] at 8:27 a.m. It read in pertinent part: The facility must ensure that pain management was provided to those residents who require such services consistent with professional standards of practice and the residents goals and preferences.The nurse on duty should evaluate residents for pain upon admission and when a significant change in status occurs.The facility should manage or prevent pain according to the comprehensive assessment and plan of care. The facility staff will observe for non-verbal communicators which may indicate the presence of pain. The facility will use a pain assessment tool which is appropriate for the resident's cognitive status.The resident should be asked the level of his or her pain using a numeric scale, a virtual or visual description of the pain, that is appropriate for the resident and approved by the resident. The pain could be described as stabbing, aching, pressure or spasms. II. Resident #10 A. Resident status Resident #10, age 75, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO) diagnoses included type two diabetes mellitus, artificial left hip joint, morbid obesity, generalized muscle weakness, pressure ulcer stage 3 on right and left buttock region. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status score (BIMS) of 13 out of 15. The resident required extensive assistance with toilet use, was totally dependent on staff for shower assistance, dressing assistance, and required moderate assistance with bed mobility. The resident did not display verbal and physical behaviors. The resident did not reject care. The skin section documented that the resident was not at risk for development of pressure ulcers and that the resident did not have two pressure ulcers. The pain section documented that the resident received PRN (as needed) pain medication. Resident #10 did not receive non-medication interventions for pain. B. Resident interview Resident #10 was interviewed on [DATE] at 10:00 a.m. The resident said he had two pressure ulcers on his bottom area. Resident #10 said the wounds were painful when the staff tried to perform wound care on him. Resident #10 said he refused the treatments because he knew they would hurt. The resident said the worst pain he had was when the wound dressing was changed and the wound was cleaned. C. Wound care observations and resident interview Wound care treatment was observed for Resident #10 on [DATE] at 12:40 p.m. The wound care physician (WCP) was accompanied by a medical student (MS) who treated the resident's wounds. An infection preventionist (IP) was in the resident's room and assisted with resident care. The resident was able to roll to his left side, and the brief was removed. Two undated dressings stained in red blood were observed on the left and right buttock. The right buttock dressing was removed first, and the resident moaned in pain. The dressing was moderately saturated in bright red blood. The left buttock dressing was removed, the resident moaned in pain and leaned away from the physician. The dressing was 100 percent saturated in bright red blood and two lines of blood were observed dripping down left buttocks to the brief. Both wounds were cleaned with normal saline and gauze while the resident continued to moan in pain. The WCP sprayed lidocaine spray to the left wound bed. Silver alginate was applied to the wound to control the bleeding, the resident was warned by the physician that it would sting. The resident moaned in pain when silver alginate was applied. The bleeding from the left wound stopped after two more gauze dressings were applied and pressed to the wound. A calcium alginate dressing was applied to both wounds and covered with large foam dressing. The foam dressing was pressed into place, no tape was applied to secure the dressing in place. The WCP stated it was a temporary dressing and it would be replaced later by the floor nurse when pain went away. The WCP instructed the floor nurse to administer some pain medication to the resident before he was cleaned up by the staff. -The WCP and IP who were in the room during wound care did not ask the resident about his pain on the pain scale. The resident was interviewed right after the above observations. He said his pain level was 11 out of 10 (on a scale from ,d+[DATE], with 10 being the worst) during this wound care. He said pain medications were not offered to him prior to wound care. He said he would start asking for it because the pain was getting worse. D. Record review The care plan for wounds was initiated on [DATE] and revealed the resident had two stage 3 pressure ulcers, one on left buttock and one on the right buttock. Interventions included administer pain medications as ordered and monitor for effectiveness. The care plan for behaviors was initiated on [DATE] and revealed the resident had verbal behaviors and ineffective coping skills related to meal time frustrations.The resident would often refuse to do care and refuse to have bedding changed at times. The staff were to come back later in the day and try again. Interventions included monitor changes that may contribute to activities of daily living (ADL) decline including metabolic changes like diabetes, liver disease or alcohol withdrawal. Monitor for decline in ADL function. Monitor medications, especially new, changed or discontinued. Monitor for pain, attempt non-pharmacological interventions and assess for effectiveness Administer pain medication as ordered and document effectiveness. Provide a consistent trusted caregiver and structured daily routine. The resident will be educated on the importance of caregiver assistance. -The resident did not have a care plan for the refusal of care related to pain management and wound care. According to the medication administration orders (MAR) for [DATE] the resident was receiving following medications for pain: Acetaminophen 325 milligram (mg), two tablets every four hours as needed for general discomfort. The order was started on [DATE]. -There were no parameters indicated when to administer Acetaminophen. The most recent wound assessment completed on [DATE] by the wound care physician (WCP) revealed the resident had two wounds. Wound #1 on the right buttock was a stage 3 pressure injury. The patient reports a wound pain level of zero out of ten. Wound #2 on the left buttock was a stage 3 pressure injury. The patient reports a wound pain of level zero out of ten. The wound was deteriorating. -However, according to the observations (see above) the resident was screaming out multiple times during the wound care. The resident was not asked what his pain level was during the course of the treatment. The progress notes were reviewed from [DATE] to [DATE]. There were no documented nursing notes mentioning the wound care on [DATE]. There were no notes by the IP who was present during the wound care or by the staff nurse who was supposed to follow up on pain assessment and replace the dressing when pain went away (per the WCP statement on [DATE] during wound care). The review of the MAR for [DATE] and next consecutive days until [DATE] revealed the resident was not given any pain medication prior to dressing changes. The dressing changes were ordered to be completed daily. The nurses note on [DATE] documented that the resident continued to refuse dressing changes. The review of the assessments between [DATE] and [DATE] revealed that the resident was not assessed for pain with a formal assessment tool. The last documented pain assessment was completed on [DATE]. The pain assessment included that the resident had no pain for the last five days. The most current wound care note on [DATE] noted Resident #10's wounds were expected to heal at a slower pace due to identified factors: diabetic complicating factors, impaired mobility, incontinence, inevitable effect of aging and non-compliance. III. Staff interviews Certified nurse aide (CNA) #2 was interviewed on [DATE] at 9:30 a.m. She said Resident #10 could get up and walk but he would not do it. She said the resident did not get out of bed because he felt more comfortable there. CNA #2 said Resident #10 experienced pain but only with wound care. She said Resident #10 refused to get out of bed to go to the shower room and only took a sponge bath. LPN #2 was interviewed on [DATE] at 11:10 a.m. He said Resident #10 had stage 3 pressure ulcers on his right buttocks and on his left buttocks. He said the resident was monitored for pain twice daily. LPN #2 said the resident said he had excruciating pain when the wound dressings were changed. LPN #2 said the resident was prescribed 650 milligrams of Tylenol (Acetaminophen) every four hours as needed for pain. Resident #10 refused to get pain medication before wound treatment. The resident said the treatment was painful especially when they took the tape off. LPN #2 said he did not think the wound treatments were helping Resident #10 very much. The WCP was interviewed [DATE] at 1:30 p.m. immediately after the wound care observations. She said the resident had many behaviors including refusal of care for personal hygiene and repositioning. She said the resident often refused care and dressing changes. The WCP said she tried to educate the resident that his behavior just made his condition worse. She said the resident was able to reposition himself, however refused to follow the recommendations. She said today he displayed more pain than before and during previous rounds he was not in so much pain. She said his wounds had deteriorated since last week and it was expected due to the lack of resident's cooperation and refusals. LPN #2 was interviewed again on [DATE] at 2:48 p.m. He said the resident was prescribed hydrocodone previously for pain as needed. LPN #2 said the hydrocodone expired so now the resident took Acetaminophen 650 milligrams for pain as needed. The LPN said Resident #10 refused pain medication most of the time. The IP was interviewed on [DATE] at 1:16 p.m. in the presence of the director of nursing. She said the WCP did not have a set time for the wound care rounds and would notify her or the DON by phone about five to ten minutes prior to the arrival. She said she followed the WCP during wound rounds only for the purpose of helping the physician to document the measurements. She said she did not document her observations or any notes about wound care after the rounds. She said she did not document her observations of wound care on [DATE]. She said LPN #4 who was a floor nurse for the Resident #10 on [DATE] was informed verbally by the physician about the pain that resident had and was supposed to follow up. The director of nursing (DON) was interviewed on [DATE] at 1:16 p.m. She said Resident #10 was offered Acetaminophen 650 milligrams every four hours as needed for pain especially before a wound treatment. The DON said Resident #10 did not take pain medication very often. She said she did not know why Resident #10 would say that he had no pain when he actually did. She said she was not aware he was in pain during wound care on [DATE]. She said floor nurses were expected to use formal tools for assessing residents for pain and document results in the residents' progress notes. LPN #2 was interviewed for the third time on [DATE] at 2:15 p.m. He said he did recall talking to the WCP on [DATE]. He said his understanding was that the resident was in pain when dressing with the tape was removed therefore tape was no longer applied to the dressing. He said he did not receive any additional orders for pain medications prior to wound care. He said he did come to the room to assess the resident for pain, but the resident was asleep and when he asked him later, the resident was not in pain. He said he did not complete any formal pain assessment and he could not recall if he documented his verbal pain assessment on [DATE]. IV. Facility follow-up Following the exit of the survey, the facility emailed on [DATE] the following: Prior to doing wound rounds on [DATE], This nurse spoke with the resident's floor nurse regarding his level of pain. His Nurse for the shift had already performed wound care due to an incontinence episode and told the resident that the wound care physician would still be in to assess the wound that day. At this time the floor nurse asked the resident if he wanted any of his PRN Tylenol prior to the wound care physician seeing him. Resident denied having any pain and did not want to take Tylenol prior to the wound care physician assessment. During wound care resident had signs of pain and stated that the area was hurting during the procedure. The resident's nurse that day was notified of him having pain and went in to speak with the resident. After wound care was performed, the resident was asleep in bed when his nurse woke him up and asked what his pain was on a scale of ,d+[DATE]. Resident stated that his pain was a 0 and denied the Tylenol that his nurse was offering to give him. -According to the documentation provided, the facility indicated that the resident did have signs of pain during the wound procedure and he was hurting. In addition, the floor nurse offering pain mediation prior to the wound procedure was not documented.

Based on observation, record review and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as COVID-19 for 39 census residents. The facility failed to have an effective surveillance tracking system in place for residents and staff that were positive or had signs and symptoms of COVID-19. The facility failed to provide ongoing staff training and guidance related to infection control during a COVID-19 outbreak. Moreover, the facility failed to ensure proper personal protective equipment (PPE) practices and proper laundry practices were followed. The facility failed to ensure the appropriate disinfectant wipes were used for resident hand hygiene. Furthermore, the facility failed to ensure the infection preventionist had qualified training in infection control which impacted the execution of the infection control program for the facility. Due to the facility's failures, it created the likelihood of immediate and serious adverse outcomes for all of the residents in the facility, who were identified as high risk, from contracting COVID-19. Cross-reference F882, the facility failed to have a qualified infection preventionist. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 2/11/21 at approximately 10:24 a.m., it was identified that the facility failed to ensure proper personal protective equipment (PPE) practices were followed; staff were wearing the same PPE into COVID positive resident rooms and COVID negative resident rooms; proper laundry practices were in place; and, the facility failed to have an effective surveillance tracking system in place for residents and staff that were positive or had signs and symptoms of COVID-19. Additionally, the lack of proper infection control practices led to the potential exposure to COVID-19 to residents, who were identified as high risk. The facility was in a current COVID-19 outbreak. B. Facility plan to remove immediate jeopardy On 2/11/21 at 2:46 p.m. the facility submitted a letter to remove the immediate jeopardy. The plan read: Corrective action: -On 2/2/2021, the center transitioned the entire center to person specific airborne and contract precautions and completed staff education on proper PPE utilization. -Effective 2/2/2021, all stations had PPE stations placed outside of resident rooms to help facilitate person specific contact/airborne PPE and monitor every shift for availability. -Staff will be re-educated beginning on 2/2/2021 on proper usage of PPE related to person specific precautions training to be completed prior to staff members next shift worked. -On 2/2/2021 Center educated (company name) laundry staff on new laundry handling procedures to differentiate between positive and negative laundry training will be completed prior to the next shift worked by each staff member. - On 2/2/2021 and 2/11/2021 Regional Clinical Quality Specialist reviewed COVID-19 line listing to verify accurate reflection of centers positive residents and appropriate signage on resident doors, and will continue daily times four weeks. Systematic Measures: -Infection Preventionist/designee will complete daily rounds to validate PPE and laundry practices are being followed. - Education will be completed for (company name)/Laundry services to ensure handling of laundry follows infection control practices and audits will be completed -Clinical Quality Specialist or designee will review Covid-19 line listing and tracker to ensure that proper tracking is being completed. Quality Assurance and Monitoring: -Quality Assurance Performance Improvement (QAPI) meeting held on February 11th, 2021 with Interdisciplinary Team members and the Medical Director specifically related to Covid-19 and Infection Control Program in the center and proper PPE usage. -The Interdisciplinary Team will review and assess all residents signage to include person specific airborne/contact precautions for proper PPE notification daily for four weeks, three times a week for four weeks, and then twice weekly for four weeks to monitor and validate compliance. -Infection Preventionist or designee will ensure that a proper line list and tracking system is in place. Audits of line listing will be conducted daily for four weeks, three times a week for four weeks, and then twice weekly for four weeks to monitor and validate compliance. -Center Executive Director or designee will audit laundry services to ensure that laundry is properly labeled, handled and able to be distinguished between positive and naive laundry. Audits of laundry handling practices will be conducted daily for four weeks, three times a week for four weeks, and then twice weekly for four weeks to monitor and validate compliance. -Center Executive Director or designee will report findings of audits and observations in the monthly Quality Assurance Performance Improvement meeting for three months to ensure compliance is achieved and sustained. Subsequent plans of correction will be implemented as needed. The Quality Assurance Performance Improvement Committee consists of: The Center Executive Director, Center Nurse Executive, Medical Director, and three other key personnel. C. Removal of immediate jeopardy On 2/11/21 at 2:46 p.m. the NHA was informed the immediate jeopardy had been lifted, based on the facility's implementation of the above plan. However, deficient practice remained at F level that was widespread with the potential for more than minimal harm. II. Professional reference Review of the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, last updated 11/20/2020, retrieved 2/4/21. It revealed in part, Educate and train healthcare professionals (HCP), including facility-based and consultant personnel (e.g., wound care, podiatry, barber) and volunteers who provide care or services in the facility. Including consultants is important, since they commonly provide care in multiple facilities where they can be exposed to and serve as a source of COVID-19. Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room. The Centers for Disease Control and Prevention (updated 11/20/2020) Preparing for COVID-19 in Nursing Homes, retrieved on 2/5/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#core-practices. It read in pertinent part, -Prioritizing gowns for activities where splashes and sprays are anticipated (including aerosol-generating procedures) and high-contact resident care activities that provide opportunities for transfer of pathogens to hands and clothing of healthcare personnel (HCP). -If extended use of gowns is implemented .the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections (e.g., [MEDICAL CONDITION]). III. Facility policy and procedure Review of the COVID-19 policy, revised 11/15/2020, provided by the nursing home administrator (NHA) on 2/2/21 at 11:13 a.m. revealed in part, In addition to standard precautions, contact and airborne precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the CDC. Review of the contact precautions policy, reviewed 11/15/2020, provided by the NHA on 2/2/21 at 11:13 a.m. revealed in part, Staff must wear barrier precautions when entering the room. Wear a gown and gloves. Wear eye protection .before exiting the room, remove the bag gown and gloves and wash hands upon exiting the room. Review of the standard precautions policy, revised 11/15/2020, provided by the NHA on 2/2/21 at 11:13 a.m. revealed in part, Handle, transport, and process used linen with blood and/or body fluid in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other individuals or environment. IV. PPE practices On 2/2/21 observations and interviews on the secure unit revealed: -At 8:01 a.m., licensed practical nurse (LPN) #1 was observed on the secure unit wearing a white reusable/washable gown. The LPN was observed during her morning medication administration. The LPN was observed entering three different rooms during the medication administration. The LPN did not change her gown in between rooms or residents. The LPN was observed wearing the same gown from 8:01 a.m. until 9:20 a.m. The LPN was interviewed during that time, she said the NHA had instructed her yesterday (2/1/21) to keep the same gown on for the entire shift. The LPN said the secure unit had both COVID-19 positive and negative residents. The LPN said she had been wearing the same gown since the start of her shift at 6:00 a.m. She said she had interacted with both the COVID-19 positive and COVID-19 negative residents. The LPN said there was a lack of consistent training throughout the facility. She said there was no one really in charge of the infection prevention in the building, and she was just trying to keep herself safe. The LPN said she could not recall the last time she had training in the facility, that most things were communicated by word of mouth, but that was not very accurate. The LPN said she had no training regarding PPE usage. -At 8:18 a.m., certified nurse aide (CNA) #1 was observed removing a gown from a storage unit. The CNA was interviewed at that time. She said she had been off for several days, and she was unsure when she needed to change her gown. She said she was getting ready to provide care for a resident and just wanted to make sure there were enough gowns. The CNA said she could not recall the last education she had been provided regarding PPE. She said she was told she needed to wear the gown all day, but she did not feel comfortable doing that. She said if the facility wanted them to change gowns after each room or resident, there were not enough gowns on the secure unit. The CNA said there were currently ten residents on the secure unit and 25 gowns for two staff. -At 8:52 a.m., the business office manager (BOM) entered the secure unit. The BOM told LPN #1 to make sure she was changing her gown between rooms, and not wearing the gown in the resident common areas. The BOM was interviewed at that time, she said the NHA told her to inform the staff to change out their gowns between rooms. -At 9:00 a.m., the social service director (SSD) entered the secure unit wearing a white reusable gown. The SSD was interviewed at that time. She said the NHA instructed yesterday (2/1/21) for her to wear a gown when she entered the secure unit, and then removed the gown when she left the unit. -At 9:05 a.m., the housekeeping supervisor (HKS) entered the secure unit, he was not wearing a gown. He was interviewed at that time. He said he was told to wear a gown if he was entering a resident room, but that he did not need to wear a gown if he was in resident common areas. The NHA was interviewed on 2/2/21 at 11:53 a.m. She said she had instructed the staff to wear the same gown, but as of today (2/2/21) the staff would be educated and trained on changing out their gown for each resident. V. Laundry practices On 2/2/21 observations and interviews on the secure unit revealed: -All of the PPE gowns on the secure unit were washable reusable gowns which were white or gold in color. There were no markings on the gowns indicating when they should be disposed of. The laundry aide (LA) was observed at 9:45 a.m. picking up the soiled PPE gowns on the secure unit. The soiled gowns were located in bins outside of the resident's room. The LA was observed removing the soiled gowns with her gloved hands and placing the gowns into a clear plastic bag. The LA was observed removing the soiled gowns from three bins, instead of containing the soiled gowns into trash bags and transporting them to the laundry facility where appropriate PPE could be worn for sorting. The LA was interviewed at that time, she said she was sorting the gowns from the other soiled linens so she could take them to the laundry room to wash them. The LA said she had not had any training about how to handle linens when she was picking them up from the various units in the facility. The housekeeping supervisor (HKS) was interviewed on 2/2/21 at 9:15 a.m. He said he currently had one laundry aide for the facility. He said he was unsure when or what training had been provided to the laundry aide. He said the facility was currently using two types of washable gowns. The HKS said the facility had white colored gowns that were good for 600 washes and gold colored gowns that were good for 75 washes. The HKS said after the 600 or 75 washes the gowns were to be thrown away. The HKS said he had no way of knowing how many washes the gowns had already had. He said he would need to come up with a way to monitor the number of washes for the gowns. The NHA was interviewed on 2/2/21 at 11:53 a.m. She said the facility was currently utilizing the washable gowns throughout the facility. The NHA said the LA should not sort the laundry in the hallway, and should sort the laundry in the laundry room away from residents. The NHA said she was not sure of the system the facility was using to monitor the washes for the disposable gowns, but stated if there was not a system in place, she would work with the HKS to come up with a system. VI. Staff education The director of nurses (DON) and assistant director of nurses (ADON) were interviewed on 2/2/21 at 9:56 a.m. After review of the training documentation, they acknowledged there had been no staff training on infection control since July 2020. Training had been last completed on 7/24/2020. No training had been completed from August 2020 through February 2021. Certified nurse aide (CNA) #2 was interviewed on 2/2/21 at 10:18 a.m. She said she received training about two months ago from the infection preventionist (IP)/CNA. She said she was trained on donning and doffing PPE along with hand hygiene. She said there was no documentation of the training. She said they did not have any computerized training. She said she completed some training on orientation but was unable to remember the topics. She said she was not sure how often training was completed. The NHA was interviewed on 2/2/21 at 10:22 a.m. She said they provided the staff with annual computerized training, last completed September 2020. The IP/CNA was interviewed on 2/2/21 at 10:33 a.m. She said she was not aware of any computerized training. She said she was unaware of when they had an in-service. She said she was not the trainer. She said the NHA and the DON were the staff responsible for training the employees on infection control. The NHA was interviewed on 2/2/21 at 11:20 a.m. She said she did huddle training but there was no documentation. She said they put signs up and hoped the staff would read the signs. She said they were going to incorporate more training. VII. Surveillance tracking of COVID-19 The DON was interviewed on 2/2/21 at 9:17 a.m. She said the outbreak started at the end of December 2020. She said a staff member was positive. She said she did not know how the staff member contracted COVID-19. She said they did complete investigations into how the staff member contracted [MEDICAL CONDITION]. She said one staff member had a positive roommate and another staff member was asymptomatic. She said they believed the first positive resident got it from the positive staff member who took care of the resident. The DON was unable to provide the line listing. The NHA was interviewed on 2/2/21 on 10:55 a.m. She provided the list of residents and staff testing results and said that was the line listing they were using. At 11:07 a.m., the NHA said they were going to put together an official line listing. She confirmed they did not have a line listing for residents or staff for tracking purposes. She said they had a lot of staff with headaches and fatigue. She said she did not have any documentation of the signs and symptoms tracking. She said they were in contact with corporate staff on a regular basis. She said they went down a list of the residents on the blank line listing form; a map of current infected residents and she had a list of positive residents and staff written on the white board in her office. She said they had 12 current COVID-19 positive residents and three staff based on her list from the white board. VIII. Chemical exposure The IP/CNA was observed on 2/2/21 at 8:22 a.m. in a residents room [ROOM NUMBER]. She was talking to the resident about how he needed to wash his face and hands. She looked for some sanitizer wipes and none were found. Another CNA was observed to have gone to the nursing station to obtain sanitizer wipes. She returned without sanitizer wipes. She reached into the PPE cart and pulled out a white container of disinfectant wipes. She was observed using this wipe. She then assisted the resident to eat a meal. The IP/CNA was interviewed and she said that they just started using these wipes. She acknowledged this product was used to wash the residents hands. She said this was the only resident she used the product on. Review of the safety data sheet for this disinfectant product revealed in part, Precautionary statement: wash thoroughly after handling. Precautionary statements: Hazards to humans and domestic animals. Wash hands thoroughly with soap and water after handling and before eating and drinking. The IP/CNA was interviewed on 2/2/21 at 10:33 a.m. She said she was not familiar with those wipes. She said they were not the normal wipes they used. The NHA was interviewed on 2/2/21 at 11:33 a.m. She said these wipes should have only been used for cleaning goggles and face shields. She said they were not to be used for hand washing. IX. Facility COVID-19 status As of 2/2/21 at 11:53 a.m. the facility had 12 COVID-19 positive residents and three positive staff (see above).

Based on record review and interviews, the facility failed to ensure a qualified infection preventionist was in place for providing guidance to the facility on the infection control policy and programs with the potential to affect 39 census residents at the time of the survey. The facility failed to ensure the infection preventionist had qualified training in infection control which impacted the execution of the infection control program for the facility. The facility failed to have an infection preventionist that attended the quality assessment and assurance committee to identify issues with the infection control program. Moreover, the facility failed to have an infection preventionist to ensure an effective surveillance tracking system in place for residents and staff who were positive or had signs and symptoms of COVID-19. Furthermore, the facility failed to have an infection preventionist to provide ongoing staff training and guidance related to infection control during a COVID-19 outbreak. Due to the facility's failures, it created the likelihood of immediate and serious adverse outcomes for all of the residents in the facility, who were identified as high risk, from contracting COVID-19. Cross-reference F880, the facility failed to have an effective infection control program. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 2/11/21 at approximately 10:24 a.m. It was identified that the facility failed to ensure the infection preventionist (IP) had the qualified training on infection control (IC) which affected the infection control program for the facility including guidance and training on infection control procedures to implement during the COVID-19 outbreak. Additionally, the failure to have a qualified IP resulted in the inability to identify COVID-19 outbreak to implement preventative infection control practices to ensure containment, provide current and ongoing education/training pertaining to the outbreak and the immediate notification to local, state and federal agencies. B. Facility plan to remove immediate jeopardy On 2/11/21 at 2:46 p.m. the facility submitted a letter to remove the immediate jeopardy. The plan read: Corrective action: -Effective 2/2/2021, the center did have a previous director of nursing (DON), still currently working at the center as an (registered nurse) RN, has completed the CDC (Center for Disease Control) IP certification. -CNA (certified nurse aide) completed her CDC IP certification in the Fall of 2020 and serves as an Infection Control champion for the center. -On 2/9/2021 Current ADON/IP (assistant director of nursing) completed her CDC IP certification within 60 days of her hire and will be the center's designated IP and fulfil all roles as designated by this title. Systematic Measures: -Center will continue to have an Infection Preventionist (IP) work with the IDT (interdisciplinary team) to complete Infection Control (IC) rounds. -Clinical Quality Specialist or designee will complete additional training with center designated IP. Quality Assurance and Monitoring: -Quality Assurance Performance Improvement (QAPI) meeting held on February 11th, 2021 with Interdisciplinary Team members and the Medical Director to ensure that IP is in place and role defined and understand responsibilities. -Infection Preventionist or designee will ensure that a proper line listing and tracking system is in place. Also will ensure that the reporting process is maintained to include local, state, and county reporting. Audits of line listing will be conducted daily for four weeks, three times a week for four weeks, and then twice weekly for four weeks to monitor and validate compliance. -Center Executive Director, Infection Preventionist, or designee will report findings of audits and observations in the monthly Quality Assurance Performance Improvement meeting for three months to ensure compliance is achieved and sustained. Subsequent plans of correction will be implemented as needed and a meeting will be held should such situations arise. The Quality Assurance Performance Improvement Committee consists of: The Center Executive Director, Center Nurse Executive, Medical Director, and threeother key personnel. C. Removal of immediate jeopardy On 2/11/21 at 2:46 p.m. the NHA was informed the immediate jeopardy had been lifted, based on the facility's implementation of the above plan. However, deficient practice remained at F level that was widespread with the potential for more than minimal harm. II. Professional reference Review of the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, last updated 11/20/2020, retrieved 2/4/21. It revealed in part, Facilities should assign at least one individual with training in infection prevention and control (IPC) to provide on-site management of their COVID-19 prevention and response activities because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of healthcare professionals (HCP), and auditing adherence to recommended IPC practices. III. Facility policy and procedure Review of the Infection Prevention and Control Program (IPCP) Description, revised 11/15/2020, provided by the NHA on 2/2/21 at 11:45 a.m. It revealed in part, The major activities of the program, the infection preventionist being a member of the quality assurance and performance improvement (QAPI) committee and coordinating and evaluating activities under the center's QAPI plan. In order to carry out the major activities of the program, the infection preventionist has the following responsibilities: -Facilitate and implementation of the infection control policies and procedures; -Facilitate the annual review and updating of the IPCP; -Educate new personnel through orientation programs on their roles in the infection control/ prevention coordinator (ICPC); -Provide ongoing infection prevention and control updates and remain current; -Facilitate (at minimum) an annual in-service on infection prevention and control; -Provide necessary staff education relating to outbreaks and other infection control related issues; -Initiate specific precautions to prevent transmission of infection; -Investigate and control outbreaks of infectious and communicable diseases; -Monitor procedures for proper infection prevention and control technique; -Collaborate with the Medical Director and Center Nurse Executive to obtain laboratory support; -Facilitate the report of reportable diseases to appropriate health department official, center executive director, medical director, center nurse executive and divisional infection control specialist; -Perform surveillance to monitor the rate of healthcare acquired infection and communicable diseases, analyze and develop action plan to address; -Complete monthly infection control report; -As a member of the center's QAPI committee, review information: obtained from the infection prevention, surveillance, and control activities to improve patient care, employee work practices, and the environment of care, and incidents under the centers IPCP. Report findings to the QAPI committee on a regular basis. -Provide consultations regarding the acquisition of equipment and supplies used for disinfection and decontamination purposes; -Participate in the screening of employees for physical, health history, and immunization status upon hiring and annually; -Monitor employee health program; -Monitor use of antibiotics and compliance with antibiotic stewardship program; -Maintain and enhance own knowledge and expertise in infection prevention and control. II. Staff training and surveillance tracking of infections Review of the infection control training book revealed the last staff training the facility provided on infection control was in July 2020. Cross-reference F880 for infection control practices. There was no line listing completed for the tracking of current COVID-19 infections along with signs and symptoms for staff and residents. Cross-reference F880 for infection control practices. III. Infection preventionist training A certificate of training was completed by the infection preventionist (IP)/certified nurse aide (CNA) on 11/16/2020, who was also the shower aide (see interviews below). Several modules related to infection control were completed by registered nurse (RN) #1 from 3/10/2020 through 5/2/2020. RN #1 was one of three staff members who had started infection control training (see NHA interview, below). A few modules on infection control were completed by the director of nurses (DON) on 12/14/2020 and 2/2/21. A few modules on infection control were completed by the assistant director of nursing (ADON), who was the current IP, on 2/2/21. III. Interviews The DON was interviewed on 2/2/21 at 9:17 a.m. She said there was nobody in the building with a certificate of training in infection control. The assistant director of nurses (ADON) was interviewed on 2/2/21 at 9:56 a.m. She said she was the new infection preventionist and had just started about five days ago. She said she had not received any special training for the infection preventionist role. She said she was waiting for the training manual to start her training. She said she had no certificate of training. She said she had not participated in QAPI yet. She said she would be training the staff on infection control. The nursing home administrator (NHA) was interviewed on 2/2/21 at 10:05 a.m. She said the ADON, the current IP, did not have a certificate of training related to infection control. She said the ADON had signed up for the course. She said the facility had an IP/certified nurse aide (CNA) that had completed the course. At 10:12 a.m., the NHA said the IP/CNA was the shower aide. She said the IP/CNA did not attend QAPI and did not complete any training to the staff. She said the IP/CNA was the eyes and ears on the floor. The IP/CNA was interviewed on 2/2/21 at 10:33 a.m. She said she had completed IC training in June or July 2020. She said the training was over her head because she was a CNA and not a nurse. She said the course was helpful but did not pertain to CNA. She said she did not educate the staff through any formal education or inservicing. She said she educated the staff on the shower room. She was unable to recall the last in-service training provided by the facility. She said her role in infection control was ensuring the personal protective equipment (PPE) carts were full. She said she never went into the COVID-19 positive unit. The NHA was interviewed again on 2/2/21 at 11:33 a.m. She said they were going to have the DON and the ADON do the infection control training. She said three staff had completed the training in the past but there was limited participation in QAPI and no training with staff. She said the DON and herself had been filling the role of the IP since the last IP left 1/4/21.

Based on observations, interviews and record reviews, the facility failed to ensure three (#2, #1, and #6) of four out of 13 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure new interventions were in place to prevent Resident #2 from having multiple falls, one which resulted in a nondisplaced linear fracture along the mid and upper aspect of the left iliac crest (pelvis). -Ensure new interventions were in place to prevent Resident #1 having multiple falls, one which resulted in a fracture of her left clavicle. -Ensure Resident #6 was positioned in a way she could not place her leg onto the electric wall heater. Resident #6 leg was on the electric wall heater for an unknown amount of time and the resident subsequently received a second degree burn on her right lower leg. As aresult of the facility's failure to implement effective interventions to prevent falls with a major injury for two residents (#1 and #2). Resident #2 suffered a nondisplaced linear fracture along the mid and upper aspect of the left iliac crest (pelvis) with the initial fall on 12/27/19. As a result of the ineffective interventions, Resident #2 fell a total of six times between the period of 12/27/19 to 1/26/2020. Furthermore, the facility's failure caused Resident #1 to suffer a fracture of her left clavicle. Also, the facility's failure to ensure Resident #6 was positioned correctly caused the resident to aquire a second degree burn to her right leg from the electric wall heater. Cross reference: F725 Insufficient staffing Findings include: I. Facility policy and procedure The Falls Management policy, dated 9/15/01 and revised on 11/1/19, was provided by the nursing home administrator (NHA) on 1/29/2020 at 4:26 p.m. It read, in pertinent part Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. To reduce risk for falls and minimize the actual occurrence of falls. Identify patient's fall risk by reviewing the following: electronic medical record systems nursing assessment and non-electronic medical record systems fall risk evaluation. Develop individualized plan of care. Review and revise care plan regularly. If patient falls, update care plan to reflect new interventions. Conduct interdisciplinary team meeting within 72 hours of fall. II. Resident #2 [NAME] Resident status Resident #2, age 91, was originally admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. According to the 1/13/2020 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She required extensive one-person physical assistance with transfers, toilet use, and personal hygiene, limited one-person physical assistance with dressing, and supervision set-up for bed mobility and eating. B. Family interview The family was interviewed on 1/28/2020 at 2:18 p.m. The family said they received a call from the facility on 12/27/19 at approximately 7:00 a.m., advising the resident had fallen earlier in the morning around 5:00 a.m. The family was told that the fall took place in the bathroom as a result of the riser (an elevated toilet seat) on the toilet coming disengaged from the toilet. The family was told the resident was discovered on the bathroom floor with the riser on top of her. The family said the staff told them the resident was non-compliant because she did not use the call light when she needed to get up and use the bathroom. However, the resident had a [DIAGNOSES REDACTED]. The family said the resident complained of left hip pain at the time of the fall and the facility ordered a portable x-ray, but the results were inconclusive (no findings) of an injury. The family said when they visited the resident the following day, she complained of excruciating pain and was unable to put weight on her left leg when she tried to stand and/or transfer. The family said they received another call, two days after the fall in the bathroom on 12/27/19, and were told that the resident had fallen again when she attempted to transfer herself in or out of bed. The family said because of the second fall and the resident's continued complaint of pain, they requested another x-ray be conducted at the hospital. The family said when the second x-ray came back inconclusive, the hospital performed a computerized tomography (CT) scan that revealed the resident had fractured her pelvis. The family asked the facility what they were going to do to assure the resident's safety when she returned from the hospital. The family said the facility placed a fall mat next to the bed as an intervention. The family said the facility told them they could pay for a caregiver to provide one on one, 24/7 supervision or they could purchase pants with padding on the sides of the pants that helped soften the impact if she were to fall. The family said they were told more frequent rounding would be provided by the facility, but the family was not certain this was happening, especially with the number of falls the resident experienced in the last 30 days. No other interventions were offered by the facility to assure the resident's safety. The family said the facility told them the resident fell two more times, once on 1/24/2020 and again on 1/26/2020. They said the facility told them the resident continued to be argumentative and non-compliant and became upset when staff asked the resident to use her call light when she needed assistance. The family said the physician ordered an alarm for when the resident was in bed, to alert the staff of a pending transfer that could result in a fall. The family was told by the facility that their policy did not allow the use of alarms. The family said they would abide by the facility's policy of not using alarms, but the facility did not provide an alternative and had no solutions on how they would assure the resident's safety. C. Observations On 1/28/2020 at 1:52 p.m., the resident was observed in bed with the fall mat on the floor next to the bed. The wheelchair was positioned on top of the fall mat towards the head of the bed. On 1/29/2020 at 10:10 a.m., the resident was observed in bed with the fall mat on the floor next to the bed. The wheelchair was positioned on top of the fall mat towards the head of the bed. On 1/29/2020 at 1:23 p.m., the resident was observed in bed with the fall mat on the floor next to the bed. The wheelchair was positioned on top of the fall mat towards the head of the bed. On 1/29/2020 at 4:15 p.m., the resident was observed to self-transfer from her wheelchair to the bed. On 1/30/2020 at 8:52 a.m., the resident was observed in bed with the fall mat on the floor next to the bed. The wheelchair was positioned on top of the fall mat towards the head of the bed. A front-wheeled walker (FWW) was observed in the middle of the room, on the opposite side of the fall mat. On 1/30/2020 at 10:32 a.m., the resident was observed in bed with the fall mat on the floor next to the bed. The wheelchair was positioned in the middle of the room, on the opposite side of the fall mat, in the line of sight of the resident. D. Record review 1. Care plan The care plan initiated on 12/14/18 revealed the resident was at risk for falls due to a decline in cognitive function related to dementia and short/long term memory loss, lack of safety awareness, impaired mobility, and a history of falls. The resident fell on [DATE], 1/1/2020, 1/12/2020, 1/18/2020, 1/24/2020, and 1/26/2020. The care plan was updated after each fall with interventions that included encourage the resident to use the call light for bathroom use, floor mat next to bed, increased supervision and visual monitoring when the resident was in her room, medication review, wheelchair out of sight when resident was in bed, and wheelchair management. Although the care plan was updated with an intervention each time Resident #2 had a fall, the interventions were not reevaluated for the effectiveness in preventing a fall and as a result, the resident sustained [REDACTED]. 2. Hospital discharge summary The hospital discharge summary dated 12/29/2019 documented the resident sustained [REDACTED]. 3. Kardex The visual/bedside kardex report, dated 8/14/19, was provided by the NHA on 1/30/2020 at 4:08 p.m. It revealed Resident #2 required supervision to limited one-person assistance for toileting and a sign was placed on the wall to remind the resident to call for assistance. Observation of the resident's room did not reveal a sign. 4. Computerized physician orders The (MONTH) 2020 CPO revealed an order for [REDACTED]. 5. Falls The event summary report for the fall on 12/27/19 documented preventative measures prior to the fall included the resident had a FWW, the bathroom light was on, and the call bell was within easy reach. No interventions were indicated immediately after the fall. No interventions were documented on the change in condition (CIC) evaluation. The event summary report for the fall on 1/1/2020 documented preventative measures prior to the fall included call light beside the resident. An intervention of a fall mat next to the bed was implemented after the fall. No interventions were documented on the CIC evaluation. The event summary report for the fall on 1/12/2020 did not reveal any preventative measures; however, increased supervision and oversight was added immediately following the fall. No interventions were documented on the CIC evaluation. The event summary report for the fall on 1/18/2020 referred to the care plan for details. An intervention of a medication review was indicated after the fall. No interventions were documented on the CIC evaluation. The event summary report for the fall on 1/24/2020 documented preventative measures prior to the fall included call light was within reach, bed in low position, fall mat, and hourly checks. An intervention for a therapy evaluation was indicated after the fall. No interventions were documented on the CIC evaluation. The event summary report for the fall on 1/26/2020 documented preventative measures prior to the fall included call light in reach and room well lit and clutter free. No interventions were indicated immediately after the fall. No interventions were documented on the CIC evaluation. The fall risk evaluation form revised on 9/9/13, was provided by the NHA on 1/29/2020. It revealed a score of 12 or above indicated a high risk for falls. The fall risk evaluation was not completed until 1/29/2020 for Resident #2, who scored a 15 on the fall risk evaluation. This form was not utilized by the facility to determine the resident's risk for fall and was not completed for Resident #2 until after the resident sustained [REDACTED]. The action plan dated 1/22/2020 documented a goal of staff education on falls management and audits. Actions included an audit of all falls from 1/1/2020 to present, falls management education to all staff, a falls management binder, and audit of the falls management binder and education. Following the implementation of the action plan, Resident #2 sustained two more falls. The audit and evaluation of the current residents in the facility, conducted on 1/29/2020 by the NHA and regional resource nurse (RRN), revealed 13 residents out of a census of 49 residents, scored a 12 or greater on the fall risk evaluation form that equated to a high risk for falls. As a result of the facility failing to utilize the fall risk evaluation during admission, quarterly, and annual assessments, the facility experienced an increased number of resident falls. E. Staff interviews and observations Certified nurse aide (CNA) #2 was interviewed on 1/28/2020 at 3:30 p.m. He said Resident #2 tended to transfer herself without calling for help. Even though the call light was within reach, the resident forgot to use it. He said the bed was kept in a low position when the resident was in bed. A fall mat was positioned alongside the bed, and hourly checks were performed. He did not think the resident was non-compliant, just forgetful. Registered nurse (RN) #1 was interviewed on 1/28/2020 at 3:38 p.m. She said the resident had dementia and was fiercely independent. She said they tried to do hourly checks, but the resident was very agile and it was sometimes difficult to keep up with the hourly checks. She said reminding the resident to use the call light did not work and was not an effective intervention because of her [DIAGNOSES REDACTED]. She said staff was limited with the interventions that could be used to keep the resident safe. The minimum data set nurse coordinator (MDSC) was interviewed on 1/28/2020 at 4:23 p.m. She said a formal fall risk assessment was not performed when a resident was admitted to the facility. She said there was a section in the nursing documentation that addressed a resident's balance, the various bodily systems and if needed, the nurse reviewed the residents past fall history. She said this review was done quarterly. She said the standard fall interventions for all residents consisted of the bed in a low position, use of a fall mat, and a scoop mattress. She said if an intervention did not work, the facility tried a different intervention. She said generic interventions were used with Resident #2 when she started having an increased number of falls. She said some of the interventions included rearranging the furniture, adding gripper strips to the floor alongside the bed, and a sign was placed in the resident's room as a reminder to use the call light. However, she said due to the resident's [DIAGNOSES REDACTED]. She did not think the resident was non-compliant but rather she just did not understand the consequences. CNA #1 was interviewed on 1/28/2020 at 4:37 p.m. She said the interventions used for the resident consisted of a fall mat next to the bed and hourly checking and toileting. She said the resident did not remember to use the call light and she thought the resident just needed to be reminded. She said because the resident had an increased number of falls, maybe the interventions were not effective, but she was not certain what else could be done to keep the resident safe. The director of therapy (DOT) was interviewed on 1/28/2020 at 5:18 p.m. She said every time a resident fell , a referral was sent to the therapy department. She said the therapist conducted a screen (a hands off assessment) of the resident as to what may have contributed to the fall. If it was determined that the resident would benefit from therapy, an evaluation (a hands on assessment) was ordered. She said therapy looked at interventions such as: use of a gait belt, positioning in the wheelchair, environmental modifications, the level of assistance a resident required, engagement of the resident, the bed height, use of a bed cane or other adaptive equipment, and staff training. She said Resident #2 had a history of [REDACTED]. She said how you approached the resident, your communication, timing, and tone of voice all came into play when engaging with the resident. She said the resident did not adhere to the therapy recommendations and did not demonstrate follow-through. She said multiple interventions were used and were re-evaluated each time the resident had a fall. She said an in-service had been given to the staff to anticipate a resident's needs. She said she was at a loss as to why the resident kept falling. She said there needed to be improved communication amongst the staff. Trending and tracking to try to identify what may have contributed to the fall. She said there was not an interdisciplinary team (IDT), but they did have a customer at risk (CAR) meeting, where management discussed what transpired and led up to the fall. She said there needed to be a more clear cut systematic approach. The NHA was interviewed on 1/28/2020 at 5:58 p.m. She said the IDT needed to think more outside the box related to interventions to minimize the number of falls and to keep residents safe. The facility needed to plan as a team, go out on the floor to train the staff and implement the interventions. The NHA was unaware that a formal fall risk assessment of a resident was not completed upon admission, quarterly, and/or annually in order to initiate appropriate, resident specific interventions to prevent and/or minimize falls. The MDSC was interviewed a second time on 1/29/2020 at 9:30 a.m. She said the facility did not complete an formal fall risk assessment of a resident. Instead, she just answered the MDS specific questions related to the number of falls a resident may have had and if any of the falls resulted in an injury. She said the IDT sat down as a group and discussed if a resident was a fall risk, but it was not captured anywhere. She said the care plans and interventions were generic and she completed a fall care plan on every resident, as she considered every resident to be a fall risk. She said the facility had other assessments, but not one that catered to falls. She said they did not document if the resident was a fall risk, but agreed said this should be addressed upon admission, quarterly, and annually. She agreed that the MDS assessment did not have an area that gave a score to determine the actual fall risk level. She said the facility did not have a formal fall assessment with an increased number of falls. She said there was a breakdown in communication when information was passed onto the CNAs with regards to proper resident care. She said the nurse documentation was to be completed to include any new interventions. She said every time a resident fell , a CIC was completed. Nurses were required to assess the resident for 72 hours after a fall and immediately implement interventions to keep the resident safe. This was all part of the post fall review. This was put in the risk management system (RMS), a computerized medical charting the facility used to document a change in a resident's condition such as a fall. The effectiveness of the current interventions were discussed during the morning meeting and changed if they were not effective. Any changes were communicated by the director of nursing (DON) or given in report during shift change. She said due to Resident #2's cognition and short term memory deficits, and her poor safety awareness, she has been a fall risk since admission to the facility. The MDSC agreed that the call light reminder on the care plan was not an effective nor appropriate intervention for the resident with her [DIAGNOSES REDACTED]. The assistant director of nursing (ADON) was interviewed on 1/29/2020 at 10:16 a.m. She said she did not know why the previous DON had all of the fall mats removed from the facility. In fact, she was unable to verbalize if fall mats were in the facility, as she was being oriented to the facility and only completed online learning. She said she did not go out on the floor. She was not aware when or why the fall mats were brought back as a fall intervention. On 1/29/2020 at 12:56 p.m., the toilet riser in the resident's bathroom was observed with the DOT. The current riser had two armrests and four legs that provided a wide base of support. It was not connected to the toilet, but rather hovered above the toilet. The RRN, the NHA, and the DON were interviewed on 1/29/2020 at 3:37 p.m. The RRN said the fall incident report should include the RMS, CIC, and statements from the staff as to the details of the fall/event. The DOT was interviewed again on 1/29/2020 at 4:07 p.m. She said she was unable to locate any therapy documentation to show when the riser for the resident's toilet was put into place. She said the only toilet risers used in the facility consisted of being over the toilet and did not attach to the bowl of the toilet. RN #2 was interviewed by telephone on 1/29/2020 at 4:32 p.m. She said the resident had numerous falls that were both witnessed and unwitnessed. She said even with numerous reminders, the resident did not remember to use her call light due to her [DIAGNOSES REDACTED]. She said nursing performed hourly rounding, but it was not helpful since the resident continued to transfer on her own. She said when the resident fell on [DATE], she had taken herself to the bathroom. The RN said she heard yelling from the resident's room and upon entering, she found the resident on the floor, to the left of the toilet with the riser on top of her. The nurse said the riser was the kind that secured to the toilet bowl with the turn of knob. She said you were not able to pull the riser off the toilet when the knob was tightened, but if the resident leaned or tilted too far one way, it became unattached from the toilet and flipped the resident off the toilet. The RN said she immediately had the CNA find a riser that was more stable. The CNA returned with the riser that was currently in the bathroom. The RN said she did not report the equipment to anyone and was not certain if the riser was still in the facility. She said she was unaware if the instability of the riser met the requirements of a reportable incident. She said the riser was not the most appropriate type for a resident with poor safety awareness and a history of falls. She said when a resident had a fall, she completed the CIC and RMS, which was essentially an incident report. She said no one ever asked her for a statement about the fall. She said she was totally and completely disillusioned that there were not any interventions that were truly effective in preventing the resident from falling. The social services director (SSD) was interviewed on 1/30/2020 at 8:55 a.m. She said interventions discussed during the care conference on 1/28/2020 included the bed in a low position, use of a fall mat, bed rails to aid with transfers, and placement of the wheelchair out of the resident's line of sight when she was in bed to promote calling for assistance versus transferring independently. She said the new interventions were communicated to the staff the same day they were discussed. She said the DOT educated the therapy staff and the DON and/or ADON educated the nurses and CNAs. She said the care plan was updated with the new interventions. She said you could not prevent a fall, you could only try to mitigate a fall. The location of the wheelchair in the resident's room was observed with the SSD following the interview. The wheelchair was located next to the bed. The SSD thought the wheelchair would be placed across the room or in the corner, which was still in the line of sight of the resident. Even though she previously said the information discussed during the care conference was communicated to the staff, she was not certain if this information had been discussed with nursing or therapy to confirm where the wheelchair would be moved. She said the wheelchair should not be placed on top of the fall mat as observed, because if the resident were to roll out of bed, she could potentially hit her head on the wheelchair. The MDSC was interviewed on 1/30/2020 at 10:35 a.m. She said she was not at the recent care conference and had not been updated on the fall interventions to be used with the resident. The MDSC conversed with the SSD and asked if there were any changes. The SSD mentioned the wheelchair was to be placed out of the line of sight of the resident when she was in bed. The MDSC said this intervention had already been discussed prior to the care conference on 1/28/2020 and the care plan had been updated. At 10:35 a.m., the location of the wheelchair in the resident's room was observed with the MDSC. The resident was in bed and the wheelchair was in the middle of the room, in the line of sight of the resident. The MDSC confirmed that the wheelchair should not be there and should be out of sight of the resident to promote the use of the call light and minimize the resident from self-transferring. She said any new interventions and/or actions that were decided upon during the care conference, were discussed in the morning meeting. She said it was then up to the DON or ADON to educate staff of the changes. She said this included the CNAs. She said the care plan had been updated, but the kardex, which was used by the CNAs, had not been updated. The MDSC said that she would update the kardex today and provide education to the CNAs. F. Follow-up The action plan for falls and risk evaluation was provided by the NHA on 1/20/2020 at 3:00 p.m. The ongoing goals included evaluate risk prior to a fall with actions of audit and evaluate all current residents for fall risk using the fall risk evaluation form, use evaluation tool for all new admissions, and residents with triggers (scores) greater than 12 would be evaluated for current number of falls and effectiveness of interventions. The RRN was interviewed on 1/29/2020 at 3:37 p.m. with the NHA and DON present. She said the fall incident report should include the RMS, CIC, and statements from the staff as to what transpired. She said they did a whole house audit on 1/29/2020 to include an assessment of the residents and their fall risk, which will continue upon admission of new residents, and then quarterly and annually. The RRN said they were trying to change the culture of the facility, but they could not fix the past. III. Resident #1 [NAME] Resident status Resident #1, age 97, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 1/24/2020 MDS assessment revealed the resident had short term and long term memory problems. The resident's daily decision making skills were severely impaired, and the resident rarely or never made daily decisions. The resident required two person physical assistance with bed mobility, transfers, walking, locomotion, dressing, toilet use and personal hygiene. She required set-up assistance with eating. The MDS identified the resident had no rejections of care. B. Family interview The resident's responsible party was interviewed on 1/28/2020 at 2:51 p.m. She said the resident had multiple falls in the facility, and had an increase in frequency of falls until the time she moved from the facility. She said the resident had fallen in the beginning of (MONTH) 2019, and that fall resulted in a fractured clavicle. The responsible party said she continually asked the facility what they were doing to ensure Resident #1's safety, but the facility staff told her the resident had a right to fall. The responsible party stated the resident continued to fall after she had fractured her clavicle, so she decided it was best to move her. C. Record review The care plan last revised on 1/24/2020, the day the resident discharged from the facility, identified the resident was at risk for falls because of cognitive loss, lack of safety awareness, impaired mobility, ambulating fast with a four wheel walker, and being on antidepressants and antianxiety medication. The goal was for the resident to remain free from falls with injury. The pertinent approaches included: Approaches initiated in (YEAR): -Non skid strips to the floor on the left side of the bed, initiated on 4/9/18. -Place glasses within reach and encourage use, and make sure they are clean, initiated on 4/17/18. -Assess for changes in medical status, pain status and report to medical doctor as indicated, initiated on 4/17/18. -Bedside commode to be used when roommate is using the bathroom, initiated on 6/10/18. -Keep light on in the bathroom, initiated on 7/27/18. -Medication evaluation as needed, initiated on 4/17/18. Approaches initiated in 2019: -Remind resident to use her walker when going to the bathroom and not to leave it by the bed, initiated on 2/18/19. -Staff to remind the resident they will make the bed, initiated on 4/20/19. -Increase visual monitoring, initiated on 8/23/19. -OT (occupational therapy) to screen, initiated on 10/28/19. Approaches initiated in 2020: -CNA (certified nurse aide) to cue the resident when in the bathroom, initiated on 1/14/2020. 1. Fall on 10/27/19 The 10/27/19 change in condition evaluation documented the resident had advanced dementia, and she was very restless upon awakening (5:30 a.m.), exit seeking, sitting down and then getting up, walking without her walker, agitated, and wanting to go home. Staff unable to reorient. The resident got up from a chair in the television room without her walker, took a couple of steps, turned, then sat on her bottom. The fall was witnessed by staff. The 10/27/19 RMS (risk management system) event summary report documented the interventions added immediately after the fall were: Resident given walker, instructed to use it. 2. Fall on 11/3/19 The 11/3/19 change in condition evaluation documented the resident had fallen during the night and had evidence of a left clavicle separation. The resident was transported to the hospital for treatment of [REDACTED]. The 11/3/19 RMS event summary report documented the staff responded to the call light in the room and found the resident on the floor beside her roommate's bed. Nursing staff attempted to sit her up but it was too painful for the resident, so 911 was called. The interventions added immediately after the fall were to send the resident to the emergency department for evaluation and treatment. The 11/3/19 emergency department after visit summary documented the resident was diagnosed with [REDACTED]. 3. Fall on 12/24/19 The 12/24/19 change in condition evaluation documented the resident had shoes on, was using her walker and had lost her balance and fallen. The fall was witnessed by staff, who were unable to get to the resident in time to prevent her from falling. The resident had a v shaped skin tear to her left elbow, nursing staff applied a dressing to the skin tear. The 12/24/19 RMS event summary report documented the interventions added were first aid applied to the skin tear, and the resident being brought into the common area. 4. Fall on 1/2/2020 The 1/2/2020 change in condition evaluation documented the resident was yelling help, help, CNA walked by and saw her sitting on the floor. CNA got LPN (licensed practical nurse) who assisted her back into the recliner. Body assessment shows no apparent injury. The 1/2/2020 RMS event summary documented the interventions added were continued frequent safety checks and anticipating her needs. 5. Fall on 1/15/2020 The 1/15/2020 change of condition

Based on record review and interview, the facility failed to ensure five (#28, #32, #43, #30, #45) of 29 sample residents were free from abuse, neglect and/or mistreatment. Specifically: --Resident #28 was left on the toilet naked for a prolonged period of time. He asked the staff member who was helping him to hurry and was yelled at by the staff member; --Resident #32 was left on the toilet for 20 minutes by a staff member. She began yelling because she started to experience pain in her bottom. She was asked to stop yelling by a nurse; --Resident #43 asked to use a bed pan to void. She was told by a staff member to 'just go in her brief' instead because it was easier for her to clean up; --Resident #30 was improperly transferred by a staff member. Her plan of care specified the use of a mechanical lift and was instead picked up by the staff member resulting in bruising to the resident's head and a skin tear; --Resident #45 was told if he did not get up out of bed, he would not receive his medications by a nursing staff member. Cross reference F225; failure to have evidence that allegations of potential abuse, mistreatment and/or neglect were thoroughly investigated and residents were protected during the investigation. The findings include: 1. Facility Policy According to the facility's abuse prohibition policy, in pertinent part: "(The facility) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation or property for all patients through the following: -Identification of possible incidents or allegations which need investigation -Investigation of incidents and allegations ... Abuse is defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health including the following: -Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation -Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ... ...Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation, the administrator or designee will perform the following: -Enter allegation into the Risk Management System -Immediately report, not to exceed 24 hours, the allegation to the Health Facilities & Emergency Medical Services Division using the Occurrence Reporting Procedure ... -Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, causative factors, and interventions to prevent further injury -The Investigation will be thoroughly documented on the center's investigation form and log. Ensure that documentation of witnessed interviews is included -The center will protect the patient from further harm during an investigation." 2. Incidents of Mistreatment and Neglect a. Resident #28 According to the face sheet, the resident was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The 2/14/14 quarterly Minimum Data Set (MD'S) showed the resident's cognition was moderately impaired. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The self care deficit care plan, dated 1/24/14, showed the resident had a self care deficit related to decreased balance, impaired coordination, loss of muscle strength, pain, and physical limitations. Approaches included one person assist with bed mobility, transfers, toileting, and personal cares and call light within reach and answer promptly. A 2/10/14 grievance/concern form showed, "(Resident) says (CNA #4) left him naked on the toilet while she worked on his chair. He told her to hurry up, he was freezing cold ...(Resident) is very upset he claims (CNA #4) left him on the toilet with no clothes while she worked on his chair. He told her to hurry up he was cold and she responded by yelling at him telling him to wait and quit talking to her that way. He apologized but feels he shouldn't have had to because he was reacting to being naked and cold." On 4/22/14 at 11:08 a.m. the resident was asked about the incident with CNA #4. He said, "She did yell at me and she left me there for about 20 minutes and I was really cold. I told her not to take care of me anymore." The undated investigation showed, " ...Staff educated on dignity ADLs/toileting." The undated resolution of grievance, "Res(ident) states that he is "ok" and he has had no further concerns." --On 4/21/14 at 12:56 p.m., the NHA (nursing home administrator) was asked about the 2/10/14 incident. He said, "It happened in his room and he had soiled himself and his wheelchair was messy and she was cleaning his wheelchair." The NHA said CNA #4 had not worked at the facility since 3/12/14 and had no further contact with the resident. b. Resident #32 According to the face sheet, the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MD'S dated 2/18/14 revealed the resident was understood and could understand. She needed extensive assistance with activities of daily living. The resident felt depressed and had little energy. The toileting care plan dated 10/9/13 showed the resident required toileting assistance related to pain and impaired mobility. The goal was for the resident to maintain the ability to toilet self safely, for the resident to appear neat, and to ask for and receive the necessary assistance. The self care deficit care plan dated 10/9/13 showed the resident had a self care deficit related to decreased balance, pain, physical limitations, unstable health conditions and weakness. A goal was that her needs would be met daily. The [MEDICAL TREATMENT] care plan, dated 6/14/13, showed the resident had very low energy upon returning from [MEDICAL TREATMENT]. A grievance form, dated 12/5/13, documented: "Resident stated on 2-10 shift on 12/4/13 she was on the commode. She waited 20 minutes and her bottom hurt. She was cold so she started yelling," I'm done. " A licensed nurse (LN) came in and told her to stop yelling, the aide was busy with other residents." Action: 1:1 counseling with nurse. Offered reassurance to the resident. On 4/17/14 at 9:41 a.m., the resident stated she was at times told she could do (the care requested) herself by staff members when she asked for assistance. c. Resident #43 According to the face sheet, the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The 2/14/14 quarterly MDS showed the resident was cognitively intact. She was totally dependent on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The 1/21/14 self care deficit care plan showed the resident had a self care deficit related to contractures, lack of limb/trunk control, pain, and physical limitations. Approaches: mechanical lift with two staff and totally incontinent of bowel and bladder. On 4/7/14, as part of the investigation into resident #30's bruising and skin tear (see below), resident #43 was asked: if any staff had been rough with her and she responded "(CNA #1) always in a hurry." She also stated when asked about inappropriate transfers, said CNA #1 used the lift alone. Finally when asked if any staff suggest she soil herself instead of using the bathroom stated, '"If I have to pee, I use the bedpan. (CNA #1) said to me if I have to go, I can just use my brief."' A 4/3/14 note left on the nursing home administrator's desk by CNA #3, documented, "This morning while I was helping (resident #43) in the shower, she told me that while (CNA #1) was working at night, she had asked to use the bed pan. (CNA #1) informed her that she had a brief on and she could just go in that. (Resident #43) told her that she was trying to save her from having to clean up a mess. (CNA #1) replied that it was easier for her to change the brief." On 4/22/14 at 10:16 a.m., CNA #3 was interviewed. She said: -"I do (resident 43's) showers on Thursday mornings ... and she had just told me. She's told me before that she didn't like (CNA #1) but she didn't elaborate and she told me that one of the night's previously that she had told (CNA #1) that she needed a bed pan and she had a brief on she could just go in her brief. (Resident #43) said I was trying to save you from cleaning up a mess and she said it was just easier to clean up the mess. She seemed upset but she said, "No, no, I don't want to make any trouble." It made me sad. -Later that day (the DON and unit manager) were on a conference call and I went ahead and told (the NHA). (The NHA) ... said that's not okay and well what are we going to do to fill those shifts?" -CNA #3 said the NHA asked her to write it down for him. She said, "I wrote it down for him. Then I was off the weekend. That Monday we had noticed a bump on (resident 30's) head and I don't think they got her up that day. (CNA #1) worked two doubles that weekend (4/5/14 and 4/6/14)." d. Resident #30 According to the face sheet, the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The 2/26/14 admission Minimum Data Set (MDS) showed the resident's long and short term memory was impaired. She was unable to recall the location of her room, current season, staff names/faces, or that she was in a nursing home. Her ability to make decisions regarding daily tasks of life was severely impaired. The resident was totally dependent on two or more staff members for bed mobility, transfers, locomotion, toilet use, and personal hygiene. The self care deficit care plan, dated 2/26/14, showed the resident had a self care deficit related to Alzhiemer's, a terminal condition with hospice services, and failure to thrive. Approaches included total staff assistance with all activities of daily living and the use of a mechanical lift. --On 4/4/14 at 10:00 a.m., an event was entered into the facility's risk management system (RMS) to address a 1.5 centimeter by 1 cm open area on the right outer calf. A top layer of resident's skin was off. The investigation into the skin tear revealed, "CNA #1 (certified nurse aide) stated she did not use hoyer lift as indicated ...she would transfer resident by herself ....Injury sustained from staff handling. First aid to area. Staff education regarding following (plan of care), suspension of CNA #1 on 4/7/14 and termination on 4/10/14." --On 4/6/14, a change of condition form was initiated and documented, "A bruise was noted on the left side of the resident's forehead. It is 1.5 centimeters (cm) in length and 1 cm in width. Faxed a notification to (the physician)." An event was initially entered into the RMS on 4/6/14. The investigation into the bruising revealed, "(Two CNAs) state that the resident did not have bruise on Friday (4/4/14) or Saturday (4/5/14). Hospice state they do give her a shower on Fridays and use the hoyer lift for all transfers. (A registered nurse) stated that the bruise was not there during the day shift on 4/6/14. The resident uses a hoyer lift for transfers and may have bumped her head on transfer bar. Bruise was isolated to (CNA #1's) shift on 4/6/14. (CNA #1) stated that she did not use the hoyer lift with transfers. e. Resident #45 According to the face sheet, the resident was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The 3/26/14 significant change of condition MDS showed the resident's cognition was moderately impaired. On 3/12/14, a grievance/concern form documented, (Resident) reported to CNA that nurse (RN #1) told him if he did not get up out of bed, she would not give him (his) medications. (Resident) stated he did not get up and he didn't want to. Again told by nurse he would not get medications and she would document that he refused medications. (Resident) stated, "I guess I'll die then." SSD approached by CNA (#2) who stated she overheard (RN #1) tell this to (resident). Approached by nurse who stated (RN #1) documented several refusals of medications." --On 4/17/14 at 12:25 p.m., RN #1 was interviewed about the incident. She said, "Certain CNAs can get him out of bed and certain ones don't and that's what started it off. I'd go in there and sometimes I try and use different ways to get him out of bed. That particular time and I asked him to get up out of bed to get his medicine. I don't like him swallowing a whole cup of pills (from bed). I get frustrated by the CNAs because they can get him up." RN #1 said CNA #2 was the aide who was working that day. She continued, "I said, let's get up out of bed so you can take your medicine." The RN said the resident would not get up and received his medications in bed that day. She said, "He gets them whether he's in the bed or not." --On 4/17/14 at 3:06 p.m., the SSD was interviewed about the incident and said, "CNA #2) had overheard (RN #1) saying to the resident if you don't get out of bed I'm not going to give you your medications. She was very upset and she was crying. I interviewed the resident and this (what was written on the grievance form) is what he told me." --On 4/21/14 at 8:10 a.m., the NHA was interviewed about the incident and asked about the grievance process. He said, "(The resident) is pretty stubborn about what he wants to do at certain times and he was laying down. The nurse was trying to get him to sit up to take his pill and she said you can't take the medicine if you're laying down. Then she tried to convince him to sit up to take his medicine and he refused. She got a hold of his daughter and between the two of them they took his medicine. He did end up taking it. With the daughter's help she was able to get him to take it." --On 4/21/14 at 11:10 a.m., CNA #2 was interviewed about the incident with the resident. She said, "That day (the resident) stated he didn't want to get up that morning and the nurses would tell me he has to get up. I told them he doesn't have to get up. That morning he didn't want to get up and (RN #1) said go in there with me and I'll talk to him. We went in there and he said I didn't want to get up and I wandered out of the room. She asked the other lady to go get him up and I went back down there and he said I didn't want to get up. She said, "If you don't get up. I'm not giving you your medicine and I'm going to write refused on all your medicine," and he said "I guess I'll just die then," and she said, "Oh well." CNA #2 said she talked to SSD about it and filled out a statement about it. 3. Staff Interviews On 4/17/14 at 10:29 a.m., the DON was interviewed about the incident involving resident #43 and #30 (see above). She said in pertinent part, that she thought CNA #1's actions were "unacceptable" and" I think it's neglect." On 4/22/14 at 3:21 p.m., the NHA was interviewed. In pertinent part, the NHA agreed CNA #1's behavior toward resident #43 involved knowingly withholding resident care, the definition of neglect.

Based on record review and interview, the facility failed to ensure alleged violations of abuse, neglect and/or mistreatment involving five of 29 sample residents (#32, #28, #30 and #43, #45), were timely and thoroughly investigated and prompt steps to prevent further incidents were implemented. The facility failures contributed to additional incidents of staff to resident abuse, neglect and/or mistreatment that included yelling, ignoring requests, and improper transfers with injuries. Cross reference F224. The findings include: A. Facility Policy According to the facility's abuse prohibition policy, in pertinent part: "(The facility) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation or property for all patients through the following: -Identification of possible incidents or allegations which need investigation -Investigation of incidents and allegations ... Abuse is defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health including the following: -Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation -Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ... ...Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation, the administrator or designee will perform the following: -Enter allegation into the Risk Management System -Immediately report, not to exceed 24 hours, the allegation to the Health Facilities & Emergency Medical Services Division using the Occurrence Reporting Procedure ... -Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, causative factors, and interventions to prevent further injury -The Investigation will be thoroughly documented on the center's investigation form and log. Ensure that documentation of witnessed interviews is included. -The center will protect the patient from further harm during an investigation." B. Allegations of abuse, neglect and/or mistreatment Record review and interviews revealed the facility failed to timely and thoroughly investigate an allegation of abuse, neglect and/or mistreatment reported by resident #32 on 12/5/13. This failure contributed to additional incidents involving abuse, neglect and/or mistreatment of [REDACTED].#45, #43, and #30. 1. Reported incident 12/5/13 involving resident #32 Resident #32 was admitted to the facility on [DATE]. According to her face sheet, her [DIAGNOSES REDACTED]. a. Resident Status A Minimum Data Set ((MDS) dated [DATE] revealed the resident was understood and could understand. She needed extensive assistance with activities of daily living. The toileting care plan, dated 10/9/13 showed the resident required toileting assistance related to pain and impaired mobility. A goal was to ask for and receive the necessary assistance. The self care deficit care plan, dated 10/9/13, showed the resident had a self care deficit related to decreased balance, pain, physical limitations, unstable health conditions and weakness. The care plan goal was for the resident to maintain a well groomed appearance with her needs met daily. b. Allegation and failure in facility response. A grievance form dated 12/5/13 documented, "Resident stated on 2-10 shift on 12/4/13 she was on the commode. She waited 20 minutes and her bottom hurt. She was cold so she started yelling "I'm done. " A licensed nurse (LN) came in and told her to "stop yelling, the aide was busy with other residents." While review of the grievance form revealed documentation LN was counseled and the resident reassured, there was no evidence an investigation was opened into the LN's actions or if other residents were interviewed about their care needs and staff's response. The resident was interviewed on 4/17/14 at 9:19 a.m. She said she tries to tell the staff she needs help and they (the certified nurse aides/CNAs) don't listen. She stated she spoke to the nursing home administrator (NHA) but nothing has changed. She stated the CNAs are the problem, not all CNAs, but some. 2. Reported incidents 1/21/14 and 2/10/14 involving resident #28 Resident #28 was a [AGE] year-old male admitted to the facility on [DATE]. According to his face sheet, his [DIAGNOSES REDACTED]. a. Resident Status The 2/14/14 quarterly MDS showed the resident's cognition was moderately impaired. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. b. Allegations (1) 1/21/14 Review of a 1/21/14 grievance documented, "(Resident) stated he feels "harassed" by nurse manager who hugs/kisses him and he doesn't like this. He doesn't like her telling him he has to take a shower today. He wanted to take a shower tomorrow because of his plans today. He felt pressure by nurse manager to take the shower today." The undated investigation showed, "UM counseled." No further investigation details were documented. Interviews with other residents on the nurse manager's unit were not documented. Interviews with staff working with the nurse manager were not documented. There was no evidence the facility recognized the incident was other than an isolated event as no facility-wide steps were taken to address resident/staff interactions. On 4/21/14 at 11:04 a.m., the director of nursing (DON) stated she had counseled the UM ("We had an open discussion about it") but the DON was unsure when it was. She did not indicate there was any further follow up with the nurse manager or staff generally about resident/staff interactions. (2) 2/10/14 Review of a 2/10/14 grievance/concern form revealed, "(Resident) says (CNA #4) left him naked on the toilet while she worked on his chair. He told her to hurry up, he was freezing cold ...(Resident) is very upset he claims (CNA #4) left him on the toilet with no clothes while she worked on his chair. He told her to hurry up he was cold and she responded by yelling at him, telling him to wait and quit talking to her that way. He apologized but feels he shouldn't have had to because he was reacting to being naked and cold." On 4/21/14 at 12:56 p.m., the Nursing Home Administrator (NHA) said about this incident, "It happened in his room and he had soiled himself and his wheelchair was messy and she was cleaning his wheelchair." The NHA said CNA #4 had not worked at the facility since 3/12/14 and had no further contact with the resident. On 4/22/14 at 11:08 a.m. the resident was asked about the incident with CNA #4. He said, "She did yell at me and she left me there for about 20 minutes and I was really cold. I told her not to take care of me anymore." Review of the undated facility investigation revealed CNA #4 was educated on "dignity, ADLs/toileting." However, there was no evidence showing other residents cared for by CNA #4 had been interviewed to see if they had received similar treatment by CNA #4 or other facility staff. There was no evidence the facility recognized the incident was other than an isolated event as no facility-wide steps were taken to address resident/staff interactions. 3. Incident reported 3/12/14 involving resident #45 Resident #45 was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. a. Resident Status The 3/26/14 significant change of condition MDS showed the resident's cognition was moderately impaired. b. Allegation On 3/12/14, a grievance/concern form documented, (Resident) reported to CNA that nurse (RN #1) told him if he did not get up out of bed, she would not give him (his) medications. (Resident) stated he did not get up and he didn't want to. Again told by nurse he would not get medications and she would document that he refused medications. (Resident) stated, "I guess I'll die then." SSD approached by CNA (#2) who stated she overheard (RN #1) tell this to (resident). Approached by nurse who stated (RN #1) documented several refusals of medications." c. Facility Investigation The investigation, dated 3/12/14, documented, "Interviewed resident at 10:00 a.m. Resident denied the statement recorded from the previous date. When I repeated back what the nurse stated he said, resident had recollection of that being said. As we talked further, (resident) thinks he may have misunderstood as (resident) and this nurse get along very well. (Resident) likes (RN #1) and feels cared by her very well. Interviewed (RN #1) and the statement was taken out of context. (RN #1) told resident as soon as he was up, she would give him his medication with his supplement to prevent choking hazard." The UM continued, "(The SSD) told me there was a grievance and (RN #1) told (the resident) I'm not going to give you your medications unless you're going to get out (of) bed, What I did is I went to (RN #1) and I said it's been reported to me you're refusing to give him his meds until he got out of bed. She said, "No I told (the resident) as soon as you get up I'll give you your meds." (RN #1) and (the resident) have a good relationship. It was out of character. I think it was something like that. She's saying as soon as you get up you'll get your meds. That's what she said. I then didn't go any further with that and it wasn't substantiated." The UM said she had talked about her interview with the resident and RN #1 in morning meeting, but didn't provide the typed up investigation to file with the grievance and said no one had asked about it. The UM was asked if she interviewed CNA #2 who claimed she overheard the exchange between RN #1 and the resident or if she had reviewed the resident's Medication Administration Record [REDACTED]. The UM was asked if other residents were interviewed to see if similar concerns were brought forward with RN #1 and she said other residents were not interviewed. The UM said she would review the March 2014 medication administration record. d. Staff Interviews On 4/17/14 at 12:25 p.m., RN #1 was interviewed about the incident. -She said, "Certain CNAs can get him out of bed and certain ones don't and that's what started it off. I'd go in there and sometimes I try and use different ways to get him out of bed. That particular time and I asked him to get up out of bed to get his medicine. I don't like him swallowing a whole cup of pills (from bed). I get frustrated by the CNAs because they can get him up." -RN #1 said CNA #2 was the aide who was working that day. She continued, "I said, let's get up out of bed so you can take your medicine." The RN said the resident would not get up and received his medications in bed that day. She said, "He gets them whether he's in the bed or not." On 4/17/14 at 3:06 p.m., the social service director (SSD) was interviewed about the incident and said, "(CNA #2) had overheard (RN #1) saying to the resident if you don't get out of bed I'm not going to give you your medications. She was very upset and she was crying. I interviewed the resident and this (what was written on the grievance form) is what he told me." On 4/21/14 at 8:10 a.m., the NHA was interviewed about the incident and asked about the grievance process. He said, "(The resident) is pretty stubborn about what he wants to do at certain times and he was laying down. The nurse was trying to get him to sit up to take his pill and she said you can't take the medicine if you're laying down. Then she tried to convince him to sit up to take his medicine and he refused. She got a hold of his daughter and between the two of them they took his medicine. He did end up taking it. With the daughter's help she was able to get him to take it." On 4/21/14 at 11:10 a.m., CNA #2 was interviewed about the incident with the resident. She said, "That day (the resident) stated he didn't want to get up that morning and the nurses would tell me he has to get up. I told them he doesn't have to get up. That morning he didn't want to get up and (RN #1) said go in there with me and I'll talk to him. We went in there and he said I didn't want to get up and I wandered out of the room. She asked the other lady to go get him up and I went back down there and he said I didn't want to get up. She said, "If you don't get up. I'm not giving you your medicine and I'm going to write refused on all your medicine," and he said "I guess I'll just die then," and she said, "Oh well." CNA #2 said she talked to SSD about it and filled out a statement about it. 4. Incidents reported 4/3/14 and 4/4/14 involving resident #30 and #43 a. Resident #30 and Resident #43 Resident #30, age 84, per 2/26/14 MDS was severely cognitively impaired. She was totally dependent on two or more staff members for bed mobility, transfers, locomotion, toilet use, and personal hygiene. The self care deficit care plan, dated 2/26/14, showed the resident had a self care deficit related to Alzheimer's, a terminal condition with hospice services, and failure to thrive. Approaches included total staff assistance with all activities of daily living and the use of a mechanical lift. Resident #43, age 89, per quarterly MDS dated [DATE] was cognitively intact. She was totally dependent on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the 1/21/14 self care deficit care plan, the resident had a self care deficit related to contractures, lack of limb/trunk control, pain, and physical limitations. She required mechanical lift with two staff and was totally incontinent of bowel and bladder. b. Incidents On 4/4/14 at 10:00 a.m., an event was entered into the facility's risk management system (RMS) to address a 1.5 centimeter by 1 cm open area on resident #30's right outer calf. A top layer of resident's skin was off. On 4/6/14, a change of condition form was initiated and documented, "A bruise was noted on the left side of the resident's forehead. It is 1.5 centimeters (cm) in length and 1 cm in width. The investigation into resident #30's bruising revealed, "(Two CNAs) state that the resident did not have bruise on Friday (4/4/14) or Saturday (4/5/14). Hospice state they do give her a shower on Fridays and use the hoyer lift for all transfers. (A registered nurse) stated that the bruise was not there during the day shift on 4/6/14. The resident uses a hoyer lift for transfers and may have bumped her head on transfer bar. Bruise was isolated to (CNA #1's) shift on 4/6/14. (CNA #1) stated that she did not use the hoyer lift with transfers. The investigation into the skin tear revealed, "CNA #1 stated she did not use hoyer lift as indicated ...she would transfer resident by herself ....Injury sustained from staff handling. On 4/7/14, as part of the investigation into resident #30's bruising and skin tear, resident #43 was asked and responded to the following questions: 1. Has any staff member been rough when providing care to you? If so, who? "(CNA #1) always in a hurry." 2. Has any staff member transferred you inappropriately? If so,who? "(CNA #1) always uses the lift alone." 3. Has any staff member suggested you soil yourself instead of using the bathroom? If so, who? "If I have to pee, I use the bedpan. (CNA #1) said to me if I have to go, I can just use my brief." c. Interviews On 4/17/14 at 9:45 a.m., the director of nursing (DON) was interviewed. -She stated she had discovered CNA #1's refusal to provide a bed pan for resident #43 (see above) through an investigation of resident #30's bruising and skin tear. During the investigation, she had discovered CNA #2 and CNA #3 had raised a concern and wrote a statement about the incident between CNA #1 and resident #43. -She said, "It was reported to our NHA on 4/3/14 or 4/4/14." The DON said, despite the allegation, the CNA was not suspended pending investigation and continued to work. She said, "She did work over that weekend." On 4/17/14 at 10:05 a.m., the nursing home administrator (NHA) was interviewed about the incident between CNA #1 and resident #43. He said, "There was kind of a culture going on of (staff) telling on each other. They had little feuds going on. I had a CNA come to me and (who) said I have a complaint about (CNA #1) and that was on the 3rd (of April 2014) and I told her to put it in writing. I found a note on my desk the next day. It said that (resident #43) had requested a bed pan and that (CNA #1) had said you can just use your brief and (resident# 43) said I'm just trying to save you from a mess and (CNA #1) told her to go ahead and go in your brief." The 4/3/14 note (referenced above), left on the NHA's desk by CNA #3, documented, "This morning while I was helping (resident #43) in the shower. She told me that while (CNA #1) was working at night, she had asked to use the bed pan. (CNA #1) informed her that she had a brief on and she could just go in that. (Resident #43) told her that she was trying to save her from having to clean up a mess. (CNA #1) replied that it was easier for her to change the brief." The NHA was asked his response to above information. He said: -"I was wanting to find out if there was really a problem or if it was just them (CNAs) feuding. I know what I did wrong. I should have just immediately suspended her (CNA #1) to investigate. -(Resident #43) doesn't want to get anyone in trouble. I talked to her and she said that she wasn't afraid but she didn't want (CNA #1) around her. -I thought it was more a matter of a need to reeducate (CNA #1) about toileting. Then, they reported that (resident #30) had a bruise on her forehead and a cut. They started investigating that then they started going backwards and we saw that (CNA #1) was the one that took care of both of these people. I realized it was more than I thought it was." The NHA continued, "It got very confusing but she did work on that weekend (4/5 and 4/6/14). There was no malice. I know it was wrong but (resident #43) described her as rushing. On the 7th (of April 2014) she was suspended and then subsequently terminated. (CNA #1) wasn't in the building after Monday. Again, I saw it as something she needed to be reeducated on but then things started unpeeling." On 4/17/14 at 10:29 a.m., the DON was again interviewed. She said she was not informed by the NHA on 4/3/14 or in the days following about the complaint made about CNA #1. She said, "I found (out) about it on Monday (4/7/14) from the investigation (into resident #30's bruising) and what happened. I didn't know about it on Friday (4/4/14). So that's what happened. Then when I was trying to find out who was working I spoke with (CNA #2) and (CNA #3) and found out about (resident #43's) complaint. The DON said she thought CNA #1's actions were "unacceptable" and" I think it's neglect." Cross reference F224. On 4/17/14 at 10:55 p.m., CNA #2 was interviewed about resident #43. -She said, "Wednesday morning (4/2/14) (resident #43) gave me her complaint. She said the evening girl refused to put her on the bedpan and said it was easier for her to go in her brief. (Resident #43) didn't like that. She brought it to my attention." CNA #2 said right after that she was called away from the facility. -CNA #2 said, "The next day CNA #3 and I were talking and she said (resident #43) brought the concern up to her also ... CNA #3 told me she had told (the NHA) what happened. On 4/22/14 at 10:16 a.m., CNA #3 was interviewed. She said: -"I do (resident #43's) showers on Thursday mornings ... and she had just told me (about the incident with CNA #1). She's told me before that she didn't like (CNA #1) but she didn't elaborate and she told me that one of the night's previously that she had told (CNA #1) that she needed a bed pan and she had a brief on she could just go in her brief. (Resident #43) said I was trying to save you from cleaning up a mess and she said it was just easier to clean up the mess. She seemed upset but she said, "No, no, I don't want to make any trouble." It made me sad. -Later that day (the DON and UM) were on a conference call and I went ahead and told (the NHA). (The NHA) ... said that's not okay and well, what are we going to do to fill those shifts?" -CNA #3 said the NHA asked her to write it down for him. She said, "I wrote it down for him. Then I was off the weekend. That Monday we had noticed a bump on (resident #30's) head and I don't think they got her up that day. (CNA #1) worked two doubles that weekend (4/5/14 and 4/6/14)." On 4/22/14 at 3:21 p.m., the NHA was interviewed again. The NHA agreed CNA #1's behavior toward resident #43 involved knowingly withholding resident care, the definition of neglect. He went on to say the staff at the facility, "Tell on each other all the time." When asked if he investigated the reports he receives, he said, "Yes and no, it depends on what it is. It's mostly junior high stuff." C. Further evidence of lack of timely/adequate investigations 1. Interviews On 4/17/14 at approximately 10:30 a.m. the social services director (SSD) was asked for a copy of the facility's grievance log for any grievance filed back to August 2013. 49 grievances were logged between 8/1/13 and 4/9/14. Of these 49 grievances, 29 grievances were unresolved. On 4/21/14 at 9:58 p.m., the NHA was asked if he maintained a log to manage abuse investigations (see the facility's abuse prohibition policy above). The NHA said he did not keep a log of abuse incidents but kept abuse investigations in a drawer in his office. 2. Facility record review Of the 29 unresolved grievances on the facility's grievance log provided by the SSD, three concerns were selected and requested on 4/21/14. The grievances selected included allegations of abuse, neglect and/or mistreatment. These grievances were not thoroughly and timely investigated See F166 and F224 for further details.

Based on record review, observation, and interview, the facility failed to ensure eight (#28, #32, #43, #30, #45, #13, #24, #35) of 29 sample residents received the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Specifically: --Residents #28 and #32 were left on the toilet for a prolonged period of time resulting in discomfort; --Resident #43 asked to use a bed pan to void. Instead, she was told by a staff member to 'just go in her brief' because it was easier for her to clean up; --Resident #30 was improperly transferred by a staff member. Her plan of care specified the use of a mechanical lift and was instead picked up by the staff member resulting in bruising to the resident's head and a skin tear; --Resident #45 was told if he did not get up out of bed, he would not receive his medications by a nursing staff member. --Detailed person-centered behavioral symptoms with interventions individualized for those symptoms were not developed for resident #13, who was diagnosed with [REDACTED]. --Skin abrasions or bruising was not timely identified and assessed for residents #13, #24, and #32; --A neurological assessment after a fall was not completed as indicated for resident #35. The findings include: I. Delay of, denial of, or improper resident care a. Resident #28 Cross reference F224 and F225; A [DATE] grievance filed by the resident and confirmed during resident interview on [DATE] at 11:08 a.m. revealed the resident was left for 20 minutes on the toilet, naked and "freezing cold," When he asked the aide to hurry up she yelled at him. b. Resident #32 Cross reference F224 and F225; A [DATE] grievance read the resident waited 20 minutes on the commode and her bottom hurt. When she yelled I'm done," a licensed nurse came in and told her to stop yelling, the aide was busy with other residents." The resident, in an interview on [DATE] at 9:19 a.m.. said she tries to tell the staff she needs help and they (the certified nurse aides/CNAs) don't listen. c. Resident #43 Cross reference F224 and F225; on [DATE], as part of the investigation into resident #30's bruising and skin tear (see below), resident #43 reported "If I have to pee, I use the bedpan. (CNA #1) said to me if I have to go, I can just use my brief." The resident reported the incident to two CNAs who were interviewed on [DATE] at 10:16 a.m. CNA #3 said, (resident #43) seemed upset but she said, "No, no, I don't want to make any trouble." d. Resident #30 Cross reference F224 and F225; on [DATE] at 10:00 a.m., an event was entered into the facility's risk management system (RMS) to address a 1.5 centimeter by 1 cm open area on the right outer calf. A top layer of resident's skin was off. On [DATE], a change of condition form was initiated and documented, "A bruise was noted on the left side of the resident's forehead. It is 1.5 centimeters (cm) in length and 1 cm in width. The investigation into the skin tear revealed, "CNA #1 (certified nurse aide) stated she did not use hoyer lift as indicated ...she would transfer resident by herself ....Injury sustained from staff handling. First aide to area. Staff education regarding following (plan of care), suspension of CNA #1 on [DATE] and termination on [DATE]." e. Resident #45 Cross reference F224 and F225; on [DATE], a grievance/concern form documented, (Resident) reported to CNA that nurse (RN #1) told him if he did not get up out of bed, she would not give him her medications. (Resident) stated he did not get up and he didn't want to. Again told by nurse he would not get medications and she would document that he refused medications. (Resident) stated, "I guess I'll die then." SSD approached by CNA (#2) who stated she overheard (RN #1) tell this to (resident). Approached by nurse who stated (RN #1) documented several refusals of medications." On [DATE] at 3:06 p.m., the SSD was interviewed about the incident and said, "(CNA #2) had overheard (RN #1) saying to the resident if you don't get out of bed I'm not going to give you your medications. She was very upset and she was crying. I interviewed the resident and this (what was written on the grievance form) is what he told me." f. Cross Reference F166 - Timely Resolution of Grievances, F224 - Prohibit Mistreatment and Neglect, F225 - Thorough Investigation of Abuse for other pertinent interviews. II. Person-Centered Dementia Care 1. Resident #13 a. Resident Status According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The [DATE] annual Minimum Data Set (MDS) showed the resident's short and long term memories were impaired. Her cognitive decisions for daily decision making were moderately impaired. The resident displayed inattention and disorganized thinking. She displayed verbal behavioral symptoms toward others but these behaviors did not put the resident or others at significant risk for physical illness or injury. She required limited assistance with bed mobility and transfers. She required total assistance with dressing. b. Record Review The [DATE] computerized physician orders [REDACTED]. --[MEDICATION NAME] M-tab (antipsychotic) .5 milligrams every day for [MEDICAL CONDITION] as of [DATE] --[MEDICATION NAME] (antidepressant) 30 milligrams at bed time every day for [MEDICAL CONDITION] as of [DATE] A [DATE] physician's progress note documented, in pertinent part: "Continues with intermittent paranoia that interferes with her well being, benefit of continuing low dose [MEDICATION NAME] outweighs the risk ...Mood and affect are withdrawn and suspicious." A [DATE] nurse practitioner's progress note documented, in pertinent part: " ...No reported [MEDICAL CONDITION] related behaviors since last encounter, (patient) stable on [MEDICATION NAME] and [MEDICATION NAME] ...She has a normal mood and affect. Her behavior is normal. Thought content is delusional. Cognition and memory are impaired. She expresses impulsivity and inappropriate judgment. She exhibits abnormal recent memory ..." A [DATE] physician's progress note documented, in pertinent part: "Pt continues with intermittent bouts of paranoia and withdrawal, dose reduction not indicated at this point ...Pt (patient) was initially to be seen to see if we could do a dose reduction on her [MEDICATION NAME], she has been on .5 (milligrams at bed time), initially started due to paranoia which interfered with cares and diet intake. She improved on this. Nursing notes the last week indicate, however, she has had at least 2 episodes of marked paranoia with withdrawal. No aggression ...mood and affect are quite paranoid. After initially talking she refused any further conversation." On [DATE] and [DATE], the nursing progress notes were reviewed back to [DATE]. The notes revealed, in pertinent part: --[DATE]: "Pt refused meds and eye (drops) last 2 med passes. Multiple attempts made over course of day to give meds. Pt repeatedly said no - last time she put them in her mouth, drank water, then spit them out. Not resistive to other cares - just medications." --[DATE]: "Patient refused AM meds. Several attempts made." --[DATE]: "Wrote note to (physician) about Pt's refusal to take [MEDICATION NAME]..the last 8 (nights). Multiple attempts made to give it - she refuses. She actually has had no change in mood thus far not taking the med. Asking (physician) to (discontinue it) or find a form where it can be given in liquid form." --[DATE]: "Res(ident) came up to this nurse and CNA (certified nurse aide) attempting to hit, then turns around, walks in hallway swinging arms as if trying to punch something. Observed res to ensure safety. She then laid down in bed. Later came out of room and began punching trays on empty food cart with both fists. Redirected to her room and calmed." --[DATE]: "Punching out at anyone getting near her - shoving furniture. Kept redirecting from others - no altercations. Calmed down when left alone." --[DATE]: CNAs reporting increased resistance with Pt in regarding to Pt care, esp(ecially) toileting ...Today Pt had patially continent, partically inc(ontinent) (bowel movement). Two (aides) went together to toilet her. One gently holding her hands and explaining what we are doing, the second cleaning her up and skin care done. This worked well this time." --[DATE]: "With toileting and peri care, Pt trying to bite us and scratch us. Calm gentle approach used. When she attempted to dig her nails into my hand stated, "That hurt didn't it?" --[DATE]: "Cooperative with all cares today, quiet, pleasant, saying thank you at meals." --[DATE]: "Very resistive to pericare - trying to hit, bite caregivers." --[DATE]: "Resistive to peri care this PM. Trying to bite and pinch. "I will kill you", "You will die." Stated it again when we were done - gentle approach used with resident." --[DATE]: "Resistant with cares. Two assist to change brief and pant. Resident tried to bite this nurse and hit. Peri care complete. Resident is ambulating on the unit at present." --[DATE]: "Multiple exit seeking attempts today." --[DATE]: "Multiple exit seeking attempts today." --[DATE]: "Scratched CNA on both forearms when toileting her." --[DATE]: "Exit seeking. Knocking on doors. Comes back easily." --[DATE]: "Pt crying - states a twin died and she is thinking about that ..." The [DATE] Behavior Monitoring form was reviewed. It showed the resident was monitored for paranoia/delusions and hitting others. How the resident exhibited paranoia/delusions was not further defined. No episodes of paranoia/delusions were documented. The [DATE] psychotherapeutic medication use evaluation form showed the resident received [MEDICATION NAME] and [MEDICATION NAME]. --Non-pharmacological interventions attempted in the last 30 days included, "Calm approach, provide support and reassurance, assess for urgent needs, encourage involvement in group and individual activities, family assistance to talk on phone, remove from stimulating environment, encourage visits from family and friends, one on one visits from staff, participate in self-cares. --Targeted symptoms or behaviors for the medications included deusional statements, paranoia, hallucinations, sadness, flat affect, little interest/please in doing things, and trouble concentrating. --Behavior trends since last monthly evaluation: No change in behavior symptoms --Interdisciplinary Team Summary: Gradual dose reduction of Risperal to be initiated when resident stabilizes, continues with occ(asional) episodes of increased paranoia, verbal aggression, threats. --Gradual dose reduction NOT recommended: Continue target behaviors, not easily redirected --Attending physician assessment: I agree with the interdisciplinary team recommendations. Pt has increased paranoia; GDR contraindicated. Still with depression so will not decrease ([MEDICATION NAME]) at this time. c. Resident Observations --On [DATE] at approximately 12:05 p.m., the resident was observed in the dining room of the special care unit. She was seated at a table with three other residents. A staff member placed a plate of food in front of the resident. She sat for two minutes without touching the food. She then pushed the plate forward and got up from the table. She went and sat in a chair away from the table and crossed her arms. The staff offered the resident something else to eat and she refused. --On [DATE] at 2:30 p.m., the resident was observed sitting in a chair in the commons area of the special care unit. Her arms were crossed and she was looking forward. A registered nurse (RN) assessed an area of impaired skin on the resident's forehead and cheek. Prior to looking, the resident was asked if it was okay for her forehead and cheek to be examined. The resident did not respond. The RN asked again and the resident said it was okay. The RN got close to the resident to look at her skin. The resident at first allowed this but then said, "Get away from me now, I mean it." The RN stopped the examination and the resident remained in her seat with her arms crossed. --On [DATE] at 5:47 p.m., the resident was observed at the dining room table seated with three other residents. The resident finished her entire plate of food and remained seated at the table. She crossed her arms at her chest and looked forward. d. Family Interview --On [DATE] at 4:24 p.m., the resident's son was interviewed via telephone. He was asked about the resident's mood. He said, "She's diagnosed with [REDACTED]. Before that she was an average, happy woman. I think it's her mental health problems that make her unfriendly at times. She sits kind of isolated, she doesn't join in the activities. When my wife and I visit she seems to appreciate people visiting her. She's never become agitated with me. I'm not sure she knows who I am quite honestly. She has mistaken me for my father before." e. Physician Interview --On [DATE] at 9:49 a.m., the resident's physician was interviewed. He said, "I've been her physician for four or five years. She's been off and on [MEDICATION NAME] and almost never totally off probably since within a month to two months of admission. When she was originally admitted she had been living in her home alone and the family found her wandering the neighborhood and muttering to herself. She came here then we ended up having a problem where she became very, very paranoid." The physician was asked how the resident was paranoid. He said, "She would sit and mutter to herself about what the facility might be doing to her. She'd socially withdraw and think they were trying to poison her. She would sometimes refuse food and stop eating. We put her on the [MEDICATION NAME] for that and about once every twelve months or so we will attempt a dose reduction even if she's been a little socially withdrawn. What we find is a flair in her paranoia. The thing that bothers me most is when she stops eating. She's still, even now, doing this, that, or the other in terms of making statements. Now we'll wait a few months." The physician stated the resident would sometimes not eat or not take medications because she was afraid it was poison. He continued, "I'm probably never going to get her not paranoid. She'll refuse any physical contact and my exams are observational exams. My progress notes usually will mention her paranoia and the ones from last year would talk about her refusal to eat." The physician stated he was hopeful to refer the resident to a geropsychiatrist he would soon be meeting with. He continued, "She's still depressed and I'm not going to decrease that (medication). It's hard to tell how much is depression and how much is paranoia." When asked about the potential for a future taper of [MEDICATION NAME], the physician said, "What I'm hoping is that her dementia will progress enough so that she forgets to be psychotic and if she does I'd love to taper her." f. Staff Interviews --On [DATE] at 1:34 p.m., a RN who was assigned to work with the resident that day was asked about the resident's behaviors. She said, "I've known her for years. She's exit seeking, resistive to care, and has a long standing paranoid component. She thinks you're going to hurt her. She hits out because of some paranoia." --On [DATE] at 1:47 p.m., the social services director (SSD) was interviewed. She said a taper of the resident's [MEDICATION NAME] was decided against because, "When we reviewed the notes she had been making statements and getting aggressive with the staff. She's not like this regularly. She likes to sit in her recliner and eat her meal." The SSD stated the statement and aggression were directed toward staff members and not toward other residents. --On [DATE] at approximately 1:45 p.m., another RN who was assigned to work with the resident that day was asked about the resident's behaviors. She said, "She has withdrawn behaviors. She doesn't like close contact and she feels threatened. During cares she thinks they are trying to harm her. We say we're trying to clean you and take care of you. Then she'll calm down and then she'll start again and then she'll let you finish. Usually if you're in her space she gets upset and that includes cares. I try to direct the other residents away from her." The RN said if the resident becomes agitated during cares, "We take a time out, step away, and then try again." --On [DATE] at 11:15 a.m., a CNA who was assigned to work with the resident was asked about the resident's behaviors. She said, "There's times she's quiet and doesn't participate. When her daughter-in-law or son come in she'll sit and smile. There's times she gets paranoid. She sees things or thinks thing(s) that are there and asks who is standing over there. She likes to stay up all night. She can be resistant to ADLs." The CNA stated the resident did not like affection and did not like anyone in her personal space. g. Care Plans The dementia with behavioral disturbances care plan, initiated on [DATE] and last revised on [DATE], showed the resident exhibited episodes of angry outbursts, difficulty with changes in routine, and resistance to care at times becoming verbally/physically aggressive. Approaches included: --Approach (resident) slowly from the front in a calm, gentle manner --Document behavior on behavior monitor sheet, note cause and successful interventions, include frequency and duration --Explain care and receive permission from (resident) prior to initiating, do not rush, allow time for processing --If (resident) refuses care and/or becomes aggressive, ensure her safety, leave resident, and reapproach in ten minutes --Provide opportunity for (resident) to make decisions and allow for flexibility in activity of daily living routine --Provide positive reinforcement when (resident) is demonstrating acceptable behavior --Remove from stimulating environment to a calm place during times of increased agitation. The behavior care plan, initiated on [DATE] and last revised on [DATE], showed the resident was taking anti-psychotic medications for episodes of delusional statements with hallucinations and paranoia which can be distressing for her. Approaches included: --Approach in a calm, gentle manner, provide support and reassurance --Assess for unmet needs - pain, hunger, thirst, toileting, hot, cold, needs to be unchanged --Encourage involvement in group and individual activities of choice --Illicit family input as needed for best approaches during episodes of behavior --Medications as ordered --Offer to call (resident's) son and daughter in law whom she trusts --Remove from stimulating environment to a calm place during times of behavior The mood care plan, initiated on [DATE] and last revised on [DATE], showed the resident had a depression disorder and was taking anti-depressant medication for symptoms of sad/flat affect, little interest/please in doing things and trouble concentrating, and refusing eye drops and medications. Approaches included: --One on one visits with social worker as needed for supportive services --Medication as ordered --Encourage visits from family and friends --Provide opportunities for (resident) to make decisions and participate in self-care within her abilities. Continue to go back and ask her again to take her meds and eye drops. Document when she refuses. Both eye doctor and physicians are aware of her refusals. Keep trying. The resident's mood and behavior care plans did not address specifically how the resident was paranoid or delusional, or explain her hallucinations. They also did not address the resident's thinking her medications or food were poison or her sensitivity over her personal space as described in the interviews above. --On [DATE] at 2:05 p.m., the director of nursing (DON) and SSD were interviewed. The SSD said, "She likes to sit on her own. She doesn't do well with others. You can't assume anything with her. She has a personal space bubble." The SSD stated the resident was suspicious of the motives of others and needed personal space. The DON said the resident was leery of people. They were asked what the resident was trying to communicate with her behaviors. The SSD said, "She's saying I don't like what you're doing." The SSD stated she would be updating the resident's behavior care plans to better reflect the resident behaviors and preferences. The DON was asked about the behavior monitoring sheet and the resident's behavior of paranoia/delusions. The DON said the forms were generic and not person centered. She said they were looking at revising the forms. On [DATE] at 11:01 a.m., the DON said she was not aware of the resident's fear of her medication or foods being poison. h. In summary: -The facility failed to describe and document detailed person-centered behavioral symptoms that the resident expressed -The facility failed to develop interventions individualized for these behavioral symptoms. III. Skin Impairments 1. Facility Policy According to the facility's skin integrity management policy, in pertinent part: " ...Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information ... Perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration ..." 2. Resident #13 a. Resident Status According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The [DATE] annual Minimum Data Set (MDS) showed the resident's short and long term memories were impaired. Her cognitive decisions for daily decision making were moderately impaired. The resident displayed inattention and disorganized thinking. She required limited assistance with bed mobility and transfers. She required total assistance with dressing. According to the skin care plan, the resident had a potential for pressure ulcers. Approaches included: --Keep skin clean and dry. --Observe skin every shift for (signs or symptoms) of potential skin breakdown (e.g. redness/discoloration or open areas). Alert charge nurse if observed for notification of physician as needed for (treatment) orders --Weekly skin assessment b. Resident Observation --On [DATE] at 9:21 a.m., the resident was observed in the dining room of the special care unit. She was seated in a chair. A dark red scab, approximately the size of a pencil eraser, was observed on the resident's forehead. A dark, reddened scab approximately a quarter inch long was observed on the resident's left cheek. --On [DATE] at 9:20 a.m., the resident was observed in the dining room of the special care unit. She was seated in a chair. The scabbing on the resident's forehead and cheek were again observed. --On [DATE] at 10:41 am., the resident was again observed in the dining room of the special care unit. The scabbing on the resident's forehead and cheek were still present. c. Record Review The [DATE] computerized physician orders [REDACTED]. On [DATE], the nursing progress notes were reviewed back to [DATE]. No documentation was found regarding the abrasions/scabs in the resident's notes. The [DATE] treatment administration record revealed the resident's skin was assessed on [DATE], [DATE], [DATE], and [DATE]. The resident's skin was documented to be intact. The [DATE] TAR was reviewed and showed the resident's skin was assessed on [DATE], [DATE], [DATE]. Skin was documented to be intact. Skin to next be assessed on [DATE] during the day shift. On [DATE], skin was documented to be intact. d. Staff Interviews --On [DATE] at 2:53 p.m., a registered nurse (RN) was asked what skin impairments she looked for during skin assessments. She said, "Skin tears, bruises, and abrasions. If it's noticed we measure it and we take care of it. We do a RMS (risk management system) in the computer, we notify the doc and the family, and we do a change of condition form." --On [DATE] at 2:07 p.m., the RN who was assigned to work with the resident and who had completed the resident's skin assessment earlier that day was interviewed. She was asked what she looked for when completing skin assessments. She said, "When I first walk in I do a general look. I look at pressure areas like the coccyx, ears, or bridge of nose with glasses on." She said she also looked for bruising, scabs, or scratches. If issues were identified, the RN said, "You're supposed to do a nurse's note, a report in RMS (the facility's risk management system), and notify the family and the doctor." The RN stated she had not noticed the scabbing on the resident's forehead or cheek. She said, "I didn't notice it before but I'll check it out." The RN examined the resident's forehead and cheek and confirmed the presence of scabbing. She confirmed it should have been identified on the skin assessment. --On [DATE] at 2:32 p.m., the DON stated scabs should be identified on the skin assessment. She said, "They should do an RMS about what they've noticed, a nursing progress note, and let the physician and the responsible party know." --On [DATE] at 2:38 p.m., the DON stated the RN was completing an RMS and a nursing progress note. She said the resident did not have a care plan addressing her picking at her skin. 3. Resident #24 a. Resident Status According to the face sheet, the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The [DATE] quarterly MDS showed the resident's cognition was severely impaired. She required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The skin care plan, dated [DATE], showed the resident had a potential for skin breakdown related to cognitive impairment and limited mobility. Approaches included: --Keep skin clean and dry --Toilet resident frequently to discourage incontinence --Observe skin every shift for signs or symptoms of potential skin breakdown (e.g. redness/discoloration or open areas). Alert charge nurse if observed for notification of physician as needed for treatment orders. --Weekly skin assessment by licensed nurse. b. Resident Observation On [DATE] at 4:24 p.m., the resident was observed in the special care unit. She was seated in the dining room and was looking at a newspaper. Three pin point red scabs were observed on the resident's nose. On [DATE] at approximately 11:30 p.m., the resident was observed in the special care unit. She was seated in the dining room. The three pin point red scabs were again observed on the resident's nose. On [DATE] at 11:06 a.m., the resident was observed in the dining room of the special care unit. She was seated in a wheelchair. The resident's nose was observed and two pin point red scabs were present. c. Record Review The [DATE] computerized physician orders [REDACTED]. On [DATE], the nursing progress notes were reviewed back to [DATE]. No documentation was found regarding the abrasions/scabs on the resident's notes. The [DATE] treatment administration record (TAR) showed the resident's skin was assessed on [DATE], [DATE], [DATE], and [DATE]. The resident's skin was documented to be intact. The [DATE] TAR revealed the resident's skin was assessed on [DATE], [DATE], [DATE], and [DATE]. The resident's skin was documented to be intact. d. Staff Interview --On [DATE] at 2:53 p.m., an RN was asked what skin impairments she looked for during skin assessments. She said, "Skin tears, bruises, and abrasions. If it's noticed we measure it and we take care of it. We do a RMS (risk management system) in the computer, we notify the doc and the family, and we do a change of condition form." --On [DATE] at 2:10 p.m., the RN who was assigned to work with the resident and who had completed the resident's skin assessment earlier that day was interviewed. She said she had not noticed the scabs on the resident's nose during the skin assessment. She stated the resident had a habit of picking the skin on her nose. When asked if scabs are something she would identify during the skin assessment, RN #2 stated, "I need to get with my director of nursing (DON) on that. I don't know if we do anything on scabs." --On [DATE] at 2:32 p.m., the DON stated scabs should be identified on the skin assessment. She said, "They should do an RMS about what they've noticed, a nursing progress note, and let the physician and the responsible party know." The DON confirmed the resident had a habit of picking at her nose and stated she believed this was in the resident's care plan. --On [DATE] at 2:38 p.m., the DON stated the RN was completing an RMS and a nursing progress note. She said the resident did not have a care plan addressing her picking at her skin. 4. Resident #32 According to the face sheet, the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her Minimum (MDS) data set [DATE] revealed the resident was understood and could understand. She needed extensive assistance with activities of daily living. Her cognition (decision making ability) was not impaired. She needed assist with walking. The care plan for potential for bruising/bleeding related to aspirin therapy, [MEDICAL CONDITION], insulin injections dated [DATE]. The goal was: will have minimal areas of bruising through nursing interventions. The approaches were: Anticoagulant therapy as per order, attempt to not bump extremities when providing cares, chest x-ray as per orders, monitor for [MEDICAL CONDITION], pain medication as ordered. On [DATE] at 9:15 a.m. the resident was interviewed. During the interview, small needle-stick sized bruises were noted on the resident's hands wrists and upper arm. She stated these were from [MEDICAL TREATMENT]. A review of the Treatment Administration Record (TAR) for the month of [DATE] under the skin sheets showed no documentation of bruises. On [DATE] at approximately 2:00 p.m. a licensed nurse was asked to show where the skin records were kept. She got the Skin Book and showed they were organized by room number and turned to resident's skin record. There were no bruises noted for the month of [DATE]. The director of nursing was interviewed on [DATE] at approximately 4:00 p.m. She was asked where the documentation would be for the tracking of bruises. She stated they (the facility) did not monitor bruises. She admitted they did not identify them or attempt to identify how they were obtained. She stated sometimes a nursing note would be made regarding bruising but said there would not be any follow up. IV. Post-Fall Neurological Assessment 1. Facility Policies The facility's Falls Management Policy (revised [DATE]) documented in pertinent part: -Policy: Residents will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. -Purpose: To reduce risk for falls and minimize the actual occurrence of falls, to address injury and provide care for a fall. -Practice Standards: 6.2.1 Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury. The facility's Assessment: Neurological policy (revised [DATE]) documented neurological assessments will be performed as indicated or ordered. When a resident sustains an injury to the head and/or had an unwitnessed fall neur

Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and that two of 27 sample residents (#65 and #27) received adequate supervision and assistance devices to prevent accidents. Specifically: -The facility failed to implement interventions after a fall with a fracture and to ensure fall interventions were appropriate. -The facility failed to ensure the environment remained free of hazards. The findings include: I. Individual Resident Safety A. Facility Policy The Fall Management Program Practice Guidelines describes the interdisciplinary approach to managing resident falls. The Fall Program uses the "APIE" approach to care giving. Assess, Plan, Implement, & Evaluate. The program focuses on two areas: -Prevention of falls through increased awareness. -Managing falls that occur, including a root-cause analysis to determine how to minimize future risk. When a resident falls: Notify the licensed nurse, who will: 1. Provide immediate care and first aid, including a complete head-to-toe evaluation. 2. Stay with the resident (residents should not be left unattended). 3. Complete neurological evaluation, if the resident hit his or her head, or if the fall is not witnessed. 4. Call 911-Emergency Medical Service (EMS) if needed. 5. Notify the physician and the resident's responsible party. Post fall documentation: After the resident has been cared for, the licensed nurse 1. Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. Note: Licensed nurses continue to document the resident's condition in the Interdisciplinary Progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. 2. Completes a Fall Evaluation to determine if there have been any changes in the resident's condition and to identify interventions that may help in preventing future falls. 3. Completes an incident and accident report (enter into RMS) including a fall investigation. 4. Updates the Care Plan with the individual interventions. 5. Updates the nursing assistance Care Card with any new procedures. 6. Completes the 24 hour report, to alert the following shifts to the fall, as well as Care Plan updates. 7. Residents are followed via the 24 hour report x 72 hours. 8. Notifies other departments as indicated. 9. Follows up with the physician and family, as needed to provide updates. 10. Continues to follow the resident every shift for the next 72 hours, documents findings and resident condition in the Interdisciplinary Progress Notes. B. Residents 1. Resident #65, a [AGE] year old female, was admitted to the facility on [DATE]. According to the facility admission record, her [DIAGNOSES REDACTED]. The resident expired at the facility on [DATE]. a. Resident Status According to the Minimum Data Set, dated dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score was a 4 (severe impairment). She required extensive assist of one for bed mobility, transfers and toileting. She was always continent of bowel and bladder. She had no behaviors. Orders on admission included: -Dilantin 400 mg PO at bedtime everyday for seizures. -Risperdal 0.25 mg by mouth every 8 hours PRN for anxious state. -Oxycodone-acetaminophen ,[DATE] mg PO for pain. -Check placement and function of bed and wheelchair alarm. b. Falls after Admission Review of the facility fall Change of Condition forms completed revealed the resident fell [DATE] and again on [DATE] x 3. (1) [DATE] -Location of fall: Resident room -Time of fall: Unable to determine (not documented anywhere) -Type of fall: Witnessed -Fall details: The resident rolled out of bed -Immediate action: Education provided regarding the use of the call light. -Interventions: Continue to monitor resident and keep bed alarm activated. Review of the nurses' notes (NN) from [DATE]-[DATE] revealed that there were no notes related to the fall. (2) [DATE] Fall #1 -Location of fall: Resident's room -Time of fall: 5:00 a.m. -Type of fall: Unwitnessed -Fall details: The resident's alarm was sounding and she was found lying on her left side on the floor. The resident stated she was getting up to use the bathroom. The resident did not use her call light. She sustained a skin tear to her right hand. -Immediate actions: Skin tear was cleansed and treated with triple antibiotic ointment. Interventions: Will continue to monitor Review of the nurses' notes at 5:00 a.m. revealed documentation that the resident had an unwitnessed fall and had a skin tear to her left hand. No further assessment of the resident's condition was documented in the note. Fall #2 -Location of fall: Resident's room -Time of fall: 9:45 a.m. -Type of fall: unwitnessed -Fall details: The resident was found on the floor next to her roommate's bed. No injuries were noted. No complaint of discomfort. -Immediate actions: The resident was taken to common area to be with other residents. -Interventions: Will continue to monitor. Review of the nurses' notes revealed no documentation regarding this fall and no documentation of the resident's assessment after the fall. Fall #3 -Location of fall: Resident's room -Time of fall: 2:00 p.m. -Type of fall: unwitnessed -Fall details: The resident was found on the floor in her room. The resident was assisted up into wheelchair after being examined and medicated for pain and fever with good effects. -Immediate interventions: Assisted up into wheelchair. Interventions: None. Review of the nurses' notes revealed no documentation regarding this fall and no documentation of the resident's assessment after the fall. c. Injury from falls [DATE] Although review of the physician's orders [REDACTED]. fall that day. Review of the x-ray results [DATE] revealed the results were available at 1:23 p.m. PST, before the resident's third fall [DATE]. The results were the resident had an acute left femoral fracture with minimal displacement. The resident was transported to the hospital on [DATE] per nurses' notes at 5:00 p.m. d. Facility failure to keep the resident safe (1) [DATE] Record review revealed no acute care plan related to the resident's fall risk on admission or after her first fall [DATE]. While the fall change of condition form documented the resident was educated to use her call light, due to her cognition status (severely impaired) the recommendation was not appropriate. The fall report intervention "to monitor" provided no instruction to staff on how frequently this should be done. (2) [DATE] Review of the fall change of condition form above revealed no documentation after the resident's second fall related to an assessment of the resident's range of motion and see above; there was no documentation of an assessment in the nurses' notes following any of the resident's falls on [DATE]. There was no documentation regarding what triggered the request for an order to x-ray the resident's left hip after the second fall until 5:00 p.m. Nurses' notes at this time read the resident had a chest and left hip x-ray because of congestion, increased temperature and increased pain from early a.m. fall. Left hip x-ray showed a fracture of the femoral neck. Physician notified. An order to send the resident to the emergency room was received. The resident was transported via non-emergent ambulance. Record review revealed no safety care plan was developed until [DATE] (three days after the resident expired), the resident was at risk for falls related to: impaired balance, poor coordination, unsteady gait, generalized weakness, decreased safety awareness, history of falls, anxiety, unwitnessed falls x 2 on [DATE] and one on [DATE] (according to the change of condition forms all three falls occurred on [DATE]). e. Further resident declines and fall after readmission Record review revealed the resident returned to the facility [DATE]. Nurses' notes [DATE] and through [DATE], revealed that the resident required a one-to-one supervision for increased restlessness. Nurses' notes on [DATE] at 5:00 a.m., revealed that the resident was medicated twice for agitation. Nurses' notes on [DATE] at 5:00 a.m., revealed the resident was agitated and attempting to crawl out of bed, PRN (as needed) Ativan given. The resident rested for about two hours and then began to yell out and was grimacing in pain. Pain medication administered. Nurses' notes at 10:50 p.m., documented the resident was medicated for restlessness. Review of a change of condition report dated [DATE] revealed the resident fell again from bed; see interview below. It was not clear if the resident was on one-to-one supervision at the time of this fall. Specifically, the report read: -Location of fall: Resident's room -Time of fall: 2:45 a.m. -Type of fall: unwitnessed -Fall details: A certified nurse aide (CNA) heard moaning from the resident's room, upon entering the resident was found on the floor lying on a floor mat. The resident was assessed by the registered nurse and assisted back into bed. The resident sustained [REDACTED]. The resident was very agitated and was given PRN (as needed) Morphine. At 3:15 a.m., the resident was still very agitated and was given 1 mg of Ativan. She required a one-to-one to help keep her in bed and safe. -Immediate action: Assisted back to bed. -Interventions: One-to-one. Review of the nurses' notes for [DATE] revealed an interdisciplinary (IDT) care note (not timed) revealed that the resident had been readmitted on [DATE] on hospice with increased anxiety and pain issues. She required a one-to-one related to poor safety awareness. -On [DATE] at 9:20 a.m., revealed that the resident had expired. f. Interviews On [DATE] at approximately 1:00 p.m., the assistant director of nursing (ADON) was interviewed. -She said the facility did not really have a fall committee but all falls are reviewed in morning meeting by the IDT team. They review the fall, the interventions that were put into place and decide as a group if any other interventions need to be implemented. She said all interventions are to be placed on the care plan when they are implemented. -She reviewed the resident's care plan and confirmed that the date on the care plan was after the date the resident expired. After reviewing the nurse' notes surrounding the dates of the fall and the change of condition forms, she confirmed that there were no interventions put into place after the three falls on [DATE] to help keep the resident safe. -She said her expectations are that the nurses chart any changes or concerns related to the resident. She indicated that if the nurse received an order for [REDACTED]. She confirmed there were none in the nurse' notes. -She said she was unaware whether or not the resident was on a one-to-one when the fall happened [DATE] or if it had been stopped and then restarted on [DATE] when the resident fell again. She indicated that there was no way to tell because the only way it would be monitored is through the nurses' notes. She confirmed that after [DATE], there were no notes related to the resident being on a one-to-one, but that there were nurses' notes revealing that the resident had increased agitation and anxiety. On [DATE] at 3:00 p.m., the floor Registered Nurse was interviewed. She said it is everyone's responsibility to keep the residents safe. She indicated that it is the nurse's responsibility to implement interventions immediately after a fall to keep the resident safe and that all of these interventions should be documented in the nurses' notes, on the care plan and on the change of condition form that is completed with each fall. She indicated that they chart by exception and so if something is going on, that would require an x-ray, there should be documentation about the issue. 2. Resident #27 According to the face sheet, the resident, an [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], showed the resident's cognition was severely impaired. She required limited assistance with bed mobility and transfers and extensive assistance with personal hygiene and toilet use. The fall care plan, dated [DATE], showed the resident was at risk for falls related to history of multiple falls, decreased safety awareness, history of aggressive, combative behavior. Interventions included: --Explain to resident what is to occur prior to initiating ADL/activity. --Monitor for gait disturbances. --Offer to toilet resident frequently. --Speak clearly and directly to the resident by name. --Use simple yes/no phrases and questions. --Have commonly used articles within easy reach. --Resident to wear non-slip footwear. --Ensure environment is free of clutter. --Encourage resident to transfer and change positions slowly. --Encourage resident to communicate needs/ask for assistance. --Educate resident on safety risks. --Toilet resident frequently ([DATE]). The resident's nursing progress notes were reviewed and showed the resident had a fall on [DATE] at 5:40 a.m. The change of condition documentation dated [DATE] revealed: "CNA (certified nurse aide) heard bed sounds from resident's room. CNA went to the door and saw resident fall to the floor with left arm and legs bracing her fall. Resident did not hit head. This RN (registered nurse) was immediately called and responded. Head to toe assessment done. No injury to left side noted. Resident has no c/o (complaints of) pain or discomfort and there is no indication of any pain. Resident has full range of motion with all extremities, responds appropriately to questions and commands, pupils equal and reactive. VS (vital signs) taken and all WNL (within normal limits) for resident except pulse OX 78%. Resident has presented with upper resp congestion and cough for past week." The [DATE] fall investigation was reviewed and showed immediate interventions put into place were, "Assessment, vital signs, and assistance back to bed." Recommendations to prevent further falls were, "Resident with impaired cognition. Resides on secure unit. Does not remember to ask for assistance. Unstable at times." Although when the resident fell , her pulse ox was at 78 percent, no interventions were immediately put into place to address this; placing her at risk for further falls (cross reference F328). On [DATE] at approximately 3:30 p.m., the director of nursing (DON) acknowledged the interventions put into place did not address the resident's low pulse ox and should have. B. Environmental Hazards The facility failed to ensure that three of 26 resident rooms, the secured unit courtyard, the oxygen transfer room, and the kitchen were free of accident hazards. 1. Resident Rooms Observations: On [DATE] at 12:00 p.m., a patio door in resident room #111 on the secured unit was noted to slide open approximately six inches and upon exit would allow residents to exit the facility. Further observation noted a steel bar approximately 18 inches long was laid in the track to keep patio style door from opening. The bar was easily lifted and removed from the track and upon removal, allowed the door to open. The top of the door had a drill bit placed in a hole. The drill bit was easily removed. Interview: On [DATE] at 12:10 p.m., the nursing home administrator (NHA) was given the steel bar and she agreed that the resident could exit the secured unit through the patio door and leave the facility. She stated to her knowledge that the door was locked and inoperable. Observation: On [DATE] at 2:41 p.m., resident room #11 was noted to have an exposed screw approximately 1 ,[DATE] inches long protruding from the closet door. Interview: On [DATE] at 2:43 p.m., the NHA observed, touched and agreed that exposed screw was present and sharp to the touch. Observation: On [DATE] at 3:05 p.m., in resident room #120, there was a missing outlet cover for electrical outlet with sufficient room to stick fingers in to electrical wires. Interview: On [DATE] at 3:10 p.m., the maintenance director observed the missing electrical outlet cover in room #120. He stated he would replace the outlet cover. At 3:30 p.m., the maintenance director stated that the cover had been replaced. 2. Courtyard Observation: On [DATE] at 11:50 a.m., a tour of the courtyard revealed a wicker loveseat that was unwoven with wicker pieces sticking out along the seat. There was a pile of rocks approximately one foot tall (each rock weighed approximately a pound) in front of wicker love seat. There were random large rocks scattered throughout the grass and along the sidewalk. Additional observations in the courtyard revealed a new concrete pad that had a gap of approximately four inches between concrete and grass and there was approximately three inches of depth all around the concrete pad. The wooden bench in the courtyard had peeling paint. The dirt area under room #106 had debris in the dirt. The dirt area had rocks, bricks, garden hose, watering device and wood lying along the surface of the dirt. Interview: On [DATE] at 12:10 p.m., the NHA said she felt the courtyard - rocks and benches and concrete - presented accident hazards. She stated that the wicker bench would be removed and the wooden bench would be painted. She further stated that the rocks would be removed and the ground graded by the cement pad. 3. Kitchen Observations of the kitchen on [DATE] at 4:00 p.m., revealed the kitchen failed to have a ground fault interrupter (GFI) in the dishwashing room. Specifically, the dishwashing room had an electrical outlet with a fan plugged into the outlet. The outlet was less than six feet from the handwashing sink and less than six feet from the dishwasher. Interview: On [DATE] at 4:15 p.m., the maintenance supervisor pushed the ground fault interrupter on the wall in the kitchen and the fan continued to operate. The dietician turned off the electrical braker to the dishroom and the fan continued to operate. The dietary supervisor, dietician and maintenance supervisor were unaware of a GFI outlet in the dishroom. On [DATE] at 5:18 p.m., the maintenance supervisor stated he had installed a GFI switch in the dishwashing room. Reference: Ground Fault Circuit Interrupters (GFCI) Consumer Product Safety Commission (Document #99). The GFCI was designed to protect people from severe or fatal electric shocks because a GFCI detects ground faults, it can also prevent some electrical fires and reduce the severity of others by interrupting the flow of electric current. 4. Oxygen Transfer Room Reference: According to NFPA (National Fire Protection Association) 99 - 1999 Edition Division of Quality Assurance - Bureau of Regulatory Compliance (Revised ,[DATE]) ,[DATE].1.11.2 Storage for nonflammable gases less than 3000 cubic feet (c) Oxidizing gases such as oxygen and nitrous oxide; shall be separated from combustibles or incompatible materials by either: 1. A minimum distance of 20 feet, or 2. A minimum distance of 5 feet if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or 3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage. Facility Oxygen Policy (revised ,[DATE]): Oxygen Administration, Skills Testing and General Overview -Storage of Cylinders - Oxygen cylinders should be stored carefully and in accordance with relevant Government regulations. There should be no flames or smoking allowed within 25 meters of stored oxygen cylinders. -Oxygen Safety - 1. Smoking and any source of open flames are not permitted in areas of oxygen administration. 4. Keep flammable materials away from equipment. Observations: On [DATE] at 12:00 noon, observations in the Oxygen Storage Room (OSR) closet revealed one large card board box (flammable item) folded together leaning against the inside wall of the closet. There were three 680-liter oxygen cylinders (tanks) chained properly to the closet wall and four Dewars (liquid oxygen tanks on wheels) standing upright (stored properly) in the center of the closet. -A Licensed Practical Nurse (LPN) was immediately notified. The LPN agreed/observed the card board box (flammable item) was leaning against the wall inside the OSR closet. The LPN stated the cardboard box should not have been stored in the OSR closet and she removed the cardboard box immediately. The LPN stated oxygen transfers occurred in the OSR closet; however, due to the small size of the closet, the door to the OSR had to remain open during oxygen transfers. Observations also revealed black cigarette ash marks (too numerous to count) on the brick wall which comprised the outside wall of the OSR closet and 14 cigarette butts discarded in the wood chip (flammable items) planting area located within ten feet of the OSR closet. The LPN agreed/observed the black cigarette ash marks located on the brick wall of the OSR closet. The LPN agreed/observed/ picked-up the 14 discarded cigarette butts in the wood chip planting. The LPN stated the area around the OSR closet was a non-smoking area. A sign on the OSR closet door documented "Danger Oxygen". No smoking and No Open flames. On [DATE] at 4:39 p.m., the Director of Nursing (DON) stated it was her expectation employees follow facility policies. The DON stated oxygen transfers did occur in the Oxygen Storage Room (OSR) closet. The DON stated she was not aware a flammable item (cardboard box) was stored in the OSR closet. The DON also stated she was not aware facility staff was smoking within ten feet of the OSR closet. On [DATE] at 4:45 p.m., the NHA stated it was her expectation employees follow facility policies. The NHA stated she was unaware a flammable item (cardboard box) was stored in the OSR closet. The NHA also stated she was not aware facility staff was smoking within ten feet of the OSR closet. The NHA stated cigarette butts should not have been discarded in the wood chip (flammable items) planting area beside the OSR closet. Facility Follow up: The facility Smoking Policy was revised [DATE] to read: Smoking is not permitted near the oxygen storage closet outside (the safe boundary is marked by red painted lines on the concrete) or under any covered walkway or patio. This is due to the fire code and no exceptions may be made.