Every finding on record at Sundance Skilled Nursing and Rehabilitation

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and temperature.Findings include: I. Facility policy and procedure The Resident Food Preferences policy, dated July 2017, was provided by the nursing home administrator (NHA) on 2/26/26 at 9:23 p.m. It read in pertinent part, The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's quality assessment and performance improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. II. Resident group interview A group of five residents (#2, #7, #24, #56 and #58) who were assessed by the facility to be interviewable, were interviewed together on 2/25/26 at 10:30 a.m. Resident #7 said the vegetables were often overcooked and she did not believe the meals were nutritious. She said she had voiced her concern about the food needing to be served hotter, but she had not received much of a response from the facility. Resident #56 said the room trays served on the second floor were barely warm at all. She said the biggest complaint she had heard from the other residents was regarding the small portion sizes and residents still feeling hungry after a meal. III. Additional resident interviews Resident #57 was interviewed on 2/23/26 at 12:18 p.m. Resident #57 said the food was so-so, and his food was too salty. Resident #55 was interviewed on 2/23/26 at 2:20 p.m. Resident #55 said the food needed help, and it did not taste homemade. Resident #17 was interviewed on 2/23/26 at 2:31 p.m. Resident #17 said some food was good and some food was bad. She said today's (2/23/26) lunch was not good. She said she only ate the rice. She said she was not able to describe what was not good about the food. Resident #17 said she wished the facility offered condiments more often and more consistently. Resident #34 was interviewed on 2/23/26 at 2:45 p.m. Resident #34 said the food needed more flavor and was served cold. Resident #16 was interviewed on 2/23/26 at 3:10 p.m. Resident #16 said the food was served cold, he did not think the food had enough flavor and he did not enjoy eating any of the meals. Resident #37 was interviewed on 2/23/26 at 3:23 p.m. Resident #37 said he had been to other facilities and this facility's food was the worst food. He said today's (2/23/26) lunch was bad. He said the rice was gummy and the stir fry should have had soy sauce. He said when he ordered from the always available menu, it was not good. He said he ordered a hamburger as a substitute meal and the burger meat was dry. He said he could tell if the food was sitting out for a while and the facility did not offer condiments, such as tomatoes and mustard. Resident #24 was interviewed on 2/24/26 at 9:01 a.m. Resident #24 said his biggest concern at the facility was the food. He said the food was served cold and the meals were either bland or too salty. Resident #30 was interviewed on 2/24/26 at 10:32 a.m. Resident #30 said the food was terrible. Resident #30 said she was unable to talk more about the food. Resident #7 was interviewed on 2/24/26 at 12:09 p.m. Resident #7 said the meals could be warmer and she said she would like to be offered condiments. She said the lunch served on 2/23/26 could have used soy sauce as a condiment. IV. Observations On 2/25/26 at 11:25 a.m. the lunch menu was observed on the wall in the dining room. It revealed the lunch being served was braised turkey roast, rice pilaf, creamed spinach, spice cake and coffee or tea and juice. During the lunch meal service on 2/25/26 from 11:53 a.m. to 1:30 p.m., the following was observed: At 12:41 p.m. dietary aide (DA) #1 asked an unidentified resident how his lunch tasted. The resident said the spinach was off and did not taste right. At 1:25 p.m. an unidentified resident told the assistant director of nursing (ADON) that lunch was horrible. V. Test tray A test tray for a regular diet was evaluated by five surveyors immediately after the last resident had been served their lunch tray on 2/25/26 at 1:30 p.m. The test tray consisted of braised turkey roast with gravy, rice pilaf, spinach and spice cake. The braised turkey roast was served with a white gravy and was salty with a temperature of 117 degrees Fahrenheit (F). The turkey was dry and the gravy was very salty. The rice pilaf looked like plain rice and had a temperature of 118.9 degrees F. The rice pilaf was bland and tasted like plain rice. The creamed spinach looked like plain spinach, was dark green and wet and had a temperature of 120 degrees F, which was not palatable. The spinach was not creamy or cheesy. VI. Record review The recipe for the creamed spinach (see test tray observation above) was reviewed on 2/25/26 at 11:28 a.m. The creamed spinach indicated the ingredients included butter, flour, salt, nutmeg and spinach. The October 2025 food committee minutes revealed hamburgers were cooked differently with each cook and french fries needed to be cooked longer. The January 2026 resident council meeting minutes revealed residents wanted and agreed to discussing all dietary topics at the food committee meeting that followed right after resident council. One resident in particular had questions regarding menu, preferences and snacks. -However, a request for the January 2026 food committee meeting minutes revealed a food committee meeting did not take place in January 2026 (see NHA interview below). The February 2026 resident council meeting minutes revealed all residents were invited to attend the upcoming food committee meeting on 2/17/26. -However, a request for the February 2026 food committee meeting minutes revealed a food committee meeting did not take place in February 2026 (see NHA interview below). VII. Staff interviews Cook (CK) #1 was interviewed on 2/25/26 at 12:41 p.m. CK #1 said he did not have the ingredients on 2/25/26 to make creamed spinach, so the spinach was frozen spinach with nothing added to it. He said the rice was made with chicken broth, garlic and rice. -However, according to the recipe, CK #1 should have added butter, flour, salt and nutmeg into the creamed spinach. Certified nurse aide (CNA) #2 was interviewed on 2/25/26 at 4:51 p.m. CNA #2 said residents complained about how the food tasted. CNA #2 said she never offered to have the residents who complained fill out a grievance form because she tried to solve the problem in real time or told the nurse of their concerns. The NHA was interviewed on 2/26/25 at 5:26 p.m. The NHA said the facility did not have a dietary manager (DM). The NHA said she had an assistant DM and a registered dietitian (RD). The NHA said she lost her most recent DM the week prior to the survey (week of 2/16/26). The NHA said she knew there were resident concerns about how the food tasted. The NHA said she did not know the recipes were not followed by the dietary staff. The NHA said the gravy should not have tasted overly salty. The NHA said if the menu said creamed spinach and rice pilaf, the creamed spinach should have looked creamy and the rice pilaf should have revealed visible ingredients besides rice.

Based on observations, record review, and interviews, the facility failed to ensure that clean linens were provided to residents on a daily basis. Specifically, the facility failed to ensure clean hand towels and washcloths were provided to residents.Findings include:I. ObservationsObservations made throughout the survey (from 2/23/26 to 2/26/26) revealed there were no towel racks inside the residents' bathrooms. On 2/23/26 at 3:38 p.m. room [ROOM NUMBER] B had no hand towels or washcloths.On 2/23/26 at 5:43 p.m. room [ROOM NUMBER] A and B had no hand towels or washclothsOn 2/25/26 beginning at 2:27 p.m., the following observations were made:-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths; and,-room [ROOM NUMBER] had no hand towels or washcloths.On 2/26/26 at 9:24 a.m. the linen closet on the first floor was observed with certified nurse aide (CNA) #7. The linen closet contained 20 washcloths and 15 hand towels. On 2/26/26 at 9:28 a.m. the linen closet on the second floor was observed with licensed practical nurse (LPN) #1. The linen closet was locked with a combination padlock. There were approximately 15 washcloths and hand towels inside the linen closet. On 2/26/26 at 3:04 p.m. the closets of room [ROOM NUMBER] bed A and bed B and room [ROOM NUMBER] bed A and bed B did not have towel racks in the closets. room [ROOM NUMBER] A and B both had a broken towel rack in the closet. II. Resident interviewsResident #55 was interviewed on 2/23/26 at 4:27 p.m. Resident #55 said that linen towels were not passed out. She said that at times, the facility had run out of bath towels. She said the bathroom had paper towels, but she said she did not like to use paper towels for her face. Resident #67 was interviewed on 2/23/26 at 5:30 p.m. Resident #67 said she was newly admitted to the facility and that she did not have any cloth linens in her room. She said the bathroom had only paper towels to dry her hands.Resident #52 was interviewed on 2/23/26 at 5:45 p.m. Resident #52 said the bathroom only had paper towels. She said that she did not get linen towels unless she asked for them.Resident #53 was interviewed on 2/25/26 at 2:35 p.m. Resident #53 said she did not have linen towels. She said that she had to use paper towels. The resident's son was present in the room and confirmed that Resident #53 did not have linen towels in her room or the bathroom.Resident #60 was interviewed on 2/25/26 at 2:45 p.m. Resident #60 said there were no towels provided. She said that the bathroom only had paper towels. She said that she had to ask for a linen towel and then she kept the towel on her bed, as there was no other place to put the towel. Resident #56 was interviewed on 2/25/26 at 2:47 p.m. Resident #56 said there were no towels provided. She said once she received a towel, she would hold onto it. Resident #60 was interviewed a second time on 2/26/26 at 3:05 p.m. Resident #60 said there were not towel racks in the closet. Resident #67 was interviewed a second time on 2/26/26 at 3:10 p.m. Resident #67 said there were no towel racks in the closet. III. Resident group interviewFive residents (#2, #7, #24, #56 and #58) who were identified by the facility and assessment as interviewable, were interviewed together as a group on 2/25/26 at 10:00 a.m.The residents said they only had paper towels for drying their hands in their bathrooms. They said they had to ask for linen towels, but the staff did not go around and pass out towels. IV. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 2/26/26 at 9:24 a.m. CNA #7 said the linens were kept locked up in the linen closets. He said that the towels were locked up because residents would take too many towels. He said that if the residents asked, then the staff would give a hand towel and a washcloth to the resident. He said that the facility was low on towels. Certified nurse aide (CNA) #6 was interviewed on 2/26/26 at 9:32 a.m. CNA #6 said the residents had to ask for towels. He said there was a cart with towels, however, the residents were not allowed to get the towels themselves. Licensed practical nurse (LPN) #1 was interviewed on 2/26/26 at 9:30 a.m. LPN #1 said the towels were locked up on the second floor. She said the residents had to ask for towels, as they were not passed out. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 2/26/26 at 2:30 p.m. The DON said the residents' towels racks were in their closets. She said the towels were replaced as used on a daily basis.-However, observations with the ADON revealed there were no towel racks in all resident's closets (see observation below).-However, according to resident interviews, there were no towel racks inside the closets and they did not receive hand towels unless they asked for them (see interviews above).V. Facility follow-upOn 2/26/26 at 3:15 p.m., the closets in room [ROOM NUMBER] and room [ROOM NUMBER] were observed with the ADON, who verified there were no towel racks in the residents; closets or in the bathroom. The resident who resided in room [ROOM NUMBER] told the ADON there were no towel racks in the closets or the bathroom.

Based on observations, record review and interviews, the facility failed to ensure the environment were free of accidents and hazards for one (#11) of two residents reviewed for accidents out of 41 sample residents and three of three emergency crash carts. Specifically, the facility failed to:-Ensure Resident #11 was assessed to determine if he was safe to smoke independently after an incident of unsafe smoking; and,-Ensure medical grade power strips were readily available in the crash carts (a specialized, mobile, and organized unit of trays and drawers on wheels containing essential life-saving equipment and medications). Findings include: I. Failed to ensure Resident #11 was assessed to determine if he was safe to smoke independently after an incident of unsafe smoking A. Facility policy and procedure The Resident Smoking policy and procedure, revised 6/12/25, was provided by the nursing home administrator (NHA) on 2/26/26 at 4:53 p.m. It read in pertinent part, Smoking is not allowed inside the facility under any circumstances. Any smoking related behavior, restrictions, or concerns shall be noted on the care plan. In the event a staff member observes a resident who is unsupervised smoking in a manner that is unsafe to themselves or others, that employee will immediately redirect the resident and inform the nurse, who is to inform the social services director (SSD) or designee, and then document the observations for review. A new smoking assessment will be performed. B. Resident #11 1. Resident status Resident #11, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes and chronic obstructive pulmonary disease. The 2/7/26 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident had no behaviors. 2. Resident interview An interview with Resident #11 was attempted on 2/23/26 at 9:38 a.m. Resident #11 declined to be interviewed. 3. Observation On 2/23/26 from 9:38 a.m. to 10:21 a.m., Resident #11 was observed in his room awake without a sitter present, despite staff interviews indicating the resident was supposed to have a sitter present due to his smoking behaviors (see interviews below). 4. Record review The smoking care plan, revised 5/2/25, revealed Resident #11 smoked cigarettes and electronic cigarettes and was an independent smoker. Interventions, dated 6/24/25, included to notify the charge nurse immediately if it was suspected that the resident had violated the facility's policies, inform the resident of the smoking policy/rules and regulations and conduct a smoking assessment quarterly and as needed. The smoking safety screen, dated 12/18/25, revealed: The resident was able to safely store his own smoking materials, followed facility policies regarding smoking and was safe to smoke independently and unsupervised. A nursing note, dated 1/17/26, revealed that Resident #11 was found in the basement conference room with a friend and the staff believed he had been smoking. The staff reminded him about the safety risks and the facility policy regarding smoking inside the building. Resident #11 did not appear receptive at the time and stated that he had opened a window. The resident was redirected back to his room and was cooperative with the staff. Ongoing monitoring was to continue. -Review of Resident #11's electronic medical record did not reveal documentation to indicate a new smoking safety screen was conducted after the incident on 1/17/26. C. Staff interviews Registered nurse (RN) #2 was interviewed on 2/25/26 at 4:30 p.m. She said Resident #11 had behaviors of verbal aggression towards staff, illicit drug usage and attempting to smoke cigarettes in his room. She said he had a sitter due to his smoking associated behaviors of attempting to smoke in his room and expressing verbal aggression when staff tried to redirect him. RN #2 said she could not recall the last time the resident had attempted to smoke in the building, but said he was not compliant with the staff reminding him of the facility's policies. She said when Resident #11 made attempts to smoke indoors, the staff reported the incident to the director of nursing (DON). Certified nurse aide (CNA) #5 was interviewed on 2/25/26 at 4:49 p.m. CNA #5 said he took shifts with other staff members to provide a sitter for Resident #11. CNA #5 said Resident #11 had a sitter related to his smoking associated behaviors of attempting to smoke in his room and expressing verbal aggression when staff tried to redirect him. SSD #2 was interviewed on 2/26/26 at 1:01 p.m. SSD #2 said smoking safety screens were completed at the time of admission, quarterly, with a change of condition, when there were behavioral issues around smoking and a failure to follow the facility's smoking policies. SSD #2 said Resident #11 was an independent smoker, but he could be defiant regarding following facility policies. She said she was not notified by nursing of the incident on 1/17/26 when the resident was smoking in the basement. SSD #2 said Resident #11 had a sitter related to allegations of inappropriate behaviors towards others. She said if she had known about the smoking incident on 1/17/26, she would have immediately completed a new smoking safety screen. The DON was interviewed on 2/26/26 at 3:12 p.m. The DON said social services conducted smoking safety screens at admission, quarterly, changes of condition and as needed. The DON said observations of unsafe smoking behaviors and refusal to follow smoking policies would trigger a new smoking safety assessment. She said if smoking related behaviors were observed, the staff would report that to the interdisciplinary team (IDT). The DON said that Resident #11 had a sitter due to an incident of unsafe smoking in January 2026 (see record review above). She said she investigated the incident and determined no new smoking safety assessment was required because Resident #11 was not observed actively smoking. The DON said she did not document her investigation or interviews because she brought it to the attention of the IDT and it was social services responsibility to document an investigation into the allegation. II. Failed to ensure medical grade power strips were readily available in the crash carts A. Observations The facility's three crash carts were observed on 2/25/26. The following was found: At 3:50 p.m. there was a commercial power strip found in the crash cart in the basement. The power strip was not a medical grad power strip. At 3:55 p.m. there was no power strip found in the crash cart on the first floor. At 4:00 p.m. there was a commercial power strip in the crash cart on the second floor. The power strip was not a medical grade power strip. The suction machine functioned appropriately. The facility's crash carts were observed again with the maintenance director (MTD) on 2/26/26. The following was found: At 11:12 a.m. the commercialized power strip in the basement crash cart was replaced with a medical grade power strip by the MTD. At 11:14 a.m. a medical grade power strip was placed in the first floor crash cart by the MTD. At 11:16 a.m. the commercialized power strip in the second floor crash cart was replaced with a medical grade power strip by the MTD. B. Staff interviews The MTD was interviewed on 2/26/26 at 11:16 a.m. The MTD said it was important to use medical grade power strips in the emergency crash carts because the commercial power strips had 20 amperes (amps; the standard unit for measuring electric current). He said the more amps, the more heat could be trapped and could cause a fire. The MTD said the medical grade power strips had 15 amps and created less heat, which decreased the risk of fire. The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 2/26/26 at 4:50 p.m. The ADON and the DON said the night nurses checked the crash carts nightly, the respiratory nurse checked them at least daily and the ADON checked the crash carts daily as a part of her morning rounds. The DON said she would expect to see a medical grade power strip stocked in the facility's crash carts so the power strip had enough power to handle the emergency equipment. C. Facility follow-up The MTD replaced the commercial power strips with medical grade power strips during the tour of the facility's crash carts on 2/26/26 beginning at 11:12 a.m. -However, the commercial power strips were not replaced with medical grade power strips in the crash carts until the concern was brought to the attention of the facility during the survey.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of two medication carts.Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy, dated February 2023, was provided by the nursing home administrator (NHA) on 1/26/26 at 9:23 p.m. It read in pertinent part, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date, when applicable; resident's name; route of administration; and, appropriate instructions and precautions.II. ObservationsOn 2/26/26 at 8:48 a.m. the second floor medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:There was one umeclidinium-vilanterol (Anoro Ellipta) inhalation aerosol powder breath activated 62.5-25 micrograms (mcg) per actuation (mcg/act) inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident's name or the date the medication was opened for Resident #62.There was one fluticasone-umeclidinium-vilanterol (Trelegy Ellipta) inhalation aerosol powder breath activated 100-62.5-25 mcg/act inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the date the medication was opened for Resident #67.There was one bottle of Systane long-lasting ophthalmic (eye) drops stored in an appropriately labeled medication box. -However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #60.On 2/26/26 at 10:08 a.m. the back hall medication cart on the first floor was observed with registered nurse (RN) #3. The following items were found:There was one dimethyl fumarate (Tecfidera) delayed release (DR) 240 milligram (mg) oral medication stored in an appropriately labeled medication box. -However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #24.There was one GenTeal severe 0.3 percent (%) ophthalmic gel stored in an appropriately labeled medication box.-However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #51.There was one umeclidinium-vilanterol (Anoro Ellipta) inhalation aerosol powder breath activated 62.5-25 mcg/act inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident's name or the date the medication was opened for Resident #61.There was one Albuterol sulfate hydrofluoroalkane (HFA) inhalation aerosol solution 108 (90 base) mcg/act inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident's name or the date the medication was opened for Resident #40.There was one Morphine sulfate immediate release (IR) 20 milligram per milliliter (mg/ml) oral solution stored in an appropriately labeled medication box. -However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #4.III. Staff interviewsLPN #1 was interviewed on 2/26/26 at 8:48 a.m. LPN #1 said medications should be labelled inside their respective boxes. She said it was important for the medications to be labelled inside the boxes in case the box was damaged by water or other liquids in the medication cart.RN #3 was interviewed on 2/26/26 at 10:08 a.m. RN #3 said the medications should be labelled inside their respective boxes so the medications did not get mixed up if the boxes were destroyed.The assistant director of nursing (ADON) was interviewed on 2/26/26 at 11:27 a.m. The ADON said she would have expected to see the medications labelled inside their medication boxes, because any medication could go in any medication box. She said this could cause a medication error.The director of nursing (DON) and the ADON were interviewed together on 2/26/26 at 4:50 p.m. The DON said it was important for medications to be labelled inside their respective boxes because the medication inside could become separated from its box. She said an unlabelled medication without its box could potentially cause a medication error, since the nursing staff would not know who the medication belonged to.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.Specifically, the facility failed to ensure necessary maintenance repairs were communicated and completed in a timely manner in the kitchen area.Findings include:I. ObservationsDuring a walkthrough of the kitchen on 2/25/26 from 11:28 a.m. to 11:53 a.m., the following was observed: -The wall behind the toaster was observed with visible burned marks. The wallpaper was observed peeling in multiple areas. There were sections of wallpaper observed missing above the toaster near the ceiling. -There were six holes observed in the wall to the right of the spice rack on the same wall as the toaster.-There were multiple areas of chipped paint observed on the ceiling along two pipes adjacent to the wall where the toaster was located. -There were multiple chipped paint marks observed on the ceiling along one pipe which was adjacent to the pipe line next to the wall where the toaster was located. -There were approximately twenty to thirty brown spots observed on the ceiling above the oven and stove. -The swamp cooler system located on the ceiling above the preparation table was observed with duct tape on one side. -The wall above and below the three-compartment sink was observed with multiple stains. At 11:33 a.m., the following was observed in the dishwasher room: -The vent to the right of the dishwasher was observed with an exposed sheetrock sheet measuring approximately six to eight inches in length.-There was a hole observed on the right side of the same vent. -There was missing tile observed on the wall and to the right of the dishwasher. -The vent above the dishwasher was observed with missing screws and was loose.-There were multiple areas of chipped paint marks observed above the sink. II. Staff interviews [NAME] (CK) #1 was interviewed on 2/25/26 at 11:50 a.m. CK #1 said if he needed anything repaired, he told the dietary manager (DM). He said he did not log if there were any repairs needed. CK #1 and dietary aide (DA) #2 were interviewed together on 2/26/26 at 4:00 p.m. CK #1 and DA #2 both said they did not know the last time the walls and ceiling in the kitchen were cleaned. DA #2 said he thought it was at least a month ago (January 2026), if not longer. The MTD was interviewed on 2/26/26 at 3:50 p.m. while touring the kitchen. The MTD said he had worked at the facility since October 2025. The MTD said he was responsible for the building's maintenance. The MTD said he tracked maintenance requests using a software system. The MTD said each department's management was responsible for informing him of maintenance requests in their departments. The MTD said there was not a dietary manager (DM) as of 2/20/26. The MTD said prior to 2/20/26, the DM did not inform him of any maintenance requests prior to leaving the facility. The MTD said the items identified on the kitchen tour, such as the holes in the wall, chipped paint and stains on the wall and ceilings, were not in his work order software system and they should be fixed.

Based on record review and interviews, the facility failed to ensure one (#69) of two residents reviewed for personal property out of 41 sample residents was able to retain their personal belongings. Specifically, the facility failed to receive consent from Resident #69 or his responsible party before disposing of his personal belongings after the resident was discharged to the hospital.Findings include:I. Resident #69A. Resident statusResident #69, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included quadriplegia and systemic lupus. The [DATE] minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Record reviewA nursing note, dated [DATE], revealed Resident #69's physician assessed him and found that the resident had phimosis (a condition where the foreskin could not be retracted) which required medical intervention. The physician ordered that the resident be transferred to the hospital. A social services note, dated [DATE], revealed the social services director (SSD) had a phone meeting with the resident's representative about his condition and discussed whether readmission would be plausible. The resident was going to start dialysis.A social services note, dated [DATE], revealed the SSD contacted the resident's representative regarding finding Resident #69's missing electronic tablet in the facility's lost and found. The representative asked if the resident's items were still in his room and the SSD informed the sister that his room had been cleaned out. The SSD said she would reach out to the director of nursing (DON) to find out if the items had been stored by someone, as the SSD was not aware of any discussions that might have happened between the family and other management. The SSD spoke with the admission director who said she had left Resident #69's representative a voicemail on [DATE] letting her know that since the resident had not been readmitted to the facility, his items would be packed up and stored. The admissions director told the SSD that the items had been packed up on [DATE] and stored in the facility's basement. The SSD spoke with the maintenance director who said that the items had been disposed of on [DATE] after storing the items for over the 30-day period (57 days). The SSD contacted both the resident's representatives on [DATE] and advised them of the disposal of many of the resident's personal items. The representatives were upset when provided with this information. A social services note, dated [DATE], revealed that the SSD called the resident's representatives back and let them know that his electric wheelchair, electronic tablet, and television had been found. When the SSD tried to discuss arrangements to pick up the items, the family discontinued the call. A social services note, dated [DATE], revealed the SSD spoke with the resident's representative and told her that she had 14 days to pick up his remaining items. The representative said she would pick up his belongings. -Review of Resident #69's electronic medical record (EMR) between [DATE] and [DATE] revealed there were no progress notes indicating the resident's representatives were notified to come and pick up the resident's belongings.-Review of the resident's EMR revealed there were no progress notes documented to indicate an initial call was made by the admissions director to the resident's representatives advising them of the potential that the resident's items would be disposed of in 30 days. II. Staff interviewsSSD #1 was interviewed on [DATE] at 1:00 p.m. SSD #1 said she had been the one to have a phone conference with Resident #69's representatives in [DATE] regarding the resident returning to the facility from the hospital. She said, at that time, she thought he was going to be readmitted to the facility, so there was not a conversation regarding storing his personal belongings. SSD #2 was interviewed on [DATE] at 1:18 p.m. SSD #2 said she had made the follow-up calls to Resident #69's representatives in February 2026. She said the admissions director did not usually make progress notes when she called families. SSD #2 said the facility would notify the families that items would be stored for 30 days and then disposed, of but the notification to Resident #69's representatives was a verbal notification. III. Facility follow-upOn [DATE] at approximately 3:00 p.m., SSD #2 provided an addendum to the facility's policy on discharge to include residents' personal items left in the facility. The policy outlined that all personal items would be packed, labeled, inventoried, and stored by the facility in a secure area of the basement. The social services department would make the verbal notification to the family and document a progress note. After 14 days, the social services department would send a reminder letter with the specific timeframe for pick up of residents' belongings. After the 30 days timeframe expired, the social services department would call the family to remind them about picking up the belongings and inquire about when items would be picked up. If the family wanted items to be disposed of or donated, a written letter would document this and the family would sign it.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically, the facility failed to ensure suction equipment was maintained in a sanitary manner.Findings include:I. Professional referenceAccording to the Healthcare Sterile Processing Association, August 2023, retrieved on 3/4/26 from https://myhspa.org/wp-content/uploads/2023/08/Fundamentals-of-sterile-storage.pdf, Healthcare facilities must take action to create an environment that properly protects sterile packages. This includes securing a proper sterile storage environment and developing policies and procedures to help ensure sterile packages are safely stored and handled. If items are not properly protected or something unexpectedly happens, stored items may become contaminated. Providing the appropriate sterile storage environment and training personnel about proper handling and other essential sterile storage practices is critical for ensuring that the items remain sterile and ready for patient care.II. ObservationOn 2/25/26 at 4:00 p.m. there was a Yankauer suction tip (a firm, plastic suction catheter designed to remove oral secretions) observed attached to the suction machine on the second floor crash cart. The Yankauer was not inside its sterile packaging.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/25/26 at 4:00 p.m. LPN #1 said she did not know what to turn the suction machine to in an emergency. She said a Yankauer suction tip was not supposed to be attached to the suction machine, because the Yankauer should be stored in a sterile container and might accidentally be used.The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 2/26/26 at 4:50 p.m. The ADON said part of the night nurse's duties when checking the crash carts was to check that the suction machine worked properly. The DON said while it might be considered best practice to have a Yankauer suction tip attached to the suction machine so it was readily available in an emergency, she did not think the Yankauer should be attached to the suction machine due to infection risk.

Based on observations, record review and interviews, the facility failed to provide ongoing programs to support choices of activities and engaging programming based on the comprehensive assessment and care plan that were designed to meet the interests of and support the physical, mental, and psychosocial well-being of two (#46 and #55) of three residents reviewed for activities out of 41 sample residents.Specifically, the facility failed to offer and provide personalized meaningful activity programs for Resident #46 and Resident #55 as documented in their care plans.Findings include:I. Resident #46A. Resident statusResident #46, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO) diagnoses included unspecified dementia, mood disturbance and anxiety. The resident was in hospice care.The 2/18/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff assistance for all activities of daily living (ADL) . The 3/14/21 MDS assessment revealed it was very important to the resident to listen to music, have animals around, keep up with the news and do her favorite activities. It was somewhat important to her to have books and magazines to read. B. Observations: On 2/23/26 at 12:10 p.m. Resident #46 was sitting in the dining room for lunch. Staff were assisting the resident with eating. There was no conversation being conducted with the resident while staff was assisting her with eating. During a continuous observation on 2/24/26, beginning at 1:58 p.m. and ending at 3:58 p.m. Resident #46 was lying in bed. There was no music playing in the resident's room or any other type of meaningful activity. During a continuous observation on 2/25/26, beginning at 1:29 p.m and ending at 4:30 p.m. Resident #46 was again lying in bed. The resident did not have any meaningful activity while she was in her room. There was no music or television (TV) playing on the resident's side of the room. The resident's roommate had the TV on, however, Resident #46 laid in bed holding the daily chronicle (facility daily bulletin) folded in a square. At 4:07 p.m. the business office manager entered Resident #46's room. The business office manager greeted Resident #46 and said she was in the room to check on the resident's bird. The business office manager remained in the room for only a few minutes. Resident #46 asked the business office manager to stay and visit, as she wanted some company. However, the business office manager said she could not stay and left the room. -No staff members from the care or activities teams were observed to come to the resident, per her request, to provide a one-on-one activity for her or to keep the resident company after the staff member left. C. Record reviewReview of Resident #46's activities care plan, updated 1/30/26, revealed the resident liked to watch TV, enjoyed visiting, her bird and reading the daily chronicle. Pertinent interventions were to assist the resident to activities of interest, encouraging the resident to participate in individual activities as desired. The activity assessment, dated 1/23/26, revealed Resident #46 liked to spend time in her room and attend group activities of her interest. She enjoyed religious prayer, arts and crafts, singing, parties, knitting and socializing. The assessment indicated that for attending the group activities, she needed more attention and encouragement. Review of Resident #46's activity participation record (from 1/29/26 to 2/26/26) revealed the resident participated in independent activities and also received supplies for independent activities. However, there was no documentation of what independent activities the resident was provided with.There was no documentation in the resident's participation record regarding group activities. II. Resident #55A. Resident statusResident #55 was admitted to the facility on [DATE]. According to the February 2026 CPO, diagnoses included depression, difficulty walking and chronic pain.The 1/26/26 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident was independent with ADLS. The 4/18/26 MDS assessment revealed it was very important for the resident to get fresh air when the weather was good and to participate in her favorite activities.B. Resident interview Resident # 55 was interviewed on 2/23/26 at 2:30 p.m. Resident #55 said she had not been able to go on any facility bus rides or shopping trips to buy certain personal items because she used a wheelchair for mobility and the facility's bus had a wheelchair lift that had been broken for a long time. The resident did not remember how long the lift had been broken for. She said she would really like to go on some of the outing activities. C. Record reviewReview of Resident #55's care plan, updated on 12/30/25, revealed Resident #55 was independent with activities, however she liked the community outings. Pertinent interventions included inviting and assisting the resident to activities of choice. Review of Resident #55's activity participation record (from 1/25/26 to 2/26/26) failed to reveal documentation to indicate the resident had participated in any activity outings. III. Staff interviewsThe activities director (AD) was interviewed on 2/25/26 at 11:41 a.m. The AD said she was newly hired to the facility. She said she was familiar with Resident #46. The AD said the resident liked to attend group activities, but she needed assistance to get to the activities. She said Resident #46 was receiving hospice care services. She said the activity department had staff coverage seven days a week, and that they were responsible for inviting the residents to group activities. She said Resident #46 received the facility's daily chronicle every day and enjoyed religious activities and coloring. The AD said the resident was not on a one-to-one activity program but she would benefit from one. She said sensory stimulation would also benefit the resident, however, other than hand massages, this had not been tried with her. She said she had not gotten in touch with hospice volunteers for the resident to see if they could provide visits. She said the business office manager should have informed activities staff that Resident #46 wanted to visit rather than just leaving the room after the resident requested her to stay (see observations above). The AD said she scheduled trips to the local store weekly. She said the facility had a van, however, the wheelchair lift was broken. She said Resident #55 could not climb the stairs of the bus and therefore was unable to go on the activity outings to the store or scenic trips. She said the facility had made attempts to repair the bus, but the bus was still broken. She said she had not looked into the possibility of using a sister facility's bus or the local city wheelchair bus so Resident #55 could attend outings. The AD confirmed that Resident #55 had requested to attend outings. The maintenance director (MTD) was interviewed on 2/25/26 at 4:20 p.m. The MTD confirmed the facility's wheelchair lift on the bus was broken. He said the attempts to repair the ramp had failed. The MTD said he could always borrow the buses from the facility's sister communities if needed.

Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent of additional pressure injuries for one (#46) of two residents out of 41 sample residents. Specifically, the facility failed to:-Ensure Resident #46, who had pressure injuries, was repositioned and provided incontinence care in a timely manner; and,-Ensure staff consistently implemented care planned pressure injury prevention interventions for Resident #46.Findings include:I. Professional referenceAccording to Basic Nursing third edition; [NAME] S. Treas, [NAME], [NAME] H. [NAME] (2022), page 1214-1215, Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort. People who are immobile are more prone to pressure injury as a result of reduced circulation, impaired oxygen exchange to the tissues and edema.According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 2/10/22, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable 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 I 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. *Bruising indicates suspected deep tissue injury. 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. Resident #46A. Resident statusResident #46, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, mood disturbance and anxiety. The 2/18/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff assistance for all activities of daily living (ADL).The MDS assessment indicated the resident was at risk for developing pressured injuries and had at least one unhealed pressure injury. B. ObservationsOn 2/23/26 at 11:50 a.m. Resident #46 was being assisted to the dining room. The resident's feet were resting on her wheelchair foot pedals, however, she did not have the protective boots on her feet. She was not wearing shoes and her sock feet were resting directly on her foot pedals.During a continuous observation on 2/24/26, beginning at 1:58 p.m. and ending at 5:20 p.m., the following was observed:At 1:58 p.m. Resident # 46 was sleeping on her back in bed.At 2:33 p.m. the resident continued to be in the same position, lying on her back with no repositioning. There were no positioning wedges observed in the room, and the resident did not have protective boots on her feet. The resident's heels were resting directly on the mattress. At 3:58 p.m. Resident #46 continued to lay on her back in bed with no repositioning offered by staff.At 5:20 p.m. the resident continued to lay on her back in bed. There had been no staff members in the resident's room to offer her repositioning with wedges or place protective boots on her feet. During a continuous observation on 2/25/26, beginning at 1:29 p.m. and ending at 4:30 p.m. the following was observed:At 1:29 p.m. Resident #46 was laying in bed on her back with her head slightly raised., There were no positioning wedges offloading the resident. At 2:35 p.m., the resident continued to lay on her back in bed with her head slightly raised.-No staff members had entered the room to provide incontinence care and repositioning to the resident. At 4:22 p.m. registered nurse (RN) #1 and RN #2 entered Resident #46's room to provide wound care for the resident. The nurses proceeded to uncover the resident in order to perform wound care. The resident's heels did not have protective boots on and her heels were lying directly on the mattress. RN #2 proceeded to open the resident's brief and perform wound care on the resident's sacrum pressure wound while RN #1 assisted. The stage 3 pressure injury on the resident's sacrum was cleaned with normal saline, patted dry, and medihoney ointment (wound treatment) was applied and the wound was covered with a dressing, per the physician's order. RN #2 began to close the resident's brief after finishing the wound care on the resident's sacrum. When prompted, RN #2 changed Resident #46's brief and said the resident was wet. After changing the resident's brief, RN #1 proceeded to perform the wound care on the resident's right heel. The unstageable pressure injury on the resident's right heel was cleaned with normal saline and covered with a dressing, per the physician's order. Before leaving the resident's room, RN #1 put Resident #46's protective boots on the resident. The resident allowed the application of the boots.On 2/26/26 at 8:30 a.m. Resident #46 was in the dining room for breakfast. The resident did not have protective boots on her feet. Resident #46's heels were resting directly on the wheelchair foot pedals. C. Record ReviewReview of Resident #46's pressure injury care plan, updated 1/28/26, identified the resident had a deep tissue injury to the right heel and a stage 3 pressure ulcer to the sacrum. Pertinent interventions included monitoring the wounds per facility protocol with offloading, treatment orders, applying heel protecting boots and offloading heels while the resident was in bed and applying heel protecting boots while the resident was up in her chair as well to prevent pressure injuries and encouraging and assisting the resident with turning and repositioning frequently while in bed, and as tolerated.The nurse progress note, dated 1/28/26, revealed the development of a new pressure injury on the resident's right heel. The progress note documented new interventions included heel offloading by pillows/heel protectors to prevent further pressure injuries and putting the resident on a repositioning schedule.-However, observations revealed staff were not consistently offloading the resident's heels or providing timely repositioning to the resident (see observations above). The nurse progress note, dated 2/10/26, revealed the resident developed a new sacral pressure injury and the wound care physician had determined that it was an unavoidable pressure injury. Per the progress note, the facility initiated frequent rounding to reinforce skin care and repositioning as tolerated, maintaining pressure-relief interventions, including low air-loss mattress, heel offloading boots, pillows, and positioning wedges for side-lying/offloading as tolerated by the resident, encouraging oral intake and supplements as tolerated, continuing frequent repositioning attempts with gentle re-approach due to refusals,and honoring resident preferences and comfort-focused goals.The wound tracking evaluation, dated 2/17/26, revealed Resident #46 had a stage 3 pressure injury on the sacral area with dimensions of 4 centimeters (cm) by 3 cm by 0 cm, initiated on 2/9/26, and a closed unstageable right heel with dimensions of 3 cm by 4 cm by 0 cm, initiated on 1/28/26. D. Staff interviews: Registered nurse (RN) #3 was interviewed on 2/26/26 at 10:22 a.m. RN #3 said Resident #46 had a pressure injury on her sacrum and one on her right heel. She said the resident was at high risk for pressure injuries due to immobility and incontinence. She said Resident #46 was to be checked on frequently. She said the resident was to have the foot protection boots and was to be repositioned when she was in bed. RN #2 was interviewed on 2/26/26 at 10:30 a.m. RN #2 said the repositioning requirements for Resident #46 had been added to the medication administration records (MAR), in order to ensure the resident was being repositioned. RN #2 said the staff had been in-serviced about the importance of residents being repositioned every two hours. She said if Resident # 46 refused repositioning, staff should document the refusal. The assistant director of nursing (ADON) was interviewed on 2/26/26 at 11:09 p.m. The ADON said she was the wound care nurse and she completed wound care rounds with the wound care physician. She said the wound care physician measured the residents' wounds, and made any changes to wound treatments in the physician's orders. The ADON said Resident #46's wounds were classified as unavoidable due to her comorbidities. She said the resident should have the interventions of the heel protectors on her heels at all times and staff should be repositioning the resident every two hours.

Based on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for two (#24 and #67) of three residents reviewed for respiratory care out of 41 sample residents.Specifically, the facility failed to:-Ensure the physician's order matched the resident's preference for oxygen administration for Resident #24; and,-Ensure there was a physician's order for oxygen use for Resident #67.Findings include: I. Facility policy and procedure The Oxygen Administration policy, dated October 2010, was provided by the nursing home administrator (NHA) on 2/26/26 at 9:23 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident and assemble the equipment and supplies as needed. II. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD - restrictive airflow caused by inflammation), multiple sclerosis (MS - autoimmune disease of the central nervous system) and neuromuscular dysfunction of the bladder (loss of normal bladder control caused by MS). The 1/28/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #24 was dependent on staff for activities of daily living (ADL), including dressing, showering, toileting and ambulating. He required set-up assistance for oral hygiene and was independent with eating. The 1/28/26 MDS assessment revealed Resident #24 required the use of oxygen therapy. B. Observations On 2/23/26 at 5:04 p.m. Resident #24 was in the dining room. The resident was not connected to a continuous oxygen source. On 2/24/26 at 9:00 a.m. Resident #24 was sitting in his powered wheelchair in his room. He was not connected to a continuous oxygen source or wearing a nasal cannula. On 2/24/26 at 5:18 p.m. Resident #24 was in the dining room. He was not connected to a continuous oxygen source. On 2/25/26 at 8:04 a.m. Resident #24 was in the dining room. The resident was not connected to a continuous oxygen source. On 2/25/26 at 11:17 a.m. Resident #24 was independently transporting himself in his powered wheelchair around the hallways on the first floor of the facility. He was not connected to a continuous oxygen source. -However, the resident's physician's order for oxygen indicated the resident was to be on continuous oxygen (see physician's orders below). C. Resident interview Resident #24 was interviewed on 2/24/26 at 9:00 a.m. Resident #24 said he used oxygen when he was lying down because he could not breathe when he was lying down. He said he particularly needed the oxygen when he took a nap or slept at night. -However, the resident's physician's order for oxygen indicated the resident was to be on continuous oxygen, not just when he was lying down (see physician's orders below). D. Record review Review of Resident #24's February 2026 CPO revealed the following physician's order: Continuous oxygen at 2 to 5 liters per minute (LPM) via nasal cannula to keep oxygen saturation between 88 to 92 percent (%), every shift, ordered 2/5/26. Resident #24's comprehensive care plan, initiated 6/2/22, revealed the resident had ordered supplemental oxygen related to COPD and chronic respiratory failure with hypoxia. Pertinent interventions included the resident preferred to wear supplemental oxygen at night, monitoring for signs/symptoms of respiratory distress and reporting to the physician as needed: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color, offering incentive spirometer (a handheld device designed to strengthen lungs and open airways by encouraging slow, deep breaths) per physician's order and evaluating lung function and utilizing oxygen settings per physician's orders. E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/25/26 at 11:05 a.m. LPN #1 named registered nurse (RN) #2 as the facility's respiratory RN. She said a resident with a physician's order for continuous oxygen should wear oxygen continuously, but she said a lot of the residents had their own preferences regarding their oxygen. RN #1 was interviewed on 2/25/26 at 2:30 p.m. RN #1 said a continuous oxygen order meant the resident should wear their oxygen continuously, but she said Resident #24's physician's order indicated to keep his oxygen saturations between 88% to 92%. She said Resident #24's oxygen saturation was last documented as 93%, so that was why the resident was not using the continuous oxygen. RN #1 said the moment Resident #24 was in bed, he would wear the oxygen. RN #1 spent a few minutes looking in Resident #24's electronic medical record (EMR), but was unable find documentation that the physician had been notified that Resident #24 did not wear the oxygen continuously as ordered. RN #2 was interviewed on 2/25/26 at 2:35 p.m. RN #2 said she did not think the physician had been notified that Resident #24 did not wear his oxygen continuously as ordered. She said the physician knew the resident did not wear the oxygen continuously because the resident smoked cigarettes, and he was unable to smoke while he wore oxygen. RN #2 said since Resident #24's oxygen order said oxygen saturations should be maintained at 88% to92%, she interpreted the order to mean that the resident did not require continuous oxygen if his oxygen saturations were within the physician ordered parameters. She said she would update the order to read at night and would notify the physician. The director of nursing (DON) was interviewed on 2/25/26 at 2:39 p.m. The DON said Resident #24's oxygen order should specify that he needed continuous oxygen at night. She said the facility could update the order to make it consistent with the resident's preferences. The DON said Resident #24 did not need to wear the oxygen if his oxygen saturations were within the physician ordered parameters. RN #2 was interviewed again on 2/25/26 at 4:46 p.m. RN #2 said she spoke with the physician and together they determined the therapeutic oxygen flow for Resident #24 was 3 LPM. She said the physician agreed to the order specifying that Resident #24 wore the oxygen continuously while in bed. F. Facility follow-up A second review of Resident #24's February 2026 CPO on 2/25/26 revealed the following physician's order: Oxygen at 3 LPM via nasal cannula continuously while in bed, every shift, ordered 2/25/26. -However, the physician's order was not changed to reflect Resident #24's preferences for wearing continuous oxygen the concern was brought to the facility's attention during the survey. The DON was interviewed again on 2/26/26 at 4:50 p.m. The DON said she saw Resident #24's updated oxygen order, and she thought the updated physician's order was more appropriate to match the resident's preferences. She said she did not think the physician's order needed to include oxygen monitoring parameters. III. Resident # 67 A. Resident status Resident #67, age [AGE], was admitted on [DATE] According to the February 2026 CPO diagnoses included type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease (COPD). According to the resident's Level I Pre-admission Screening and Resident Review (PASRR) assessment, the resident was cognitively intact. B. Observations On 2/23/26 at 4:30 p.m. Resident #67 was sitting in bed. She was wearing a nasal cannula and her oxygen was set to 3 liters per minute (LPM). On 2/25/26 at 11:23 a.m. Resident #67's oxygen was set to 2.5 LPM. C. Record review A review of Resident #67's February 2026 CPO on 2/25/26 revealed the resident had no physician's order for oxygen therapy. The progress note, dated 2/20/26, documented Resident #67 was started on oxygen at 2 LPM via nasal cannula. D. Staff interview LPN #1 was interviewed on 2/25/26 at 9:56 a.m She said Resident #67 was on oxygen therapy for her diagnosis of COPD. She confirmed oxygen was considered a medication and required a physician's order to administer it. After reviewing Resident #67's physician's orders, LPN #1 said she was not able to locate the physician's order for the resident's use of oxygen. E. Facility follow-up A second review of Resident #67's February 2026 CPO on 2/26/26 revealed a physician's order for oxygen administration was obtained on 2/25/26 at 10:46 a.m. -However, the physician's order for Resident #67's oxygen administration was not obtained until the concern was brought to the facility's attention during the survey.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#37) of two residents out of 41 sample residents. Specifically, the facility failed to: -Ensure a complete and thorough pain assessment was completed that identified Resident #37's history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident's quality of life; -Identify Resident #37's goals for pain management and acceptable level of pain; -Identify Resident #37's locations of pain; and, -Ensure Resident #37's location of pain was consistently identified when administering pain medication to the resident.Findings include: I. Facility policy and procedureThe Pain Management policy, revised June 2022, was provided by the nursing home administrator (NHA) on 2/26/26 at 6:46 p.m. It read in pertinent part, The facility will evaluate and identify residents experiencing pain, evaluate the existing pain and the use, determine the type and severity of the pain and develop a care plan for management consistent with the resident's goals and preferences. The care plan is implemented and evaluated for its effectiveness. The staff monitors and documents the resident's response to pain management interventions. Pain screening is conducted upon admission, quarterly and annually thereafter using the pain evaluation. The goal of the pain management system is to effectively and consistently identify and treat pain.II. Resident #37 A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic pain syndrome, malignant neoplasm of rectum and rectosigmoid junction (cancer located in the lower part of the large intestine where the colon meets the rectum), obesity, major depressive disorder, peripheral vascular disease (a circulatory condition that reduces blood flow to the arms or legs), chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it difficult to breathe due to airflow blockage), unilateral inguinal hernia (a condition where tissue pushes through a weak spot in the abdominal muscles on one side of the groin), osteoarthritis, spinal stenosis (narrowing of the spaces within the spine), acute kidney failure, benign prostatic hyperplasia (BPH - noncancerous enlargement of the prostate gland that can cause urinary problems) and hypoxemia (lower-than-normal levels of oxygen in the blood). The 1/20/26 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. He was independent with eating, oral hygiene, toileting and personal hygiene. He required partial assistance with showering. The assessment revealed Resident #37 did not have a pain management regimen. He took pain medication as needed and received non-medication interventions for pain. He had pain in the past five days of the look back assessment period. The assessment revealed the resident's pain occasionally occurred and occasionally made it difficult to sleep and occasionally limited his day to day activities because of pain. A numeric scale was completed for pain intensity and his worst pain was a 3 on a scale of 0 to 10. The resident said his pain intensity was described as mild.B. Resident interview Resident #37 was interviewed on 2/23/26 at 3:23 p.m. Resident #37 said he had been prescribed oxycodone (opioid pain medication) for the last eight years due to surgery he had on his neck. He said he used to ride his bike five to ten miles a day but could no longer do so because of the pain. He said his physician wanted to discontinue all oxycodone orders. He said he used to be on oxycodone 20 milligrams (mg) three times a day and now he was on oxycodone 10 mg every 12 hours. Resident #37 said if the physician stopped prescribing his oxycodone he had ways of obtaining oxycodone. He said he knew people on the street and that was what he had been doing since his physician changed his oxycodone order. He said yesterday, 2/22/26, he bought two 5 mg oxycodone tablets on the street in addition to the oxycodone administered by the facility. Resident #37 said he experienced pain where his hernia was located as well as abdominal pain. He said he had abdominal surgery because his intestines were twisted. Resident #37 lifted his shirt and showed the surgical scar that was vertically along his abdomen, extending from a few inches above his belly button to a few inches below his belly button. He said his physicians and nurses asked him if he knew he had a hernia and he said he knew because he was reminded of it all day because of the pain. Resident #37 said he additionally had pain in both knees. He said he had cancer and the chemotherapy damaged the ligaments in his knees. He said his current pain level was a 6 out of 10 and increased to an 8 on some days. He said his goal for pain management was to have a pain level of 0. He said his goal was to be able to return to his previous lifestyle as much as possible. C. Record review Resident #37's pain care plan, revised 9/29/25, revealed he had acute pain related to an abdominal incision from a colon resection, history of cervical spine fusion, carpal tunnel syndrome, spinal stenosis and COPD. Interventions included administering analgesia (pain relief) as ordered, monitoring and recording pain characteristics every shift and as needed, monitoring and reporting to nurse any signs and symptoms of non-verbal pain, and notifying the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. -The care plan did not include non-pharmacological interventions, monitoring for pain medication effectiveness, and monitoring for side effects of opioid (a class of natural, man-made, or semi-synthetic chemical compounds that interact with opioid receptors on nerve cells in the body and brain to reduce the intensity of pain signals) use. The 10/6/25 pain assessment revealed Resident #37 had pain in the last five days. He had a pain management regime, he took pain medication as needed and he received non-medication interventions for pain. The assessment documented the resident's pain rarely occurred, rarely interfered with therapy activities and rarely interfered with his day-to-day activities. A numeric scale was completed for pain intensity and his worst pain was a 3 on a scale of 0 to 10. -However, the treatment, side effects and effectiveness of pain medications sections were left blank for the scheduled pain medication regimen. The administration patterns, side effects and effectiveness sections were left blank. The non-medication interventions and effectiveness section was left blank. The 1/7/26 pain assessment revealed Resident #37 had had pain in the last five days. He took pain medication as needed and he received non-medication interventions for pain. The assessment documented his pain occasionally occurred, occasionally interfered with sleep and occasionally interfered with his day-to-day activities. A numeric scale was completed for pain intensity and his worst pain was a 3 on a scale of 0 to 10. -However, the administration patterns, side effects and effectiveness sections were left blank for pain medication as needed. The non-medication interventions and effectiveness section was left blank.Resident #37's February 2026 CPO revealed the following physician's orders: Oxycodone 5 mg. Take one tablet by mouth every four hours as needed for moderate to severe pain, ordered 9/28/25 and discontinued 1/16/26. Oxycodone 5 mg. Take one tablet by mouth every six hours as needed for moderate to severe pain for 14 days, ordered 1/16/26 and discontinued 2/10/26.Oxycodone 5 mg. Take one tablet by mouth every eight hours as needed for moderate to severe pain, ordered 1/16/26 and discontinued 2/10/26. Oxycodone 5 mg. Take one tablet by mouth every 12 hours as needed for a pain level of 5 to 10, ordered 2/10/26. Cymbalta 60 mg. Take one capsule by mouth one time a day for pain, ordered 9/29/25 and stopped 10/9/25. Cymbalta 60 mg. Take one capsule by mouth one time a day for pain and depression, ordered 10/9/25. Gabapentin 300 mg. Take two capsules by mouth at bedtime for pain, ordered 9/29/25. Acetaminophen. Take 1000 mg by mouth every six hours as needed for pain. Maximum dose is less than 3000 mg, ordered 12/5/25. Document nonpharmacological interventions attempted prior to pain medication using the key provided every shift. Repositioning, reassurance, distraction, exercise, rest, deep breathing exercises, massage, guided imagery, laughter, socialization, aromatherapy or other, ordered 9/28/25.Evaluate pain utilizing the 0 to 10 pain scale as appropriate for the resident every shift for pain management, ordered 9/28/25. -Review of Resident #37's electronic medical record (EMR) did not reveal documentation indicating if the non-pharmacological pain interventions were effective.The 1/1/26, 1/2/26, 1/3/26, 1/5/26, 1/7/26, 1/8/26, 1/10/26, 1/14/26, 1/16/26, 1/17/26, 1/24/26, 1/25/26, 1/29/26, 1/31/26, 2/6/26, 2/7/26, 2/14/26, 2/21/26 and 2/24/26 nurse notes revealed Resident #37 was administered oxycodone 5 mg. The 1/9/26 and 1/30/26 nurse notes revealed the resident was administered acetaminophen 1000 mg. -However, there was no documentation indicating where the pain was located when the oxycodone 5 mg or acetaminophen 1000 mg were administered between 1/1/26 and 2/24/26. - A review of Resident #37's EMR revealed the non-pharmacological interventions were not determined as a personalized pain management intervention for the resident. The 12/9/25 physician notes revealed Resident #37 had a history of spinal stenosis, cervical spondylotic myeloradiculopathy (age-related spinal cord compression), myelopathy (spinal cord compression causing nerve symptoms) and degenerative disc disease of the cervical spine. Treatment had included decompression, discectomy (surgical disc removal), laminectomies (spinal decompression surgery), and spinal fusion. The resident had peripheral neuropathy (nerve numbness that causes pain) due to and not concurrent with chemotherapy, as well as baseline neuropathy related to cervical and lumbar spine conditions. Chemotherapy and radiation had been completed in October 2020, with chemotherapy discontinued due to neuropathy. The resident had ulnar neuropathy at the elbow of the left upper extremity (nerve damage or irritation affecting the elbow and arm). Additionally, the resident had chronic bilateral knee pain, including osteoarthritis of the right knee and chronic left knee pain. Pain had been reported as fairly well controlled with acetaminophen (Tylenol) 1000 mg every six hours as needed, duloxetine (Cymbalta) 60 mg daily, gabapentin 600 mg at bedtime, and oxycodone 5 mg every four hours as needed. The resident had been scheduled to see pain management on 12/22/25. He had additionally been scheduled for surgery on the left arm and wrist on 1/27/26, with plans to continue coordination of care with orthopedics. Therapies and supportive care had been continued as indicated.The 1/16/26 physician note revealed there was an update from the pain management clinic indicating the resident was discharged from the pain management clinic due to a toxicology screen in December 2025 being positive for methamphetamine (often called meth or crystal meth, is a potent and highly addictive synthetic stimulant drug that affects the central nervous system). The urinalysis was reviewed with the resident and was positive for methamphetamines. It was reported that the office would be discharging the resident from their practice due to this result. The resident was educated that he continued to receive oxycodone as needed; however, due to the positive drug screen and for his safety, the medication would need to be gradually weaned. The resident voiced understanding. He communicated to multiple people at the office he would find oxycodone off the street if needed. The resident was educated on the risk of overdose, death or injury by using drugs purchased on the street. The 1/21/26 physician's social worker note revealed Resident #37 said pain management dropped him and he would no longer receive pain medication after 1/30/26 due to him popping hot (testing positive for methamphetamine in a toxicology screen). The resident reported he was unsure what the plan was to manage his pain starting at the beginning of next month (February 2026). He reported he did not understand the reason pain management discharged him. Shortly after stating that, he mentioned this was discussed with his physician during their visit as well as informed risk regarding taking certain medications while utilizing illicit drugs. The 2/10/26 physician note revealed Resident #37 reported pain in his hands, knees and from hernias. His pain control was unclear. He was likely using methamphetamine and likely using opioids he got from the street. Concurrent use of methamphetamine and opioids was not safe and they would continue to wean the resident off oxycodone. The plan was to decrease oxycodone to 5 mg every 12 hours as needed.-However, the facility failed to ensure other non-opioid medications were implemented in place of the oxycodone medication that was being weaned in order to ensure Resident #37 was able to achieve effective pain management without the opioid medication. III. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 2/26/26 at 10:47 a.m. CNA #4 said today (2/26/26) was her first day working in the facility. She said if a resident reported pain, she asked the resident where the pain was located and reported the pain to the nurse. CNA #4 said she was not sure if CNAs documented pain at this facility, but some facilities had CNAs document pain in their daily charting. CNA #4 said she met Resident #37 this morning and he was not happy. She said he did not report any pain to her. She said she did not know what helped his pain go away or what made his pain worse. CNA #5 was interviewed on 2/26/26 at 11:03 a.m. CNA #5 said if a resident reported pain to him, he asked the resident to rate their pain and where they experienced pain. He said he told the resident he informed the nurse. He said he asked the nurse if they could assess the resident due to what the resident reported to him. He said he did not document if a resident reported pain to him. CNA #5 said he was familiar with Resident #37. He said he had pain in his back and legs. CNA #5 said pain medication helped the resident and sometimes something cold to drink or coffee helped alleviate his pain. He said Resident #37 talking to his family or friends on the phone helped him with his pain. Licensed practical nurse (LPN) #1 was interviewed on 2/26/26 at 11:30 a.m. LPN #1 said pain assessments were completed when the residents were admitted , quarterly and as needed. She said pain was documented on an assessment form in their EMRs. She said the pain assessment documented where a resident's pain was located, the intensity of the pain, what medications were used for pain before, what worked for relieving the pain and what did not work to help the resident get to baseline. She said she asked what non-pharmacological interventions worked for pain relief. She said she asked what their baseline goal level for pain was and what their acceptable pain level was. LPN #1 was familiar with Resident #37. She said he had pain and he complained about pain a lot. She said he had pain in his hands, wrists and his lower back. She said sometimes he had a headache. She said his goal was to be pain free or a 0 out of 10 pain level. She said he did not complain about pain everyday but approximately 75% of the time, he complained about pain. She said he had pain since she started working at the facility in December 2025. She said too much exertion made his pain worse, such as going outside and therapy. LPN #1 said if Resident #37 used his wheelchair too much, his pain in his hands would hurt. She said he never asked for pain medications for his knees or abdominal incision, she said it was mostly for his hands and wrists. The director of nursing (DON) was interviewed on 2/26/26 at 5:00 p.m. The DON said pain assessments were completed when the residents were admitted , quarterly and as needed. She said pain was documented on an assessment form in their EMRs. She said the assessment covered where the pain was located, the intensity of the pain, what worked for treating the pain and what did not work to help the resident get to baseline. She said she asked what non-pharmacological interventions worked for pain relief. She said she asked what their baseline goal level for pain was and what their acceptable pain level was. The DON said she was familiar with Resident #37. She said he had pain in his hands due to carpal tunnel syndrome. She said he rarely complained about pain. The DON said he was mostly outside of the building smoking. She said his pain management was to not have any pain. She said he had been in pain since he was admitted to the facility. She said his physician was not a facility physician and the physician decreased his pain medications. IV. Facility follow up The NHA provided the following information on 2/27/26 at 3:57 p.m., after the survey exit. Per the NHA, the documentation provided revealed the facility's diligence in monitoring Resident #37's pain, offering pain medication as needed and non-pharmacological interventions each time he voiced his pain concerns. According to the documentation, it was effective in managing his pain levels at those times. The documentation included the 2/10/26 physician's progress note indicating the resident tested positive for methamphetamines, the resident admitted to using methamphetamine and buying oxycodone off the street (see record review above). He said he typically took 10 mg more oxycodone than what he received from the physician. The 1/7/26 pain assessment for Resident #37 was provided which highlighted the resident's pain frequency as occasional. Resident #37's January 2026 MAR was provided and highlighted that nonpharmacological interventions were utilized, the resident's pain was evaluated every shift and acetaminophen and oxycodone were administered when requested by the resident.-However, the documentation did not indicate Resident #37's pain assessment was complete, identify what the resident' pain management goals were, identify all pain locations or indicate the location of pain was identified when administering pain medication to Resident #37.

Based on observations, record review and interviews, the facility failed to ensure one (#30) of three residents reviewed for ancillary services out of 41 sample residents received dental services timely. Specifically, the facility failed to: -Ensure Resident #30 was provided timely emergency dental services after reporting tooth pain; and, -Ensure Resident #30 was offered routine dental care.Findings include: I. Facility policy and procedure The Dental Services policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 2/26/26 at 6:46 p.m. It read in pertinent part, Routine and 24-hour emergency dental services are provided to the residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, referral to community dentist or referral to other health care organizations that provide dental services. Selected dentists must be available to provide follow up care. Failure of a dentist to provide follow up services will result in the facility's right to use its consultant dentist to provide the resident's dental needs. Social services representatives assist residents with appointments, transportation arrangements and for reimbursement of dental services under the state plan, if eligible. All dental services provided are recorded in the resident's medical record.II. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included osteoarthritis, chronic pain syndrome, hyperlipidemia, polyneuropathy, insomnia, major depressive disorder, generalized anxiety disorder and post traumatic anxiety disorder. The 1/19/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required a wheelchair. She was independent with eating, oral hygiene, toileting, showering, and personal hygiene. The MDS assessment indicated the resident had no dental issues. B. Resident interview and observation Resident #30 was interviewed on 2/24/26 at 10:32 a.m. Resident #30 said she had to have a tooth pulled on 2/25/26. She said she needed to see a dentist because it had been a while. During the interview, Resident #30 was observed visibly in pain on her right side of her face, specifically her cheek and jawline. She had her head titled down to her right shoulder while being interviewed. When asked if she was in pain, Resident #30 said she was in pain and on a pain scale of zero to 10, zero being no pain, her pain level was currently an 8. Resident #30 asked to end the interview because of her pain, and she did not want to talk. There was a white caked substance observed on her upper front teeth. C. Record review The informed consent for dental, audiology and optometry services revealed Resident #30 signed the consent on 12/1/25. The 12/9/25 physician progress note revealed that Resident #30 was asked not to return to the dental office where she was previously seen due to behaviors related to obtaining local anesthesia during the last visit. The physician's referral included an order for an external dental exam, Xrays and prophy (a routine preventative cleaning for healthy gums or gingivitis) at the nursing facility. The timeframe to complete the order was one week. The 1/15/26 social services progress note revealed Resident #30 was on the schedule to see the dentist on 1/6/26, however, Resident #30 was out of the facility so the appointment was to be rescheduled. -The appointment was scheduled for 1/6/26, 28 days after the physician referred Resident #30 to be seen by the facility dentist (see physician's progress note above). The 2/10/26 dental emergency evaluation form revealed Resident #30 had pain on her upper right and lower right side of her mouth. The pain level was a 7 out of 10 and the pain had been present for seven days. There were no antibiotics or pain medication prescribed. The 2/12/26 nurse note revealed Resident #30 was seen by the dentist in the morning for a recent complaint of pain in her gums and mouth. The dentist ordered oral antibiotics. The 2/13/26 nurse note revealed Resident #30 started her first dose of antibiotics and was compliant with the treatment. There were no side effects noted. The resident said she had pain on her gums that goes on and off. Resident #30 was on scheduled pain medication. The 2/18/26 social services note revealed Resident #30 was evaluated on an emergency basis due to dental pain. The dentist determined the affected tooth was infected and recommended extraction. Nursing reported Resident #30 recently completed a course of antibiotics for the infection and her pain was being managed. She was scheduled for an oral surgery consultation and treatment on 2/25/26 at 12:30 p.m. Social services director (SSD) #1 notified the physician of the upcoming appointment. Social services remained available for support and services as needed. -However, the social services note was completed one week after the dental emergency form was completed by nursing (see 2/10/26 dental emergency form above). The 2/19/26 social services note revealed Resident #30 had been on the dentist schedule for 2/9/26, however, the resident was not seen and would be rescheduled for the dentist's next visit to the facility. -The appointment was scheduled on 2/9/26, 62 days after the physician referred Resident #30 to be seen by the facility dentist (see physician's progress note above). The 2/22/26 at 12:43 p.m. nurse note revealed Resident #30 complained about pain around her right ear, below her right jaw and neck. There was no complaint of gum pain or oral pain. During the assessment, there was a complaint of swelling or redness on her gum or mouth. Resident #30 said the pain came with mild to moderate intensity. The physician was notified through the on-call nurse. Resident #30 was taking scheduled pain medications. Diclofenac gel applied to the affected pain area and the resident was waiting for a new order from the physician to treat the pain. The 2/22/26 at 6:01 p.m. nurse note revealed there was a faxed physician's order received for naproxen (medication to treat pain) and the resident was notified of the new medication. IV. Staff interviews SSD #1, SSD #2, and the social services assistant (SSA) were interviewed together on 2/26/26 at 1:19 p.m. SSD #1 said when a resident requested dental services, social services sent a referral to the dentist after obtaining consent from the resident or responsible party. The SSA said the dentist provided social services with a list of residents to be seen at the next on-site dental visit. The SSA said the dentist came to the facility every other month.The SSA said residents were seen by the dentist annually or quarterly, depending on their insurance coverage. SSD #1 said if a resident had a specific dental need or emergency, the facility figured out a way for the resident to be seen by a dentist sooner, regardless of insurance coverage. SSD #1 said residents could be seen at the dentist's next scheduled visit to the facility, unless the situation was considered an emergency.The SSA said the dentist provided the list of residents to be seen on the day of the visit to the facility and sometimes one week prior to their visit. The SSA said during the dentist's February 2026 visit to the facility, the dentist did not see all residents on the list because he ran out of time. SSD #1 and the SSA said the dentist usually was able to see all of the residents who were scheduled to be seen. SSD #1 said if a resident complained of tooth pain, an emergency dental form was completed by the dentist. She said nursing was responsible for notifying the physician and the responsible party. SSD #1 said she used the emergency form to send to the dentist to schedule an appointment. SSD #1 said residents referred for oral surgery could usually be seen the same day.SSD #1 said she was familiar with Resident #30. She said she had received an email on 12/1/25 from the physician requesting a referral to the in-house dentist. SSD #1 said consent was obtained from Resident #30 and she was added to the next dentist visit to the facility. SSD #1 and the SSA said there needed to be better communication with the physician to confirm dental visits. SSD #1 said she did not know how the referral for Resident #30 had been made in December 2025 and did not know when Resident #30 was last seen by a dentist. SSD #1 said she was unaware the referral had been made to the facility dentist because Resident #30 had been discharged from the physician's dental provider.SSD #1 was interviewed a second time on 2/26/26 at 4:17 p.m. SSD #1 said she contacted the oral surgeon's office and learned Resident #30 did not attend her scheduled oral surgery appointment on 2/25/26. SSD #1 said she contacted the dental provider for clarification on why the resident was not seen for oral surgery on 2/25/26. She said the provider told her they told Resident #30 not to go to the appointment as the procedure would have resulted in an out of pocket expense for the resident and the dental provider did not contract with the oral surgeon. SSD #1 said the dental provider said the original referral to the oral surgeon was sent by the dentist before realizing the provider was not within their network. SSD #1 said the dental provider informed her of one contracted provider and they required a full set of dental Xrays before scheduling the procedure. SSD #1 said she followed up with Resident #30 to review the updated plan. She said Resident #30 told her she was contacted by her provider, understood the new plan and agreed to the new plan. SSD #1 said the resident reported no current oral discomfort and expressed she was comfortable waiting to schedule her oral surgery. SSD #1 said the dental provider said they planned to schedule Resident #30's oral procedure in March 2026. -However, SSD #1 did not know the appointment was cancelled or why the appointment was cancelled until the first interview on 2/26/26 at 119 p.m. (see interview above). SSD #1 was interviewed on 2/26/26 at 4:17 p.m. SSD #1 said, based on the date the consent for dental services was signed by the resident in December 2025, Resident #30 should have been offered dental services sooner than what was offered.

Based on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences for one (#37) of five residents out of 41 sample residents. Specifically, the facility failed to offer food choices according to Resident #37's preferences.Findings include: I. Facility policy and procedure The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/26/26 at 9:23 p.m. It read in pertinent part, Staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. The food services department will offer a variety of foods at each scheduled meal. II. Resident #37A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic pain syndrome, malignant neoplasm of rectum and rectosigmoid junction (cancer located in the lower part of the large intestine where the colon meets the rectum), obesity, major depressive disorder, peripheral vascular disease (a circulatory condition that reduces blood flow to the arms or legs), chronic obstructive pulmonary disease, (COPD - a long-term lung disease that makes it difficult to breathe due to airflow blockage) unilateral inguinal hernia (a condition where tissue pushes through a weak spot in the abdominal muscles on one side of the groin), osteoarthritis, spinal stenosis (narrowing of the spaces within the spine), acute kidney failure, benign prostatic hyperplasia (BPH - noncancerous enlargement of the prostate gland that can cause urinary problems) and hypoxemia (lower than normal levels of oxygen in the blood). The 1/20/26 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. He was independent with eating, oral hygiene, toileting and personal hygiene. He required partial assistance with showering. B. Resident interview Resident #37 was interviewed on 2/23/26 at 3:23 p.m. Resident #37 said the facility did not give him the food he wanted for meals. He said for breakfast, he hated oatmeal and the facility always gave him oatmeal for breakfast. He said he wanted cold cereal and the facility never offered cold cereal. He said he hated turkey and they served him turkey. Resident #37 said the way the facility provided meals made him want to leave the facility because no one was listening to him. He said when the kitchen served him meals that he did not order, he would go without eating or he would leave the building to eat somewhere else. He said he talked to the male nurses in his unit about not receiving the food he wanted and the nurses said there was nothing they could do about it. C. ObservationsDuring a continuous breakfast observation on 2/24/26, beginning at 8:03 a.m. and ending at 8:30 a.m., Resident #37 was observed in the dining room. An unidentified staff member brought him breakfast. Resident #37's breakfast consisted of pancakes, bacon and oatmeal. Resident #37 said he did not want oatmeal, however, the unidentified staff member did not offer the resident a replacement and left the oatmeal sitting on the dining room table. During a facility tour on 2/25/26 at 11:20 a.m., the meal menu, the alternative menu and the snack menu was observed in the elevator closest to the dining room and posted on a bulletin board in the main hallway near the lobby.-However, the menus posted did not have an alternative menu listed for breakfast. During a continuous observation on 2/25/26, beginning at 11:58 a.m. and ending at 1:30 p.m., the lunch preparation was observed in the main kitchen. Resident #37's meal ticket did not reveal his dislike for turkey. He was served the posted lunch meal of braised turkey roast, rice pilaf, creamed spinach and spice cake. D. Record review The nutrition care plan, initiated and revised on 10/1/25, revealed Resident #37 was at potential nutrition and hydration risk due to a history of intussusception (a serious medical emergency where part of the intestine slides into another part, telescoping and causing a blockage), surgical aftercare following digestive surgery, absence of other specified parts of the digestive tract, hypoxemia, COPD, MDD, osteoarthritis, obesity, iron deficiency, anemia, hydronephrosis, hypercalcemia, acute kidney failure and neoplasm of the rectum. Interventions included providing and serving diet as ordered, administering medications as ordered, encouraging fluids as needed, encouraging healthy choices, inviting the resident to activities that involved food and fluids, monitoring for dysphagia and monitoring for malnutrition. -However, the care plan did not indicate Resident #37's likes and dislikes. The 10/8/25 food preferences assessment documented that Resident #37 did not like turkey. The assessment said no turkey sandwiches or hot turkey. The 11/11/25 food preference assessment revealed he did not like turkey and cabbage. -However, Resident #37's dietary meal ticket did not indicate the resident did not like turkey and observation during the survey revealed the resident received turkey roast for lunch on 2/25/26 (see observations above).III. Staff interviews [NAME] (CK) #1 was interviewed on 2/25/26 at 12:25 p.m. CK #1 said certified nurse aides (CNA) were responsible for completing the resident's meal ticket on behalf of the resident. CK #1 said CNAs took lunch and dinner orders and residents were served whatever was on the breakfast menu for breakfast. CK #1 said the way a resident was served something different than what was on the breakfast menu was when the dietary manager (DM) updated the meal ticket with the resident's preferred breakfast meal. CNA #2 was interviewed on 2/25/26 at 4:51 p.m. CNA #2 said the night shift CNAs were responsible for completing the resident's meal ticket on behalf of the resident for the following day's lunch and dinner meals. She said if the resident was not in their room when the night shift CNA asked residents what they wanted for lunch and dinner, the day shift CNA was responsible for completing the remaining incomplete tickets. She said breakfast meals were not ordered on behalf of the resident. CNA #2 said if the resident did not want what was on the menu, she was responsible for offering a substitution. She said sometimes residents did not like anything on the menu so she tried to offer what they wanted or asked the resident what they wanted to eat. CNA #2 said residents could change their mind and let the day CNA know by 10:00 a.m. She said if the resident changed their mind after 10:00 a.m. the resident had to tell the kitchen staff. CNA #2 said residents were served cold cereal based on their likes and dislikes. She said the cold cereal showed up on the breakfast meal ticket as a like. CNA #2 said there were residents who received hot cereal who did not like hot cereal. She said she tried to double check to make sure the residents received what they wanted. CNA #2 said she was familiar with Resident #37. She said he did not like turkey. She said he did not eat lunch (on 2/25/26) because he was served turkey. She said he was easily frustrated when he was not served what he preferred. CNA #2 said Resident #37 always asked for cold cereal. She said she had to remind the kitchen of his likes and dislikes because he was not always served cold cereal. The NHA was interviewed on 2/26/25 at 5:26 p.m. The NHA said the facility did not have a DM. The NHA said she had an assistant DM and a registered dietitian (RD). The NHA said she lost her most recent DM the week prior to the survey (week of 2/16/26). The NHA said the DM was responsible for completing the food preferences assessment for residents. The NHA said once the food preferences assessment was completed, the DM manually entered the likes and dislikes to the resident's meal tickets. She said since she did not have a DM, the RD was responsible for completing the assessments and entering the likes and dislikes to the residents' meal tickets. The NHA said breakfast orders were not taken for residents and if they wanted something different than what was on the menu, it would show up on their meal ticket as a like or dislike. The NHA said she was familiar with Resident #37 and she did not know his likes and dislikes. The NHA said she did not know Resident #37's meal ticket did not match his likes and dislikes.

Based on record review and interviews, the facility failed to consider resident and family group views and act upon grievances and recommendations.Specifically, the facility failed to provide the residents the opportunity to share views, grievances, and recommendations to dietary related issues in the resident council meetings.Findings include:I. Facility policy and procedureThe Grievance policy, undated, was provided by the nursing home administrator (NHA) on 2/26/26 at 4:53 p.m. It read in pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups will be considered. Actions on such items will be responded to in writing, including a rationale for the response.II. Resident group interviewFive alert and oriented residents (#24, #2, #7, #56 and #58) who regularly attended the resident council meetings and were deemed interviewable by assessment and the facility were interviewed together on 2/25/26 at 10:30 a.m. The residents were identified as alert and oriented through facility and assessment.The group of residents said the facility did not include dietary concerns in the resident council meetings and instead had a separate food committee meeting, but it had been several months since the facility had provided the residents with the opportunity to have a food committee meeting. Resident #24 said the dietary concerns brought up in the resident council meetings were redirected to the food committee meeting. He said any food concerns brought up in the resident council meeting were not addressed by staff. III. Record reviewA review of the resident council meeting minutes, dated December 2025, revealed the resident council meeting was cancelled due to a COVID-19 outbreak in the facility. A review of the resident council meeting minutes, dated 1/7/26, revealed all concerns regarding dietary were deferred to the food committee. A review of the resident council meeting minutes, dated 2/11/26, revealed all concerns regarding dietary were deferred to the food committee on 2/17/26.-However, the facility was unable to provide documentation that a food committee meeting took place on 2/17/26.A review of the food committee meeting notes revealed the food committee meeting had not been conducted since 10/25/25. IV. Staff interviewsSocial services director (SSD) #2 was interviewed on 2/26/26 at 1:01p.m. SSD #2 said she facilitated the resident council meetings and the facility had a process for addressing grievances identified in the resident council. SSD #2 said that dietary issues brought up in the resident council meetings were redirected to the food committee and the food committee meeting was run by the dietary manager. She said that the facility did not currently have a dietary manager and SSD #2 was not sure when the facility last had a food committee meeting. She said concerns brought up in the food committee meetings would be taken to the grievance official, the NHA. The NHA was interviewed on 2/26/25 at 2:35 p.m. The NHA said that the facility had not had a dietary manager since the previous week (the week of 2/16/26) and prior to that, the dietary manager was sporadically running the food committee meetings. The NHA said any food concerns brought up in the food committee meeting should be handled the same way as concerns brought up in resident council meetings, with a written concern form. She said she did not have any food committee meeting minutes from November 2025, December 2025, January 2026 or February 2026 and she could not say if the dietary manager was holding the food committee meetings during those months.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#67) of two residents reviewed out of 41 sample residents.Specifically, the facility failed to:-Ensure physician's orders were obtained for Resident #67's insulin pump and that the insulin pump was being appropriately monitored; -Ensure Resident #67's blood glucose (sugar) levels were being monitored; and,-Ensure Resident #67 received a carbohydrate-controlled diet, per her request.Findings include:I. Professional referenceAccording to the American Diabetes Association's Check Your Blood Glucose - Diabetes Testing And Monitoring retrieved on 3/4/26 from https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar, The logging of your blood glucose results is vital. When you bring your log to your health care provider, you will have a good picture of your body's response to your diabetes care plan.II. Facility policy and procedureThe Insulin Therapy policy, dated March 2025, was provided by the nursing home administrator (NHA) on 2/26/26. The policy read in pertinent part, The facility is to routinely assess residents who self manage their insulin therapy for their ongoing willingness and ability to do so safely and effectively. Residents who manage their glucose monitoring and/or insulin administration are routinely assessed for their ongoing willingness and ability to do so safely and effectively.III. Resident #67A. Resident statusResident #67, age [AGE], was admitted on [DATE], post hospitalization for vertigo and continued dizziness. According to the February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease (COPD). Per the admission assessment, the resident was cognitively intact.B. Resident observations and interview On 2/23/26 at 4:30 p.m. Resident #67's arm was observed with an attached Dexcom freestyle glucometer (blood sugar monitor that continuously monitors blood sugar levels) and an insulin pump attached to her left arm. The resident said she was newly admitted to the facility. She said she was a diabetic and she had to watch the carbohydrates that she ate. She said she was receiving a regular diet and not a carbohydrate controlled diet. She said she had been requesting a carbohydrate controlled diet, but nobody was listening to her. She said she had an insulin pump and a glucometer and the results went directly to her phone. She said she had had these devices for a while and was able to manage them.On 2/23/26 at 5:20 p.m. Resident #67 received her dinner meal tray; however, she did not receive a carbohydrate controlled meal. The resident's meal tray ticket documented the resident was on a regular diet.Resident #67 was interviewed again on 2/24/26 at approximately 10:00 a.m. Resident #67 said she had changed her insulin pump earlier in the morning. She said the dexcom freestyle glucometer would read directly to her phone. She said the insulin pump would then automatically dispense the appropriate amount of insulin into her body. She said that none of the nurses from the facility had asked to see her blood sugar. levels She said that it was important for her to watch what she ate in order to keep her blood sugars in a manageable range. On 2/24/26 at 5:30 p.m. Resident #67 received cheese ravioli for dinner and a piece of cake, which was not a carbohydrate controlled diet. Resident #67 was interviewed a third time on 2/25/26 at 10:00 a.m. Resident #67 was being assisted to therapy by the physical therapy assistant. She said she did not receive the carbohydrate diet again for breakfast. She said she had not been receiving the controlled carbohydrates as she requested and needed because of her diabetes since she was admitted to the facility. C. Record reviewThe 2/19/26 hospital records revealed Resident #67 was discharged from the hospital to the facility with the following physician's orders:Insulin aspart 100 units/milliliter (ml) solution pump. Inject into the skin continuously via Omnipod (insulin pump) as directed. The discharge hospital records additionally indicated the resident should eat a carbohydrate controlled diet with a maximum of 25 percent (% )to 50% of the calories to come from carbohydrates for each meal. -Review of Resident #67's February 2026 CPO failed to reveal the resident had a physician's order for the insulin pump. -The February 2026 CPO failed to reveal that the resident had a physician's order to monitor the resident's blood glucose levels and the use of the dexcom glucometer. -The February 2026 CPO failed to reveal physician's orders to monitor the resident's insulin pump for any dysfunction or complications. -Review of the February 2026 CPO revealed the resident had a physician's order for a regular diet (not a carbohydrate controlled diet). -There was no documentation in Resident #67's EMR to indicate the facility had attempted to obtain appropriate monitoring orders from the physician (see DON interview below).The at-risk review note, dated 2/20/26, documented staff were to monitor Resident #67's blood glucose levels, insulin pump functionality , and observe for signs and symptoms of low or high blood sugar levels. -However, review of Resident #67's electronic medical record (EMR) did not reveal documentation to indicate the facility was monitoring the resident's blood glucose levels, insulin pump or signs and symptoms of low or high blood sugar levels. A review of Resident #67's meal tray ticket on 2/25/26 revealed the resident's diet order had been changed from a regular diet to a carbohydrate controlled diet (during the survey). IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/25/26 at 9:56 a.m. LPN #1 said she was the admitting nurse when Resident #67 was admitted to the facility on [DATE]. She said the resident was admitted from the hospital due to vertigo. LPN #1 confirmed Resident #67 had a diagnosis of diabetes and that she had an insulin pump which she managed on her own. She said the blood glucose levels went to the resident's phone. She said she had not asked to see the resident's phone to monitor her blood sugar levels, however, she said she had not worked since the resident was admitted to the facility. LPN #1 reviewed Resident #67's EMR and confirmed that there was no documentation in the resident's EMR related to the resident's blood sugars. She additionally confirmed, after reviewing the resident's EMR, that there was no physician's order to monitor Resident #67's blood sugars or a physician's order for the resident's insulin pump. LPN #1 said she would have another nurse call the physician for the orders. Registered nurse (RN) #2 was interviewed on 2/26/26 at 1:00 p.m. RN #2 said she had phoned the physician for the insulin pump and blood glucose monitoring physician's orders for Resident #67. She said she had not seen the physician's order on the hospital discharge record for the carbohydrate controlled diet and the physician ordered a regular diet. RN #2 said Resident #67 managed the insulin pump and the freestyle glucometer herself and was planning on only being at the facility for a few weeks, therefore, she thought it was okay that the monitoring orders were not in the February 2026 CPO. The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 2/26/26 at 2:10 p.m. The ADON confirmed there were no physician's orders for the blood glucose monitoring and the insulin pump in Resident #67's EMR. She said a physician's order for both devices obtained on 2/25/26 (during the survey). The DON said she had attempted to call the physician for orders however, had not received. -However, review of Resident #67's EMR did not reveal any documentation of the DON's attempts to call the physician (see record review above). The ADON said she was responsible for reviewing residents' EMRs after they were admitted to the facility to ensure all physicians orders were in place; however, she had not reviewed Resident #67's EMR yet. V. Facility follow-upA second review of Resident #67's EMR on 2/25/26 revealed physician's orders had been obtained for monitoring the resident's blood sugar levels and the insulin pump. Additionally, a blood sugar value of 370 mg/dl (milligrams per deciliter) was recorded in the EMR on 2/25/26 at 11:30 a.m.-However, the physician's orders were not obtained for monitoring the insulin pump and recording the resident's blood sugar levels until the concern was brought to the facility's attention during the survey.

Based on observations and interviews, the facility failed to have an adequately equipped call system to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff area. Specifically, the facility failed to ensure all parts of the call light system were functioning properly in the common bathroom near the main dining room and the day room on the first floor.Findings include:I. Resident interviewResident #38 was interviewed on 2/23/26 at 1:00 p.m. Resident #38 said he was newly admitted to the facility and had gone to the bathroom in the common bathroom in the basement, near the dining room. He said he pulled the cord to call staff for help. He said the help never came as he waited for more than 20 minutes. Resident #38 said he used his cell phone and called a family member to ask for the facility to be called to come and help him. II. Observations and staff interviewOn 2/23/26 at 5:14 p.m. the bathroom call light was turned on in the common resident bathroom in the basement , next to the dining room. There was no call light above the door. There was a digitalized hanging monitor which displayed the room numbers when the call light was pulled. -However, the common bathroom did not display any notification when the call light in the bathroom was pulled. On 2/25/26 at 3:00 p.m. the lounge common area had a sign outside titled Day Room on the first floor. There were two residents sitting in the lounge watching television. The call light cord for the Day Room was clipped to the wall. -However, when the call light for the Day Room was pushed, it did not light up above the door outside the Day Room. Additionally, the big digitized hanging monitor which indicated which room the call lights were on was not displaying that the call light in the Day Room had been pushed. At 3:15 p.m. the call light was pushed a second time and the light above the door did light up. -However, the big digitized hanging monitor still did not display that the call light in the Day Room had been pushed. The computer at the nurses desk was logged out. Registered nurse (RN) #1 said the call lights which were pulled would register on the computer monitor, along with the big digitized sign. -However, RN #1 said she did not know how to log into the computer to visualize the rooms which had pulled the call light cords. III. Additional staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/23/26 at 5:33 p.m. CNA #1 said each floor had their own call light board to notify staff of call light activations.The nursing home administrator (NHA) was interviewed on 2/23/26 at 5:33 p.m. The NHA said the facility was not aware of the call light issue and was calling maintenance to look into the issue. She said the call light in the common area bathroom in the basement should have notified the staff on the first floor of the call light's activation.The NHA was interviewed again on 2/23/26 at 5:37 p.m. The NHA said the call light in the common area bathroom near the dining room in the basement registered in the call light in the system and notified the staff at the nurses' station, but not on the digitalized hanging monitor on the first or basement floors. She said she was closing the bathroom in the basement until maintenance resolved the issue.The maintenance director (MTD) was interviewed on 2/25/26 at 4:19 p.m. The MTD said the bathroom call light in the basement was fixed. He said it worked, however, it did not translate to the display board which was downstairs in the dining room. He said it also did not go upstairs, but he had fixed the problem. He said the call light now displayed on the big digitized board and on the computer.

Based on observations and interviews the facility failed to have adequate outside ventilation by means of a window or mechanical ventilation or a combination of the two for two out of three common bathrooms and two resident bathrooms, affecting eight residents.Specifically the facility failed to ensure the ventilation fans were clean and in good repair.Findings include:I. ObservationsOn 2/23/26 at 10:00 a.m. the 2nd floor was odorous.On 2/23/26 at 2:30 p.m. the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER] had strong odors of a combination of urine and feces. There were no windows in the bathroom and the ventilation fan could not be heard. The ventilation fan cover had dust built up on it. The bathroom was shared by four residents.On 2/24/26 at 12:48 p.m. the shared bathroom in room [ROOM NUMBER] had strong odors of a combination of urine and feces. The ventilation fan cover had dust built up on it. The bathroom was shared by four residents.On 2/24/26 at 1:00 p.m. the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER] continued to have strong odors of combination of urine and feces. On 2/24/26 at 1:30 p.m. the men's public bathroom on the second floor had strong odors of a combination of urine and feces. There were not any windows in the bathroom and the ventilation fan could not be heard. On 2/24/26 at 1:33 p.m. the women's public bathroom on the second floor had strong odors of a combination of urine and feces. There was a window in the bathroom; however, it was high up on the wall and blocked off by a bathtub with bars built up above the bathtub lip, which did not allow access to the window to open it. The ventilation fan could not be heard. On 2/25/26 at 2:30 p.m. the maintenance director (MTD) observed the men's and women's public bathrooms on the second floor and found that the ventilation fans were not working. The MTD observed room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom and found that the ventilation fan was not working. The MTD observed that the ventilation fan cover in room [ROOM NUMBER] was dirty and the ventilation fan was not working properly. The ventilation fan was pulling in a little air, however, it was not working at full strength.II. Staff interviewThe MTD was interviewed on 2/25/26 at 2:30 p.m. The MTD confirmed the second floor had urine odors. He said the bathrooms all had individual ventilation fans. He said he checked the ventilation fans monthly. The MTD said the women's public bathroom on the second floor had a window, however, he said he had to close the window up because when it was opened, it would make the hallway cold. The MTD said because the bathrooms did not have windows, the ventilation fans needed to work properly. He said he would get the ventilation fans replaced.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents received adequate supervision out of 14 sample residents.Specifically, the facility failed to ensure Resident #1 was not able to access hazardous chemicals.Resident #1, who was admitted to the facility on [DATE], had a history of dementia and of wandering within the facility. On [DATE] at 1:40 p.m., Resident #1 was able to obtain a bottle of a cleaning chemical that was located in a residential hallway on a maintenance cart that was unsecured and unsupervised.Resident #1 was found by certified nurse aide (CNA) #1 holding the bottle containing a cleaning chemical. Resident #1 was observed to have a blue substance on his lips, which was determined by the facility to be consistent with the contents of the bottle.Resident #1 was reported to have mouth and stomach pain after the incident. He was evaluated by a physician at the facility immediately following the incident and transferred to the hospital where additional evaluation was completed to determine if the resident had an esophageal (tube that runs from the throat to the stomach) injury, airway (breathing) compromise or electrolyte abnormality. Resident #1 was provided intravenous (IV) fluids and the hospital physician determined the resident likely had not ingested the toxic substance. Resident #1 was monitored at the hospital and returned to the nursing facility on [DATE].The facility determined the product in the bottle was a cleaning product (Gel Pro). The material safety data sheet (MSDS - a document that describes the hazards of a chemical product and provides information on safe handling, storage, disposal and emergency procedures) revealed the product was reserved for industrial and professional use and if swallowed, required immediate medical attention. Ingestion of the product could cause digestive tract burns.Resident #1 experienced pain and required hospital evaluation to confirm he had not ingested a sufficient amount of the chemical to cause further injury.The facility's failure to ensure residents were not able to access hazardous chemicals placed Resident #1 and other residents at serious risk of harm, serious impairment or death if the situation were not corrected immediately. Findings include:Observations, record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on [DATE] to [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE].I. Situation of serious [NAME] [DATE] at 1:40 p.m., Resident #1 was able to obtain a bottle of a cleaning chemical that was located in a residential hallway on a maintenance cart that was unsecured and unsupervised.Resident #1 was found by CNA #1 holding the bottle containing a cleaning chemical. Resident #1 was observed to have a blue substance on his lips, which was determined by the facility to be consistent with the contents of the bottleResident #1 was reported to have mouth and stomach pain after the incident. He was evaluated by a physician at the facility immediately following the incident and transferred to the hospital where additional evaluation was completed to determine if the resident had an esophageal injury, airway compromise or electrolyte abnormality. Resident #1 was provided IV fluids and the hospital physician determined the resident likely had not ingested the toxic substance. Resident #1 was monitored at the hospital and returned to the nursing facility on [DATE].II. Facility investigation and plan of correctionThe investigation and performance improvement plan (PIP) the facility implemented in response to the accident on [DATE] involving Resident #1 was provided by the nursing home administrator (NHA) on [DATE] at 1:07 p.m. The plan read as follows:A. Problem statementOn [DATE], a cognitively impaired resident (Resident #1) was found ingesting drain cleaner that had been left unattended and unsecured on a maintenance cart. CNA #1 intervened and removed the chemical. The chemical had been left unsecured by the maintenance supervisor during routine work. B. GoalThe facility's goal was to eliminate unsafe chemical exposure risks within the facility by implementing a facility wide safety initiative with compliance monitoring and retraining all staff on accident prevention and emergency response protocols. C. Root Cause Analysis A root cause analysis (a problem solving method used to identify the underlying reasons why a problem occurred) was completed and revealed the following:-An unsecured hazardous chemical was left unattended in a resident accessible area;-Staff were unfamiliar with chemical handling/storage policies;-There was a lack of supervision or enforcement of the facility's environmental safety procedures;-The cognitive impairment of the resident was not adequately considered in environmental planning; and,-There was not a current interdisciplinary team (IDT) environmental hazard audit process.D. Immediate Actions TakenCNA #1 immediately removed the chemical and reported the incident to the nurse. The nursing staff contacted a poison control center and reviewed the MSDS. The primary care physician (PCP) assessed the resident and Resident #1 was transported to the hospital. The maintenance supervisor was suspended from duties pending an internal review. The nursing home administrator (NHA) and the director of nursing (DON) initiated an internal investigation. E. Corrective actions and prevention planThe corrective actions included the following:An in-service on chemicals was completed on [DATE]. A mandatory in-service for all departments on accident hazards was completed on [DATE].Hazard identification scenarios were integrated into training on [DATE].All maintenance carts were secured with locks or stored in secured areas when unattended by [DATE].The facility implemented facility-wide weekly environmental safety audits beginning [DATE].Accident prevention compliance checks were added to the monthly quality assurance performance improvement (QAPI) agenda beginning [DATE].Care plans for cognitively impaired residents were updated with supervision and safety risk protocols by [DATE].IV. Facility policy and procedureThe Hazardous Areas, Devices and Equipment policy, revised [DATE], was provided by the NHA on [DATE] at 3:22 p.m. It read in pertinent part, A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to:-Equipment and devices that are left unattended or are malfunctioning;-Devices and equipment that are improperly used or poorly maintained;-Sharp objects that are accessible to vulnerable residents;-Open areas or items that should be locked when not in use;-Irregular floor surfaces (cords, buckled carpeting, etc);-Objects in the hallways that obstruct a clear path;-Access to toxic chemicals;-Insufficient lighting or glare;-Unsafe exposure to heating elements or water temperatures;-Furniture that is unstable or positioned at an improper height for residents; or,-Disabled locks, latches or alarms. Assessment and analysis of hazardous areas and equipment will include resident specific information including identification of vulnerable residents. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments (medications). Interim safety measures for temporary hazards, such as painting or construction work, may be necessary. These may include posting warning signs, redirecting foot traffic, increasing supervision and if necessary, limiting access to anyone but authorized personnel.V. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included dementia, COPD, osteoarthritis, depressive episodes and anxiety disorder. The [DATE] minimum data sets (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. He required set up assistance with eating, substantial assistance with toileting, showering and dressing and was independent with the use of a manual wheelchair to wheel at least 150 feet in a corridor.B. Record reviewResident #1's behavior care plan, revised [DATE], documented the resident self-propelled his wheelchair and enjoyed riding up and down in the main elevator. Interventions included redirection of Resident #1 as needed.Resident #1's safety alert care plan, initiated [DATE], documented Resident #1 was at risk for injury due to his ingestion of non-edible or hazardous items related to his cognitive impairment, poor safety awareness and impaired judgment secondary to dementia. Interventions included environmental rounds conducted by staff every shift, documenting the resident's attempts to access inappropriate items and ensuring all chemicals and hazardous materials were stored in locked non-resident areas.The primary care physician's (PCP) progress note, dated [DATE] at 1:33 p.m., documented an urgent evaluation of Resident #1 for ingestion of drain cleaner. It documented the PCP evaluated the resident and remained with the resident until emergency medical services (EMS) arrived. It documented the amount of chemical ingested was not known, but the PCP estimated 10 milliliters (ml) had been ingested. The PCP documented Resident #1 was provided water to rinse with but he swallowed it. The PCP documented the resident was stable, but developed stomach pain immediately prior to the arrival of EMS. The note documented a poison control center was contacted and EMS was provided with a case number from the poison control center.The hospital emergency department progress note was provided by the NHA on [DATE] at 1:07 p.m. The note, dated [DATE] at 1:50 p.m., documented Resident #1 presented to the hospital for ingestion of a drain cleaning gel. It documented the EMS team reported the nursing facility staff said they witnessed Resident #1 taking a swig of the drain cleaning gel, but the facility was unsure how much was in the bottle before ingestion and unsure of the amount Resident #1 ingested. The EMS team also reported Resident #1's mouth hurt, but otherwise he had no pain. The summary documented diagnoses considered were esophageal injury, airway compromise or electrolyte abnormality. The summary documented Resident #1 was stable and improved after IV fluids. The note documented the presentation and work up suggested Resident #1 had not ingested the toxic substance. A nursing progress note, dated [DATE] at 2:20 p.m., documented Resident #1 ingested drain cleaning gel on [DATE]. It documented Resident #1 initially had no complaints of pain after the incident, but near time of EMS arrival to the facility, Resident #1 began to complain of abdominal pain.An in-service education, dated [DATE] was provided by the NHA on [DATE] at 1:07 p.m. The in-service education included 33 staff signatures. The training description included the process used if a resident ingested chemicals, poison control contact information and the location where the MSDS were kept.An in-service education, dated [DATE], was provided by the NHA on [DATE] at 1:07 p.m, and included 51 staff signatures. It documented the audience as all nursing, housekeeping, maintenance and support staff. The learning objectives included:-Identifying common environmental accident hazards and how to reduce resident risk;-Properly storing hazardous materials in compliance with federal and facility policy; and,-Understanding mandatory reporting obligations.The MSDS for the product Gel Pro was provided by the NHA on [DATE] at 1:07 p.m. It revealed the following: Recommended use as a cleaning product reserved for industrial and professional use. The product is corrosive to metals, causing severe burns and eye damage. If swallowed, rinse the mouth. Do not induce vomiting. If inhaled, remove the person to fresh air and keep comfortable for breathing. Immediately call a poison center/doctor. Store locked up. Store in corrosive resistant container with a resistant liner Ingredients include sodium chloride, sodium hypochlorite and sodium carbonate. First aid measures include if swallowed, rinse mouth with water, do not induce vomiting. Get medical attention immediately. Note to physician, treat symptomatically. Handling and storage, do not ingest. If ingested, it causes digestive tract burns.Facility-wide weekly environmental safety audits were provided by the NHA on [DATE] at 1:07 p.m. Weekly audits from [DATE] to [DATE] were reviewed. The audits documented all chemicals on carts were secured or locked if unattended, storage rooms with hazardous materials were locked, MSDS were visible and accessible, chemicals were clearly labeled and not expired and high risk resident areas were free of hazards.VI. Staff interviewsCNA #3 was interviewed on [DATE] at 12:50 p.m. CNA #3 said Resident #1 had a history of wandering on the unit in his wheelchair. CNA #1 said there was an incident when Resident #1 drank something from the maintenance cart. He said all of the facility staff received training, both online and in person about hazardous materials and the importance of securing the items. CNA #3 said he was told to report any observations of hazardous materials at the facility.The DON was interviewed on [DATE] at 4:00 p.m. The DON said she was present at the facility and responded to Resident #1's room after the incident on [DATE]. She said she learned Resident #1 might have put the bottle of drain cleaner in his mouth. The DON said Resident #1 had a blue substance around his mouth from the chemical. The DON said the facility was inspected for hazardous materials on that day and she participated in providing staff education for hazardous materials after the incident.The maintenance supervisor was interviewed on [DATE] at 8:50 a.m. The maintenance supervisor said on [DATE], he and his assistant were painting the day room, a resident lounge. The maintenance supervisor said he had painting supplies on the maintenance cart, and there was also a bottle of drain cleaner, as he planned to clean a drain in the facility's kitchen area after he completed painting. The maintenance supervisor why she was holding the bottle and she said Resident #1 drank from it. The maintenance supervisor said he contacted the PCP, who was present at the facility, and then obtained the MSDS for the drain cleaner. The maintenance supervisor said he observed Resident #1 with a blue color present on his lower lip which was consistent with the contents of the drain cleaner. The maintenance supervisor said after the incident, the facility ensured there were not any chemicals which were accessible to residents.The maintenance supervisor said he received training upon hire about hazardous chemicals and the need to ensure they were not accessible to residents, and again received training from the NHA after the incident on [DATE]. The maintenance supervisor said the facility purchased new maintenance carts in [DATE] which were always locked. The NHA was interviewed on [DATE] at 9:04 a.m. The NHA said the maintenance cart should have been secured and the items on the cart should not have been accessible to residents on [DATE]. The NHA said the facility completed an audit on the day of the incident to be certain there were no accessible hazardous materials. She said staff training began immediately after the incident, and the training was completed by [DATE]. The NHA said weekly audits for environmental and hazardous items would continue for at least three months and would be reviewed at QAPI meetings. Registered nurse (RN) #2 was interviewed on [DATE] at 9:50 a.m. RN #2 said CNA #1 came to her holding a drain cleaner bottle and informed her she had just taken bottle from Resident #1. RN #2 said she went to the resident and saw that he had a blue color on his lips. RN #2 said the instructions on the bottle revealed his mouth should be rinsed out, so she and CNA #1 attempted to do this, but Resident #1 swallowed the water. RN #2 said the PCP was at the facility and came to the resident's bedside immediately. RN #2 said while waiting for the EMS team to arrive, Resident #1 said he had started to have stomach pain. RN #2 said she contacted Resident #1's representative about the incident and transfer to the hospital. RN #2 said all facility staff received re-education about hazardous items after the incident. RN #2 said the staff audited the building to be certain there were no hazardous items accessible to residents.The PCP was interviewed on [DATE] at 12:15 p.m. The PCP said on [DATE], a staff member notified him that Resident #1 had consumed drain cleaner. The PCP said he reviewed the MSDS for the product and contacted a poison control center. The PCP said he was told the resident had blue color on his lips, and he estimated the resident drank approximately 10 ml of the drain cleaner, based upon staff reports and the amount remaining in the bottle. The PCP said Resident #1 appeared stable, but was sent to the hospital out of an abundance of caution, as he began to have abdominal pain. The PCP said the facility did a PIP related to the incident and addressed the cause of the ingestion. He said if Resident #1 had ingested more drain cleaner he would have been in trouble, as it could have caused a hole through his esophagus or his stomach.CNA #1 was interviewed on [DATE] at 12:45 p.m. CNA #1 said on [DATE], she saw Resident #1 sitting in his wheelchair in the hallway drinking from a bottle that contained a chemical. CNA #1 said she took the bottle away from the resident. CNA #1 said she realized Resident #1 had drank some of the chemical when she noticed his lips and tongue were blue. She said she notified the charge nurse, and the charge nurse and PCP evaluated the resident. CNA #1 said the facility had all staff check the facility, including all residents' rooms for hazardous items, including chemicals, following the incident on [DATE]. CNA #1 said the facility provided inservice training after the incident for all staff, which included both in person and online training and included the need to ensure residents could not access hazardous items.The social services director (SSD) was interviewed on [DATE] at 9:30 a.m. The SSD said she received hazardous material training upon hire and again recently completed training in person and online after the incident involving Resident #1. The SSD said the training focused on the need to protect residents from hazardous items. The SSD said she was one of the staff members who were doing weekly rounds to check for any hazardous items. She said the extensive training post-incident for all staff helped to make the staff sensitive to the potential hazards that existed to residents.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure resident's medical supplies for catheter irrigation were labeled, dated and stored in a sanitary environment. Findings include: I. Facility policies and procedures The Infection Control policy and procedure, undated, was received by the nursing home administrator (NHA) on 2/22/24 at 11:27 a.m. It read in pertinent part, An infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections. The program is based on accepted national infection prevention control standards. The elements of the infection prevention program includes: coordination/oversight of prevention of infection. Important facets of infection prevention include: -educate staff to ensure they adhere to proper techniques and procedures; and. -following established general disease-specific guidelines such as those of the Centers for Disease Control (CDC). The Catheter Irrigation, open system policy, undated, was received by the NHA on 2/22/24 at 3:11 p.m. It read in pertinent part, The purpose of this procedure is to maintain patency of the catheter. Steps in the procedure: -Open the sterile irrigation tray using sterile technique; -Pour irrigation solution into the sterile solution container; -Draw solution into the irrigating syringe; -Insert the syringe into the catheter and slowly instill the solution; -Remove the syringe and allow the catheter to drain into the sterile collection basin; -Discard disposable items into designated containers. II. Observations and staff interviews On 2/22/24 at 11:22 a.m., a graduated triangular intake/output container was observed on top of an unidentified resident's dresser and behind his television. Dried water droplets were observed inside and outside of the container. -The container was not dated and not labeled for its specific use. An open piston syringe (a large syringe utilized to irrigate catheters) was stored inside the triangular container. Dried water droplets were observed inside and outside of the syringe. -The syringe was not dated and not labeled for its specific use. Registered nurse (RN) #1 was interviewed on 2/22/24 at 11:23 a.m. She observed the cylinder container and syringe and said the items were used to irrigate the resident's indwelling supra pubic catheter (a catheter which is inserted just below the belly button directly into the bladder). She said the supplies should be labeled when they were opened. RN#1 said the cylinder and syringe should be replaced once a week. She said she was unable to determine how many days the supplies had been unwrapped and used and said she would replace the items. She said they were stored on the resident's dresser because it was a shared room. The director of nursing (DON), who was also the infection preventionist (IP) was interviewed on 2/22/24 at 11:38 a.m. The DON said the supplies should be labeled when opened. She was not certain when the supplies should be replaced and said she would find out. -On 2/22/24 at 12:45 p.m., the catheter irrigation supplies had not been removed, labeled or replaced. -On 2/26/24 at 9:07 a.m. the urinary catheter flushing supplies continued to be stored on the resident's dresser, open to air, and next to the television. The triangular cylinder was dated 2/22/24 and the piston syringe was dated 2/23/24. -Neither item included labeling for its specific use. The DON was interviewed a second time on 2/26/24 at 11:15 a.m. The DON said the piston syringe dated 2/23/24 was replaced with a new syringe on 2/26/24. She said irrigation of catheters required a new sterile piston syringe and she was uncertain why the used syringe had not been discarded and replaced. III. Facility follow up The DON was interviewed again on 2/27/24 at 10:55 a.m. The DON said the facility's medical director had clarified the physician's order for the catheter irrigation and said a clean procedure was used for the graduated cylinders and they should be replaced weekly. The DON said the February 2024 CPO was updated to clarify the piston syringe should be sterile and replaced daily. She said going forward, a new sterile syringe would be used for irrigation of the catheter. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for one (#17) of three out of 18 sample residents. Specifically, the facility failed to ensure records were provided timely upon request for Resident #17 from a court appointed guardian. Findings include: I. Facility policy and procedure The Access to Personal and Medical Records policy, revised May 2017, was provided by the nursing home administrator (NHA) on 10/5/23 at 5:56 p.m. It revealed, in pertinent part, A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request. II. Failure to provide medical records as requested A. Resident representative interview The court-appointed guardian was interviewed on 10/5/23 at 2:08 p.m. She said she had requested Resident #17's medical records on 9/6/23 via email to the NHA. She said the NHA had forwarded the email to the medical records personnel, however she said she had not heard back from the facility. She said prior to the 9/6/23 email, she had made multiple attempts to contact the facility and still had received a response. She said on her first attempt the phone rang without answer, the second attempt a resident answered the phone and said they could not provide assistance, and the third attempt a staff member told her she would receive the medical records. She said on 10/2/23 she had sent an additional email to the medical records personnel indicating she had still not received the medical records. She said the medical records personnel told her she was not able to complete the request sooner because she did not have documentation of the court appointed guardianship. She said no staff from the facility had asked her to provide that information until she provided it on 10/2/23, of her own volition. B. Record review A records request was sent via email from the court appointed guardian to the NHA and the medical records manager (MRM) for Resident #17 on 9/6/23. An additional was sent by the court appointed guardian on 10/2/23 which read, I have still not received the medical records I requested. Please review the attached order appointing me as guardian ad litem. The order contains an authorization to release medical records. The MRM responded to the court appointed guardian's email on 10/3/23 indicating she did not have documentation of court appointed guardian to release the records, however a request had never been sent to the court appointed guardian prior to that date and when the request for medical records was made on 9/6/23. The MRM indicated she would be able to provide the medical records. On 10/4/23, the court appointed guardian sent an additional email stating the court had been asking for updates on Resident #17 and she needed the medical records as soon as possible. The MRM responded on 10/5/23 that the file was too large to download and the guardian could pick up a flash drive containing the information. On 10/6/23, during the survey process, the medical records were delivered to the guardian's office, 30 days after the request for medical records. III. Staff interviews The MRM was interviewed on 10/5/23 at 3:04 p.m. She said the email request was received on 9/6/23 from the guardian however, the facility was not aware Resident #17 had a court-appointed guardian. The MRM said she attempted to contact the guardian but was unsuccessful so she left a voicemail requesting documentation that showed the guardianship status. She said she did not document any phone calls made to the guardian and had not attempted to contact her via email, which was how the initial request was submitted. She said she did not know why she did not contact the guardian via email. She said the medical records for Resident #17 were not provided to the court appointed guardian until 10/6/23, 30 days after the initial request was made.

Based on record review and interviews the facility failed to keep six residents (#6, #3, #5, #7, #10 and #11) free from resident to resident physical abuse of nine residents reviewed out of 13 sample residents. The facility failed to ensure there was an effective plan to monitor, or provide increased oversight and effective interventions to protect residents from Resident #6's behavior. Resident #6 physically assaulted at least three residents, between 3/19/23 and 6/11/23. Four additional residents complained of Resident #6's behavior in the facility's abuse investigations. This included Resident #3 who told a staff member during an interview that he had been hit by Resident #6. There was no further investigation of this allegation. The residents involved in the allegations reported pain, fear of Resident #6 hitting them again, feelings of being attacked and frustration with Resident #6's behavior. There was no plan to provide supervision or monitoring of Resident #6's behaviors, except after the third known altercation when the facility implemented monitoring in the smoking area. Physical Altercation 3/19/23, Resident #6 struck Resident #5 causing pain and fear Record review and interviews revealed Resident #6 struck Resident #5 on the arm four times on 3/19/23. The incident was witnessed by staff and residents. Resident #5 was interviewed and said Resident #6 hit her in the arm with a closed fist and with her knuckles. She said it was painful. Resident #5 said she tried to stay away from Resident #6, and she was fearful Resident #6 would hit her again. Review of the facility investigation revealed Resident #5 said on 3/19/23, that she felt Resident #6 would hit her again and she, worries for her safety. Eight staff members interviewed during the facility investigation reported the resident was mean, aggressive, rough or disrespectful to staff. This included being punched and scratched by Resident #6. No plan for increased supervision or monitoring was developed for Resident #6. Physical altercation 5/8/23, Resident #6 struck Resident #7 Record review and interviews revealed Resident #6 struck Resident #7 in the hallway of the facility on 5/8/23 at 6:10 p.m. Interviews revealed Resident #6 and Resident #7 were in the front lobby. Resident #6 and Resident #7 had words, Resident #6 flipped Resident #7 off. Resident #7 headed away down the hall, but Resident #6 followed her down the hall to the nurses station where Resident #6 slapped Resident #7. Resident #7 said she felt attacked. Resident #7 said she was fine, but hoped it would not happen again. Her interview on 5/9/23 in the facility investigation documented she did not feel safe in the facility. She said, not until you know people, it is not safe to be around them and people feel free to hit people around here. No plan for increased supervision or monitoring was documented for Resident #6. Physical altercation 6/11/23, Resident #6 struck Resident #7 again and Resident #7 struck Resident #6 in response Record review and interviews revealed residents and staff had witnessed a physical altercation between Resident #6 and Resident #7 on 6/11/23. Resident #6 was observed hitting Resident #7 multiple times and yelling at her in the smoking area. Resident #7 turned and swung back at Resident #6, slapping her in the face. A red mark was left on Resident #6's left cheek. Staff attempted to escort Resident #6 from the area, but she continued to scream and hit the staff. Resident #7 was not interviewed until three days later on 6/14/23. She said she was concerned that Resident #6 was going to hit a resident who could not defend themselves. Furthermore, the facility's interviews with staff and residents on 6/11/23, documented multiple residents had stated Resident #6 shakes her fists at people, she was physically aggressive and threatening to other residents and two residents said she had hit them previously. There was no follow up by the facility to further investigate the information relayed in interviews to ensure the safety of residents in the facility. Additionally, the facility failed to: -Ensure Resident #11 was free from physical abuse from Resident #10; and, -Ensure Resident #10 was free from verbal abuse from Resident #11. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation, Reporting and Investigating policy, revised September 2022, was received from the nursing home administrator (NHA) on 6/27/3 at 1:44 p.m. It documented in pertinent part, If abuse, neglect, exploitation or misappropriation is suspected, the suspicion must be reported to the administrator immediately and to other officials according to state law. All allegations are thoroughly investigated. The administrator is responsible for determining what actions are needed for protection of the residents. II. Substantiated physical abuse, 3/19/23, Resident #6 struck Resident #5 A. Facility investigation The abuse investigation dated 3/19/23 was reviewed on 6/26/23. The investigation documented on 3/19/23 at 10:00 a.m., Resident #6 hit Resident #5. Staff and residents witnessed the abuse and the physical abuse was substantiated. A typed document from a staff member, undated, documented she was taking Resident #6 outside to smoke. The staff member asked the resident if she had her cigarettes. Resident #6 gave the staff member a derogatory gesture with her finger. Resident #5 was seated outside. Resident #5 told Resident #6 to be nice. Resident #6 then went over to Resident #5 and began punching her in the arm. A second typed document dated 3/19/23 at 9:55 a.m. documented Resident #5 had gone down to the therapy gym and reported that Resident #6 had hit her in the arm four times. It documented the residents were told to stay away from each other. A document dated 3/19/23 at 10:00 a.m., written by a staff member and signed by Resident #5, documented Resident #5 was seated outside. Resident #6 was being combative with the nurse. Resident #5 told Resident #6 to be nice. Resident #6 then went over to Resident #5 and struck her four times. Resident #5 said she was afraid Resident #6 would strike her again and worried about her safety. The facility reported to the State Agency as Resident #5 was worried about her safety if she was around the assailant. An undated, handwritten note from a resident, who was a witness, documented Resident #6 had socked Resident #5. The note documented Resident #5 told Resident #6 not to hit her and Resident #6 flipped her off (using her middle finger in an offensive way). Residents and staff were not interviewed until the next day on 3/20/23. A resident interview documented Resident #6 cursed at the staff and was verbally rude. Resident #6 hits people if they get too close or if someone tells her no. The resident said she had not seen her hit anyone. The resident said people need to just leave her alone. Eight staff interviews on 3/20/23, documented Resident #6 was mean, aggressive and rough. The staff said Resident #6 scratched and pinched them. A social service note in the investigation file documented on 3/22/23 at 12:42 p.m., documented Resident #5 was not afraid as long as she could maintain her distance from Resident #6. The social worker told Resident #5 she should not have been in Resident #6's space. -However, according to witnesses and the investigation, Resident #5 was seated outside and Resident #6 approached Resident #5 and began hitting her. A follow up message by the State Agency on 4/19/23 asked the facility if Resident #5 was fearful of the assailant. The facility responded on 4/21/23 and said Resident #5 was worried about her safety if she was around the assailant. B. Resident #6 1. Resident status Resident #6, under age 65, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included vascular dementia, cerebral vascular accident (stroke) with frontal lobe executive function deficit (brain loses ability to control thoughts, emotions and behavior), aphasia (loss of ability to understand or express speech) and pseudobulbar affect (involuntary laughing or crying). The 3/27/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) with a score of three out of 15. She required limited one person assistance with bed mobility and transfers and extensive one person assistance with dressing, toileting and personal hygiene. She had physical and verbal aggression toward others, including hitting, scratching, threatening and screaming. The assessment documented her behavior significantly disrupted care and the living environment. 2. Record review The physical aggression care plan initiated 11/14/22 documented Resident #6 had a history of aggression per her medical power of attorney, raising her fists, slapping, biting, cursing, flipping her middle finger at you, growling, and slapping her hand against her forehead when she was frustrated. The goal was that she would not harm herself or others. Interventions included, administer medications per physician orders, initiated 11/14/22, allow her time to verbalize dissatisfaction initiated 3/20/23, allow resident to calm down and re approach in a few minutes, and assess her needs initiated 3/20/23, call her MPOA (medical power of attorney) initiated 3/20/23. Resident #6 will need to be a supervised smoker due to exhibiting aggressive behavior towards others while in the smoking area. She has issues with impulse control and strikes out when she is angry. Having her as a supervised smoker will allow staff to be close by if or when she gets angry and staff will be able to intervene quicker, initiated 6/12/23. Inform Resident #6 that inappropriate behavior is not accepted. If she becomes frustrated with redirection, staff is to back away, allow her to calm down and re-approach when she is calm, initiated 3/20/23. Medication review by MD (medical doctor), psychiatrist and pharmacist routinely or PRN (as needed), psychiatric evaluation as needed, initiated 5/9/23. Monitor her for triggers to aggressive behavior, initiated 3/20/23, offer one to one activity or social services for support and companionship initiated 5/9/23, provide positive feedback for appropriate behavior, initiated 11/14/23. A second physical aggression care plan, initiated 3/20/23, documented Resident #6 has the potential to be physically aggressive related to poor impulse control and past history of trauma and neglect. The goal was that Resident #6 will not harm herself or others, interventions included, communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encouraging seeking out of staff members when agitated. Triggers for physical aggression include: staff asking for her to give up food and drink (she remains nothing by mouth, and is at risk of choking), when she is touched or when others brush by her, when she is asked to wait when wanting something and when frustrated. Resident's behaviors are de-escalated by giving her space, explaining to her in detail and in a manner she can understand as to why she cannot have food and drink, allowing the resident to make choices and not reaching for her or the item she is holding. Psychiatric/Psychogeriatric consult as indicated/as she allows. Will be sending referrals for the resident to attend day activities through a day program. When she becomes agitated intervene before agitation escalates; Guide her away from source of distress (if she allows); Engage calmly in conversation; If response is aggressive towards staff, staff are to walk calmly away and approach later. The resident had a supervised smoking care plan, initiated 10/14/22. It documented encourage resident not to go smoke with cold temperatures below 20 degrees (Fahrenheit), notify charge nurse immediately if it is suspected resident has violated facility smoking policy, observe clothing and skin for signs of cigarette burns, smoking assessment quarterly and as needed, smoking materials are to be kept by staff, educate resident and family regarding smoking policy. -While the care plan had many interventions that could help the staff with caring for her, it did not include a plan to supervise or monitor Resident #6 to protect the other residents with her known aggressive behavior. The other residents in the facility did not know her triggers, how to de-escalate her, assess her needs or calm her down. The other residents could not guide her away or tell her when her behavior was not appropriate. The interventions did not help the other residents if Resident #6 became aggressive. The facility placed on supervised smoking three months later in June 2023 due to her behavior in the smoking area, but this did not protect residents at any other time in or around the facility. There were no interventions aimed at the protection of other residents. Resident #6 continued to physically abuse additional residents (see below). The medication administration record (MAR) and treatment administration record (TAR) for June 2023 were reviewed. The only behavior tracking on the MAR and TAR was for signs of depression, as the resident was on an antidepressant. There was no tracking of her physical aggression or other behaviors. An SBAR (situation, background, assessment, recommendation), dated 3/19/23, documented the Resident #6 had been physically aggressive. It documented that it was unknown if this had occurred before. C. Resident #5 1. Resident status Resident #5, under age 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO diagnoses included traumatic brain injury and major depression. The 5/6/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) with a score of 15 of 15. She required supervision with bed mobility, transfers, toileting and personal hygiene. She required limited one person assistance with dressing. The assessment documented she had no behaviors. 2. Resident interview Resident #5 was interviewed on 6/27/23 at 1:11 p.m. She said Resident #6 hit her in the arm with a closed fist and with her knuckles. She said her arm was painful for a while. Resident #5 said she had tried to stay away from Resident #6 and she was fearful Resident #6 would hit her again. 3. Record review An SBAR dated 3/19/23 documented Resident #5 had no injury and no pain. The physician was notified at 3:00 p.m. -It did not document what time the assessment occurred. A pain assessment dated [DATE] at 11:37 p.m. (more than two hours after the altercation) documented the resident had pain at a level of 1 (out of 10, with 10 being the worst pain on the scale). The assessment documented Tylenol and rest made the pain better. -According to the resident interview (see above), she experienced pain for a while and continued to have fear. III. Substantiated physical abuse 5/8/23, Resident #6 struck Resident #7 A. Facility investigation The investigation revealed on 5/8/23 at around 6:10 p.m. Resident #6 was holding a cigarette in the front lobby. Resident #7 told Resident #6 not to light the cigarette in the facility. Resident #6 flipped Resident #7 off. Resident #7 left the lobby and headed down the hall to the nurses station. Resident #6 followed her. According to a witness, Resident #6 followed her down the hall to the nurses station where Resident #6 hit Resident #7 in the right arm and a staff member was there. Resident #7 said she felt attacked. Resident #7 said she was fine, but hoped it would not happen again. Resident #7's interview on 5/9/23 in the facility investigation file documented she did not feel safe in the facility. She said, not until you know people, it is not safe to be around them, and people feel free to hit people around here. At some point, an undated note by the social worker documented on the resident's statement that she felt safe. The facility substantiated the abuse. A nurse note investigation documented Resident #7's left arm was assessed and there was no injury. An SBAR dated 5/8/23 documented it was unknown if this happened before, the physician for Resident #7 was notified at 11:55 p.m. and said to monitor for safety. There were no injuries to her left harm. -However, the physician was notified five hours after the altercation, a pain evaluation was not indicated and the left arm had no injuries, even though she was hit on the right arm. In the investigation file, an email to the nursing home administrator (NHA) on 5/8/23 at 7:43 p.m. documented the event, both residents have hashed it out, but we are keeping them in line of sight to ensure safety. -However, it was unclear from the care plan, investigation or resident's electronic medical records (EMR) how long the residents were kept in line of sight. Resident and staff interviews the next day on 5/9/23 documented no further information except for one resident who said he had witnessed Resident #6 flipping off Resident #7. An IDT (interdisciplinary note) note dated 5/9/23 at 10:13 a.m. documented Resident #7 had increased aggression. Resident #7 had recently broken up with a love interest and that may be contributing to her aggression. The plan was to offer her some one-on-one activities or social service visits and request a psychological evaluation. Social services would provide support as needed. -Despite the facility's documented knowledge of the resident's increased aggression, there were no new interventions to keep other residents safe. No monitoring or supervision for the increased aggression. The care plan documented, medication review by physician, psychiatrists and pharmacist routinely or PRN, psychiatric evaluation as needed and offer one-to-one activity or social services for support and companionship initiated 5/9/23. -It remained unclear in the investigation file, the care plan and the EMR what the facility was doing to protect Resident #6, and other residents. Resident #6 had a known history of aggression, prior to admission according to the medical power of attorney as referenced in the care plan. She had two known altercations at the facility at this time and the social worker documented she had increased aggression. There was no monitoring or supervision of Resident #6 and the increased physical aggression. B. Resident #7 Resident #7, age 77, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included chronic pain and depression. The 4/30/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score (BIMS) with a score of 12 of 15. She required supervision with bed mobility and transfers. Resident #7 required limited one person assistance with dressing, and extensive one person assistance with toileting and personal hygiene. The assessment documented she had no behaviors, but did show signs of depression and feeling down. IV. Substantiated physical abuse 6/11/23, Resident #6 struck Resident #7 again, Resident #7 struck Resident #6 in response A. Facility investigation The investigation file revealed residents and staff had witnessed a physical altercation between Resident #6 and Resident #7 on 6/11/23 in the smoking area. Resident #6 was observed hitting Resident #7 multiple times and yelling at her in the smoking area. Resident #7 turned and swung back at Resident #6, slapping her in the face. A red mark was left on Resident #6's left cheek. Staff attempted to escort Resident #6 from the area, but she continued to scream and hit the staff. Resident #7 was interviewed three days later on 6/14/23. She said Resident #6 was handing out cigarettes to other residents and asking them for cigarettes. Resident #7 told her she was not supposed to do that. Resident #6 flipped her off and began to curse at her. Resident #6 started to go toward Resident #7 and then Resident #6 punched Resident #7 in the right shoulder. Resident #7 said Resident #6 then came at her again. Resident #7 said she blocked her and slapped her. Resident #7 said she could hear the staff coming to help intervene. She said Resident #6 kept coming at her and she tried to back up in her wheelchair, but she was not that fast. She said, I did not feel like there was anywhere for me to go. She said staff did then intervene but Resident #6 began to hit them as well. Resident #7 said in her interview on 6/14/23 her shoulder was a bit sore but there were no marks. Resident #7 she was concerned that Resident #6 was going to hit a resident who could not defend themselves. A skin assessment on 6/11/23 documented Resident #6 had a red mark on her left cheek. An SBAR dated 6/11/23 for Resident #6 documented there was a physical altercation, the resident was physically aggressive, it was unknown if this had occurred before and a pain assessment was not applicable. A second pain assessment on 6/11/23 at 6:57 p.m. documented Resident #6 had no signs of pain. An SBAR dated 6/11/23 for Resident #7 documented it was unknown if this occurred before, the resident was in an altercation with another resident, witnessed by staff and the resident had no pain or injuries. A pain assessment dated [DATE] at 4:59 p.m. documented Resident #7 had pain at level 4 out of 10. The resident said she rarely had pain in the last five days. The resident received Tylenol. The nurse documented the resident had chronic back pain and not pain from the incident. An email from SSD to the NHA dated 6/15/23 at 6:01 p.m. documented she was unable to obtain any details on the altercation from Resident #6 due to her aphasia. Social services documented Resident #6 was going to be a supervised smoker due to her behavior and because she was asking others for cigarettes. The email documented the social services department would reach out to see if Resident #6 wanted to visit or if she would do group therapy. A staff member who witnessed the altercation on 6/11/23 documented another resident had come to get her due to two residents fighting outside. The staff member observed Resident #6 hitting Resident #7 multiple times and yelling. Resident #7 then turned and hit Resident #6 in the face. Resident #6 continued to try and go after Resident #7 even as the staff tried to remove her from the area. Resident #7 was observed screaming and hitting the nurse. The facility interviews in the investigation file for staff and residents were reviewed for the 6/11/23 altercation. The interviews were signed by the by the social service manager (SSM), for the altercation on 6/11/23, documented the following: Certified nurse aide (CNA) #4, in an undated interview, documented Resident #6 and Resident #7 had been in an altercation before. -The facility did not clarify or investigate if that was the known incident on 5/8/23 or a new incident. On 6/12/23, Resident #10 complained Resident #6 stood up and shook her fist at people. -There was no further investigation, or interview regarding whether Resident #10 was fearful. On 6/12/23, Resident #8 said Resident #6 shook her fist at people and mainly hit staff, but she would hit anyone. -There were no further interviews or investigation as to whether Resident #8 was fearful. On 6/12/23, Resident #13 said Resident #6 would stand up and shake her fists when she was angry. -There were no further interviews or investigation as to whether Resident #13 was fearful. On 6/12/23, Resident #5 said she had witnessed Resident #6 being physically aggressive and threatening to other residents and Resident #6 had hit her before. -There was no further investigation by the facility regarding when Resident #5 was hit or if the resident was referencing the known altercation on 3/19/23 (see above). On 6/12/23, Resident #3 said he had witnessed Resident #6 being physically aggressive and threatening to other residents. Resident #6 shook her fists at other residents. He said Resident #6 had hit him before. The resident said it did not hurt. -However, in an interview on 6/27/23, Resident #3 said that it did hurt (see below). -There was no follow up documented, no investigation of abuse or reporting to the State Agency. On 6/6/23 at 12:33 p.m. (during the survey) the social service director (SSD) documented Resident #6 was on supervised smoking due to her behaviors while smoking and staff would continue to help redirect her behaviors. The SSD documented Resident #6 had been responding better to redirection from social services. B. Resident #3 1. Resident status Resident #3, age 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO diagnoses included multiple sclerosis, seizures, pain, rheumatoid arthritis, scoliosis with cervical fusion, depression and anxiety. The 4/19/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 of 15. He required extensive two person assistance with bed mobility. He required extensive one person assistance with transfers, dressing, toileting and personal hygiene. Resident #3 had no behavior concerns. 2. Resident interview and observation Resident #3 was interviewed on 6/27/23 at 12:30 p.m. Resident #3 was sitting in his electric wheelchair in his room. His neck was flexed forward with his chin toward his chest. He said he had surgery on his spine a few years ago and he was unable to lift his head upright as a result. Resident #3 said he was familiar with Resident #6. He said Resident #6 had hit him, more than once, probably three times. He said he reported it to the social worker and nurses. He said when Resident #6 got angry, like when the staff did not give her what she wanted, she would flip them off and curse at them. He said for example, if they did not take her out to smoke. He said she would threaten other residents when she would shake her fist at them. Resident #3 said she hits hard. He said it hurt, especially the first time she did it. He did not recall the dates of the physical abuse. Resident #3 could not recall if there was bruising. He said he steered clear of her if she came near him. The resident said he was not fearful, but he was frustrated with her behavior and having to make sure he was not near her. Resident #3 said Resident #6 and Resident #7 have had fights more than once. V. Staff interviews The NHA, social service director (SSD), assistant director of nursing (ADON) and nurse consultant (NC) were interviewed on 6/26/23 at 2:45 p.m. regarding the last physical abuse altercation on 6/11/23. The NHA said the physical abuse on 6/11/23 between Resident #6 and Resident #7 was substantiated. She said Resident #6 hit Resident #7 in the smoking area. She said Resident #6's behaviors were always in the smoking area, so the facility had made her a supervised smoker. She said Resident #7 did hit Resident #6 back in the face and then Resident #6 hit the nurse as the staff attempted to separate them. The NHA and SSD said they did not know what the plan was to keep the other residents safe from Resident #6 or whether any increased supervision or monitoring had been provided previously. The NHA said the facility had made Resident #6 a supervised smoker due to the altercations. -However, the supervised smoking care plan was initiated on 10/14/22 so she was supposed to be supervised prior to the resident altercations. The SSD said the plan for Resident #6 after this altercation was she would need to be a supervised smoker due to her behavior in the smoking area. The SSD said Resident #6's behavior was many times around smoking but not always. The SSD clarified before this incident, Resident #6 would be given one cigarette at a time to smoke and her lighter. She said Resident #6 would give away her cigarettes. She said the staff take her out and monitor her. The SSD did not know why Resident #6 was not monitored in the smoking area after the first altercation on 3/19/23 and when she was supposed to be supervised smoking according to her plan of care. The SSD said after the second known altercation on 5/8/23, which was not in the smoking area, the plan was to offer anger management and group therapy classes to Resident #6. The SSD said she did not feel her behavior was aggression but her way of communicating. The NHA said she had not seen the interviews with the staff and other residents conducted as part of the 6/11/23 investigation. The NHA said she should have reviewed and investigated the staff and resident interviews. She said all interviews should be dated. The NHA and the SSD said they did not recall any investigations regarding Resident #3 and they did have one for Resident #5 from March 2023. -However, they were unable to say, based on the documented interview, whether Resident #5 was referring to the 3/19/23 altercation or another one. The NHA said she could not determine from the staff interview whether CNA #4 was referring to a known altercation between Resident #6 and Resident #7 or a new one. The NHA said the SSM had done the interviews. She said she would investigate the concerns in resident interviews for Residents #3, #5, #8, #10 and #13. The SSM was interviewed on 6/26/23 at 3:30 p.m. She said she had done the interviews with staff and residents on 6/11/23. She said she had been trained on interviewing. The SSM said she should have asked Resident #3 more information like the date of the physical abuse. She said she should have notified the NHA about the interview with Resident #3 and Resident #5. The SSM said she should have asked more questions and clarified with the residents their concerns for Resident #8, #10 and #13. She said she was distracted with multiple requests by the staff. She said in the future she would tell the staff she was busy and focus on investigations. The SSM said there were no behaviors by Resident #7 in the smoking area, except for the two altercations with Resident #6. The SSM said resident behaviors were tracked on the resident's TAR or MAR and reviewed at the weekly psychotropic meeting. She said Resident #7 did not have behaviors and she would provide a copy of the behavior tracking for Resident #6. The NHA was interviewed on 6/27/23 at 10:45 a.m. She said she had spoken to CNA #4 regarding her interview 6/11/23 and clarification the comment Resident #6 and Resident #7 had been in a scuffle before. She said the CNA was referring to the known incident in May 2023. The NHA said the CNA was not asked any further clarifying questions at the time of the interview. She said the human resources (HR) staff had done the interview with CNA #4. The ADON and director of nursing (DON) were interviewed on 6/27/23 at 11:04 a.m. The ADON said on 6/11/23 Resident #6 and Resident #7 had an altercation. Resident #6 approached Resident #7 and tried to grab her cigarette. She said then Resident #7 slapped her. She said the resident had interactions in the smoking area before but she did not think it was physical. The DON said the plan to keep residents safe was to have Resident #6 supervised while smoking. He said he was not familiar with the investigations but he said Resident #3 and Resident #5 were not verbally or physically aggressive. He said the residents in the smoking area were capable of reporting altercations, therefore he did not think there were altercations that had not been investigated. The DON said behaviors were tracked on the resident's MAR or TAR. He reviewed the MAR and TAR for Resident #6. He said there was no tracking of her aggressive behaviors. He said there was nothing tracked about her striking out, grabbing or shaking her fist. He said her depression symptoms were tracked and she was on an antidepressant. He said the staff would know if her behavior was [TRUNCATED]

Based on record review, interviews and observations, the facility failed to ensure the resident environment remained as free from accident hazards as was possible and that residents received adequate supervision to prevent accidents for four (#1, #2, #16, and #6) out of five residents reviewed for accidents out of 16 sample residents. The facility failed to implement effective interventions and provide adequate supervision to prevent falls for Resident #1, who was a known fall risk, had a recent history of a fall with major injury, and was dependent on staff for assistance. On 12/14/21, Resident #1 experienced an unwitnessed fall in the facility resulting in hip pain. The resident was sent to the hospital on 12/15/21 due to unrelieved pain and was discovered to have a right intertrochanteric femur fracture which required surgical repair. The interventions the facility implemented in response to the resident's fall risks and past falls were not effective in preventing future falls as the resident experienced a subsequent unwitnessed fall on 2/13/22. Additionally, neurological checks and follow ups were not completed and documented for the resident to rule out possible brain and latent injuries. The facility further failed to implement effective interventions to prevent falls, and complete neurological checks after unwitnessed falls, for Residents #2, #16 and #6; and, The facility failed to ensure environmental safety hazards were identified and remediated in resident rooms. Findings include: I. Facility policies and procedures The Resident Safety and Supervision policy, revised July 2017, was provided by the nursing home administrator on 2/21/22 at 4:17 p.m. It read, in pertinent part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Our facility oriented approach to safety addresses risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (quality assurance process improvement) reviews of safety and incident/accident data; and a facility wide commitment to safety at all levels of the organization. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. Employees shall be trained on potential accident hazards, on how to identify and report accident hazards and try to prevent avoidable accidents. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. Our individualized, resident-centered approach to safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks shall include the following -Communicating specific interventions to all relevant staff; -Assigning responsibility for carrying out interventions; -Providing training as necessary; -Ensuring interventions are implemented; and -Documenting interventions. Monitoring effectiveness of interventions shall include the following: -Ensuring that interventions are implemented correctly and consistently; -Evaluating the effectiveness of interventions; -Modifying or replacing interventions as needed; and -Evaluating the effectiveness of new or revised interventions. The Neurologic Check Policy, dated 10/10/06, was provided by the clinical resource (CR) on 2/22/22 at 11:30 a.m. It read, in pertinent part: Residents who have a fall involving striking the head or unwitnessed falls where it is not apparent if head injury occurred will have neurologic checks done by the nurse in charge of their care. The only exception would be if the resident is alert and oriented and has no evidence of head injury and denies hitting the head. Assess vital signs, temperature, pulse, respirations and blood pressure. Check orientation via verbal responses to questions regarding name, place, person, date, time, and events, attention span, mood, affect and behavior. Check ability to respond to verbal commands, raise arms, close eyes, move in bed. Check responses to tactile stimuli, squeeze hand, apply pressure to arm or leg on both sides of body. Check eyes for size and shape and ability to open and close; note symmetry of both eyes, compare pupil size to chart and equality. Use a penlight to check response to pupils to light. Check eye movement by noting ability to follow finger with eyes in all directions. First group of neurologic checks will be done at 15 minute intervals times four. Second group of neurologic checks will be done at 30 minute intervals times four. Third group of neurologic checks will be done at one hour intervals times four. Fourth group of neurologic checks will be done at four hour intervals times four. Fifth group of neurologic checks will be done at each shift times four. Sixth group of neurologic checks will be continued at each shift intervals through 72 hours. Document results of the neurologic checks on approved form per the policy. Documentation additional nurses notes for any abnormal finding and notify the physician of these finds for intervention. Continue documentation for the full 72 hours after the fall or head injury incident. II. Resident #1 A. Resident status Resident #1, age 73, was admitted on [DATE] and discharged to the hospital on 2/14/22. He had not yet returned to the facility. According to the February 2022 computerized physician orders (CPO), the diagnoses included type 2 diabetes mellitus with ketoacidosis without coma, displaced intertrochanteric fracture of right femur, [CONDITION(S)] infection, unspecified fracture of upper end of right humerus, need for assistance with personal care, [CONDITION(S)], weakness, abnormality of gait and mobility, anorexia, history of falling, history of [CONDITION(S)], and adult failure to thrive. The 12/20/21 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. He exhibited rejection of care. He required extensive assistance of two staff members with transfers and bed mobility and extensive assistance of one with activities of daily living (ADLs). The resident's fall history was not assessed. The resident had a disease or condition that may result in a life expectancy of less than six months. He did not have a pressure ulcer, he was identified to be at risk for developing pressure ulcers, he had a surgical wound and a skin tear. The resident received oxygen and hospice services in the facility. -Review of Resident #1's medical record revealed although he had a BIMS score of 15 out of 15, his cognition was at times severely impaired. B. Record review A fall care plan, initiated on 10/30/19 and last revised on 2/14/22 read: Potential for falls and has had falls related to low blood glucose, weakness and fall with fractured clavicle. The goals of the care plan included: The resident will be free from falls initiated 10/30/19, and Will be free from further major injury related to falls initiated 12/22/21. Pertinent interventions included: 10/30/19: Encourage/assist to have proper non-skid footwear; Keep room free from clutter and pathways clear; PT/OT to evaluate and treat prn (as needed); 3/29/21: Call light within reach of resident; 8/6/21: Resident prefers to wear wide shoes at times, family to provide new shoes to reduce tripping hazard; 8/9/21: Nightstand in resident's room to be padded to prevent future injuries from bumping against or falling against while ambulating independently in room; 10/28/21: Staff to provide frequent rounding to assess for incontinence issues. Record review revealed Resident #1 had a past fall with injury on 10/27/21 at 6:55 a.m. where the nurse was at the medication cart, heard a loud noise and found the resident on the floor on his right side. He stated his right shoulder hurt. His blood glucose was checked and was too high to detect. The resident was sent to the hospital where a right humerus fracture was discovered upon x-ray. An intervention was added to his care plan on 10/28/21 to call for assistance with incontinence cares and staff to do more frequent rounding to monitor for incontinence and nonskid footwear. -After Resident #1's falls on 10/27/21 and 12/14/21 (see below) high blood glucose levels were identified, yet there were no interventions related to high blood glucose possibly being related to his falls. A fall risk assessment dated [DATE] revealed the resident was at high risk for falls with a score of 16. A fall note dated 12/14/21 at 5:00 p.m. read: Found resident on floor on his right side. Resident had empty cup in his hand. Resident says he was trying to empty his cup and fell . He states he did not hit his head only hurts on his right hip. Pain is 8/10. Called CNAs to assist, VS taken, all WNL. BG 264, 2 units insulin [MEDICATION(S)] given. Neuro assessment normal. Resident able to move all extremities. Resident's brief changed and placed back in bed. Notified daughter, Hospice and DON. Hospice sending on call nurse to assess pt. 72 hour neuros started. A nursing note dated 12/14/21 at 8:30 p.m. read: Hospice came to assess the resident at 2200 (8:00 p.m.) due to continuous c/o (complaints) of pain at the right hip following an unwitnessed fall. New order received 50mg of [MEDICATION(S)] tablet via mouth prn. The hospice nurse administered the first dose of [MEDICATION(S)]. No effectiveness of pain. continue to monitor. A nursing note dated 12/14/21 at 11:40 p.m. read: Resident continues with neuros following fall. Vital signs 122/78, 98.2, 88, 18, 94%. Refused ADLs and complains of severe pain. Informed hospice nurse. No new orders received at this time. Continue to monitor. A nursing note dated 12/15/21 at 1:44 a.m. read: The resident was being monitored for neuros due to a fall that happened at 4:30 p.m. last evening. He complained of severe pain to the right hip. [MEDICATION(S)] was administered as ordered. Ineffective pain control. Resident states pain is still severe and interferes with ADLs. Called hospice and spoke with nurse. Hospice nurse stated resident to be sent to hospital as per family request. Call placed to transport company to transfer the resident to the hospital. EMS (emergency medical services) arrived at 1:30 a.m. and resident left facility at 1:40 a.m. A fall IDT (interdisciplinary team) note dated 12/15/21 revealed the resident fell on [DATE] at 4:45 p.m. The resident was assessed by a registered nurse (RN), appropriate notifications were made. The fall was unwitnessed and neurological checks were performed. The resident complained of pain 8/10 after the fall and PRN pain medications were administered and non-pharmalogical pain interventions were implemented. The root cause was identified as the resident had severe cognitive deficits. Resident may have been confused about his fluids and wanted a drink of water. The intervention added was Offer fluids frequently. The fall care plan was updated on 12/14/21 to reflect the intervention of offer fluids frequently. -This intervention was also a nutritional intervention already in place and is a basic care activity. -Records of the resident's neurological checks were requested and were not received. C. Hospital records Review of the resident's hospital records revealed the resident presented to the emergency department on 12/15/21 after a mechanical fall at the nursing facility and complained of right hip pain. X-rays of the right hip revealed a comminuted intertrochanteric fracture of the right proximal femur. Laboratory results from the hospital revealed the resident also had a urinary tract infection. The resident underwent surgical repair of the fracture. D. Additional record review An admission summary note dated 12/16/21 revealed the resident returned from the hospital with new orders for as needed pain medications, a muscle relaxer, and a [MEDICATION(S)]. Hospice, administration, and the physician were informed of the resident's return. The resident was alert and oriented x 1 (to person) as per usual baseline. He denied pain at the time. A fall risk assessment dated [DATE] revealed the resident was at high risk for falls, though with a lower score of 13 than the previous assessment on 11/10/21 (see above). A nursing note dated 12/17/21 revealed the resident was status post right hip surgery. Vital signs were normal. Right hip post surgery precautions were implemented. Resident was complaining of pain and pain medications were administered which were effective. Surgical wound care orders were received and performed. A nursing note on 12/19/21 revealed the resident was calm, and received pain medications which were effective. Repositioning was offered for comfort. A nursing note dated 1/7/22 revealed the resident developed a new skin issue, an unstageable pressure injury to his thoracic spine. (Cross Reference F686 Pressure Injuries). The wound was treated in the facility, though worsened and became infected on 2/8/22. A nursing note dated 2/13/22 at 10:57 a.m. revealed the resident was found on the floor by the manager on duty. The RN assessed the resident and was determined to be stable, vital signs within normal limits, and no injuries found. Neurological checks were started. Hospice was informed and scheduled a visit to the resident. Daughter was notified and the resident was educated to use his call light and ask for help to move to his wheelchair. An activities note dated 2/13/22 at 5:22 p.m. revealed the resident was found on the floor by activities staff at 9:15 a.m. The activities staff called the RN and CNA on duty to assess and assist him. Review of the resident's fall care plan revealed an intervention of a physical and occupational therapy evaluation was added on 2/13/22. -While the resident could be evaluated by physician and occupational therapy, despite hospice status, this intervention was already in place for the resident and was not related to the root cause of the fall. A fall note dated 2/14/22 at 1:40 a.m. revealed the resident was on fall follow up and no delayed injuries related to the fall. Vital signs and neurological checks were within normal limits. A post fall risk assessment dated [DATE] revealed the resident was at high risk for falls with a score of 18. A nursing note dated 2/14/22 at 4:18 p.m. revealed the resident's wound had deteriorated. The resident requested to go to the emergency room . The resident was on hospice and the writer revealed the resident had requested to go to the emergency department the day before, though hospice wanted to wait for the results of the wound culture to return. The resident was transported to the emergency department per resident and family request. -Documentation of the resident's neurological checks for this period were requested, though were not received. -The resident had not returned to the facility as of the exit of the onsite investigation. E. Interviews Licensed practical nurse (LPN) #1 was interviewed on 2/22/22 at 10:30 a.m. She stated when a resident fell , the nurse completed an assessment for injuries and neurological checks for all falls. She stated the nurse needed to complete a risk management note, call the director of nursing and physician and also document the fall. Certified nurse aide (CNA) #3 was interviewed on 2/22/22 at 10:35 a.m. She stated when a resident fell , she would get the nurse to assess, do vitals and neurological checks. The administrative team, including the nursing home administrator (NHA) , director of nursing (DON), clinical resource (CR), and assistant director of nursing (ADON) were interviewed on 2/22/22 at 11:05 a.m. They stated issues with the facility fall program were identified prior to the onsite investigation and a house wide fall audit was conducted on 1/24/22. They stated there was an attempt to improve the facility fall program at that time. They stated the fall program still needed work in terms of follow up, ensuring appropriate interventions were added to resident care plans and a process to ensure the interventions were in place and effective. They stated the IDT team met weekly to review all falls and discussed all falls in the daily morning meeting. They stated the IDT team had not been effectively monitoring interventions. They stated unwitnessed falls and witnessed falls with head involvement should have neurological checks. They stated the previous DON kept a binder of neurological check forms, though the binder could not be located. They stated the neurological check forms would now be uploaded into the electronic health record when completed, so they could not get lost. They stated residents were assessed for fall risk upon admission, after a fall, after a change in condition, and at least quarterly. They stated all residents who were identified as a fall risk should have interventions in place to prevent falls. They stated a new intervention should be added for the resident after each fall and should be related to the root cause of the fall and should be monitored for effectiveness. The CR was interviewed on 2/22/22 at 11:35 a.m. She stated Resident #1 was a fall risk and had experienced falls with injury in the facility. She stated the interventions added to the resident's care plan for the falls on 12/14/22 and 2/13/22 were not related to the root cause of the falls and were not appropriate or effective interventions for the resident, specifically because they were already attempted and should already be in place as regular care activities. She stated the intervention of reminding the resident to use his call light was not appropriate due to the resident's dementia. She stated if a resident requests to go to the hospital, whether they are on hospice or not, it was their right to go to the hospital for evaluation. She stated the record of the resident's neurological checks could not be located. III. Resident #2 A. Resident status Resident #2, age 76, was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), the diagnoses included dysthymic disorder (persistent depression), unspecified [CONDITION(S)], muscle weakness and history of falls and urinary tract infections (UTIs). The 12/31/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. He required limited one person assistance with bed mobility, and extensive one person assistance with transfers, dressing, toileting and personal hygiene. Resident #2 had two or more falls since his last assessment. B. Observations and interviews Resident #2 was observed in bed on 2/21/22. His bed was pushed up against the wall. On the other side of his bed, a large recliner was pushed up against the bed covering the top three fourths, leaving only a one fourth opening toward the bottom of the bed (cross-reference F604, physical restraints). Licensed practical nurse (LPN) #1 observed the resident's bed, and was interviewed on 2/21/22 at 11:57 a.m. She said, I see an issue that he cannot get in or out of his bed, except at the foot of the bed. She said he had to get in at the foot of the bed and crawl to the top. She said she did not know if he was a fall risk, but he could fall if he tried getting out of the bed by climbing over the recliner. She said the recliner is blocking the entire upper half of his bed and limiting his ability to get in and out of his bed. LPN #1 said the room was too small for the recliner and there was no way to move it away from the bed. On 2/22/22 the resident was observed in a new room. He did not have non-skid strips on the floor by his bed, as documented in his care plan. C. Record review and interviews The NHA, CR, ADON, and DON were interviewed on 2/22/22 at 11:12 a.m. The CR had her laptop and the resident's falls since 12/17/21 were reviewed as follows: Fall 12/17/21 On 12/17/21 at 7:13 p.m. the nurse notes documented, the resident was found on the floor sitting by his bed, leaning against his recliner. He said he was trying to put his shoes on, to go to the bathroom. He slid as he was trying to get his shoes. There was no injury. On 12/20/21 at 9:55 a.m., the IDT (interdisciplinary team) documented a review of the fall. The intervention was non skid tape to side of bed. However, the intervention did not address the root cause, the resident had to go to the bathroom. He needed extensive one person assistance with transfers. The CR looked at her laptop, and said the root cause was not addressed. She said the resident's need to use the bathroom was the root cause. Additionally, she said the facility had no record of neurological checks for this unwitnessed fall, per the facility policy. Fall 1/11/22 On 1/11/22 at 10:19 p.m., the nurse notes documented, Summoned by nurse LPN assigned to this resident to further assess him for falling and landing on his buttocks outside his room. Neuros and vs (vital signs) taken and is wnl (within normal limits). Res(ident) denied pain. BLE (bilateral lower extremities) and BUE (bilateral upper extremities) within normal power. Legs length equal and strength strong. Hand grip strong, no deformities noted at this time. Eyes PERRLA (pupils, equal, round, reactive to, light, accomodation). Res stated he was trying to ambulate without a walker lost balance and fell . Res reminded to always use walker for safety while walking. Res stated 'ok.' On 1/12/22, the IDT documented the resident was attempting independent mobility in the room, and was attempting to locate his walker. Will have PT (physical therapy) assess resident to ensure staff are using and teaching safest mobility. Staff will place his walker within arms reach. However, the resident had already been on therapy and was discharged on [DATE]. The physical therapy discharge summary, dates of service 11/2/21 to 1/5/22, documented the resident required supervision with ambulation. The CR looked at her laptop, and said the root cause was not addressed. The resident should not have been ambulating with his walker independently, he required stand by assistance. Additionally, she said she did not have a record of the neurological checks after this unwitnessed fall. Fall 1/12/22 On 1/12/22 at 3:49 a.m., the nurse's notes documented, The resident was overheard calling for help. Upon responding, the resident was observed laying on his back in the hallway. RN was from the 1st-floor was alert for assessment. Denies pain and no physical injury was noted at this time, VS WNL. Resident's to be within reach at all times. Neuros initiated as per protocol. There were no IDT notes or record of the neurological calls for this unwitnessed fall in the progress notes or medical record. The ADON said she did not know why there was no IDT note. The CR reviewed her laptop and confirmed there were no neurological checks, and no new intervention or IDT note. Fall 1/15/22 On 1/15/22 at 11:00 p.m., the nurse notes documented, CNA found resident on the floor when she was doing her rounds, Nurse asked resident what had happened, he stated he slipped off his chair. Nurse asked if he had any pain, he stated he did not. Nurse assessed resident no injuries found. CNA and Nurse lifted resident back up onto his chair. On 1/15/22, the care plan was revised, OT will assess the need for a non-slip mat for recliner. On 1/18/22, the IDT documented, the resident had slipped out of his reclining chair . OT will assess need for a non-slip mat for recliner. However, the resident had fallen again since that note on 1/16/22, see below. The CR was interviewed previously on 2/21/22 at 4:24 p.m. She said there were no therapy notes that OT assessed Resident #2 for a non-skid mat in front of his wheelchair. The NHA said therapy would have been at the IDT meeting, when placing a mat in front of the recliner was discussed. She did not know why the assessment was not completed. She said there was no non skid fall mat that had been placed in front of his recliner. The CR again looked at her laptop and said there were no neurological assessments and no assessment by OT related to a mat in front of the resident's recliner. Fall 1/16/22 On 1/16/22 at 1:00 a.m., the nurse's notes documented, CNA found resident on the floor of the bathroom, when Nurse asked what happened he stated he was trying to go to the bathroom on his own. Asked resident if he had any pain, he stated his neck was hurting, nurse assessed neck and head and found no injuries. The neurological checks were received from the CR and were completed. On 1/17/22 at 6:09 a.m., the nurse's notes documented, The resident noted frequent bathroom visits than usually. Denies pain with voiding at this time .On-call doctor notified. An order for UA was received. On 1/20/22 he was diagnosed with a [CONDITION(S)] (urinary tract infection), and started on antibiotics on 1/21/22. -The resident had a history of UTIs. However, he was not assessed for a [CONDITION(S)] until 1/17/22. The IDT notes dated 1/18/22, the resident ambulated to the bathroom independently. Therapy to assess the need for additional support. The CR said therapy was not an effective new intervention, asd the resident was already on therapy at that time. The NHA said it was not an appropriate intervention to have therapy assess the resident. She said she was already on therapy, and the IDT should have addressed the toileting needs, and reviewed the nurses notes related to his urinary symptoms. The fall care plan, initiated 5/23/12, was reviewed and documented in pertinent part, Resident #2 is at risk for falls and has falls r/t [CONDITION(S)] med use and hx of falls, use of walker, slight shuffle gait and generalized weakness. OT will assess the need for a non-slip mat for (resident's) recliner. Therapy will assess the need for additional support. Non skid strips to the side of bed. Offer a night light to be on during night hours. Staff to educate to reach back for the chair before sitting. Encourage/assist to have proper non-skid footwear. Prefers to have his call light attached to the cord in his room. Encourage/remind to call for assist if needing assist with transfers/ADL's. Keep room free from clutter and pathways clear. Perform investigation to determine and address causative factors of the fall. Pharmacy consult to evaluate medications prn. PT/OT to evaluate and treat prn. Monitor for adverse effects to medications and report any findings to physician. -However, OT did not assess the resident for non skid strips in front of his recliner. The pathways were not kept clear, with a recliner pushed up against his bed. Investigations did not look at causative factors for falls. IV. Resident #16 A. Resident status Resident #16, age 75, was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), the diagnoses included [CONDITION(S)] and dementia. The 12/31/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of 6 out of 15. He required extensive one person assistance with bed mobility, and was totally dependent on staff for transfers. He required extensive one person assistance with dressing, toileting and personal hygiene. Resident #16 had two or more falls since his last assessment. B. Observations The resident was observed in bed on 2/21/22 at 10:40 a.m. His bed was pushed up against the wall, and on the opposite side there was a bolster in place which extended the entire length of the bed. The bed was not in the low position. There was a mat on the floor next to the bed. On 2/22/22 at 9:00 a.m., the resident was observed in bed. There was no mat on the floor next to his bed. C. Record review and interviews The resident's assessments were reviewed in the electronic medical record (EMR). There was no restraint assessment, no consent from the MDPOA for the use of a bolster to the resident mattress, no physician's order on the February 2022 CPO, and no care plan for the bolster. The NHA, CR, ADON, and DON were interviewed on 2/22/22 at 11:12 a.m. The CR had her laptop, and the residents falls since 1/12/22 were reviewed as follows: Fall 1/12/22 On 1/12/22 at 11:51 a.m., Resident found on floor on fall mat during med pass. Resident was lying on left side. Resident was able to move past wedge pillow during fall .resident very lethargic due to recent hospital stay. States no pain, no injuries found, can move all extremities. DON, Administrator and family (POA) notified of fall. Started 72 hour neuro checks. Neurological checks were completed and reviewed. There was no IDT note in the progress notes. The CR said the risk management form documented the bed was to remain in a low position. She said that was not an effective intervention, as the bed should have already been kept in a low position. A copy of the risk management form was requested and not received by the end of the survey. The fall care plan, initiated 4/7/21, was reviewed. There were no changes to the care plan after this fall. The care plan did not address keeping the bed in a low position. On 1/16/22 at 2:08 a.m., the nurse's notes documented, Resident remains on one to one due to frequent falls. -There was no documentation in the progress notes regarding when the one to one began or ended for Resident #16. On 1/24/22 at 1:48 p.m., 12 days after the fall, the IDT documented, Fall committee met today to discuss (resident's) most recent frequent falls, post review IDT has concluded that the staff will follow a up/down schedule so as to anticipate when (resident) would like to get up in his wheelchair. Staff will continue to remind to ask for help when he needs assistance with ADLs. Activities will review their program and the need to increase visits. MD will be contacted for psych consult. There was no update to the fall care plan regarding an up/down schedule or psych consult. Fall 1/29/22 On 1/29/22 at 5:52 p.m. the nurse notes documented, Resident was found lying on the floor in his room beside his bed. Resident unable to describe what led to the fall. The fall probably resulted from resident attempting to stand from bed while supporting self-using the bedside table which he had used during lunch meals. No injuries noted. Skin was intact. No redness noted. Redness denied pain. Resident was assessed and assisted WC. Neuros initiated per the protocol. He was moved close to the nurses station for closer supervision. Notifications made to family, DON .Neuros and VS are stable and within his baseline. We will continue to monitor. On 1/31/22 at 2:33 p.m., the IDT documented, Current interventions: Low bed, mat on floor, Call don't fall signage, .OT contacted via email asked to address his frequent falls and encourage up in wheelchair for all meals. Please note that IDT has concluded that (resident) will continue to fall, interventions will be in place to minimize injury. Neurological checks were completed and reviewed. On 1/29/22 the fall care plan was updated to include, staff will offer resident to sit up in his wheelchair for meels. -The care plan did not include low bed, mat on the floor, fall signage, encourage to

Based on record review, observations, and interviews, the facility failed to ensure that two (#1 and #15) out of 16 sample residents received care and services to prevent the development and worsening of pressure injuries. Resident #1 was dependent on staff for mobility, transfers and repositioning and was identified at risk for developing pressure injuries. The facility failed to prevent the development and worsening of a pressure injury for Resident #1. On 1/7/22 an unstageable pressure injury was discovered on Resident #1's thoracic spine. The resident was noted to be resistant to care with minimal documentation done in response to the resident's resistance. Wound care treatment orders were not consistently followed. Due to the facility's failures, the resident developed an avoidable, facility-acquired unstageable pressure wound to his thoracic spine. The resident was transferred to the hospital on 2/14/22 where he was discovered to have an infected stage three pressure injury which required intravenous antibiotics, an invasive debridement and a wound vac to treat the infection and heal the wound. Resident #15 was dependent on staff for mobility, transfers and repositioning and was identified at risk for developing pressure injuries. The resident was admitted to the facility without any pressure ulcers and developed a pressure injure on the coccyx area two month after initial admission the facility. The pressure injury healed within two months but the pressure injury to Resident #12 coccyx redeveloped a month after healing. Upon reemerging the pressure injury was first noted to be a stage-3 pressure injury there was no documentation of the resident coccyx showing signs of breakdown at any stage prior to the injury bed observed as a stage-3 pressure injury. Due to the facility's failure to identify and treat the resident impaired skin condition the skin continued to breakdown and the resident developed a second stage-3 facility acquired pressure injury. This deficiency was cited previously during a recertification survey 10/27/21 and specifically for Resident #15. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include: I. Professional reference The National Pressure Ulcer Advisory Panel (2016) NPUAP Pressure Injury Stages, retrieved on 2/8/22 from: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed the following pertinent information: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. II. Facility policy and procedure The facility Pressure Injury policy, revised March 2020, was provided by the nursing home administrator on 2/22/22 at 3:40 p.m. It read, in pertinent part: Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: -Evaluation of the resident's clinical condition and risk factors; -Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; -Monitoring or evaluation of the impact of the interventions; or -Revision of the interventions as appropriate. Tissue tolerance is the ability of the skin and its supporting structures to endure the effects of pressure without adverse effects. Tissue tolerance affects the length of time a resident can maintain a position without suffering a pressure ulcer/injury. III. Resident #1 A. Resident status Resident #1, age 73, was admitted on [DATE] and discharged to the hospital on 2/14/22. He had not yet returned to the facility. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/20/21 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. He exhibited rejection of care. He required extensive assistance of two staff members with transfers and bed mobility and extensive assistance of one with activities of daily living (ADLs). The resident's fall history was not assessed. The resident had a disease or condition that may result in a life expectancy of less than six months. He did not have a pressure ulcer, he was identified to be at risk for developing pressure ulcers, he had a surgical wound and a skin tear. He had a pressure reducing device for his bed and his chair. The MDS assessment documented the resident was not on a turning and repositioning program and was not receiving nutritional interventions. The resident received oxygen and hospice services in the facility. B. Record review A skin care plan updated 11/3/21 read: Resident has actual impairment to skin integrity related to self inflicted scratches. Pertinent interventions included: Educate (resident)/family/caregivers of causative factors and measures to prevent skin injury; and Encourage good nutrition and hydration in order to promote healthier skin. A skin committee meeting note dated 11/4/21 read: Full house skin sweep completed. Resident noted to have reddened coccyx. No open areas noted. Shearing to LLE. Resident states that it happened in the hospital when he brushed his leg while trying to go to the bathroom. Wound MD in to assess. New orders for protective barrier cream and protective dressing to coccyx. Wound to LLE to apply [MEDICATION(S)] and bordered gauze. Air mattress ordered. Denies pain or discomfort when asked. Staff assists with positioning at times. Resident incontinent. Staff to assist with frequent positioning and incontinence cares. Will continue to observe for change. MD, POA and DON notified. An air mattress was ordered for the resident on 11/4/21 due to redness to his coccyx. An order on 11/5/21 read: Offer resident frequent repositioning as resident allows for offloading every two hours for prevention. An IDT (interdisciplinary team) weight committee meeting note dated 11/11/21 read: Reason for review: Sig (significant) wt (weight) loss. Current wt: 97.2lbs (pounds) Previous wt: 100lbs. 71% meals consumed. Loss of 19.5% in 30 days; resident was hospitalized for DKA (diabetic ketoacidosis) and fall with fx (fracture) x (for) 3 days. Orders for glucerna (nutritional supplement) 1.5, QID (four times daily)- 100%, fortified foods, double portions and CCHO (controlled carbohydrate) diet. Under hospice care. Current nutrition regimen meets estimated needs. Comfort is goal. Will continue to follow. A hospice care initiated 11/11/21 read: Resident has a terminal prognosis and is on hospice services related to senile deterioration of the brain. Pertinent interventions included: Adjust provision of ADLs to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate; Work with nursing staff to provide maximum comfort for the resident; wound care. A skin committee meeting note dated 11/13/21 read: Late Entry: Note Text: Wound MD (medical doctor) in to assess stage 1 to coccyx 11/12/12-pressure #2 shearing to right shin. Measurement Healed #2 5.0 CM (centimeters) x 1.0cm drainage: none #2 no drainage odor: None. Treatment: continue to provide frequent repositioning and incontinence cares as resident allows. Barrier creams with each incontinent episode. Continue with air mattress for prevention. #2 continue as above and dressing change to left shin every other day. cleanse with NS (normal saline), pat dry, apply [MEDICATION(S)] or equivalent and cover with bordered gauze every other day and PRN (as needed). Interventions: daily observation by staff, remain on weekly follow up with wound MD, weekly skin checks, provide barrier creams with incontinent episodes. Resident to continue with daily dietary supplements. Weekly skin checks by licensed staff. #2 continue with daily and PRN dressing changes. Education: resident education on importance of frequent offloading, skin care, and barrier creams. Resident dietary intake including protein and supplements will be monitored by dietician and weight and skin team. Resident will be monitored with hospice care givers weekly and will be encouraged to eat foods appropriate for CCHO dietary recommendations. Resident barriers: Resident bed bound and often refuses to get out of bed and participate in therapies. Resident impulsive and at times will attempt to get out of bed without assistance. Unsteady gait and has poor memory recall. Resident hospice patient and Diabetic. Sugars are irregular as resident is brittle diabetic and often consumes items not recommended for diet, or does not consume recommended portions of CCHO diet. A braden scale (pressure ulcer risk) assessment dated [DATE] revealed the resident was at high risk for pressure ulcers. A skin note dated 11/19/21 read: Resident was seen by Wound Dr. (doctor) for Left shin wound, area is not improving as resident is resistant to repositioning and skin care. Continue current treatment and encourage resident to increase mobility. An IDT weight committee meeting note dated 11/24/21 read: Sig weight loss-wound healed. Current weight: 101.4. Previous weight: 96.0. BMI (body mass index): 13.8 (underweight, normal range 18.5-24.9). Meal Consumption: 51-75% intake this week. Supplements: QID Glucerna 1.5, 95% intake of supplement. Amount of weight loss or gain: 5.4 lb increase. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommendations: Receiving hospice services. Fortified lunch and dinner in place. Glucerna is giving approx 1,400 calories to (resident). Orders obtained from provider to change weights to monthly due to Dx(diagnosis) of unavoidable wt loss secondary to terminal dx. Hospice notified. Continue current regimen with comfort focused care as goal. A nursing note dated 11/25/21 read: Blood sugar at 2130 (9:30 p.m.) was 384 (normal range 140 of lower), appropriate insulin given. Displays no S/S (signs/symptoms) of [CONDITION(S)] at this time. Appears more confused, was asking for dinner, which he already had, Gave him snacks, fluids. Has denied pain/discomfort at this time. Refusing to allow staff to change his soiled linens, 'leave me alone.' Will try again later. Monitoring. On 12/14/21 the resident suffered a fall which resulted in hip fracture which required hospitalization and surgical repair. The resident returned to the facility on [DATE] and an updated braden scale was not completed upon return. (Cross reference F689 Accidents). A nursing note dated 12/17/21 read: Res S/P R. (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R. hip post-surgery precautions implemented this shift. Res c/o (complained) of pain during this shift and prn (as needed) [MEDICATION(S)] 10 mg administered with 1000 mg Tylenol TID (three times daily), effective. R. hip surgical incision noted with 8 sutures above and 6 sutures below, and is clean dry and intact. Surgical incision well approximated, and no s/sx of infection noted this shift. Dressing change order received from doctor today and updated in TARs (treatment administration). (Named) Hospice nurse in for the visit. Incoming shift notified to continue to monitor. A nursing note dated 12/19/21 read: Res(ident) noted calm at this time, received [MEDICATION(S)] 10 mg prn this am, effective. Repositioning offered for comfort. Res continues on S/P R. hip surgery and no s/x of infection noted at this time. VS stable. Dressing changed to site this am (morning). A weekly summary assessment dated [DATE] revealed a pressure ulcer was discovered on the resident's back during the skin assessment. A follow-up braden scale assessment dated [DATE] revealed the resident was at high risk for pressure ulcers. An interdisciplinary team (IDT) weight committee meeting note dated 1/7/22 read the reason for review was skin. The resident's current weight was 115 lbs with meal consumption of 50 - 75%. The resident was receiving supplements of Glucerna four times a day with 100% acceptance. The recommendations included: receiving hospice services, weight loss expected. Accepts fortified lunch and dinner provided. Continue current regimen with comfort focused care as goal. -There were no skin related recommendations from this meeting. An order on 1/8/22 read: posterior left upper back pressure injury wound care, clean with wound cleanser, allow to dry, apply [MEDICATION(S)] to wound bed, do not exceed wound margins, apply bordered foam dressing, change daily and prn every shift for wound care. -The January 2022 treatment administration record (TAR) revealed this wound care order was missed on 1/8/22 and 1/11/22. The resident was seen by the wound care physician on 1/11/22 for the wound to the resident's lower back. The note revealed an unstageable pressure injury obscured full thickness skin and tissue loss pressure injury and had received a status of not healed. Initial wound encounter measurements were 5cm x 5cm with no measurable depth, with an area of 25 sq cm (square centimeters). There is a moderate amount of serosanguinous drainage noted which had no odor. Wound bed was 70% eschar and 30% slough. The periwound skin exhibited [CONDITION(S)] (reddening). The resident was at increased risk of wound incidence due to impaired mobility, decrease in functional ability, co-morbid conditions, diabetic complicating factors, and resident refusal of care and treatment. Orders were written to cleanse and irrigate the wound with normal saline, apply honey-based ointment-[MEDICATION(S)], cover with dry dressing. Change the dressing every day and as needed. Recommendations to implement pressure relieving measures and offloading as tolerated. Low air loss mattress, reposition every two hours while awake to offload pressure. -Repositioning was not added to the care plan. An order on 1/11/22 read: posterior left upper back pressure injury wound care, clean with wound cleanser, allow to dry, apply [MEDICATION(S)] to wound bed, do not exceed wound margins, apply bordered foam dressing, change daily and prn every shift for wound care. -The January 2022 TAR revealed this order was missed on 1/18/22. A pressure ulcer care plan was initiated on 1/11/22, it read: Pressure ulcer to mid back. The goal for the care plan read: Pressure injury heals without major complications. Pertinent interventions included: Doctor aware; encourage off loading; air mattress in place; registered dietician following; hospice aware; and wound orders in place. -Review of the resident's care plans revealed no mention of the resident refusing to reposition or offload, nor were there any interventions related to what to do when the resident refused. The resident was seen by the wound care physician on 1/18/22 during wound rounds. The note revealed an unstageable pressure injury obscured full thickness skin and tissue loss pressure injury and had received a status of not healed. Subsequent encounter measurements were 5cm x 5cm with no measurable depth, with an area of 25 sq cm. There was a light amount of serosanguinous drainage noted which had no odor. Wound bed was 100% slough. There was no change noted in the wound progression. The periwound skin exhibited [CONDITION(S)]. The resident was at increased risk of wound incidence due to impaired mobility, decrease in functional ability, co-morbid conditions, diabetic complicating factors, and resident refusal of care and treatment. The wound was debrided and post debridement measurements were 5 cm x 5 cm x .1 cm. There was noted to be a very thick layer of slough and debridement was difficult. -No changes were made to treatment orders or recommendations. An IDT committee note dated 1/18/22 read: Review of resident's weight and intake. Resident continues on hospice care and now presents with a new PU (pressure ulcer) that was identified recently. After a long discussion the team has concluded that this PU is unavoidable due to resident remaining on his back at all times. Staff continue to educate resident on the importance of off loading; he expresses understanding however continues to lay supine in bed. Prostat (nutritional supplement) was added BID (twice daily) to promote wound healing. An order on 1/18/22 read: Prostat two times a day for wound healing. -The January 2022 TAR revealed this order was missed on 1/21/22 on the day shift. The resident was seen by the wound care physician on 1/25/22 during wound rounds. The note revealed an unstageable pressure injury obscured full thickness skin and tissue loss pressure injury and had received a status of not healed. Subsequent encounter measurements were 4.5cm x 4.5cm with no measurable depth, with an area of 20.25 sq cm. There was a light amount of serosanguinous drainage noted which had no odor. Wound bed was 100% slough. There was no change noted in the wound progression. The periwound skin exhibited [CONDITION(S)]. The resident was at increased risk of wound incidence due to impaired mobility, decrease in functional ability, co-morbid conditions, diabetic complicating factors, and resident refusal of care and treatment. The wound was debrided to promote viable tissue and formation of granulation. Post debridement measurements were 4.5 cm x 4.5 cm x .1 cm. There was noted to be a very thick layer of slough so only the top layer was removed. -No changes were made to treatment orders or recommendations. A wound committee note dated 1/25/22 read: Wound committee met today to discuss resident's PU, it currently measures 4.5x4.5xUTD (undetermined depth) with 100% slough and scant drainage. Last week measurements 5.0x5.0xUTD. This wound currently shows evidence of improvement, wound MD made rounds this morning and made no changes in his orders. Current orders read [MEDICATION(S)] to base of wound, cover with dry dressing daily. Wound doctor and I spoke in length with regards to santyl. Wound doctor mechanically debrided the top layer of the wound today and reports if he does not see significant change by next week's rounds he will add the santyl. Wound doctor is aware that hospice will not cover santyl and that the center has agreed to cover the cost if needed. Resident is continually educated on the importance of repositioning to his side to off load pressure to aid in healing, however he continues to lay supine on the air mattress. Staff will continue to encourage intake and hydration. An order on 1/26/22 read: Mid Left back pressure injury wound care - cleanse with wound cleanser, allow to dry, apply [MEDICATION(S)] to wound bed, do not exceed wound margins, apply bordered foam dressing, change daily and prn drainage. one time a day for wound care. -The January 2022 TAR revealed this order was missed on 1/28/22 and the February 2022 TAR revealed the order was missed on 2/7/22. An IDT weight committee note dated 1/29/22 read RD (registered dietitian) review for weight and wound. Weight up 0.8 lbs from 1/19/22 to 1/26/22. BMI of 14.6 remains underweight. Overall significant weight loss of 6.4% (7.4 lbs) from 1/1/22 to 1/26/22. Prostat added 1/18 and res consuming 100%. Glucerna w/carb steady 1.5cal 4x/day - consuming 100%. Meal intakes ~ (about) 50% and fluid intake ~1800 mls/day. Per recent wound rounds, PU currently shows evidence of improvement and wound MD made no changes to orders at this time. PU unavoidable d/t (due to) res remaining in supine position. Resident is noted to continually be educated on the importance of repositioning to his side to off load pressure to aid in healing, however he continues to lay supine on the air mattress. Staff will continue to encourage intake and hydration. Weight stable and wound improving - no further nutrition interventions recommended at this time. Will continue to monitor weekly with IDT. The resident was seen by the wound care physician on 2/1/22 during wound rounds. The note revealed an unstageable, obscured full thickness skin and tissue loss pressure injury and a status of not healed. Subsequent encounter measurements were 4.2 cm x 4.1cm with no measurable depth, with an area of 17.22 sq cm. There was a light amount of serosanguinous drainage noted which had no odor. Wound bed was 90% slough and 10% granulation. The wound was noted to be improving. The periwound skin exhibited [CONDITION(S)]. The resident was at increased risk of wound incidence due to impaired mobility, decrease in functional ability, co-morbid conditions, diabetic complicating factors, and resident refusal of care and treatment. The wound was debrided to promote viable tissue and formation of granulation. Post debridement measurements were 4.2 cm x 4.1 cm x .1 cm. There was noted to be a very thick layer of slough and debridement was difficult. No changes were made to treatment orders or recommendations. A wound committee note dated 2/1/22 read: Wound committee met today post MD wound rounds to discuss resident's PI (pressure injury) to his mid-back. Current measurements: 4.2x4.1cmxUTD, 0 odor with scant drainage, no sxs (signs or symptoms) of infection. Wound bed is 90% slough with 10% epi (epitheliazation). Resident tolerated assessment/treatment well. We will continue with current treatment orders and interventions. Hospice will be updated on wound progress. Staff continue to encourage resident to off load from the supine position, however this is a major barrier as we explain to resident the benefits of off-loading, he will recognize this however will go back to the supine position. Staff will continue to encourage this. Treatment will continue as medi-honey to base of wound, cover with dry dressing qday (every day) and PRN. Care plans updated. The resident was seen by the wound care physician on 2/8/22 during wound rounds. The note revealed an unstageable obscured full thickness skin and tissue loss pressure injury and a status of not healed. Subsequent encounter measurements were 4.7 cm x 4 cm with no measurable depth, with an area of 18.8 sq cm. There was a moderate amount of serosanguinous drainage noted which had no odor. Wound bed was 80% slough with 20% granulation. The wound was noted to be deteriorating. The periwound skin exhibited [CONDITION(S)]. Other observations included cellulites (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), moderate to large amount of purulent (pus) drainage. The resident was at increased risk of wound incidence due to impaired mobility, decrease in functional ability, co-morbid conditions, diabetic complicating factors, and resident refusal of care and treatment. The wound was debrided and post debridement measurements were 4.7 cm x 4 cm x .1 cm. The purulent fluid was evacuated from the site during the debridement. Wound treatment orders were changed to cleanse wound with normal saline, apply Santyl ointment, cover with dry dressing. Change dressing every day and as needed. An order was also added for an antibiotic and to discuss with hospice providers prior to starting the medication. -Wound infection had developed. A wound committee meeting note dated 2/9/22 read: Wound committee met today post MD wound rounds to discuss resident PI to his med-back. Current measurements: 4.7x4.0cmxUTD. Wound bed is 80% slough with 20% granulation. Moderate to large amounts of purulent fluid was evacuated from site using scissors/forceps. Periwound noted to have cellulites and [CONDITION(S)] present. 50% of wound debrided with [NAME]. (Resident) does not tolerate treatment well so Dr is only able to do little at a time. Hospice will be updated on wound progress. Staff continue to encourage resident to off load from the supine position, however this is a major barrier as we explain to resident the benefits of off-loading, he will recognize this however will go back to the supine position. Staff will continue to encourage this. Treatment will be updated to use Santyl to base of wound, cover with dry dressing qday and PRN. Care plans updated. -However, the care plan was not updated to reflect the resident's current wound status and refusals. An order on 2/9/22 read: [MEDICATION(S)] Capsule 500 MG ([MEDICATION(S)], antibiotic) Give 1 capsule by mouth three times a day for Infection. For 7 Days. -The February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An order on 2/9/22 read: Mid Left back pressure injury wound care - cleanse with wound cleanser, allow to dry. Apply Santyl to wound bed, do not exceed wound margins, apply bordered foam dressing. Change daily and prn drainage. One time a day for wound care. -The February 2022 TAR revealed this order was missed on 2/13/22 and 2/14/22. See interviews below A nursing note dated 2/10/22 read: Res. continues on an antibiotic for back wound infection. No adverse effects noted to the antibiotic. Dressing soiled with purulent drainage and changed as per orders. Fluids encouraged et (and) res tolerated well. Res afebrile (no fever). An IDT weight committee note dated 2/10/22 read: NAR (nutrition at risk) review for weight and wound status. Current body weight: 104.6, Previous body weight: 106.4. Weight gain or loss: loss of 1.8 lbs. Diet: CCHO/reg/thin Meal consumption: 26-50%, Fluids 400 mls w/meals +360 mls Q12H (every 12 hours). Nutrition interventions: Prostat 30 mls BID, fortified meals. Recommendations: Reduced sugar med pass. DC (discontinue) glucerna New TSH ([CONDITION(S)] stimulating hormone blood test) to r/o (rule out) related weight loss. Wound is noted to be infected, encourage fluids and maintain comfort focused measures. Continue all other nutrition interventions as ordered. Will continue to monitor weekly with IDT. A nursing note dated 2/12/22 read: Resident alert and oriented to self, continues with [MEDICATION(S)] 500mg 3x a day, afebrile, black eschar (dark, dry scab) on the wound on mid upper back, yellow drainage, erythematous to surrounding area, bulge when palpated. Dressing changed per orders. Resident encouraged to be up with meals to relieve pressure from his back. Resident receptive. Encourage good nutrition and hydration. Continue to monitor for signs and symptoms of infection. A nursing note dated 2/13/22 read: Resident found on floor by MOD (manager on duty). Resident stable, VS WNL, no new injuries found. Neuro checks started, Hospice notified and will visit this morning, MOD aware, Daughter notified. Resident educated to use call light and ask for help to move to WC (wheelchair). (Cross reference F689 Accidents). A nursing note dated 2/14/22 read: Per the dayshift nurse report, culture of the resident's wound to the back was requested by hospice. Culture obtained this shift and sent to the lab. A nursing note dated 2/14/22 read: Resident remains on antibiotic for a wound infection to the back. No adverse reactions noted to the antibiotics. Resident afebrile, vital signs stable through this shift. Wound continues to have purulent drainage and minimal odor. Wound culture sample sent to the lab during this shift. Fluids encouraged and resident tolerated well. A nursing note dated 2/14/22 read: While completing wound care on resident noted change in skin area around the wound. An area of three inches on all sides of the wound was increasingly red and inflamed from previous day. Notified the DON (director of nursing) that resident asked to go to the hospital. Transport company contacted to transport the resident to the hospital, daughter notified, hospice notified. -The resident had not returned from the hospital as of the exit of the onsite investigation. C. Hospital records The resident's hospital records from admission on 2/14/22 were reviewed and revealed the resident was admitted with multiple comorbidities and issues with an acute stage three decubitus ulcer in the thoracic region. The wound was between thoracic T5 to T7 and measured 4 cm with black eschar oozing pustular discharge in a large square of [CONDITION(S)]. The resident's daughter elected to stop hospice services to treat the wound and infection. Laboratory values in the hospital revealed the resident met [CONDITION(S)] criteria and was started on two intravenous antibiotics. Notes from the infectious disease specialist revealed a decubitus ulcer overlying thoracic region, stage three with associated staph aureus bacteremia. status post [MEDICAL RECORD OR PHYSICIAN ORDER] Notes from the wound specialist revealed a bedside debridement was performed on the resident to remove all devitalized and infected tissue. The post debridement measurements resulted in a stage 4 pressure injury which was 5 cm x 3 cm x 2 cm with a large amount serosanguineous, tan and green drainage. A wound vac was placed on the resident for treatment and hea

Based on record review and interviews, the facility failed to ensure three residents (#5, #7 and #3) of five residents reviewed, out of 16 sample residents were kept free from neglect. The facility failed to ensure Resident #5 and Resident #7 were not neglected by staff and were provided the care and services required to maintain the highest practicable well-being. Specifically, Resident #5 and Resident #7's call lights were not answered for over two hours on 1/27/22, as evidenced by the call light record, resident and staff interviews. Resident #5 expressed fear and anxiety about having her call light answered timely in the future, if she had an emergency or fell . Resident #7 reported her legs and feet had gone numb, seated on the toilet on 1/27/22, waiting for help. She said she was afraid she was going to fall. Resident #7 reported continued fear of her call light being answered timely in the future when she was on the toilet. Furthermore, five additional residents had call light wait times over two hours. Additionally, Resident #3 alleged she was verbally abused by a dietary staff member on 2/16/22. Findings include: I. Facility policy and procedure The Abuse Prevention Program policy, revised December 2016, was received from the clinical resource nurse (CR) on 2:21 p.m., at 4:19 p.m. The policy documented in pertinent part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Implement measures to address factors that may lead to abusive situations, for example: Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; Instruct staff regarding appropriate ways to address interpersonal conflicts; and Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. II. Failure to prevent neglect for Resident #5 and Resident #7 A. Resident #5 1. Resident status Resident #5, age 72, was admitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/6/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score (BIMS) of 15 out of 15. Resident #5 required supervision with bed mobility and personal hygiene, limited assistance of one person with transfers and toileting, and extensive one person assistance with dressing. She was occasionally incontinent of bladder and continent of bowel. She had no behaviors, or refusals of care. 2. Resident interview Resident #5 was interviewed on 2/21/22 at 12:01 p.m. She said a week or so ago, she waited two hours to be taken to the bathroom. She said the staff did not answer her call light for one and a half to two hours. She said she was afraid it could happen again. Resident #5 said, she was afraid and anxious if it was an emergency, or she fell , no one would come help her for two hours. She said he was still feeling anxious, and afraid about the lack of help. She said I am so afraid. Resident #5 said her voice had been affected by her stroke, and she had no way to call out for help. She said he had spoken to the staff regarding the incident, but she could not remember who. She said she was told the nursing home administrator (NHA) would be following up with her, but she had not spoken to NHA. 3. Record review and staff interviews Grievances or concern forms for Resident #5 and Resident #7 (see below) in the last 30 days were requested from the CR on 2/21/22 at 1:14 p.m. She said she did not have a grievance form for Resident #5 or Resident #7, but the NHA did have an investigation for both residents on 1/27/22. The Facility Investigation Template, dated 1/27/22 at 8:30 a.m., was received from the NHA on 2/21/22 at 1:47 p.m. It documented in pertinent part, Event-extended call light wait time, related information-one staff member on (the floor where the resident resided). Resident #5 pushed her call light and it took an extended period of time for her need to get met .LPN (licensed practical nurse) was suspended pending investigation for neglect. The ADON (assistant director of nursing) and CNA (certified nurse aide) immediately went and took ownership of the unit. Social services and the DON (director of nursing) checked with Resident #5 to make sure she didn't have any lingering fears about her call light not getting answered. The form documented the police and the State Agencywere notified. The form documented N/A (not applicable) under was the resident assessed for pain, and was the resident's skin assessed. The form documented the resident was assessed for emotional support, and the staff member was terminated and reported to the Board of Nursing. The investigation was signed by the NHA on 2/1/22. Included in the investigation was a statement from Resident #5, titled Investigation Interview, dated 1/27/22. It documented, I put my call light on. No one came. I was scared. Why didn't anyone come? I had to wait a long time. The staffing coordinator (SC) finally came and helped me. There was a form attached to the investigation dated 1/27/22, that listed seven resident names. The form documented the seven residents had no concerns with call light wait times or concerns they wanted to report. -It did not document that the five other residents were interviewed who had extended call light wait times over two hours that morning, according to the Call Light Detail Report (see below), on 1/27/22. Additionally, there was a statement from the SC dated 1/27/22, which documented Went to answer Resident #5's call light, and she reported that she had her call light on for a long time. She was upset and tearful. She said she is afraid that no one was in the building to assist her. -The investigation did not include an interview with LPN #3, who was working on 1/27/22. Resident #5's bladder care plan, initiated 10/24/21, documented in pertinent part, Resident #5 is continent of bladder. Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has unobstructed path to the bathroom. Resident #5's bowel care plan, initiated 10/24/21, documented in pertinent part, Resident #5 is continent of bowel. Check resident every two hours and assist with toileting as needed. Provide loose fitting, easy to remove clothing. -The care plan did not document the limited assistance the resident needed with toileting on the 1/6/22 MDS assessment. On 1/27/22 at 11:27 a.m., a late entry nurses note documented,IDT (interdisciplinary team) Investigation of a grievance/concern that was shared with staff. Interview conducted with Resident #5: Resident #5 reports that she pressed her call light and it was not answered timely. A self-report via the state was made for possible neglect. MD (physician) made aware. PD (police department) made aware and message left with sister, the healthcare proxy. Resident #5 denies pain and she also reports that she feels safe here at the facility. SSD (social service director) will provide support and comfort. Line staff aware. Frequent checks implemented. Staff will encourage Resident #5 to share her feelings about the incident. On 1/27/22 at 3:35 p.m. a late entry nurses note documented the following, SSA (social services assistant) spent 20 mins with resident to give support and encourage Resident #5 to talk about her feelings regarding recent grievance. Resident #5 stated thank you I'll be fine. SSA checked on resident three times throughout the day to offer additional emotional support. On 1/28/22 at 10:05 a.m., the nurses notes documented,Checked in on resident today, she is doing well and has no concerns. All needs are being met by staff. Nothing adverse noted related to reported incident. On 2/2/22 at 3:37 p.m., the social service assistant (SSA) note documented in pertinent part, met with resident . needs are being met by staff. No concerns from Resident #5 today. -There were no further notes after 2/2/22 when reviewed during the survey on 2/22/22 regarding the resident's mental or psychological status related to the event on 1/27/22. Certified nurse aide (CNA) #7 was interviewed on 2/21/22 at 10:05 a.m. She said Resident #5 was continent of bowel and bladder, and will use her call light when she needs assistance going to the bathroom. B. Resident #7 1. Resident status Resident #7, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score (BIMS) of 15 out of 15. Resident #7 required supervision with bed mobility. She was independent with transfers and personal hygiene. She required extensive one person assistance with toileting, and dressing. She was always incontinent of bladder, and continent of bowel. She had no documented behaviors of refusals of care in the assessment. 2. Resident interview Resident #7 was interviewed on 2/21/22 at 12:30 p.m. She said a few weeks ago she had to sit on the toilet for two hours, because no one would answer her call light. Resident #7 said she can ambulate to the bathroom herself, but needed assistance with wiping and getting off the toilet. She said that morning she waited for two hours, her legs had gone numb and she could not feel her feet. She said she was afraid she was going to fall. Resident #7 said she was still nervous and afraid it could happen again. 3. Record review and staff interviews A document titled Facility Investigation Template, dated 1/27/22 at 8:30 a.m., was received from the NHA on 2/21/22 at 1:47 p.m. It documented in pertinent part, Event-extended call light wait time, related information-one staff member on (floor where the resident resided). Resident #7 pushed her call light and it took an extended period of time for her need to get met .LPN was suspended pending investigation for neglect. The ADON and CNA immediately went and took ownership of the unit. Social services and the DON checked with Resident #7 to make sure she didn't have any lingering fears about her call light not getting answered. -The investigation had the exact verbiage that was documented for Resident #5 (see above). The form documented police and State Agencywere notified. The form documented the resident was assessed for pain, skin, adn emotional support. It documented the staff member was terminated and reported to the Board of Nursing. The investigation was signed by the NHA on 2/1/22. The investigation included a statement from Resident #7. It documented, I pressed my call button when I was in the bathroom. I need help after I use the toilet. I was sitting there waiting, I don ' t (sic) know how long it took, but it was a long time. The SC came to help me. I asked her what took so long and she didn't say anything. The investigation included a statement from the SC. It documented, I answered Resident #7's call light and she told me that she had been waiting a long time for someone to come help her in the bathroom. She said she walked to the bathroom by herself but she needed help to clean and that she was waiting a long time. -The investigation did not include an interview with LPN #3, who was working on 1/27/22. On 1/27/22 at 10:59 a.m. the nurses notes documented, late entry, Investigation of a grievance shared with staff. According to the resident she pressed her call light and it was not answered timely, please note that Resident #7 can independently ambulate herself using her FWW (front wheeled walker) to the bathroom she will do this then call for help for staff to assist her off the toilet.A self report of possible neglect was reported via the state portal. MD made aware. PD make aware and message left with sister .Skin assessment revealed no breakdown and Resident denies pain. When prompted Resident reports she feels safe here at the center. SSD will provide support and comfort. Line staff aware. Frequent checks implemented. Staff will encourage Resident to share her feelings. On 1/28/22 at 6:27 a.m., the nurses notes documented, This writer assisted resident to the toilet this AM (morning) and provided peri-care. No concerns noted this day. Mood is calm and cheerful, resident is talkative and joking with this writer. Soiled linens changed, needs met as requested by resident, and resident transferred back to her recliner. Call light within reach, ice water refreshed,and no questions or concerns verbalized. Will continue to monitor. On 1/31/22 at 10:14 a.m., the nurses notes documented, Resident #7 is doing well today, all needs are being met by staff. Nothing adverse noted related to the reported call light incident. On 2/2/22 at 3:39 p.m. the social service notes documented, SSA met with Resident. Resident's needs are being met by staff. No concerns from Resident #7 today .SSA spent 15 mins (minutes) with resident to give support and encourage resident to talk about her feelings regarding recent grievance. SSA checked on resident 3 times throughout the day to offer additional emotional support. -There was no further follow-up documentation regarding the effect on the resident as of 2/22/22. The continence care plan, initiated 11/16/21, documented in pertinent part, has occasional bladder, Clean peri-area with each incontinence episode, Encourage fluids during the day to promote prompted voiding responses, Ensure the resident has has unobstructed path to the bathroom, Monitor/document for s/sx (signs/symptoms) [CONDITION(S)] (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency,foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. CNA #7 was interviewed on 2/21/22 at 10:15 a.m. She said Resident #7 was usually continent of urine and used her call light for staff assistance with wiping after using the bathroom. C. Administrative interviews The NHA and CR were interviewed on 2/21/22 at 1:47 p.m. The NHA said she had reported the incident that happened with Resident #5 and Resident #7 to the State Agency as neglect. She said on 1/27/22, licensed practical nurse (LPN) #3 was on duty the morning of 1/27/22. His shift started at 6:00 a.m. She said the unit where the residents resided was normally staffed with one licensed nurse and one certified nurse aide (CNA). The NHA said that morning the CNA did not show up, and no one in the facility knew that. She said the night shift left before the day shift arrived. The NHA said the facility had now identified this as a concern which contributed to the neglect that morning on 1/27/22. The NHA said LPN #3 was having a mental health crisis. He was not passing medications to residents, and not aware there were call lights going off. She said he did not know there was no CNA on the floor. The NHA said the SC came in around 7:45 a.m. and noticed multiple call lights were going off on the floor. The NHA said the SC thought LPN #3 was acting differently. The SC notified the NHA. The NHA notified the director of nursing (DON), and had the assistant director of nursing go to the floor to take over the medication pass from LPN #3. The NHA said the DON had a CNA from another floor cover the floor where LPN #3 was working. The NHA said she did not know how many call lights were going off, but she knew the call light for Resident #5 and Resident #7 had been on. She said LPN #3 had been terminated and reported to the Board of Nursing. She said the facility did skin assessments on all residents on that floor on 1/28/22. There were no new concerns. She said she had not interviewed all the residents residing on that floor regarding the call light delays (see Call Light Detail Report below) and should have. The NHA provided a resident daily census sheet during the interview. It documented there were 21 residents on the floor where Resident #5 and Resident #7 resided. It documented that two residents were fall risks, five were dependent on staff for toileting, and four were dependent on staff for transfers. The NHA said since 1/27/22, the facility had implemented walking rounds between shifts so one shift did not leave before the next shift arrived, and she was reviewing the call light detail reports randomly. She said ideally, she would like the call lights answered within 10 minutes. Additionally, she has begun calling the facility daily at 6:00 a.m., to check the staffing, had moved the office of the social service assistant to the floor where the residents resided (#5 and #7), and had inserviced the staff on their mental health. A voice message was left for LPN #3 on 2/22/22 at 10:45 a.m. There was no return call by the end of the survey, or within 24 hours after. D. Call light reports for other residents on the floor 1/27/22 The Call Light Detail Report for 1/27/22 was received and reviewed with the NHA on 2/22/22 at 3:28 p.m. The NHA said she had not reviewed the report on 1/27/22. The Call Light Detail Report for 1/27/22, documented the call light for Resident #5 went on at 7:00 a.m. and was turned off at 8:56 a.m. It had been going off for one hour and 56 minutes. The Call Light Detail Report for 1/27/22, documented the bathroom call light for Resident #7 went on at 6:13 a.m. and was turned off at 8:22 a.m. It had been going off for two hours and nine minutes. Additionally, the following were documented for call light times: -The call light for a resident room on the floor went on at 6:01 a.m. and was turned off at 9:16 a.m. It had been going off for three hours and 15 minutes. The NHA said she did not interview this resident on 1/27/22. She said I am not sure what happened, or why he was not interviewed. -The call light for a resident room on the floor went on at 6:34 a.m. and was turned off at 12:35 p.m. It had been on for six hours and one minute. The NHA said the resident pushed his call light frequently and she felt the staff had call light fatigue (see or hear the call light, but your brain filters it out due to overuse). -The call light for a resident room on the floor went on at 7:06 a.m. and was turned off at 9:21 a.m. It had been on for two hours and 15 minutes. The NHA said she had not spoken to this resident on 1/27/22, and should have. -The call light for a resident room on the floor went on at 7:07 a.m. and was turned off at 12:36 p.m. It had been on for five hours and 29 minutes. This resident was listed as interviewed in the 1/27/22 in the facility investigation. It documented she had no concerns with call lights. E. Additional interviews The ADON was interviewed on 2/22/22 at 10:26 a.m. She said she usually comes in between 7:45 a.m. and 8:00 a.m. and then gets a report from the nurses on the floors around 8:30 a.m. She did not recall what time she went to to the floor on 1/27/22. The ADON said she went to the floor that morning, she did not recall what time. She said LPN #3 seemed off. She said his eyes seemed tired and heavy. She said they began to review a resident's insulin dose, and he just seemed off. The ADON said she went and reported this to the DON. The ADON said the DON came to the floor and escorted LPN #3 downstairs, and the ADON took over the medication cart. The ADON said she remembered there were multiple call lights going off, and she did not recall if there was a CNA on the floor. She said she thought at some point a CNA was sent to the floor, but she did not know when that was. The ADON said she was not involved in the investigation of what occured. The SC was interviewed on 2/22/22 at 2:21 p.m. She said she was the staffing coordinator. She said she went up to the floor around 7:45 a.m. She said there were call lights going off everywhere, and there was no CNA on the floor. She said a CNA had been scheduled, but had not shown up. The SC said LPN #3 seemed, confused, like he wasn't all there. She said she reported what she had seen to the DON. The SSD was interviewed on 2/22/22 at 3:00 p.m. She said she worked with residents on the first and second floor. She said she did not know how long the residents were without help on the morning of 1/27/22. She said she did not talk to any of the residents about that specific morning. She said she had not visited Resident #5 or Resident #7 about what had happened on 1/27/22. She said she had not spoken to them regarding any specific call light concerns.The SSD said maybe her assistant spoke to the residents, but she said her assistant was unavailable today for an interview. The SSD said if she had known Resident #5 and Resident #7 had expressed fear, social services should have been following up with them daily. She said she had not discussed call light concerns with any of the residents on the floor where Resident #5 and Resident #7 resided. F. LPN #3 employee record The employee record for LPN #3 was received from the NHA on 2/22/22 at 4:43 p.m. The license verification record, printed by the facility 4/26/21, from the department of regulatory agencies (DORA) documented LPN #3 had a letter of admonition (warning) effective 3/20/2020. The NHA said she was unaware of the admonition. The DORA website documented, On or about August 30, 2019, you showed no sense of urgency to a declining patient who was having trouble breathing, you failed to contact a physician about potential change in the patient's condition and you failed to make essential entries in said patient's chart. The NHA said the facility was not aware of this history, however the license verification printed by the facility on 4/26/21 documented there was a letter of admonition. G. Facility follow-up On 2/22/22 at 4:00 p.m., the NHA provided an undated document, titled, Abuse and Neglect Investigate, Prevent, Correct, Alleged violation. Corrective Action-Resident was assessed on 1/27/22 for psychological harm by SSD and on 1/31/22 by Administrator. Based on resident interviews Resident did not display any psychological harm. Resident had head to toe skin observation conducted by DON on 1/27/22 no skin issues identified. On 1/27/22 (LPN #3) was placed on suspension, reported to Board of Nursing, and terminated on 2/3/22. Identification of Others: All residents requiring toileting assistance are at risk of this alleged deficient Practice. A full house Toileting Assistance Audit was conducted on 2/1/22 by DON for residents requiring toileting assistance. No other residents were identified. A full house call Light Audit was conducted by IDT on 2/1/22 to ensure no other residents had issues with delayed call light response times. No other residents were identified. Systemic Changes: staff will be be re-educated by DoN/designee on or before 2/4/22 on importance of answering call lights timely.Nursing staff will be re-educated on providing toileting assistance timely for residents who need assistance.Nursing staff will be re-educated by HR (human resources)/designee on not coming to work if impaired.Education will be provided to new hires, annually and as needed.Weekly Ambassadors rounds will be conducted by IDT to include asking if a call lights are being answered timely and toileting needs are being addressed timely. Weekly Ambassador round concerns will be immediately addressed by Administrator/designee. Monitoring: Purposeful rounding, Ambassador rounds,. Shift to shift walking rounds to ensure that staff has shown up for their shift immediately, call at the start of shift when out of the building to confirm staff has arrived. When in the building, check in with the units to ensure that staff has shown up. -However, a full house call light audit had not been done by 2/1/22 as documented in the plan, and according to the NHA interview on 2/22/22. She had not reviewed the Call Light Detailed Event Report from 1/27/22 (see above) for other residents residing on the floor. She had not followed-up, and had no documentation of follow-up, with all residents who had extended call light times on the morning of 1/27/22. III. Resident #3 A. Resident status Resident #3, age under [AGE] years, was admitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/14/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. No behaviors were exhibited. She required supervision and set up help with mobility and transfers. B. Resident interview Resident #3 was interviewed on 2/17/22 at 1:35 p.m. She stated she was happy in the facility and they did a good job with most things. She stated meals had been arriving late to her room lately and this sometimes caused her to feel sick because she was so used to the routine of the normal meal times. She stated she had requested a grilled cheese sandwich the day before which was delivered to her room at 5:00 p.m., though the meal did not come with the milk she requested. She stated she walked down to the kitchen to request the milk and the dietary staff member yelled at her, telling her she only had two hands and that the resident needed to take an anxiety pill. She stated this interaction had upset her greatly and triggered her [CONDITION(S)] and gave her anxiety. She stated the interaction was witnessed by a staff member and then the interaction was reported to the nursing home administrator (NHA). She stated she felt it was verbal abuse. C. Facility investigation The facility investigation was reviewed and revealed the NHA received the report and the investigation was started on 2/16/22. The dietary staff member was suspended pending the investigation. The investigation revealed the resident was interviewed and confirmed the report. The resident was also noted to be forgiving to the staff member and understanding that staff members get rushed and feel frazzled, but did not want this to happen again. Additional residents were interviewed during the investigation with no reports of abuse. The investigation concluded that the incident did occur, the staff member received sensitivity training related to interacting with residents prior to returning to work. The remainder of the facility staff received the same training by 2/22/22. The resident received friendly support visits from social services and activities staff to ensure no lingering effects from the interaction. -The facility investigation acknowledged the incident occurred between Resident #3 and the dietary staff member, however it did not document as substantiated verbal abuse. Based on the resident's interview above, she felt it was verbal abuse towards her and triggered her [CONDITION(S)]. D. Interview The NHA was interviewed on 2/18/22 at 2:45 p.m. She stated the incident was reported to her immediately and the investigation was ongoing. She stated the staff member had been suspended during the investigation, though the resident was asking for the staff member to return to work and had forgiven her for yelling at her. She stated the incident did occur and the staff member would undergo sensitivity training for interacting with residents prior to returning to work. -The NHA acknowledged the incident occurred between Resident #3 and the dietary staff member, however it did not say it was substantiated as verbal abuse. Based on the resident's interview above, she felt it was verbal abuse towards her and triggered her [CONDITION(S)].

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Record review revealed the facility was in outbreak status as of 10/2/21, when a staff member tested positive for COVID-19. On 10/18/21, another staff member tested positive for COVID-19 and on 10/19/21, four residents tested positive for COVID-19. Observations, record review and staff interviews from 10/18/21-10/25/21 revealed multiple and repeated failures in the facility's infection control program, creating a situation for the likely transmission of highly infectious COVID-19 and placing all facility residents at risk of serious harm. Specifically: -The facility failed to follow outbreak testing guidance on 10/2/21 creating a situation for the likely transmission of highly infectious COVID-19 and routinely test unvaccinated staff prior to the start of their shift. Cross-reference F886L. -The facility failed to ensure staff properly wore personal protective equipment (PPE) throughout the facility, and when caring for residents in quarantine and cleaning their rooms. -The facility failed to ensure staff encouraged and assisted residents to wear masks, encouraged quarantined residents to remain in their rooms and residents to socially distance. -The facility failed to ensure staff followed proper hand hygiene procedures for themselves and for the residents. Findings include: I. The facility's COVID-19 status The facility had one confirmed positive case of COVID-19 in one staff member, certified nurse aide (CNA) #1 as of 10/2/21. CNA #1 was symptomatic. Another staff member tested positive on 10/18/21 with a point-of-care (POC) test, the results from the polymerase chain reaction test (PCR) test had not been received as of 10/25/21 As of 10/19/21, the facility had four COVID-19 positive residents. The facility placed eight residents on the first floor in quarantine as they were the roommates of the four residents who had tested positive. II. Immediate Jeopardy A. Findings of Immediate Jeopardy Record review revealed the facility was in outbreak status as of 10/2/21, when a staff member tested positive for COVID-19. On 10/18/21, another staff member tested positive for COVID-19 and on 10/19/21, four residents tested positive for COVID-19. Observations, record review and staff interviews from 10/18/21-10/25/21 revealed multiple and repeated failures in the facility's infection control program, including failed to follow outbreak testing guidance and routinely test unvaccinated staff, failure to properly and appropriately use PPE, failure to perform staff and resident hand hygiene, as well as wear masks, implement quarantine restrictions and ensure social distancing. The above failures created an immediate jeopardy situation that placed all facility residents at risk due to the likely transmission of highly infectious COVID-19. B. Facility notice of immediate jeopardy On 10/21/21 at 4:19 p.m., the nursing home administrator (NHA) was notified that the failures in the facility's infection control program created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). C. Facility plan to remove immediate jeopardy On 10/22/21 at 6:00 p.m. the NHA provided a plan to remove the immediate jeopardy. The plan read: 1. NHA or Designee will assign Department heads and mangers on duty will provide monitoring and ensure compliance with all staff through shift change to ensure immediate education and compliance with PPE and COVID. Outbreak mitigation guidance, Education was initiated 10/21/2021 and will (be) on going. 2. DON/ADON Post transmission-based precautions signs for current, positive and/or presumptive COVID-19 residents on 10/19/21. 3. The ICP ADON [name] [ICP from another facility) completed education and checkoffs with ADON and DON on 10/21/21. Director of Nursing (DON), Assistant Director of Nursing (ADON) or designee began in-servicing and competencies of staff 10/21/21 and will receive training at the beginning of each shift until all staff are educated. a. COVID-19 Outbreak b. Current residents who are identified as COVID-19 positive and/or presumptive c. Transmission-based Precautions: Droplet d. Hand Hygiene for staff and residents to include before and after meals, snack, beverages, personal cares, high touch surfaces, before and after smoking. e. When to utilize PPE and the correct PPE for Isolation and Quarantine rooms (i.e. N95, Gown, Face shield or goggles, gloves). f. How to don/doff PPE g. Cleaning/disinfecting of resident equipment (i.e. vital sign equipment-dispose of disinfectant wipe after one use). h. Offer/remind residents on hand hygiene, masking, and social distancing i. DON/ADON/Designee to Educate the staff difference between quarantine and isolation room by 10/25/21. j. Social Distancing and resident mask usage/encouragement k. Hand Hygiene Before and after meals, beverages/snacks, before and after smoking, personal care tasks and as indicated. l. All Residents should be encouraged to maintain appropriate social distancing. m. All staff to be immediately educated on encouraging and redirecting residents who are on isolation and quarantine to remain in rooms with the door closed. Education started 10/21/2021. n. DON/ADON to educate all staff on where to take meal breaks, store lunches and beverages. Education began 10/22/2021 and ongoing. 4. Training was provided to ADON/DON (name of IP) 10/22/21 on proper use of Line Listing submission and ongoing management. 5. DON, ADON or assigned IDT member will monitor every shift for adherence to hand hygiene for residents and staff, posting of signs for transmission-based precautions, use of PPE (donning/doffing; N95, face shield/goggles, gown, gloves), and cleaning/disinfecting of resident equipment until the facility is COVID-19free. 6. All residents who are currently on Isolation or Quarantine will be placed on 15 minute checks and redirected as needed. a. All staff will be educated that they are to frequently encourage Quarantine/Isolation guidelines. b. Staff will immediately be educated on ensuring they are encouraging and not forcing. c. Staff will be immediately educated on safety strategies if resident is unwilling to stay in room. i. Offering and placing Mask and Gown on resident not willing to stay in room. ii. Hand hygiene offered and assisting resident with HH. Offer to take resident outdoors for a few minutes to give them a break from their room. Offer open area where social distancing can be maintained (Basement/Day room if available). iii. Keep quarantine/isolation residents 6 feet apart as possible via social distancing, frequent reminders, redirection. If resident is non-compliant then notification to DON/NHA for alternate options. iv. IDT team education on discontinuation of group activities during outbreak status to be completed by NHA 10/20/2021. 7. NHA/DON/ADON/Receptionist/Charge Nurse direct staff to testing area. Test needs to be completed in testing room with the door closed or outdoors. Staff education to be initiated by 10/21/21 and will be ongoing with all staff at the beginning of each shift until all staff are educated. 8. ADON/DON/Designee to educate all staff on the appropriate PPE to be worn while testing staff or residents (N95, Face shield or googles, gown and gloves) . Education began 10/22/2021. 9. DON/ADON will complete CDC IPC training and receive certification by 11/05/2021. a. Facility will utilize IPC Clinical Resource to oversee 20 hrs per week until DON/ADON complete CDC IPC training. b. Clinical Resource will continue to monitor systems 2 x weekly including observations of staff and IDT team members, review all assigned audits weekly to ensure completion. 10. ADON/DON will track all residents and staff vaccination status on the line listing including adding agency staff started on 10/20/21 and ongoing. C. Removal of immediate jeopardy On 10/22/21 at 6:08 p.m. the NHA was notified the immediate jeopardy was lifted based evidence of on the facility's implementation of the above plan. However, deficient practice remained at F level, widespread with the potential for more than minimal harm. II. Failure to maintain an effective infection prevention and control program A. The facility failed to follow outbreak testing guidance on 10/2/21, creating a situation for the likely transmission of highly infectious COVID-19 and failed to routinely test unvaccinated staff prior to the start of their shift. Cross-reference F886 Record review and interview revealed the facility failed to follow outbreak testing guidance when a staff member was symptomatic and had a positive POC (point-of-care) test on 10/2/21, creating a situation for the likely transmission of highly infectious COVID-19. Specifically, contrary to CMS and the local public health authority, the facility failed to test all staff following notification of an outbreak on 10/2/21, failed to properly handle test materials and perform timely follow up testing of residents as well as staff, and failed to prevent staff who refused testing from working their shift. B. The facility failed to ensure staff properly and appropriately wore personal protective equipment (PPE) throughout the facility, as well as when caring for residents in quarantine rooms. 1. CDC and CMS Guidance on PPE when COVID-19 has been identified in the building According to the Centers for Medicare and Medicaid Services (CMS) directive COVID-19 Long-Term Care Facility Guidance April 2, 2020, retrieved on 10/23/21from https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf, If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] According to the Centers for Disease Control (CDC) Key Strategies to Prepare for Coronavirus COVID-19 in Long Term Care Facilities, updated 9/10/21 read in pertinent part: If COVID-19 is identified in the facility, have health care providers (HCP) wear all recommended PPE for care of all residents (regardless of symptoms) on the affected unit (or facility-wide depending on the situation). This includes: a N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and gown . According to the CDC guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 9/10/21, retrieved on 10/23/21 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html: -PPE must be donned correctly before entering the patient area. - PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. - Face masks should be extended under the chin. - Both your mouth and nose should be protected . 2. Observations revealed staff failed to properly wear PPE On 10/20/21 at 8:08 a.m., registered nurse (RN) #2 was observed to enter room [ROOM NUMBER]. The resident was in quarantine. The RN put a gown, gloves and eye protection on, however, she did not wear a N95 respirator mask, wearing instead a surgical mask. The RN was interviewed as she came out of the room. She said she was not educated that she needed to wear the N95 mask. On 10/20/21 at 9:53 a.m., housekeeper (HSK) #1 was observed to wear a surgical mask under a N95 respirator. HSK #1 was observed to enter an isolation room with the surgical mask under the N95 respirator, then left the isolation room and did not change his face mask. The HSK #1 was interviewed on 10/20/21 at 10:10 a.m. The HSK said that he was not aware that he could not wear the surgical mask under the respirator. He said he thought it provided more protection. On 10/20/21 at 2:35 p.m. licensed practical nurse (LPN) #2 was observed to wear her surgical mask under her chin. She was standing in the nurses' station eating a piece of pizza. There were two other staff members present at the nurses' station. Two residents were in the hallway, and within three feet of the unmasked LPN #2. On 10/20/21 at approximately 1:00 p.m., the receptionist (RPT) #1 was observed to conduct point of care (POC) testing with staff members. RPT #1 wore only a surgical mask; she was not wearing a N95 respirator. On 10/21/21 at approximately 4:00 p.m., an unidentified RPT was observed conducting the POC testing with staff members. The RPT wore only a surgical mask. 3. Interview confirmed improper use of PPE. The director of nurses (DON) was interviewed on 10/20/21 at 8:30 a.m. The DON said staff needed to wear the N95 mask, gown, and eye protection when they entered the isolation rooms. The unidentified RPT was interviewed on 10/21/21 at approximately 4:00 p.m. The RPT said she had just returned from vacation and she had not been instructed to wear a N95 mask. The DON, the assistant director of nurses (ADON), regional director of operations, and the regional clinical resource (CR) were interviewed on 10/20/21 at 2:39 p.m. The DON said she would ensure the receptionist used the proper mask of a N95. The clinical resource (CR) was interviewed on 10/27/21 at p.m. The CR said that throughout the pandemic, the facility had trained staff on how to properly wear PPE. She said surgical masks were not to be worn under the N95 respirator, especially when entering an isolation room. C. The facility failed to ensure staff encouraged and assisted residents to wear masks and wear them properly when outside their rooms, ensure staff implemented quarantine restrictions and ensure residents were socially distanced when in group. Professional references The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes (updated 9/10/21), retrieved on 10/27/21 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, Remind residents to wear a cloth face covering (if tolerated) and perform hand hygiene. 1. Masks - Observations and staff interviews - absence of encouragement and use of masks by non-quarantined residents. 10/18/21: At 10:30 a.m. the second floor certified nurse aide (CNA) #4 and activities staff person were observed in the hallway. They did not encourage the following residents to wear a mask when out of their rooms. -Resident #40 and Resident #2, waiting in the hall, who were not wearing a mask. -Resident #13, propelling his wheelchair in the hall, who was not wearing a mask. -Resident #15, who came out of her room without a mask and spoke to CNA #4. The CNA did not encourage the resident to don a mask. -At 2:00 p.m., the NHA was observed getting in an elevator with an unidentified resident. The resident was not wearing a mask and no mask was offered or encouraged. -At 2:30 p.m. Resident #30 was observed in the second floor TV room, sitting close to another resident. Staff were in the room but did not encourage the residents to don a mask. 10/19/21: At 9:14 a.m., the following residents were not observed wearing masks on the first floor. Staff were present in the area. -Resident #23, observed in a wheelchair in the first floor hallway. He was not wearing a mask and he was not encouraged to wear one. -Resident #51, observed in the first floor hallway. She was not wearing a mask and she was not encouraged to wear one. -Resident #30, at 9:30 a.m., walking in the hallway on the second floor. He was not wearing a mask. Staff were present in the area; however, he was not encouraged to wear a mask. b. Interviews CNA #11 was interviewed on 10/19/21 at 10:13 a.m. Contrary to the observations above, she said staff do encourage the residents to wear masks outside their rooms, but they cannot force them to do so. She said the residents with dementia will fight the staff if they try to get them to wear a mask. She said she did not know of any interventions to use when a resident refused to wear a mask The activity assistant (AA) was interviewed on 10/19/21 at 12:52 p.m. She said that she conducted an exercise activity on 10/18/21 at 10:45 a.m. She said the residents did not wear masks and she did not encourage them to do so. She said that six residents attended the exercise activity after 2. Masks - Observations and staff interviews - absence of encouragement and use of masks by quarantined residents as well as absence of redirection to return to their rooms. a. See above; on 10/19/21 the facility had four residents test positive for COVID-19. The facility placed eight residents on isolation. Observations revealed the residents who were quarantined were out of their rooms without masks and were not redirected by staff to return to their rooms or to don a mask. 10/19/21: -At 9:14 a.m. Resident #22 was observed in the hallway outside of his room. The ADON saw him and asked the resident if he wanted help putting on a mask. The resident pulled a mask out of his pocket but did not put it on, and the ADON moved on to other tasks. Although quarantined, Resident #22 was not redirected to his room. -At 10:10 a.m. Resident #17, who was in quarantine, was observed getting on the first floor elevator. She was not wearing a mask. Staff were in the area, however, she was not encouraged to wear one. 10/20/21: -At 9:05 a.m. Resident #17 was observed roaming around the halls on the first floor in her wheelchair. Her mask was down below her nose. She was not redirected to return to her room or to pull up her mask over her nose. -At 10:04 a.m. Resident # 17 went into room [ROOM NUMBER]. This was a quarantine room. -At 12:59 p.m. Resident #17 was in the first floor lobby with her mask below her nose. Staff did not redirect her to go back to her room or to pull up her mask. 10/21/21: -At 10:59 a.m. Resident # 17 got off the elevator and entered the basement area to the main dining room. Her mask was below her nose. Three different staff members walked past the resident and did not encourage her to go back to her room or to pull up her mask. Although under quarantine, she was not encouraged or directed back to her room. -At 11:37 a.m. Resident # 17 sat at one of the tables in the dining room drinking a soda. Her mask was below her nose when she was not drinking. She was not encouraged by staff who were present to return to her room. -At 1:12 p.m. Resident #17 again was in the first floor lobby in her wheelchair. Her mask was below her nose. She was not redirected to return to her room or to pull up her mask, although staff were in the area. b. The infection preventionist (IP) was interviewed on 10/20/21 at 10:08 a.m. He said Resident #17 was supposed to be in her room since she was in quarantine. He said it was very difficult to keep her in her room because of her dementia. Contrary to multiple observations above, he said the staff were supposed to encourage her to stay in her room and to wear a mask when she came out of her room. 2. Observations and interviews - absence of social distancing On 10/18/21 at 3:00 p.m., a group activity was conducted in the basement by the piano. There were seven residents attending and none of the residents were wearing masks, even though the facility was in outbreak status for COVID-19. On 10/20/21 at approximately 3:00 p.m., four residents were outside smoking. The residents were not social distancing, and all of the residents, two of whom were not smoking, had their masks off. D. The facility failed to ensure staff followed proper hand hygiene procedures for themselves and for the residents. 1. CDC references and facility policy The Centers for Disease Control (CDC) Hand Hygiene updated 5/17/2020, retrieved on 10/19/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, read in part: -Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. -The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate [CONDITION(S)]-CoV-2. -ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The facility Handwashing/Hand Hygiene policy and procedure (undated), was provided by the Regional Director of Operations on 10/26/21 at 9:00 a.m. It read in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) water for the following situations: . Before and after eating or handling food; Before and after assisting a resident with meals. 2. Handwashing - Observations and staff interviews - Staff and resident failures a. Staff not offering hand hygiene prior to serving residents their meals Lunch menu on 10/18/21 was thyme chicken, potatoes, broccoli, and bread rolls to be buttered and eaten with hands. i. First floor lunch observation -At 12:07 p.m. certified nurse aide (CNA #5) took a food tray to room [ROOM NUMBER]. She did not offer hand hygiene to the residents in this room. -At 12:09 p.m. CNA #11 delivered five food trays to the residents who were in the activity room. She did not offer hand hygiene to any of the residents. -At 12:12 p.m. CNA #5 delivered food trays to the residents in rooms #102 and #103. She did not offer hand hygiene to the residents. -At 12:24 p.m. CNA #5 delivered food trays to residents in rooms #104 to #107. She did not offer hand hygiene to the residents. -At 12:13 p.m. a lunch tray was delivered to Resident #23 in his room. There was no offer of hand hygiene. Resident #23 had fingerless gloves on which he uses to wheel his own wheelchair, touching the wheels. His gloves are brown and his hands are brown with dirt when the gloves are removed. There were no hand sanitizing wipes on his lunch tray. -At 12:23 p.m., a lunch tray was served to Resident #46. Hand hygiene was not offered. -At 12:25 p.m., a lunch tray was served to Resident #58. Hand hygiene was not offered. ii. Second floor lunch observation -At 12:18 p.m. CNA #4 took a tray from the cart. She took the tray to Resident #14; hand hygiene was not offered to the resident. The tray was set down in front of the resident and CNA #4 went back to the cart and without performing hand hygiene, the CNA touched the next tray. -At 12:20 p.m. CNA #4 took a lunch tray to Resident #13. He had propelled himself into his room from the hallway; no hand hygiene was offered to the resident or encouraged. -At 12:21 p.m. CNA #4 went to the cart, got another lunch tray from the cart. She did not apply hand sanitizer before entering the resident's room. She took a lunch tray to Resident #19, and did not offer the resident hand hygiene. Without performing hand hygiene, CNA #4 went back to the cart and took the next tray. -At 12:23 p.m. CNA #4 took a lunch tray to Resident #5 without offering the resident hand hygiene. -At 12:25 p.m. CNA #4 took a lunch tray to Resident #6, without offering hand hygiene to the resident. -At 12:26 p.m. CNA #4 took a lunch tray to Resident #32, without offering hand hygiene to the resident. -At 12:28 p.m. CNA #4 took a lunch tray to Resident #49 without offering hand hygiene to the resident. -At 12:29 p.m. CNA #4 took a lunch tray to Resident #28 without offering hand hygiene to the resident. b. Staff not performing or offering hand hygiene or passing ice in a manner consistent with infection control. i. Hand hygiene -At 9:33 a.m. on 10/20/21, CNA #4 was observed to enter a room on the second floor. She filled a water cup up and then left the room. She did not sanitize her hands prior to entering another room. She then filled another water cup up without performing hand hygiene. -At 12:45 p.m., CNA #2 delivered a lunch tray to Resident #35 in her room. CNA #2 dropped off the tray and left without offering hand hygiene to the resident. -At 12:20 p.m., CNA #11 was observed to serve a tray to Resident #40. The CNA did not offer hand washing to the resident. -At 12:27 p.m., CNA #11 passed the lunch tray to Resident #15. The CNA did not offer hand hygiene to the resident. The trays on the second floor continued to be passed out, and none of the residents were offered hand hygiene prior to eating the meal. The clinical resource (CR) was interviewed on 10/27/21 at 11:27 a.m. The CR said staff should offer hand hygiene in the form of hand sanitizer, hand wipes or the sink to wash hands to residents prior to serving their meal. ii. Ice On 10/20/21 at 9:33 a.m., CNA #4 was observed to enter a room on the second floor. She removed an individual drinking jug from the room and used the scoop from the ice chest to fill the cup. As she filled the cup she touched the cup. The CNA then was observed to enter another room, and used the scoop to fill the thermal cup of another resident. On 10/25/21 at 10:57 a.m., a resident was in the hallway with his thermal cup, LPN #3 took the cup from the resident and filled it with the ice using the ice scoop and cooler of ice. On 10/27/21 at 3:00 p.m., the CR was interviewed The CR said the residents were to receive ice water by filling up clean cups and then bringing the cup to the residents' rooms.

Based on interviews and record review, the facility failed to test residents, facility staff, individuals providing services under arrangement and volunteers for COVID-19 which had the potential to affect all 59 residents residing in the facility at the time of the survey. Record review and interview revealed the facility failed to follow outbreak testing guidance when a staff member was symptomatic and had a positive POC (point-of-care) test on 10/2/21, creating a situation for the likely transmission of highly infectious COVID-19. Specifically, contrary to CMS and the local public health authority, the facility failed to test all staff following notification of an outbreak on 10/2/21, failed to properly handle test materials and perform timely follow up testing of residents as well as staff, and failed to prevent staff who refused testing from working in the facility. The facility failures beginning 10/2/21, created an immediate jeopardy situation, a situation that was preceded by the facility's failure to consistently test unvaccinated staff for the purpose of early detection of asymptomatic, pre-symptomatic and symptomatic staff. Findings include: I. Facility status COVID-19 positive staff and residents The facility had one confirmed positive case of COVID-19 in one staff member, certified nurse aide (CNA) #1 as of 10/2/21. CNA #1 was symptomatic. Another staff member tested positive on 10/18/21 with a point-of-care (POC) test, the results from the (PCR) test had not been received as of 10/25/21. As of 10/19/21, the facility had four COVID-19 positive residents. The facility placed eight residents on the first floor in quarantine as they were the roommates of the four residents who had tested positive. II. Immediate Jeopardy A. Findings of immediate jeopardy Record review and interview revealed the facility failed to follow outbreak testing requirements when a staff member was symptomatic and had a positive POC test for COVID-19 on 10/2/21. The facility did not test all staff from 10/3 through 10/7/21, did not properly handle test materials, did not timely conduct follow up testing, and did not prevent staff who refused to test from working their shift. The facility's failure to follow outbreak testing requirements created an immediate jeopardy situation due to the likelihood the facility's failures would lead to transmission of COVID-19. B. Facility notice of immediate jeopardy On 10/21/21 at 4:19 p.m., the nursing home administrator (NHA) was notified that the failures in the facility's infection control program and testing created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). C. Plan to remove immediate jeopardy On 10/22/21 at 6:00 p.m., the regional director of operations (RDO) presented the following final plan to address the immediate jeopardy situation: 1. DON (Director of Nurses)/ADON (Assistant Director of Nurses)/DOR (Director of Operations) will Complete PCR testing of all residents. If any residents refuse testing, they will be quarantined for 14 days starting 10/22/2021. 2. ADON/DON/DOR will Complete PCR testing of all staff. Receptionist and or charge nurse will complete POC testing. If any staff refuse, they will be excluded from work for 14 days. a. DON/ADON/Charge Nurse/NHA (Nursing Home Administrator) have the authority to remove staff member from the facility if testing requirements are not met. b. Testing requirements and frequency will be based on CMS/CDC and local public health authority guidance starting 10/21/2021. c. Testing frequency and latest COVID-19 guidance for outbreak testing and Public Health recommendations will be monitored by DON/ADON weekly starting 10/22/21. 3. ADON/Designee will Identify any current, positive and/or presumptive COVID-19 residents in the facility via POC and PCR testing completed 10/21/2021. a. DON/ADON to ensure any staff member or resident identified as exposed or presumptive positive are immediately tested via POC and PCR testing. 4. Director of Nursing and Assistant Director of nursing have been educated by (name of IP) ICP on effective testing tracking, testing both POC and PCR, line listing expectations, competencies with checkoffs, policy procedures and protocols for COVID-19 completed 10/21/2021. 5. The Director of Nursing(DON), Assistant Director of Nursing(ADON) or designee will in-service 100% of staff on the below items. Education began 10/20/2021 and will be completed by 10/25/2021. a. COVID-19 surveillance and outbreak testing requirements. b. Staff Expectations of testing and outcome if testing is not performed. 6. DON, ADON or designee will ensure that residents testing requirements are completed and followed up daily for staff and residents starting 10/22/21. a. Identified testing tracking system established. i. All resident not in 90-day window of COVID-19 have POC testing added to EMAR effective 10/21/21 and will continue throughout break status. ii. ADON/DON to complete daily audit of results of resident and staff POC testing starting 10/22/21. iii. Lab scheduling dates changed to Monday and Thursday; ADON confirmed scheduling dates 10/21/21. iv. ADON/DON to place call to lab on pickup day's Monday and Thursdays to ensure scheduled pickup will be completed. v. ADON/DON/Medical Records to visually confirm every PCR lab test when receives conformation from lab that results are processed. vi. If no notification is received for processed results within 24 hrs ADON will place followup call to lab to ensure processing status. b. Double check tracking system established. 1. DON/Medical records will both receive access and training for use of state lab site by 10-29-21. a. DON and Medical records will be cross trained online listing: how to pull test results from lab online, how to read the test results, how to log them in line listing, how to notify the county if positive result is obtained. c. Clinical resource will audit IC POC and PCR tracking 2 x weekly while in outbreak status; then weekly to ensure 100% compliance to testing expectations starting 10/22/2021. i. ADON/DON will ensure any missed or incorrect items necessary for accurate lab results will be monitored biweekly in outbreak status and weekly ongoing starting 10/22/21 7. DON, ADON or designee to ensure pick up and or delivery of PCR tests per testing protocol. a. Nurse manager to remain at facility until PCR pick up completed starting 10/22/2021. b. If samples are not picked up as scheduled, then Nurse manager or designee will be assigned to deliver samples to lab starting 10/22/2021. c. ADON/DON will call the lab with 24 hours to ensure that all samples are able to be process. If we haven't heard anything back from the lab within 48 hours the ADON/DON will contact the state lab for guidance. If any information is requested or needed ADON/DON will provide requested information starting 10/22/2021. d. If PCR test is unable to be ran a follow up PCR will be obtained and submitted to the lab to ensure there is a PCR on file to meet testing requirements starting 10/21/2021. e. If PCR not obtained, then staff member will be removed from schedule until compliance is obtained starting 10/21/21. f. If a staff member declines POC testing or PCR testing, then charge nurse, DON/ADON/NHA have the authority to excuse the staff member from their shift. Staff member will not be allowed back to work until they are able to meet COVID-19 requirements starting 10/21/21 g. ADON/DON/Staffer will ensure that any agency staff that work at facility must submit a copy of their COVID-19 vaccination card. Agency person must follow facility COVID-19 testing requirements starting 10/22/2021. D. Removal of immediate jeopardy On 10/22/21 at 6:08 p.m. the NHA was notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at an F level, widespread potential for more than minimal harm. III. Facility failure to follow COVID-19 testing guidance A. Failure to follow COVID-19 outbreak testing guidance According to Centers for Medicare and Medicaid Services (CMS) Ref: QSO-20-38-NH revised 9/10/21 it reads in pertinent part, Staff with symptoms or signs of COVID-19, vaccinated or not vaccinated, must be tested immediately and are expected to be restricted from the facility pending the results of COVID-19 testing. If COVID-19 is confirmed, staff should follow Centers for Disease Control and Prevention (CDC) guidance. Once a staff member (or resident) has been newly identified as COVID-19 positive, the facility must initiate outbreak testing. This means the facility must test all staff and residents immediately regardless of vaccination status by way of molecular or [MEDICATION(S)] testing. PCR testing should also be done twice a week until no new positives are identified. 1. Interview with the regional director of operations (RDO) on 10/19/21 at 2:00 p.m. revealed that on 10/2/21, the facility identified a certified nurse aide (CNA) #1 tested positive for COVID-19 with a POC test. The PRC test was completed by the director of nurses (DON) however, the test results were not picked up by the lab (see below). 2. Interview and record review revealed the facility did not test all staff from 10/3 through 10/8/21, did not properly handle test materials obtained 10/3, 10/4, 10/6/21 and 10/7/21, and did not timely conduct follow up testing after 10/8/21. a. Failure to test all staff Interview with the director of nurses (DON), the assistant director of nurses (ADON) and the regional clinical resource (CR) on 10/20/21 at 2:39 p.m. revealed PCR tests on all residents had been initiated on 10/3/21 and 10/4/21 after CNA #1 tested positive for COVID-19. The ADON said some staff were swabbed for the PCR test, but not all. The DON and ADON said some vaccinated and unvaccinated staff refused to come in to get tested . However, they were not taken off the schedule and were allowed to work without being tested . The facility had not addressed staff refusal of testing in its policy. While PCR tests were presented for staff from 10/15/21 to 10/18/21, results were provided for only 32 staff out of approximately 50 staff. b. Failure to properly handle test materials obtained 10/3, 10/4, 10/6 and 10/7/21, and perform follow up testing after 10/7/21. The ADON said he called the facility at night on 10/3/21 to see if the swabs collected on 10/3/21 were picked up and was told they were not picked up. Due to the sensitivity of the PCR swabs, the swabs were no longer valid after 72 hours and had to be thrown out. The ADON said they swabbed all residents again on 10/6/21 and 10/7/21; however, the swabs, again, were not picked up. The ADON said the next scheduled pick up was 10/8/21 for tests completed 10/6/21 and 10/7/21. The swabs from all the residents and some staff were picked up on 10/8/21; however, the facility did not receive any results from the lab regarding these tests. The DON said the facility did not follow-up, figuring no news was good news. The ADON said he did not have access to the computerized system for the state lab until 10/19/21 to view test results. Review of facility records confirmed no PCR test results from tests completed on 10/3/21, 10/4/21 and 10/6/21 and 10/7/21 were received from the state lab. Review of emails forwarded by the NHA on 10/21/21 revealed mishandling of completed PCR tests after 10/2/21. Specifically, an email dated 10/19/21 from the state lab read there were no tests received from the facility 10/3 and 10/4/21. Another email from the lab dated 10/20/21 read there were no courier requests for these dates (10/3/21 or 10/4/21), and on 10/6/21 and 10/7/21, the PCR tests for all residents and some staff were not processed because the facility failed to send an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Finally, although the facility did not receive any results from the lab after the 10/8/21 courier pick up, facility records revealed no evidence to show PCR testing was completed on 10/11, 10/12 and 10/14/21; PCR testing was not completed again until 10/15/21. c. Failure to follow local health department guidance. The local health authority communicated with the facility on 10/5/21 and asked for contact tracing to be completed for 48 hours before the staff member became positive and to do the POC testing of unvaccinated residents and staff, as well as to isolate any resident who had direct contact with CNA #1. The nursing schedule was reviewed for the previous 48 hours that CNA #1 worked and revealed he worked on the first floor with all 38 residents. The CNA worked with 12 staff members from 9/28/21 to 10/1/21. His last work day was 10/1/21. Thereafter on 10/2/21, CNA #1 reported respiratory symptoms, fever, weakness and flu-like symptoms. The DON, in an interview on 10/19/21 at 2:30 p.m., said neither contact tracing nor daily POC testing was completed for unvaccinated staff or residents as directed by the local health department. See details below. In another interview on 10/20/21 at 2:39 p.m. with the ADON, NHA and CR, the DON confirmed the residents with whom CNA #1 had worked in the 48 hours were not put on isolation and did not have any increased monitoring. Test results obtained 10/18/21 revealed a staff member, unvaccinated (UV) #6, was positive for COVID-19. S/he had worked with CNA #1 in the 48 hours before the CNA was tested . Additional results on 10/19/21 revealed four residents were positive for COVID-19. The four residents were all living on the first floor and had been cared for by CNA #1 in the previous 48 hours that the CNA had worked. B. Failure to follow routine testing requirements prior to the identification of CNA #1's COVID-19 positive test, to ensure early detection of asymptomatic, pre-symptomatic and symptomatic COVID-19. Review of the facility's COVID-19 Testing Strategies and Cohorting policy, was received from the NHA on 10/21/21. The policy read in pertinent part, Routine [CONDITION(S)]-CoV-2 diagnostic screening testing of SNF, HCP (health care provider), and response testing of SNF residents and HCP is essential to protect the vulnerable SNF population. Routine diagnostic screening testing at a minimum weekly cadence should continue for SNF HCP who are unvaccinated or partially vaccinated. SNF's should implement strategies to increase and maintain vaccination coverage among HCP as high as possible, including verifying vaccination status of new hirers, and offering education, listening sessions, counseling and vaccination at every opportunity, even to those HCP who have previously refused. Testing should continue to be performed for HCP with signs or symptoms consistent with COVID-19, regardless of their vaccination status. The policy did not include the procedure if the staff refused to be tested for COVID-19 with either the POC or the PCR test. Further, the policy was not consistent with CMS guidance, state guidance for residential care facilities and information the facility received from the local health department on 11/5/21. Specifically: According to Centers for Medicare and Medicaid Services (CMS) Ref: QSO-20-38-NH revised 9/10/21 read in pertinent part, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested . Facilities should use their community transmission level as the trigger for staff testing frequency. State guidance, Comprehensive Mitigation for Residential Care Facilities, p. 26, found at https://cdphe.colorado.gov/health-facility-covid-19-response/residential-care-strike-team/guidance-by-facility-type reads that the facility should test all health care providers (HCP) using a rapid molecular or [MEDICATION(S)] test at the beginning of every shift and complete once weekly lab-based PCR testing based on a community level of transmission (of less than 10 percent). Consistent with CMS and state guidance above, the local public health authority told the facility on 11/5/21, to test unvaccinated staff prior to the beginning of each shift. Yet, record review and interview revealed the facility failed to do so and also allowed unvaccinated staff who refusing testing to work their shift. 1. On 10/19/21 the facility provided a list with six unvaccinated staff working in the facility. 2. The POC daily rapid test record was reviewed from 9/18/21 to 10/19/21. The record was compared to the staff schedule and it revealed the following unvaccinated staff did not have a POC test prior to their shift. -Unvaccinated staff (UV) #1 had a POC test prior to shift five times out of 13 opportunities from 10/1/21 to 10/19/21. -UV #2 had no POC tests prior to the shift out of nine opportunities from 10/1/21 to 10/19/21. -UV #3 had a POC test prior to shift seven times out of 12 opportunities from 10/1/21 to 10/19/21. -UV #4 had a POC test prior to shift nine times out of 13 opportunities from 10/1/21 to 10/19/21. -UV #5 had a POC test prior to shift 11 times out of 14 opportunities from 10/1/21 to 10/19/21. On 10/22/21 at 5:55 p.m., after the immediate jeopardy was called, the POC daily rapid test record was reviewed and it revealed the facility was testing all staff prior to their shift. Forty-three (43) tests were administered and were negative for COVD-19. However, seven of the test results did not have a result of either positive or negative. The RDO also reviewed the sheets and confirmed seven test results were missing. The RDO said the receptionist had been trained on how to perform and document the POC test on 10/21/21. He said he would provide further training. 3. Interviews confirmed the facility neither tested unvaccinated staff as required nor barred those who refused testing from working their shift. Receptionist (RPT) #1 was interviewed on 10/19/21 at 4:21 p.m. The RPT said she worked the front desk five days a week. She said she did not have a list of staff members who were vaccinated or unvaccinated. She said she would ask the staff members and then, if the staff member said they were not vaccinated, the staff member would perform a POC rapid test. She said the staff members test on their own and fill out form in book which she then signs. The DON, the ADON, and the regional clinical resource (CR), and RDO were interviewed on 10/20/21 at 2:39 p.m. The DON and ADON said some unvaccinated staff refused to come in to get tested . They said when that occurred, the staff member was not taken off of the schedule, but would allow the staff member to work without being tested . The RDO said they were not strict enough on following the policy for staff who refused testing and allowing them to work. He said he was not aware the unvaccinated staff were refusing to be tested .

Based on interviews and record review, the facility failed to ensure two (#9 and #51) of four out of 42 sample residents were kept free from neglect and abuse. The facility failed to ensure Resident #9 was not neglected by staff on 6/8//21 by providing the care and services the resident required to maintain the highest practicable well-being. Resident #9 was left on the toilet commode for more than eight hours which resulted in the resident being fearful. During the time she was left on the commode, she cried with endless frustration and fear. She was tired and wanted to sleep, but stayed awake due to her position on the commode. She was uncomfortable, could not shift her legs and her bottom hurt. She describe the experience as torture and she was sore after being left on on the commode. In addition, Resident #51 had a resident to resident altercation with Resident #27 which resulted in having hair pulled and an episode of being choked. Findings include: I. Facility policy The Abuse Prevention Program policy, dated 11/17/17, was received from the nursing home administrator (NHA) on 10/18/21 at p.m., read in pertinent parts, Our residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. II. Resident #9 A. Resident status Resident #9, age was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) assessment dated , 7/30/21 documented the resident had no cognitive impairments with a score of 15 out of 15 for the brief interview for mental status (BIMS). The resident required extensive assistance with transfers and mobility and activities of daily living. B. Resident interview The resident was interviewed on 10/25/21 at 11:27 a.m. The resident said on 6/8/21 she was assisted onto the commode at 10:20 p.m. She said when she called for help at 10:30 p.m., she said she did not panic at first, because she knew she had to wait at times. She said she kept hitting her call light and began to use the metal wheelchair break to hit it against the metal of the wheelchair. She said when it was 11:00 p.m. and 11:30 p.m. she was concerned. At midnight, she said she became convinced that a certified nurse aide was not coming, but she thought a night nurse would check on her being new to the facility. She said at 1:00 a.m., and 2:00 a.m., she said she tried several times to get up, but she was unable to do it. She said she had visions of lying on the floor without help. She said she cried endlessly with frustration and fear. She said she was uncomfortable and could shift her legs. She said her bottom was hurting. She said by 4:00 a.m., she was tired and wanted to sleep, but because of her position she had to force herself to stay awake. By 5:00 a.m., she hoped the day shift would come and help her. She said she continued to press the call button and make noise when she heard people in the hallway. However, no staff came. She said the longest hour was 5:00 a.m. to 6:00 a.m., she said she became frustrated every time she heard someone in the hallway. She said at 7:10 a.m., the door opened and she was assisted off the commode. She said she was sore and tired but alive. The resident said she was disappointed that no one checked on her, and that she lived through 8.5 hours of torture. She said if one person would have checked on her, it would have made a big difference. Resident #9 said an investigation was completed, the police were called and the nursing home administrator told her it would never happen again. C. Record review The care plan last revised on 8/5/21 identified the resident had an activities of daily living (ADL) self-care performance deficit related to [CONDITION(S)] ([CONDITION(S)], stroke). Pertinent care interventions included, occupational therapist to work with the resident with bed mobility and toilet transfers. An investigation was requested on 10/26/21 at approximately 11:00 a.m. from the regional director of operations regarding the incident on 6/28/21, however the investigation was not provided (see regional clinical resource interview below). D. Interviews The director of nurses (DON) was interviewed on 10/27/21 at approximately 5:00 p.m. The DON confirmed the incident did occur as Resident #9 stated. She said a brand new CNA came on shift and assisted the resident on the commode and proceeded onto her assignment. The CNA helped with the shift change and the CNA did not check on the resident as it was not her assigned resident. She then went home and the one who was assigned never went and checked. The CNA was turned into the board of nursing and terminated. She said all staff training was completed, on answering call lights, and checking on residents. The DON said the resident had said she did not want to be checked on at night, however, the DON said the CNA/nurse should peek inside the room quietly to check on the resident. The DON said the room had a portable air conditioner which was loud, and that was why no staff could hear the banging. The regional clinical resource (RCR) was interviewed on 10/27/21 at approximately 5:00 p.m. The RCR said an investigation was completed, however, she was unable to locate the investigation as there was a change in leadership. III. Resident-to-resident altercation between Resident #51 and Resident #27 A. Resident #51 1. Resident status Resident #51, age 55 was admitted on [DATE]. According to the October 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] showed the resident had no cognitive impairments with a score of 15 out of 15 for the brief interview for mental status (BIMS). The resident required supervision with activities of daily living. 2. Record review On 8/29/21 the progress note showed Resident #51 was choked in the hall by Resident #27. The note documented the resident felt an arm around her neck. She screamed and the Resident #27 was removed. No injury occured. The 9/29/21 incident report showed Resident #51 had her hair pulled by Resident #27. The two residents were separated. B. Resident #27 1. Resident status Resident #27, age was admitted on [DATE]. According to the October 2021 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The minimum data set (MDS) assessment dated [DATE] showed the resident had severe cognitive impairments with a score of three out of 15 on the BIMS. The resident ambulated and required limited assistance with activities of daily living. 2. Record review The progress note dated 8/29/21 documented the resident walked up to another resident and attempted to choke the resident. Resident #51 said he came up from behind and got a hold of her neck, Resident #51 then screamed right away and this resident let go after about four seconds. RN assessment completed, no noted apparent injuries on either resident. This resident walked back to his room immediately after the incident. Residents do not report any fears or feeling threatened. Both have been separated and they reside in different areas in the building. Abuse coordinator notified, all responsible parties notified. Staff will continue to monitor them for safety. resident unable to state what happened and why he did it. law enforcement notified. residents remain in line of sight of staff for safety. The care plan identified the resident had dementia with behaviors and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Pertinent interventions included, to redirect the resident, provide activities of interest. The October 2021 CPO showed Rispeidone 0.5 mg twice a day was started on 9/8/21. C. Interview The DON was interviewed on 10/27/21 at approximately 5:00 p.m. The DON said Resident #27 has had resident to resident altercations. She said the resident was on one-to-one staff supervision. She said the physician had changed his medications and added the [MEDICATION(S)], which has had an improvement in his behaviors. She said they were actively seeking placement in a secured all male unit, however unable to find placement at this time. The DON said the resident was consistently monitored for behaviors and would need to be redirected.

Based on observation, record review, and staff interviews, the facility failed to ensure two (#38 and #41) of two out of 42 sample residents received care consistent with professional standards of practice to promote healing of pressure injuries. Resident #41 was admitted to the facility on [DATE] with an unstageable pressure ulcer to her sacrum and remained at risk for pressure ulcer development due to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to timely implement sufficient measures to minimize her risks. The facility failed timely implement treatment orders for Resident #41's pressure injury, which was a delay in treatment over eight days (a treatment order was not obtained until 6/16/21). Resident #41's wounds were not assessed, monitored or evaluated consistently to include size, tissue types, evidence of undermining (the destruction of tissue or ulceration extending under the skin edges/margins so that the pressure ulcer is larger at its base that at the skin's surface), tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), exudate (fluid that has been forced out of tissue or capillaries because of inflammation or injury), and odor. Due to the facility failures, Resident #41's pressure injury was documented as a stage 4 on 6/30/21 by the wound physician. Furthermore, Resident #38's coccyx stage 3 pressure ulcer was not consistently assessed and monitored to include size, stage, tissue types, evidence of undermining, tunneling, exudate and odor. According to the minimum data set (MDS) assessment documented the resident had a stage 2 pressure ulcer on 10/1/21, which then worsened to a stage 3 pressure ulcer on 10/4/21 (see record review below). In addition, there was no documentation of a collaborative interdisciplinary (IDT) review of Resident #38 or #41's wound to indicate if the resident's wounds were improving or worsening. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org (11/1/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). II. Facility policy The Wound Care policy was provided by the regional clinical resource (RCR) on 10/26/21 at 11:30 a.m. It documented in pertinent part, to verify there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The following information should be recorded in the resident's medical record: -The type of wound care given; -The date and time the wound care was given; -The name and title of the individuals performing the wound care; -Any change in the resident's condition; -All assessment data (i.e., wound bed color, size, drainage etc.) obtained when inspecting the wound; -How the resident tolerated the procedure; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; and -The signature and title of the person recording the data. III. Resident #41 A. Resident status Resident #41, age 79, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/11/21 minimum data set (MDS) assessment revealed Resident #41 was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive two-person assistance with all activities of daily living (ADLs) and was always incontinent of bowel and bladder. -She had one unstageable pressure injury over a bony prominence. She had a pressure reducing device for her chair and bed. She was not on a turning/repositioning program. She was receiving pressure ulcer/injury care, contradictory to record review (see below). The 9/24/21 MDS documented she received hospice services. B. Delay in obtaining treatment orders 1. Baseline care plan The baseline care plan, initiated on 6/7/21, was incomplete and it documented the resident did not have current skin integrity issues or history of integrity issues. 2. The skin/incontinence care plan, initiated on 6/27/21, documented Resident #41 had an unstageable pressure ulcer to her sacrum related to caloric malnutrition and the wound was unavoidable. Interventions included to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. CPO Review of the June 2021 CPO revealed upon admission Resident #41 did not have treatment orders for her sacral wound. On 6/16/21 treatment orders were obtained, and read, [MEDICATION(S)] (treatment which supports removal of necrotic tissue) on eschar of wound q (every) shift every day and night shift for unstageable sacral ulcer. Additionally, the CPO documented an order to admit the resident to hospice on 6/22/21. C. Failure to assess, monitor and evaluate the wound consistently Review of Resident #41's record revealed her sacral ulcer was not consistently monitored to include size, tissue types, evidence of undermining, tunneling, exudate and odor. 1. Admission assessment The 6/8/21 nursing assessment documented Resident #41 had an open area on her coccyx, which had no drainage or presence of odor. Treatment included to clean the area with normal saline and opti-foam (absorbent dressing) was applied. 2. Braden scales (tools used for predicting pressure ulcer development, score of 15-18 is at risk, score of 13-14 is moderate risk, score of 10-12 is high risk and score of nine or below is very high risk) -The 6/7/21 Braden scale documented Resident #41 was at high risk (score=10) for pressure ulcer development. -The 6/14/21 Braden scale documented Resident #41 was at moderate risk (score=14) for pressure ulcer development. -The 6/21/21 Braden scale documented Resident #41 was at high risk (score=11) for pressure ulcer development. -The 6/28/21 Braden scale documented Resident #41 was at moderate risk (score=13) for pressure ulcer development. 3. Skilled nursing notes Review of skilled nursing notes from 6/8/21 to 6/15/21 revealed staff documented Resident #41 had a sacral wound and physician ordered treatment was not obtained during this time period. Documentation revealed, in pertinent part, the following. -On 6/8/21 it was documented Resident #41 had an open necrotic wound to her sacrum, dressing change performed every shift to open area on coccyx. -On 6/9/21 it was documented Resident #41 had a necrotic decubitus to her coccyx. -On 6/10/21 it was documented Resident #41 had an open necrotic wound to her sacrum, dressing changed performed every shift to open area on coccyx. -On 6/11/21 it was documented Resident #41 had an open necrotic wound to her sacrum, dressing change performed every shift to open area on coccyx. -On 6/12/21 at 9:34 a.m. it was documented Resident #41 had an open necrotic wound to her sacrum, dressing changed performed every shift to open area on coccyx. -On 6/12/21 at 6:40 p.m. it was documented Resident #41 had an unstageable decubitus with eschar (necrotic tissue) to her sacrum, foam dressing applied. -On 6/13/21 it was documented Resident #41 had an open necrotic wound to her sacrum, dressing change performed every shift to open area on coccyx. -On 6/14/21 it was documented Resident #41 had an open necrotic wound to her sacrum, dressing changed performed every shift to open area on coccyx. -On 6/15/21 it was documented Resident #41 had an open necrotic wound to her sacrum, dressing changed performed every shift to open area on coccyx. Although skilled documentation indicated treatment was performed, specific treatment was not indicated to promote healing, orders were not obtained from the physician until 6/16/21 and the sacral ulcer was not consistently monitored to include size, tissue types, evidence of undermining, tunneling, exudate and odor. -There was no documentation in the record that an IDT review was completed to identify if the resident's wounds were improving or deteriorating. 4. Wound physician notes and interview The initial consult wound dated 6/30/21 documented Resident #41 had a stage 4 sacral/coccyx wound. It measured 4.9 cm (centimeters) x (by) 6 cm x 3.9 cm depth, with 3 cm of undermining at 12 o'clock. The wound had moderate exudate, with 80% granular tissue, 20% slough and [CONDITION(S)] (redness to skin that results from capillary congestion) to the periwound. The wound physician continued to assess the resident's wounds through 8/4/21. It was documented no change under wound progression and transfer care (to hospice) under wound status. The wound physician was interviewed on 10/27/21 at 10:44 a.m. He said he had been rounding at the facility since 2019. He said Resident #41 had stage 3 to stage 4 wound with nonviable tissue. He said the facility had already taken measures to offload/reposition the resident and they had started [MEDICATION(S)] treatment management. He and the facility talked with the resident's son regarding management of the wound. He said the goal would be to try to heal the wound, but the concern was the resident was declining and then was placed on hospice care. He said hospice took over and started to manage the wound (starting 8/4/21) so he no longer assessed the resident's wound. D. Wound observation On 10/26/21 at 12:07 p.m. licensed practical nurse (LPN) #1 was observed providing wound care to Resident #41. Resident #41 was lying in bed on an alternating air mattress, bunny boots in place to her bilateral heels, and she had a high back wheelchair with gel cushion. LPN #1 and certified nurse aides (CNAs) #10 and #11 performed hand hygiene. CNAs #10 and #11 provided incontinence care to Resident #41 and positioned her on her left side. LPN #1 donned gloves and removed the dressing from Resident #41's sacrum, doffed her gloves, performed hand hygiene, donned clean gloves and cleansed the area with wound cleanser. There was a moderate amount of serosanguineous drainage to the wound; the wound bed was pink with scattered areas of slough; the surrounding skin was pink; undermining was present; there were no signs and symptoms of infection or signs and symptoms of pain during the treatment. LPN #1 doffed her gloves, performed hand hygiene, donned clean gloves and packed the wound with calcium alginate (dressing for heavily exuding wounds) and covered it with a [MEDICATION(S)] (absorbent) dressing. E. Staff interview LPN #1 was interviewed on 10/27/21 at 8:33 a.m. She said there was a wound physician who completed weekly wound rounds for residents with wounds. She said when a resident was admitted to the facility a registered nurse would assess the resident's wounds and obtain treatment orders from the physician. She said the hospice nurse completed weekly assessments of residents with wounds. F. Weekly wound documentation provided by hospice Resident #41's sacral ulcer was not consistently monitored to include size, tissue types, evidence of undermining, tunneling, exudate and odor until admitted to hospice on 6/22/21, and even then weekly monitoring was not consistent (see below). Review of the documentation revealed weekly assessments were not consistently completed from 8/4/21 to 10/25/21. -Specifically, Resident #41 was assessed by the hospice nurse and wound treatment was provided. However, Resident #41's sacral ulcer was monitored to include size, tissue types, evidence of undermining, tunneling, exudate and odor only four times, on 9/13/21, 10/12/21, 10/18/21 and 10/25/21, over the 12 week period. The 9/13/21 hospice note documented Resident #41 had an unstageable wound to her medial buttock. The wound had 75% granular tissue, less than 25% slough and less than 25% eschar. The wound edges were intact, periwound was ping and it measured 5.7 cm x 6.2 cm x 3.4 cm depth. The 10/12/21 hospice note documented Resident #41 had a stage 4 pressure injury. The right buttock wound had 15% slough and 85% granulation tissue. The wound edges were rolled, periwound had [CONDITION(S)] and it measured 4.5 cm x 3.5 cm x 0.9 cm depth with 2.6 cm of undermining at five o'clock, 0.5 cm at 12 o'clock and 4.2 cm from one to three o'clock. Wound #2 to Resident #41's left buttock had a tunnel at eight o'clock measuring eight cm. The 10/18/21 hospice note documented Resident #41 had a stage 4 wound to her coccyx. The wound (wound #1) measured 4.4 cm x 5 cm x 0.3 cm depth. There was undermining which measured 2.6 cm at five o'clock, 0.5 cm at 12 o'clock, 4.2 cm at one to three o'clock and 2.4 cm at one to four o'clock. Wound #2 to Resident #41's left buttock had a tunnel at eight o'clock measuring eight cm. The 10/25/21 hospice note documented Resident #41 had an unstageable wound to her right buttock/coccyx. The wound (wound #1) measured 4.5 cm x 5 cm x 0.8 cm depth. There was tunneling at nine o'clock which measure 2.8 cm and 4.0 cm. There was undermining which measured 2.5 at five o'clock, 0.5 cm at 12 o'clock, 4.2 cm from one to three o'clock, 2.4 cm from one to four o'clock and 1.8 cm at eight o'clock. Wound #2 to Resident #41's left buttock had a tunnel at eight o'clock measuring eight cm. IV. Resident #38 A. Resident status Resident #38, age less than 60, was admitted on [DATE] and readmitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/1/21 MDS assessment revealed Resident #38 was cognitively intact with a BIMS score of 14 out of 15. She required two-person assistance with most ADLs. She was always incontinent of bowel and bladder. She received hospice services. She had one stage 2 pressure injury over a bony prominence. She had a pressure reducing device for her chair and bed. She was not on a turning/repositioning program. She was receiving pressure ulcer/injury care. B. Failure to assess, monitor and evaluate the wound consistently 1. Care plan The skin care plan, initiated 8/27/2020 and revised on 9/28/21, revealed Resident #38 had an open area to her coccyx. Interventions included to apply dressing as ordered. Resident #38 had an air mattress, needed assistance with peri-care and hygiene, monitoring skin for signs and symptoms of irritation related to incontinent episodes, and encouraging hydration/nutrition to promote healthier skin. 2. Braden scales The 9/10/21 Braden scale documented Resident #38 was at moderate risk (score=13) for pressure ulcer development. The 10/1/21 Braden scale documented Resident #38 was at moderate risk (score=13) for pressure ulcer development. 3. Progress note The 9/10/21 at 6:28 p.m. nursing note documented Resident #38 had an open area to her coccyx which measured 0.5 x 0.7 cm. The wound was cleansed with normal saline, and a dry dressing was applied by hospice and the physician was notified. -There was no documentation of Resident #38's coccyx ulcer to include stage, tissue types, evidence of undermining, tunneling, exudate and odor when it was first identified. -Additionally, review of progress notes from 9/11/21 to 10/25/21 revealed no further documentation of Resident #38's wound to include stage, size, tissue type, evidence of undermining, tunneling, exudate or odor. 4. CPO The September 2021 CPO revealed an order dated 9/11/21 which read to cleanse open area to coccyx with normal saline, pat dry, then apply 3 (three) x 3 foam dressing, and to entire reddened peri-wound area apply [MEDICATION(S)] (barrier) cream one time a day for wound care. -It did not include the stage of the wound. 5. Weekly summary The 9/11/21 weekly summary documented the resident had a pressure injury. It read, in pertinent part, the resident had a coccyx wound with current treatment orders in place and hospice was aware. -It did not include the stage of the wound. C. Staff interview Registered nurse (RN) #1 was interviewed on 10/27/21 at 8:49 a.m. She said the RN was responsible for assessing wounds and obtaining a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Hospice notes Review of 9/10/21 hospice notes revealed Resident #38 had an open area to her right buttock the size of my pointer finger nail. [MEDICATION(S)] cream was applied and covered with 3 x 3 foam dressing daily. -It did not include the stage of the wound. -Resident #38's wound was not assessed again to include size, tissue type, evidence of undermining, tunneling, exudate or odor until 9/20/21. -Additionally, there was no assessment of Resident #38's wound to include tissue type, evidence of undermining, tunneling, exudate or odor for the hospice visit on 9/20/21. It documented the resident had a superficial open area to her coccyx measuring 2.2 cm x 3.1 cm, apply [MEDICATION(S)] cream with a foam dressing every shift. -It did not include the stage of the wound. Resident #38's wound was not staged until 10/4/21, when it was documented Resident #38 had a stage 3 pressure ulcer to her coccyx. The 9/29/21 hospice note documented wound care was performed cleansed area with normal saline applied [MEDICATION(S)] with foam dressing. The 10/4/21 hospice note documented Resident #38 wound care was performed. Resident #38's wound was a stage 3 pressure ulcer. It measured 3 x 2 x 1.5 cm depth, tunneling 2.6 cm at 3 o'clock and undermining 0.8 cm at 12 o'clock to 9 o'clock. -There was no documentation in the record that an IDT review was completed to identify if the resident's wounds were improving or deteriorating. V. Administrative interviews The director of nursing (DON) and regional clinical resource (RCR) were interviewed on 10/27/21 at 4:53 p.m. The DON said Resident #41 and Resident #41's husband were admitted at the same time and they shared a room. She said Resident #41's husband was very controlling and would not let staff provide care. Eventually they were able to convince him to let staff provide care, a week or so went by and he allowed staff to provide consistent care. She said during the admission process registered nurses were responsible for assessing and treating resident's wounds. They said they were not aware of hospice's inconsistent documentation of characteristics of wounds and measurements, but they should had completed house audits of wounds to ensure things were not missed. They acknowledged the facility staff were not assessing resident wounds and missed monitoring and obtaining treatments orders for Residents #41 and #38. The RCR said the facility was ultimately responsible and they planned to start training to include assessment of causation of wounds, obtaining orders, monitoring and implementation of interventions for pressure ulcers.

Based on observations, record review, and interviews; the facility failed to maintain acceptable parameters of nutritional status for two (#40 and #43) of five residents reviewed for nutrition out of 42 sample residents. The facility failed to ensure Resident #40 was assessed in a timely manner by a registered dietitian (RD) and interventions were implemented to address his weight loss. The resident was not provided supervision and encouragement with eating, including offering alternatives for meals when meals were not eaten. Due to the facility's failures, Resident #40 sustained a 27.8 lb weight loss from 3/5/21 to 10/13/21, which was 15.0% considered a significant weight loss. Furthermore, Resident #43 was not provided assistance with eating, nor offered alternatives to meals when his meal intake was inadequate. The facility failed to consistently monitor and assess the resident's nutritional status with him being at nutritional risk. The resident's comprehensive care plan was not updated with interventions/strategies to address his nutritional status. Due to the facility's failures, Resident #43 sustained a weight loss of 17.8 lbs from 8/6/21 to 10/13/21, which was 13.26% considered significant weight loss. Findings include: I. Resident #40 A. Resident status Resident #40, age 65, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data assessment (MDS) assessment, dated 9/23/21, showed the resident had a score of 15 out of 15 on the brief interview for mental status. The resident required supervision with activities of daily living and supervision with eating. The MDS showed the resident was 5'8 feet tall and weighed 162 pounds. B. Observations Resident #40 received his meal on 10/25/21 at 12:20 p.m. The meal did not include the fortified potatoes or the fortified pudding (see record review below). Certified nurse aide (CNA) #11 dropped off his tray and left the room. He was served 240 cc of juice. -At 12:33 p.m., the resident brought his tray out of his room and placed it on the cart in the hallway, the resident had only eaten bites of the meal. -At 12:44 p.m., the CNA #11 picked up the tray and scraped the food off of the plate. The CNA did not approach the resident and ask if he wanted an alternative. -At 5:12 p.m., the resident received his meal of a grilled cheese, rice, carrots/broccoli and mandarin oranges. The resident received 240 cc of orange juice. The resident did not receive the fortified potatoes or the fortified pudding. -At 5:18 p.m., the resident brought his tray back out to the cart. The resident ate half of the grilled cheese sandwich. The social service director (SSD) told the resident he did not eat much. She asked if he was hungry, but he did not reply. He was not offered any alternative to his meal. 10/26/21 -At 5:45 p.m., the resident was served his tray. He was served fish, rice, roll and a vegetable. The fish was not mechanical soft as the diet order instructed (see record review below). Licensed practical nurse (LPN) #3 was notified of the wrong meal texture. The LPN #3 told the resident she would get him another meal. The tray ticket also requested fruit, which he did not receive. -At 5:51 p.m., the resident received the replacement tray. He was now served the mechanical soft ham, with rice, peas and two bowls of cantaloupe. The door was closed by the SSD after he was served. -At 6:00 p.m., the resident brought his tray out of his room and placed it on the cart. The resident ate only bites of food. There was no staff near when he brought his tray out to the hallway and therefore was not offered any alternative to his meal. D. Record review The October 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's weights were as follows: 3/5/21 185 lbs 4/11/21 181.4 lbs 5/3/21 183 lbs 6/8/21 175 lbs 7/2/21 169.8 lbs 8/2/21 168.4 lbs 9/2/21 164.6 lbs 10/4/21 158.6 lbs 10/13/21 157.2 lbs, weight loss of 27.8 lbs The resident had significant weight loss between 3/5/21 and 10/13/21 of 27.8 lbs, which was 15.0% weight loss. The RD note dated 8/22/21 documented the resident had a 10.7% weight loss within 180 days. The Medpass supplement was increased to 120 cc three times a day for nutrition support. The note documented that the resident's intakes were variable and he required supervision with his meals. -The facility failed to have a registered dietitian (RD) assess the resident until 8/22/21 when he had suffered a 10.7% weight loss. The resident's meal preferences were not evaluated. The dietary note dated 10/7/21 was assessed by the RD and had a 12.2% weight loss from 4/11/21 to 10/6/21. His current weight was 159.2 pounds with a usual body weight of 170 pounds. The Medpass (nutritional supplement) was increased on 9/28/21 to four times a day. The note documented that the resident had a swallowing eval which showed a decreased swallowing difficulty. The resident required 1809-2171 kcal/day. The RD added power (fortified) potatoes and fortified pudding twice daily with lunch and dinner for additional calories and protein. He was also added to weekly weights for close monitoring. The October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan last updated 10/6/21 identified the resident was at nutrition/hydration risk related to [CONDITION(S)], and dementia. Pertinent approaches included, encourage good meal intakes and offer substitutes for uneaten food, fortified pudding and potatoes. The meal ticket was reviewed on 10/26/21 at 5:30 p.m., it did not include the fortified potatoes or fortified pudding to be served at lunch and dinner meals as indicated in his care plan and an intervention for the resident's significant weight loss. C. Fortified foods Observations of the tray line in the kitchen on 10/26/21 at 4:50 p.m., showed no fortified potatoes on the tray line and no fortified pudding on the tray line. Resident #40 did not receive the fortified potatoes or the fortified pudding on 10/26/21 at 5:51 p.m. The dietary manager was interviewed on 10/27/21 at 8:20 a.m. She confirmed the fortified potatoes were not on the tray line, but they were on the stove top. She said the fortified potatoes and the fortified pudding needed to make it on the plate, regardless of where the potatoes were being held. She said the potatoes were fortified with butter and half and half. She said she would provide education to the dietary staff about ensuring the potatoes and pudding were served to the residents. D. Staff interview The SSD was interviewed on 10/25/21 at 5:25 p.m. The SSD said she was worried about Resident #40 as he was declining in health and cognitive status. She said she worried he was not eating. The registered dietitian (RD) was interviewed on 10/27/21at 2:24 p.m. The RD said the facility did not have an RD until late August 2021. She said when she assessed the resident she put into place the fortified pudding and the power potatoes for extra calories. She said he had experienced a significant weight loss at 12.2%. She said an alternative should always be offered when he did not eat his meal. The director of nurses (DON) was interviewed on 10/27/21 at approximately 5:00 p.m. The DON said the resident did suffer a significant weight loss. She said the resident was now placed on the nutrition at risk committee, and also on weekly weights. She said they went a period of time without a RD. She said the resident snacked when he was down visiting with his friends. She said if the resident ate less than 50% of his meal, then he should always be offered an alternative. She said the kitchen was available for alternative meals. She said they would begin tracking the snacks he ate while downstairs. He fed himself, but did require encouragement and cueing to eat. II. Resident #43 A. Resident status Resident #43, age 72, was admitted on [DATE] and readmitted from hospital 10/2/21. According to the October 2021 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/7/21 minimum data set (MDS) indicated the resident was mildly cognitively impaired with a brief interview for mental status (BIMS) score of 14 out of 15. He required extensive assistance with toileting, bathing, dressing and personal hygiene; he was an independent eater. The resident had experienced over ten percent weight loss in the past six months and was not on a physician prescribed weight loss regimen. B. Meal observations 10/25/21 -At 5:15 p.m. Resident #43's dinner meal was served to him. The plate contained double portions of the meal. Observations of the resident's meal continued until 5:45 p.m. The resident did not eat any of his evening meal. He did not receive any encouragement or assistance from the staff with eating. -At 5:50 p.m. certified nurse aide (CNA) #8 took the plate from Resident #43. It was full of food. He was not offered an alternative. 10/26/21 -At 12:15 p.m. Resident #43 was served the lunch meal. Observations from 12:15 p.m. to 12:45 p.m. indicated the resident did not eat any of his food. He was not offered an alternative. C. Resident interview Resident #43 was interviewed on 10/26/21 at 12:45 p.m. He said the lunch meal was very bad and he did not eat any of it. He said he was not offered an alternative. E. Record Review Resident weights were as follows: 8/6/21 134.2 lbs 9/7/21 133.2 lbs 9/11/21 133.0 lbs 10/4/21 124.2 lbs, returned from hospital on 10/2/21 10/7/21 119.6 lbs 10/12/21 117.4 lbs 10/13/21 116.4 lbs, a weight loss of 17.8 lbs. The resident lost weight from 8/6/21 to 10/13/21 of 17.8 lbs which was 13.26%, which indicated significant weight loss that was not prescribed. The dietary quarterly assessment dated [DATE] indicated that Resident #43 was an independent eater and would let his dietary needs be known. It revealed that the resident consumed 50 percent to 75 percent of his meals. A dietary note added on 10/7/21 (five days after the resident returned from hospital) indicated Resident #43 had triggered significant weight loss of 6.8% from 9/7/21 to 10/4/21. A possible error was suspected due to a reported good appetite. It was suggested by the RD for the resident to be weighed again. -However, there was no follow-up from the RD to determine if the weight was an error. The resident's meal preferences or intake were not reviewed. The resident's supplement was increased from two times a day to three times a day, but the percentage the resident was consuming was not indicated. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR from 10/1-10/7/21, the resident refused the supplement three times. The October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 10/25/21. According to the MAR from 10/7/21-10/25/21, the resident refused the supplement three times. The amount eaten history record from 10/14/21 to 10/24/21 indicated Resident #43 ate 25 percent to 50 percent of his meals for eight of 16 meals, he ate 76 percent to 100 percent of his meals for six out of 16 meals. On the other days he ate 50 percent to 75 percent of his meals. -According to meal observations above on 10/25/21 and 10/26/21, the resident did not consume any of his meal nor was he offered an alternative meal. A dietary note added on 10/20/21 revealed that Resident #43 had been informed of his weight loss by the RD and was asked why he thought he had lost weight. He replied, I do not know, I guess I am not hungry. The RD increased the supplement drink from two times per day to three times per day. -However, the resident's supplement order was already increased on 10/7/21 to three times a day. The resident's meal preferences, supplement and meal intake were not reviewed. A new order for one carton of Glucerna shake four times daily was started on 10/25/21 (this order was written during the survey). The nutrition care plan, updated on 10/25/21 (during survey), revealed Resident #43 experienced additional weight loss for one week. It did have an update of the orders for the Glucerna shake which started on 10/7/21 for one carton two times daily. The next update was on 10/17/21 for one shake three times daily and the last update was 10/25/21 for one shake four times daily. -The resident did have a comprehensive care plan that included strategies/interventions for his nutritional needs.There was one update from 10/25/21 (during survey) which included the increase of the Glucerna shake from three times daily to four times daily. -Although the RD ordered a supplement, it was not documented how much the resident was consuming. In addition, the resident's meal preferences were not evaluated nor was the resident offered meal alternatives when he did not eat his meals (see observations above). The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to monitor and assess the resident with ongoing weight loss. D. Staff interviews CNA #8 was interviewed on 10/25/21 at 6:00 p.m. She said that Resident #43 ate nothing all day today which was normal for him. She said the staff gave the resident a sandwich every evening because he was diabetic. She said he ate the sandwich half of the time. She said the staff did not help the resident eat because he ate on his own. She said they did not encourage him to eat and he was offered nothing else to eat except for the sandwich in the evening. The assistant director of nursing (ADON) was interviewed on 10/26/21 at 12:45 p.m. He said Resident #43 would become angry if the staff tried to encourage him to eat or help him to eat. He said the resident would not go to the dining room and prefered to stay in his room for meals. He said he did not realize the resident had not been offered alternatives to the meals. He said he would offer one to him today and encourage the staff to do so in the future. The registered dietitian consultant (RD) was interviewed on 10/21/21 at 10:36 a.m. She said Resident #43 came back from the hospital on 10/2/21 and that was when she did an initial assessment on him, which was the dietary note entered into the medical record on 10/7/21. She said the interventions she used were to order fortified drinks for the resident and also to serve him a double portion of food at mealtimes. She said the resident was offered snacks at snack time which he usually ate. She said the resident was getting weighed weekly. She said she observed the resident at one meal but did not indicate which one. She said he ate all of his food.

Based on observations, interviews, and record review, the facility failed to monitor and manage pain for one (#15) of two residents reviewed for pain out of 42 sample residents. The facility failed to: -Adequately assess and treat Resident #15's pain; -Update Resident #15's pain care plan timely; -Ensure Resident #15's tolerable pain level was assessed and attained; and, -Ensure non-pharmacological approaches were identified and attempted to assist with alleviating the resident's pain. As a result of these failures, Resident #15's pain was not adequately managed or relieved. Routine and as-needed (PRN) pain medication was not given, which contributed to the resident experiencing unrelieved back pain that she described as steady and deep, at a level eight (severe on a pain scale of 0-10) per interview and observation. During October 2021, the resident experienced moderate to severe pain at level four to seven on 13 occasions per facility documentation. Cross-reference F755, failure to ensure medications were available to residents. Findings include: I. Facility policy The Pain policy was provided by the clinical resource (CR) on 10/26/21. It read, in pertinent part, Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Pharmacological interventions may be prescribed to manage pain. Strategies that may be employed when establishing the medication regimen include: combining long-acting medications with PRNs (as-needed medications) for breakthrough pain. II. Resident status Resident #15, age 86, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/30/21 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. It documented the resident was on a scheduled pain medication regimen and did not receive any pain medications as needed (PRN). It was documented the resident's worst pain level was four out of 10 in the past five days and pain did not interfere with her sleep or daily activities. A. Pain management plan The pain care plan, initiated 3/8/17 and revised on 2/24/21, revealed Resident #15 had chronic [CONDITION(S)]. Interventions included to administer [MEDICATION(S)] ([MEDICATION(S)]) per physician orders, apply Biofreeze Gel 4% topically to joints every four hours as needed for arthritis pain and evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Offer non-pharmacological interventions (taking a nap in the afternoon, listening to music and reading a book) and notify the physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain. B. Failure to assess and manage Resident #15's pain 1. Assessments The pain assessment dated [DATE] documented Resident #15 had moderate pain (level=5 out of 10) to her left hip, right hip and sacrum. Increased activity made her pain worse and [MEDICATION(S)] helped manage her pain. The pain interview dated 10/9/21 documented Resident #15 had occasional mild to moderate pain (level=4 out of 10), and scheduled and as needed [MEDICATION(S)] provided effective pain management. -The pain assessment did not document the resident's preferred/tolerated level of pain, or specific non-pharmacological measures that helped the resident's pain. 2. CPO The October 2021 CPO included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The October 2021 CPO and recent physician telephone orders revealed current orders for pain control included: -[MEDICATION(S)] cream 4% applied to lower back as needed for pain with a start date of 5/21/21; -[MEDICATION(S)] tablet 7.5 milligrams (mg) every morning for neck [CONDITION(S)] with a start date of 5/17/21; -[MEDICATION(S)] capsule 100 mg three times a day for chronic pain with a start date of 9/18/21; -[MEDICATION(S)] tablet 5-325 mg every six hours for pain with a start date of 12/14/2020; and, -[MEDICATION(S)] tablet 5-325 mg every six hours as needed for moderate pain with a start date of 12/14/2020. 3. Observation and interview Resident #15 was observed on 10/20/21 at 9:30 a.m. Resident #15 was at the nurses station and she grimaced and cried out it hurts! while she pointed to her back. She was observed to ask licensed practical nurse (LPN) #4 for something to manage the pain since the facility did not have her [MEDICATION(S)]. The nurse responded that she could give the resident Tylenol. Resident #15 was observed on 10/20/21 at 10:01 am. Resident #15 was in bed and told LPN #4 her pain was at an eight out of 10. Resident #15 said her pain was steady and deep. She was observed groaning and grimacing. 4. Pain level summary Review of the pain level summary revealed it was documented Resident #15 had a zero pain level on 10/20/21 at 6:58 a.m., 9:20 a.m., 12:29 p.m., 7:33 p.m., and 11:06 p.m., contradictory to the observation (see above). According to the pain level summary from 10/1 to 10/20/21, the resident's pain level was documented 13 times at level four to seven out of 10. Her pain was documented five times at two to three out of 10, and 50 times at zero out of 10. 5. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 missed a total of six routine doses, three on 10/18/21, two on 10/19/21 and one on 10/20/21. -In addition to pain medication being missed, review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -Tylenol 500 mg (milligram) give two tablets was ordered on 10/20/21 at 9:44 a.m. (one time order) and given at 11:18 a.m.; however it was not documented as effective or ineffective and no further intervention was documented. 6. Progress notes Review of progress notes from 10/18/21 to 10/20/21 revealed staff documented the following: -On 10/18/21 at 5:38 a.m. [MEDICATION(S)] tablet 5-325 mg waiting to be delivered from hospice pharmacy; -On 10/18/21 at 6:41 a.m. [MEDICATION(S)] tablet 5-325 mg waiting delivery from pharmacy; -On 10/19/21 at 12:18 a.m. [MEDICATION(S)] tablet 5-325 mg waiting to be delivered by hospice; -On 10/19/21 at 12:19 a.m. [MEDICATION(S)] tablet 5-325 mg waiting to be delivered by hospice; -On 10/20/21 at 1:33 a.m. [MEDICATION(S)] tablet 5-325 mg waiting to be delivered from pharmacy; and, -On 10/20/21 at 1:34 a.m. [MEDICATION(S)] tablet 5-325 mg waiting to be delivered from pharmacy. -There was no further documentation in the progress notes related to pain management due to medication not being available or non-pharmacological interventions being provided. -There was no evidence the resident's physician was notified of her moderate to severe pain levels, and that her pain medication was unavailable until 10/20/21 (during survey). 7. Nurse practitioner (NP) note The 10/15/21 NP note documented Resident #15 was a recent hospice graduate (she graduated from hospice on 9/29/21). III. Interviews LPN #4 was interviewed on 10/20/21 at 9:52 a.m. She said [MEDICATION(S)] was not ordered from the pharmacy and there must have been a miscommunication. She said she knew the resident needed [MEDICATION(S)], but it was not sent to the pharmacy, but she would give the resident Tylenol to manage her pain. She said Tylenol was not the same as [MEDICATION(S)]. She said the physician was notified today of the error. The director of nursing (DON) and regional clinical resource (RCR) were interviewed on 10/27/21 at 5:01 p.m. They said the facility did have an emergency kit available for pain medication, antibiotics, insulin and various other medications. They said they contracted with backup pharmacies to obtain medications if unavailable. They talked to the pharmacist about the medication being unavailable in quality assurance (QA), and they were investigating on their end why medications were not being delivered from the pharmacy. The RCR said they planned to re-educate staff to ensure medication was received from the pharmacy, how to access from the emergency kit and exhaust every option to ensure the residents had their medications. The DON said when a resident requested pain medication the licensed nurses needed to assess the resident's pain level and administer pain medication, if the resident did not have pain medication available, the physician should be notified. She said when she learned Resident #15 had not received her pain medication, the nurse was terminated.

Based on record review and interviews, the facility failed to ensure three (#24, #36 and #40) of eight residents reviewed for medication administration out of 42 sample residents were free from significant medication errors. Resident #24 was not given 13 doses of [MEDICATION(S)], prescribed to treat depressed mood and passive death wish related to [CONDITION(S)]. The medication was not available, the facility did not ensure the medication was reordered timely, and the resident's physician was not notified the resident had missed this medication. These failures contributed to Resident #24's hospitalization after a mental breakdown and self-injurious behavior. The facility further failed to: -Administer 14 doses of [MEDICATION(S)] ointment, prescribed to treat Resident #36's [CONDITION(S)] eye condition; and -Apply seven [MEDICATION(S)] patches, prescribed to treat Resident #40's hallucinations. Findings include: I. Facility policy and procedure The Medication Administration policy, dated 2007, provided by the regional director of operations (RDO) on 10/27/21, read in pertinent part: Medications shall be administered in a safe and timely manner. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified. II. Resident #24 A. Resident status Resident #24, under age 60, was initially admitted on [DATE] and readmitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/26/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required one to two person assistance with all activities of daily living (ADLs) and was independent for locomotion. The MDS reported antipsychotics were received on a routine basis. B. Record review Review of Resident #24's progress notes from July and August 2021 revealed her [MEDICATION(S)] tablet 25 milligrams (mg) for depressed mood and passive death wish related to [CONDITION(S)] were not delivered by the pharmacy and not available for the resident from 7/26/21 through 8/11/21 (cross-reference F755). The progress notes did not reveal the physician was notified (cross-reference F580). Review of Resident #24's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note on 8/8/21 at 10:14 a.m. revealed the resident stated to a certified nurse aide (CNA) that she wanted to commit suicide. The nurse was notified and removed objects that could be harmful from her room and placed her on 15 minute checks. The progress note on 8/11/21 at 12:22 p.m. revealed the resident stated she wanted to harm herself with her comb. The comb was removed from her room and a crisis mental health team was notified. The progress note on 8/11/21 at 3:05 p.m. revealed the resident stated she would cut herself and bleed out. The manager on duty was notified and she was placed on 15 minute checks. The physician was notified and provided an order to send the resident to the hospital. The progress note on 8/12/21 at 5:14 p.m. was a late entry that revealed the resident was sent out to the hospital for psychiatric evaluation. The resident stated she planned to kill herself. She was picked up by ambulance on 8/11/21 at 9:30 p.m. The progress note on 8/17/21 at 5:00 p.m. revealed the resident returned from the hospital with self-inflicted bruises on her right upper arm, left leg and stomach. The progress note on 8/18/21 at 4:32 p.m. revealed the monthly medication regimen review was completed. The hospital admission paperwork dated 8/12/21 noted chief complaints as suicidal history and [CONDITION(S)] [CONDITION(S)]. The report revealed the resident had a plan to use an aluminum can to cut her wrists open. She confirmed increasing family related stress and she did not like her nursing facility due to understaffing. The psychiatric evaluation revealed her mood as depressed with withdrawn behavior. The resident had suicidal ideation that included a plan. She stated she wished she would fall asleep and not wake up. The resident stated after discussion she was motivated to live for her son and needed help from the facility to stay in compliance. C. Staff interview The regional clinical resource (RCR) and director of nursing (DON) were interviewed on 10/27/21 at 4:45 p.m. The DON said in August 2021 they discovered the nurses did not understand how to order and track the delivery of medications ordered through their pharmacy. She said there were multiple medications that were not delivered and missed doses for multiple residents. She said she provided education to the nurses on how to properly order and track the delivery of medications. She said the education also included notifying the physician every time a medication was not given or not available. The RCR stated that the company now works with a local pharmacy as a back up when medications were not available through their mail pharmacy. She said the nurses were educated on how to contact the DON when a medication was not available or delayed and the DON has the ability to order the medication through the local pharmacy for a one time order for emergencies. The RCR said the physician should be notified when a medication was not available or when a medication was not given. The RCR said the multiple missed doses of [MEDICATION(S)] may have contributed to the mental break and hospitalization of Resident #24. D. Facility follow-up Record review revealed that after the resident's hospitalization on [DATE] and when she returned to the facility on [DATE], her medications were changed, mental health services were provided, and her psychosocial condition was improving. III. Resident #36 A. Resident status Resident #36, age 66, was initially admitted on [DATE] and readmitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/3/21 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required supervision to one person assistance with all activities of daily living (ADLs). The MDS reported impaired and limited vision. B. Record review Review of Resident #36's progress notes from September and October 2021 revealed her [MEDICATION(S)] ointment for her left eye to be administered two times a day for Chalazion ([CONDITION(S)] lump in the oil gland of the eyelid) was not delivered and administered according to physician orders. The progress notes did not reveal the physician was notified (cross-reference F580). Resident #36's progress note dated 9/15/21 at 7:18 p.m. revealed [MEDICATION(S)] ointment to be administered two times daily for Chalazion was ordered and pending arrival from the pharmacy (cross-reference F755). Resident #36's note dated 9/22/21 at 8:29 a.m. revealed the [MEDICATION(S)] ointment was on order and unable to be administered. Resident #36's progress note dated 9/29/21 at 8:19 a.m. revealed the [MEDICATION(S)] ointment was on order and unable to be administered. Resident #36's progress note dated 10/10/21 at 8:49 a.m. revealed the resident stated she no longer used the [MEDICATION(S)] ointment. Resident #36's progress note dated 10/18/21 at 7:14 p.m. revealed the resident declined the [MEDICATION(S)] ointment to be administered. Resident #36's progress note dated 10/19/21 revealed the [MEDICATION(S)] ointment was on order and unable to be administered. Review of Resident #36's medical administration record (MAR) for September and October 2021 revealed the resident missed 14 doses of the [MEDICATION(S)] ointment from 9/15/21 through 10/25/21. Resident #36's care plan, revised on 10/9/21, revealed the resident was visually impaired with nuclear [CONDITION(S)] with a benign neoplasm of the left eye. C. Staff interview The regional clinical resource (RCR) and director of nursing (DON) were interviewed on 10/27/21 at 4:45 p.m. The DON said she did an inservice for all of the nurses that covered medication ordering and tracking of the medications. The DON said either a registered nurse (RN) or a licensed practical nurse (LPN) could order the medications from the pharmacy. She said the inservice was done in August (2021) and she would provide another education to the current staff on medication administration, ordering and documentation. IV. Resident #40 A. Resident status Resident #40, age 65, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/23/21 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. It indicated the resident did not have hallucinations or delusions and did not have behaviors including resistance to care. B. Record Review The October 2021 CPO included the following: -[MEDICATION(S)] patch (a cognition enhancing medication; stopping suddenly may cause mental/behavioral changes) 24 hour, 4.6 milligrams per hour. Apply one patch transdermally one time a day for hallucinations and remove per schedule, with a start date of 9/15/21. The October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] patch was not administered from 10/15-10/20/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] patch was administered in the evening on 10/21/21. The nursing progress notes revealed the following: -The 10/15/21 progress note indicated the patch was not administered due to Resident #40 not completing lower dosage. -The 10/16/21 progress note indicated the patch was not administered due to awaiting delivery from the pharmacy. -The 10/17/21 progress note did not indicate a reason the patch was not administered. -The 10/18/21 progress note indicated the patch was not administered due to awaiting delivery from the pharmacy. -The 10/19/21 progress note indicated the patch was not administered due to awaiting delivery from the pharmacy. -The 10/20/21 progress note indicated the patch was not administered due to awaiting delivery from the pharmacy. -The 10/21/21 progress note indicated the patch was not administered due to patch not on Resident #40 did not receive the medication seven times throughout seven days. There was no evidence the physician was notified that the resident did not receive the medication. The care plan, last updated on 3/3/21, indicated Resident #40 was at risk for pacing, worrying, and hallucinations related to his diagnoses. Interventions included administration of medications as ordered and support and reassurance of safety at times of hallucinations. C. Interview The director of nurses was interviewed on 10/27/21 at 11:00 a.m. The DON reviewed the record and confirmed the resident did not receive his scheduled Rivastgmine patch. The DON said all licensed nurses were responsible for ordering the medications. She said she had conducted recent training which instructed the nurses to order the medications as early as 10 days prior to running out, then fax the request to the pharmacy. When the pharmacy delivered medications, the nurse was to review the received medications and compare them to the sheet faxed. She said if medication was not received, then they needed to call the pharmacy and track the whereabouts.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life, quality of care. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program policy last revised March 2020 was received on 10/29/21 at 8:05 a.m., from the regional director of operations. The policy read in pertinent parts, The Administrator, whether a member of the QAPI Committee or not, is ultimately responsible for the QAPI Program, and for interpreting its results and findings to the governing body. The responsibilities of the QAPI Committee are to: Collect and analyze performance indicator data and other information; Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services; Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process; Utilize root cause analysis to help identify where identified problems point to underlying systemic problems; Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care; Establish benchmarks and goals by which to measure performance improvement; Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and Communicate all phases of the QAPI process to the Administrator and governing body through sharing meeting minutes, committee activities and results of QAPI activities. II. Review of the facility ' s regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F 692 Nutrition/hydration During an abbreviated survey on 11/17/2020, nutrition/hydration was cited at a G (harm) level. During the recertification survey on 10/27/21 nutrition/hydration was cited at a G level. F600 Prevention of resident abuse and neglect During an abbreviated survey on 10/22/2020 resident to resident abuse was cited at a E level. During the recertification survey on 10/27/21 the facility was cited at an increase of scope and severity for abuse at a G (harm) level. F880 infection control During an infection control focused survey the facility was cited at a E pattern level. During the recertification survey on 10/27/21 the facility was cited a L (immediate jeopardy) for not having an effective infection control program. III. Cross-referenced citations Cross-reference F600: The facility failed to protect residents after allegations of abuse. Cross-reference F610: The facility failed to thoroughly investigate allegations of resident verbal abuse. Cross-reference F692: The facility failed to ensure that residents timely interventions in order to prevent significant weight loss. Cross-reference F880: The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of COVID-19. Cross-reference F886: The facility failed to have an effective program to test for COVID-19 residents, facility staff and individuals providing services to residents of the facility. IV. Interviews The regional director of operations (RDO) and clinical resource (CR) were interviewed on 10/27/21 at 6:33 p.m. The RDO said the QAPI committee met monthly with the interdisciplinary team attending. The RDO said the facility had had a lot of turnover in administration within the past year. He said he continued to have turnover in the department heads receiving two this past week. A new nursing home administrator was scheduled to start on 10/28/21. The previous NHA had resigned and vacated the position approximately three weeks prior. The RDO said the last QAPI he attended was in May or June 2021. He said the QAPI had an agenda which was followed. He said the QAPI was to be used to identify and solve problems within the facility. The RDO reviewed the minutes and said infection control was discussed every month, however, the facility had a change in the infection preventionist (IP) who vacated the position roughly two weeks prior to the survey. The facility had appointed the assistant director of nurses (ADON) as the IP, however, he had not received any training and he had not started the training for the certificate to be an IP. The CR was assisting with the infection preventionist. The RDO said the facility needed to ensure education and ensure the changes in local authority, and CDC were followed. The RDO said the NHA was responsible to follow up on any of the items which were identified to ensure performance improvement changes were put into place. The CR said significant weight loss and significant weight gains were discussed at each meeting. She said the providers were notified and the residents were placed on the nutrition at risk (NAR) meeting. The registered dietitian attended the NAR meeting. The RDO confirmed the facility was without a RD until late August. The RD was now ensuring all residents were being assessed. The RDO said at every meeting abuse was discussed, the allegations and the risk management investigations were followed. The RDO said the staff need to identify what constitutes abuse and work together to fully investigate and prevent abuse.

Based on record review and interviews, the facility failed to ensure one (#18) out of five residents reviewed for hydration out of 18 sample residents received a sufficient amount of fluids. Failures to sufficiently address Resident #18's hydration needs after admission date of [DATE] resulted in his dehydrated condition upon being admitted to the hospital on [DATE] from the facility. The facility's failures to care plan Resident #18's needs for dining/drinking assistance upon admission; re-assess Resident #18's needs following fluctuations in his ability to eat and drink; and, continuously monitor to address documented decreases in Resident #18's fluid intake contributed to Resident #18 's declined condition. Futhermore, because of Resident #18's condition upon arriving at the hospital, he had to be intubated (is the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing during anesthesia, sedation, or severe illness). Additionally, the following [DIAGNOSES REDACTED]. Findings include: I. Family interview of Resident #18 's condition during a visit to the facility A family member was interviewed on 11/12/2020 at 8:54 a.m. The family member said the family visited with the resident at the facility on 10/6/2020 at approximately 2 p.m. She said the resident was difficult to arouse even though staff said he was alert earlier for lunch. She said staff brought him back inside the facility and decided to transport the resident to the hospital. The family member said the resident appeared to have lost a significant amount of weight. She believed the resident weighed 145-150 lbs. when he was admitted to the facility in July. The family member said the resident was very dehydrated upon admission to the hospital and thought his sodium levels were so high his brain shut down and that's why he was unresponsive. II. Resident #18 A. Resident status Resident #18, age 77, was admitted on [DATE] and discharged on [DATE]. According to the July 2020 computerized physician orders, pertinent [DIAGNOSES REDACTED]. According to the 7/27/2020 admission minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He experienced [MEDICAL CONDITION] described as fluctuating inattention and disorganized thinking. The resident did not exhibit behaviors of concern but did reject care one to three days during the seven day assessment. He required supervision for eating and drinking. B. Assessments The 7/23/2020 hydration risk screen revealed the resident was at moderate risk of dehydration. He required extensive physical assistance for fluid intake/eating and had a history of [REDACTED]. The admission dietary nutritional assessment, completed by a registered dietitian (RD) on 7/25/2020, documented the resident required limited assistance or supervision during meals. According to the assessment the resident's weight was 175 lbs./79.5 kg. His estimated fluid intake was 2370 ml per day based on 30ml per kg. C. Pre-admission laboratory results A 7/1/2020 laboratory report, completed during an earlier hospitalization , revealed the resident's sodium level was 140 (reference range 136-145 mmol/L); potassium level was 3.9 (reference range 3.5-5.1 mmol/L); chloride level was 108 (reference range 96-111 mmol/L); BUN (blood urea nitrogen) was 22 (reference range 6-24 mg/dL); creatinine level was 1.08 (reference range 0.65-1.36 mg/dL); and, his BUN/creatinine ratio was 20 (reference range 6-25). An additional hospital note written on 7/9/2020 revealed the resident's potassium was measured at 5.2 mmol/L on 7/9/2020. The measurement was described as trivial and his potassium level returned to normal. A 7/21/2020 laboratory report, completed prior to discharge to the facility revealed the resident's sodium level was 140 mmol/L; potassium level was 3.9 mmol/L; chloride level was 109 mmol/L; BUN was 23 mg/dL; and, creatinine was 0.96 mg/dL. All documented results from both preadmission basic metabolic panels (BMP) were within normal limits. D. Care plans The 7/23/2020 baseline care plan documented the resident required physical assistance from one person for eating. He was alert but cognitively impaired. The resident required a regular diet with thin liquids and ate in the dining room. The baseline care plan identified no other nutrition or hydration needs, supports or interventions. The comprehensive care plan included goals and approaches for nutrition/hydration on 9/2/2020. The care plan identified the resident was at nutrition/hydration risk due to fractured ribs, dementia, [MEDICAL CONDITION] (disease), [MEDICAL CONDITION] and hypertension. The resident's goals were to remain adequately hydrated and maintain weight without significant weight variance. Pertinent interventions included encourage fluid intake between meals, fresh water at bedside, monitor all food and fluid intake and monitor, record and report labs when ordered. He was independent with meals. -The last sentence the resident was independent with meals is inaccurate, see section E-records below. E. Records The 7/23/2020 occupational therapy (OT) evaluation and plan of treatment identified the resident. One stated goal of therapy was to have the resident require minimal assistance to close supervision for self cares including dressing, toileting .and self-feeding. A referral from OT to restorative therapy, dated 8/19/2020, revealed the resident required max assistance with HOH (hand over hand) during two to three meals for increased independence with self feeding, provide simple verbal cues with tactile cues. Weight/Skin interdisciplinary team notes dated 9/2/2020 documented the resident's average daily fluid intake was 1600ml. III. Failures A. Record review Fluid intake records revealed the resident consumed 960 ml on 9/26/2020, 720ml on 9/27/2020, 960ml on 9/28/2020, 840 ml on 9/29/2020, 1440 ml on 9/30/2020, 1200ml on 10/1/2020, 1440 ml on 10/2/2020, 720ml on 10/3/2020 (no evening entry), 480 ml (no evening entry) on 10/4/2020, 480 ml (no afternoon or evening entry) on 10/5/2020 and 240ml (prior to being transported to the hospital) on 10/6/2020. No refusals were noted. Daily skilled nursing documentation completed between 7/23/2020 and 8/17/2020 revealed the resident's support needs for eating and drinking ranged from supervision to total dependence. Weekly summaries described the resident's support needs for eating and drinking as extensive assistance on 7/29/2020, independent on 8/5/2020, limited assistance on 8/12/2020, total assistance on 8/26/2020; limited assistance on 9/2/2020, limited assistance on 9/9/2020, and total assistance on 10/1/2020. Review of nursing, restorative and physician notes completed between 7/23/2020 and 10/6/2020 did not reveal concerns over the resident's nutrition/hydration status, documented decrease in fluid intake or of fluctuations in self-care. Review of the resident's clinical record revealed the facility failed to develop a comprehensive care plan for nutrition/hydration based on the needs identified on nutritional assessments, occupational therapy assessments and nursing assessments between 7/23/2020 and 9/2/2020. Review of the clinical record failed to reveal the resident's care plan was revised after 9/2/2020 when changes in his ability to eat and drink were noted on daily skilled nursing documentation and weekly nursing summaries. The 10/6/2020 discharge MDS assessment revealed the resident's weight was 140 lbs. (or 63.5 kg). He had short and long term memory loss with severely impaired skills for daily decision making. The resident did not exhibit behaviors of concern and did not reject care during the seven day assessment period. He required extensive assistance for eating and drinking. -Based on the formula used by the facility in nutritional assessments, the resident required 1905ml of fluids per day at the time of discharge (63.5kg x 30ml/kg). The resident received an average of 253.33 ml per shift and an average of 760ml per day, seven out of ten days between 9/26/2020 and 10/5/2020. B. Hospital records Hospital admission records revealed the resident was brought to the emergency department on 10/6/2020 due to alteration in mental status. He required intubation to protect his airway. Assessment of the resident's condition revealed acute [MEDICAL CONDITION] resulting from the resident's altered mental status; dehydration and [MEDICAL CONDITION]; and, acute [MEDICAL CONDITION] secondary to dehydration and hypovolemia. Laboratory results from BMP drawn on 10/6/2020 revealed the resident's sodium level was 156 (reference range 136-145 mmol/L); potassium level was 3.7 (reference range 3.5-5.1 mmol/L); chloride level was 127 (reference range 96-111 mmol/L); BUN (blood urea nitrogen) was 34 (reference range 6-24 mg/dL); and, his creatinine level was 1.38 (reference range 0.65-1.36 mg/dL). A 10/6/2020 physician's report from the hospital noted a conversation with facility staff describing the resident's baseline as highly dependent for ADLs (activities of daily living). The physician was informed the resident was unable to reach for objects to eat/drink independently prior to hospitalization . Based on the resident's condition and the staff's description, the physician suspects diminished fluid intake. A 10/16/2020 physician's note revealed the resident responded to intravenous fluids and became more alert and stable during his hospital stay. The physician described the resident as safe and semi-improved upon being enrolled in hospice services and discharged to the family home. C. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 11/17/2020 at 11:05 a.m. The LPN said the resident was on her floor for the first two weeks for quarantine as a new admission. The LPN said the resident took meals in his room and needed total assistance. She said he would try to drink beverages on his own but really did need assistance. The LPN said she did not recall the resident asking for additional fluids or having any issues with drinking. Certified nurse aide (CNA) #1 was interviewed on 11/17/2020 at 11:25 a.m. The CNA said she worked with the resident while he was on quarantine. She said the resident had dementia and needed assistance with everything, including eating and drinking. She said the resident required hand-over-hand assistance. The CNA said staff had to offer fluids to the resident because he did not ask for them. The CNA said the resident became agitated with receiving assistance at times but he drank better than he ate. CNA #2 was interviewed on 11/17/2020 at 11:35 a.m. The CNA said she worked with the resident when he moved from the quarantined area to a general care unit. The CNA said the resident was totally dependent on others for assistance with eating and drinking. She said the resident did not care for water but really liked juice. She said staff always kept pitchers of water and juice in his room but had to get it for him because he could not. The CNA said the resident drank well for her but she was not sure how he did for other staff. The dietary manager (DM) was interviewed on 11/17/2020 at 11:45 a.m. The DM said the facility recognized in September 2020 that there was an issue with monitoring weight variances and care plan revision. She said the facility developed a plan to review all residents and revisions began based upon the greatest variances. She said the initial nutritional assessment was completed remotely by the RD and was based on record review. The resident's initial weight of 175 lbs. was from the hospital record on July 2, 2020. She said the resident was not weighed at admission on July 22, 2020 and the next weight measurement was not taken until August 2020. She said the initial estimate for daily fluid intake was based upon the resident's initial weight which was questionable. The DM said she was not sure why there was not a nutrition/hydration care plan in place prior to 9/2/2020. The DM said the resident was gaining weight at the time of his discharge and did not appear to be dehydrated. The director of nursing (DON) was interviewed with the nursing home administrator (NHA) and the corporate clinical director (CCD) on 11/17/2020 at 2:27 p.m. The DON said there were no signs of dehydration for the resident and noted the facility was very surprised when he became non-responsive. The DON said the resident was doing well the day of his discharge and had eaten and drank well. The CCD noted the resident's blood pressure and pulse were stable across his stay. She said the resident was at increased risk for nutrition and hydration problems because of having [MEDICAL CONDITION] and [MEDICAL CONDITION]. She said his estimated daily intake was based on the needs of an average person and noted the resident had multiple medication changes that may have increased his risk of dehydration. The DON said she was unaware the resident had a decrease in fluid intake and did not know why a care plan or additional nutritional assessments were not completed based on fluid intake records and fluctuating needs represented on daily/weekly nursing documentation.

Based on record review and interviews with residents and staff, the facility failed to ensure seven of 54 sample residents (#20, #64, #65, #75, #28, #16 and #63) were free from physical, verbal, and mental abuse. Cross-reference F225 (investigation of abuse and protection of residents) and F226 (abuse policies). The facility's failure created a situation of immediate jeopardy for serious harm. The findings include: I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY On 7/18/11, the Colorado Department of Health and Environment (CDPHE) received a complaint of alleged verbal and physical abuse of a resident (resident #75) by a staff member (Nursing Home Administrator). Interviews beginning on 7/20/11, revealed this event had been witnessed by various staff members and a family member; witnesses confirmed the staff member's use of verbally and physically aggressive behavior towards resident #75. Further interviews 7/20/11 through 8/10/11, revealed additional instances of physical and mental abuse by staff as well as residents' fear punishment/reprisal. Instances of abuse included the misuse of physical maneuvers associated with the Crisis Prevention Institute (CPI) that are designed to address residents' aggressive behaviors, as well as the use of intramuscular (IM) antipsychotic medication against residents' wishes. On 8/1/11 at 3:54 p.m., the Nursing Home Administrator (NHA), the interim director of nursing (IDON), and the vice president of operations (VPO) (over the telephone) were informed by CDPHE that the facility failure to protect residents from physical, verbal and mental abuse created a situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY 1. Initial plan 8/1/11 On 8/1/11 at 8:30 p.m., the NHA presented a plan to keep the residents safe for the night. This plan documented "alternatives" to the CPI physical maneuvers, such as to first try to redirect the resident, to use as needed medications with a physician order [REDACTED]. At 9:15 p.m., the NHA presented a copy of a planned inservice on interventions to address behaviors in dementia residents. The facility held an inservice on 8/1/11 at 10:10 p.m. to educate the staff on duty of the above plan. The next inservice was scheduled at 5:30 a.m. on 8/2/11. However, on 8/2/11 at 9:42 a.m., staff interviews and observations revealed the 5:30 a.m. scheduled inservice had not been completed. The NHA was interviewed on 8/2/11 at 9:42 a.m. She stated that she had phoned into the facility that morning and informed the charge nurse to put it on the 24 hour report that CPI physical maneuverers were not to be used. The VPO was interviewed by telephone on 8/2/11 at 9:50 a.m. The VPO was informed an inservice to educate the staff on abuse and also on the prohibition of CPI physical maneuvers and IM medications against resident wishes was not completed as planned at 5:30 a.m. The VPO was informed that staff were working the floor without this information. The VPO stated an inservice would be held immediately. The facility's 8/1/11 plan was incomplete; it did not include any behavioral management interventions for residents with mental illness and aggression and did not address the use of antipsychotic medications against residents' wishes. Therefore, the immediate jeopardy was not removed. 2. Additional Plans 8/2/11, 8/4/11 and 8/9/11 The facility's additional proposed plans to remove immediate jeopardy, submitted on 8/2/11 at 8:00 p.m., 8/04/11 at 2:23 p.m. and again on 8/9/11 at approximately 2:00 p.m., also were rejected by CDPHE as incomplete. All of these plans failed to provide victims and witnesses of abuse access to report such abuse to an individual not involved with the facility operations. Therefore, the immediate jeopardy was not removed. 3. Plan 8/10/11 The facility submitted another plan on 8/10/11 at 2:19 p.m. This plan included a timeline of actions taken since the facility was informed of the immediate jeopardy situation on 8/1/11. The plan read: Upon notification of concerns regarding failure to adequately investigate complaints of abuse the facility regional vice president (RVP), the vice president (VP) of Business Development and the vice president human resource (VP HR) Director began to complete re-investigations of all alleged reported allegations of abuse. The identified staff members involved in the allegations were placed on suspension pending an internal investigation. An allegation of physical abuse was made against the NHA. The NHA was placed on suspension and was subsequently terminated and reported to the NHA licensing board. An allegation of sexual assault was made; the facility completed a re-investigation of this allegation on 8/8/2011 and (it) was unsubstantiated. A Licensed Professional Counselor who held the position at the facility as a Behavioral Health Director was placed on suspension pending investigation and was subsequently terminated and reported to the licensing board. Two certified nursing assistants were suspended, terminated and reported to the nursing board. All of these incidents were reported on the Colorado Occurrence Web Portal per guidelines. The facility completed resident interviews on 8/4/11 to rule out any other potential allegations of abuse. Some residents reported during these interviews of reports fear or being afraid. The facility re-interviewed these residents on 8/8/11 to further probe whether or not these reports were actual reportable incidents. None of these reported allegations of fear or being afraid could be substantiated as verbal/physical/neglect per state operating guidelines. The facility completed staff interviews on 8/4, 8/5, 8/6 and & 8/7 to rule out potential knowledge of any type of abusive situations current in the facility. These interviews substantiated alleged allegations of abuse as outlined above. The facility modified the Abuse Policy and Procedure on 8/4/11. The facility staff received re-education and training on this policy and procedure on 8/4/11 through 8/8/11. The abuse policy was modified on 8/10/2011 with the addition of a 1-888 phone number. Additionally, all facility team members were trained on the abuse policy on 8/10/2011. The facility failed to thoroughly investigate injuries of unknown origin. The facility completed re-education and training with facility staff on the Policy and Procedure for investigating Bruises and Skin Tears of Unknown Origin. Two residents reported allegation of potential abuse (#28 and #16) to Social Services Director - the investigation was not complete at the time of initial report made to Social Service Director. The facility completed re investigations of the allegations of potential abuse with both of the identified residents. The VP of Business Development for company and facility Nurse Consultant provided re-education and training on abuse allegation investigations with the social services director on 8/8/2011. On 8/8/11, the Social Service Director also received verbal counseling on failure to follow facility Abuse policy and procedure from the VP Business Development and Nurse Consultant. The facility adopted a new Behavior Management policy and procedure, Problematic Behavior Management - Clinical Protocol, which identifies methods of managing residents with challenging behaviors. On 8/8/11, staff received training and education on the new Behavior Management policy and procedure as well as the facility's expectation regarding avoiding physical intervention and or use of intramuscular (IM) psychoactive medications without a residents consent. Additional training is being completed on 8/9/11 for all current employees. All new employees going forward will be trained as part of their new hire orientation on both Resident Abuse Behavioral Management policy and procedure. No employee will be allowed to start working until this training is completed and acknowledged by the employee. All employees at corporate will also be trained on the resident Abuse Policy and will sign an acknowledgement indicating completion of the training. The facility has reassessed five residents identified to potentially require a specific behavior management plan/alternative placement. One resident (#20) was assessed by the Medical Director on 8/8/11 to potentially benefit from a transfer to another facility that specializes in Behavioral Health issues. The Social Services Director has placed calls to other behavioral facilities to seek alternative placement. The facility revised Abuse Policy and Procedure on 8/4/11 to include clearly defining what constitutes abuse and who to notify if abuse is suspected. The facility has implemented a company local "hotline" number to report suspected abuse. The VP of Business Development will be responsible to follow up on all potential allegations of abuse until an Executive Director is retained. This will be accomplished by 24 hour accessible via facility visits and telephonically. Additionally, the facility is going to initiate a Toll Free number for residents, families and staff to use to report potential allegations of abuse. The facility will contract with outside Management Company. A letter of intent has been signed and further detail to be determined as they visit the facility, deficiencies are determined and a full scope of the work will be finalized to include education, training, oversight and monitoring. Outside management representative/s will be at facility on Monday, August 15, to do a tour, meet the team and the Interim Administrator. An Interim Administrator has been offered and accepted the position on an interim basis for 30 days and on a renewal basis as needed until such time that the facility recruits and hires a permanent Administrator and then ongoing until substantial compliance is achieved with state and federal regulatory requirements. C. REMOVAL OF IMMEDIATE JEOPARDY On 8/10/11 at 4:32 p.m., the interim NHA and consultant were informed that the facility's 8/10/11 plan to remove immediate jeopardy was accepted. The immediate jeopardy was removed at 4:32 p.m. However, record review and interviews revealed deficient practice remained at a G (actual harm) level. II. FACILITY POLICIES, PROCEDURES IN EFFECT PRIOR TO IMMEDIATE JEOPARDY A. Review of the undated policy "Abuse Investigations" revealed the following (in pertinent part): "Policy Statement: All reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation: 1. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator (NHA), or his/her designee, will appoint a member of management to investigate the alleged incident. The NHA will provide to the person in charge of the investigation a completed copy of the "Resident Abuse Report Form" and any supporting documents relative to the alleged incident. 3. The individual conducting the investigation will, as a minimum: a. Review the completed Resident Abuse Report Form; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's attending physician to determine the resident's current mental status; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview the other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location; b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process; and c. Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected (e.g., representation by legal counsel). 5. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the "Abuse Investigation Report Form.") 6. The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the investigation process. 7. Should the ombudsman decline the invitation to participate in the investigation, a notation of such data will be entered into the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 8. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the NHA. Policies governing visitation are outlined in a separate policy in this section entitled "Visitation." B. Review of the undated "Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures" revealed the following: "Policy Statement: The NHA assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation: 1. The NHA has the overall responsibility for the coordination and implementation or our facility's abuse prevention program policies and procedures. 2. The NHA has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility. These may include: a. The Director of Nursing Service (DNS); b. The Social Services Director (SSD); c. The assistant Director of Nurses(ADNS); the UR/QAA Committee; and e. Other staff members as determined by the administrator." C. Review of the undated policy "Reporting Abuse to Facility Management" revealed (in pertinent part): "1. Our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. Employees, facility consultants and/or attending physicians must report any suspected abuse or incidents of abuse to the DNS promptly. In the absence of the DNS such reports may be made to the nurse supervisor on duty. 3. The NHA and the DNS must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the NHA and DNS must be called at home or must be paged and informed of such incident. 4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator (NHA), or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law Enforcement Officials; f. The Resident's Attending Physician; and g. The Facility Medical Director. 5. Notices to the above agencies/individuals may be submitted via US mail, special carrier, fax, e-mail, or by telephone. such notices will include, as a minimum: a. The name of the resident; b. The number of the room in which the resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred; e. The names of all persons involved in the alleged incident; and f. What immediate action was taken by the facility. 6. All personnel, residents, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 9. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. 11. A completed copy of the "Resident Abuse Report Form: and written statements from witnesses, if any, must be provided to the administrator within 48 hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator within 3 working days of the occurrence of such incident. When an incident of resident abuse is suspected or determined, such incident must be reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. 17. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense SHALL report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. 18. A person shall not knowingly-- a. Attempt, with or without threats or promises of benefit, to induce another to fail to report an incident of mistreatment or other offense; b. Fail to report an incident of mistreatment or other offense; c. Alter, change without authorization, destroy or render unavailable a report made by another; and/or d. Screen reports or withhold information to reporting agencies." III. INCIDENTS OF RESIDENT ABUSE A. VERBAL AND PHYSICAL ABUSE 1. Resident #75 Resident #75, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was at the facility for 11 days, sent to the hospital emergency roiagnom on [DATE], on a mental health hold and discharged that day. The resident did not return to the facility and was unavailable for interviews. a. Resident Status on Admission The resident did not have an admission Minimum Data Set (MDS) due to her short stay in the facility. However, the facility's admission assessment, dated 7/7/11, indicated the resident was alert, agitated, walked independently, had a history of [REDACTED]. The assessment read that the resident was not on [MEDICAL CONDITION] medications. However, review of the resident's orders revealed the medication orders on admission included: -[MEDICATION NAME] 600 mg, orally at 9 a.m. and at 6 p.m. for mood -Klonopin 0.5 mg, orally one at H.S. and one as needed for [MEDICAL CONDITION] -Trazadone 50 mg, orally at 9 a.m. and at 1 p.m. for anxiety -Trazadone 100 mg, orally at 3 p.m. and at 9 p.m. for anxiety -[MEDICATION NAME] 400 mg, orally at 9 p.m. 1 p.m. and at 6 p.m. for intermittent [MEDICAL CONDITION] -[MEDICATION NAME] 600 mg and Trazadone 50 mg take together orally every three hours as needed for anxiety -[MEDICATION NAME] 1 mg orally as needed not to exceed three doses in 24 hours if [MEDICATION NAME] and Trazadone are ineffective The admission care plan, dated 7/7/11, included cognitive loss (approaches listed were to approach in a calm manner, explain actions when providing care and anticipate the resident's needs and observe for non-verbal cues), needed assistance of staff with all activities of daily living except with ambulation or transfer, had her own teeth that were in poor condition, was on a regular diet, "ate a lot," and wore a device for wandering. A behavioral care plan was required by the Division for Developmental Disabilities (DDM) before the resident was to be admitted to this facility. It included three problems to be addressed by the facility. These were: (1) PROBLEM #1 - The resident has aggressive behaviors including pinching, biting, grabbing, and pulling hair. The facility listed goals with an intervention for each goal. These were: -Goal #1- The resident would be with other residents, but not within reach to harm them in any way. The intervention listed was the resident would remain a safe distance from other residents at all times, including meals. This distance should be outside her reach, but not far enough to be isolated. -Goal #2- The resident will receive all the cares and services she needs and wants, but will be unable to harm staff. The intervention listed was that staff would maintain a vigilant position when providing cares, handing her things, and at all times when the resident is nearby to maintain her safety. -Goal #3 - All staff will be alerted to the resident's possible behaviors, maintain visual contact so that all persons in the resident's direct reach/vicinity will remain safe. The intervention listed was that staff will redirect the resident, give her activities, provide other objects to give her something to do, keep her calm, and keep staff/others safe. (2) PROBLEM #2 - The resident has aggressive behaviors stemming from an unknown stimulus. -Goal #1 - The facility's goal was that the staff will be able to determine causes and remove them from the resident's area, treatment, etc. to reduce behaviors. The intervention listed was that staff would observe the resident to determine causes of behaviors, find solutions, that diminished/not cause further behaviors. -Goal #2 - The resident's medications will be efficacious in treating her symptoms, but not cause adverse symptoms. The intervention listed was the resident will receive their medications as prescribed or(by) her psychiatrist and medical doctors. These medications and their effects will be documented to determine efficacy and any changes needed. (3) PROBLEM #3 - DDM is concerned that (name of facility) may not be able to handle the resident's care. -Goal #1 - All of the resident's cares will be met. The intervention related to this read, "(name of facility) is the only long term care facility (LTCF) with a State Approved Behavioral Health Department with a Licensed, PhD BH director on staff." -Goal #2 - The resident's cares will be provided and her needs met. The intervention listed was that if the resident needed a medications/behavioral review, the facility would work in [MEDICATION NAME] with (name of discharging behavioral health facility) and follow their recommendations related to her medications, care, and needs.) -Goal #3 - The resident will be handled with care by professionals trained to manage any behavior. The intervention listed for this was that the facility had a State Approved Crisis Intervention program to manage difficult behaviors including takedowns. -Goal #4 - The resident will receive the care she requires for her specific needs either by (the name of the facility) or a more appropriate facility, if necessary. The intervention listed was that if for any reason the resident's care/behaviors cannot be managed by (the name of the facility), the Social Service Department will find appropriate placement in another facility. (An incorrect name of the resident) will only be discharged under "safe conditions." Further medical record review revealed (social service notes and the resident's 6/23/11 Pre-admission Screening and Resident Review (PASRR) Psychiatric Evaluation faxed to the facility on [DATE], six days after being admitted to the facility) revealed: -The resident perseverates on food and does not know when she is full. -The resident had exhibited mood instability, aggressive behavior, agitation and self neglect, communicated mostly in one-word answers, orientated only to person, had perseverative and concrete thought processes, an anxious mood and no overt [MEDICAL CONDITION] and would need constant monitoring. -The resident had been compliant with medications. -Recommended precautions were "one to one observation, frequent redirection, reassurance, offering food and drink often, and pain monitoring." -Recommended interventions were verbal redirection, decrease in environmental stimuli, time out in the room, scheduled in education, PRN (as needed) medications, and one to one observation. Interventions that have been used include: verbal redirection, decrease in environmental stimuli, timeout in room, scheduled educations, PRN medications, 1:1 observation. b. Incident of Verbal and Physical Abuse 7/18/11 On 7/20/11, staff #49 was interviewed at 8:30 a.m. and at 10:15 a.m. Staff #49 was interviewed again on 7/26/11 at 8:30 a.m. -He stated that on 7/18/11, he had returned from lunch and was by the housekeeping closet in the front lobby and saw the interactions between the NHA and resident #75. The staff member went on to say that resident #75 was yelling over and over that she was hungry and she was trying to go in the NHA's office. The NHA was observed to "yell" loudly at the resident that she could not be hungry, that she had breakfast and had just finished lunch. The NHA was also heard to tell the resident that she knew what she was doing. The NHA was then observed to forcefully escort the resident out of her office and hand her over to the restorative certified nurse aide (CNA). He commented that the NHA spoke to the resident in a condescending, sarcastic tone. -He stated he had reported the events to his supervisor when he left work for the day. On 7/20/11 at 10:39 a.m. and again on 8/1/11 at approximately 11:15 a.m.. staff #47, a restorative CNA (RCNA) was interviewed. -Staff #47 stated she heard a commotion in the front lobby on 7/18/11 around 12:00 p.m. The staff member stated that as she came around the corner of the hallway into the lobby, she saw the resident come out of the NHA's office with a box of chocolate mints. The NHA was observed going after the resident, trying to retrieve the box of candy. -Staff #47 stated the box of candy was pretty torn up when the resident was handed over to her (by the NHA) to take the resident to her room. She stated she overheard the NHA state, "We need to stop treating her (like) she doesn't know what she is doing. She knows what she is doing." She, too, said the NHA spoke to the resident in a condescending, sarcastic tone. -Staff #47, in the interview on 8/1/11 (see above) stated the resident was observed to have fresh red scratch-like marks on her arms. -Staff #47 said she did not report the incident because it involved the NHA and she was fearful of losing her job. On 7/26/11 at approximately 4:30 p.m., CNA #7 handed her home phone number to a surveyor and stated she was scared of losing her job by talking with the surveyor, however, she had important information she wanted to share regarding resident #75. CNA #7 was interviewed on 8/8/11 at 5:40 p.m. -The CNA stated that she was in the facility near the reception desk during the incident on 7/18/11 between resident #75 and the NHA. -The CNA stated that she observed the NHA chasing the resident with a manilla folder while waving it at the resident to get the resident out of the office. -The CNA said the NHA screamed at the resident, "You know what you are doing!" She stated the NHA was observed to grab a hold of the resident's arm with a strong grip and physically walked her toward the doorway to the unit. A family member of another resident, who witnessed the events on 7/18/11 as he was leaving the facility, was interviewed on 7/20/11 at 11:02 a.m. and again on 7/28/11 at 11:15 a.m. -He stated he was familiar with resident #75 for she had been at another facility where his wife had previously resided. He stated resident #75 was trying to get into the NHA's office; there were boxes under her desk or around there on the floor. The NHA kept telling the resident she couldn't come in there, but the resident went in. -He stated resident #75 kicked open a box and retrieved something that looked like a box of candy. He then heard the NHA "yell out loudly for help stat." The family member stated he remembered the NHA took the resident by the arm and removed her from her office when the resident wouldn't leave. He said he overheard the NHA tell the resident, "She was getting rid of her. She couldn't stay here." The NHA was interviewed on 7/27/11 at 11:35 a.m. -She stated that she was unable to remember the correct date of the incident involving resident #75, however, she recalled that resident #75 was "out of control," stating that the resident "charged into the office and tore open the candy." She stated that she had been instructed by the speech therapist to not give resident #75 any food, as she was eating out of behavior and not hunger. She stated that she tried to get the junior mints candy away from the resident and that she was able to get one M & M away from her. -She further stated that the resident "knew what she was doing." She stated that there were two other staff members present. She stated that she would never abuse anyone. The NHA stated that she and the behavioral health director (BHD) were the only ones that the resident would not "attack." c. Facility Response to 7/18/11 Incident None of the staff that witnessed the incident on 7/18/11 reported it to facility administration. The incident was not investigated and no interventions to prevent further verbal and physical abuse between resident #75 and the NHA were initiated. d. Actions Taken During Survey (1) On 7/26//11 at 4:38 p.m., the corporate Vice President of Operations (VPO) was informed in person of the allegations of verbal and physical abuse by the NHA towards resident #75 and told that the staff members that witnessed the allegations were fearful of the NHA and in losing their employment and did not want to be named in their initial interviews. The VPO replied that she would talk to the NHA about the allegation and let her respond. "This was only fair to her." The VPO also stated that she did not want to put the NHA on a plan of action at this time. She stated that the NHA was sometimes loud and hasty to say or do things. There was no discussion about suspending the NHA while the investigation was being completed. On 7/27/11 at 4:51 p.m., the VPO stated she had visited with the NHA about the incident on 7/18/11. -The VPO stated she was present at the facility on 7/13/11 and 7/14/11, and witnessed an event that had occurred in the lobby with resident #75. At that time, the resident kept alarming the front door. She went on to say that the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the receptionist, and others were present and also witnessed this event. She said during those incidents, the NHA had visited with the resident in her office and was not observed to be verbally or physically abusive. -The VPO said the facility's "nitch" was the Behavioral Management Program and that was this current NHA's 'forte.' She said that with Behavioral Management Specialist, who had a PHD, they worked well together. -The VPO stated she was still conducting interviews with the managing staff about the 7/18/11 incident. However, there was no verbal dialogue that she intended to interview any direct care staff, just administrative staff (NHA, IDON, ADON, Dietary Manager, (DM), Medical Records, Activities Manager, Social Service director (SSD), Business Office Manager, MDS Coordinator, and the Housekeeping Manager). (2) On 7/28/11 beginning at 4:10 p.m., the medical director was interviewed. -When asked about allegations of abuse and the procedures of investigating abuse, he stated that "Abuse is abuse until proven otherwise." He went on to say no matter whom the allegation was against, whether it be a CNA, a nurse, even the NHA, they should be suspended and then the investigation completed. He continued, stating that the residents should be encouraged to talk freely and not to be retaliated against. -When told of the witne

Based on record review and interviews, the facility failed to ensure incidents of abuse, neglect and injuries of unknown origin involving ten of 54 sample residents (#13, #16, #35, #21, #28, #60, #64, #55, #75, and #20) were thoroughly investigated and that measures were taken to protect residents from further incidents of abuse, neglect and injuries of unknown origin. Cross-reference F223 (abuse) and F226 (abuse policies). The facility's failure created a situation of immediate jeopardy for serious harm. The findings include: I. IMPOSITION OF IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY On 7/18/11, the Colorado Department of Health and Environment (CDPHE) received a complaint of alleged verbal and physical abuse of a resident (resident #75) by a staff member (Nursing Home Administrator/NHA). Interviews beginning on 7/20/11 revealed this event had been witnessed by various staff members and a family member and that the witnesses confirmed the staff member's use of verbally and physically aggressive behavior towards resident #75. Further interviews 7/20/11 through 8/10/11 revealed the 7/18/11 incident of verbal and physical abuse and neglect had not been investigated and no steps had been taken to prevent further staff to resident abuse. Although the corporate Vice President of Operations (VPO) was informed of the witnessed allegations on 7/20/11, the NHA was observed in the facility 8/1/11 and was not suspended until days later. The only staff that had been interviewed at that time were front line staff. No residents were interviewed. Interview and record review further revealed instances of physical abuse through misuse of Crisis Prevention Institute (CPI) maneuvers and antipsychotic medication in addressing residents' aggressive behaviors, as well as injuries of a suspicious nature (due to size or location of injury) and that were of unknown origin were not thoroughly investigated. Finally, review of facility policies revealed victims of abuse lacked access to an authority outside the facility for reporting incidents of potential abuse. On 8/1/11 at 3:54 p.m., the Nursing Home Administrator (NHA), the interim director of nursing (IDON), and the vice president of operations (VPO) (over the telephone) were informed by CDPHE that the facility failure to thoroughly investigate incidents of verbal and physical abuse and suspicious injuries of unknown origin, as well as abuse victims lack of access to an outside authority to report abuse, created a situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY 1. Initial Plan 8/1/11 On 8/1/11 at 8:30 p.m., the NHA presented a plan to keep the residents safe for the night from staff abuse in managing residents' aggressive behaviors. This plan documented "alternatives" to the CPI physical maneuvers, such as to first try to redirect the resident, to use as needed medications with a physician order [REDACTED]. At 9:15 p.m., the NHA presented a copy of a planned inservice on interventions to address behaviors in dementia residents. The facility held an inservice, on 8/1/11 at 10:10 p.m., to educate the staff on duty of the above plan. The next inservice was scheduled at 5:30 a.m. on 8/2/11. However on 8/2/11 at 9:42 a.m., staff interviews and observations revealed the 5:30 a.m. scheduled inservice had not been completed. The NHA was interviewed, on 8/2/11 at 9:42 a.m. She stated that she had phoned into the facility that morning and informed the charge nurse to put it on the 24 hour report that CPI physical maneuverers were not to be used. The VPO was interviewed by telephone on 8/2/11 at 9:50 a.m. The VPO was informed an inservice to educate the staff on abuse and also on the prohibition of CPI physical maneuvers and IM medications against resident wishes was not completed as planned at 5:30 a.m. The VPO was informed that staff were working the floor without this information. The VPO stated an inservice would be held immediately. The facility's 8/1/11 plan was incomplete; it did not include any behavioral management interventions for residents with mental illness and aggression and did not address the use of antipsychotic medications against residents' wishes. Therefore, the immediate jeopardy was not removed. 2. Additional Plans 8/2/11, 8/4/11 and 8/9/11 The facility's additional proposed plans to remove immediate jeopardy, submitted on 8/2/11 at 8:00 p.m., 8/04/11 at 2:23 p.m. and again on 8/9/11 at approximately 2:00 p.m., also were rejected by CDPHE as incomplete. All of these plans failed to provide victims and witnesses of abuse access to report such abuse to an individual not involved with the facility operations. Therefore, the immediate jeopardy was not removed. 3. Plan 8/10/11 The facility submitted another plan on 8/10/11 at 2:19 p.m. This plan included a timeline of actions taken since the facility was informed of the immediate jeopardy situation on 8/1/11. The plan read: Upon notification of concerns regarding failure to adequately investigate complaints of abuse the facility regional vice president (RVP), the vice president (VP) of Business Development and the vice president human resource (VP HR) Director began to complete re investigations of all alleged reported allegations of abuse. The identified staff members involved in the allegations were placed on suspension pending an internal investigation. An allegation of physical abuse was made against the NHA. The NHA was placed on suspension and was subsequently terminated and reported to the NHA licensing board. An allegation of sexual assault was made; the facility completed a re- investigation of this allegation on 8/8/2011 and (it) was unsubstantiated. A Licensed Professional Counselor who held the position at the facility as a Behavioral Health Director was placed on suspension pending investigation and was subsequently terminated and reported to the licensing board. Two certified nursing assistants were suspended, terminated and reported to the nursing board. All of these incidents were reported on the Colorado Occurrence Web Portal per guidelines. The facility completed resident interviews on 8/4/11 to rule out any other potential allegations of abuse. Some residents reported during these interviews of reports fear or being afraid. The facility re interviewed these residents on 8/8/11 to further probe whether or not these reports were actual reportable incidents. None of these reported allegations of fear or being afraid could be substantiated as verbal / physical / neglect per state operating guidelines. The facility completed staff interviews on 8/4, 8/5, 8/6 and & 8/7 to rule out potential knowledge of any type of abusive situations current in the facility. These interviews substantiated alleged allegations of abuse as outlined above. The facility modified the Abuse Policy and Procedure on 8/4/11. The facility staff received re-education and training on this policy and procedure on 8/4/11 through 8/8/11. The abuse policy was modified on 8/10/2011 with the addition of a 1-888 phone number. Additionally, all facility team members were trained on the abuse policy on 8/10/2011. The facility failed to thoroughly investigate injuries of unknown origin. The facility completed re- education and training with facility staff on the Policy and Procedure for investigating Bruises and Skin Tears of Unknown Origin. Two residents reported allegation of potential abuse (#28 and #16) to Social Services Director - the investigation was not complete at the time of initial report made to Social Service Director. The facility completed re investigations of the allegations of potential abuse with both of the identified residents. The VP of Business Development for company and facility Nurse Consultant provided re education and training on abuse allegation investigations with the social services director on 8/8/2011. On 8/8/11 the Social Service Director also received verbal counseling on failure to follow facility Abuse policy and procedure from the VP Business Development and Nurse Consultant. The facility adopted a new Behavior Management policy and procedure, Problematic Behavior Management - Clinical Protocol, which identifies methods of managing residents with challenging behaviors. On 8/8/11 staff received training and education on the new Behavior Management policy and procedure as well as the facility's expectation regarding avoiding physical intervention and or use of intramuscular (IM) psychoactive medications without a residents consent. Additional training is being completed on 8/9/11 for all current employees. All new employees going forward will be trained as part of their new hire orientation on both Resident Abuse Behavioral Management policy and procedure. No employee will be allowed to start working until this training is completed and acknowledged by the employee. All employees at corporate will also be trained on the resident Abuse Policy and will sign an acknowledgement indicating completion of the training. The facility has reassessed five residents identified to potentially require a specific behavior management plan/alternative placement. One resident (#20) was assessed by the Medical Director on 8/8/11 to potentially benefit from a transfer to another facility that specializes in Behavioral Health issues. The Social Services Director has placed calls to other behavioral facilities to seek alternative placement. The facility revised Abuse Policy and Procedure on 8/4/11 to include clearly defining what constitutes abuse and who to notify if abuse is suspected. The facility has implemented a company local "hotline" number to report suspected abuse. The VP of Business Development will be responsible to follow up on all potential allegations of abuse until an Executive Director is retained. This will be accomplished by 24 hour accessible via facility visits and telephonically. Additionally, the facility is going to initiate a Toll Free number for residents, families and staff to use to report potential allegations of abuse. The facility will contract with outside Management Company. A letter of intent has been signed and further detail to be determined as they visit the facility, Deficiencies are determined and a full scope of the work will be finalized to include education, training, oversight and monitoring. Outside management representative/s will be at facility on Monday August 15, to do a tour, meet the team and the Interim Administrator. An Interim Administrator has been offered and accepted the position on an interim basis for 30 days and on a renewal basis as needed until such time that the facility recruits and hires a permanent Administrator and then ongoing until substantial compliance is achieved with state and federal regulatory requirements. C. REMOVAL OF IMMEDIATE JEOPARDY On 8/10/11 at 4:32 p.m., the interim NHA and consultant were informed that the facility's 8/10/11 plan to remove immediate jeopardy was accepted. The immediate jeopardy was removed at 4:32 p.m. However, record review and interviews revealed deficient practice remained at an E level (pattern with the potential for more than minimal harm). II. FACILITY POLICIES, PROCEDURES IN EFFECT PRIOR TO IMMEDIATE JEOPARDY A. Review of the undated policy "Abuse Investigations" revealed the following (in pertinent part): "Policy Statement: All reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation: 1. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator (NHA), or his/her designee, will appoint a member of management to investigate the alleged incident. The NHA will provide to the person in charge of the investigation a completed copy of the "Resident Abuse Report Form" and any supporting documents relative to the alleged incident. 2. The individual conducting the investigation will, as a minimum: a. Review the completed Resident Abuse Report Form; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's attending physician to determine the resident's current mental status; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview the other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 3. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location; b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process; and c. Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected (e.g., representation by legal counsel). 4. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the "Abuse Investigation Report Form.") 5. The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the investigation process. 6. Should the ombudsman decline the invitation to participate in the investigation, a notation of such data will be entered into the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 7. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the NHA. Policies governing visitation are outlined in a separate policy in this section entitled "Visitation." B. Review of the undated "Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures" revealed the following: "Policy Statement: The NHA assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation: 1. The NHA has the overall responsibility for the coordination and implementation or our facility's abuse prevention program policies and procedures. 2. The NHA has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility. These may include: a. The Director of Nursing Service (DNS); b. The Social Services Director (SSD); c. The assistant Director of Nurses(ADNS); d. the UR/QAA Committee; and e. Other staff members as determined by the administrator." C. Review of the undated policy "Reporting Abuse to Facility Management" revealed (in pertinent part): "1. Our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. Employees, facility consultants and/or attending physicians must report any suspected abuse or incidents of abuse to the DNS promptly. In the absence of the DNS such reports may be made to the nurse supervisor on duty. 3. The NHA and the DNS must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the NHA and DNS must be called at home or must be paged and informed of such incident. 4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator (NHA), or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law Enforcement Officials; f. The Resident's Attending Physician; and g. The Facility Medical Director. 5. Notices to the above agencies/individuals may be submitted via US mail, special carrier, fax, e-mail, or by telephone. such notices will include, as a minimum: a. The name of the resident; b. The number of the room in which the resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred; e. The names of all persons involved in the alleged incident; and f. What immediate action was taken by the facility. 6. All personnel, residents, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 9. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. 11. A completed copy of the "Resident Abuse Report Form: and written statements from witnesses, if any, must be provided to the administrator within 48 hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator within 3 working days of the occurrence of such incident. When an incident of resident abuse is suspected or determined, such incident must be reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. 17. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense SHALL report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. 18. A person shall not knowingly-- a. Attempt, with or without threats or promises of benefit, to induce another to fail to report an incident of mistreatment or other offense; b. Fail to report an incident of mistreatment or other offense; c. Alter, change without authorization, destroy or render unavailable a report made by another; and/or d. Screen reports or withhold information to reporting agencies." III. FAILURE TO THOROUGHLY INVESTIGATE INCIDENTS OF WITNESSED AND OR REPORTED RESIDENT ABUSE AND/OR NEGLECT OR INJURIES OF UNKNOWN ORIGIN A. ABUSE AND NEGLECT 1. Resident #75 Resident #75, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was at the facility for 11 days, sent to the hospital emergency roiagnom on [DATE] on a mental health hold and discharged that day. The resident did not return to the facility and was unavailable for interviews. a. Resident Status on Admission The resident did not have an admission Minimum Data Set (MDS) due to her short stay in the facility. However, the facility's admission assessment dated [DATE], indicated the resident was alert, agitated, walked independently, had a history of [REDACTED]. The assessment read that the resident was not on [MEDICAL CONDITION] medications. However, review of the resident's orders revealed the medication orders on admission included: -[MEDICATION NAME] 600 mg. orally at 9 a.m. and at 6 p.m. for mood. -Klonopin 0.5 mg. orally one at H.S and one as needed for [MEDICAL CONDITION]. -Trazadone 50 mg. orally at 9 a.m. and at 1 p.m. for anxiety. -Trazadone 100 mg. orally at 3 p.m. and at 9 p.m. for anxiety. -[MEDICATION NAME] 400 mg orally at 9 p.m. 1 p.m. and at 6 p.m. for intermittent [MEDICAL CONDITION]. -[MEDICATION NAME] 600 mg and Trazadone 50 mg take together orally every three hours as needed for anxiety. -[MEDICATION NAME] 1 mg orally as needed not to exceed 3 doses in 24 hours if [MEDICATION NAME] and Trazadone are ineffective. The admission care plan dated 7/7/11, included cognitive loss (approaches listed were to approach in a calm manner, explain actions when providing care and anticipate the resident's needs and observe for non-verbal cues), needed assistance of staff with all activities of daily living except with ambulation or transfer, had her own teeth that were in poor condition, was on a regular diet, "ate a lot," and wore a device for wandering. A behavioral care plan was required by the Division for Developmental Disabilities (DDM) before the resident was to be admitted to this facility. It included three problems to be addressed by the facility. These were: (1) PROBLEM #1 - The resident has aggressive behaviors including pinching, biting, grabbing, and pulling hair. The facility listed goals with an intervention for each goal. These were: -Goal #1- The resident would be with other residents, but not within reach to harm them in any way. The intervention listed was the resident would remain a safe distance from other residents at all times, including meals. This distance should be outside her reach, but not far enough to be isolated. -Goal #2- The resident will receive all the cares and services she needs and wants, but will be unable to harm staff. The intervention listed was that staff would maintain a vigilant position when providing cares, handing her things, and at all times when the resident is nearby to maintain her safety. -Goal #3- All staff will be alerted to the resident's possible behaviors, maintain visual contact so that all persons in the resident's direct reach/vicinity will remain safe. The intervention listed was that staff will redirect the resident, give her activities, provide other objects to give her something to do, keep her calm, and keep staff/others safe. (2) PROBLEM #2 - The resident has aggressive behaviors stemming from an unknown stimulus. -Goal #1- The facility's goal was that the staff will be able to determine causes and remove them from the resident's area, treatment, etc. to reduce behaviors. The intervention listed was that staff would observe the resident to determine causes of behaviors, find solutions, that diminished/not cause further behaviors. -Goal #2- The resident's medications will be efficacious in treating her symptoms, but not cause adverse symptoms. The intervention listed was the resident will receive their medications as prescribed by her psychiatrist and medical doctors. These medications and their effects will be documented to determine efficacy and any changes needed. (3) PROBLEM #3 - DDM is concerned that (name of facility) may not be able to handle the resident's care. -Goal #1- All of the resident's cares will be met. The intervention related to this read, "(name of facility) is the only long term care facility (LTCF) with a State Approved Behavioral Health Department with a Licensed, PhD BH director on staff." -Goal #2- The resident's cares will be provided and her needs met. The intervention listed was that if the resident needed a medications/behavioral review, the facility would work in [MEDICATION NAME] with (name of discharging behavioral health facility) and follow their recommendations related to her medications, care, and needs.) -Goal #3- The resident will be handled with care by professionals trained to manage any behavior. The intervention listed for this was that the facility had a State Approved Crisis Intervention program to manage difficult behaviors including takedowns. -Goal #4- The resident will receive the care she requires for her specific needs either by (the name of the facility) or a more appropriate facility, if necessary. The intervention listed was that if for any reason the resident's care/behaviors cannot be managed by (the name of the facility), the Social Service Department will find appropriate placement in another facility. (An incorrect name of the resident) will only be discharged under "safe conditions." Further medical record review revealed (social service notes and the resident's 6/23/11 Preadmission Screening and Resident Review (PASRR) Psychiatric Evaluation faxed to the facility on [DATE], six days after being admitted to the facility) revealed: -The resident perseverates on food and does not know when she is full. -The resident had exhibited mood instability, aggressive behavior, agitation and self neglect, communicated mostly in one-word answers, orientated only to person, had perseverative and concrete thought processes, an anxious mood and no overt [MEDICAL CONDITION] and would need constant monitoring. -The resident had been compliant with medications. -Recommended precautions were "one to one observation, frequent redirection, reassurance, offering food and drink often, and pain monitoring. -Recommended interventions were verbal redirection, decrease in environmental stimuli, time out in the room, scheduled in education, PRN (as needed) medications, and one to one observation. Interventions that have been used include: verbal redirection, decrease in environmental stimuli, timeout in room, scheduled educations, PRN medications, 1:1 observation. b. Incident of Verbal and Physical Abuse 7/18/11 On 7/20/11 staff #49 was interviewed at 8:30 a.m. and at 10:15 a.m. Staff #49 was interviewed again on 7/26/11 at 8:30 a.m. -He stated that on 7/18/11, he had returned from lunch and was by the housekeeping closet in the front lobby and saw the interactions between the NHA and resident #75. The staff member went on to say that resident #75 was yelling over and over that she was hungry and she was trying to go in the NHA's office. The NHA was observed to "yell" loudly at the resident that she could not be hungry, that she had breakfast and had just finished lunch. The NHA was also heard to tell the resident that she knew what she was doing. The NHA was then observed to forcefully escort the resident out of her office and hand her over to the restorative certified nurse aide (CNA). He commented that the NHA spoke to the resident in a condescending, sarcastic tone. -He stated he had reported the events to his supervisor when he left work for the day. On 7/20/11 at 10:39 a.m. and again on 8/1/11 at approximately 11:15 a.m. staff #47, a restorative CNA (RCNA) was interviewed. -Staff #47 stated she heard a commotion in the front lobby on 7/18/11 around 12:00 p.m. The staff member stated that as she came around the corner of the hallway into the lobby, she saw the resident come out of the NHA's office with a box of chocolate mints. The NHA was observed going after the resident, trying to retrieve the box of candy. -Staff #47 stated the box of candy was pretty torn up when the resident was handed over to her (by the NHA) to take the resident to her room. She stated she overheard the NHA state, "We need to stop treating her (like) she doesn't know what she is doing. She knows what she is doing." She, too, said the NHA spoke to the resident in a condescending, sarcastic tone. -Staff #47, in the interview on 8/1/11 (see above) stated the resident was observed to have fresh red scratch-like marks on her arms. -Staff #47 said she did not report the incident because it involved the NHA and she was fearful of losing her job. On 7/26/11 at approximately 4:30 p.m., CNA #7 handed her home phone number to a surveyor and stated she was scared of losing her job by talking with the surveyor, however, she had important information she wanted to share regarding resident #75. CNA #7 was interviewed on 8/8/11 at 5:40 p.m. -The CNA stated that she was in the facility near the reception desk during the incident on 7/18/11 between resident #75 and the NHA. -The CNA stated that she observed the NHA chasing the resident with a manilla folder while waving it at the resident to get the resident out of the office. -The CNA said the NHA screamed at the resident, "You know what you are doing!" She stated the NHA was observed to grab a hold of the resident's arm with a strong grip and physically walked her toward the doorway to the unit. A family member of another resident, who witnessed the events on 7/18/11 as he was leaving the facility, was interviewed on 7/20/11 at 11:02 a.m. and again on 7/28/11 at 11:15 a.m. -He stated he was familiar with resident #75 for she had been at another facility where his wife had previously resided. He stated resident #75 was trying to get into the NHA's office; there were boxes under her desk or around there on the floor. The NHA kept telling the resident she couldn't come in there, but the resident went in. -He stated resident #75 kicked open a box and retrieved something that looked like a box of candy. He then heard the NHA "yell out loudly for help stat." The family member stated he remembered the NHA took the resident by the arm and removed her from her office when the resident wouldn't leave. He said he overheard the NHA tell the resident, "She was getting rid of her. She couldn't stay here." The NHA was interviewed on 7/27/11 at 11:35 a.m. -She stated that she was unable to remember the correct date of the incident involving resident #75, however, she recalled that resident #75 was "out of control," stating that the resident "charged into the office and tore open the candy." She stated that she had been instructed by the speech therapist to not give resident #75 any food, as she was eating out of behavior and not hunger. She stated that she tried to get the junior mints candy away from the resident and that she was able to get one M & M away from her. -She further stated that the resident "knew what she was doing." She stated that there were two other staff members present. She stated that she would never abuse anyone. The NHA stated that she and the behavioral health director (BHD) were the only ones that the resident would not "attack." c. Facility Response to 7/18/11 Incident None of the staff that witnessed the incident on 7/18/11 reported it to facility administration. The incident was not investigated and no interventions to prevent further verbal and physical abuse between resident #75 and the NHA were initiated. d. Actions Taken During Survey (1) On 7/26/11 at 4:38 p.m. the corporate Vice President of Operations (VPO) was informed in person of the allegations of verbal and physical abuse by the NHA towards resident #75 and told that the staff members that witnessed the allegations were fearful of the NHA and in losing their employment and did not want to be named in their initial interviews. The VPO replied that she would talk to the NHA about the allegation and let her respond. "This was only fair to her." The VPO also stated that she did not want to put the NHA on a plan of action at this time. She stated that the NHA was sometimes loud and hasty to say or do things. There was no discussion about suspending the NHA while the investigation was being completed. On 7/27/11 at 4:51 p.m., the VPO stated she had visited with the NHA about the incident on 7/18/11. -The VPO stated she was present at the facility on 7/13/11 and 7/14/11, and witnessed an event that had occurred in the lobby with resident #75. At that time, the resident kept alarming the front door. She went on to say that the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the receptionist, and others were present and also witnessed this event. She said during those incidents, the NHA had visited with the resident in her office and was not observed to be verbally or physically abusive. -The VPO said the facility's "nitch" was the Behavioral Management Program and that was this current NHA's 'forte.' She said that

Based on record review and staff and resident interview, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Cross-reference F223 (abuse) and F225 (investigation of abuse and protection of residents). The facility's failure created a situation of immediate jeopardy for serious harm. The findings include: I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY On 7/18/11, the Colorado Department of Health and Environment (CDPHE) received a complaint of alleged verbal and physical abuse of a resident (resident #75) by a staff member (Nursing Home Administrator). Interviews beginning on 7/20/11, revealed this event had been witnessed by various staff members and a family member and that the witnesses confirmed the staff member's use of verbally and physically aggressive behavior towards resident #75. Further interviews 7/20/11 through 8/10/11, revealed additional instances of physical and mental abuse by staff, as well as residents' fear of punishment/reprisal. Instances of abuse included the misuse of physical maneuvers associated with the Crisis Prevention Institute (CPI) that are designed to address residents' aggressive behaviors, as well as the use of intramuscular (IM) antipsychotic medication, at times without physician order [REDACTED]. -Record review and interviews, revealed the facility failed to ensure staff were adequately screened prior to hire, adequately trained in CPI maneuvers, and adequately educated to identify the potential of abuse with CPI maneuvers and medication administration against resident wishes. -Review of facility policies on abuse, neglect, injuries of unknown origin and misappropriation of property, revealed the policies did not offer victims of such treatment access to report abuse and/or neglect to an individual not involved with the facility operations. Staff and residents feared reprisal if attempts were made to report abuse. -Record review and interviews, revealed facility policies designed to protect residents from further abuse were not consistently implemented. On 8/1/11 at 3:54 p.m., the Nursing Home Administrator (NHA), the interim director of nursing (IDON), and the vice president of operations (VPO) (over the telephone) were informed by CDPHE that the facility failure to have and to operationalize abuse policies to protect residents from physical, verbal and mental abuse created a situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY 1. Initial plan 8/1/11 On 8/1/11 at 8:30 p.m., the NHA presented a plan to keep the residents safe for the night. This plan documented "alternatives" to the CPI physical maneuvers, such as to first try to redirect the resident, to use as needed medications with a physician order [REDACTED]. At 9:15 p.m., the NHA presented a copy of a planned inservice on interventions to address behaviors in dementia residents. The facility held an inservice on 8/1/11 at 10:10 p.m., to educate the staff on duty of the above plan. The next inservice was scheduled at 5:30 a.m. on 8/2/11. However, on 8/2/11 at 9:42 a.m., staff interviews and observations, revealed the 5:30 a.m. scheduled inservice had not been completed. The NHA was interviewed on 8/2/11 at 9:42 a.m. She stated that she had phoned into the facility that morning and informed the charge nurse to put it on the 24 hour report that CPI physical maneuverers were not to be used. The VPO was interviewed by telephone on 8/2/11 at 9:50 a.m. The VPO was informed an inservice to educate the staff on abuse and also on the prohibition of CPI physical maneuvers and IM medications against resident wishes was not completed as planned at 5:30 a.m. The VPO was informed that staff were working the floor without this information. The VPO stated an inservice would be held immediately. The facility's 8/1/11 plan was incomplete; it did not include any behavioral management interventions for residents with mental illness and aggression and did not address the use of antipsychotic medications against residents' wishes. Therefore, the immediate jeopardy was not removed. 2. Additional Plans 8/2/11, 8/4/11 and 8/9/11 The facility's additional proposed plans to remove immediate jeopardy, submitted on 8/2/11 at 8:00 p.m., 8/04/11 at 2:23 p.m. and again on 8/9/11 at approximately 2:00 p.m., also were rejected by CDPHE as incomplete. All of these plans failed to provide victims and witnesses of abuse access to report such abuse to an individual not involved with the facility operations. Therefore, the immediate jeopardy was not removed. 3. Plan 8/10/11 The facility submitted another plan on 8/10/11 at 2:19 p.m. This plan included a timeline of actions taken since the facility was informed of the immediate jeopardy situation on 8/1/11. The plan read: Upon notification of concerns regarding failure to adequately investigate complaints of abuse the facility regional vice president (RVP), the vice president (VP) of Business Development and the vice president human resource (VP HR) Director began to complete re investigations of all alleged reported allegations of abuse. The identified staff members involved in the allegations were placed on suspension pending an internal investigation. An allegation of physical abuse was made against the NHA. The NHA was placed on suspension and was subsequently terminated and reported to the NHA licensing board. An allegation of sexual assault was made; the facility completed a re- investigation of this allegation on 8/8/2011, and (it) was unsubstantiated. A Licensed Professional Counselor who held the position at the facility as a Behavioral Health Director was placed on suspension pending investigation and was subsequently terminated and reported to the licensing board. Two certified nursing assistants were suspended, terminated and reported to the nursing board. All of these incidents were reported on the Colorado Occurrence Web Portal per guidelines. The facility completed resident interviews on 8/4/11, to rule out any other potential allegations of abuse. Some residents reported during these interviews of reports fear or being afraid. The facility re interviewed these residents on 8/8/11, to further probe whether or not these reports were actual reportable incidents. None of these reported allegations of fear or being afraid could be substantiated as verbal/physical/neglect per state operating guidelines. The facility completed staff interviews on 8/4, 8/5, 8/6 and 8/7 to rule out potential knowledge of any type of abusive situations current in the facility. These interviews substantiated alleged allegations of abuse as outlined above. The facility modified the Abuse Policy and Procedure on 8/4/11. The facility staff received re-education and training on this policy and procedure on 8/4/11 through 8/8/11. The abuse policy was modified on 8/10/2011, with the addition of a 1-888 phone number. Additionally, all facility team members were trained on the abuse policy on 8/10/2011. The facility failed to thoroughly investigate injuries of unknown origin. The facility completed re education and training with facility staff on the Policy and Procedure for investigating Bruises and Skin Tears of Unknown Origin. Two residents reported allegation of potential abuse (#28 and #16) to Social Services Director - the investigation was not complete at the time of initial report made to Social Service Director. The facility completed re investigations of the allegations of potential abuse with both of the identified residents. The VP of Business Development for company and facility Nurse Consultant provided re education and training on abuse allegation investigations with the social services director on 8/8/2011. On 8/8/11, the Social Service Director also received verbal counseling on failure to follow facility Abuse policy and procedure from the VP Business Development and Nurse Consultant. The facility adopted a new Behavior Management policy and procedure, Problematic Behavior Management - Clinical Protocol, which identifies methods of managing residents with challenging behaviors. On 8/8/11, staff received training and education on the new Behavior Management policy and procedure as well as the facility's expectation regarding avoiding physical intervention and or use of intramuscular (IM) psychoactive medications without a residents consent. Additional training is being completed on 8/9/11, for all current employees. All new employees going forward will be trained as part of their new hire orientation on both Resident Abuse Behavioral Management policy and procedure. No employee will be allowed to start working until this training is completed and acknowledged by the employee. All employees at corporate will also be trained on the resident Abuse Policy and will sign an acknowledgement indicating completion of the training. The facility has reassessed five residents identified to potentially require a specific behavior management plan/alternative placement. One resident (#20) was assessed by the Medical Director on 8/8/11, to potentially benefit from a transfer to another facility that specializes in Behavioral Health issues. The Social Services Director has placed calls to other behavioral facilities to seek alternative placement. The facility revised Abuse Policy and Procedure on 8/4/11, to include clearly defining what constitutes abuse and who to notify if abuse is suspected. The facility has implemented a company local "hotline" number to report suspected abuse. The VP of Business Development will be responsible to follow up on all potential allegations of abuse until an Executive Director is retained. This will be accomplished by 24 hour accessible via facility visits and telephonically. Additionally, the facility is going to initiate a Toll Free number for residents, families and staff to use to report potential allegations of abuse. The facility will contract with outside Management Company. A letter of intent has been signed and further detail to be determined as they visit the facility, Deficiencies are determined and a full scope of the work will be finalized to include education, training, oversight and monitoring. Outside management representative/s will be at facility on Monday, August 15, to do a tour, meet the team and the Interim Administrator. An Interim Administrator has been offered and accepted the position on an interim basis for 30 days and on a renewal basis as needed until such time that the facility recruits and hires a permanent Administrator and then ongoing until substantial compliance is achieved with state and federal regulatory requirements. C. REMOVAL OF IMMEDIATE JEOPARDY On 8/10/11 at 4:32 p.m., the interim NHA and consultant were informed that the facility's 8/10/11 plan to remove immediate jeopardy was accepted. The immediate jeopardy was removed at 4:32 p.m. However, record review and interviews, revealed deficient practice remained at a G (actual harm) level. II. FACILITY POLICIES, PROCEDURES IN EFFECT PRIOR TO IMMEDIATE JEOPARDY A. Review of the undated policy "Abuse Investigations", revealed the following (in pertinent part): "Policy Statement: All reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation: 1. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator (NHA), or his/her designee, will appoint a member of management to investigate the alleged incident. The NHA will provide to the person in charge of the investigation, a completed copy of the "Resident Abuse Report Form" and any supporting documents relative to the alleged incident. 3. The individual conducting the investigation will, as a minimum: a. Review the completed Resident Abuse Report Form; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's attending physician to determine the resident's current mental status; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview the other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location; b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process; and c. Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected (e.g., representation by legal counsel). 5. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the "Abuse Investigation Report Form.") 6. The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the investigation process. 7. Should the ombudsman decline the invitation to participate in the investigation, a notation of such data will be entered into the investigation record. The ombudsman will be notified of the results of the investigation, as well as any corrective measures taken. 8. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the NHA. Policies governing visitation are outlined in a separate policy in this section entitled "Visitation." B. Review of the undated "Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures" revealed the following: "Policy Statement: The NHA assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation: 1. The NHA has the overall responsibility for the coordination and implementation or our facility's abuse prevention program policies and procedures. 2. The NHA has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility. These may include: a. The Director of Nursing Service (DNS); b. The Social Services Director (SSD); c. The assistant Director of Nurses(ADNS); d. The UR/QAA Committee; and e. Others staff members as determined by the administrator." C. Review of the undated policy "Reporting Abuse to Facility Management" revealed (in pertinent part): "1. Our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. Employees, facility consultants and/or attending physicians, must report any suspected abuse or incidents of abuse to the DNS promptly. In the absence of the DNS, such reports may be made to the nurse supervisor on duty. 3. The NHA and the DNS must be promptly notified of suspected of abuse or incidents of abuse. If such incidents occur or are discovered after hours, the NHA and DNS must be called at home or must be paged and informed of such incident. 4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator (NHA), or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law Enforcement Officials; f. The Resident's Attending Physician; and g. The Facility Medical Director. 5. Notices to the above agencies/individuals may be submitted via US mail, special carrier, fax, e-mail, or by telephone. such notices will include, as a minimum: a. The name of the resident; b. The number of the room in which the resident resides; c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred; e. The names of all persons involved in the alleged incident; and f. What immediate action was taken by the facility. 6. All personnel, residents, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 9. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. 11. A completed copy of the "Resident Abuse Report Form: and written statements from witnesses, if any, must be provided to the administrator within 48 hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the administrator within 3 working days of the occurrence of such incident. When an incident of resident abuse is suspected or determined, such incident must be reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. 17. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense SHALL report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. 18. A person shall not knowingly-- a. Attempt, with or without threats or promises of benefit, to induce another to fail to report an incident of mistreatment or other offense; b. Fail to report an incident of mistreatment or other offense; c. Alter, change without authorization, destroy or render unavailable a report made by another; and/or d. Screen reports or withhold information to reporting agencies." III. FAILURE IN THE SCOPE AND OPERATION OF FACILITY ABUSE POLICIES A. SCREENING 1. Policy Review of the undated policy/procedure "Background Screening Investigations" revealed (in pertinent part): "Our facility will not knowingly hire any individual who has a history of abusing other persons. This facility will conduct employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment with this facility. 1. The Assistant Director of Nursing (ADNS), or other person designated by the administrator, will conduct employment background checks, reference checks, and criminal conviction checks (including fingerprinting as required by state law) on persons making application for employment with this facility. Such investigation will be initiated within 1 day of employment or offer of employment. 8. Inquiries concerning employee background investigation screenings should be referred to the administrator (NHA)." 2. Failure to check references on two of ten newly-hired employees: Review of ten newly-hired employees was completed 8/8/11. a. Review of the Nursing Home Administrator (NHA) (employed early 5/11), revealed no check of previous/current employers' references. Instead, the facility's Medical Director (also Medical Director of the NHA's previous employer), vouched for her skills and expertise, and contact was made of a co-worker for the previous [AGE] years vouched for her working relationship. There was no evidence of contact with previous employers, even to verify dates of employment. b. Review of the Behavioral Health Director (BHD)'s employee file, revealed no reference checks were done. In interview on 8/16/11 at 3:45 p.m., the Business Office Assistant said there were no reference checks in her file. She was hired under the recommendation of the NHA, who was no longer employed by the facility. B. TRAINING 1. Cross-reference F223 for further details. Record review and interviews, revealed staff misuse of Crisis Prevention Institute (CPI) maneuvers to address resident aggression involving resident #20 and resident #64. Residents #20 and #64 were subject to "safety holds" and/or "takedowns," per "Accident Occurrence and Incident Reports." Interviews revealed that a staff member sat on resident #20 to hold him down. Resident #64 complained that she was held in a painful manner. Both residents complained that they had been administered intramuscular antipsychotic medication against their wishes at various times. 2. Misuse of CPI maneuvers: On 7/28/11 at 1:05 p.m., the Behavioral Health Director (BHD) was interviewed. -The BHD stated that she had participated in the CPI "take down" for resident #20. She stated that after the take down, she sat on resident #20 while two certified nurse aides held his arms. She said that while being held down by the three staff, resident #20 was injected with [MEDICATION NAME]. Following the injection, the staff continued to hold resident #20 to the floor until he had calmed down. -The BHD, when asked about her CPI training, stated "I have been trained in the past at other facilities and considered myself certified." The BHD was asked to provide documentation of certification at this time. As of 8/2/11 at 11:45 a.m., no documentation was provided. Review of the refresher workbook for the review of nonviolent crisis intervention distributed by the Crisis Prevention Institute (CPI training), revealed it read in pertinent part (Page 23): "Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breath. This includes sitting or lying across a person's back or stomach." On 8/2/11 at 1:02 p.m., staff #27, a licensed practical nurse (LPN), was interviewed. Staff #27 stated that she was the only CPI trainer for the facility. Documentation of her trainer status was provided. She reported that she had been the facility's CPI trainer for the past year. -When asked if she had provided training to the BHD (who had been employed at the facility since 5/13/11) she stated "no". She further stated that any staff that had been trained and certified to utilize CPI techniques needed to be able to provide documentation of the training in the form of a certification card in case of an investigation. -When the LPN was asked about holding residents on the floor she stated "You never do that. As soon as you come into any surface, the wall, a chair or the floor, you need to disengage because of the risk of positional asphyxiation". -When asked if there was any circumstance when staff may need to sit on a resident, the LPN stated. "No, that's not what CPI teaches and that's not what I teach. The LPN went on to state that CPI techniques do not include "take downs; CPI does holds, but we don't do take downs". The Nursing Home Administrator (NHA) was interviewed 7/27/11 at 11:35 a.m. The NHA stated she was not trained in the CPI. 3. Medication Administration Against Resident's Wishes/Fear of Retaliation: On 8/2/11 at 4:45 p.m., an interview was conducted with resident #20. -The resident stated that he had been "taken down a few times, you know just when I was acting up." Resident #20 stated that during one of these incidents, three or four of the facility staff had physically brought him to the ground and one of the staff (he identified the BHD by name and title) sat on his chest and while being held to the floor, he was given a shot of medication. -He was asked if he knew what he was given a shot of and he replied "I think it was [MEDICATION NAME] or something like that." The resident further stated he had not given consent for the facility nurse to give the shot stated, "No I didn't want it, I told them that." -He further reported that he could recall being given injections against his wishes and without consent on two occasions, once in the shoulder and once in the hip. The resident could not recall the exact date of these incidents, however, he stated "maybe four or five weeks ago". On 8/2/11 at 6:17 p.m., resident #64 was interviewed. She recalled being "taken down." She stated that it had happened twice in the past and that once they held her down by twisting her arm. She also stated that she had been given intramuscular (IM) [MEDICATION NAME] against her will. She stated that she had not wanted ([MEDICATION NAME]). She stated that it made her scared and that she was a small woman and three employees took her down. C. IDENTIFICATION OF ABUSE Cross-reference F225 for further details. Interview and record review, revealed staff failed to recognize instances of physical abuse and the potential for abuse through misuse of Crisis Prevention Institute (CPI) maneuvers, through the administration of antipsychotic medication against resident's wishes, and as evidenced through injuries of a suspicious nature (due to size or location of injury). D. INVESTIGATION Cross-reference F225 for further details. Interviews 7/20/11 through 8/10/11, revealed a 7/18/11 incident of verbal and physical abuse and neglect had not been investigated and no steps had been taken to prevent further staff to resident abuse. Although the corporate Vice President of Operations (VPO) was informed of the witnessed allegations on 7/20/11, the NHA was observed in the facility 8/1/11 and was not suspended until days later. The only staff that had been interviewed at that time were front line staff. No residents were interviewed. Interview and record review further revealed instances of physical abuse through misuse of Crisis Prevention Institute (CPI) maneuvers and antipsychotic medication in addressing residents' aggressive behaviors, as well as injuries of a suspicious nature (due to size or location of injury) and that were of unknown origin were not thoroughly investigated. E. PROTECTION Review of facility policies (see above), revealed victims of abuse lacked access to an authority outside the facility for reporting incidents of potential abuse. Cross-reference F223 and F225 for details on resident abuse and neglect and resident and staff fears of reporting abuse. Interviews 7/20/11 through 8/10/11, revealed a witnessed incident of verbal and physical abuse on 7/18/11, involving resident #75 and the nursing home administrator had not been investigated or reported to the State Agency and no steps had been taken to prevent further staff to resident abuse. Although the corporate Vice President of Operations (VPO) was informed of the witnessed allegations on 7/20/11, the NHA was observed in the facility 8/1/11 and was not suspended until days later. Interviews 7/20/11 through 8/10/11, revealed several residents, including resident #28, were fearful to report staff abuse/neglect. The facility failed to remove two certified nurse aides (CNA) identified by resident #28 from the resident's care after she had reported the CNAs as failing to provide her care and speaking to her in demeaning manner. -Resident #44, age 34, who per 5/15/11 MDS, was able to verbalize her needs and understand the communication of others, stated during an interview on 7/20/11 at 11:55 a.m., that she was not feeling comfortable going to a person of authority if she wanted to report an allegation of abuse, or any other concerns. -Resident #20, age 60, who per 5/15/11 MDS, the resident had severe cognitive impairment, but who was usually able to verbalize his needs and understand the communication of others, expressed reluctance during an interview on 7/19/11 at 11:45 a.m., to give details of concerns. -Resident #63, [AGE] years old, who per 4/24/11 MDS, was cognitively intact, stated during an interview on 7/24/11 at 4:40 p.m. " Man I am glad you guys (surveyors) are here, things are really bad here (facility). They (nursing home administrator (NHA) and behavioral health director (BHD) mentioned by name) are nice to us when you are here, but as soon as you guys leave they treat us like we are pieces of (profanity). It's like we don't have rights or anything you know I just can't believe how they treat us". Resident #63 was asked to be more specific. He stated "It's like when you guys (surveyors) left they came in our room and interrogated us, they wanted to know everything you had asked us and wanted to know what we had told you". Resident #63 stated that he had been a prisoner of war and stated "so I know what I'm talking about when I say interrogation, what they are doing here is just not right". He further stated that he had seen the NHA and the BHD questioning other residents. Resident #63 concluded this interview and stated he had concerns about retribution if he was seen talking to the surveyor.

Based on observations, record review, and resident/staff interviews, the facility failed to ensure one out of 54 sample residents (#60) who was known to be at nutritional risk, did not experience unplanned weight loss. Specifically, the facility failed to: -Timely recognize, address, and communicate the resident's documented weight loss. -Implement planned nutritional interventions to promote weight gain and to prevent further weight loss. -Assist the resident with meals in the manner recommended by speech therapy. The resident, per facility documentation, experienced a 47 pound weight loss from 5/13/11 - 7/11/11. She was not re-weighed until 8/2/11 (during survey). On 8/2/11, the resident weighed 156.6 pounds, representative of another 20.4 pound weight loss. Cross-reference F362; competency of dietary personnel. Findings include: Resident #60 was a [AGE] year old female originally admitted on [DATE]. According to her resident face sheet, her [DIAGNOSES REDACTED]. The resident was transferred to the hospital 7/25/11 (dehydration/medication toxicity) and returned to the facility on [DATE]. 1. Known Nutritional Risks - dependency, weight loss, skin breakdown, poor intake. a. According to her most recent quarterly minimum data set ((MDS) dated [DATE]: -Resident #60 was unable to participate in the brief interview for mental status (BIMS) due to her being identified as rarely or never being understood. -Resident #60 was totally dependent on staff to perform all activities of daily living (ADLs) such as bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. -Resident #60 was identified as having a weight loss of five percent or more in the last month or loss of 10% or more in the last six months. b. Review of monthly weights revealed a significant weight loss. On 5/13/11, the resident weighed 224 pounds. She was not weighed in 6/11; however, her weight on 7/11/11 was 177 pounds, indicating a weight loss of 47 pounds. c. Review of nurses' notes revealed documentation of skin breakdown. Specifically, on 7/16/11 nurses notes documented the resident had two small open areas to right buttocks, medial 0.75 X 0.5, lateral 2 X 2.5. (On 7/20/11 at 10:44 a.m. a licensed practical nurse confirmed the resident had two open areas on her right buttocks and was being treated with a hydro gel dressing.) d. Review of the most recent laboratory results dated [DATE] revealed the resident's protein level was low at 5.2 (normal range 6.0 to 8.0) and her [MEDICATION NAME] was low at 2.7 (normal range 3.5 to 4.8) e. Review of dietary progress notes, written by the dietary manager (DM) revealed a note 6/21/11, documenting that the resident's intake was not good. Another dietary note dated 7/13/11 (quarterly progress note), documented the resident had been refusing to eat her dinner meal. The note documented the resident's meal intake was sporadic, between 25% to 75%. 2. Facility Response to Nutritional Risks a. Orders A 6/14/11 physician's telephone order documented the resident was to receive health shakes between the hours of midnight to two a.m. A readmission order dated 7/29/11 documented the resident was to receive a magic cup with meals. b. Care Plan A 6/14/11 care plan identified the resident had experienced unintended weight loss. The goal was for the resident to maintain current weight and to comply with dietary program throughout the next review. Pertinent interventions included two weekly weights, high calorie supplements between meals, nectar thick liquids, and food served in 12 ounce glasses mixed with liquids. c. Swallowing/Eating Recommendations According to the Eating/Swallowing Recommendations dated 6/15/11, the resident was to receive liquefied pureed solids and thinned to nectar thick. The recommendations documented, "...solids will not be given by spoon...total assist by staff for food and liquid presentation. Do not attempt to give food or drinks if (name of resident) is very lethargic. Give one sip at a time and make sure she swallows..." d. Dietary Progress Notes -On 6/21/11 a dietary note by the DM documented that the resident was to have her food served in 12 ounce cups for meals. The resident required nectar thick liquids. -On 7/13/11, a quarterly dietary progress note documented, in pertinent part: The resident weight was 177.4 pounds down 9.8% in six months. The note documented the resident was receiving health shakes between 12:00 a.m., and 2:00 a.m. to promote weight gain. The resident was reported to have low protein. The note documented the RD would review labs at next visit. 3. Failures in Facility's Response a. Failure to timely recognize the resident's weight loss (1) There was no documentation in the resident's record that the resident was re-weighed on 7/11/11, despite a 47 pound weight loss between 5/13/11 and 7/11/11. The Dietary Manager (DM) was interviewed on 7/28/11 at 12:50 p.m. The DM stated that the resident had received a new geri-chair and she was not sure if she had lost that much weight. The DM stated the weight of the chair was recalibrated. On 8/2/11, the DM provided a memo (undated) that read, "FYI - when the weight of any resident drops or increases 5 pounds since last weight they will have to be reweighted so we know it was accurate." (2) There was no documentation the resident was weighed weekly beginning 6/14/11, as care planned. See above; no weights in 6/11 and no weights in 7/11 until 7/11/11. b. Failure to reassess the resident's nutritional needs Review of the resident's medical record failed to show the registered dietitian (RD) had assessed the resident in the past 20 months. The last note documented by the RD was a Nutritional Risk Review dated 12/9/09. The note documented the resident weighed 239.5 pounds. The resident was to be weighed every four weeks. The note documented the resident's caloric needs were adjusted for obesity. The resident was calculated as requiring 1800 calories a day. The resident had not had any calculations of nutritional needs for the past 20 months. The RD was interviewed on 7/26/11 at 2:30 p.m. The RD stated that she was in the building roughly three times a month on average. She was contracted for 9 to 12 hours a month. She stated that when she arrives, she obtained information from the DM. The DM informs her which residents required an initial, annual assessments and residents she was concerned about. She said she also was informed of labs, weight loss, and the weight report. The RD stated that she was unaware of the resident having pressure ulcers and she was unaware of the resident having experienced a 9.8% weight loss. She confirmed the resident had not had a calculation of her nutritional needs since the last annual assessment completed in 12/09. The RD stated that she was not notified of the resident's low [MEDICATION NAME] from 5/17/11. The RD stated that if she was aware of the situation with resident #60, she would have prescribed a vitamin, and addressed both the weight loss and the low [MEDICATION NAME]. c. Failure to implement and monitor planned interventions Observations revealed the resident was not assisted to eat in the manner recommended by the ST (liquefied pureed solids, thinned to nectar thick, solids will not be given by spoon, not to feed if very lethargic). In addition, observations revealed the resident failed to receive health shakes and magic cups as ordered and care planned. Observations: (1) 7/19/11 - Breakfast Observation on 7/19/11 at 7:45 a.m. revealed resident #60 in the assisted dining room on the first floor with three other residents, one certified nurse aide (CNA) and a speech therapist. Resident #60 was in a Geri-chair facing the television while sitting by the sink while the other residents were around the table. The speech therapist (ST) mixed resident #60's supplements and orange juice with thickener, then placed a towel on the resident who was reclined back and to the right in the Geri-chair. The ST poured the mixture into the resident's mouth. The resident did not react and most of the mixture poured from the side of her mouth. The ST then thinned resident #60's mixtures and poured a small amount into the resident's mouth again. The mixture came out of the resident's open mouth. The ST did not speak to the resident as she was trying to feed her. At 7:54 a.m. the ST, having given resident #60 a small amount of the mixtures, stated that she had to go and would see the others later. The ST removed the towel from resident #60 and left the dining area. At 8:19 a.m. when the CNA was finished feeding a resident, she stated that another resident's food was cold, and she was relieved by another CNA so she could leave the dining area and reheat the resident's food. The CNA that relieved the original CNA saw that resident #60 had very little mixture absent from her cups, so she retrieved the dirty towel off of the cart, placed it back on the resident and tried to pour the mixture into the resident's mouth. The resident was not able to swallow and the mixture ran from her mouth. The CNA then stated that the mixture was too thick and she needed to thin the mixture with water. At 8:36 a.m. resident #60 was removed from the dining area. At 8:42 a.m. the dietary manager entered and asked how everyone ate. The CNA stated that they ate well, and did not mention the lack of intake by resident #60. (2) 8/1/11 Lunch At 12:01 p.m., the resident was observed sitting in her chair, asleep. At 12:14 p.m., the resident remained in her chair. She had milk of 240 cc and also had five glasses with the food in them. She also had a small plastic container of ice cream. The resident did not receive any magic cup. -The CNA gave the resident a bite of (liquid) "chicken" with a special spoon. The resident was observed to accept the food, and to be awake. She did not put any type of milk into the food as she was spoon feeding the resident. -The CNA began feeding the resident potatoes. The CNA did not wait until the resident swallowed before giving her another bite of food. The CNA used the spoon to wipe the resident's mouth. At 12:24 p.m., the resident ate another bite of food. She had not received anything to drink. At 12:29 p.m., the CNA #2 stopped feeding her, to address another resident. When the CNA returned to the resident at 12:31 p.m., the resident had her eyes closed and at 12:32 p.m., the CNA left the resident. She did not attempt to wake the resident up. At 12:33 p.m., the CNA came back with thickener for the milk. She added two blue scoops of the thickener into the 240 cc of milk. The CNA attempted to give the resident a bite of melted ice cream; however, the resident's eyes were closed. The CNA attempted to awaken the resident. At 12:39 p.m., the resident took another bite of food. The CNA was giving her a bite of the milk, as it was thicker than nectar thick. The resident then went back to sleep. Shortly thereafter, the CNA moved the milk to the other side and put the cover onto the ice cream. The resident was observed to eat the vegetable and the potatoes, and a bite of the bread. She did not eat the other two food items or the ice cream. The resident's tray was removed from the table. (3) 8/2/11 Dinner At 6:15 p.m., the resident remained in bed. The meal trays were observed to be in the day room. At 6:20 p.m., the resident remained in bed. The resident began to make noises. A CNA from another floor walked by the room and went in to tend to the resident. The CNA asked the resident if she was fed. She was observed to give her a sip of water. The CNA then left the resident. At 6:36 p.m., the nurse walked by and asked the activity director (AD) if the resident had eaten. The AD was not sure and went to look for her tray. The tray was not in the day room. At 6:42 p.m., the resident's tray was located in the nutrition room. The nurse began to feed the resident. The resident was not served a magic cup protein supplement. (4) 8/3/11 Lunch At 11:45 a.m., the trays arrived for the sun room. Resident #60 was observed sitting in her geri-chair. At 11:56 a.m., the residents were being served; however, resident #60 sat alone across the room. Her meal tray sat on the cart. At 11:57 a.m., CNA #22 was observed to put three big scoops of thickener into the resident's milk and at 11:58 a.m., she gave the resident a bite of food with a spoon. The resident was not sitting at the table, but was sitting away from the table next to the bathroom. At 12:00 p.m., CNA #22 left at the request of the nurse and stopped feeding the resident. At 12:03 p.m., the resident was making noise and moving her feet. The other CNA in the day room did not attempt to feed the resident. At 12:08 p.m., CNA #19 began to pour milk into the 12 ounce glasses of pureed food. The resident had not been given any food. At 12:11 p.m., the resident was awakened by the nurse and administered her medications. At 12:13 p.m., the resident had not eaten any of her food. The resident was asleep in her chair. She was not assisted again until 12:23 p.m. when CNA #22 returned to the dining room. At 12:23 p.m., CNA #22 came back to feed the resident. She poured food into the resident's mouth, although the food did not appear quite thin enough to pour. The resident had not received either magic cup or Ensure (health shake) with her meal. At 12:30 p.m., while the resident had her eyes closed, the CNA poured some of the drink into her milk and told the resident to wake up. The resident swallowed, but kept her eyes closed. The CNA then poured vegetables into the resident's mouth. At 12:35 p.m., CNA #22 finished feeding the resident. The resident was observed to eat approximately 30% of her meal. Record Review: Review of the resident's tray card failed to document on the card that the resident was to receive a magic cup. Further record review revealed there was no tracking mechanism in place to ensure the resident was offered and drank the shakes. Interview: The DM was interviewed on 8/3/11 at approximately 2:00 p.m. The DM stated the magic cups came out of the kitchen. She stated that she would update the tray card to reflect the magic cup. d. Failure to communicate resident's weight loss (1) RD See RD interview above; the RD was unaware of the resident's weight loss, skin breakdown, or low protein and [MEDICATION NAME]. The DM, during an interview on 7/28/11 at 12:50 p.m. said she had been completing the resident's quarterly assessments. The DM stated that she informs the RD of any skin issues and weight loss. She stated that she does not routinely receive a weight report. She stated that she recently found out that there was a skin book. The DM stated that she did not inform the RD about the resident's low [MEDICATION NAME]. (2) Physician review of the resident's medical record revealed [REDACTED]. -The 5/12/11 physician's progress note documented "...the patient's most recent vital signs were again reviewed and her last weight was noted to be 237...no [MEDICAL CONDITION] -The physician's progress note dated 7/17/11 failed to show the resident's weight loss was addressed. The charge nurse (CN) was interviewed on 8/3/11 at 1:45 p.m. The CN stated that she had not informed the physician of weight loss. 4. Actions taken during survey The resident was weighed with both the dietary manager and the surveyor present on 8/2/11 at 1:00 p.m. The resident weighed in at 156.6, a loss of another 20.4 pounds. A 8/2/11 dietary note, written during survey, documented, "...(Resident #60) weight is 156.6- -21 pounds since last weight recorded in July 2011 (Resident #60) weighed 177.4 before she went out to the hospital...(Resident #60) is 66 inches tall lying down it has been reported 60 inches...strike it out and put in new height...due to (resident #60's) continued weight loss I will notify family and ask expectations also will have at risk team discuss this also consult RD at next visit...has not been eating well I've seen food being left in her cups...the CNA explained that she can get name of resident to eat if she's awake and aware enough to eat and eats about 100% when she is successful...will continue to watch intake. However, interviews revealed the facility continued to fail to take steps to ensure the resident's additional weight loss was communicated and that her special dietary needs were being met. Specifically: -The charge nurse (CN) was interviewed on 8/3/11 at 2:00 p.m. The CN stated that she was not notified of the weight loss identified 8/2/11 (see above). -The Interim Director of Nursing Services (IDNS) was interviewed on 8/4/11 at 11:30 a.m. The IDNS stated that resident weights were completed by the restorative aides. She stated that if a resident experienced a 5% weight gain or loss, the resident would be flagged for monitoring. The IDNS stated that she was not informed of the resident's additional 20.4 pound weight loss identified 8/2/11 (see above). -The DM was interviewed on 8/3/11 at 2:00 p.m. The DM stated that she was not aware the resident was not being fed in the manner the ST recommended, even though she stated that she had noticed the resident's glasses coming back to the kitchen full. She did not indicate that she had observed staff's interactions with the resident during meals despite the observation of the full glasses being returned. -The CNA #22 was interviewed on 8/3/11 at approximately 2:00 p.m. The CNA #22 stated that when she was pulled from feeding the resident on 8/3/11 (see above), she was asked to take another resident to the bathroom. She stated that it was not an emergency. She said she was unsure how to feed the resident, stating she was told about using the glasses, but not the thickness of the meal. -The IDNS was interviewed on 8/4/11 at 11:30 a.m. The IDNS stated the CNA should not be pulled away from feeding a resident to assist another resident. She stated the nurse should have assisted in feeding the resident or assist the other resident to the bathroom. -Review of the resident's record on 8/3/11 revealed no documentation that the resident's physician had been notified of the weight loss identified 8/2/11.